Breastfeeding and the Use of Human Milk - POLICY STATEMENT
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
Organizational Principles to Guide and Define the Child
Health Care System and/or Improve the Health of all Children
POLICY STATEMENT
Breastfeeding and the Use of Human Milk
SECTION ON BREASTFEEDING
KEY WORDS
abstract
breastfeeding, complementary foods, infant nutrition, lactation, Breastfeeding and human milk are the normative standards for infant
human milk, nursing
feeding and nutrition. Given the documented short- and long-term med-
ABBREVIATIONS
AAP—American Academy of Pediatrics
ical and neurodevelopmental advantages of breastfeeding, infant nu-
AHRQ—Agency for Healthcare Research and Quality trition should be considered a public health issue and not only
CDC—Centers for Disease Control and Prevention a lifestyle choice. The American Academy of Pediatrics reaffirms its
CI—confidence interval
recommendation of exclusive breastfeeding for about 6 months, fol-
CMV—cytomegalovirus
DHA—docosahexaenoic acid lowed by continued breastfeeding as complementary foods are intro-
NEC—necrotizing enterocolitis duced, with continuation of breastfeeding for 1 year or longer as
OR—odds ratio mutually desired by mother and infant. Medical contraindications to
SIDS—sudden infant death syndrome
WHO—World Health Organization
breastfeeding are rare. Infant growth should be monitored with the
This document is copyrighted and is property of the American
World Health Organization (WHO) Growth Curve Standards to avoid mis-
Academy of Pediatrics and its Board of Directors. All authors labeling infants as underweight or failing to thrive. Hospital routines
have filed conflict of interest statements with the American to encourage and support the initiation and sustaining of exclu-
Academy of Pediatrics. Any conflicts have been resolved through sive breastfeeding should be based on the American Academy of
a process approved by the Board of Directors. The American
Academy of Pediatrics has neither solicited nor accepted any Pediatrics-endorsed WHO/UNICEF “Ten Steps to Successful Breastfeed-
commercial involvement in the development of the content of ing.” National strategies supported by the US Surgeon General’s Call
this publication. to Action, the Centers for Disease Control and Prevention, and The
All policy statements from the American Academy of Pediatrics Joint Commission are involved to facilitate breastfeeding practices in
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
US hospitals and communities. Pediatricians play a critical role in
their practices and communities as advocates of breastfeeding and
thus should be knowledgeable about the health risks of not breast-
feeding, the economic benefits to society of breastfeeding, and the
techniques for managing and supporting the breastfeeding dyad. The
“Business Case for Breastfeeding” details how mothers can maintain
lactation in the workplace and the benefits to employers who facili-
tate this practice. Pediatrics 2012;129:e827–e841
INTRODUCTION
www.pediatrics.org/cgi/doi/10.1542/peds.2011-3552
Six years have transpired since publication of the last policy statement
doi:10.1542/peds.2011-3552 of the American Academy of Pediatrics (AAP) regarding breastfeeding.1
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Recently published research and systematic reviews have reinforced
Copyright © 2012 by the American Academy of Pediatrics the conclusion that breastfeeding and human milk are the reference
normative standards for infant feeding and nutrition. The current
statement updates the evidence for this conclusion and serves as
a basis for AAP publications that detail breastfeeding management
and infant nutrition, including the AAP Breastfeeding Handbook for
Physicians,2 AAP Sample Hospital Breastfeeding Policy for Newborns,3
AAP Breastfeeding Residency Curriculum,4 and the AAP Safe and
Healthy Beginnings Toolkit.5 The AAP reaffirms its recommendation
of exclusive breastfeeding for about 6 months, followed by continued
breastfeeding as complementary foods are introduced, with continuation
PEDIATRICS Volume 129, Number 3, March 2012 e827
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as mutually desired by mother and WIC, it was 84.6%.12 Breastfeeding Methodologic Issues
infant. initiation rate was 37% for low-income
non-Hispanic black mothers.7 Similar Breastfeeding results in improved in-
fant and maternal health outcomes in
EPIDEMIOLOGY disparities are age-related; mothers
both the industrialized and developing
younger than 20 years initiated breast-
Information regarding breastfeeding world. Major methodologic issues have
feeding at a rate of 59.7% compared
rates and practices in the United States been raised as to the quality of some
is available from a variety of govern- with the rate of 79.3% in mothers
of these studies, especially as to the
ment data sets, including the Centers older than 30 years. The lowest rates
size of the study populations, quality of
for Disease Control and Prevention (CDC) of initiation were seen among non-
the data set, inadequate adjustment
National Immunization Survey,6 the Hispanic black mothers younger than
for confounders, absence of distin-
20 years, in whom the breastfeeding
NHANES,7 and Maternity Practices and guishing between “any” or “exclusive”
Infant Nutrition and Care.8 Drawing on initiation rate was 30%.7
breastfeeding, and lack of a defined
these data and others, the CDC has Although over the past decade, there causal relationship between breast-
published the “Breastfeeding Report has been a modest increase in the rate feeding and the specific outcome. In
Card,” which highlights the degree of of “any breastfeeding” at 3 and 6 addition, there are inherent practical
progress in achieving the breastfeed- months, in none of the subgroups and ethical issues that have precluded
ing goals of the Healthy People 2010 have the Healthy People 2010 targets prospective randomized interventional
targets as well as the 2020 targets been reached. For example, the 6- trials of different feeding regimens.
(Table 1).9–11 month “any breastfeeding” rate for As such, the majority of published
The rate of initiation of breastfeeding the total US population was 43%, the reports are observational cohort
for the total US population based on rate for the Hispanic or Latino sub- studies and systematic reviews/meta-
the latest National Immunization Sur- group was 46%, and the rate for the analyses.
vey data are 75%.11 This overall rate, non-Hispanic black or African Ameri-
To date, the most comprehensive
however, obscures clinically signifi- can subgroup was only 27.5%. Rates
publication that reviews and analyzes
cant sociodemographic and cultural of exclusive breastfeeding are further
the published scientific literature that
differences. For example, the breast- from Healthy People 2010 targets, with
compares breastfeeding and com-
feeding initiation rate for the Hispanic only 13% of the US population meeting
mercial infant formula feeding as to
or Latino population was 80.6%, but the recommendation to breastfeed ex-
health outcomes is the report pre-
for the non-Hispanic black or African clusively for 6 months. Thus, it appears
pared by the Evidence-based Practice
American population, it was 58.1%. that although the breastfeeding ini-
Centers of the Agency for Healthcare
Among low-income mothers (partic- tiation rates have approached the
Research and Quality (AHRQ) of the US
ipants in the Special Supplemental 2010 Healthy People targets, the tar-
Department of Health Human Services
Nutrition Program for Women, Infants, gets for duration of any breastfeeding
titled Breastfeeding and Maternal and
and Children [WIC]), the breastfeeding and exclusive breastfeeding have not
Infant Health Outcomes in Developed
initiation rate was 67.5%, but in those been met.
Countries.13 The following sections
Furthermore, 24% of maternity serv- summarize and update the AHRQ meta-
ices provide supplements of com- analyses and provide an expanded
mercial infant formula as a general analysis regarding health outcomes.
TABLE 1 Healthy People Targets 2010 and
2020(%) practice in the first 48 hours after Table 2 summarizes the dose-response
2007a 2010 2020 birth. These observations have led to relationship between the duration of
Target Target the conclusion that the disparities in breastfeeding and its protective effect.
Any breastfeeding breastfeeding rates are also associ-
Ever 75.0 75 81.9 ated with variations in hospital rou- Respiratory Tract Infections and
6 mo 43.8 50 60.5 Otitis Media
1y 22.4 25 34.1 tines, independent of the populations
Exclusive breastfeeding served. As such, it is clear that greater The risk of hospitalization for lower
To 3 mo 33.5 40 44.3 emphasis needs to be placed on im- respiratory tract infections in the first
To 6 mo 13.8 17 23.7
Worksite lactation support 25 — 38.0
proving and standardizing hospital- year is reduced 72% if infants breastfed
Formula use in first 2 d 25.6 — 15.6 based practices to realize the newer exclusively for more than 4 months.13,14
a
2007 data reported in 2011.10 2020 targets (Table 1). Infants who exclusively breastfed for 4
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TABLE 2 Dose-Response Benefits of Breastfeedinga study of preterm infants fed an exclu-
Condition % Lower Riskb Breastfeeding Comments ORc 95% CI sive human milk diet compared with
Otitis media13 23 Any — 0.77 0.64–0.91 those fed human milk supplemented
Otitis media13 50 ≥3 or 6 mo Exclusive BF 0.50 0.36–0.70 with cow-milk-based infant formula pro-
Recurrent otitis media15 77 Exclusive BF Compared with 1.95 1.06–3.59
ducts noted a 77% reduction in NEC.19
≥6 mod BF 4 to 6 mo Exclusive BF 0.30 0.18–0.74 One case of NEC could be prevented if
tract infection17 10 infants received an exclusive human
Lower respiratory 72 ≥4 mo Exclusive BF 0.28 0.14–0.54 milk diet, and 1 case of NEC requiring
tract infection13
Lower respiratory 77 Exclusive BF Compared with 4.27 1.27–14.35 surgery or resulting in death could be
tract infection15 ≥6 mod BF 4 to 4 mo — 0.26 0.074–0.9
NEC19 77 NICU stay Preterm infants 0.23 0.51–0.94
and Infant Mortality
Exclusive HM Meta-analyses with a clear definition of
Atopic dermatitis27 27 >3 mo Exclusive BFnegative 0.84 0.59–1.19
family history
degree of breastfeeding and adjusted
Atopic dermatitis27 42 >3 mo Exclusive BFpositive 0.58 0.41–0.92 for confounders and other known risks
family history for sudden infant death syndrome
Gastroenteritis13,14 64 Any — 0.36 0.32–0.40
(SIDS) note that breastfeeding is as-
Inflammatory bowel 31 Any — 0.69 0.51–0.94
disease32 sociated with a 36% reduced risk of
Obesity13 24 Any — 0.76 0.67–0.86 SIDS.13 Latest data comparing any ver-
Celiac disease31 52 >2 mo Gluten exposure 0.48 0.40–0.89 sus exclusive breastfeeding reveal that
when BF
Type 1 diabetes13,42 30 >3 mo Exclusive BF 0.71 0.54–0.93 for any breastfeeding, the multivariate
Type 2 diabetes13,43 40 Any — 0.61 0.44–0.85 odds ratio (OR) is 0.55 (95% confidence
Leukemia (ALL)13,46 20 >6 mo — 0.80 0.71–0.91 interval [CI], 0.44–0.69). When com-
Leukemia (AML)13,45 15 >6 mo — 0.85 0.73–0.98
SIDS13 36 Any >1 mo — 0.64 0.57–0.81
puted for exclusive breastfeeding, the
ALL, acute lymphocytic leukemia; AML, acute myelogenous leukemia; BF, breastfeeding; HM, human milk; RSV, respiratory
OR is 0.27 (95% CI, 0.27–0.31).20 A pro-
syncytial virus. portion (21%) of the US infant mortality
a
Pooled data.
b
% lower risk refers to lower risk while BF compared with feeding commercial infant formula or referent group
has been attributed, in part, to the in-
specified. creased rate of SIDS in infants who
c
OR expressed as increase risk for commercial formula feeding. were never breastfed.21 That the posi-
d
Referent group is exclusive BF ≥6 months.
tive effect of breastfeeding on SIDS
rates is independent of sleep position
to 6 months had a fourfold increase infants who exclusively breastfed for 6 was confirmed in a large case-control
in the risk of pneumonia compared months.17 study of supine-sleeping infants.22,23
with infants who exclusively breastfed It has been calculated that more than
for more than 6 months.15 The severity Gastrointestinal Tract Infections
900 infant lives per year may be saved
(duration of hospitalization and oxygen Any breastfeeding is associated with in the United States if 90% of mothers
requirements) of respiratory syncytial a 64% reduction in the incidence of exclusively breastfed for 6 months.24 In
virus bronchiolitis is reduced by 74% nonspecific gastrointestinal tract infec- the 42 developing countries in which
in infants who breastfed exclusively for tions, and this effect lasts for 2 months 90% of the world’s childhood deaths oc-
4 months compared with infants who after cessation of breastfeeding.13,14,17,18 cur, exclusive breastfeeding for 6 months
never or only partially breastfed.16 and weaning after 1 year is the most
Any breastfeeding compared with ex- Necrotizing Enterocolitis effective intervention, with the potential
clusive commercial infant formula Meta-analyses of 4 randomized clinical of preventing more than 1 million infant
feeding will reduce the incidence of trials performed over the period 1983 deaths per year, equal to preventing 13%
otitis media (OM) by 23%.13 Exclusive to 2005 support the conclusion that of the world’s childhood mortality.25
breastfeeding for more than 3 months feeding preterm infants human milk is
reduces the risk of otitis media by associated with a significant reduction Allergic Disease
50%. Serious colds and ear and throat (58%) in the incidence of necrotizing There is a protective effect of exclusive
infections were reduced by 63% in enterocolitis (NEC).13 A more recent breastfeeding for 3 to 4 months in
PEDIATRICS Volume 129, Number 3, March 2012 e829
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asthma, atopic dermatitis, and eczema patterns of intestinal colonization in Up to a 30% reduction in the incidence
by 27% in a low-risk population and breastfed versus commercial infant of type 1 diabetes mellitus is reported
up to 42% in infants with positive formula–fed infants may add to the for infants who exclusively breastfed for
family history.13,26 There are conflict- preventive effect of human milk.33 at least 3 months, thus avoiding expo-
ing studies that examine the timing of sure to cow milk protein.13,42 It has been
adding complementary foods after 4 postulated that the putative mechanism
Obesity
months and the risk of allergy, including in the development of type 1 diabetes
food allergies, atopic dermatitis, and Because rates of obesity are signifi-
mellitus is the infant’s exposure to cow
asthma, in either the allergy-prone or cantly lower in breastfed infants, na-
milk β-lactoglobulin, which stimulates
nonatopic individual.26 Similarly, there tional campaigns to prevent obesity
an immune-mediated process cross-
are no convincing data that delaying begin with breastfeeding support.34,35
reacting with pancreatic β cells. A re-
introduction of potentially allergenic Although complex factors confound
duction of 40% in the incidence of type
foods after 6 months has any protective studies of obesity, there is a 15% to
2 diabetes mellitus is reported, possi-
effect.27–30 One problem in analyzing 30% reduction in adolescent and adult
bly reflecting the long-term positive
this research is the low prevalence of obesity rates if any breastfeeding oc-
effect of breastfeeding on weight con-
exclusive breastfeeding at 6 months in curred in infancy compared with no
trol and feeding self-regulation.43
the study populations. Thus, research breastfeeding.13,36 The Framingham
outcomes in studies that examine the Offspring study noted a relationship of
breastfeeding and a lower BMI and Childhood Leukemia and
development of atopy and the timing of Lymphoma
introducing solid foods in partially higher high-density lipoprotein con-
breastfed infants may not be applica- centration in adults.37 A sibling dif- There is a reduction in leukemia
ble to exclusively breastfed infants. ference model study noted that the that is correlated with the duration of
breastfed sibling weighed 14 pounds breastfeeding.14,44 A reduction of 20%
Celiac Disease less than the sibling fed commercial in the risk of acute lymphocytic leuke-
There is a reduction of 52% in the risk infant formula and was less likely to mia and 15% in the risk of acute my-
of developing celiac disease in infants reach BMI obesity threshold.38 The eloid leukemia in infants breastfed for
who were breastfed at the time of duration of breastfeeding also is in- 6 months or longer.45,46 Breastfeeding
gluten exposure.31 Overall, there is an versely related to the risk of over- for less than 6 months is protective but
association between increased dura- weight; each month of breastfeeding of less magnitude (approximately 12%
tion of breastfeeding and reduced risk being associated with a 4% reduction and 10%, respectively). The question of
of celiac disease when measured as in risk.14 whether the protective effect of breast-
the presence of celiac antibodies. The The interpretation of these data is feeding is a direct mechanism of human
critical protective factor appears to confounded by the lack of a definition milk on malignancies or secondarily
be not the timing of the gluten expo- in many studies of whether human mediated by its reduction of early child-
sure but the overlap of breastfeeding milk was given by breastfeeding or by hood infections has yet to be answered.
at the time of the initial gluten in- bottle. This is of particular importance,
gestion. Thus, gluten-containing foods because breastfed infants self-regulate Neurodevelopmental Outcomes
should be introduced while the infant intake volume irrespective of maneu- Consistent differences in neurodevel-
is receiving only breast milk and not vers that increase available milk vol- opmental outcome between breastfed
infant formula or other bovine milk ume, and the early programming of and commercial infant formula–fed
products. self-regulation, in turn, affects adult infants have been reported, but the
weight gain.39 This concept is further outcomes are confounded by differences
Inflammatory Bowel Disease supported by the observations that in parental education, intelligence, home
Breastfeeding is associated with a infants who are fed by bottle, formula, environment, and socioeconomic sta-
31% reduction in the risk of child- or expressed breast milk will have tus.13,47 The large, randomized Pro-
hood inflammatory bowel disease.32 increased bottle emptying, poorer self- motion of Breastfeeding Intervention
The protective effect is hypothesized regulation, and excessive weight gain Trial provided evidence that adjusted
to result from the interaction of the in late infancy (older than 6 months) outcomes of intelligence scores and
immunomodulating effect of human compared with infants who only nurse teacher’s ratings are significantly
milk and the underlying genetic from the breast.40,41 greater in breastfed infants.48–50 In
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addition, higher intelligence scores These neurodevelopmental outcomes TABLE 3 Recommendations on
Breastfeeding Management for
are noted in infants who exclusively are associated with predominant and Preterm Infants
breastfed for 3 months or longer, and not necessarily exclusive human milk
1. All preterm infants should receive human milk.
higher teacher ratings were observed feeding. Human milk feeding in the NICU • Human milk should be fortified, with protein,
if exclusive breastfeeding was practiced also is associated with lower rates of minerals, and vitamins to ensure optimal
for 3 months or longer. Significantly severe retinopathy of prematurity.62,63 nutrient intake for infants weighingmonths, the relative risk of rheuma- DURATION OF EXCLUSIVE year and beyond as more and varied
toid arthritis was 0.8 (95% CI: 0.8–1.0), BREASTFEEDING complementary foods are introduced.
and if the cumulative duration of
The AAP recommends exclusive breast-
breastfeeding was longer than 24 CONTRAINDICATIONS TO
feeding for about 6 months, with con-
months, the relative risk of rheu- BREASTFEEDING
tinuation of breastfeeding for 1 year or
matoid arthritis was 0.5 (95% CI:
longer as mutually desired by mother There are a limited number of medical
0.3–0.8).73 An association between
and infant, a recommendation con- conditions in which breastfeeding is
cumulative lactation experience and
curred to by the WHO78 and the In- contraindicated, including an infant with
the incidence of adult cardiovascular
stitute of Medicine.79 the metabolic disorder of classic ga-
disease was reported by the Women’s
Health Initiative in a longitudinal study Support for this recommendation of lactosemia. Alternating breastfeeding
of more than 139 000 postmenopausal exclusive breastfeeding is found in the with special protein-free or modified
women.74 Women with a cumulative differences in health outcomes of in- formulas can be used in feeding in-
lactation history of 12 to 23 months fants breastfed exclusively for 4 vs 6 fants with other metabolic diseases
had a significant reduction in hyper- months, for gastrointestinal disease, (such as phenylketonuria), provided
tension (OR: 0.89; 95% CI: 0.84–0.93), otitis media, respiratory illnesses, that appropriate blood monitoring is
hyperlipidemia (OR: 0.81; 95% CI: 0.76– and atopic disease, as well as dif- available. Mothers who are positive for
0.87), cardiovascular disease (OR: ferences in maternal outcomes of human T-cell lymphotrophic virus type
0.90; 95% CI: 0.85–0.96), and diabetes delayed menses and postpartum I or II84 or untreated brucellosis85
(OR: 0.74; 95% CI: 0.65–0.84). weight loss.15,18,80 should not breastfeed nor provide ex-
pressed milk to their infants Breast-
Cumulative lactation experience also Compared with infants who never
feeding should not occur if the mother
correlates with a reduction in both breastfed, infants who were exclu-
has active (infectious) untreated tu-
breast (primarily premenopausal) and sively breastfed for 4 months had
berculosis or has active herpes sim-
ovarian cancer.13,14,75 Cumulative du- significantly greater incidence of lower
plex lesions on her breast; however,
ration of breastfeeding of longer than respiratory tract illnesses, otitis me-
expressed milk can be used because
12 months is associated with a 28% dia, and diarrheal disease than infants
there is no concern about these in-
decrease in breast cancer (OR: 0.72; exclusively breastfed for 6 months or
fectious organisms passing through
95% CI: 0.65–0.8) and ovarian cancer longer.15,18 When compared with in-
the milk. Breastfeeding can be re-
(OR: 0.72; 95% CI: 0.54–0.97).76 Each fants who exclusively breastfed for lon-
sumed when a mother with tubercu-
year of breastfeeding has been calcu- ger than 6 months, those exclusively losis is treated for a minimum of 2
lated to result in a 4.3% reduction in breastfed for 4 to 6 months had a four- weeks and is documented that she is
breast cancer.76,77 fold increase in the risk of pneumonia.15 no longer infectious.86 Mothers who
Furthermore, exclusively breastfeeding develop varicella 5 days before through
ECONOMIC BENEFITS for 6 months extends the period of 2 days after delivery should be sepa-
lactational amenorrhea and thus im- rated from their infants, but their
A detailed pediatric cost analysis
proves child spacing, which reduces expressed milk can be used for feed-
based on the AHRQ report concluded
the risk of birth of a preterm infant.81 ing.87 In 2009, the CDC recommended
that if 90% of US mothers would comply
with the recommendation to breastfeed The AAP is cognizant that for some that mothers acutely infected with
exclusively for 6 months, there would be infants, because of family and medical H1N1 influenza should temporarily be
a savings of $13 billion per year.24 The history, individual developmental status, isolated from their infants until they
savings do not include those related to and/or social and cultural dynamics, are afebrile, but they can provide
a reduction in parental absenteeism complementary feeding, including gluten- expressed milk for feeding.88
from work or adult deaths from dis- containing grains, begins earlier than In the industrialized world, it is not re-
eases acquired in childhood, such as 6 months of age.82,83 Because breast- commended that HIV-positive mothers
asthma, type 1 diabetes mellitus, or feeding is immunoprotective, when such breastfeed. However, in the developing
obesity-related conditions. Strategies complementary foods are introduced, it world, where mortality is increased in
that increase the number of mothers is advised that this be done while the non-breastfeeding infants from a com-
who breastfeed exclusively for about infant is feeding only breastmilk.82 bination of malnutrition and infectious
6 months would be of great economic Mothers should be encouraged to con- diseases, breastfeeding may outweigh
benefit on a national level. tinue breastfeeding through the first the risk of the acquiring HIV infection
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from human milk. Infants in areas milk, and their use by breastfeeding milk.111,112 Consumption of 1 to 2 por-
with endemic HIV who are exclusively mothers is of concern, particularly tions of fish (eg, herring, canned light
breastfed for the first 3 months are at with regard to the infant’s long-term tuna, salmon) per week will meet
a lower risk of acquiring HIV infection neurobehavioral development and thus this need. The concern regarding the
than are those who received a mixed are contraindicated.97 Alcohol is not possible risk from intake of excessive
diet of human milk and other foods a galactogogue; it may blunt prolactin mercury or other contaminants is
and/or commercial infant formula.89 response to suckling and negatively offset by the neurobehavioral benefits
Recent studies document that com- affects infant motor development.98,99 of an adequate DHA intake and can be
bining exclusive breastfeeding for 6 Thus, ingestion of alcoholic beverages minimized by avoiding the intake of
months with 6 months of antiretroviral should be minimized and limited to an predatory fish (eg, pike, marlin, mack-
therapy significantly decreases the occasional intake but no more than erel, tile fish, swordfish).113 Poorly
postnatal acquisition of HIV-1.90,91 0.5 g alcohol per kg body weight, nourished mothers or those on selec-
There is no contraindication to breast- which for a 60 kg mother is approxi- tive vegan diets may require a supple-
feeding for a full-term infant whose mately 2 oz liquor, 8 oz wine, or 2 ment of DHA as well as multivitamins.
mother is seropositive for cytomega- beers.100 Nursing should take place
lovirus (CMV). There is a possibility 2 hours or longer after the alcohol MATERNAL MEDICATIONS
intake to minimize its concentration in
that CMV acquired from mother’s milk Recommendations regarding breast-
the ingested milk.101 Maternal smok-
may be associated with a late-onset feeding in situations in which the
ing is not an absolute contraindica-
sepsis-like syndrome in the extremely mother is undergoing either diagnostic
tion to breastfeeding but should be
low birth weight (birth weightconcentrations. In addition, data re- emphasis is placed on the need to revise TABLE 4 WHO/UNICEF Ten Steps to
Successful Breastfeeding
garding the long-term neurobehavioral or discontinue disruptive hospital
effects from exposure to these agents policies that interfere with early skin- 1. Have a written breastfeeding policy that is
routinely communicated to all health care staff.
during the critical developmental pe- to-skin contact, that provide water, 2. Train all health care staff in the skills necessary
riod of early infancy are lacking. A glucose water, or commercial infant to implement this policy.
recent comprehensive review noted formula without a medical indication, 3. Inform all pregnant women about the benefits
and management of breastfeeding.
that of the 96 psychotropic drugs that restrict the amount of time the 4. Help mothers initiate breastfeeding within the
available, pharmacologic and clinical infant can be with the mother, that first hour of birth.
information was only available for 62 limit feeding duration, or that provide 5. Show mothers how to breastfeed and how to
maintain lactation even if they are separated
(65%) of the drugs.116 In only 19 was unlimited pacifier use. from their infants.
there adequate information to allow In 2009, the AAP endorsed the Ten Steps 6. Give newborn infants no food or drink other
for defining a safety protocol and thus program (see Table 4). Adherence to than breast milk, unless medically indicated.
qualifying to be compatible for use by 7. Practice rooming-in (allow mothers and infants
these 10 steps has been demonstrated to remain together) 24 h a day.
lactating mothers. Among the agents to increase rates of breastfeeding ini- 8. Encourage breastfeeding on demand.
considered to be least problematic tiation, duration, and exclusivity.122,123 9. Give no artificial nipples or pacifiers to
were the tricyclic antidepressants am- breastfeeding infants.a
Implementation of the following 5 post- 10. Foster the establishment of breastfeeding
itriptyline and clomipramine and the
partum hospital practices has been support groups and refer mothers to them on
selective serotonin-reuptake inhibitors discharge from hospital.
demonstrated to increase breastfeeding
paroxetine and sertraline. a
The AAP does not support a categorical ban on pacifiers
duration, irrespective of socioeconomic because of their role in SIDS risk reduction and their
Detailed guidelines regarding the ne- status: breastfeeding in the first hour analgesic benefit during painful procedures when breast-
cessity for and duration of temporary after birth, exclusive breastfeeding, feeding cannot provide the analgesia. Pacifier use in the
hospital in the neonatal period should be limited to spe-
cessation of breastfeeding after ma- rooming-in, avoidance of pacifiers, and cific medical indications such as pain reduction and
ternal exposure to diagnostic radio- receipt of telephone number for sup- calming in a drug-exposed infant, for example. Mothers
of healthy term breastfed infants should be instructed to
active compounds are provided by the port after discharge from the hospi- delay pacifier use until breastfeeding is well-established,
US Nuclear Regulatory Commission tal.124 usually about 3 to 4 wk after birth.
and in medical reviews.117–119 Special
The CDC National Survey of Maternity
precaution should be followed in the
Practices in Infant Nutrition and Care
situation of breastfeeding infants with
has assessed the lactation practices in reported that they distributed to
glucose-6-phosphate-dehydrogenase
more than 80% of US hospitals and breastfeeding mothers discharge packs
deficiency. Fava beans, nitrofurantoin,
noted that the mean score for imple- that contained commercial infant for-
primaquine, and phenazopyridine should
mentation of the Ten Steps was only mula, a practice that has been docu-
be avoided by the mother to minimize
65%.34,125 Fifty-eight percent of hospi- mented to negatively affect exclusivity
the risk of hemolysis in the infant.120
tals erroneously advised mothers to and duration of breastfeeding.127 Few
limit suckling at the breast to a spec- birth centers have model hospital pol-
HOSPITAL ROUTINES ified length of time, and 41% of the icies (14%) and support breastfeeding
The Sections on Breastfeeding and hospitals gave pacifiers to more than mothers after hospital discharge (27%).
Perinatal Pediatrics have published some of their newborns—both prac- Only 37% of centers practice more
the Sample Hospital Breastfeeding tices that have been documented than 5 of the 10 Steps and only 3.5%
Policy that is available from the AAP to lower breastfeeding rates and du- practice 9 to 10 Steps.34
Safe and Healthy Beginnings Web site.3,5 ration.126 The survey noted that in There is, thus, a need for a major
This sample hospital policy is based 30% of all birth centers, more than conceptual change in the organization
on the detailed recommendations of half of all newborns received supple- of the hospital services for the mother
the previous AAP policy statement mentation commercial infant formula, and infant dyad (Table 5). This re-
“Breastfeeding and the Use of Human a practice associated with shorter quires that medical and nursing rou-
Milk”1 as well as the principles of the duration of breastfeeding and less tines and practices adjust to the
1991 WHO/UNICEF publication “Tens exclusivity.34,125 As indicated in the principle that breastfeeding should
Steps to Successful Breastfeeding” benefits section, this early supple- begin within the first hour after birth
(Table 4)121 and provides a template for mentation may affect morbidity out- (even for Cesarean deliveries) and
developing a uniform hospital policy for comes in this population. The survey that infants must be continuously ac-
support of breastfeeding.122 In particular, also reported that 66% of hospitals cessible to the mother by rooming-in
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arrangements that facilitate around- until after the first feeding at the TABLE 5 Recommendations on
Breastfeeding Management for
the-clock, on-demand feeding for the breast but not later than 6 hours of Healthy Term Infants
healthy infant. Formal staff training age is recommended. A single oral
1. Exclusive breastfeeding for about 6 mo
should not only focus on updating dose of vitamin K should not be used, • Breastfeeding preferred; alternatively
knowledge and techniques for breast- because the oral dose is variably expressed mother’s milk, or donor milk
feeding support but also should ac- absorbed and does not provide ade- • To continue for at least the first year and
beyond for as long as mutually desired by
knowledge the need to change attitudes quate concentrations or stores for the mother and child
and eradicate unsubstantiated beliefs breastfed infant.132 • Complementary foods rich in iron and other
about the supposed equivalency of micronutrients should be introduced at about 6
Vitamin D deficiency/insufficiency and mo of age
breastfeeding and commercial infant rickets has increased in all infants as 2. Peripartum policies and practices that optimize
formula feeding. Emphasis should be a result of decreased sunlight expo- breastfeeding initiation and maintenance
placed on the numerous benefits of sure secondary to changes in lifestyle, should be compatible with the AAP and
Academy of Breastfeeding Medicine Model
exclusive breastfeeding. The importance dress habits, and use of topical sun- Hospital Policy and include the following:
of addressing the issue of the impact screen preparations. To maintain an • Direct skin-to-skin contact with mothers
of hospital practices and policies on adequate serum vitamin D concen- immediately after delivery until the first feeding
breastfeeding outcomes is highlighted is accomplished and encouraged throughout
tration, all breastfed infants routinely the postpartum period
by the decision of The Joint Commission should receive an oral supplement of • Delay in routine procedures (weighing,
to adopt the rate of exclusive breast vitamin D, 400 U per day, beginning at measuring, bathing, blood tests, vaccines, and
milk feeding as a Perinatal Care Core eye prophylaxis) until after the first feeding is
hospital discharge.133 completed
Measure.127 As such, the rate of exclu-
Supplementary fluoride should not be • Delay in administration of intramuscular
sive breastfeeding during the hospital vitamin K until after the first feeding is
provided during the first 6 months.
stay has been confirmed as a critical completed but within 6 h of birth
From age 6 months to 3 years, fluoride • Ensure 8 to 12 feedings at the breast every
variable when measuring the quality of
supplementation should be limited to 24 h
care provided by a medical facility. • Ensure formal evaluation and documentation
infants residing in communities where
of breastfeeding by trained caregivers
the fluoride concentration in the water (including position, latch, milk transfer,
Pacifier Use is(Brazil, Ghana, India, Norway, Oman, TABLE 6 Role of the Pediatrician support for mothers in the early weeks
and the United States).135 As such, the 1. Promote breastfeeding as the norm for infant postpartum. To assist in the educa-
WHO curves are “standards” and are feeding. tion of future physicians, the AAP rec-
2. Become knowledgeable in the principles and
the normative model for growth and management of lactation and breastfeeding. ommends using the evidence-based
development irrespective of infant 3. Develop skills necessary for assessing the Breastfeeding Residency Curriculum,4
ethnicity or geography reflecting the adequacy of breastfeeding. which has been demonstrated to im-
4. Support training and education for medical
optimal growth of the breastfed in- students, residents and postgraduate
prove knowledge, confidence, practice
fant.136 Use of the WHO curves for the physicians in breastfeeding and lactation. patterns, and breastfeeding rates. The
first 2 years allows for more accurate 5. Promote hospital policies that are compatible pediatrician’s own office-based prac-
monitoring of weight and height for with the AAP and Academy of Breastfeeding tice should serve as a model for how
Medicine Model Hospital Policy and the WHO/
age and, in comparison with use of UNICEF “Ten Steps to to support breastfeeding in the work-
the CDC reference curves, results in Successful Breastfeeding.” place. The pediatrician should also take
more accurate (lower) rates of un- 6. Collaborate with the obstetric community to the lead in encouraging the hospitals
develop optimal breastfeeding support
dernutrition and short stature and programs. with which he or she is affiliated to
(higher) rates of overweight. Fur- 7. Coordinate with community-based health care provide proper support and facilities
thermore, birth to 6-month growth professionals and certified breastfeeding for their employees who choose to
counselors to ensure uniform and
charts are available where the curves comprehensive breastfeeding support.
continue to breastfeed.
are magnified to permit monitoring of
weight trajectories. As such, the WHO
curves serve as the best guide for guide for coding to facilitate appropri- BUSINESS CASE FOR
assessing lactation performance because ate payment, suggested guidelines for BREASTFEEDING
they minimize mislabeling clinical sit- telephone triage of maternal breast- A mother/baby-friendly worksite pro-
uations as inadequate breastfeeding and feeding concerns, and information vides benefits to employers, including
identify more accurately and promptly regarding employer support for a reduction in company health care
overweight and obese infants. As of Sep- breastfeeding in the workplace. costs, lower employee absenteeism,
tember 2010, the CDC, with the concur- Evidence-based protocols from organ- reduction in employee turnover, and
rence of the AAP, recommended the use izations such as the Academy of increased employee morale and pro-
of the WHO curves for all children Breastfeeding Medicine provide de- ductivity.145,146 The return on invest-
younger than 24 months.137,138 tailed clinical guidance for manage- ment has been calculated that for
ment of specific issues, including the every $1 invested in creating and
recommendations for frequent and supporting a lactation support pro-
ROLE OF THE PEDIATRICIAN unrestricted time for breastfeeding so gram (including a designated pump
Pediatricians have a critical role in as to minimize hyperbilirubinemia site that guarantees privacy, avail-
their individual practices, communi- and hypoglycemia.4,142,143 The critical ability of refrigeration and a hand-
ties, and society at large to serve as role that pediatricians play is high- washing facility, and appropriate
advocates and supporters of suc- lighted by the recommended health mother break time) there is a $2 to $3
cessful breastfeeding (Table 6).139 De- supervision visit at 3 to 5 days of age, dollar return.147 The Maternal and
spite this critical role, studies have which is within 48 to 72 hours after Child Health Bureau of the US De-
demonstrated lack of preparation and discharge from the hospital, as well partment of Health and Human Serv-
knowledge and declining attitudes as pediatricians support of practices ices, with support from the Office of
regarding the feasibility of breast- that avoid non–medically indicated Women’s Health, has created a pro-
feeding.140 The AAP Web site141 pro- supplementation with commercial in- gram, “The Business Case for Breast-
vides a wealth of breastfeeding-related fant formula.144 feeding,” that provides details of
material and resources to assist and Pediatricians also should serve as economic benefits to the employer
support pediatricians in their critical breastfeeding advocates and educa- and toolkits for the creation of such
role as advocates of infant well-being. tors and not solely delegate this role programs.148 The Patient Protection
This includes the Safe and Healthy to staff or nonmedical/lay volunteers. and Affordable Care Act passed by
Beginnings toolkit,5 which includes re- Communicating with families that Congress in March 2010 mandates
sources for physician’s office for pro- breastfeeding is a medical priority that that employers provide “reasonable
motion of breastfeeding in a busy is enthusiastically recommended by break time” for nursing mothers and
pediatric practice setting, a pocket their personal pediatrician will build private non-bathroom areas to express
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breast milk during their workday.149 and the mother and, in turn, optimize Richard J. Schanler, MD
The establishment of these initiatives infant, child, and adult health as well as
as the standard workplace environ- child growth and development. Re- SECTION ON BREASTFEEDING
ment will support mothers in their cently, published evidence-based stud- EXECUTIVE COMMITTEE, 2011–2012
Margreete Johnston, MD
goal of supplying only breast milk to ies have confirmed and quantitated the Susan Landers, MD
their infants beyond the immediate risks of not breastfeeding. Thus, infant Larry Noble, MD
postpartum period. feeding should not be considered as Kinga Szucs, MD
a lifestyle choice but rather as a basic Laura Viehmann, MD
health issue. As such, the pediatrician’s
CONCLUSIONS PAST CONTRIBUTING EXECUTIVE
role in advocating and supporting
Research and practice in the 5 years COMMITTEE MEMBERS
proper breastfeeding practices is es-
Lori Feldman-Winter, MD
since publication of the last AAP policy sential and vital for the achievement of Ruth Lawrence, MD
statement have reinforced the conclu- this preferred public health goal.35
sion that breastfeeding and the use of STAFF
human milk confer unique nutritional LEAD AUTHORS Sunnah Kim, MS
and nonnutritional benefits to the infant Arthur I. Eidelman, MD Ngozi Onyema, MPH
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