Human milk provides ideal nutrients for human growth and is considered the best feeding choice for infants. The benefit of human milk is far more than simply nutritional, however, as it allows gut microflora to be established in the infant through sharing of the mother's microbiome; the breast milk microbiome changes based on the age of the infant.1 Human milk is complex, specific, and able to adapt: for example, milk produced at night has higher melatonin levels and lower cortisol. Animal and early human studies indicate milk for male offspring often has a higher fat content than that for female offspring.1 Emerging human research suggests other possible sex-specific differences in human milk, although the impact of nutritional and hormonal differences requires further research.2
The 2022 US Breastfeeding Report Card indicates that 83% of infants receive some human milk, but only 25% receive exclusive human milk feeding in the first 6 months of life, far below the 42% target of Healthy People 2030.3,4 Evidence exists that many families do not breastfeed as long as intended, and race and ethnicity disparities are prevalent.3 The steady monthly decline in breastfeeding rates indicates a strong need for supportive systems, including those involving the provider.3
Historically, the acceptance of breastfeeding as the normative standard for infant feeding has vacillated. Just prior to the 20th century, the breastfeeding rate was 90%.5 Breastfeeding rates steadily declined until the early 1970s. The American Academy of Pediatrics (AAP) has since been a strong proponent of breastfeeding legislation and public education directed at reestablishing formula, as originally intended, as an infant nutrition replacement when breastfeeding is not possible. The AAP's revised policy statement on breastfeeding and the use of human milk aligns with that of the World Health Organization (WHO) and strengthens its stance on human milk as the infant feeding standard.6 In its policy statement, the AAP “recommends exclusive breastfeeding for approximately 6 months after birth.” It also “supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond.”6 For the purpose of this article, “mother” is defined as any person, regardless of gender identity, who is currently lactating or has lactated in the past.
Public health imperative
The AAP published its revised policy statement on breastfeeding and the use of human milk in July 2022. This policy revision addresses infant feeding from a public health perspective, indicating: “The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding, or the provision of human milk, a public health imperative.”7 The revised policy statement updates breastfeeding recommendations and aims to serve as a reference for other infant nutrition policies and publications. The alignment of the AAP breastfeeding policy on the practice's benefits beyond 1 year with those of the WHO and the American Academy of Family Physicians (AAFP) is encouraging. It signifies a recognition that it is time for government and health systems to fully support lactating families. Weak national policies and a lack of medical system education have compromised breastfeeding rates and longevity in the past.8 The policy revision should serve as a catalyst for improving other maternal and infant health policies, bolstering lactation support, and inspiring political action.
Several nursing and professional organizations align with the AAP policy update, particularly in terms of recognizing breastfeeding as a public health priority. The Association of Women's Health, Obstetric and Neonatal Nurses recognizes breastfeeding as “one of the most important health behaviors that affects morbidity and mortality among women and children” and strongly recommends pasteurized donor human milk as the preferred substitute before supplementation with formula.9 The National Association of Pediatric Nurse Practitioners indicates that breastfeeding less than the AAP recommends or nonexclusive breastfeeding in the first 6 months after birth increases the risk of infant morbidity and mortality and poses a significant healthcare burden economically.10
The AAP policy revision comes at an opportune time, on the heels of a significant national formula shortage triggered by contamination in one manufacturing facility and supply chain issues.8 The crisis was made worse by longstanding poor support for breastfeeding and aggressive formula marketing strategies.11 About half of the formula produced in the US is purchased using the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits.11 As such, the socioeconomically disadvantaged and most vulnerable families were hit hardest by the formula crisis. Recommendations provided by government and the AAP failed to mention strengthening support for breastfeeding and decreasing the demand for and dependence on infant formula.11 According to a consumer update by the US FDA, the safest option for infants under 2 months of age, if they are not receiving breast milk, is liquid formula, due to the potential for Cronobacter contamination in powdered infant formula.12 Notably, the US is the only high-income country with no statutory national paid maternity leave policy, which contributes to many mothers discontinuing lactation upon returning to work.11 The urgency to improve policies for maternal healthcare during pregnancy and postdelivery, strengthen workplace breastfeeding policy protection, and tighten formula manufacturer marketing policy has never been higher. Interestingly, despite the formula shortage, legislation to strengthen workplace policy protection for pumping (PUMP for Nursing Mothers Act; H.R.3110) failed to pass in the Senate in June 2022, following passage in the House in October 2021.13 However, The PUMP Act, which will provide 9 million workers not covered by the 2010 Break Time for Nursing Mothers law equal rights and required paid break time for pumping, passed in December 2022 as part of a $1.7 trillion federal spending package.14 Returning to work is one of the greatest contributors to decreased breastfeeding rates or discontinued lactation.7 Specifically, in addition to cultural norms and a lack of family support, unaccommodating work policies contribute to high breastfeeding discontinuation rates.14
Updated guidelines: What's new?
The AAP's prior breastfeeding policy statement was published in 2012.15 The updated guidelines are intended to increase access for breastfeeding support.6 Notable updates include:
- a recommendation for increased duration of breastfeeding and normalizing extended breastfeeding based on current evidence that there are health benefits past the 12-month mark for the lactating parent and child;
- emphasis on health inequities with breastfeeding and targeting interventions for groups with lower rates;
- a focus on viewing breastfeeding through a public health lens, moving away from focusing primarily on nutrition for the growing child; and
- a recommendation regarding strengthening support and policies for lactating mothers in the workplace and breastfeeding in public.
The most significant change in the revised guidelines is an increase in the length of recommended breastfeeding time from 1 year of age to 2 years and beyond, as long as mutually desired by mother and child.6,7 This revision aligns with longstanding recommendations from WHO and AAFP. Human milk after 12 months of age continues to support toddler growth with significantly higher protein, lactoferrin, and immunoglobulin A than first-year milk.7 The first 2 years of life are an important time for brain development, and breast milk contains macronutrients for this growth.16 Evidence also exists that maternal-child attachment is enhanced with longer breastfeeding duration up to age 3 years and that maternal rates of diabetes, hypertension, and breast and ovarian cancers are decreased with breastfeeding.7 Exclusive breastfeeding for the first 6 months after birth, with complementary food introduced around 6 months, continues to be recommended. Abnormal infant gut microbiota and increased respiratory illness, diarrhea, otitis media, and childhood obesity are associated with less than 6 months of exclusive breastfeeding.7 Exclusive breastfeeding for 6 months is an evidence-based recommendation.
Health benefits for the child
The latest evidence strongly supports previously known and suspected health benefits for the infant or child. Infants who are exclusively breastfed for more than 4 months have lower risk of overweight and obesity.17 Additionally, a duration of breastfeeding of at least 4 months is associated with reduced risk of asthma among children ages 3 to 6 years and reduced risk of urinary tract infections.18,19 Initiation of breastfeeding may reduce postneonatal mortality by 31% for Black infants.7 Considerable data confirm that the following acute and chronic disorders are less likely to occur in infants and children who are breastfed:
- otitis media,
- acute diarrhea,
- lower respiratory illness,
- sudden infant death syndrome,
- childhood leukemia,
- diabetes mellitus,
- atopic dermatitis,
- childhood and adult obesity, and
Health benefits for the lactating parent
Emerging evidence suggests that the health benefits of longer breastfeeding duration may be most important for maternal outcomes.7 The recent change in the AAP's recommendation for breastfeeding duration is based on evidence that indicates that breastfeeding for longer than 12 months is beneficial for the lactating mother. The following maternal outcomes are reduced with breastfeeding, based on meta-analyses:
- type 2 diabetes mellitus,
- gestational diabetes mellitus,
- breast cancer,
- ovarian cancer,
- thyroid cancer, and
- endometrial cancer.7
A study of 1.2 million women published in the Journal of the American Heart Association found that breastfeeding decreases the risk of dying from cardiovascular disease by 17%.20 Hypertension risk decreases by 13% for the parent who breastfeeds longer than 12 months, as compared with those who breastfeed for shorter durations.7
Breastfeeding positively affects maternal mood and has been shown to reduce the stress response.21 The nonlactating mother is more likely to experience postpartum depression (PPD) (or vice versa), with exclusive breastfeeding correlating with lower likelihood of depressive symptoms.22-24 Especially when paired with limited social support and increased stress levels, the discontinuation of exclusive breastfeeding is associated with significantly higher odds of PPD.22 Longer duration of breastfeeding may promote maternal attachment, specifically maternal response to the infant, maternal sensitivity, and maternal ability to read the infant's cues.7 Breastfeeding positively correlates with maternal bonding.23
Healthcare provider support
The AAP's new breastfeeding policy emphasizes the role of the pediatrician, noting limited provider awareness, knowledge, skills, and practices as barriers to successful exclusive breastfeeding for 6 months.7 Pediatricians, family practice physicians, and other healthcare providers, including NPs, play a key role through the health supervision visits that follow hospital discharge after birth. Breastfeeding rates begin to decline significantly by 6 months postbirth: the rate of infants receiving any breast milk decreases from more than 80% initially after birth to 55% by the age of 6 months; similarly, the rate of infants who are exclusively breastfed decreases from more than 60% to 25% from birth to the age of 6 months.3 This decline indicates that evidence-based support is warranted, particularly in the first 2 weeks of the infant's life when many breastfeeding problems occur. In one study, about 38% of women who reported that their pediatric primary care provider was unsupportive of breastfeeding past the first year chose to change providers.7 The AAP emphasizes the importance of the provider's ability to assess breastfeeding effectiveness, manage common problems, and provide guidance to preserve the lactating parent's milk supply.7 Breastfeeding-supportive office practices outlined in the AAP policy include a focus on creation of a written breastfeeding-friendly policy, staff education, community collaboration, and use of noncommercial patient education materials on breastfeeding.7
Health impact on parent-baby dyad
Providers equipped with adequate knowledge and tools to support and manage breastfeeding effectively can have a significant impact on short- and long-term health of the parent-baby dyad. A systematic review of behavioral interventions to improve maternal mental health and breastfeeding outcomes found that targeting breastfeeding alone may be as effective as targeting both mental health and breastfeeding.21 Pezley et al. states, “Perhaps by supporting the breastfeeding experience, we are supporting something more; we are supporting the whole person and their community.”21
Failure to achieve the breastfeeding rate goals set by the US Office of Disease Prevention and Health Promotion and the CDC is estimated to cost more than $3 billion US dollars (USD) in resultant medical costs yearly.25,26 Global costs of not breastfeeding are estimated at more than 694,000 lives lost annually and economic losses of greater than $341 billion USD.25 In 2018, a study by the US Department of Agriculture found that if breastfeeding rates in the WIC program were to rise to the medically recommended levels, then total health-related costs would be reduced by $9.1 billion, 75% of which would result from a reduction in early deaths and the remainder of which would be due to savings in medical and nonmedical costs.27 The AAP describes breastfeeding as environmentally friendly. Breastfeeding's contributions to reducing the carbon footprint and improving food security should be considered nationally and globally when determining breastfeeding goals.7
Disparities exist in terms of breastfeeding rates in the US. Specifically, Black women initiate breastfeeding at a rate (73.6%) below the national average (84.1%), which constitutes a health inequity.28 For infants eligible for WIC, only 77% ever breastfeed, as compared with 92% for those ineligible for WIC.7 Non-Hispanic Black infants have twice the number of excess child deaths associated with suboptimal breastfeeding compared with non-Hispanic White infants.26
Across the US, differences in rates of breastfeeding among Black women vary dramatically, ranging from 97.6% in Vermont to 52.3% in Arkansas.28 “Historical, cultural, social, economic, political, and psychosocial factors” contribute to disparities in rates of breastfeeding among Black women.29 Barriers include, for example, less job control and the need for childcare.30-32 Although support is available for breastfeeding mothers, low-income Black women have reported lack of social, workplace, and cultural support as barriers to breastfeeding.3,29 These barriers may be exacerbated by a lack of cultural acceptance of breastfeeding, especially in public.29,33
Educating Black women about the new AAP guidelines is critical for increasing rates of breastfeeding and extended breastfeeding among this population. The need to increase rates of breastfeeding among Black women is especially relevant considering the recent baby formula shortage. However, there is a need for cultural change to reduce the stigma associated with breastfeeding.33 The role of educating the public in this capacity cannot be overstated. Using a patient-centered approach is necessary for promoting breastfeeding beyond the first year of life. Both medical professionals, including NPs, and the public can help to promote policies designed to support breastfeeding and its associated benefits. According to the AAP, to eliminate disparities, biases that stem from systemic racism must be addressed.7 These biases can be associated with overall negative health outcomes in individuals, families, and communities. Educating the public on the new AAP position statement may be beneficial in decreasing poor health outcomes and may contribute to healthy families.
Identification of breastfeeding problems and routine management
The AAP stresses the importance of utilizing evidence-based guidance versus personal experience in managing or counseling breastfeeding families.7 Chesnel et al. found that, amid providers, consistent collaboration, adequate knowledge, efficient referral systems, and strong belief in the value of breastfeeding positively influence overall breastfeeding support.34 The provider can positively impact the health of the parent-infant dyad by providing competent feeding management.
Patient-centered approach to postdelivery care
Providers should assess breastfeeding as part of routine postdelivery care for the lactating parent and infant.35,36 First, providers should collect history relevant to breastfeeding by inquiring about any concerns or difficulties with the process. Use of open-ended questions (such as “How is breastfeeding going?”) allows the lactating parent to describe their experience and talk about difficulties, and it also helps the provider to gather additional history. Providers should additionally ask about infant feeding frequency, the number of wet diapers and stools per day, and infant behavior at the breast in order to determine whether key goals are being met and to ensure that intake and hydration are adequate. Specifically, benchmarks are as follows:
- Feeding frequency: Goal of 8 feedings or more in 24 hours. Frequent feeding is required to establish and maintain breast milk supply.
- Voids and stools: In the first 4 days of life, goal of at least 1 void per day of age plus at least 1 stool per 24 hours; by day 5, goal of at least 6 to 8 voids and 1 yellow, seedy stool daily.
- Behavior at the breast: Ideally, baby should be alert and active at the breast. If baby is sleepy, provider should encourage frequent maternal breast massage while feeding and arousing baby to ensure adequate breast emptying. If baby is frustrated, provider should consider possibilities of inadequate milk production and/or infant reflux.35,36
While collecting history, the provider should ask about any changes to the breasts during pregnancy and/or since delivery to assess for potential suboptimal milk production. A lack of change to the breasts during pregnancy could point to insufficient glandular development or, particularly in the case of a history of breast surgery, nerve disruption. Either could lead to suboptimal milk production. Lactogenesis II, or the onset of copious milk production, typically occurs by day 3 or 4 postpartum; however, up to 35% of primiparous women experience delayed lactogenesis II, which is a marker for suboptimal milk production.35,36
Providers should inquire about about potential barriers to breastfeeding, such as pain or discomfort during the process. Asking about pain or discomfort screens for ineffective latch, nipple trauma, and/or poor milk transfer. Typically, nipple pain in particular is caused by nipple compression (that is, a poor latch, as opposed to a deep latch). In these cases, the provider should recommend that the mother remove the infant from the breast prior to reattaching.35,36
Following history collection, providers should conduct a physical exam, assessing infant weight and hydration status, which can evaluate for insufficient milk intake, and general appearance, which can help screen for signs of illness. Specifically, benchmarks and recommendations are as follows:
- Weight and hydration status: Insufficient weight gain is defined by a weight below the 75th percentile curve on the newborn weight loss tool (NEWT) nomogram; a failure to regain birth weight by day 14; and/or gaining less than 0.5 oz daily. If the infant meets any of these criteria, the provider should identify the root cause(s), refer the lactating parent and baby to a lactation specialist, and advise supplementation (see “Volume and type of supplement” below). Observing the baby's mucous membranes, skin turgor, and anterior fontanelle may help the provider to determine hydration status. If there are any concerns regarding weight or hydration, the provider should conduct a complete feeding evaluation and compile a comprehensive feeding plan, scheduling frequent follow-ups until the issues are resolved.
- General appearance: Healthy infants typically awaken when stimulated. A jaundiced appearance is cause for concern, as insufficient intake is a risk factor for pathologic jaundice.35,36
Following the physical exam, the provider should observe the mother and baby during breastfeeding. The infant should effectively latch to the lactating parent's breast; the infant's chin should be touching the breast with nose free and ear, shoulder, and hip in alignment; the latch should be asymmetric (with more areola visible above the nipple than below); and the infant's swallow should be audible. If the provider observes an ineffective latch or any difficulty, or if the lactating parent notes any pain or discomfort, then the NP should teach the mother latching technique, indicate how to recognize an effective latch, and assess and adjust the infant's position and latch as needed.35,36 Additionally, the provider should monitor weight to verify adequate milk transfer.
Finally, the provider should gauge the lactating parent's overall wellbeing as well as the degree of mother-infant bonding. Poor maternal focus on the infant may be a sign of perinatal mood and/or anxiety disorders or exhaustion, warranting further follow-up and/or referral.35,36
Poor weight gain
Extracellular fluid loss and passage of meconium following birth accounts for most weight loss in healthy term infants during the first few days of life.37 Infants delivered via cesarean section may have increased weight loss versus those delivered vaginally. Excess newborn weight loss correlates with maternal receipt of intrapartum I.V. fluids and may falsely exaggerate early weight loss, especially when fluid administration exceeds 1,500 mL.38 Establishment of increased milk production or lactogenesis II typically occurs 3 to 4 days after delivery.6 Risk factors for delayed milk production leading to insufficient infant weight gain risk include retained placenta, postpartum hemorrhage, maternal obesity, polycystic ovarian syndrome, maternal diabetes, hypertension in pregnancy, preterm labor, cesarean delivery, and excessive blood loss during labor.6,35 Infants with these maternal risk factors should be monitored closely. A comprehensive breastfeeding assessment includes obtaining a detailed infant and maternal history regarding pregnancy, birth, postnatal period, infant feeding, current and past lactation experiences, and infant and maternal health.35
Perceived inadequate milk supply and increasing milk volume
Studies suggest that perceived insufficient milk supply, defined as the maternal belief that breast milk production is inadequate for the infant's needs, strongly influences unnecessary early formula supplementation.39 Employed lactating mothers with less than a college education are at an increased risk of reduced lactation confidence, leading to perceived insufficient milk supply.39 Early skin-to-skin contact between the mother and newborn may facilitate exclusive breastfeeding and improve lactation confidence.36,39 When milk supply is insufficient, increase of breast milk volume can be supported by:
- offering both breasts at each feeding and increaseing feeding frequency (more than eight times daily);
- allowing the infant to feed on one breast until audible swallowing has decreased, then offering the second breast;
- instructing the lactating mother to massage the breast just prior to and during feeding and/or pumping;
- considering breastfeeding for infant comfort or skin-to-skin contact between feedings; and
- if supplementing, encouraging pumping after feeding at the breast to stimulate supply, particularly during the daytime (maternal rest should be encouraged at night).35
Volume and type of supplement
When supplemental feedings are warranted, the first choice is the mother's expressed breast milk, given after breastfeeding and in limited volume. This encourages continued infant cueing. Donor human milk is the second choice, followed by formula when donor milk is unavailable.37 Protein hydrolysate formula may be preferable to standard formula when concern for hyperbilirubinemia is present, as it may reduce bilirubin levels more rapidly.37 Supplementation with glucose water is inappropriate and can cause hyponatremia.37 The Academy of Breastfeeding Medicine suggests the following supplement volumes for healthy term infants based on infant age:
- First 24 hours–2 to 10 mL/feed
- 24 to 48 hours–5 to 15 mL/feed
- 48 to 72 hours–15 to 30 mL/feed
- 72 to 96 hours–30 to 60 mL/feed36,37
When to refer
NPs should consider referral to a lactation specialist or other relevant professional for further assessment when significant anatomical, functional, or medical conditions are suspected.39 Unresolved lactation issues in the first 2 weeks of life should be referred, as many lactating mothers cease breastfeeding by day 14 when problems are unresolved.
NPs should maintain an inventory of breastfeeding resources, both for their own use in supporting families throughout the breastfeeding process and for sharing directly with families for their reference (see Breastfeeding resources).
The 2022 AAP breastfeeding policy compiles the latest evidence for strengthening lactation support through a patient-centered approach. Providing nonjudgmental support and evidence-based information to guide parents in infant feeding is mutually beneficial for the breastfeeding dyad, decreasing the risk of health disparities for both mother and child. The AAP policy now aligns with longstanding recommendations of feeding breast milk for 2 years and beyond.6,14 There has never been a better opportunity for healthcare providers to improve the health of their community and nation physically, psychologically, and economically. It is time to provide equitable care regarding infant feeding to all mother-infant dyads.
CDC Guide to Strategies to Support Breastfeeding Mothers and Babies: www.cdc.gov/breastfeeding/pdf/BF-Guide-508.pdf
Academy of Breastfeeding Medicine: www.bfmed.org/
Breastfeeding handouts in multiple languages: https://medlineplus.gov/languages/breastfeeding.html
Maternal Nipple Pain Clinical Practice Guideline: www.cahs.health.wa.gov.au/-/media/HSPs/CAHS/Documents/Community-Health/CHM/Breastfeeding-and-lactation-concerns—assessment.pdf
AAP Breastfeeding Practice Tools for Health Professionals: www.aap.org/en/patient-care/breastfeeding/breastfeeding-practice-tools-for-health-professionals/
International Breastfeeding Centre's Information Sheets: http://ibconline.ca/information-sheets/
Drugs and Lactation Database (LactMed): www.ncbi.nlm.nih.gov/books/NBK501922/
InfantRisk Center website: https://infantrisk.com
InfantRisk Call Center: 1-806-352-2519
Book: Hale TW, Krutsch K. Hale's Medications and Mother's Milk. 20th ed. Springer Publishing; 2022.
CDC Breastfeeding Parent Resources: www.cdc.gov/nutrition/InfantandToddlerNutrition/breastfeeding/index.html
Breastfeeding Attachment Video: https://globalhealthmedia.org/videos/breastfeeding-attachment
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