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Journal of Human Lactation
1 –12
© The Author(s) 2015
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DOI: 10.1177/0890334415618668
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Review
Background
As the benefits of breastfeeding to mothers and infants are
well known, improving breastfeeding initiation rates and
maintenance has become a universal objective. Several
countries have conducted literature reviews to summarize
the evidence on effective and ineffective interventions. There
is generally a high level of consistency in the findings. Public
policy makers for Australia,1 Canada,2 the United Kingdom,3
the United States,4 and the European Union5 have all
reviewed the literature on breastfeeding interventions and
reported on what appear to be effective breastfeeding strate-
gies. Breastfeeding interventions presently being used to
improve breastfeeding outcomes include the use of policies
or guidelines, the distribution of written materials, the adop-
tion of government or World Health Organization (WHO)
initiatives, or the use of structured counseling, education, or
support programs.6 Interventions may be stand-alone or part
of a multicomponent program, can be implemented by a
variety of providers, and can be delivered in a variety of
settings.6
Systematic reviews have shown that various breastfeed-
ing education and support interventions increase breastfeed-
ing initiation, duration, and incidence. However, it is not
clear which type of health professional is the most effective
in providing breastfeeding education and support. Physicians
are not often adequately prepared for their role in breastfeed-
ing management.7 Similarly, nurses have reported breast-
feeding training and management as lacking in their
education programs.8 Dedicated certified lactation special-
ists, International Board Certified Lactation Consultants
618668JHLXXX10.1177/0890334415618668Journal of Human LactationPatel and Patel
research-article2015
1Duke Primary Care Wake Forest, Duke University Health Systems,
Durham, NC, USA
2Wake County Human Services, Care Coordination for Children,
Northern Regional Centre, Wake Forest, NC, USA
Date submitted: January 14, 2015; Date accepted: October 23, 2015.
Corresponding Author:
Sanjay Patel, MD, Duke Primary Care Wake Forest, 11635 Northpark
Drive, Building 1, Suite 200, Wake Forest, NC 27587, USA.
Email: Sanjay.Patel@duke.edu
The Effectiveness of Lactation
Consultants and Lactation Counselors
on Breastfeeding Outcomes
Sanjay Patel, MD1 and Shveta Patel, RN, BSN, IBCLC2
Abstract
Breastfeeding for all infants starting at birth and continuing until at least 6 months of age has been recommended by the
World Health Organization and the American Academy of Pediatrics. The health benefits to infants and mothers have
been demonstrated in many studies. Dedicated lactation specialists may play a role in providing education and support to
pregnant women and new mothers wishing to breastfeed to improve breastfeeding outcomes. The objective of this review
was to assess if lactation education or support programs using lactation consultants or lactation counselors would improve
rates of initiation and duration of any breastfeeding and exclusive breastfeeding compared with usual practice. A systematic
literature review of the evidence was conducted using electronic databases. The review was limited to randomized trials
and yielded 16 studies with 5084 participants. It was found that breastfeeding interventions using lactation consultants
and counselors increase the number of women initiating breastfeeding (odds ratio [OR] for any initiation vs not initiating
breastfeeding = 1.35; 95% confidence interval [CI], 1.10-1.67). The interventions improve any breastfeeding rates (OR for
any breastfeeding up to 1 month vs not breastfeeding = 1.49; 95% CI, 1.09-2.04). In addition, there were beneficial effects
on exclusive breastfeeding rates (OR for exclusive breastfeeding up to 1 month vs not exclusive breastfeeding = 1.71; 95%
CI, 1.20-2.44). Most of the evidence would suggest developing and improving postpartum support programs incorporating
lactation consultants and lactation counselors.
Keywords
breastfeeding, consultant, duration, initiation, outcomes, support
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2 Journal of Human Lactation
(IBCLCs), and Certified Lactation Counselors (CLCs) may
be better prepared to provide support and education to preg-
nant women and new mothers wishing to breastfeed.
Integrating these specialists in breastfeeding support pro-
grams could improve breastfeeding outcomes to meet the
goals set forth by the US Department of Health and Human
Services through the national health initiative, Healthy
People 2020.9
Lactation consultants and lactation counselors commonly
intervene by providing antenatal education and postnatal
support. Breastfeeding education is disseminated during
pregnancy using defined, goal-oriented programs, whereas
support is usually aimed at the individual mother as the need
arises.10 The primary focus of support is on counseling,
encouragement, and management of lactation crises for nurs-
ing families in order to meet their breastfeeding goals.6
Support involves managing different lactation problems such
as latch and positioning of the infant or counseling mothers
returning to work or school.6 Support can be psychological,
physical, financial, or informational.10 Support sometimes is
given prenatally and can be very helpful in addressing indi-
vidual women’s barriers to breastfeeding.6 Finally, support is
particularly critical in the first few weeks after delivery,
when lactation is being established.6
Past systematic reviews on breastfeeding support have
examined the overall effect of breastfeeding interventions on
breastfeeding initiation and duration, exclusive or any breast-
feeding incidence, and infant or maternal health out-
comes.11-14 However, the reviews did not specifically
evaluate the effects of lactation consultants or counselors on
breastfeeding outcomes.
A 2008 systematic review of 5 studies investigated the
effects of IBCLCs on breastfeeding success. However, the
quality of this review was limited by the inclusion of only 2
randomized controlled trials, low sample sizes, and varied
outcome measurements. Positive correlations between
breastfeeding duration and use of IBCLCs were noted. No
meta-analysis was done.15
Since 2008, there have been several randomized studies
published involving lactation consultants and counselors.
This review will look at only randomized trials involving
lactation consultants or counselors providing antenatal edu-
cation, postpartum support, or both. This information could
help policy makers in health systems and public health
departments make decisions on whether to incorporate these
professionals in their breastfeeding support programs, thus
enabling better allocation of health care dollars.
Methods
Criteria for Considering Studies for This Review
Types of studies. We considered all randomized controlled
trials (RCTs) with or without blinding and cluster random-
ized controlled trials (cRCTs) undertaken between January
1985 and January 2014. Only English language studies con-
ducted in developed countries were included.
Types of interventions. We included studies that looked at the
use of IBCLCs, CLCs, lactation consultants, or lactation coun-
selors to affect breastfeeding outcomes (Table 1). Relevant
studies were those looking at the use of these professionals in
breastfeeding programs that intervene through counseling,
structured education, or support for the maternal–infant unit as
well as the health care team or system providing the breast-
feeding support. Interventions were stand-alone or part of a
multicomponent structured program. Interventions took place
antenatal, intrapartum, or postpartum. The comparator groups
were as defined within the individual studies. This could mean
interventions run by midwives, nurses, physicians, or peer
counselors, or it could mean no intervention program at all.
Types of outcome measures. Studies were included in the review
if they reported any of the following primary outcomes: breast-
feeding initiation rates, breastfeeding duration, any breastfeed-
ing rates, and exclusive breastfeeding rates. In addition, studies
were included if they reported any of the following secondary
outcomes: infant health outcomes, maternal health outcomes.
Search Methods for Identification of Studies
The primary reviewer searched the following databases to
identify potentially relevant citations for this review: Cochrane
Library, EMBASE, CINAHL, Medline, ClinicalTrials.gov.
Data Extraction and Management
The primary reviewer abstracted and collected data using a data
extraction form that was modified from the Joanna Briggs
Institute Data Extraction Form for Experimental and Obser-
vational Studies.18 All data were entered into RevMan 5.19
Assessment of Risk of Bias in Included Studies
The primary and secondary reviewers independently assessed
the studies for methodological quality using the study quality
form that was developed using criteria recommended by the
Cochrane Effective Practice and Organisation of Care.20
Domains of bias assessed included allocation sequence gen-
eration, allocation concealment, baseline outcome measure-
ments, baseline characteristics, incomplete data assessment,
knowledge of the intervention(s) during the study, contami-
nation bias, selective outcome bias, and other risk of bias.
Data Synthesis and Analysis
For all outcomes, as far as possible, analysis was carried with
intention to treat. The denominator for each outcome was the
number of participants randomized. The assumption was that all
women who were lost to follow up had stopped breastfeeding.
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Patel and Patel 3
Statistical heterogeneity was assessed and quantified
using the Tau², I², and Chi² statistics.
Data for incidence (breastfeeding rates) were grouped
into categories of up to 1 month, > 1 month up to 3 months,
and > 3 months up to 6 months. Statistical analysis was done
using RevMan 5.19
Possible sources for methodological heterogeneity such
as trial design, attrition, knowledge of the intervention(s),
whether support was given face-to-face versus by phone, and
type of intervention (education vs only support) were
explored with sensitivity analyses. Levels of attrition were
defined as follows: a loss to follow up of ≤ 5% was consid-
ered a low-level threat to validity, whereas a loss of ≥ 20%
was considered a serious threat, and in-between rates were
considered an intermediate threat.21
Results
Results of the Search
The literature search resulted in 44 full text reports being
assessed (Figure 1). Two publications reported data from
multiple trials. One trial resulted in multiple publications.
The net search result corresponded with 16 separate studies.
Fourteen of the studies contributed outcome data for this
review. There were 5084 participants from 7 countries
(Australia, Canada, Denmark, the United Kingdom,
Malaysia, Singapore, and the United States) contributing to
the data. All studies were conducted between 1985 and
January 2014 with 7 studies done after the 2008 systematic
review15 that focused specifically on lactation consultants.
The size of the studies ranged from 50 participants to 1312
participants. Of the 16 studies, 15 studies were conducted
from individually RCTs and 1 study was from a cRCT. The
studies included in the review varied with respect to country
of origin, urban–rural setting classification, ethnicity, income
status, and risk status (Table 2).
The studies were of mixed methodological quality. The
risk of bias for studies is summarized for each bias domain in
Figure 2.
Effects of Interventions
Primary outcomes
Breastfeeding initiation rates. In the meta-analysis for the
any breastfeeding initiation outcome, interventions involv-
ing lactation consultants and counselors demonstrated a
beneficial effect in increasing any breastfeeding initia-
tion. The odds ratio for any initiation versus not initiat-
ing breastfeeding was 1.35 with a 95% confidence interval
(CI) of 1.10 to 1.67. There was no substantial heterogene-
ity and sensitivity analyses demonstrated beneficial treat-
ment effects (Figure 3).
Breastfeeding duration. Breastfeeding duration was exam-
ined in this review. Five studies reported median duration for
any breastfeeding. Two studies reported median duration for
exclusive breastfeeding. Three studies reported mean dura-
tion for any breastfeeding and 1 study reported mean dura-
tion for exclusive breastfeeding. The interventions involving
lactation consultants and counselors to increase any breast-
feeding and exclusive breastfeeding duration appear to have
a beneficial effect with increased median and mean duration.
Meta-analysis was not done because of paucity of studies
reporting mean duration.
Any breastfeeding rates. Interventions involving lactation
consultants and counselors to increase any breastfeeding
Table 1. Intervention Definitions Used in Search for Studies.
Intervention Intervention Definition
International Board Certified
Lactation Consultants
(IBCLC)
The study specified that lactation consultants in the trial were certified through the
International Board of Lactation Consultant Examiners (IBLCE), which was established
in 1985. Lactation consultants obtain certification through the IBLCE by demonstrating
clinical competence and satisfying the certification exam. Recertification is obtained by
fulfilling continuing education requirements every 5 years and by examination every
10 years. Both health care professionals as well as nonprofessionals can be trained to
be lactation consultants. Community centers and hospitals can employ consultants for
inpatient as well as outpatient settings. IBCLCs can work independently.16
Lactation consultants The study did not specify that the lactation consultants were certified through the IBLCE.
Certified Lactation
Counselors (CLC)
The study specified that CLCs in the trial received training and competency certification
in breastfeeding and human lactation support through various agencies. The training
involves 45 hours of didactic and experiential activities during a 5-day course along with
satisfying an assessment test. Recertification is every 3 years by completing 18 hours
of required continuing education in breastfeeding and human lactation. Much like the
IBCLC, the CLC works in a variety of health care settings to provide counseling and
support to breastfeeding infants, children, and their mothers.17
Lactation counselors The study did not specify that the lactation counselors in the trial received formal training
and certification through an overseeing agency.
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4 Journal of Human Lactation
rates up to 1 month, between 1 month and up to 3 months,
and between 3 months and up to 6 months were evaluated.
The interventions appear to have a beneficial effect on rates
up to 1 month with the odds ratio for any breastfeeding ver-
sus not breastfeeding being 1.49 with a 95% CI of 1.09 to
2.04. However, there was substantial heterogeneity for this
outcome, and the true effect size could vary depending on
the setting. Results should therefore be interpreted with some
caution. Sensitivity analyses demonstrated beneficial treat-
ment effects (Figure 4).
In the meta-analysis for breastfeeding between 1 month and
up to 3 months, beneficial treatment effects were seen with the
odds ratio for any breastfeeding versus not breastfeeding being
1.76 with a 95% CI of 1.20 to 2.57. Again, there was substantial
heterogeneity for this outcome. Sensitivity analyses demon-
strated beneficial treatment effects (Figure 5).
In the meta-analysis for any breastfeeding between 3
months and up to 6 months, beneficial effects were again
demonstrated. The odds ratio of any breastfeeding versus not
breastfeeding was 1.29 with a 95% CI of 1.05 to 1.58 with no
substantial heterogeneity. Sensitivity analyses also demon-
strated beneficial treatment effects (Figure 6).
Exclusive breastfeeding rates. The effects of the interven-
tions on exclusive breastfeeding rates were also reported.
For exclusive breastfeeding up to 1 month, the odds ratio of
exclusive breastfeeding versus not exclusive breastfeeding
was 1.71 with a 95% CI of 1.20 to 2.44. There was substan-
tial heterogeneity for this outcome but sensitivity analyses
demonstrated beneficial treatment effects (Figure 7).
For exclusive breastfeeding between 1 month and up to 3
months, the interventions also appeared to have a beneficial
effect with the odds ratio of exclusive breastfeeding versus
not exclusive breastfeeding being 1.80 with a 95% CI of 1.14
to 2.83. Again, there was substantial heterogeneity for this
outcome but sensitivity analyses demonstrated beneficial
treatment effects (Figure 8).
Finally, in the meta-analysis for breastfeeding rates between
3 months and up to 6 months, there was no statistical effect on
the number of women engaging in exclusive breastfeeding. The
odds ratio of exclusive breastfeeding versus not exclusive
breastfeeding was 1.17 with a 95% CI of 0.82 to 1.67 (Figure 9).
Secondary outcomes
Infant health outcomes. One study reported infant health
outcomes. Infant health care uses for symptoms of breastfeed-
ing-sensitive illnesses (otitis media, respiratory tract illness,
and gastrointestinal illness) were evaluated. In this study, it
appears that interventions involving lactation consultants and
counselors have no statistical effect on reducing sick outpa-
tient or emergency room visits for these illnesses.
Maternal health outcomes. One study reported mater-
nal health outcomes. The interventions involving lactation
consultants showed statistically significant improvement in
LATCH scores (a measure of breastfeeding success), nipple
pain, and nipple trauma when compared with usual care. The
interventions did not decrease the incidence of mastitis.
Discussion
Summary of Main Results
Overall, the results were consistent and provide evidence for
the use of lactation consultants and lactation counselors in
health systems and local communities. Breastfeeding sup-
port interventions using these professionals increased the
number of women initiating breastfeeding, improved any
Figure 1. Study Eligibility Flow Chart.
Abbreviation: RCT, randomized controlled trial.
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Patel and Patel 5
Table 2. Study Characteristics.
Study
Country;
Urban vs
Rural
No. of
Participants Type of Study
Ethnicity; Income
Status; Risk Status Outcome
Bonuck 2006,
200522,23
United States;
urban
382 Randomized
controlled trial
A majority of the
participants were African
American or Hispanic;
low income
Any breastfeeding, exclusive
breastfeeding, infant
outcomes
Bonuck 201424 United States;
urban
666 Randomized
controlled trial
A majority of the
participants were African
American or Hispanic;
low income
Any breastfeeding, exclusive
breastfeeding
Bonuck 201424 United States;
urban
275 Randomized
controlled trial
A majority of the
participants were African
American or Hispanic
Any breastfeeding, exclusive
breastfeeding
Brent 199525 United States;
urban
115 Randomized
controlled trial
A majority of the
participants were white;
low income
Any breastfeeding initiation,
breastfeeding duration, any
breastfeeding rates
Carlsen 201326 Denmark 226 Randomized
controlled trial
Obese women Breastfeeding duration, any
breastfeeding, exclusive
breastfeeding
Duffy 199727 Australia; urban 75 Randomized
controlled trial
Low income Maternal outcomes
Lavender 200528 United
Kingdom;
urban
1312 Cluster randomized
controlled trial
A majority of the
participants were white
Any breastfeeding initiation,
any breastfeeding, exclusive
breastfeeding; review
included breastfeeding
initiation rates, any
breastfeeding, and exclusive
breastfeeding data only
Mattar 200729 Singapore;
urban
401 Randomized
controlled trial
A majority of the
participants were Malay,
Chinese, or Indian; low
income
Exclusive and predominant
breastfeeding; data for
only any or exclusive
breastfeeding not reported;
data from this study not
included in review
McKeever 200230 Canada 101 Randomized
controlled trial
A majority of the
participants were white;
middle income
Exclusive breastfeeding;
data from this study not
included in the review;
exclusive breastfeeding
expressed as proportion of
baby’s feeds in the past 24
hours that were exclusively
breastfeeding and % of
mothers who used no
supplementation in past 24
hours
Petrova 200931 United States;
urban
104 Randomized
controlled trial
A majority of the
participants were African
American or Hispanic;
low income
Any breastfeeding, exclusive
breastfeeding
Pinelli 200132 Canada 128 Randomized
controlled trial
A majority of the
participants were white;
high income; mothers of
infants with a birth weight
of less than 1500 g who
planned to breastfeed
Breastfeeding duration,
breastfeeding exclusivity;
only breastfeeding duration
data included in review
(continued)
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6 Journal of Human Lactation
breastfeeding rates, and improved exclusive breastfeeding
rates (Figure 10). The size of the treatment effects varied
considerably in the different trials and average treatment
effects may not be applicable in different settings.
There was diversity in terms of how the lactation consul-
tants and lactation counselors were used in the interventions.
Some studies evaluated the effects of prenatal education
interventions whereas others looked at support interventions
with or without education. Studies looked at support inter-
ventions that were delivered face-to-face or by phone. All of
these factors could have contributed to heterogeneity.
Sensitivity analysis explored some of the issues with hetero-
geneity, and the beneficial effects of the interventions on
breastfeeding initiation, any breastfeeding rates, and exclu-
sive breastfeeding rates remained.
The overall evidence for intervention effects on breast-
feeding duration, infant health outcomes, and maternal health
outcomes in this review was too limited to draw any conclu-
sions or generalizations. Five studies reported either median
or mean duration of any breastfeeding or exclusive breast-
feeding. The interventions appear to have a beneficial effect
with increased median and mean duration reported in the
studies. A meta-analysis was not done because of paucity of
studies reporting mean duration.
One randomized trial reported infant health outcomes.
The interventions did not positively or negatively affect
infant health care use for symptoms of breastfeeding-sensi-
tive illnesses.
Finally, only 1 randomized trial reported maternal health
outcomes. There was some evidence for intervention bene-
fits on maternal health outcomes with improved LATCH
scores, decreased nipple pain, and nipple trauma. However,
the interventions did not affect the incidence of mastitis.
Overall Completeness and Applicability of
Evidence
Although the studies in the review were from 7 different
countries, all were from countries with very high human
development or high human development.38 This may
affect its applicability in less developed countries. Racial/
ethnic groups varied with participants being Malay,
Chinese, Indian, African American, or white. Most study
participants were recruited from low-income populations,
were done in urban areas, and were set in medical centers
or university hospital clinics. This, again, could affect the
applicability of the findings in more rural, nonhospital-
based clinics.
Study
Country;
Urban vs
Rural
No. of
Participants Type of Study
Ethnicity; Income
Status; Risk Status Outcome
Rasmussen
201133
United States;
rural
50 Randomized
controlled trial
Low income; obese women Breastfeeding initiation,
breastfeeding duration, any
breastfeeding, exclusive
breastfeeding
Serafino-Cross
199234
United States;
urban
52 Randomized
controlled trial
Low income Any breastfeeding
Su 200735 Singapore;
urban
450 Randomized
controlled trial
A majority of the
participants were Malay,
Chinese, or Indian; low
income
Any breastfeeding initiation,
exclusive breastfeeding
initiation, any breastfeeding,
exclusive breastfeeding
Tahir 201336 Malaysia; urban 357 Randomized
controlled trial
A majority of the
participants were Malay,
Chinese, or Indian; low
income
Any breastfeeding, exclusive
breastfeeding
Wambach 201137 United States;
urban
390 Randomized
controlled trial
A majority of the
participants were African
American or Hispanic;
low income
Breastfeeding duration, any
breastfeeding, exclusive
breastfeeding
Table 2. (continued)
Figure 2. Risk of Bias Graph.
Review authors’ judgments about each risk of bias item presented as
percentages across all included studies.
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Patel and Patel 7
Figure 3. Any Breastfeeding Initiation, Sensitivity Analysis.
Group
Experimental
n/N
Control
n/N OR, 95% CI; Heterogeneity
Excluding studies that were not individual
randomized controlled trials
668/804 421/577 1.60, 1.19-2.15; Tau² = 0.00, Chi² = 3.83, df = 5 (P = .57), I² = 0%
Excluding studies deemed high risk of bias
for attrition
1089/1330 800/1051 1.38, 1.04-1.83; Tau² = 0.02, Chi² = 4.94, df = 4 (P = .29), I² = 19%
Excluding studies with high risk of bias for
knowledge of the intervention
1154/1425 866/1153 1.28, 1.05-1.56; Tau² = 0.00, Chi² = 3.55, df = 5 (P = .62), I² = 0%
Excluding studies involving only antenatal
education interventions
668/804 421/527 1.60, 1.19-2.15; Tau² = 0.00, Chi² = 3.83, df = 5 (P = .57), I² = 0%
Excluding studies not including face-to-face
support as part of the intervention
668/804 421/527 1.60, 1.19-2.15; Tau² = 0.00, Chi² = 3.83, df = 5 (P = .57), I² = 0%
Abbreviations: CI, confidence interval; OR, odds ratio.
Figure 4. Any Breastfeeding up to 1 Month, Sensitivity Analysis.
Group
Experimental
n/N Control n/N OR, 95% CI; Heterogeneity
Excluding studies that were not individual
randomized controlled trials
780/1043 543/815 1.63, 1.17-2.26; Tau² = 0.09, Chi² = 11.53, df = 6 (P = .07), I² = 48%
Excluding studies deemed high risk of bias
for attrition
1023/1509 766/1229 1.58, 1.11-2.24; Tau² = 0.11, Chi² = 13.81, df = 5 (P = .02), I² = 64%
Excluding studies with high risk of bias for
knowledge of the intervention
1012/1476 774/1179 1.32, 0.94-1.87; Tau² = 0.10, Chi² = 12.32, df = 5 (P = .03), I² = 59%
Excluding studies involving only antenatal
education interventions
780/1043 543/815 1.63, 1.17-2.26; Tau² = 0.09, Chi² = 11.53, df = 6 (P = .07), I² = 48%
Excluding studies not including face-to-face
support as part of the intervention
621/864 393/637 1.64, 1.11-2.43; Tau² = 0.12, Chi² = 11.36, df = 5 (P = .04), I² = 56%
Abbreviations: CI, confidence interval; OR, odds ratio.
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8 Journal of Human Lactation
Figure 5. Any Breastfeeding > 1 Month and up to 3 Months, Sensitivity Analysis.
Group
Experimental
n/N
Control
n/N OR, 95% CI; Heterogeneity
Excluding studies that were not
individual randomized controlled trials
491/979 276/753 1.94, 1.24-3.02; Tau² = 0.31, Chi² = 30.66, df = 8 (P = .0002), I² = 74%
Excluding studies deemed high risk of
bias for attrition
694/1367 462/1089 2.20, 1.29-3.73; Tau² = 0.33, Chi² = 32.02, df = 5 (P < .0001), I² = 84%
Excluding studies with high risk of bias
for knowledge of the intervention
709/1386 493/1109 1.59, 1.00-2.53; Tau² = 0.28, Chi² = 30.82, df = 6 (P < .0001), I² = 81%
Excluding studies involving only antenatal
education interventions
459/942 266/715 1.60, 1.14-2.23; Tau² = 0.11, Chi² = 14.88, df = 7 (P = .04), I² = 53%
Excluding studies not including
face-to-face support as part of the
intervention
459/942 266/715 1.60, 1.14-2.23; Tau² = 0.11, Chi² = 14.88, df = 7 (P = .04), I² = 53%
Abbreviations: CI, confidence interval; OR, odds ratio.
Figure 6. Any Breastfeeding > 3 Months up to 6 Months, Sensitivity Analysis.
Group
Experimental
N
Control
N OR, 95% CI; Heterogeneity
Excluding studies that were not individual
randomized controlled trials
1126 908 1.45, 1.18-1.78; Tau² = 0.00, Chi² = 2.79, df = 6 (P = .83), I² = 0%
Excluding studies deemed high risk of bias
for attrition
1617 1347 1.32, 1.04-1.68; Tau² = 0.04, Chi² = 9.35, df = 6 (P = .15), I² = 36%
Excluding studies with high risk of bias for
knowledge of the intervention
1559 1290 1.32, 1.02-1.70; Tau² = 0.04, Chi² = 8.98, df = 5 (P = .11), I² = 44%
Excluding studies involving only antenatal
education interventions
1126 908 1.45, 1.18-1.78; Tau² = 0.00, Chi² = 2.79, df = 6 (P = .83), I² = 0%
Excluding studies not including face-to-face
support as part of the intervention
839 612 1.41, 1.10-1.81; Tau² = 0.00, Chi² = 1.87, df = 4 (P = .76), I² = 0%
Abbreviations: CI, confidence interval; OR, odds ratio.
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Patel and Patel 9
Figure 7. Exclusive Breastfeeding up to 1 Month, Sensitivity Analysis.
Group
Experimental
N
Control
N OR, 95% CI; Heterogeneity
Excluding studies deemed high risk of bias
for attrition
880 657 2.15, 1.60-2.88; Tau² = 0.02, Chi² = 4.70, df = 4 (P = .32), I² = 15%
Excluding studies with high risk of bias for
knowledge of the intervention
957 734 1.90, 1.34-2.70; Tau² = 0.09, Chi² = 10.50, df = 6 (P = .10), I² = 43%
Excluding studies not including face-to-face
support as part of the intervention
858 632 1.56, 0.94-2.58; Tau² = 0.24, Chi² = 13.22, df = 5 (P = .02), I² = 62%
Abbreviations: CI, confidence interval; OR, odds ratio.
Figure 8. Exclusive Breastfeeding > 1 Month up to 3 Months, Sensitivity Analysis.
Group
Experimental
N
Control
N OR, 95% CI; Heterogeneity
Excluding studies deemed high risk of bias for
attrition
701 479 2.27, 1.58-3.27; Tau² = 0.00, Chi² = 1.32, df = 3 (P = .72), I² = 0%
Excluding studies with high risk of bias for
knowledge of the intervention
753 531 2.19, 1.54-3.11; Tau² = 0.00, Chi² = 1.95, df = 4 (P = .74), I² = 0%
Excluding studies not having face-to-face
support as part of the intervention
833 607 1.71, 0.93-3.13; Tau² = 0.23, Chi² = 8.13, df = 4 (P = .09), I² = 51%
Abbreviations: CI, confidence interval; OR, odds ratio.
Quality of the Evidence
More than half of the trials used methods to generate random
sequencing and randomly allocated participants to experi-
mental and control groups that were judged to be at low risk
of bias. The majority of the trials described similar baseline
characteristics for the control and intervention groups and
were felt to be low risk of bias for that domain.
The rates of attrition varied from study to study, and with
use of intention to treat, the effect estimate may have been
diluted. Nevertheless, sensitivity analysis, excluding studies
with high attrition rates, demonstrated beneficial effects of
the interventions on any breastfeeding initiation, any breast-
feeding, and exclusive breastfeeding.
The risk of bias from inadequate blinding and contami-
nation was unclear in most studies. It would be difficult to
blind participants or those providing care because of the
nature of the intervention. Blinding of outcome assessors,
however, would be important. Five studies did not blind
outcome assessors and were deemed high risk of bias.
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10 Journal of Human Lactation
Figure 9. Exclusive Breastfeeding > 3 Months up to 6 Months, Sensitivity Analysis.
Group
Experimental
N
Control
N OR, 95% CI; Heterogeneity
Excluding studies that were not individual
randomized controlled trials
960 733 1.19, 0.71-1.99; Tau² = 0.07, Chi² = 5.01, df = 4 (P = .29), I² = 20%
Excluding studies deemed high risk of bias
for attrition
1451 1172 1.30, 0.89-1.88; Tau² = 0.00, Chi² = 2.64, df = 4 (P = .62), I² = 0%
Excluding studies with high risk of bias for
knowledge of the intervention
1451 1172 1.30, 0.89-1.88; Tau² = 0.00, Chi² = 2.64, df = 4 (P = .62), I² = 0%
Excluding studies involving only antenatal
education interventions
960 733 1.19, 0.71-1.99; Tau² = 0.07, Chi² = 5.01, df = 4 (P = .29), I² = 20%
Excluding studies not having face-to-face
support as part of the intervention
781 555 1.23, 0.56-2.73; Tau² = 0.24, Chi² = 4.73, df = 3 (P = .19), I² = 37%
Abbreviations: CI, confidence interval; OR, odds ratio.
Sensitivity analysis, excluding studies deemed high risk of
bias for knowledge of the intervention, demonstrated ben-
eficial effects of the interventions on any breastfeeding ini-
tiation, any breastfeeding, and exclusive breastfeeding.
Potential Biases and Limitations
The review process itself may introduce bias. Two reviewers
independently assessed the studies for inclusion using inclusion
criteria and risk of bias. However, because of circumstances,
only 1 reviewer carried out data extraction, which could have
introduced some bias. The review may have some limitations as
heterogeneity secondary to the type of intervention and inter-
vention fidelity were not explored.
Agreements and Disagreements with Other
Studies or Reviews
These findings are similar to previous reviews on breastfeed-
ing support. The 2012 review14 demonstrated that all forms of
support showed a positive correlation between support from
professionals, trained lay people, or both, and breastfeeding
duration. The 2008 systematic review15 specifically looked at
breastfeeding support from IBCLCs. It suggested a positive
correlation between IBCLC use and breastfeeding duration.
This review adds 15 randomized controlled trials and did not
include the nonrandomized studies reported in the Thurman
study. It further supports the use of breastfeeding interven-
tions using lactation consultants and counselors.
Conclusion
Implications for Practice
Health care settings serving low-income populations should
consider the use of lactation consultants and lactation coun-
selors in their breastfeeding education and support programs.
The evidence would suggest developing and improving
intrapartum and postpartum support programs that can be
delivered face-to-face in the hospital, in the clinic, and at
home, or via telephone contact. There is some evidence that
antenatal education may also improve maternal health out-
comes. Breastfeeding initiation, any breastfeeding rates, and
exclusive breastfeeding rates are positively affected by the
use of these professionals.
Implications for Research
This review has highlighted other areas that need to be
researched. Trials to determine the optimal timing and fre-
quency of support as well as assess the effects of use of
lactation consultants and lactation counselors in high-risk
populations, such as infants in the neonatal intensive care
unit, should be undertaken. Early support intervention may
be critical in establishing adequate milk supply and ulti-
mately increasing breastfeeding duration. High-risk infants
are vulnerable to stopping breastfeeding and may require
different types of support and education modalities.
Trials are needed to investigate whether home visits or
video/phone contacts would be the best way to use lactation
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Patel and Patel 11
consultants and lactation counselors. This would be important
in rural health settings and may be a more cost-effective way
to deliver the intervention to a larger number of participants.
Trials should explore how lactation consultants and lac-
tation counselors could use their skills in improving mater-
nal and health care staff satisfaction; how they could work
in collaboration with existing support personnel such as
peer counselors, staff physicians, and nurses; and whether
specific education interventions delivered by these profes-
sionals to health system staff affect the evidence-based
knowledge being implemented and, ultimately, breastfeed-
ing outcomes.
Finally, more research is needed to evaluate the economic
impact and cost-effectiveness of use of lactation consultants
and lactation counselors to health systems.
Acknowledgments
Dr Sanjay Patel would like to acknowledge Dr Sharon Mickan, his
University of Oxford supervisor, for her guidance and assistance in
undertaking and completing this project.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
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