A New Policy Update on Breastfeeding: What All Clinicians Need To Know

Editor’s note: Article originally published in the Cleveland Clinic Journal of Medicine (2023; 90 [8]:469-473)

By Heidi Szugye, DO; Ali Murra, BS and Suet Kam Lam, MD, MPH, MS,

The most recent policy statement on breastfeeding from the American Academy of Pediatrics (AAP)1 focuses on enhanced communication with and support for breastfeeding mothers and babies — i.e., the breastfeeding dyad — and urges clinicians to increase their understanding of breastfeeding and their ability to support it.

For brevity, this article uses terms such as mother and breastfeeding, but the authors recognize there is terminology that may be preferred over these terms for patients depending on their gender identity and feeding method, such as chestfeeding, breast-milk feeding, lactating parent, and human-milk feeding, and efforts should be made to use the patient’s preferred language in the clinical setting.2

Who is the intended audience?

The updated guidelines primarily address clinicians caring for pediatric patients, but the recommendations are relevant for any clinician caring for a breastfeeding mother or infant.

Who wrote the guidelines?

The policy update relied on the consensus of the clinical expertise of the AAP Section on Breastfeeding Executive Committee and evidence from recently published peer-reviewed literature. No conflicts of interest were reported.1

Which recommendations remain the same?

The update reinforces the importance, duration, and considerations of breastfeeding and human milk consumption in mothers and newborns. Some of these recommendations remain unchanged from previous AAP guidelines.

Benefits

Breastfeeding confers short-term and long-term benefits to mothers and infants that are important to communicate to patients, especially in the prenatal setting. The beneficial effects encompass disease processes that represent most specialties, and clinicians of all disciplines should be aware of them.

For infants, breastfeeding is associated with decreased risk of otitis media, upper and lower respiratory tract infections, asthma, bronchiolitis, necrotizing enterocolitis, atopic dermatitis, celiac disease, gastroenteritis, inflammatory bowel disease, type 1 and type 2 diabetes mellitus, leukemia, childhood obesity, and sudden infant death syndrome. Maternal benefits include lower risk of postpartum hemorrhage, postpartum depression, cardiovascular disease, hypertension, hyperlipidemia, type 2 diabetes, rheumatoid arthritis, endometrial cancer, thyroid cancer, breast cancer, and ovarian cancer.1,3–7

Duration

The AAP recommends that infants be breastfed exclusively for 6 months with slow integration of complementary foods, when developmentally appropriate, at about 6 months. Earlier introduction of complementary foods can increase the risk of acute respiratory and diarrheal illnesses.1

Contraindications

The policy reiterates known contraindications to breastfeeding, including galactosemia, maternal human T-cell lymphotropic virus type I or II, untreated maternal brucellosis or tuberculosis, and human immunodeficiency virus (HIV) with high viral loads. (Note: A recommendation from the US Department of Health and Human Services published after the AAP guideline allows for breastfeeding in mothers with undetected HIV viral load.8) Infants should not breastfeed from or receive milk from a breast with active herpes lesions, but babies can breastfeed from or receive milk from the unaffected breast.1

Special considerations

Maternal medications. Most medications are compatible with breastfeeding, and information is readily available. Drugs and Lactation Database (LactMed)9 of the National Library of Medicine and National Institutes of Health can be accessed online at no cost. The book Hale’s Medications and Mother’s Milk 202310 is available through the libraries of many medical institutions. The website InfantRisk Center11 provides information, an app for a small fee, and a free hotline with access to a trained nurse.

Medications with an L5 rating are incompatible with breastfeeding. The L5 rating means that “studies in breastfeeding mothers have demonstrated that there is significant and documented risk to the infant based on human experience…and the risk of using the drug in breastfeeding women clearly outweighs any possible benefit from breastfeeding.”12 Most L5-rated medications are chemotherapeutic agents.10

Preterm infants. Additional benefits of breast milk include prevention of respiratory illness and improved neurodevelopmental outcomes in preterm infants.1

Advocacy and support

Early clinician intervention to support breastfeeding initiation, duration, and exclusivity leads to longer duration of and compliance with exclusive breastfeeding.13 Hospitals and birth centers should implement maternity care practices to encourage breastfeeding initiation, duration, and exclusivity. Initiating skin-to-skin contact and frequent breastfeeding with support as early as possible maximizes breastfeeding benefits, duration, and compliance. Clinicians are encouraged to assess breastfeeding dyads for challenges and to grow comfortable managing them or, alternatively, to cultivate appropriate referral sources and contacts for patient support.1

What differs from prior guidelines?

Since its last update in 2012,14 the AAP made several new recommendations and additions to its breastfeeding policy.

Benefits

Research has shown that cumulative breastfeeding time correlates inversely with maternal risk of breast, ovarian, endometrial, and thyroid cancer.15–17 The updated policy addresses the effects of sociodemographic and cultural differences and other disparities on rates of breastfeeding, as well as health outcomes of populations affected by disparities.

Duration

The most publicized part of the update is support for mothers to breastfeed for 2 years and beyond. Previously, the AAP had recommended breastfeeding for at least 1 year. The change was made in response to patients reporting feeling alienated or shamed from breastfeeding longer than 1 year. Neutral, nonjudgmental language will promote support for breastfeeding mothers and diminish shaming of their infant-feeding decisions.

Inclusive and supportive language is important for lactating mothers, especially those who choose to breastfeed beyond 1 year. Questions such as “Are you still breastfeeding?” rather than “What and how are you feeding your child?” can feel judgmental and lead to feelings of alienation and embarrassment and withholding information. The policy change was also a response to new research concluding additional benefit associated with breastfeeding beyond 1 year.15,18 These recommendations align with those of the World Health Organization (WHO) and US Centers for Disease Control and Prevention (CDC).1

Contraindications

Suspected or confirmed Ebola virus was added to the list of contraindications to breastfeeding.1

Special considerations

The 2022 AAP policy emphasizes the need for clinicians to recognize the impact of various infant and maternal factors on breastfeeding management.1

Maternal delayed lactogenesis II, or a delay in the breast milk “coming in” around 72 hours postpartum, affects a special population. Maternal risk factors for delayed lactogenesis include obesity, diabetes mellitus, hypertension, cesarean delivery, and preterm labor. Monitoring the infant’s weight, intake, and output is important, as these infants are at risk for the need of supplementation with formula or donor breast milk. Mothers also need support, as they are at earlier risk of breastfeeding cessation despite the low milk supply being temporary.

Very low birth-weight infants. Mothers of very low birth-weight infants are encouraged to continue to use expressed breast milk to decrease the risks of necrotizing enterocolitis, late-onset sepsis, chronic lung disease, and retinopathy of prematurity in infants. Compared with term infants, late-preterm and early-term infants reportedly have decreased breastfeeding rates, stressing the need for more support for these infants.1

Infant hyperbilirubinemia. Increased numbers of breastfeeding sessions per day were associated with lower infant bilirubin concentrations among infants with hyperbilirubinemia. Phototherapy is not an indication for formula supplementation if the baby is hydrated or levels of bilirubin are above exchange transfusion levels. Breast milk jaundice can persist for up to 3 months, and no specific management is needed.1

Infants at high risk of peanut allergy. In infants with high risk of peanut allergy (severe eczema or known egg allergy), introducing peanut products as early as 4 to 6 months has been shown to decrease the risk of developing peanut allergies by over 80% at 5 years of age compared to delaying introduction until 12 months.19 It is recommended that these patients consult a pediatric allergist prior to offering peanut products.19

Adoption and surrogacy. Breastfeeding is possible in the case of adoption or surrogacy. It requires the adopting or intended breastfeeding parent to prepare months in advance to offset the lack of typical hormonal changes that occur with pregnancy. Preparation includes taking oral contraceptive therapy and providing stimulation of the breasts every 3 hours with a breast pump.1

Prenatal maternal opioid users. It is preferable to breastfeed exclusively and have the mother and newborn sleep in the same room (i.e., to “room in”). While this decreases withdrawal symptoms in infants, infants should be closely monitored in inpatient and outpatient settings for withdrawal symptoms.1

Marijuana. Although the use of marijuana is discouraged, there are insufficient data to assess the exposure effects on breastfeeding infants.1

Smoking cessation. Most nicotine smoking cessation products are safe for breastfeeding mothers to use. Although varenicline can be effective for nicotine smoking cessation, little is known about its safety during lactation, so it is not recommended at this time.1,9,10

Hepatitis B virus. In mothers known to be hepatitis B surface antigen-positive, their infants should receive the initial dose of the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. However, administration should not delay the initiation of breastfeeding, ideally within the first hour of birth.1

Hepatitis C virus. Hepatitis C is detected in maternal milk, but transmission is not documented. Breastfeeding is contraindicated only if the nipples are cracked and bleeding.1

Mastitis. Mastitis occurs in one-third of postpartum women and is compatible with breastfeeding. The Academy of Breastfeeding Medicine (ABM) published a protocol in 202220 that addresses the clinical spectrum and management of this inflammatory condition. Risk factors include exclusive pumping and hyperlactation. Initial management should include continued physiologic breastfeeding or pumping to comfort rather than to empty completely, ice, ibuprofen, and lymphatic drainage techniques to reduce soft-tissue edema. If no improvement is seen with conservative measures, management may require antibiotics against Staphylococcus aureus (dicloxacillin 500 mg 4 times per day for 10 to 14 days).20 Abscesses require drainage.1,20

Children of gender-diverse parents. These patients may have less access to human milk because of social and biologic constraints. Additionally, the word breastfeeding itself may be both triggering and inaccurate. Chestfeeding may be the preferred term in this population.1

Maternal imaging. Routine administration of iodinated contrast or gadolinium is not contraindicated in breastfeeding mothers, as very little contrast enters breast milk and an even smaller fraction is absorbed in the infant gastrointestinal system. Some nuclear medicine procedures require separation of mother and infant for 12 hours immediately after imaging because of the radioactive substances in the mother’s system. Radiography and mammography are safe for breastfeeding mothers. “Trash the Pump and Dump,”21 a website created by the Institute for the Advancement of Breastfeeding and Lactation Education, includes detailed evidence-based information on safety of various radiologic procedures.1,21,22

Advocacy and support beyond pediatrics

The updated policy calls for support and advocacy beyond the pediatric community. Regardless of specialty or discipline, clinicians must be aware of rare and absolute contraindications to breastfeeding. It is also important to know which medications, procedures, and imaging modalities are compatible with breastfeeding. Ideally, this information is included in medical training. Awareness among clinicians can help mothers and their infants avoid unnecessary breastfeeding disruptions and risks associated with breastfeeding cessation.23 Policies created at the federal, state, local, and workplace levels should encourage and implement strategies to support breastfeeding, including adequate universal paid maternity and partner/paternity leave, broader insurance coverage, and workplace-protected time and space to express milk and otherwise support and encourage mothers to sustain breastfeeding.1

Do other societies agree or disagree?

The CDC, WHO, ABM, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, United Nations International Children’s Emergency Fund, and Canadian Pediatric Society all make the same duration recommendations as the AAP, including exclusive breastfeeding for the first 6 months of life, followed by slow integration of complementary foods until 1 year, and encouraging breastfeeding for 2 years or longer as mutually desired.24–29

How will this change daily practice?

The AAP policy update emphasizes the breadth and depth of care needed for the breastfeeding dyad. Mothers at risk of breastfeeding challenges should be identified prenatally by their clinician and be provided appropriate education, counseling, and resources. Those with feeding challenges immediately after delivery warrant close follow-up by their primary care physician and a breastfeeding specialist. Breastfeeding medicine, an emerging specialty, can offer these families an added layer of support and expertise. The challenges mothers and infants face are varied, and the mother-infant dyad should be assessed by a clinician experienced in diagnosing and managing breastfeeding challenges.

Clinicians and other healthcare providers need to be aware of patient populations with lower rates of breastfeeding and develop interventions to ensure easy access to support. Breastfeeding support groups, printed and online educational resources, care coordinators, virtual visits, and a larger geographic presence of lactation consultants and breastfeeding medicine clinicians can ensure improved support. We encourage healthcare institutions to promote a supportive environment for breastfeeding that includes lactation training at all levels of patient-facing healthcare and to create their own evidence-based patient education breastfeeding resources or curate existing resources such as those of the ABM and the Institute for the Advancement of Breastfeeding and Lactation Education.30 Clinicians and patients should be made aware of the health benefits of breastfeeding for mothers and infants and view it as a preventive health measure beyond a nutritional source for infants.

When would the guidelines not apply?

The new AAP policy recommendations align with those of other societal and global organizations, such as the WHO and CDC. Guidelines may be difficult to apply to all settings, as access to resources may vary. For example, the benefits of breastfeeding may outweigh the risks for mothers with HIV in resource-constrained countries. In addition, cultural norms surrounding breastfeeding inform many areas of this practice, such as duration, exclusivity, and support. While the guidelines would be difficult to implement in settings with limited public and workplace policies to support breastfeeding, there is much work to be done at local and widespread levels to make these new recommendations applicable to all interested dyads.

Disclosures

The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.

References

1. Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics 2022; 150(1):e2022057988.
2. Bartick M, Stehel EK, Calhoun SL, et al. Academy of Breastfeeding Medicine Position Statement and Guideline: Infant Feeding and Lactation-Related Language and Gender. Breastfeed Med. 2021;16(8):587–590.
3. Schwarz EB, Brown JS, Creasman JM, et al. Lactation and maternal risk of type 2 diabetes: a population-based study [published correction appears in Am J Med 2011; 124(10):e9]. Am J Med 2010; 123(9):863.e1–863.e8636.
4. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol 2009; 113(5):974–982.
5. Gunderson EP, Jacobs DR Jr., Chiang V, et al. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: a 20-year prospective study in CARDIA (Coronary Artery Risk Development in Young Adults). Diabetes 2010; 59(2):495–504.
6. Stuebe AM, Michels KB, Willett WC, Manson JE, Rexrode K, Rich-Edwards JW. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. Am J Obstet Gynecol 2009; 200(2):138.e1–138.e1388.
7. Ram KT, Bobby P, Hailpern SM, et al. Duration of lactation is associated with lower prevalence of the metabolic syndrome in midlife—SWAN, the Study of Women’s Health Across the Nation. Am J Obstet Gynecol 2008; 198(3):268.e1–268.e2686.
8. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretro-viral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Department of Health and Human Services. Updated January 31, 2023. https://clinicalinfo.hiv.gov/en/guidelines/perinatal. Accessed July 10, 2023.Google Scholar
9. National Institute of Child Health and Human Development. Drugs and lactation database (LactMed). https://www.ncbi.nlm.nih.gov/books/NBK501922/?report=reader. Accessed July 10, 2023.Google Scholar
10. Hale TW, Krutsch K. Hale’s medications & mothers’ milk 2023: a manual of lactational pharmacology. New York, NY: Springer Publishing Company; 2022.
11. Texas Tech University Health Sciences Center. InfantRisk Center. https://infantrisk.com. Accessed July 10, 2023.
12. Springer Publishing. Dr. Hale’s lactation risk categories. https://www.halesmeds.com/mnemonics/47704. Accessed July 10, 2023.
13. Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 2003; 112(1 Pt 1):108–115.
14. Section on Breastfeeding; Eidelman AI, Schanler RJ, et al. Breastfeeding and the use of human milk. Pediatrics 2012; 129(3):e827–e841.
15. Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr 2015; 104(467):96–113.
16. Jordan SJ, Na R, Johnatty SE, et al. Breastfeeding and endometrial cancer risk: an analysis from the Epidemiology of Endometrial Cancer Consortium. Obstet Gynecol 2017; 129(6):1059–1067.
17. Yi X, Zhu J, Zhu X, Liu GJ, Wu L. Breastfeeding and thyroid cancer risk in women: a dose-response meta-analysis of epidemiological studies. Clin Nutr 2016; 35(5):1039–1046.
18. Rameez RM, Sadana D, Kaur S, et al. Association of maternal lactation with diabetes and hypertension: a systematic review and meta-analysis. JAMA Netw Open 2019; 2(10):e1913401.
19. Trogen B, Jacobs S, Nowak-Wegrzyn A. Early introduction of allergenic foods and the prevention of food allergy. Nutrients 2022; 14(13):2565.
20. Mitchell KB, Johnson HM, Rodríguez JM, et al. Academy of Breastfeeding Medicine clinical protocol #36: The mastitis spectrum, revised 2022 [published correction appears in Breastfeed Med 2022; 17(11):977–978]. Breastfeed Med 2022; 17(5):360–376.
21. Institute for the Advancement of Breastfeeding and Lactation Education. About trash the pump and dump. https://trashthepumpanddump.org/about/. Accessed July 10, 2023.
22. Mitchell KB, Fleming MM, Anderson PO, Giesbrandt JG; Academy of Breastfeeding Medicine. ABM clinical protocol #31: radiology and nuclear medicine studies in lactating women. Breastfeed Med 2019; 14(5):290–294.
23. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep) 2007; (153):1–186.
24. Centers for Disease Control and Prevention. Breastfeeding. Maternity practices in infant nutrition and care (mPINC) survey. Updated May 25, 2023. https://www.cdc.gov/breastfeeding/data/mpinc/.
25. World Health Organization. Breastfeeding. https://www.who.int/health-topics/breastfeeding#tab=tab_1. Accessed July 10, 2023.
26. American College of Obstetricians and Gynecologists Breastfeeding Expert Work Group, Committee on Obstetric Practice; Crowe SD, Hanley LE. ACOG Committee Opinion Number 756. Optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol 2018; 132(4):e187–e196.
27. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). https://www.aafp.org/about/policies/all/breastfeeding-position-paper.html. Accessed July 10, 2023.
28. Chantry CJ, Eglash A, Labbok M. ABM position on breastfeeding—revised 2015. Breastfeed Med 2015; 10(9):407–411.
29. Canadian Paediatric Society. The baby-friendly initiative: protecting, promoting and supporting breastfeeding. Updated February 2, 2021. https://cps.ca/en/documents/position/baby-friendly-initiative-breastfeeding.
30. Institute for the Advancement of Breastfeeding and Lactation Education. https://lacted.org/. Accessed July 10, 2023.