Wednesday, August 31, 2011

Convincing new mothers that "breast is best"

A recent report from the Centers for Disease Control and Prevention found that despite evidence that birthing environments strongly influence new mothers' feeding practices, only 3.5 percent of surveyed U.S. hospitals met most quality indicators of the Baby-Friendly Hospital Initiative, an international program that seeks to reduce obstacles to successful breastfeeding. Hospitals received low marks on items such as restricting pacifier use and supplemental infant formula, and only a minority permitted 24-hour "rooming in," which makes it easier for infants to breastfeed on demand.

Although the American Academy of Family Physicians and the American Academy of Pediatrics recommend that mothers exclusively breastfeed infants for the first 6 months of life, and supports continuing breastfeeding to at least one year of age, data from the 2004-2008 National Immunization Survey document that only 73% of U.S. women attempt to breastfeed after birth, and only 42% and 21% are still breasfeeding at 6 and 12 months of life. The percentages are even lower for Black women: only 54% attempt breastfeeding, and just 27% and 11% are still doing so at 6 and 12 months.

Family physicians can help convince expectant and new mothers that "breast is best" by applying a number of evidence-based interventions recommended by the U.S. Preventive Services Task Force. Patients should be informed that the Department of Health and Human Services mandates first dollar coverage of comprehensive lactation support and breastfeeding equipment (e.g., breast pumps) for insurance plans starting in August 2012. Recognizing that primary care clinicians have many opportunities to support breastfeeding throughout pregnancy and the newborn period, we have included related content in each of the AFP By Topic collections on Prenatal Care, Labor and Delivery, and Newborn Care.

Monday, August 22, 2011

Does aspirin prophylaxis improve health in older adults?

Every day, family physicians are confronted with the clinical question of whether or not to start a patient on aspirin for the primary prevention of cardiovascular disease. The editorials in the June 15th issue of AFP by Dr. W. Fred Miser ("Appropriate Aspirin Use") and Drs. Bailey, Smyth, and Campbell ("The Case Against Routine Aspirin Use") highlight the current difficulties in putting the 2009 U.S. Preventive Services Task Force recommendations on aspirin prophylaxis into practice. There is limited information available to inform benefit versus risk decisions regarding aspirin prophylaxis in healthy older adults. Given the significant projected growth of the elderly population, especially of older minorities, family physicians will need to address aspirin prophylaxis decisions more frequently in the future.

To address areas of uncertainty beyond the 2009 USPSTF guidelines, the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial aims to answer a simple question with significant public health relevance: Does daily low-dose aspirin use maintain longevity without cognitive and functional disability in healthy men and women age 70 years or older? Currently, recruitment of 19,000 older adults who do not require aspirin for a cardiovascular condition is ongoing at over 20 sites in the U.S. in addition to general practices in Australia. In the U.S., results from ASPREE should hopefully provide insight on how aspirin works in all older persons, including members of minority groups. In order to succeed, ASPREE will require the engagement of family physicians and other primary care clinicians. Family physicians can make a significant contribution by identifying healthy, older persons from minority communities and providing them with information about how to participate in the study. More information about the study and locations of study sites in the United States can be found at

Raj C. Shah, MD
Rush University Medical Center
Chicago, Illinois

Disclosure: The author is a co-investigator on the ASPREE study.

Tuesday, August 16, 2011

Autism: to screen or not screen?

The August 15th issue of AFP features a pair of editorials that stake out opposite positions in the intensifying debate about the benefits of routinely screening young children for autism spectrum disorders (ASDs). Dr. Paul Lipkin and Susan Hyman argue that the rising incidence of ASDs and studies suggesting a benefit from early diagnosis and behavioral interventions make it imperative for pediatricians and family physicians to incorporate developmental screening tools into their practices. They assert that developmental screening does not impose significant time burdens on physicians, and that false-positive screening results can be minimized by scheduling follow-up interview visits.

On the other hand, Dr. Doug Campos-Outcalt counters that screening for ASDs has not yet met several critical criteria for establishing the effectiveness of a screening test. In particular, the following important questions remain unanswered:

1) What are the sensitivity and false-positive rate of the best screening test for ASDs available in an average clinical setting?

2) How much earlier can screening tests detect ASDs compared with an astute clinician who asks a few key questions about, and acts on, parental concerns regarding a child's communication and interactions?

3) What are the potential harms of testing?

4) Does earlier detection by screening result in meaningful and long-lasting improvements compared with detection through routine care?

Although a recent systematic review published in Pediatrics found limited evidence that early intensive behavioral interventions improve "cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs," it remains uncertain if routine screening leads to improved outcomes. Therefore, Dr. Campos-Outcalt recommends, "Family physicians who provide care for young children should ask parents about any concerns, be alert for the signs and symptoms of ASDs, and use available diagnostic testing tools to assist in making clinical decisions when an ASD is suspected."

Tuesday, August 2, 2011

Climate change and family physicians

At first glance, the topic of the cover article of AFP's August 1st issue, "Slowing Global Warming: Benefits for Patients and the Planet," might seem out of place in a journal that aims to provide practical clinical guidance for family physicians. Past summer-themed articles have included clinical reviews of heat-related illness, medical advice for commercial air travelers, and even health issues for surfers. By addressing climate change, AFP joins other widely read medical journals such as The Lancet and BMJ in recognizing the essential role that physicians can play in mitigating the negative impacts of environmental stress on patients' health.

After summarizing the serious potential health effects of climate change, Dr. Cindy Parker recommends that primary care clinicians counsel patients regarding two lifestyle changes that are likely to improve personal health as well as slow global warming: reducing meat consumption and increasing "active transportation" (substituting bicycling or walking for short car trips). In addition, physician practices and larger medical organizations can positively affect climate change by "going green":

Medical offices and hospitals can help by recycling; using recycled items and Energy Star certified appliances and computers; minimizing waste and waste transport by replacing single-use items with sterilizable or washable items; purchasing wind-generated electricity; and reducing energy use by turning off appliances, computers, and lights when not in use. In 2008, the U.S. health care sector spent $8.8 billion on energy to meet patient needs, not including the transportation of employees or patients to and from health care facilities, resulting in 8 percent of all U.S. greenhouse gas emissions.

In an accompanying editorial, Dr. Robert Gould reviews several national and international initiatives that encourage hospitals and health systems to reduce greenhouse gas emissions, including the Healthier Hospitals Initiative and Health Care Without Harm.