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AMERICAN ACADEMY OF PEDIATRICS
POLICY STATEMENT
Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children Breastfeeding and the Use of Human Milk
ABSTRACT.
Considerable advances have occurred in
tions are consistent with the goals and objectives of recent years in the scientific knowledge of the benefits of
Healthy People 2010,4 the Department of Health and breastfeeding, the mechanisms underlying these bene-
Human Services’ HHS Blueprint for Action on Breastfeed- fits, and in the clinical management of breastfeeding.
ing,5 and the United States Breastfeeding Committee’s This policy statement on breastfeeding replaces the 1997
Breastfeeding in the United States: A National Agenda.6 policy statement of the American Academy of Pediatrics
This statement provides the foundation for issues and reflects this newer knowledge and the supporting
publications. The benefits of breastfeeding for the in-
related to breastfeeding and lactation management fant, the mother, and the community are summarized,
for other AAP publications including the New Moth- and recommendations to guide the pediatrician and other
er’s Guide to Breastfeeding7 and chapters dealing with health care professionals in assisting mothers in the ini-
breastfeeding in the AAP/American College of Ob- tiation and maintenance of breastfeeding for healthy
stetricians and Gynecologists Guidelines for Perinatal term infants and high-risk infants are presented. The
Care,8 the Pediatric Nutrition Handbook,9 the Red policy statement delineates various ways in which pedi-
Book,10 and the Handbook of Pediatric Environmental atricians can promote, protect, and support breastfeeding
not only in their individual practices but also in the
hospital, medical school, community, and nation. Pedi-
atrics 2005;115:496–506; breast, breastfeeding, breast milk,
human milk, lactation.
Child Health Benefits
Human milk is species-specific, and all substitute feeding preparations differ markedly from it, making ABBREVIATIONS. AAP, American Academy of Pediatrics; WIC,Supplemental Nutrition Program for Women, Infants, and Children; human milk uniquely superior for infant feeding.12 CMV, cytomegalovirus; G6PD, glucose-6-phosphate dehydrogenase.
Exclusive breastfeeding is the reference or normativemodel against which all alternative feeding methods INTRODUCTION
must be measured with regard to growth, health, Extensive research using improved epidemio- development,andallothershort-andlong-termout- logic methods and modern laboratory tech- comes. In addition, human milk-fed premature in- niques documents diverse and compelling ad- fants receive significant benefits with respect to host vantages for infants, mothers, families, and society protection and improved developmental outcomes from breastfeeding and use of human milk for infant compared with formula-fed premature infants.13–22 feeding.1 These advantages include health, nutri- From studies in preterm and term infants, the fol- tional, immunologic, developmental, psychologic, lowing outcomes have been documented.
social, economic, and environmental benefits. In1997, the American Academy of Pediatrics (AAP) published the policy statement Breastfeeding and the Research in developed and developing countries Use of Human Milk.2 Since then, significant advances of the world, including middle-class populations in in science and clinical medicine have occurred. This developed countries, provides strong evidence that revision cites substantial new research on the impor- human milk feeding decreases the incidence and/or tance of breastfeeding and sets forth principles to severity of a wide range of infectious diseases23 in- guide pediatricians and other health care profession- cluding bacterial meningitis,24,25 bacteremia,25,26 di- als in assisting women and children in the initiation arrhea,27–33 respiratory tract infection,22,33–40 necro- and maintenance of breastfeeding. The ways pedia- tizing enterocolitis,20,21 otitis media,27,41–45 urinary tricians can protect, promote, and support breast- tract infection,46,47 and late-onset sepsis in preterm feeding in their individual practices, hospitals, med- infants.17,20 In addition, postneonatal infant mortal- ical schools, and communities are delineated, and the ity rates in the United States are reduced by 21% in central role of the pediatrician in coordinating breast- feeding management and providing a medical homefor the child is emphasized.3 These recommenda- Some studies suggest decreased rates of sudden infant death syndrome in the first year of life49–55 and doi:10.1542/peds.2004-2491PEDIATRICS (ISSN 0031 4005). Copyright 2005 by the American Acad- reduction in incidence of insulin-dependent (type 1) and non–insulin-dependent (type 2) diabetes melli- tus,56–59 lymphoma, leukemia, and Hodgkin dis- mothers who are using drugs of abuse (“street ease,60–62 overweight and obesity,19,63–70 hypercho- drugs”); and mothers who have herpes simplex le- lesterolemia,71 and asthma36–39 in older children and sions on a breast (infant may feed from other breast adults who were breastfed, compared with individ- if clear of lesions). Appropriate information about uals who were not breastfed. Additional research in infection-control measures should be provided to In the United States, mothers who are infected with human immunodeficiency virus (HIV) have Breastfeeding has been associated with slightly en- been advised not to breastfeed their infants.112 In hanced performance on tests of cognitive develop- developing areas of the world with populations at ment.14,15,72–80 Breastfeeding during a painful proce- increased risk of other infectious diseases and nutri- dure such as a heel-stick for newborn screening tional deficiencies resulting in increased infant death rates, the mortality risks associated with artificialfeeding may outweigh the possible risks of acquiring Maternal Health Benefits
HIV infection.113,114 One study in Africa detailed in 2 Important health benefits of breastfeeding and lac- reports115,116 found that exclusive breastfeeding for tation are also described for mothers.83 The benefits the first 3 to 6 months after birth by HIV-infected include decreased postpartum bleeding and more mothers did not increase the risk of HIV transmis- rapid uterine involution attributable to increased sion to the infant, whereas infants who received concentrations of oxytocin,84 decreased menstrual mixed feedings (breastfeeding with other foods or blood loss and increased child spacing attributable to milks) had a higher rate of HIV infection compared lactational amenorrhea,85 earlier return to prepreg- with infants who were exclusively formula-fed.
nancy weight,86 decreased risk of breast cancer,87–92 Women in the United States who are HIV-positive decreased risk of ovarian cancer,93 and possibly de- should not breastfeed their offspring. Additional creased risk of hip fractures and osteoporosis in the studies are needed before considering a change from Community Benefits
CONDITIONS THAT ARE NOT
In addition to specific health advantages for in- CONTRAINDICATIONS TO BREASTFEEDING
fants and mothers, economic, family, and environ- Certain conditions have been shown to be compat- mental benefits have been described. These benefits ible with breastfeeding. Breastfeeding is not contra- include the potential for decreased annual health indicated for infants born to mothers who are hepa- care costs of $3.6 billion in the United States97,98; de- titis B surface antigen–positive,111 mothers who are creased costs for public health programs such as the infected with hepatitis C virus (persons with hepati- Special Supplemental Nutrition Program for Women, tis C virus antibody or hepatitis C virus-RNA–posi- Infants, and Children (WIC)99; decreased parental em- tive blood),111 mothers who are febrile (unless cause ployee absenteeism and associated loss of family in- is a contraindication outlined in the previous sec- come; more time for attention to siblings and other tion),117 mothers who have been exposed to low- family matters as a result of decreased infant illness; level environmental chemical agents,118,119 and decreased environmental burden for disposal of for- mothers who are seropositive carriers of cytomega- mula cans and bottles; and decreased energy demands lovirus (CMV) (not recent converters if the infant is for production and transport of artificial feeding prod- term).111 Decisions about breastfeeding of very low ucts.100–102 These savings for the country and for fam- birth weight infants (birth weight Ͻ1500 g) by moth- ilies would be offset to some unknown extent by in- ers known to be CMV-seropositive should be made creased costs for physician and lactation consultations, with consideration of the potential benefits of human increased office-visit time, and cost of breast pumps milk versus the risk of CMV transmission.120,121 and other equipment, all of which should be covered Freezing and pasteurization can significantly de- by insurance payments to providers and families.
Tobacco smoking by mothers is not a contraindi- CONTRAINDICATIONS TO BREASTFEEDING
cation to breastfeeding, but health care professionals Although breastfeeding is optimal for infants, should advise all tobacco-using mothers to avoid there are a few conditions under which breastfeeding smoking within the home and to make every effort to may not be in the best interest of the infant. Breast- wean themselves from tobacco as rapidly as possi- feeding is contraindicated in infants with classic galactosemia (galactose 1-phosphate uridyltrans- Breastfeeding mothers should avoid the use of ferase deficiency)103; mothers who have active un- alcoholic beverages, because alcohol is concentrated treated tuberculosis disease or are human T-cell lym- in breast milk and its use can inhibit milk produc- photropic virus type I– or II–positive104,105; mothers tion. An occasional celebratory single, small alcoholic who are receiving diagnostic or therapeutic radioac- drink is acceptable, but breastfeeding should be tive isotopes or have had exposure to radioactive materials (for as long as there is radioactivity in the For the great majority of newborns with jaundice milk)106–108; mothers who are receiving antimetabo- and hyperbilirubinemia, breastfeeding can and lites or chemotherapeutic agents or a small number should be continued without interruption. In rare of other medications until they clear the milk109,110; instances of severe hyperbilirubinemia, breastfeed- Breastfeeding Rates for Infants in the United States: Any (Exclusive) NA indicates that the data are not available.
ing may need to be interrupted temporarily for a lack of guidance and encouragement from health THE CHALLENGE
Data indicate that the rate of initiation and dura- RECOMMENDATIONS ON BREASTFEEDING FOR
tion of breastfeeding in the United States are well HEALTHY TERM INFANTS
below the Healthy People 2010 goals (see Table 1).4,125 1. Pediatricians and other health care professionals Furthermore, many of the mothers counted as breast- should recommend human milk for all infants in feeding were supplementing their infants with for- whom breastfeeding is not specifically contrain- mula during the first 6 months of the infant’s life.5,126 dicated and provide parents with complete, cur- Although breastfeeding initiation rates have in- rent information on the benefits and techniques creased steadily since 1990, exclusive breastfeeding of breastfeeding to ensure that their feeding de- initiation rates have shown little or no increase over that same period of time. Similarly, 6 months after • When direct breastfeeding is not possible, ex- birth, the proportion of infants who are exclusively breastfed has increased at a much slower rate than ed.150,151 If a known contraindication to breast- that of infants who receive mixed feedings.125 The feeding is identified, consider whether the AAP Section on Breastfeeding, American College of contraindication may be temporary, and if so, Obstetricians and Gynecologists, American Acad- advise pumping to maintain milk production.
emy of Family Physicians, Academy of Breastfeeding Before advising against breastfeeding or rec- Medicine, World Health Organization, United Na- tions Children’s Fund, and many other health orga- benefits of breastfeeding against the risks of nizations recommend exclusive breastfeeding for the first 6 months of life.‡2,127–130 Exclusive breastfeeding 2. Peripartum policies and practices that optimize is defined as an infant’s consumption of human milk breastfeeding initiation and maintenance should with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for • Education of both parents before and after vitamins, minerals, and medications.131 Exclusive delivery of the infant is an essential compo- breastfeeding has been shown to provide improved nent of successful breastfeeding. Support and protection against many diseases and to increase the encouragement by the father can greatly assist likelihood of continued breastfeeding for at least the the mother during the initiation process and Obstacles to initiation and continuation of breast- arise. Consistent with appropriate care for the feeding include insufficient prenatal education about mother, minimize or modify the course of ma- breastfeeding132,133; disruptive hospital policies and ternal medications that have the potential for practices134; inappropriate interruption of breast- altering the infant’s alertness and feeding be- feeding135; early hospital discharge in some popula- havior.152,153 Avoid procedures that may inter- tions136; lack of timely routine follow-up care and fere with breastfeeding or that may traumatize postpartum home health visits137; maternal employ- the infant, including unnecessary, excessive, and ment138,139 (especially in the absence of workplace overvigorous suctioning of the oral cavity, facilities and support for breastfeeding)140; lack of esophagus, and airways to avoid oropharyngeal family and broad societal support141; media por- mucosal injury that may lead to aversive feeding trayal of bottle feeding as normative142; commercial promotion of infant formula through distribution of 3. Healthy infants should be placed and remain in hospital discharge packs, coupons for free or dis- direct skin-to-skin contact with their mothers im- counted formula, and some television and general mediately after delivery until the first feeding is magazine advertising143,144; misinformation; and accomplished.156–158• The alert, healthy newborn infant is capable of latching on to a breast without specific assis- ‡ There is a difference of opinion among AAP experts on this matter. The tance within the first hour after birth.156 Dry Section on Breastfeeding acknowledges that the Committee on Nutritionsupports introduction of complementary foods between 4 and 6 months of the infant, assign Apgar scores, and perform age when safe and nutritious complementary foods are available.
the initial physical assessment while the infant is with the mother. The mother is an optimal clearly communicated to both parents and to heat source for the infant.159,160 Delay weigh- ing, measuring, bathing, needle-sticks, and 8. All breastfeeding newborn infants should be eye prophylaxis until after the first feeding is seen by a pediatrician or other knowledgeable and completed. Infants affected by maternal med- experienced health care professional at 3 to 5 days ications may require assistance for effective of age as recommended by the AAP.124,176,177 latch-on.156 Except under unusual circum- • This visit should include infant weight; phys- stances, the newborn infant should remain ical examination, especially for jaundice and with the mother throughout the recovery pe- hydration; maternal history of breast problems (painful feedings, engorgement); infant elimi- 4. Supplements (water, glucose water, formula, and nation patterns (expect 3–5 urines and 3– 4 other fluids) should not be given to breastfeeding stools per day by 3–5 days of age; 4 – 6 urines newborn infants unless ordered by a physician and 3– 6 stools per day by 5–7 days of age); when a medical indication exists.148,162–165 and a formal, observed evaluation of breast- 5. Pacifier use is best avoided during the initiation feeding, including position, latch, and milk of breastfeeding and used only after breastfeed- transfer. Weight loss in the infant of greater than 7% from birth weight indicates possible • In some infants early pacifier use may interfere breastfeeding problems and requires more in- with establishment of good breastfeeding prac- tensive evaluation of breastfeeding and possi- tices, whereas in others it may indicate the pres- ble intervention to correct problems and im- ence of a breastfeeding problem that requires 9. Breastfeeding infants should have a second am- • This recommendation does not contraindicate bulatory visit at 2 to 3 weeks of age so that the pacifier use for nonnutritive sucking and oral health care professional can monitor weight gain training of premature infants and other special and provide additional support and encourage- ment to the mother during this critical period.
6. During the early weeks of breastfeeding, moth- 10. Pediatricians and parents should be aware that ers should be encouraged to have 8 to 12 feed- exclusive breastfeeding is sufficient to supportoptimal growth and development for approxi- ings at the breast every 24 hours, offering the mately the first 6 months of life‡ and provides breast whenever the infant shows early signs of continuing protection against diarrhea and respi- hunger such as increased alertness, physical ac- ratory tract infection.30,34,128,178–184 Breastfeeding should be continued for at least the first year of • Crying is a late indicator of hunger.171 Appro- life and beyond for as long as mutually desired priate initiation of breastfeeding is facilitated by continuous rooming-in throughout the day • Complementary foods rich in iron should be and night.172 The mother should offer both breasts at each feeding for as long a period as months of age.186–187 Preterm and low birth the infant remains at the breast.173 At each weight infants and infants with hematologic feed the first breast offered should be alter- disorders or infants who had inadequate iron nated so that both breasts receive equal stim- stores at birth generally require iron supple- ulation and draining. In the early weeks after mentation before 6 months of age.148,188–192 Iron may be administered while continuing aroused to feed if 4 hours have elapsed since • Unique needs or feeding behaviors of individ- • After breastfeeding is well established, the fre- ual infants may indicate a need for introduc- quency of feeding may decline to approxi- tion of complementary foods as early as 4 mately 8 times per 24 hours, but the infant months of age, whereas other infants may not may increase the frequency again with growth be ready to accept other foods until approxi- spurts or when an increase in milk volume is • Introduction of complementary feedings be- 7. Formal evaluation of breastfeeding, including fore 6 months of age generally does not in- observation of position, latch, and milk transfer, crease total caloric intake or rate of growth should be undertaken by trained caregivers at least and only substitutes foods that lack the pro- twice daily and fully documented in the record during each day in the hospital after birth.174,175 • During the first 6 months of age, even in hot • Encouraging the mother to record the time climates, water and juice are unnecessary for and duration of each breastfeeding, as well as breastfed infants and may introduce contami- urine and stool output during the early days of breastfeeding in the hospital and the first • Increased duration of breastfeeding confers weeks at home, helps to facilitate the evalua- significant health and developmental benefits tion process. Problems identified in the hospi- for the child and the mother, especially in tal should be addressed at that time, and a delaying return of fertility (thereby promoting • There is no upper limit to the duration of feeding alternative for infants whose mothers are breastfeeding and no evidence of psychologic unable or unwilling to provide their own milk.
Human milk banks in North America adhere to into the third year of life or longer.197 national guidelines for quality control of screening • Infants weaned before 12 months of age and testing of donors and pasteurize all milk be- should not receive cow’s milk but should re- fore distribution.206–208 Fresh human milk from unscreened donors is not recommended because 11. All breastfed infants should receive 1.0 mg of of the risk of transmission of infectious agents.
vitamin K1 oxide intramuscularly after the first • Precautions should be followed for infants with feeding is completed and within the first 6 hours glucose-6-phosphate dehydrogenase (G6PD) defi- ciency. G6PD deficiency has been associated with • Oral vitamin K is not recommended. It may an increased risk of hemolysis, hyperbiliru- not provide the adequate stores of vitamin K binemia, and kernicterus.209 Mothers who breast- necessary to prevent hemorrhage later in in- feed infants with known or suspected G6PD defi- fancy in breastfed infants unless repeated ciency should not ingest fava beans or medications doses are administered during the first 4 such as nitrofurantoin, primaquine phosphate, or phenazopyridine hydrochloride, which are known 12. All breastfed infants should receive 200 IU of to induce hemolysis in deficient individuals.210,211 oral vitamin D drops daily beginning during thefirst 2 months of life and continuing until the ROLE OF PEDIATRICIANS AND OTHER HEALTH
daily consumption of vitamin D-fortified for- CARE PROFESSIONALS IN PROTECTING,
PROMOTING, AND SUPPORTING
• Although human milk contains small amounts BREASTFEEDING
of vitamin D, it is not enough to prevent rick- Many pediatricians and other health care profes- ets. Exposure of the skin to ultraviolet B wave- sionals have made great efforts in recent years to lengths from sunlight is the usual mechanism support and improve breastfeeding success by fol- for production of vitamin D. However, signif- lowing the principles and guidance provided by icant risk of sunburn (short-term) and skin the AAP,2 the American College of Obstetricians cancer (long-term) attributable to sunlight ex- and Gynecologists,127 the American Academy of posure, especially in younger children, makes Family Physicians,128 and many other organiza- it prudent to counsel against exposure to sun- tions.5,6,8,130,133,142,162 The following guidelines light. Furthermore, sunscreen decreases vita- summarize these concepts for providing an opti- 13. Supplementary fluoride should not be provided • From 6 months to 3 years of age, the decision • Promote, support, and protect breastfeeding en- whether to provide fluoride supplementation thusiastically. In consideration of the extensively should be made on the basis of the fluoride published evidence for improved health and de- concentration in the water supply (fluoride velopmental outcomes in breastfed infants and supplementation generally is not needed un- their mothers, a strong position on behalf of less the concentration in the drinking water is Ͻ0.3 ppm) and in other food, fluid sources, • Promote breastfeeding as a cultural norm and en- courage family and societal support for breast- 14. Mother and infant should sleep in proximity to each other to facilitate breastfeeding.203 • Recognize the effect of cultural diversity on breast- 15. Should hospitalization of the breastfeeding feeding attitudes and practices and encourage mother or infant be necessary, every effort variations, if appropriate, that effectively promote should be made to maintain breastfeeding, pref- and support breastfeeding in different cultures.
erably directly, or pumping the breasts and feed- Education
• Become knowledgeable and skilled in the physiol- ogy and the current clinical management of breast- ADDITIONAL RECOMMENDATIONS FOR
HIGH-RISK INFANTS
• Encourage development of formal training in • Hospitals and physicians should recommend hu- breastfeeding and lactation in medical schools, in man milk for premature and other high-risk in- residency and fellowship training programs, and fants either by direct breastfeeding and/or using the mother’s own expressed milk.13 Maternal sup- • Use every opportunity to provide age-appropriate port and education on breastfeeding and milk ex- breastfeeding education to children and adults in pression should be provided from the earliest pos- the medical setting and in outreach programs for sible time. Mother-infant skin-to-skin contact and direct breastfeeding should be encouraged as earlyas feasible.204,205 Fortification of expressed human Clinical Practice
milk is indicated for many very low birth weight • Work collaboratively with the obstetric commu- infants.13 Banked human milk may be a suitable nity to ensure that women receive accurate and sufficient information throughout the perinatal pe- • Encourage employers to provide appropriate facil- riod to make a fully informed decision about in- ities and adequate time in the workplace for breastfeeding and/or milk expression.
• Work collaboratively with the dental community • Encourage child care providers to support breast- to ensure that women are encouraged to continue feeding and the use of expressed human milk pro- to breastfeed and use good oral health practices.
Infants should receive an oral health-risk assess- • Support the efforts of parents and the courts to ment by the pediatrician between 6 months and 1 ensure continuation of breastfeeding in separation year of age and/or referred to a dentist for evalu- ation and treatment if at risk of dental caries or • Provide counsel to adoptive mothers who decide to breastfeed through induced lactation, a process • Promote hospital policies and procedures that fa- requiring professional support and encourage- cilitate breastfeeding. Work actively toward elim- inating hospital policies and practices that discour- • Encourage development and approval of govern- age breastfeeding (eg, promotion of infant formula mental policies and legislation that are supportive in hospitals including infant formula discharge of a mother’s choice to breastfeed.
packs and formula discount coupons, separationof mother and infant, inappropriate infant feeding Research
images, and lack of adequate encouragement and • Promote continued basic and clinical research in support of breastfeeding by all health care staff).
the field of breastfeeding. Encourage investigators Encourage hospitals to provide in-depth training and funding agencies to pursue studies that fur- in breastfeeding for all health care staff (including ther delineate the scientific understandings of lac- physicians) and have lactation experts available at tation and breastfeeding that lead to improved clinical practice in this medical field.216 • Provide effective breast pumps and private lacta- tion areas for all breastfeeding mothers (patients CONCLUSIONS
and staff) in ambulatory and inpatient areas of the Although economic, cultural, and political pres- sures often confound decisions about infant feeding, • Develop office practices that promote and support the AAP firmly adheres to the position that breast- breastfeeding by using the guidelines and materi- feeding ensures the best possible health as well as the als provided by the AAP Breastfeeding Promotion best developmental and psychosocial outcomes for in Physicians’ Office Practices program.214 the infant. Enthusiastic support and involvement of • Become familiar with local breastfeeding resources pediatricians in the promotion and practice of breast- (eg, WIC clinics, breastfeeding medical and nurs- feeding is essential to the achievement of optimal ing specialists, lactation educators and consult- infant and child health, growth, and development.
ants, lay support groups, and breast-pump rentalstations) so that patients can be referred appropri- ately.215 When specialized breastfeeding services are used, the essential role of the pediatrician as the infant’s primary health care professional within the framework of the medical home needs • Encourage adequate, routine insurance coverage for necessary breastfeeding services and supplies, including the time required by pediatricians and other licensed health care professionals to assess and manage breastfeeding and the cost for the • Develop and maintain effective communication and coordination with other health care profes- sionals to ensure optimal breastfeeding education, support, and counseling. AAP and WIC breast- feeding coordinators can facilitate collaborative re- lationships and develop programs in the commu-nity and in professional organizations for support • Advise mothers to continue their breast self-exam- inations on a monthly basis throughout lactationand to continue to have annual clinical breast ex- REFERENCES
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