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 2018 Breastfeeding Report Card from the CDC shows that 83.2% of US infants are breastfed at least once after being born, but by six months, the percentage of infants breastfeeding decreases to 57.6%. Rates of exclusive breastfeeding, the method of infant feeding most likely to protect against infection and chronic disease, are less impressive. Seventeen percent of breastfed infants receive formula supplementation by the second day of life. At three months, exclusive breastfeeding rates fall to 46.9%, and at six months they fall to about 25%.6
Breastfeeding and Disparities
According to the CDC’s National Immunization Survey, 2011-2015, 81.5% of White non-Hispanic and 81.9% of Hispanic women initiated breastfeeding, but only 64.3% of Black, non-Hispanic women initiated breastfeeding. The disparity is even more alarming when looking at breastfeeding exclusivity. White non-Hispanic exclusive breastfeeding rates at 6 months are 22.5%, while Hispanic women and Black non-Hispanic women were 18.2% and 14.0%.7 This dramatic decline reflects a myriad of breastfeeding obstacles that our Black and Hispanic mothers encounter. Women of color face may more barriers including lack of access to specialized breastfeeding support, less social and family support, shorter maternity leave, as well as unfavorable maternity care practices.
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 and improving maternity care practices nationwide will influence social change to address health disparities and improve health outcomes for all. Recent initiatives such as (Communities and Hospitals Advancing Maternity Practices) CHAMPS and Best Fed Beginnings Project have demonstrated positive outcomes in breastfeeding among African American breastfeeding dyads.8
Dispelling Myths about Breastfeeding
Perception of Insufficient Milk Supply
The vast majority of mothers and babies have the biological capability to breastfeed.
- Insufficient 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.”9 However, birth intervention and medical complication rates in women have increased such that the percentage of women with primary insufficiency is likely higher.
- As with many medical conditions (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 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
- caution with bleeding nipples-hepatitus C is usually contraindicated while nipples are healing.
- mothers who are febrile
- 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 drink
Contraindications for Breastfeeding
The Center for Disease Control describes special circumstances and contraindications to breastfeeding.
Reasons mothers should NOT breastfeed or feed expressed breast milk:
- Infant diagnosed with Galactosemia
- Mother is infected with the human immunodeficiency virus (HIV)1 (Note: recommendations about breastfeeding and HIV may be different in other countries)
- Mother is infected with human T-cell lymphotropic virus type I or type II
- Mother using illicit street drugs such as PCP (phencyclidine) or cocaine1 (Exception: Narcotic-dependent mothers who are enrolled in a supervised methadone program and have a negative screening for HIV infection and other illicit drugs can breastfeed)
Mothers should temporarily NOT breastfeed and should NOT feed expressed breast milk to their infants if:
- Mother is infected with untreated brucellosis
- Mother is taking certain medications
- The mother is undergoing diagnostic imaging with radiopharmaceuticals
- Mother has an active herpes simplex virus (HSV) infection with lesions present on the breast (Note: Mothers can breastfeed directly from the unaffected breast if lesions on the affected breast are covered completely to avoid transmission)
Mothers should temporarily NOT breastfeed, but CAN feed expressed breast milk if:
- Mother has untreated, active tuberculosis (Note: The mother may resume breastfeeding once she has been treated appropriately for 2 weeks and is documented to be no longer contagious)
- Mother has active varicella external (chicken pox) infection that developed within the 5 days prior to delivery to the 2 days following delivery
The American Academy of Pediatrics policy statement offers recommendations on other conditions that may require further investigation.5