Comparison of Support for Breastfeeding Beyond 12 Months of Age from Conventional and Alternative Pediatric Primary Care Providers

Introduction

Clinician advice has been shown to be important to women's decisions about breastfeeding and is associated with attained breastfeeding duration; however, pediatric care providers commonly report low confidence in their abilities to resolve breastfeeding problems and lack of time during office visits to assist.^1–4 Pediatricians provide most of the primary care for infants and toddlers in the United States. Over 80% of pediatric office visits for children younger than 1 year are to general pediatricians, with family physicians and nurse practitioners also providing significant primary care. ⁵ As a result, these primary care providers are in critical positions to help women and young children with breastfeeding.

Although most U.S. infants are cared for by a primary care provider trained in conventional medicine (a “conventional HCP”), an unknown proportion of families opt to receive primary care from an alternative pediatric healthcare provider (“AltHCP”) like a naturopath or chiropractor. A 2007 Washington study reported that the most common reason for pediatric naturopath office visits was health supervision, especially for very young patients, which suggests some families consider naturopathic physicians their usual source of primary care. ⁶ Some families choose an AltHCP for their child in addition to or instead of a conventional HCP because they find AltHCPs align better with their values and beliefs about health ⁷ or because their child has a medical condition for which parents believe complementary or alternative approaches may help. ⁸ Like pediatricians, AltHCPs providing primary care for infants are in a position to offer breastfeeding support. In fact, breastfeeding is often referred to as a natural approach to health and is aligned with many AltHCP philosophies and practices.^9,10

It is possible that families who are particularly inclined toward breastfeeding may select a primary care HCP for their child, at least partly, based on the availability and quality of breastfeeding support offered by the provider office, or switch providers if they feel unsupported with breastfeeding. We are unaware of studies that have directly examined this possibility, however. Whether the breastfeeding support provided by conventional HCPs like pediatricians is rated by patients as highly as the support provided by AltHCPs is unknown, but an improved understanding of any difference would inform ongoing efforts to improve breastfeeding support among pediatric care providers. This study reports findings based on a cross-sectional survey of U.S. women who were particularly dedicated breastfeeders (those who had breastfed their child for more than 12 months) and their perceptions of breastfeeding support provided by their child's primary HCP.

Materials and Methods

Results

Of 49,091 eligible respondents who answered the question to identify a primary HCP for their child when the child was an infant/toddler, 561 (1.1%) reported an AltHCP for their child and 48,530 (98.9%) reported a conventional HCP (Table 1). The characteristics of respondents by HCP type are displayed in Table 2. Women whose child had an AltHCP were slightly more likely to have some college education, but less than a 4-year college degree, much more likely to reside in the Mountain or Pacific regions and to be primiparous, and slightly less likely to be Black/African American or Asian. At the time of the survey, 27% children were aged 1 year, 20% were aged 2, and 25% were aged 3–5.

Mothers in the AltHCP group were more likely to have discussed their decision to breastfeed more than 12 months with their child's HCP (58% versus 46% for conventional HCP group) (Table 3). Women in the AltHCP group were extremely likely to report feeling comfortable or very comfortable (98%) and supported or very supported (97%) by the AltHCP in breastfeeding for more than 12 months, more so than the group with conventional HCPs (84% and 77%, respectively), even after adjusting for parity, education, race, and region (adjusted RR for feeling comfortable or very comfortable = 1.17, 95% confidence interval [CI] 1.15–1.19; adjusted RR for feeling provider was supportive or very supportive = 1.25, 95% CI 1.23–1.28).

When asked about factors that were important or very important to the decision to breastfeed for more than 12 months, women in both HCP groups identified similar leading factors as being important or very important, except the AltHCP group was less likely to indicate that their family's recommendations or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) support were important. Families who used an AltHCP were just as unlikely as families who used a conventional HCP (only 21%) to report that the recommendation of the child's HCP was an important or very important factor in their decision to breastfeeding for more than 12 months (adjusted RR = 0.96, 95% CI 0.82–1.12).

When analyses were restricted to women who did not participate in La Leche League programs, none of the effect estimates displayed in Tables 3 and 4 changed appreciably (all changes <7%, results not shown).

Discussion

This large study of U.S. women and children who successfully breastfed for a long duration found that the vast majority worked with a conventional HCP as the primary source of healthcare for their child as an infant or toddler, but a minority (1.1%) reported using an AltHCP, most often a naturopath or chiropractor. These proportions are similar to those reported by Downey et al. in a study of Washington children aged 1–2 years in which 3.4% of privately insured children saw both conventional and AltHCPs and 0.4% saw only AltHCPs. ¹¹ Use of AltHCPs was related to parity, and less so to educational attainment and race. Families who used an AltHCP were more likely to live in the Mountain or Pacific regions, which coincides with many of the states that license or regulate naturopaths. ¹² To our knowledge, this is the first U.S. study to examine use of AltHCPs as primary care providers and sources of support for breastfeeding beyond infancy.

Less than half of women in this study discussed their decision to breastfeed for more than 1 year with their HCP. It is likely that most HCPs broached the topic of feeding earlier in infancy because it is a standard part of well-baby care, but we lacked information about this time period. It is possible that women who did not discuss this topic with their HCP felt that they did not need HCP support around 12 months or felt that breastfeeding was not a relevant topic to discuss with their provider. Of the women who did discuss breastfeeding more than 12 months with their HCP, the women in the AltHCP group almost universally rated their HCP as supportive, while conventional HCPs received such favorable ratings only 77% of the time. While it is a positive finding that women rated HCP support favorably overall, there is room for improvement for conventional HCPs.

While we could not directly examine why families chose an AltHCP for their child, it is possible that breastfeeding support was a reason for choosing an AltHCP or switching from a conventional HCP to an AltHCP for their child's primary care. Alternatively, families may have been attracted to a pediatric AltHCP for other reasons like alternative vaccination practices, particular therapies offered by AltHCPs, or overall approaches to healthcare, which also happen to be associated with a strong inclination toward breastfeeding. If perceived poor breastfeeding support is a reason for choosing an AltHCP for some families, families need to be aware that education and training specific to pediatric populations is limited for many AltHCP professional programs and licensing requirements vary widely across states, especially for naturopaths. ¹³ Therefore, it is difficult to guarantee quality, comprehensive, evidence-based primary care for children from AltHCPs. For instance, vaccination is one controversial topic in alternative pediatric healthcare. Downey et al. reported that children who received at least some care from an AltHCP had 0.22 times the odds of receiving the measles, mumps, and rubella vaccine compared to children who saw only conventional HCPs. ¹¹ We were unable to determine whether children had both an AltHCP and a conventional HCP.

Women in this sample appear to have been largely motivated to breastfeed beyond 12 months by factors internal to the mother-infant dyad, with those who saw AltHCPs even less likely to indicate that family and WIC support were important influencers. This is in contrast to previous studies that reported family support and WIC programming as important in promoting breastfeeding initiation and duration; however, previous studies generally involved women at high risk of breastfeeding discontinuation or focused on achieving short-term breastfeeding duration goals of less than 12 months.^14,15 Nevertheless, our findings are in line with those of Rempel who reported that as breastfeeding duration approached 12 months, support from family declined, which may also have been the case in our sample. ¹⁶

This study is subject to several limitations. The study sample was one of convenience, so our results may or may not apply to all U.S. women and children who breastfeed for longer than 12 months. However, our sample reflected all regions of the United States and diversity in terms of maternal education. Because the sample was recruited through La Leche League channels, many women would have received peer breastfeeding support, which may have made them less reliant on their child's HCP for such support. Because our results did not meaningfully change when the sample was restricted to women who did not participate in La Leche League, and only modest percentages of the sample rated La Leche League support or support from their child's HCP as important factors, we do not have evidence to suggest that receipt of La Leche League supports undermined ratings of HCP support. Second, the proportion of families that used an AltHCP was small; however, our large total study sample was what permitted examination of this special, understudied group. Also, recall may have affected the accuracy of some survey responses. However, 72% of the sample reported regarding a child younger than 5 years at the time of the survey, and recall of breastfeeding duration has been found to be very good to at least 3 years in a previous systematic review. ¹⁷ Finally, respondents were asked to identify the primary source of care for their child, not all sources of care; so we cannot rule out that families in the AltHCP group were not also seeing a conventional HCP for a portion of their healthcare.

Our study offered strengths in the uniquely large sample of mothers and children who breastfed beyond 12 months of age. Because breastfeeding beyond infancy remains a relatively uncommon practice in the United States, research on any topic involving this population has been limited to small samples. Second, our detailed questions about breastfeeding support permitted examination of the role of HCP support by provider type and in relationship to other sources of support. Finally, we had access to data on key confounders to account for the influence of education, race, region, and parity, as these factors may underlie decisions about the type of HCP for pediatric care and also perceptions about breastfeeding support.

Conclusion

Women who used an AltHCP as the primary source of healthcare for their child rated their HCP's support of breastfeeding for beyond infancy more favorably than women whose child used a conventional HCP, most commonly a pediatrician. Continued efforts to improve breastfeeding support may be one way to attract and retain families in pediatric primary care.