Updated AAP guidance continues to recommend exclusive breastfeeding for six months, with complementary foods introduced around six months. Under the new policy, the AAP now supports continued breastfeeding until two years or beyond, as mutually desired by mother and child.
The recommendation is consistent with those of the American Academy of Family Physicians and Canadian Paediatric Society.
An updated policy statement and technical report outline the medical and neurodevelopmental advantages of breastfeeding, along with the role pediatricians play as advocates and clinicians.
The policy and report Breastfeeding and the Use of Human Milk, from the Section on Breastfeeding, are available at https://doi.org/10.1542/peds.2022-057988 and https://doi.org/10.1542/peds.2022-057989 and will be published in the July issue of Pediatrics.
The new AAP guidance is an update from 2012, which recommended continued breastfeeding for up to one year or longer.
Preliminary data reveal that human milk in the second year of life continues to be a significant source of macronutrients and immunologic factors for growing toddlers. Studies and meta-analyses also have confirmed the impact of breastfeeding longer than 12 months on maternal health, in decreasing maternal type 2 diabetes mellitus, hypertension, breast cancer and ovarian cancer rates.
The AAP policy statement approaches infant feeding from a public health perspective. It states that breastfeeding is about far more than the nutrition provided to the growing child. It also is about the relationship between parent and child.
More than 80% of women in the U.S. initiate breastfeeding, but only 25.8% exclusively breastfeed by six months. In addition, 19% of breastfed infants receive infant formula supplements in the first 48 hours after birth.
There are significant sociodemographic and cultural differences in breastfeeding, with the lowest rates of initiation among non-Hispanic Black or African American populations. Similar disparities exist among low-income mothers, younger women and those with a high school education or less.
Implementation of one breastfeeding support program decreased the disparity between Black and White infants by nearly 9.6%, and peer-support interventions by Women, Infants and Children programs also have improved rates and duration.
Pediatricians’ communication with families about the benefits of breastfeeding can increase initiation, duration and exclusivity. Still, the policy states that exclusive or any breastfeeding is not always possible, and mothers and families need support for their decisions.
Data show that for children who were breastfed, the following acute and chronic pediatric disorders occur less frequently: otitis media, acute diarrheal disease, lower respiratory illnesses, sudden infant death syndrome, inflammatory bowel disease, childhood leukemia, diabetes mellitus, obesity, asthma and atopic dermatitis.
Establishment of breastfeeding
Early skin-to-skin care and frequent feeding are recommended to facilitate the transition from drops of colostrum to ounces of milk. By the third to fourth day after delivery, most mothers experience more copious milk production.
Implementation of hospital practices that support breastfeeding also include breastfeeding in the first hour after birth, rooming-in and exclusive breastfeeding.
The policy addresses breastfeeding and human milk for the very low birth weight infant, late preterm and early term infants, hyperbilirubinemia, adoption or surrogacy, infants born to gender-diverse families, and vitamin and mineral supplements such as the need for vitamin K and vitamin D.
Contraindications, special considerations
Infants with classic galactosemia should not be breastfed. While most maternal infections are compatible with breastfeeding, U.S. mothers should not breastfeed or express their milk to infants if they have HIV infection, human T-cell lymphotropic virus type I or II infection, untreated brucellosis or confirmed Ebola virus disease.
Breastfeeding also is contraindicated if mothers are using illicit opioids, cocaine or PCP.
In most cases, mothers with prenatal opioid use can initiate breastfeeding and practice exclusive breastfeeding to mitigate the impact of potential withdrawal on the newborn. Some newborns may require pharmacologic treatment. Infants need close monitoring throughout hospitalization and in the outpatient setting for signs of withdrawal and for appropriate weight gain.
Maternal marijuana use is discouraged because data are insufficient to assess the effects of infants’ exposure. Women should be informed of the potential risk, including the risk of secondhand smoke exposure.
Moderate alcohol consumption (up to one standard drink per day) is not known to be harmful to the infant.
Breastfeeding mothers should be encouraged strongly to stop smoking and minimize secondhand exposure.
Other key recommendations
- Birth centers and hospitals should implement maternity care practices that improve breastfeeding initiation, duration and exclusivity.
- Pediatricians need to be knowledgeable about the health benefits of breastfeeding and its management. They can implement supportive practices in their office and partner with community resources such as lactation specialists.
- Most maternal conditions, medications and vaccinations are compatible with breastfeeding. Resources include LactMed (https://bit.ly/3amUC7Y).
- Pediatricians can assist parents who have given birth to preterm and other vulnerable infants to establish a full supply of milk by working with hospital staff to facilitate early, frequent milk expression. Pasteurized donor human milk is recommended for very low birth weight infants when the mother’s milk is not available or as a supplement to it.
- Pediatricians can promote socially and culturally sensitive policies that support breastfeeding families and address inequities in the delivery of care in the office, hospital and community to eliminate disparities in breastfeeding.
- Pediatricians play a key role in leading and advocating for policies that protect breastfeeding, including universal paid maternity leave and insurance coverage for lactation support and breast pumps.