AAP eBooks

Breastfeeding: Support, Challenges, and Benefits

By American Academy of Pediatrics

This print compendium of AAP editor-curated articles provides quick access to the latest, most salient studies to give a better understanding of the individual and public health effects of breastfeeding.


  1. Page 6
  2. Page 10
    Address correspondence to Joan Younger Meek, MD, MS, RD, FAAP, IBCLC. E-mail: joan.meek@med.fsu.edu.

    The landscape of breastfeeding has changed over the past several decades as more women initiate breastfeeding in the postpartum period and more hospitals are designated as Baby-Friendly Hospitals by following the evidence-based Ten Steps to Successful Breastfeeding. The number of births in such facilities has increased more than sixfold over the past decade. With more women breastfeeding and stays in the maternity facilities lasting only a few days, the vast majority of continued breastfeeding support occurs in the community. Pediatric care providers evaluate breastfeeding infants and their mothers in the office setting frequently during the first year of life. The office setting should be conducive to providing ongoing breastfeeding support. Likewise, the office practice should avoid creating barriers for breastfeeding mothers and families or unduly promoting infant formula. This clinical report aims to review practices shown to support breastfeeding that can be implemented in the outpatient setting, with the ultimate goal of increasing the duration of exclusive breastfeeding and the continuation of any breastfeeding.

  3. Page 39
    Address correspondence to Lori Feldman-Winter, MD, MPH, FAAP, Department of Pediatrics, Children’s Regional Hospital at Cooper University Hospital, Three Cooper Plaza Suite 309, Camden, NJ 08103. E-mail: winter-lori@cooperhealth.edu

    BACKGROUND AND OBJECTIVES The American Academy of Pediatrics (AAP) has affirmed breastfeeding as the preferred method of infant feeding; however, there has been little systematic examination of how pediatricians’ recommendations, affiliated hospitals’ policies, counseling practices, and attitudes toward breastfeeding have shifted over the past 2 decades. These trends were examined from 1995 to 2014.

    METHODS Data are from the Periodic Survey (PS) of Fellows, a nationally representative survey of AAP members. PS #30 (1995; response rate = 72%; N = 832), PS #57 (2004; response rate = 55%; N = 675), and PS #89 (2014; response rate = 51%; N = 620) collected demographics, patient and practice characteristics, and detailed responses on pediatricians’ recommendations, affiliated hospitals’ policies, counseling practices, and attitudes toward breastfeeding. By using bivariate statistics and logistic regression models, the analysis investigated changes over time with predicted values (PVs).

    RESULTS From 1995 to 2014, more pediatricians reported their affiliated hospitals applied for “baby-friendly” designation (PV = 12% in 1995, PV = 56% in 2014; P < .05), and more reported that they recommend exclusive breastfeeding (65% to 76% [P < .05]). However, fewer respondents indicated that mothers can be successful breastfeeding (PV = 70% in 1995, PV = 57% in 2014; P < .05) and that the benefits outweigh the difficulties (PV = 70% in 1995, PV = 50% in 2014; P < .05). Younger pediatricians were less confident than older pediatricians in managing breastfeeding problems (P < .01).

    CONCLUSIONS Pediatricians’ recommendations and practices became more closely aligned with AAP policy from 1995 to 2014; however, their attitudes about the likelihood of breastfeeding success have worsened. These 2 divergent trends indicate that even as breastfeeding rates continue to rise, continued efforts to enhance pediatricians’ training and attitudes about breastfeeding are necessary.

  4. Page 50
    Address correspondence to Trang Nguyen, MD, DrPH, Offi ce of Public Health Practice, New York, State Department of Health, Room 913 Corning Tower at ESP, Albany, NY 12237. E-mail: trang.nguyen@health.ny.gov

    OBJECTIVES We examined the variation between 126 New York hospitals in formula supplementation among breastfed infants after adjusting for socioeconomic, maternal, and infant factors and stratifying by level of perinatal care.

    METHODS We used 2014 birth certificate data for 160 911 breastfed infants to calculate hospital-specific formula supplementation percentages by using multivariable hierarchical logistic regression models.

    RESULTS Formula supplementation percentages varied widely among hospitals, from 2.3% to 98.3%, and was lower among level 1 hospitals (18.2%) than higher-level hospitals (50.6%–57.0%). Significant disparities in supplementation were noted for race and ethnicity (adjusted odds ratios [aORs] were 1.54–2.05 for African Americans, 1.85–2.74 for Asian Americans, and 1.25–2.16 for Hispanics, compared with whites), maternal education (aORs were 2.01–2.95 for ≤12th grade, 1.74–1.85 for high school or general education development, and 1.18–1.28 for some college or a college degree, compared with a Master’s degree), and insurance coverage (aOR was 1.27–1.60 for Medicaid insurance versus other). Formula supplementation was higher among mothers who smoked, had a cesarean delivery, or diabetes. At all 4 levels of perinatal care, there were exemplar hospitals that met the HealthyPeople 2020 supplementation goal of ≤14.2%. After adjusting for individual risk factors, the hospital-specific, risk-adjusted supplemental formula percentages still revealed a wide variation.

    CONCLUSIONS A better understanding of the exemplar hospitals could inform future efforts to improve maternity care practices and breastfeeding support to reduce unnecessary formula supplementation, reduce disparities, increase exclusive breastfeeding and breastfeeding duration, and improve maternal and child health outcomes.

  5. Page 63
    Address correspondence to Jennifer Abbass-Dick, PhD, Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe St North, Oshawa, Ontario, Canada, L1H 7K4. E-mail: jennifer.abbassdick@uoit.ca

    OBJECTIVE To evaluate the effectiveness of a coparenting intervention on exclusive breastfeeding among primiparous mothers and fathers.

    METHODS A randomized controlled trial was conducted in a large teaching hospital in Toronto, Canada. Couples were randomized to receive either usual care (n = 107) or a coparenting breastfeeding support intervention (n = 107). Follow-up of exclusive breastfeeding and diverse secondary outcomes was conducted at 6 and 12 weeks postpartum.

    RESULTS Significantly more mothers in the intervention group than in the control group continued to breastfeed at 12 weeks postpartum (96.2% vs 87.6%, P = .02). Although proportionately more mothers in the intervention group were exclusively breastfeeding at 6 and 12 weeks, these differences were not significant. Fathers in the intervention group had a significantly greater increase in breastfeeding self-efficacy scores from baseline to 6 weeks postpartum compared with fathers in the control group (P = .03). In addition, significantly more mothers in the intervention group than in the control group reported that their partners provided them with breastfeeding help in the first 6 weeks (71% vs 52%, P = .02) and that they were satisfied with their partners’ involvement with breastfeeding (89% vs 78.1%, P = .04). Mothers in the intervention group were also more satisfied with the breastfeeding information they received (81% vs 62.5%, P < .001).

    CONCLUSIONS The significant improvements in breastfeeding duration, paternal breastfeeding selfefficacy, and maternal perceptions of paternal involvement and assistance with breastfeeding suggest that a coparenting intervention involving fathers warrants additional investigation.

  6. Page 74
    Address correspondence to Chelsea O. McKinney, PhD, MPH, NorthShore University HealthSystem Department of Pediatrics and Research Institute, 1001 University Place, Suite 348, Evanston, IL 60201. E-mail: chelseaomckinney@gmail.com

    OBJECTIVES Breastfeeding rates differ among racial/ethnic groups in the United States. Our aim was to test whether racial/ethnic disparities in demographic characteristics, hospital use of infant formula, and family history of breastfeeding mediated racial/ethnic gaps in breastfeeding outcomes.

    METHODS We analyzed data from the Community and Child Health Network study (N = 1636). Breastfeeding initiation, postnatal intent to breastfeed, and breastfeeding duration were assessed postpartum. Hierarchical linear modeling was used to estimate relative odds of breastfeeding initiation, postnatal intent, and duration among racial/ethnic groups and to test the candidate mediators of maternal age, income, household composition, employment, marital status, postpartum depression, preterm birth, smoking, belief that “breast is best, ” family history of breastfeeding, in-hospital formula introduction, and WIC participation.

    RESULTS Spanish-speaking Hispanic mothers were most likely to initiate (91%), intend (92%), and maintain (mean duration, 17.1 weeks) breastfeeding, followed by English-speaking Hispanic mothers (initiation 90%, intent 88%; mean duration, 10.4 weeks) and white mothers (initiation 78%, intent 77%; mean duration, 16.5 weeks); black mothers were least likely to initiate (61%), intend (57%), and maintain breastfeeding (mean duration, 6.4 weeks). Demographic variables fully mediated disparities between black and white mothers in intent and initiation, whereas demographic characteristics and in-hospital formula feeding fully mediated breastfeeding duration. Family breastfeeding history and demographic characteristics helped explain the higher breastfeeding rates of Hispanic mothers relative to white and black mothers.

    CONCLUSIONS Hospitals and policy makers should limit in-hospital formula feeding and consider family history of breastfeeding and demographic characteristics to reduce racial/ethnic breastfeeding disparities.

  7. Page 85
    Address correspondence to Prof. Dr. med. Dietrich Rothenbacher, MPH, Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstrasse 22, D-89081 Ulm, Germany. E-mail: dietrich.rothenbacher@uni-ulm.de

    BACKGROUND Breastfeeding is an important determinant of early infant immune function and potentially future health. Although numerous studies have reported rising breastfeeding initiation rates and duration, few longitudinally investigated the impact of shifting societal and lifestyle factors on breastfeeding patterns in developed nations.

    METHODS The Ulm Birth Cohort Study (UBCS) and Ulm SPATZ Health Study (SPATZ) cohorts consist of newborns and their mothers recruited, respectively, from 2000 to 2001 and 2012 to 2013 at the University Medical Center Ulm, Germany. Cox proportional hazards models were used to estimate crude and mutually adjusted hazard ratios for study effect (time trend) and individual risk factors on noninitiation and duration of predominant and total breastfeeding.

    RESULTS Compared with UBCS mothers, SPATZ mothers had lower cessation rates of both predominant breastfeeding by 4 months and total breastfeeding by 6 months: hazard ratio (95% confidence interval) 0.79 (0.67–0.93) and 0.71 (0.60–0.82), respectively. However, this crude time trend was limited to mothers with higher educational achievement. Similar time trend effects were observed among less educated mothers only after adjustment for early cessation risk factors. Mutually adjusted hazard ratios for individual risk factors were similar in both studies: low education, high BMI, smoking within 6 weeks of delivery, and cesarean delivery were associated with early breastfeeding cessation beginning at 6 weeks. In addition, actively abstaining from drinking alcohol was associated with lower rates of early cessation.

    CONCLUSIONS Our results suggest widening socioeconomic disparity in breastfeeding and potentially subsequent child health, which may require new targeted interventions.

  8. Page 96
    Address correspondence to Karen Glazer Peres, BDS, PhD, Australian Research Centre for Population Oral Health, Adelaide Dental School, University of Adelaide, 122, Frome St, Adelaide, Australia 5000. E-mail: karen.peres@adelaide.edu.au

    BACKGROUND Few studies have assessed the effect of breastfeeding, bottle feeding, and sugar consumption on children’s dental caries. We investigated whether the duration of breastfeeding is a risk factor for dental caries in the primary dentition, independently of sugar consumption.

    METHODS An oral health study (n = 1303) nested in a birth cohort study was carried out in southern Brazil. The average number of decayed, missing, and filled primary tooth surfaces (dmfs) and severe early childhood caries (S-ECC: dmfs ≥6) were investigated at age 5 years. Breastfeeding was the main exposure collected at birth and at 3, 12, and 24 months of age. Data on sugar consumption were collected at 24, 48, and 60 months of age. Marginal structural modeling was used to estimate the controlled direct effect of breastfeeding (0-12, 13-23, and ≥24 months) on dmfs and on S-ECC.

    RESULTS The prevalence of S-ECC was 23.9%. The mean number of dmfs was 4.05. Children who were breastfed for ≥24 months had a higher number of dmfs (mean ratio: 1.9; 95% confidence interval: 1.5–2.4) and a 2.4 times higher risk of having S-ECC (risk ratio: 2.4; 95% confidence interval: 1.7–3.3) than those who were breastfed up to 12 months of age. Breastfeeding between 13 and 23 months had no effect on dental caries.

    CONCLUSIONS Prolonged breastfeeding increases the risk of having dental caries. Preventive interventions for dental caries should be established as early as possible because breastfeeding is beneficial for children’s health. Mechanisms underlying this process should be investigated more deeply.

  9. Page 111
    Address correspondence to Lisa-Christine Girard, PhD, School of Public Health, Physiotherapy, and Sports Science, University College Dublin, Geary Institute for Public Policy, Room B205, Belfi eld, Dublin 4, Ireland. E-mail: lisa.girard@ucd.ie

    BACKGROUND AND OBJECTIVES There is mixed evidence from correlational studies that breastfeeding impacts children’s development. Propensity score matching with large samples can be an effective tool to remove potential bias from observed confounders in correlational studies. The aim of this study was to investigate the impact of breastfeeding on children’s cognitive and noncognitive development at 3 and 5 years of age.

    METHODS Participants included ∼8000 families from the Growing Up in Ireland longitudinal infant cohort, who were identified from the Child Benefit Register and randomly selected to participate. Parent and teacher reports and standardized assessments were used to collect information on children’s problem behaviors, expressive vocabulary, and cognitive abilities at age 3 and 5 years. Breastfeeding information was collected via maternal report. Propensity score matching was used to compare the average treatment effects on those who were breastfed.

    RESULTS Before matching, breastfeeding was associated with better development on almost every outcome. After matching and adjustment for multiple testing, only 1 of the 13 outcomes remained statistically significant: children’s hyperactivity (difference score, –0.84; 95% confidence interval, –1.33 to –0.35) at age 3 years for children who were breastfed for at least 6 months. No statistically significant differences were observed postmatching on any outcome at age 5 years.

    CONCLUSIONS Although 1 positive benefit of breastfeeding was found by using propensity score matching, the effect size was modest in practical terms. No support was found for statistically significant gains at age 5 years, suggesting that the earlier observed benefit from breastfeeding may not be maintained once children enter school.

  10. Page 127
    Address correspondence to John M.D. Thompson, PhD, Department of Paediatrics: Child and Youth Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. E-mail: j.thompson@auckland.ac.nz

    CONTEXT Sudden infant death syndrome (SIDS) is a leading cause of postneonatal infant mortality. Our previous meta-analyses showed that any breastfeeding is protective against SIDS with exclusive breastfeeding conferring a stronger effect. The duration of breastfeeding required to confer a protective effect is unknown.

    OBJECTIVE To assess the associations between breastfeeding duration and SIDS.

    DATA SOURCES Individual-level data from 8 case-control studies.

    STUDY SELECTION Case-control SIDS studies with breastfeeding data.

    DATA EXTRACTION Breastfeeding variables, demographic factors, and other potential confounders were identified. Individual-study and pooled analyses were performed.

    RESULTS A total of 2267 SIDS cases and 6837 control infants were included. In multivariable pooled analysis, breastfeeding for <2 months was not protective (adjusted odds ratio [aOR]: 0.91, 95% confidence interval [CI]: 0.68–1.22). Any breastfeeding ≥2 months was protective, with greater protection seen with increased duration (2–4 months: aOR: 0.60, 95% CI: 0.44– 0.82; 4–6 months: aOR: 0.40, 95% CI: 0.26–0.63; and >6 months: aOR: 0.36, 95% CI: 0.22– 0.61). Although exclusive breastfeeding for <2 months was not protective (aOR: 0.82, 95% CI: 0.59–1.14), longer periods were protective (2–4 months: aOR: 0.61, 95% CI: 0.42–0.87; 4–6 months: aOR: 0.46, 95% CI: 0.29–0.74).

    LIMITATIONS The variables collected in each study varied slightly, limiting our ability to include all studies in the analysis and control for all confounders.

    CONCLUSIONS Breastfeeding duration of at least 2 months was associated with half the risk of SIDS. Breastfeeding does not need to be exclusive to confer this protection.

  11. Page 138
    Address for correspondence to Takashi Yorifuji, MD, PhD, Department of Human Ecology, Okayama University Graduate School of Environmental and Life Science, 3-1-1 Tsushima-naka, Kita-ku, Okayama 700-8530, Japan. E-mail: yorichan@md.okayama-u.ac.jp

    BACKGROUND AND OBJECTIVES Kawasaki disease (KD) is the most common cause of childhood-acquired heart disease in developed countries. However, the etiology of KD is not known. Aberrant immune responses are considered to play key roles in disease initiation and breastfeeding can mature immune system in infants. We thus examined the association between breastfeeding and the development of KD.

    METHODS We used a nationwide population-based longitudinal survey ongoing since 2010 and restricted participants to a total of 37 630 children who had data on their feeding during infancy. Infant feeding practice was queried at 6 to 7 months of age, and responses to questions about hospital admission for KD during the period from 6 to 30 months of age were used as outcome. We conducted logistic regression analyses controlling for child and maternal factors with formula feeding without colostrum as our reference group.

    RESULTS A total of 232 hospital admissions were observed. Children who were breastfed exclusively or partially were less likely to be hospitalized for KD compared with those who were formula fed without colostrum; odds ratios for hospitalization were 0.26 (95% confidence interval: 0.12–0.55) for exclusive breastfeeding and 0.27 (95% confidence interval: 0.13–0.55) for partial breastfeeding. Although the risk reduction was not statistically significant, feeding colostrum only also provided a protective effect.

    CONCLUSIONS We observed protective effects of breastfeeding on the development of KD during the period from 6 to 30 months of age in a nationwide, population-based, longitudinal survey in Japan, the country in which KD is most common.

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