Residency Curriculum Improves Brestfeeding Cre Lori Feldmn-Winter, Luren Brone, Brry Milcrek, Krystl Hunter, Jon Meek, Jne Morton, Tr Willims, Audrey Nylor nd Ruth A. Lwrence Peditrics 2010;126;289-297; originlly published online Jul 5, 2010; DOI: 10.1542/peds.2009-3250 The online version of this rticle, long with updted informtion nd services, is locted on the World Wide Web t: http://www.peditrics.org/cgi/content/full/126/2/289 PEDIATRICS is the officil journl of the Americn Acdemy of Peditrics. A monthly publiction, it hs been published continuously since 1948. PEDIATRICS is owned, published, nd trdemrked by the Americn Acdemy of Peditrics, 141 Northwest Point Boulevrd, Elk Grove Villge, Illinois, 60007. Copyright 2010 by the Americn Acdemy of Peditrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
ARTICLES Residency Curriculum Improves Brestfeeding Cre AUTHORS: Lori Feldmn-Winter, MD, MPH, Luren Brone, MPH, b Brry Milcrek, PhD, c Krystl Hunter, MBA, c Jon Meek, MD, MS, RD, d Jne Morton, MD, e Tr Willims, MD, f Audrey Nylor, MD, DrPH, g,h nd Ruth A. Lwrence, MD i Division of Adolescent Medicine, Deprtment of Peditrics, nd c Division of Reserch nd Sttistics, Cooper University Hospitl, University of Medicine nd Dentistry of New Jersey-Robert Wood Johnson Medicl School, Cmden, New Jersey; b Division of Peditric Prctice, Americn Acdemy of Peditrics, Elk Grove Villge, Illinois; d Deprtment of Peditrics, Arnold Plmer Hospitl for Children, Florid Stte University College of Medicine, Orlndo, Florid; e Deprtment of Peditrics, Stnford University, Plo Alto, Cliforni; f Division of Reserch nd Sttistics, Deprtment of Peditrics, Cse Western Reserve University, Clevelnd, Ohio; g Deprtment of Peditrics, University of Vermont College of Medicine, Burlington, Vermont; h Wellstrt Interntionl, Shelburne, Vermont; nd i Deprtments of Peditrics nd Obstetrics nd Gynecology, University of Rochester, School of Medicine nd Dentistry, Rochester, New York KEY WORDS brestfeeding, eductionl intervention, resident eduction/ trining ABBREVIATIONS AAP Americn Acdemy of Peditrics PP prctice pttern OR odds rtio www.peditrics.org/cgi/doi/10.1542/peds.2009-3250 doi:10.1542/peds.2009-3250 Accepted for publiction Apr 12, 2010 Address correspondence to Lori Feldmn-Winter, MD, MPH, Cooper University Hospitl, University of Medicine nd Dentistry of New Jersey-Robert Wood Johnson Medicl School, 3 Cooper Plz, Suite 200, Cmden, NJ 08103-1438. E-mil: winter-lori@cooperhelth.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2010 by the Americn Acdemy of Peditrics FINANCIAL DISCLOSURE: The uthors hve indicted they hve no finncil reltionships relevnt to this rticle to disclose. WHAT S KNOWN ON THIS SUBJECT: Despite rise in overll brestfeeding, lck of physicin support hs continued to undermine the prctice of exclusive brestfeeding. Indequcies exist in brestfeeding eduction during residency, nd study results hve suggested tht support of brestfeeding is decresing mong prcticing peditricins. WHAT THIS STUDY ADDS: The uthors used n AAP curriculum to trin multispecilty group of primry cre residents. This trining on brestfeeding improved knowledge, confidence, nd prctice ptterns relted to brestfeeding cre mong residents nd resulted in incresed brestfeeding rtes in their ptients. bstrct OBJECTIVES: Multiple studies hve reveled indequcies in brestfeeding eduction during residency, nd results of recent studies hve confirmed tht ttitudes of prcticing peditricins towrd brestfeeding re deteriorting. In this we study evluted whether residency curriculum improved physicin knowledge, prctice ptterns, nd confidence in providing brestfeeding cre nd whether implementtion of this curriculum ws ssocited with incresed brestfeeding rtes in ptients. SUBJECTS AND METHODS: A prospective cohort of 417 residents ws enrolled in controlled tril of novel curriculum developed by the Americn Acdemy of Peditrics in conjunction with experts from the Americn College of Obstetricins nd Gynecologists, Americn Acdemy of Fmily Physicins, nd Assocition of Peditric Progrm Directors. Six intervention residency progrms implemented the curriculum, wheres 7 control progrms did not. Residents completed pretests nd posttests before nd fter implementtion. Brestfeeding rtes were derived from rndomly selected medicl chrts in hospitls nd clinics t which residents trined. RESULTS: Trined residents were more likely to show improvements in knowledge (odds rtio [OR]: 2.8 [95% confidence intervl (CI): 1.5 5.0]), prctice ptterns relted to brestfeeding (OR: 2.2 [95% CI: 1.3 3.7]), nd confidence (OR: 2.4 [95% CI: 1.4 4.1]) thn residents t control sites. Infnts t the institutions in which the curriculum ws implemented were more likely to brestfeed exclusively 6 months fter intervention (OR: 4.1 [95% CI: 1.8 9.7]). CONCLUSIONS: A trgeted brestfeeding curriculum for residents in peditrics, fmily medicine, nd obstetrics nd gynecology improves knowledge, prctice ptterns, nd confidence in brestfeeding mngement in residents nd increses exclusive brestfeeding in their ptients. Implementtion of this curriculum my similrly benefit other institutions. Peditrics 2010;126:289 297 PEDIATRICS Volume 126, Number 2, August 2010 289
Incresing the rte of brestfeeding hs been public helth priority in the United Sttes for more thn century. 1 Multiple strtegies hve been studied, including prentl promotion, improvement of hospitl policies, public helth wreness cmpigns, peer support, nd work-site improvements. 2 Physicin promotion nd support of brestfeeding is less well studied. In 1974, when brestfeeding rtes were recovering from n ll-time low, only 30% of physicins routinely encourged brestfeeding, nd only 52% sid tht they would encourge brestfeeding if the mother ws lredy interested. 3 Attitudes bout brestfeeding hd improved 20 yers lter, with 90% of physicins indicting tht they encourged brestfeeding but only 50% sying tht they felt confident in their bility to counsel brestfeeding ptients. 4 Prcticing physicins nd residents hve reported indequcies in the trining nd preprtion they received to help them dvise brestfeeding mothers. 4,5 In 1999, results of the Americn Acdemy of Peditrics (AAP) Periodic Survey indicted lck of knowledge, confidence, nd positive ttitudes towrd brestfeeding counseling in rndom smple of peditricins tht included US peditric residents nd fellows. 6 Most respondents in tht survey reported tht brestfeeding nd formul feeding were eqully cceptble. In follow-up 2004 survey, more peditricins recommended exclusive brestfeeding but were up to 5 times more likely thn peditricins in 1995 to recommend termintion of brestfeeding for inpproprite resons. 7 The results of these studies demonstrted need to improve brestfeeding knowledge nd ttitudes mong prcticing physicins nd to develop more effective fculty, mentors, nd role models for physicins in trining. However, mny primry cre physicins, who hve n influentil role in mothers decisions to brestfeed, lck the necessry clinicl skills to provide lcttion mngement. 4,5,8 10 Furthermore, if physicins hve poor ttitudes nd bsent skills, they re more likely to discourge continued brestfeeding. 10 In October 2000, the US Deprtment of Helth nd Humn Services Office on Women s Helth relesed the HHS Blueprint for Action on Brestfeeding, 1 which documented comprehensive ntionl policy in which brestfeeding ws identified s the idel method of feeding nd nurturing infnts nd declred ntionl helth priority. The uthors dvocted chnges in the helth cre system tht included providing professionl mternl nd child helth cre providers with culturlly pproprite clinicl nd in-service trining nd continuing eduction on the bsics of lcttion, brestfeeding counseling, nd lcttion mngement. To ddress this issue, the AAP, with funding from the Helth Resources nd Services Administrtion s Mternl nd Child Helth Bureu, prtnered with orgniztions such s the Americn College of Obstetricins nd Gynecologists, Americn Acdemy of Fmily Physicins, nd Assocition of Peditric Progrm Directors to develop model residency brestfeeding curriculum. In this we study evluted the impct of tht curriculum on brestfeeding knowledge, prctice ptterns (PPs), nd confidence mong prticipting residents, s well s the impct of implementing the curriculum on the institution s brestfeeding rtes. Our primry hypothesis ws tht residents would improve their brestfeeding knowledge, skills, nd PPs s result of curriculum implementtion. Our secondry hypothesis ws tht brestfeeding rtes t the institutions implementing the curriculum would increse. METHODS Development of Curriculum The AAP Brestfeeding Residency Curriculum ws developed by project dvisory committee tht included expert representtion from the AAP, Americn College of Obstetricins nd Gynecologists, Americn Acdemy of Fmily Physicins, Assocition of Peditric Progrm Directors, nd other professionl orgniztions. Two previously studied models, field-trip design nd the second edition of the Wellstrt Lcttion Mngement Self-study Modules 11,12 were incorported into the new curriculum tht lso included comprehensive resource nd reference list. The curriculum contined 7 mjor sections: dvoccy, community outrech nd coordintion of cre, ntomy nd physiology, bsic skills, periprtum support, mbultory mngement, nd culturl competency. For ech ctegory, gols, lerner objectives, suggested ctivities, clinicl correltions, nd evlution strtegies were specified. The uthors structured the curriculum ccording to the Accredittion Council of Grdute Medicl Eduction Core Competencies (www.cgme. org/outcome/comp/compmin.sp) to llow for flexibility during implementtion. The full curriculum nd relted mterils re vilble online (www. p.org/brestfeeding/curriculum) for generl use. Selection of Pilot Intervention Sites nd Control Sites In 2006, the AAP sent request for pplictions to directors of residency progrms in peditrics, obstetrics, nd fmily medicine, nd 69 of those directors responded. The AAP selection committee chose pplictions from progrms reported to hve low or unknown brestfeeding rtes, nd enrollment included t lest 20 ethniclly diverse peditrics, fmily medicine, obstetrics nd gynecology resi- 290 FELDMAN-WINTER et l
ARTICLES dency progrms. Additionl siteselection criteri included sites tht serve diverse ptient popultion, represent different geogrphicl regions, lck locl Bby-Friendly Hospitl Inititive certifiction, nd hve the bility to dminister pretests nd posttests nd to collect brestfeeding dt. Seven sites were selected for curriculum intervention, nd 7 mtched sites were selected s controls. At ech intervention site, personnel were expected to (1) implement the curriculum within 1 yer with prticiption level of t lest 20 residents representing ll 3 disciplines, (2) ttend preimplementtion trining meeting nd follow-up evlution meeting, (3) host site visit with dy of ctivities nd lectures with visiting professor for residents nd other hospitl stff, (4) dminister n online pretest nd posttest to ll prticipting residents, nd (5) collect dt on brestfeeding rtes t the initition of the progrm nd 6 months lter. Ech control site ws expected to perform the dt collection in items 4 nd 5 nd, t the completion of the study, ws grnted full ccess to the curriculum, which included site visits with visiting professors. Resident Subjects nd Procedures The project ws pproved by the institutionl review bords of the AAP, the institution of the overll project director, nd t ech intervention nd control site. Residents who greed to prticipte provided signed consent nd were ssigned n identifier tht mintined subject blinding to investigtors. Enrolled residents completed secure online pretests before implementtion, which begn in July 2006, nd posttests fter completion of the curriculum. Curriculum Implementtion Two fculty members from ech implementtion site prticipted in 2-dy curriculum-trining progrm t the AAP, during which ech developed site-specific curriculum-implementtion pln. Implementtion of the curriculum took plce fter completion of resident pretests nd collection of bseline brestfeeding dt. In ll progrms, resident trining begn with self-study mterils on ntomy nd physiology nd bsic skills. Residents then met with fculty who led discussion questions, didctic lectures, nd skills workshops. Residents lerned periprtum brestfeeding support during the newborn-nursery rottion. During this time, the residents were required to ssist 3 new mothers with brestfeeding, with t lest 1 encounter (live or role-ply) being observed nd scored by fculty. Sites generlly fulfilled the requirement for community outrech nd coordintion of cre by rrnging field trip to or presenttion from locl brestfeeding support groups. The fculty tught dvoccy of brestfeeding to residents by reviewing the World Helth Orgniztion/United Ntions Children s Fund Ten Steps to Successful Brestfeeding 13 nd compring this informtion with their hospitl s current policy. Residents lerned bout mbultory mngement through discussion of clinicl cse scenrios in smll-group setting nd with hnds-on prctice during continuity clinic. Culturl competency cses were lso discussed. Collection nd Anlysis of Resident Knowledge, Confidence, nd PPs The AAP ssisted sites in collecting dt regrding resident knowledge, confidence, nd PPs by posting the pretests nd posttests on Survey Monkey (www. surveymonkey.com). The pretests nd posttests cn be viewed t http://p. org/brestfeeding/curriculum. The tests were dpted from the Acdemy of Brestfeeding Medicine Wht Every Physicin Needs to Know About Brestfeeding course nd the Americn Acdemy of Peditrics Periodic Survey. 7,14 Three scles were used to mesure the impct of curriculum completion. Knowledge ws mesured by 25 items in the pretest nd 26 items in the posttest with right-or-wrong nswers. Perceived confidence ws mesured by using questions from 2 domins: dequtely ddressing prentl questions nd competently mnging common brestfeeding problems. An ordinl scle ws used to determine residents confidence. PPs were summrized s composite on the bsis of 3 specific prctices: (1) ssessment of mother brestfeeding; (2) counseling mother bout infnt feeding choices; nd (3) teching mother brestfeeding techniques. Residents reported ech PP by using scle from never to 5 times or more. Composite scores were clculted s the men response overll for the 3 PP items. There were dditionl PP items tht ddressed culturl competency: (1) sking bout culturl beliefs nd prctices before counseling bout brestfeeding; (2) sking bout culturl beliefs nd prctices regrding colostrum; (3) sking for ssistnce by nother stff member (chperone) when observing brestfeeding; nd (4) using the ssistnce of bilingul stff member or certified interpreter for mother who hd low English proficiency. PP scores were nlyzed with nd without the inclusion of items tht ssessed culturl competency. Medin group differences in demogrphic vribles were tested for significnce by using the Mnn-Whitney U test. Men scled scores within groups were tested for significnce by using pired t test. Men differences between groups were tested by n independent-smples t test with homogeneity of vrince correction s indicted by Levene-test results. Improve- PEDIATRICS Volume 126, Number 2, August 2010 291
ments (binry) in scle scores between groups were summrized s odds rtios (ORs) nd tested for significnce by using 2-tiled log-likelihood 2. Smple-Size Determintion On the bsis of vilble resources, we determined tht the study could include up to 14 sites. A minimum of 20 residents were chosen t ech site to provide 80% power to detect n OR of 2.0 between groups on ny increse in ny of the 3 scles nlyzed by using 2-tiled log-likelihood 2 test t.05 nd llowing for n increse in up to 33% mong control-group residents. FIGURE 1 Study lgorithm. 14 residency sites enrolled in project 7 intervention sites 7 control sites 253 residents completed pretest 154 residents took both tests 1 intervention site withdrew Brestfeeding Rtes Ech site collected rtes of brestfeeding t study initition nd 6 months lter by rndomly selecting 100 medicl records t specific intervls. Ech site determined its bseline brestfeeding rtes by selecting newborn nd residency continuity-clinic medicl records for 3-month intervl (July through September 2006). Sites derived their postintervention rtes from chrts tht were dted fter completion of the curriculum nd fter residents completed their posttests. Brestfeeding-initition dt were collected My through July 2007, nd 6-month brestfeeding dt were collected December 2007 through Jnury 2008. Site coordintors were instructed to record feeding in 1 of 3 ctegories: exclusive brestfeeding, nonexclusive brestfeeding (brestfeeding plus feeding of formul or other foods nd/or fluids), nd exclusive formul feeding. Sites were sked to define exclusive brestfeeding s n infnt s consumption of humn milk with no supplementtion of ny type (wter, juice, nonhumn milk, or foods) except for vitmins, minerls, nd medictions. Overll brestfeeding ws defined for the purpose of nlysis s the sum of nonexclusive brestfeeding nd exclusive brestfeeding. Brestfeeding rtes between intervention nd control groups were compred in the preintervention nd postintervention periods by using Person s 2 or Fischer s exct test depending on expected vlues. The odds of incresed brestfeeding rtes t birth nd 6 months (overll nd exclusive) were clculted by using the percentge of exclusive or overll brestfeeding t ech point in time nd tested for significnce s rtio. A smple of 450 chrts in ll sites combined provided 82% power to detect n OR of 1.5 between the exclusive brestfeeding rtes before nd fter the intervention by using 2-tiled log-likelihood 2 test t.05, llowing for bseline preintervention rtes up to 25%. 99 dropped out 164 residents completed pretest 106 residents took both tests 58 dropped out RESULTS A totl of 417 residents were enrolled from 13 sites (6 interventions nd 7 controls) (Fig 1). One intervention site ws unble to obtin institutionl review bord pprovl. Resident chrcteristics re listed in Tble 1. There were 157 residents who completed pretests but did not complete posttests (noncompleters), which resulted in 260 residents who completed both pretests nd posttests (completers). Completers nd noncompleters were similr except for higher rte of exclusive brestfeeding mong completers. This difference ws not observed in comprisons between intervention nd control residents in the completers group. Resident Knowledge, Confidence, nd PPs Residents t the intervention sites improved significntly in knowledge, PPs, nd confidence (Tble 2). Residents who completed the curriculum were more thn twice s likely to improve their knowledge, PP (djusted), nd confidence compred with residents t control sites (Tble 3). Bseline scores were nlyzed for residents ccording to completion sttus. Bseline confidence nd PP between completers nd noncompleters were similr. Residents who completed the study (intervention nd control groups) hd more knowledge on their pretest thn noncompleters (P.01). Completers in the intervention group scored 64.8%, nd completers in the control group scored 68.3%; noncompleters in the intervention group scored 60.1%, nd noncompleters in the control group scored 61.3%. 292 FELDMAN-WINTER et l
ARTICLES TABLE 1 Resident Demogrphics: Completers Versus Noncompleters nd Intervention Versus Control Sites Completer Noncompleter P Completers Only Intervention Control P Age, n (medin, y) 254 (30) 150 (30).24 148 (30) 106 (30).590 Rce 256 153 150 106 Asin, % 29.6 22.2.11 30.7 28.3.78 Blck, % 6.3 7.8.69 8.0 3.8.20 Hispnic, % 8.6 7.9.85 5.3 13.2.04 Ntive Hwiin, % 0.8 0.6.99 0.7 0.9.99 Americn Indin, % 0.4 0.0.99 0.0 0.9 White, % 54.3 61.4.31 52.8 55.3.70 Gender 256 154 150 106 Femle, % 70.3 77.3 70.7 69.8 Mle, % 29.7 22.7.13 29.3 30.2.88 Other demogrphics Speks other lnguge, n (%) 256 (66.4) 153 (61.4).31 150 (73.3) 106 (56.6).01 Hve children, n (%) 257 (25.3) 154 (26.6).77 150 (27.3) 107 (22.4).39 Any brestfeeding, exclusive nd 65 (92.3) 41 (80.5).07 41 (92.7) 24 (91.7).99 combined, n (%) Exclusive brestfeeding, ll, n (%) 65 (86.2) 41 (65.9).01 41 (82.9) 24 (91.7).47 Exclusive brestfeeding, 6 mo, n (%) b 65 (46.2) 41 (39).47 41 (43.9) 24 (50.0).80 Exclusive formul feeding, n (%) 65 (7.6) 41 (14).33 41 (7.3) 24 (8.3).99 Exclusive brestfeeding (humn milk without other food or fluids) for ny mount of time by resident or spouse. b Exclusive brestfeeding of ll children for t lest 6 months by resident or spouse. TABLE 2 Chnges in Resident Knowledge, Confidence, nd PPs Intervention Control P c n Men Pretest Score Men Posttest Score Men Score Difference P n Men Pretest Score Men Posttest Score Men Score Difference Knowledge d 154 64.8 80.7 15.9.001 106 68.2 76.3 8.1.001.022 Confidence e 154 2.770 3.895 1.125.001 103 3.146 3.665.519.001.013 PPs f 154 1.796 2.239.443.001 103 1.822 2.148.326.001 NS PPs, excluding culturl 152 1.992 2.432.440.001 101 2.034 2.254.220.005.034 questions g NS indictes not significnt. P vlue of the men difference between pretest nd posttest scores for the intervention group only. b P vlue of the men difference between the pretest nd posttest scores for the control group only. c P vlue of the difference between the men score differences for the intervention versus control group. d Knowledge scores indicte percent correct responses for test (perfect score 100). e Confidence levels were mesured on the scle: 1 not t ll confident; 2 not confident; 3 neutrl; 4 confident; nd 5 very confident. f PP vlues re men differences for which point vlues were defined s 1 never, 2 once or twice, 3 3 or 4 times, nd 4 5 times. g Adjusted to exclude PPs relted to culturl competency (see Methods ). P b TABLE 3 Improvements in Knowledge, Confidence, nd PPs mong Residents Exposed Versus Not Exposed to Curriculum Intervention Control OR 95% CI Improvements in knowledge, confidence, nd PP were nlyzed ccording to the size of the residency progrm, to determine if effects were N n Improved n Not Improved N n Improved n Not Improved Knowledge 154 129 25 106 69 37 2.767 1.541 4.970 Confidence 152 115 37 103 58 45 2.411 1.409 4.127 PPs 152 111 41 103 72 31 1.166 0.671 2.026 PPs, excluding culturl questions 152 106 46 101 52 49 2.171 1.289 3.658 CI indictes confidence intervl. shred eqully, by using the weighted number of residents who completed the study t ech site (Tble 4). After djustments were mde for size, men improvements remined significnt. Knowledge, PP, nd confidence were exmined ccording to gender mong residents in the intervention group who completed the study (Tble 5). Despite bseline nd posttest differences in PP, men improvements did not differ between genders. When compred mong the 3 medicl specilties, peditric residents improved most in their confidence, wheres residents in obstetrics/gynecology nd fmily medicine improved most in knowledge (Tble 6). PEDIATRICS Volume 126, Number 2, August 2010 293
TABLE 4 Weighted Averges of Men Differences in Scores Bsed on Size of Residency Progrm N Men Score (SD) Difference Intervention Men Score (SD) Difference Control P, Unweighted P, Weighted (Unweighted/Weighted) (Unweighted/Weighted) Knowledge 154 15.9 (15.6) 8.1 (9.1).001.003 Confidence 154 1.125 (1.07) 0.519 (.550).001.001 PPs 154 0.443 (.431) 0.326 (.322).173.198 PPs, excluding culturl questions 152 0.440 (.435) 0.226 (.220).023.022 Adjusted for PPs relted to culturl competency (see Methods ). Impct of Curriculum on Brestfeeding Initition nd Continution t 6 Months Twelve sites (5 intervention nd 7 control progrms) provided dt t bseline (initition nd 6-month rtes) nd brestfeeding initition fter intervention, nd 8 sites (3 intervention nd 5 control progrms) provided 6-month dt. Brestfeeding of infnts ws more likely to be initited nd continued t intervention sites fter curriculum implementtion (Tble 7). The curriculum hd the most significnt effect on incresing exclusive brestfeeding t intervention sites (OR: 4.1 [95% confidence intervl: 1.8 9.7]), wheres mong control sites, 6-month-old infnts were hlf s likely (OR: 0.53 [95% confidence intervl: 0.32 0.78]) to be exclusively brestfeeding fter the intervention period. DISCUSSION Previous studies hve reveled tht neither residents nor prcticing physicins believe tht they received dequte trining in clinicl brestfeeding mngement. 4 Our study results demonstrte tht trgeted brestfeeding curriculum cn improve brestfeeding knowledge, PPs, nd resident confidence in mnging brestfeeding. Becuse generl knowledge bout brestfeeding is incresing mong helth cre professionls, more institutions re improving their brestfeeding prctices. 6,7,15 In ddition, brestfeeding rtes hve incresed in most popultions nd geogrphic res over the pst decde nd driven needed improvements in professionl cre. 16 It ws importnt, therefore, to include control sites to reduce bck- TABLE 5 Knowledge, PPs, nd Confidence Scores According to Gender-Intervention Group Bseline After Intervention Men Score Differences Mle (n 79) Femle (n 175) P Mle (n 79) Femle (n 175) P Mle (n 79) Femle (n 175) P Knowledge 65 (14) 68 (13).079 77 (14) 80 (16).116 12 12.665 Confidence 3.1 (.99) 2.91 (.96).230 3.9 (.68) 3.75 (.69).158 0.8 0.84.590 PPs 1.69 (.65) 1.9 (.53).028 2.15 (.68) 2.2 (.59).444 0.46 0.3.167 PPs, excluding culturl 1.76 (.64) 2.13 (.64).000 2.2 (.68) 2.4 (.64).015 0.44 0.27.060 questions Scores re men (SD). Adjusted for PPs relted to culturl competency (see Methods ). TABLE 6 Improvements According to Specilty Before Intervention Intervention Control P After Intervention Difference Before Intervention After Intervention Difference Peditrics (N 166), n 84 82 Knowledge 68 (12) 82 (17) 14 71 (13) 80 (14) 9.057 PPs 1.74 (0.51) 2.21 (0.64) 0.47 1.81 (0.63) 2.15 (0.62) 0.34.208 PPs, excluding culturl questions b 1.87 (0.54) 2.35 (0.64) 0.48 1.95 (0.66) 2.30 (0.62) 0.35.277 Confidence 2.76 (0.89) 3.76 (0.87) 1.00 3.27 (1.02) 3.85 (0.63) 0.58.015 Obstetrics nd gynecology (N 48), n 35 13 Knowledge 63 (14) 81 (10) 18 62 (14) 67 (13) 5.007 PPs 2.07 (0.56) 2.42 (0.59) 0.34 2.08 (0.52) 2.13 (0.50) 0.05.062 PPs, excluding culturl questions b 2.34 (0.58) 2.7 (0.59) 0.36 2.49 (0.63) 2.44 (0.52) 0.05.063 Confidence 2.71 (1.03) 3.65 (0.71) 0.94 2.62 (1.17) 2.75 (0.89) 0.13.052 Fmily medicine (N 46), n 35 11 Knowledge 59 (14) 77 (13) 18 56 (14) 58 (17) 2.009 PPs 1.64 (0.52) 2.18 (0.58) 0.54 1.58 (0.67) 1.86 (0.81) 0.28.279 PPs, excluding culturl questions b 1.83 (0.60) 2.42 (0.60) 0.59 1.72 (0.77) 2.02 (0.84) 0.30.302 Confidence 2.95 (0.88) 3.97 (0.59) 1.22 2.95 (0.88) 3.45 (0.96) 0.5.072 Scores re men (SD). P vlue of the difference between men score differences intervention versus control. b Adjusted for PPs relted to culturl competency (see Methods ). 294 FELDMAN-WINTER et l
ARTICLES TABLE 7 Impct of Curriculum on Brestfeeding Rtes in Infnts t Study Initition nd 6 Months Lter Type of Feeding ground improvements in brestfeeding trining nd cre from chnges tht were mesured s result of the trgeted intervention with the AAP brestfeeding curriculum. Intervention-group residents showed significnt improvements in knowledge over control-group residents, nd these differences were most striking in the obstetrics/gynecology nd fmily medicine residents. Improvements in knowledge were lso independent of the size of the residency progrm, suggesting tht progrms of ll sizes cn benefit from the use of these mterils. Residents t the intervention sites indicted chnge in their PPs (ie, they were more likely to perform bedside ssessment of brestfeeding, counsel mothers bout brestfeeding issues, or tech brestfeeding techniques thn they were before implementing the curriculum). When compring PPs of residents who received the intervention to those who did not, however, there ws no significnt difference before djusting for items relting to culturl competency. One explntion for the lck of difference my hve been n emphsis on Before, n (%) After, n (%) Chnge, % Brestfeeding rtes in infnts t study initition before nd fter implementtion Intervention sites Totl 504 493 Exclusive brestfeeding 78 (15.5) 114 (23.1) 7.5.002 Overll brestfeeding 383 (76.0) 398 (80.7) 4.7.071 Control sites Totl 701 701 Exclusive brestfeeding 193 (27.5) 214 (30.5) 3.0.239 Overll brestfeeding 454 (64.8) 467 (66.6) 1.8.500 Brestfeeding rtes 6 mo before nd fter implementtion Intervention sites Totl 300 300 Exclusive brestfeeding 7 (2.3) 27 (9.0) 6.7.001 Overll brestfeeding 76 (25.3) 86 (28.7) 3.4.291 Control sites Totl 499 550 Exclusive brestfeeding 58 (11.6) 34 (6.2) 5.4.002 Overll brestfeeding 134 (26.9) 139 (25.3) 1.6.574 culturl competency trining t the control sites coincidentl to the implementtion of the brestfeeding curriculum t the intervention sites. For residents who received the intervention, perceived confidence significntly improved. This result my reflect both incresed knowledge nd more frequent opportunities to ssist mother-infnt brestfeeding dyds. Improvement of physicin knowledge nd prctice skills is criticl, becuse lck of physicin support hs contributed to dwindling rtes of exclusive brestfeeding, nd ttitudes of prcticing peditricins towrd brestfeeding re currently deteriorting. 7 Results of previous studies hve demonstrted tht those residents nd prcticing physicins who hve personl experience with brestfeeding hve the gretest confidence in providing support. In this study, 70% of the completing residents were femle, nd 92% of women who completed the study hd personl brestfeeding experience. Femle residents were more likely thn mle residents to provide brestfeeding cre for their ptients. P However, both femle nd mle prticipnts demonstrted similr improvements in brestfeeding cre fter implementtion. It is importnt to trget brestfeeding support nd mngement to both mle nd femle physicins s prt of their residency trining. The AAP brestfeeding curriculum resulted in improved rtes of brestfeeding. The helth eduction theory, diffusion of innovtion, provides rtionle for why trining residents my hve improved the institution s overll brestfeeding cre. 17 Fculty who chmpioned the new curriculum nd their trined residents becme the innovtors by chnging their own knowledge, confidence, nd PPs. Fellow residents nd other helth cre prctitioners in ech helth system then becme the erly dopters to new prctices. Trined residents served s ctlysts for chnge by disseminting new informtion to their collegues, which resulted in improved policies nd prctices tht supported incresed brestfeeding. Although there my hve been other influences of chnge during the study period, the degree of chnge for control sites is consistent with ntionl trends. It is not cler why this intervention ws most influentil for exclusive brestfeeding t 6 months. One explntion is tht physicins support for exclusive brestfeeding ws stronger component of the curriculum thn prentl brestfeeding promotion. Although this study is one of the first to evlute the effectiveness of stndrdized brestfeeding curriculum, there were limittions. The number of completing residents nd prticipting residency progrms ws smll. The progrms were not rndomized, nd the prticipting fculty nd residents could not be blinded to whether they were n intervention or control PEDIATRICS Volume 126, Number 2, August 2010 295
site. In ddition, becuse ech residency progrm constntly revised nd improved its own curriculum, the control sites might hve received some exposure to brestfeeding through fculty, Web-bsed, or print mterils or through exposure to knowledgeble lcttion consultnts or nursing personnel, which would serve to minimize ny significnt differences in improvements seen between sites. Finlly, the mesurement of brestfeeding rtes t the hospitls nd resident continuity clinics were imprecise nd my not represent sttisticl smple popultion of brestfeeding infnts. Trcking brestfeeding rtes ws reflection of institutionl rther thn individul chnge. REFERENCES 1. US Deprtment of Helth nd Humn Services. Brestfeeding: HHS Blueprint for Action on Brestfeeding. Wshington, DC: US Deprtment of Helth nd Humn Services, Office on Women s Helth; 2000. Avilble t: www.womenshelth.gov/ espnol/llctnci/bluprntbk2.pdf. Accessed October 27, 2009 2. Shely KR, Li R, Benton-Dvis S, Grummer- Strwn LM. The CDC Guide to Brestfeeding Interventions. Atlnt, GA: US Deprtment of Helth nd Humn Services, Centers for Disese Control nd Prevention; 2005. Avilble t: www.cdc.gov/brestfeeding/pdf/ brestfeeding interventions.pdf. Accessed October 27, 2009 3. Hollen BK. Attitudes nd prctices of physicins concerning brest-feeding nd its mngement. J Trop Peditr Environ Child Helth. 1976;22(6):288 293 4. Freed GL, Clrk SJ, Sorenson J, Lohr JA, Ce- CONCLUSIONS Our results demonstrte tht trgeted brestfeeding curriculum for residents in peditrics, fmily medicine, nd obstetrics nd gynecology improves knowledge, PPs, nd confidence in brestfeeding mngement in the residents nd leds to increses in exclusive brestfeeding in their ptients. Trining residents to improve cre of brestfeeding ptients influences prctices throughout the medicl institution, which leds to incresed rtes of brestfeeding. Opportunities for dditionl reserch depend on wider dissemintion of the curriculum to residency progrms through the Web site nd mesurement of the ultimte gol of incresed rtes of brestfeeding initition, exclusivity, nd durtion. ACKNOWLEDGMENTS This study ws supported in prt by Helth Resources nd Services Administrtion Mternl nd Child Helth Bureu grnt 4 H04 MD 00009-07-01 CFDA 93.110 nd Centers for Disese Control Americn Medicl Colleges Potentil Extrmurl Reserch Topics grnt MM-0993-07/07. We thnk the project sites nd their project coordintors: Bellevue Hospitl, New York University School of Medicine, Susn Vierczhlek, MD; Duke University School of Medicine, Aditee Nryn, MD, MPH, Jonne Bnd, MD; Forum Helth Center, Lis Weiss, MD; Hrbor University of Cliforni Los Angeles, Julie Noble, MD; Jcobi Medicl Center, Lwrence Noble, MD, FAAP, Ivn Hnd, MD, nd Dine Indyk, MD; Johns Hopkins University, Jessic Bienstock, flo R, Curtis P. Ntionl ssessment of physicins brest-feeding knowledge, ttitudes, trining, nd experience. JAMA. 1995; 273(6):472 476 5. Wlton DM, Edwrds MC. Ntionwide survey of peditric residency trining in newborn medicine: preprtion for primry cre prctice. Peditrics. 2002;110(6): 1081 1087 6. Schnler RJ, O Connor KG, Lwrence RA. Peditricins prctices nd ttitudes regrding brestfeeding promotion. Peditrics. 1999;103(3). Avilble t: www.peditrics. org/cgi/content/full/103/3/e35 7. Feldmn-Winter LB, Schnler RJ, O Connor KG, Lwrence RA. Peditricins nd the promotion nd support of brestfeeding. Arch Peditr Adolesc Med. 2008;162(12): 1142 1149 8. Lu MC, Lnge L, Slusser W, Hmilton J, Hlfon N. Provider encourgement of brest- MD; Medicl College of Georgi, Kthryn McLeod, MD; Medicl University of South Crolin, Crol Wgner, MD, nd Allyson Chmbers, MD; MetroHelth Medicl Center, Susn Sntos, MD, nd Tr Willims, MD; St Louis University School of Medicine, Shhid Nseer, MD; Texs Tech University Helth Science Center, Amrillo, Fred McCurdy, MD, PhD, nd Thoms Hle, PhD; Texs Tech University Helth Science Center, El Pso, Rlist Akins, MD, nd Ines Anchondo, PhD; nd University of Minnesot Medicl School, Phillip Ruk, MD; nd White Memoril Medicl Center, Ernie Guzmn, MD. Other contributors to the curriculum not listed s uthors of this rticle include Tony Ogburn, MD, FACOG; My Bunik, MD, FAAP; Susn Lnders, MD, FAAP; Anne Eglsh, MD, FAAFP; Susn Bostwick, MD, FAAP; Susn Brunsell, MD, FAAP; Eve Espey, MD, FACOG; Lourdes Foster, MD, FACOG; Libby Hinemn, MD; Mrynn O Hr, MD, FAAFP; Jnine Rethy, MD; DeShont Springs, MD; Wendy Slusser, MD, FAAP; King Szucs, MD, FAAP; Michl Young, MD, FAAP; Rebecc Rmsey, MPH; nd Betty Crse, IBCLC. feeding: evidence from ntionl survey. Obstet Gynecol. 2001;97(2):290 295 9. Tvers EM, Cpr AM, Brvemn PA, Jensvold NG, Escobr GJ, Lieu TA. Clinicin support nd psychosocil risk fctors ssocited with brestfeeding discontinution. Peditrics. 2003;112(1 pt 1):108 115 10. Tvers EM, Li R, Grummer-Strwn L, et l. Opinions nd prctices of clinicins ssocited with continution of exclusive brestfeeding. Peditrics. 2004;113(4). Avilble t: www.peditrics.org/cgi/content/full/ 113/4/e283 11. Bunik M, Go D, Moore L. An investigtion of the field trip model s method for teching brestfeeding to peditric residents. J Hum Lct. 2006;22(2):195 202 12. Ogburn T, Espey E, Leemn L, Alvrez K. A brestfeeding curriculum for residents nd medicl students: multidisciplinry pproch. J Hum Lct. 2005;21(4):458 464 296 FELDMAN-WINTER et l
ARTICLES 13. World Helth Orgniztion/United Ntions Children s Fund. Ten Steps to Successful Brestfeeding. New York, NY: United Ntions Children s Fund; 2004. Avilble t: www. unicef.org/newsline/tenstps.htm. Accessed My 13, 2010 14. Acdemy of Brestfeeding Medicine. Wht every physicin needs to know bout brestfeeding [pre-conference course progrm]. Presented t: 14th nnul interntionl meeting of the Acdemy of Brestfeeding Medicine; November 5, 2009; Willimsburg, VA 15. DiGirolmo AM, Grummer-Strwn LM, Fein SB. Effect of mternity-cre prctices on brestfeeding. Peditrics. 2008;122(suppl 2):S43 S49 16. Centers for Disese Control nd Prevention. Brestfeeding Among U.S. Children Born 1999 2006, CDC Ntionl Immuniztion Survey. Atlnt, GA: US Deprtment of Helth nd Humn Services, Centers for Disese Control nd Prevention; 2006. Avilble t: www.cdc.gov/brestfeeding/dt/nis dt. Accessed My 9, 2010 17. Rogers EM. Diffusion of Innovtions. 5th ed. New York, NY: Free Press; 2003 Wht Will Be the Second Disese Eliminted Worldwide fter Smllpox nd Not Require Vccine? Guine Worms!: It is hrd to believe tht qurter century go, there were 3.5 million cses of guine worm reported in 20 countries nd now there re fewer thn 3200 cses in four countries. According to n rticle in The New York Times (Kristof ND, April 28, 2010), thnks to efforts sper-heded by former President Jimmy Crter, the cses of Guine worms now remin only in Sudn (primrily) nd in Ethiopi, Ghn nd Mli. This prsite, which grows up to yrd long inside the body nd eventully pokes out of the skin with burning pin, is propgted when lrv from the open skin where the worm hs burrowed re deposited in unclen wter tht others then drink. Tretment involves keeping those with guine worm out of wter cmpign tht hs been successful, not becuse of vccine or medicine, but due to behviorl chnge becuse villgers themselves volunteer to inspect other villgers for signs of blister suggestive of the worm nd then keep n infected person out of the wter while the worm is pulled out slowly n inch or two dy. Former President Crter, ge 85, hs stted tht he is determined to outlive the Guine worm nd recently stted, If I cn survive two more yers, I ll meet my gol. He is certinly close! Noted by JFL, MD PEDIATRICS Volume 126, Number 2, August 2010 297
Residency Curriculum Improves Brestfeeding Cre Lori Feldmn-Winter, Luren Brone, Brry Milcrek, Krystl Hunter, Jon Meek, Jne Morton, Tr Willims, Audrey Nylor nd Ruth A. Lwrence Peditrics 2010;126;289-297; originlly published online Jul 5, 2010; DOI: 10.1542/peds.2009-3250 Updted Informtion & Services References including high-resolution figures, cn be found t: http://www.peditrics.org/cgi/content/full/126/2/289 This rticle cites 9 rticles, 7 of which you cn ccess for free t: Post-Publiction Peer Reviews (P 3 Rs) Permissions & Licensing Reprints http://www.peditrics.org/cgi/content/full/126/2/289#bibl One P 3 R hs been posted to this rticle: http://www.peditrics.org/cgi/eletters/126/2/289 Informtion bout reproducing this rticle in prts (figures, tbles) or in its entirety cn be found online t: http://www.peditrics.org/misc/permissions.shtml Informtion bout ordering reprints cn be found online: http://www.peditrics.org/misc/reprints.shtml