Monday, March 12, 2018

Breastfeeding + pacifiers = no problem

- Jennifer Middleton, MD, MPH

In the designated "Baby-Friendly" hospital where I round, the use of pacifiers is discouraged in breastfeeding infants in the newborn nursery. Advising breastfeeding mothers about the risks of pacifier use contributing to early weaning is common practice, despite conflicting studies regarding the validity of this risk. A Cochrane meta-analysis, reviewed in the March 1 issue of AFP, may put the controversy to rest, as the reviewers found that pacifier use did not interfere with the establishment or duration of breastfeeding.

The Cochrane reviewers identified two randomized controlled trials (RCTs) for their meta-analysis, both of which divided breastfeeding mothers of newborn infants into two groups: one where pacifiers were prohibited, and one where pacifiers were permitted. Researchers in both RCTs found no difference in breastfeeding rates at 3-4 months of life between these two groups. Arguments against pacifier use have cited previous observational studies finding that pacifier use correlates with diminished establishment of maternal milk supply; the permissive pacifier groups in both of these RCTs, however, included pacifier use even in the immediate newborn period.

As these RCTs only included outcomes on breastfeeding rates in the first months of life, the AFP reviewers rightly encourage future research focusing on pacifiers' possible effect on additional outcomes including maternal confidence and total duration of breastfeeding. These more robust outcomes may dispel any lingering concerns about pacifier use. Adding pacifiers back to the tools available for comforting newborns certainly may benefit both babies and parents; since nonnutritive sucking is a natural self-soothing reflex in newborns, I suspect many parents would concur with my own experience regarding a pacifier's utility in calming a fussy baby.

If you'd like to read more, there are recent AFP articles on "Strategies for Breastfeeding Success" and "Risks and Benefits of Pacifiers," an editorial on "The Maternal Health Benefits of Breastfeeding," and a patient information page on "Helpful Tips for Breastfeeding." (Although these earlier articles do not reflect the findings of this new meta-analysis regarding pacifier use, they still contain a wealth of useful information for supporting breastfeeding in your practice.) The AAFP has a position paper on breastfeeding which encourages breastfeeding education in medical schools and residencies, breastfeeding-friendly office practices, and community advocacy to support breastfeeding mothers. This Society of Teachers of Family Medicine blog post from 2013 puts a compelling personal spin on the challenges of returning to work while breastfeeding, including suggestions on supporting breastfeeding within our own profession of working mothers.

Monday, March 5, 2018

Public health and advocacy resources in American Family Physician

- Kenny Lin, MD, MPH

Shaping local and national policies to improve patients' health outcomes is an appropriate and important role for family physicians. For the past several years, I have taught public health and advocacy skills to medical students, and last month, I attended Academy Health's National Health Policy conference in Washington, DC, for the first time. Although the majority of participants were researchers or policy analysts, family physicians were well-represented as medical directors, public health and insurance officials, and leaders of privately funded community health improvement projects.

In a previous blog post, I discussed the concept of assessing social determinants of health through "community vital signs," geocoded and individually linked data derived from public data sources. Although American Family Physician focuses on health interventions that clinicians provide in offices, emergency rooms, hospitals, and long-term care facilities, it also publishes resources to help family physicians improve social determinants outside of health care settings. For example, a 2014 editorial examined the role of the family physician in preventing and managing adverse childhood experiences, and a review article in the February 1 issue discussed implications for physicians of childhood bullying.

Previous editorials and articles have addressed environmental health hazards such as lead, radonair pollution and climate change, and a 2011 Letter to the Editor urged family physicians to take action to affect the built environment of American communities by "working to ensure that our patients have safe, convenient, and enjoyable places to walk, run, and bike." Other public health issues where physician advocacy can make a positive difference include food insecurity, homelessness, and firearm safety.

Family physicians are often first responders to natural and unnatural disasters in their communities. From influenza pandemics to bioterrorism, preparedness and early recognition is essential to protecting our patients. A 2015 editorial argued that the rapid spread of infectious diseases and migration and displacement of diverse populations have made global health knowledge essential for every family physician, regardless of location: "As the recent Ebola epidemic demonstrated, the world is not only smaller than ever, but it is also more intricately connected. Exotic diseases once confined to the third or developing world are now everyone's concern. Global has truly become local." For example, clinicians are likely to encounter victims of sex trafficking and labor trafficking in their practices.

AFP's sister publication, FPM, also provides resources for primary care clinicians with community and public health roles, from launching a community-wide flu vaccination plan, to following the Grand Junction, Colorado example of improving health system cost and quality outcomes, to working with community-based senior organizations. Finally, family medicine advocates can stay abreast of national initiatives that will shape the specialty's future, such as direct primary care, the patient-centered medical home, and the Medicare Access and CHIP Reauthorization Act (MACRA).