More and more women are breastfeeding in the United States; >83% of infants born in 2016 initiated breastfeeding, exceeding the Healthy People 2020 goal of 81.9%. Unfortunately, only 25% were still exclusively breastfeeding through 6 months,1 falling short of American Academy of Pediatrics (AAP) recommendations that mothers should exclusively breastfeed their infants for the first 6 months of life and then continue breastfeeding for at least the first year of life with the addition of complementary foods.2 Moreover, data from the Centers for Disease Control and Prevention Infant Feeding Practices Study II indicate that 60% of US women are not reaching their own breastfeeding goals.3 In this issue of Pediatrics, Eilers et al4 describe similar findings of high breastfeeding initiation in Texas but with short duration, especially among Mexican-origin women born in the United States. This observation coincides with disparities in breastfeeding that are especially pronounced among African American mothers, with both decreased initiation compared with other groups as well as a rapid drop off in both duration and exclusivity.5
Importantly, the authors found that in all subpopulations, formula supplementation within the first week was a strong predictor of cessation of breastfeeding,4 a finding that is consistent with other studies.6 This is a key lesson for pediatricians, who are perfectly positioned to direct breastfeeding care in these early days of life and should limit formula supplementation to only what is medically necessary. Pediatricians should assist mothers in breastfeeding support through in-office assessments as well as connections to local breastfeeding resources. Pediatrician referral to community support groups may help diminish supplementation as mothers feel more secure and less inclined to use unnecessary milk substitutes.
Medically necessary supplementation guidelines have been outlined recently by the Academy of Breastfeeding Medicine.7 In addition, new weight-loss nomograms can assist clinicians by predicting infant weight-loss trajectories so that, along with clinical information, supplementation can be carefully addressed in the early days of life.8 When supplementation is required, the first choice is a mother’s own milk, by pumping or hand expression, followed by pasteurized donor human milk if available and then formula as a last option, in volumes that are appropriate for infant age and size.7 Furthermore, pediatricians play a crucial role in protecting the maternal milk supply by encouraging milk expression with pumping and/or hand expression whenever supplementation is required and decreasing the amount of supplementation as clinically appropriate (increased maternal milk supply, improved infant transfer, etc).9
Pediatricians also can make a difference in a mother’s success toward reaching her breastfeeding goals in other ways. Perhaps unsurprisingly, breastfeeding problems in the first 3 to 7 days of life (exactly when pediatricians first see newborns in the outpatient setting) are associated with decreased duration of breastfeeding. Commonly cited breastfeeding concerns include difficulties with latching on, painful breastfeeding, and concerns about milk supply.10 Although pediatricians may not think that maternal nipple pain is a part of the infant’s visit, recognition of this issue at the 3- to 5-day checkup, with appropriate breastfeeding management to assess latching or refer for help, can save the breastfeeding relationship. Pediatricians can also assess risk factors for low milk supply and be alert to issues with infant weight gain related to maternal conditions (eg, obesity, diabetes, thyroid disease, polycystic ovarian syndrome, or breast surgeries) as well as infant conditions.9 Special situations such as late-preterm breastfeeding can be particularly challenging because these infants often do not transfer milk effectively and fall asleep during feeding. Pediatricians then can identify the need for supplementation and give advice about protecting the maternal milk supply through pumping until the infant is ready to feed successfully. Pediatricians can also help mothers navigate maternal medications while breastfeeding with the use of excellent resources such as the Drugs and Lactation Database (also known as LactMed).11
Eilers et al4 highlight the importance of cultural influences on infant feeding. Pediatricians need to understand the cultural context of their patients and provide culturally appropriate support. A new AAP policy statement defines racism as a core social determinant of health and key driver of health inequities,12 and this is certainly true for breastfeeding disparities.13,14 This statement urges pediatricians to implement systems to ensure that all families will be treated with respect, offer culturally effective guidance, and provide high-quality care to all. For breastfeeding to be more successful in the 21st century, our health care system must shift gears and invest more heavily in training health providers to ensure community- and culturally-based breastfeeding counseling that will help induce behavior change.15
To that end, the AAP is leading a cooperative agreement funded by the Centers for Disease Control and Prevention, “Physician Education and Training on Breastfeeding,” to equip physicians to give culturally appropriate and necessary care to the breastfeeding dyad to improve breastfeeding success.16 The Physician Advisory Committee, which includes stakeholders from a variety of medical specialities and advocacy groups, is also addressing the importance of breastfeeding support beyond the physician office; the need to support our physicians in training with their own breastfeeding experience; and revising the Breastfeeding Curriculum, expanding to learners in medical school and beyond residency. Pediatricians can also access breastfeeding education and guidelines on the Section on Breastfeeding Web site and connect to their AAP chapter breastfeeding coordinators (www.aap.org/breastfeeding). The Academy of Breastfeeding Medicine protocols (www.bfmed.org) are evidenced-based resources that are available to the public and address a multitude of breastfeeding topics for both mothers and infants.
As pediatricians, we are the right persons, in the right place, at the right time, to support mothers and families for breastfeeding success.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2742.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.