Updated Breastfeeding Guidance Recommends Longer Breastfeeding for Benefits

Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP

The American Academy of Pediatrics (AAP) issued new breastfeeding guidelines, “Policy Statement: Breastfeeding and the Use of Human Milk,” that extend the optimum timeline for breastfeeding to up to 2 years. The guideline was published in the July 2022 issue of Pediatrics.

The last AAP guideline on breastfeeding was published in 2012. It called for infants to be fed breast milk exclusively for their first 6 months and recommended continued breastfeeding while introducing complementary foods for a period of 1 year or longer. The 2022 guideline continues to recommend exclusive breastfeeding for 6 months, with complementary foods introduced around 6 months, but now recommends continued breastfeeding until 2 years or beyond, as mutually desired by mother and child. There is no need to introduce infant formula or other sources of nutrition for most infants. Beyond 6 months, breastfeeding should be maintained along with nutritious complementary foods, the guideline recommends.

There are continued benefits from breastfeeding beyond 1 year, and up to 2 years, especially in the mother, the AAP states. Long-term breastfeeding is associated with protection against diabetes, hypertension, and cancers of the breast and ovaries.

Preliminary data show that human milk in the second year of life continues to be a significant source of macronutrients and immunologic factors for growing toddlers. Data show that for children who are breastfed, acute and chronic pediatric disorders occur less frequently: otitis media, acute diarrheal disease, lower respiratory illnesses, sudden infant death syndrome, inflammatory bowel disease, childhood leukemia, diabetes mellitus, obesity, asthma, and atopic dermatitis. In addition to the nutrition provided to the growing child, AAP stresses that breastfeeding is also about the relationship between parent and child.

US Breastfeeding Rates and Need for Support

More than 80% of women in the United States initiate breastfeeding, but only 25% exclusively breastfeed by 6 months. Nineteen percent of breastfed infants receive formula supplements in the first 48 hours after birth.

Breastfeeding rates differ among different cultural and sociodemographic groups. The lowest rate of breastfeeding initiating is among non-Hispanic Black or African American populations. Similar disparities exist among low-income mothers, younger women, and those with a high school education or less. Breastfeeding support programs have been shown to improve rate and duration of breastfeeding and decreased the disparity between Black and White infants by nearly 9.6%, and peer-support interventions by Women, Infants, and Children programs also have improved breastfeeding rates and duration. Healthcare practitioners’ communications with families about the benefits of breastfeeding can increase initiation, duration, and exclusivity, AAP notes, and they recommend that birth centers/hospitals implement maternity care practices that improve breastfeeding initiation, duration, and exclusivity:

• Early skin-to-skin care and frequent feeding are recommended to facilitate the transition from drops of colostrum to ounces of milk.
• Breastfeeding in the first hour after birth, rooming-in, and exclusive breastfeeding

“Mothers who choose to breastfeed beyond the first year need support from their medical care providers, as well as protections against workplace barriers,” the AAP breastfeeding guideline states. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers. Policies that protect breastfeeding, including universal paid maternity leave; the right to breastfeed in public; insurance coverage for lactation support and breast pumps; on-site childcare; universal workplace break time with a clean, private location for expressing milk; the right to feed expressed milk; and the right to breastfeed in childcare centers and lactation rooms in schools are all essential to supporting families in sustaining breastfeeding.

Special Considerations

The guidelines also address breastfeeding for the very low birth weight infant, late preterm and early term infants, hyperbilirubinemia, adoption, surrogacy, infants born to gender-diverse families, and the need for vitamin and mineral supplements.

Most maternal conditions, medications, and vaccinations are compatible with breastfeeding.1 However, the guideline addresses infants in whom breastfeeding is contraindicated, such as those with classic galactosemia. While most maternal infections are compatible with breastfeeding, mothers should not breastfeed or express milk if they have HIV, human T-cell lymphotropic virus type I or II infection, untreated brucellosis, or confirmed Ebola virus disease. Breastfeeding is also contraindicated if mothers are using illicit opioids, cocaine, or phencyclidine

When Breastfeeding May Not Be Possible

The new AAP guideline acknowledges that exclusive, or any, breastfeeding is not always possible, and mothers and families need support for their decisions. However, the Fed is Best Foundation—whose goal is to assist families and healthcare professionals with current research on the safe feeding of infants, whether with breast milk, formula, or a combination—believes the new breastfeeding guideline is rigid and one-sided for the 75% of US mothers who use formula either by necessity or choice. Mothers need to hear that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation, notes Christie del Castillo-Hegyi, MD, cofounder of Fed is Best and an emergency physician in Little Rock, AR. There is a long list of factors that could affect the health outcomes of infants with respect to breastfeeding versus formula feeding: socioeconomic status, baseline maternal health and education, maternal genetics, and developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. She pointed out that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months, and even earlier, to meet her infant’s nutritional requirements. The pressure to meet the AAP’s high expectations can cause harm to mothers and babies, notes Dr. del Castillo-Hegyi, because not all nursing mothers can produce enough breast milk to feed their baby. Healthcare providers play an important role in supporting mothers and babies through the challenges and rewards of infant feeding.

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