SUMMARY: 

There are many maternal and fetal benefits to breastfeeding yet many women find multiple barriers to successful breastfeeding.  Both ACOG and the American Academy of Pediatrics recommend exclusive breastfeeding the first 6 months. Childhood benefits to breastfeeding include decreased rate of infections, decreased rates of obesity, and decreased rates of sudden infant death syndrome.  Maternal benefits include decreased risk of metabolic syndrome and decreased rates of ovarian and breast cancer as well as better birth spacing.  Below, we summarize how to optimize support and address barriers to breastfeeding.

Background 

Initiation and Continuation of Breastfeeding

• Initiation rate for breastfeeding: 84.1%
  •  Rate is high and above the Healthy People 2020 target of 81.9%
• Disparities within breastfeed initiation are notable
  • Low-income women and those receiving WIC have lower initiation rates
• Continuation rates at 6 months are much lower than initiation rates

Education and Support

• Obstetric history should include
  • Breast surgeries | Prior breastfeeding duration | Prior difficulties
• Pregnant women with breastfeeding difficulties are at higher risk of depression
• There are very few contraindications to breastfeeding and include
  • Active untreated tuberculosis or varicella
  • Active herpes simplex lesions on the nipple

HIV

• AAP recommends that a parent with HIV should be counseled that the only infant feeding method that removes any risk for postnatal HIV transmission is complete avoidance of breastfeeding
• However, AAP recommends that breastfeeding “should be supported” for those with HIV following comprehensive counseling if the following conditions are met
  • ART was initiated early in or before pregnancy
  • There is evidence of sustained viral suppression in the parent (HIV viral load <50 copies per mL)
  • The parent demonstrates a commitment to consistently taking their own ART and to giving infant ARV prophylaxis
  • The parent has continuous ART access

Prenatal Care

• Begin conversations with open-ended questions
  • Phrasing such as: “What have you heard about breastfeeding?”
• Discuss prior difficulties
• Breast examination: Assessment and evaluation
  • Lactation during pregnancy and tandem nursing are expected to increase as breastfeeding rates increase
  • Decrease in milk supply or new-onset nipple soreness should prompt pregnancy testing with decreased lactation
  • No increase in abortions or preterm birth among breastfeeding women who become pregnant
  • Increased risk of anemia in current pregnancy

The WHO’s “Ten Steps to Successful Breastfeeding”

The Relevant Intrapartum Components for Clinicians and Nurses Include:

• Written infant feeding policies, monitoring of data, and clear communication
• Knowledgeable staff with skills to support breastfeeding
• Discuss breastfeeding with patients, including importance and management
• Early skin-to-skin
• Assist in initiation of breastfeeding and manage common difficulties
• Avoid medically unnecessary alternative food or fluids to breastfed infants
• Infant rooming-in 24-hours
• Feed on demand and assist in recognizing infants’ hunger cues
• Provide counseling on bottles and pacifiers
• Coordinate discharge with out-of-hospital support resources

Note: The WHO’s Ten Steps to Successful Breastfeeding (see ‘Learn More – Primary Sources’) leads to higher rates of initiation and continuation of breastfeeding, as well as lowered racial inequities between rates

Common Concerns

• Preterm delivery:
  • May affect infant’s latch and feeding stamina
  • Should still be encouraged even if begins with pumping
  • As infant grows, lactation support or RN can aid in latch and feeding
  • Infants fed human milk have lower rates of: Necrotizing enterocolitis | Retinopathy of prematurity | Late onset sepsis | Lower readmission rates first year of life
  • Counseling and support should be emphasized for patients with preterm infants
• Mothers taking medications
  • Most medications are safe for breastfeeding and lactation pharmacy resources should be consulted for up-to-date resources
  • LactMed® is a database of the National Library of Medicine which contains information on drugs and other chemicals to which breastfeeding mothers may be exposed (see ‘Learn More – Primary Sources’ below)
• Self-perception of low milk supply
  • Typically reflects misinterpretation of normal infant feeding behaviors, low production, or inadequate milk transfer
  • Most common cause is inadequate breast stimulation
  • Limited evidence for medications and herbal galactagogues to increase supply
• Pain with feeding
  • Many women find pain to be a serious concern and limiting factor
  • Most common cause is poor or inadequate latch | Recommend evaluation or lactation consultation to improve effective milk transfer
  • Engorgement can occur 3-5 days postpartum, evidence of lactogenesis II and more mature milk production
  • Other mechanical concerns, such as misuse or trauma from breast pump can occur
  • Infection is commonly on the differential, including candida, herpes, mastitis, or zoster
  • Consider more rare causes, such as vasospasm or allodynia (functional pain)
• Limitations on forms of birth control options
  • Progesterone-only contraception is acceptable for postpartum with estrogen-containing contraceptives is safe after 1 month given risk of VTE
  • Progesterone-only OCP (“mini-pill”) requires same time administration daily which may prove challenging given lack of consistent life schedule with infant
  •  Of note, the WHO and the CDC diverge on recommendations with the WHO recommending that primarily breastfeeding persons avoid any hormonal contraception the first 6 months after birth

Barriers to Breastfeeding

Hospital Barriers to Breastfeeding

• In-hospital breastfeeding support is an important aspect to improve breastfeeding rates
• Practitioners should be aware of alternatives such as donor human milk banks, especially for high-risk neonates such as low birth weight or preterm infants

Societal Barriers to Breastfeeding

• Individual experiences, including historical factors and racialized experiences, play a role in initiation and continuation rates
• Lack of, or inadequate parental leave policies, may have a detrimental effect with fewer resources at lower-wage jobs
• ACA supports breastfeeding through coverage of breast pumps, reasonable lactation breaks at work, and privacy to express breast milk

Other Barriers

• Practitioner barriers include lack of resources and availability of community resources
• Consider
  • Prenatal lactation classes | Lactation consultants | Home-visit practitioners | Local and national support groups
  • Telehealth interventions
• Provide
  • Trauma-informed approach to care for patients
  • Information and support for LGBQT+ individuals
• Complex medical issues decrease rates of breastfeeding
  • Substance use disorder is not a strict contraindication to breastfeeding

KEY POINTS:

• Breastfeeding has many benefits
• While initiation rates are comparable to goals, continuation at 3 and 6 months could be improved
• Identification of community resources and barriers to support breastfeeding is key to improve continuation rates
• Practitioners should know the available community and online resources for patients
• ACOG, in alignment with the AAP, “supports continued breastfeeding while complementary foods are introduced, as long as mutually desired by lactating parent and child for two years or beyond”

Learn More – Primary Sources and Additional Guidelines:

ACOG Committee Opinion 821: Barriers to Breastfeeding: Supporting Initiation and Continuation of Breastfeeding

ACOG Committee Opinion 756: Optimizing Support for Breastfeeding as Part of Obstetric Practice

ACOG: Practice Advisory to Update the Duration of Breastfeeding

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

NIH: Drugs and Lactation Database (LactMed)

WHO’s Ten Steps to Successful Breastfeeding

AAP: Infant Feeding for Persons Living With and at Risk for HIV in the United States

Breastfeeding Resources for Families of Color

National Medical Association: Breastfeeding

HHS (Office of Women’s Health): It’s Only Natural

Black Mothers Breast Feeding Association