Section 1: Breastfeeding Background
Breastfeeding as the Norm
Breastfeeding is widely acknowledged as the ideal method of providing optimal infant nutrition. Breastmilk is the most complete food for babies and provides all of the nutrients needed for the first 6 months.1
ACOG supports the AAP recommendation of breastfeeding for one year or more with exclusive breastfeeding for about the first 6 months. Artificial milk interferes with the newborn’s immune system and gut colonization.2
Not breastfeeding is associated with a wide array of health risks to the infant including ear, respiratory and gastrointestinal infection, SIDS, allergic disease, celiac and inflammatory bowel disease, necrotizing enterocolitis, certain pediatric cancers, type 1 diabetes, and obesity.3
Improved maternal outcomes for breastfeeding mothers have been recognized for a range of health conditions including type 2 diabetes mellitus, breast and ovarian cancer, rheumatoid arthritis, cardiovascular disease, and post-partum depression.4
The 2013 Breastfeeding Report Card from the CDC6 shows that 77% of US infants are breastfed at least once after being born, but by six months, the percentage of infants breastfeeding decreases to 49%. Rates of exclusive breastfeeding, the method of infant feeding most likely to protect against infection and chronic disease, are less impressive. Twenty-four percent of infants receive formula supplementation by the second day of life. At three months, exclusive breastfeeding rates fall to 37.7%, and at six months they fall to 16.4%.67
Breastfeeding and Disparities
Breastfeeding rates among WIC participants have improved significantly in recent years. The WIC breastfeeding initiation rate increased from 42% in 1998 to 67% in 2012. However, disparities still exist as rates among low-income families still fall short of those achieved in the general population. In comparison to the US data reported above, the proportion of WIC infants with any breastfeeding for six or more months ranged from 22% to 29%.7 2011 WIC data demonstrate that there is also a significant disparity with exclusive breastfeeding; nationally only 11% of WIC infants were exclusively breastfeeding at three months, and only 8% were exclusively breastfeeding at six months. Read more.
A recent article based on nationally-representative longitudinal data highlighted the importance of breastfeeding in addressing socioeconomic disparities.
Infants predominantly fed formula for the first six months were 2.5 times more likely to be obese at 24 months of age compared to infants predominantly fed breast milk. The early introduction of solid foods (<4 months) and putting the child to bed with a bottle also increased the likelihood of obesity.
Based on the findings from this study, unhealthy infant feeding practices were identified as the primary mechanism mediating the relationship between socioeconomic status and early childhood obesity.49
The data demonstrate that the majority of families want to breastfeed, but many do not always have the support to continue the recommended durations or intensity. Interventions aimed at improving breastfeeding exclusivity in the immediate postpartum period as well as those targeting increasing breastfeeding durations are required to meet public health breastfeeding goals and to achieve maximum health outcomes. Interventions must include community-level partnerships that enable social change to address health disparities and improve health outcomes for all.
Dispelling Myths about Breastfeeding
Perception of Insufficient Milk Supply
The vast majority of mothers and babies have the biological capability to breastfeed.
Image courtesy of Hallmark Health SystemInsufficient supply is a common myth and needs to be addressed as it is a frequent cause of early weaning.- Most women have the ability to produce a sufficient milk supply for their babies. Neifert estimates that “5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.” 8
- As with many health states (e.g., diabetes) there are interactions among genetics, physiological phenomena, and environmental or external factors when it comes to achieving successful breastfeeding, including a sufficient milk supply. It is very difficult to discern which variables cause a specific outcome because the variables are related and study designs that could adequately disentangle them are not feasible or ethical.
- Since building milk production capabilities is a prerequisite, the woman needs support, encouragement and education to feed often in the early weeks to build her milk supply and reduce doubt about her ability to meet her infant’s nutrition needs. Women who are not confident and who have a negative body image are likely to less likely to trust in their ability to provide sufficient nutrition to their newborn.
- Health care professionals have vital roles in helping mothers achieve self-efficacy in developing their milk supplies as they do with other health behaviors related to nutrition and physical activity. Evidence exists for how to build milk supply and health professionals can encourage the behaviors that help build the supply, along with recognizing when there is a physiological basis for lactation shortfalls, as we do with other health states that are determined from a blend of physiology and behavior.
Lactation specialists can help sort through the variables associated with achieving sufficient milk supply if there are doubts or concerns.
Perceptions about Contraindications for Breastfeeding
Breastfeeding is NOT contraindicated with the following conditions5:
- infants born to mothers who are hepatitis B surface antigen-positive
- mothers who are infected with hepatitis C virus (persons with hepatitis C virus antibody or hepatitis C virus-RNA-positive blood)
- mothers who are febrile (unless cause is a contraindication)
- mothers who have been exposed to low-level environmental chemical agents
- mothers who are seropositive carriers of cytomegalovirus (CMV) (not recent converters if the infant is term)
- mothers who smoke tobacco (though they should be encouraged to quit) or have an occasional celebratory drink
Contraindications for Breastfeeding
The following contraindications for breastfeeding are based on The Joint Commission’s Perinatal Care Core Measure PC-05 1:
- HIV infection
- Human t-lymphotrophic virus type I or II
- Substance abuse and/or alcohol abuse
- Active, untreated tuberculosis
- Taking certain medications, i.e., prescribed cancer chemotherapy, radioactive isotopes, antimetabolites, antiretroviral medications and other medications where the risk of morbidity outweighs the benefits of breast milk feeding
- Undergoing radiation therapy
- Active, untreated varicella
- Active herpes simplex virus with breast lesions (however, feeding on breast without lesions is fine)
The American Academy of Pediatrics policy statement offers recommendations on other conditions that may require further investigation.5
Dr. David Meyers, Director of the Center for Primary Care at AHRQ said it best: “The evidence suggests that the debate over the relative value of breastfeeding compared with artificial means of feeding is over, as the data are unequivocal in favor of breastfeeding. The challenge must now be to establish appropriate systems and resources to support women and families who are interested in breastfeeding.” 48
This support becomes critical in the context of the Healthy People 2020 goals for breastfeeding: 81.9% ever breastfeeding, 60.6% breastfeeding at six months, 34.1% breastfeeding at one year, 46.2% exclusively breastfeeding at three months, and 25.5% exclusively breastfeeding at six months (the recommendation of the American Academy of Pediatrics).5
