Knowledge, Attitudes, and Practices of Lebanese Pediatricians in Relation to Supporting Breastfeeding

Abstract

Background: Worldwide rates of breastfeeding are still suboptimal despite its confirmed importance and benefits during the first 1000 days of a child’s life. Using the Social Cognitive Theory, the determinants of breastfeeding can be divided into personal and environmental factors. Evidence has emphasized the role of pediatricians as an environmental determinant of breastfeeding. In Lebanon, the rates of breastfeeding remain below recommendations, as evidenced by low rates of exclusive and continued breastfeeding.

Objectives: The main objective of this study is to examine the knowledge, attitudes, and practices of Lebanese pediatricians in relation to supporting breastfeeding. A secondary objective is to explore the sociodemographic correlates of the breastfeeding knowledge, attitudes, and practices of the Lebanese pediatricians.

Methods: A national cross-sectional survey of Lebanese pediatricians was conducted online through Lime Survey. The list of pediatricians’ emails was obtained from the Lebanese Pediatric Society and the Lebanese Order of Physicians. After consenting to participate, pediatricians completed a multicomponent questionnaire covering four main sections: 1) Sociodemographic characteristics; 2) Practices related to supporting breastfeeding (12 questions); 3) Attitudes towards breastfeeding (15 questions), and 4) Knowledge of breastfeeding (22 questions). Data from the lime survey were exported into the Statistical Package for Social Sciences (SPSS version 23). Frequency, proportions, as well as means and standard deviations were used to describe categorical and continuous variables. Summary Scores were computed for each section. The sociodemographic correlates of the knowledge, attitudes, and practices scores were examined through simple and multiple linear regression. Statistical significance was established at a p-value < 0.05.

Results: A total of 117 pediatricians attempted to answer the questionnaire resulting in response rate of 11%. The study sample consisted of 59.6% female pediatricians, 44.9% above 50 years of age, and 76.6% from Beirut and Mount Lebanon. Almost 66% of pediatricians spent the majority of their time in a clinical setting, and 69% did their residency training in Lebanon. Regarding the knowledge section, the results of the study revealed deficiencies in the knowledge related to breastfeeding. For instance, more than one third of the pediatricians did not recognize the correct age for introducing solid foods and around 36% believed that breastfeeding is contraindicated in mothers with hepatitis C. A significant number of pediatricians (56.6%) chose bottles as the best option for providing pumped or formula milk and 50.6% did not acknowledge that breastmilk retains its core components after 2 years of age. Moreover, 33.8% of pediatricians showed suboptimal knowledge in addressing breastfeeding positioning (33.8%), sore nipples (32%), frequent feedings (44.5%), and latching issues (65%). With regards to the attitudes towards breastfeeding, the study sample reported unfavorable attitudes to more than one theme. More specifically, negative attitudes towards breastfeeding in public (34.1%), breastfeeding while working (25.3%), and breastfeeding while pregnant (40%) were reported. Almost 30% of pediatricians considered that mixed feeding is a more practical feeding method and 33% believed that formula-fed babies are as healthy as breastfed babies. The majority of pediatricians reported to be comfortable in assessing and evaluating breastfeeding problems while 20% disagreed that their residency prepared them well to support breastfeeding. As for the practices section, the pediatricians’ answers showed varied practices. For instance, 36.3% of pediatricians asked mothers (frequently enough) to breastfeed in front of them so that they can assess the feeding, 30.8% referred mothers to lactation consultants, and only 24.2% kept brochures about breastfeeding resources to give to mothers. Furthermore, more than 40% of pediatricians kept formula samples in their clinics to distribute to mothers and their babies, and more than 20% had formula-related advertising in their clinics. Around 32% of pediatricians would recommend supplementing with formula if a healthy baby has not regained weight by 2 weeks, and 25.3% would do so if the mother feels her milk is inadequate. Most pediatricians (72.5%) would recommend timed feeding instead of feeding on demand. Despite the aforementioned gaps, a sizeable proportion of the study sample exhibited good knowledge, positive attitudes, and favorable practices towards breastfeeding. After adjustment for covariates using linear multiple regression, being a female remained the sole predictor of a higher knowledge score (B=1.893, 95%CI 0.584 to 3.203). Spending the majority of time at a hospital was the only predictor of the attitude score (B=1.583, 95%CI 0.202 to 2.964). Practice scores were predicted by being between 35 and 40 years old (B=-1.273, 95%CI -2.402 to -0.144) and spending most worktime at a hospital (B=0.925, 95%CI 0.129 to 1.721).

Conclusion: This research study is the first attempt in Lebanon and in the region to explore the knowledge, attitudes, and practices of pediatricians in relation to supporting breastfeeding. The results of this study revealed important gaps in the knowledge of pediatricians and considerable prevalence of negative attitudes and practices related to breastfeeding support. These findings unveiled a critical opportunity which, if addressed, could potentially increase the rates of exclusive breastfeeding. Concentrated and coordinated efforts ought to be exerted to educate and equip pediatricians with the knowledge and skills to support breastfeeding. In addition, a better understanding of the barriers and enablers to supporting breastfeeding among pediatricians is warranted.