Bibliographic Source(s)

• Gartner LM Morton J Lawrence RA Naylor AJ O'Hare D Schanler RJ Eidelman AI. Breastfeeding and the use of human milk. Pediatrics 2005 Feb;115(2):496-506. [216 references] PubMed

Guideline Status

This is the current release of the guideline. It is intended to replace the previously issued policy statement of the American Academy of Pediatrics (AAP).

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body at which time a recommendation is made that the policy be retired revised or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation or retires a statement the current policy remains in effect.

Guideline Category

Prevention

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

• To promote breastfeeding of infants as the foundation of good feeding practices and healthy development
• To present recommendations on breastfeeding practices and the role of pediatricians in promoting and protecting breastfeeding

Target Population

Pregnant women in the prenatal perinatal or postpartum period and their infants

Interventions and Practices Considered

1. Breastfeeding (human milk feeding)
2. Patient education
3. Formal evaluation of breastfeeding
4. Vitamin K and D supplementation of infants (Note: fluoride supplementation is considered but not recommended during the first 6 months.)
5. Patient referral to breastfeeding support groups

Major Outcomes Considered

• Rates of breastfeeding initiation and duration
• Incidence and/or severity of acute and chronic illness (for both children and women)
• Risk of acute and chronic diseases (for both children and women)
• Health care costs
• Employee absenteeism for care attributable to child illness

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not stated

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Multiple American Academy of Pediatrics (AAP) committees and the AAP Board of Directors reviewed the guideline.

Major Recommendations

Recommendations on Breastfeeding For Healthy Term Infants

1. Pediatricians and other health care professionals should recommend human milk for all infants in whom breastfeeding is not specifically contraindicated and provide parents with complete current information on the benefits and techniques of breastfeeding to ensure that their feeding decision is a fully informed one (Gartner 1994; American Academy of Pediatrics [AAP] Committee on Nutrition "Breastfeeding" 2004; Position of the American Dietetic Association [ADA] 2001).
   • When direct breastfeeding is not possible expressed human milk should be provided (Schanler & Hurst 1994; Lemons Stuart & Lemons 1986). If a known contraindication to breastfeeding is identified consider whether the contraindication may be temporary and if so advise pumping to maintain milk production. Before advising against breastfeeding or recommending premature weaning weigh the benefits of breastfeeding against the risks of not receiving human milk.
2. Peripartum policies and practices that optimize breastfeeding initiation and maintenance should be encouraged.
   • Education of both parents before and after delivery of the infant is an essential component of successful breastfeeding. Support and encouragement by the father can greatly assist the mother during the initiation process and during subsequent periods when problems arise. Consistent with appropriate care for the mother minimize or modify the course of maternal medications that have the potential for altering the infant's alertness and feeding behavior (Kron Stein & Goddard 1966; Ransjo-Arvidson et al. 2001). Avoid procedures that may interfere with breastfeeding or that may traumatize the infant including unnecessary excessive and overvigorous suctioning of the oral cavity esophagus and airways to avoid oropharyngeal mucosal injury that may lead to aversive feeding behavior (Widstrom & Thingstrom-Paulson 1993; Wolf & Glass 1992).
3. Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished (Righard & Alade 1990; Wiberg Humble & de Chateau 1989; Mikiel-Kostyra Mazur & Boltruszko 2002).
   • The alert healthy newborn infant is capable of latching on to a breast without specific assistance within the first hour after birth (Righard & Alade 1990). Dry the infant assign Apgar scores and perform the initial physical assessment while the infant is with the mother. The mother is an optimal heat source for the infant (Christensson et al. 1992; Van Den Bosch & Bullough 1990). Delay weighing measuring bathing needle-sticks and eye prophylaxis until after the first feeding is completed. Infants affected by maternal medications may require assistance for effective latch-on (Righard & Alade 1990). Except under unusual circumstances the newborn infant should remain with the mother throughout the recovery period (Sosa et al. 1976).
4. Supplements (water glucose water formula and other fluids) should not be given to breastfeeding newborn infants unless ordered by a physician when a medical indication exists (AAP Committee on Nutrition "Breastfeeding" 2004; AAP & American College of Obstetricians and Gynecologist [ACOG] 2002; Shrago 1987; Goldberg & Adams 1983 Eidelman 2001).
5. Pacifier use is best avoided during the initiation of breastfeeding and used only after breastfeeding is well established (Howard et al. 1999; Howard et al. 2003; Schubiger Schwartz & Tonz 1997).
   • In some infants early pacifier use may interfere with establishment of good breastfeeding practices whereas in others it may indicate the presence of a breastfeeding problem that requires intervention (Kramer et al. 2001).
   • This recommendation does not contraindicate pacifier use for nonnutritive sucking and oral training of premature infants and other special care infants.
6. During the early weeks of breastfeeding mothers should be encouraged to have 8 to 12 feedings at the breast every 24 hours offering the breast whenever the infant shows early signs of hunger such as increased alertness physical activity mouthing or rooting (Gunther 1955).
   • Crying is a late indicator of hunger. Appropriate initiation of breastfeeding is facilitated by continuous rooming-in throughout the day and night (Procianoy et al. 1983). The mother should offer both breasts at each feeding for as long a period as the infant remains at the breast (Anderson 1989). At each feed the first breast offered should be alternated so that both breasts receive equal stimulation and draining. In the early weeks after birth nondemanding infants should be aroused to feed if 4 hours have elapsed since the beginning of the last feeding.
   • After breastfeeding is well established the frequency of feeding may decline to approximately 8 times per 24 hours but the infant may increase the frequency again with growth spurts or when an increase in milk volume is desired.
7. Formal evaluation of breastfeeding including observation of position latch and milk transfer should be undertaken by trained caregivers at least twice daily and fully documented in the record during each day in the hospital after birth (Riordan et al. 2001; Hall et al. 2002).
   • Encouraging the mother to record the time and duration of each breastfeeding as well as urine and stool output during the early days of breastfeeding in the hospital and the first weeks at home helps to facilitate the evaluation process. Problems identified in the hospital should be addressed at that time and a documented plan for management should be clearly communicated to both parents and to the medical home.
8. All breastfeeding newborn infants should be seen by a pediatrician or other knowledgeable and experienced health care professional at 3 to 5 days of age as recommended by the American Association of Pediatrics (AAP) ("Management of hyperbilirubinemia" 2004; AAP Committee on Practice and Ambulatory Medicine 2000;"Hospital stay for healthy term newborns 1995).
   • This visit should include infant weight; physical examination especially for jaundice and hydration; maternal history of breast problems (painful feedings engorgement); infant elimination patterns (expect 3-5 urines and 3-4 stools per day by 3-5 days of age; 4-6 urines and 3-6 stools per day by 5-7 days of age); and a formal observed evaluation of breastfeeding including position latch and milk transfer. Weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer.
9. Breastfeeding infants should have a second ambulatory visit at 2 to 3 weeks of age so that the health care professional can monitor weight gain and provide additional support and encouragement to the mother during this critical period.
10. Pediatricians and parents should be aware that exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life* and provides continuing protection against diarrhea and respiratory tract infection (Popkin et al. 1990; Bachrach Schwartz & Bachrach 2003; American Academy of Family Physicians [AAFP] 2001; Ahn & MacClean 1980; Brown Dewey & Allen 1998; Heinig et al. 1993; Kramer & Kakuma 2002; Chantry Howard & Auinger 2002; Dewey et al. 2001; Butte Lopez-Alarcon & Garza 2002). Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child (Sugarman & Kendall-Tackett 1995).

    *There is a difference of opinion among AAP experts on this matter. The Section on Breastfeeding acknowledges that the Committee on Nutrition supports introduction of complementary foods between 4 and 6 months of age when safe and nutritious complementary foods are available.

    • Complementary foods rich in iron should be introduced gradually beginning around 6 months of age (Dallman 1990; Domellof et al. 2002). Preterm and low birth weight infants and infants with hematologic disorders or infants who had inadequate iron stores at birth generally require iron supplementation before 6 months of age (AAP Committee on Nutrition "Breastfeeding " 2004; AAP Committee on Fetus and Newborn & ACOG 2002; AAP Committee on Nutrition "Nutritional needs" 2004; Pisacane De Vizia & Valiente 1995; Griffin & Abrams 2001; Dewey et al. 1998). Iron may be administered while continuing exclusive breastfeeding.
    • Unique needs or feeding behaviors of individual infants may indicate a need for introduction of complementary foods as early as 4 months of age whereas other infants may not be ready to accept other foods until approximately 8 months of age (Naylor & Morrow 2001).
    • Introduction of complementary feedings before 6 months of age generally does not increase total caloric intake or rate of growth and only substitutes foods that lack the protective components of human milk (Cohen et al. 1995).
    • During the first 6 months of age even in hot climates water and juice are unnecessary for breastfed infants and may introduce contaminants or allergens (Ashraf et al. 1993).
    • Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother especially in delaying return of fertility (thereby promoting optimal intervals between births) (Huffman et al. 1987).
    • There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer (Dettwyler 1995).
    • Infants weaned before 12 months of age should not receive cow's milk but should receive iron-fortified infant formula ("Iron fortification of infant formulas" 1999).
11. All breastfed infants should receive 1.0 mg of vitamin K₁ oxide intramuscularly after the first feeding is completed and within the first 6 hours of life ("Controversies concerning vitamin K" 2003).
    • Oral vitamin K is not recommended. It may not provide the adequate stores of vitamin K necessary to prevent hemorrhage later in infancy in breastfed infants unless repeated doses are administered during the first 4 months of life (Hansen & Ebbesen 1996).
12. All breastfed infants should receive 200 IU of oral vitamin D drops daily beginning during the first 2 months of life and continuing until the daily consumption of vitamin D-fortified formula or milk is 500 mL (Gartner & Greer 2003).
    • Although human milk contains small amounts of vitamin D it is not enough to prevent rickets. Exposure of the skin to ultraviolet B wavelengths from sunlight is the usual mechanism for production of vitamin D. However significant risk of sunburn (short-term) and skin cancer (long-term) attributable to sunlight exposure especially in younger children makes it prudent to counsel against exposure to sunlight. Furthermore sunscreen decreases vitamin D production in skin.
13. Supplementary fluoride should not be provided during the first 6 months of life ("Recommendations for using fluoride" 2001).
    • From 6 months to 3 years of age the decision whether to provide fluoride supplementation should be made on the basis of the fluoride concentration in the water supply (fluoride supplementation generally is not needed unless the concentration in the drinking water is <0.3 ppm) and in other food fluid sources and li>
14. Mother and infant should sleep in proximity to each other to facilitate breastfeeding (Blair et al. 1999).
15. Should hospitalization of the breastfeeding mother or infant be necessary every effort should be made to maintain breastfeeding preferably directly or pumping the breasts and feeding expressed milk if necessary.

Additional Recommendations For High-Risk Infants

• Hospitals and physicians should recommend human milk for premature and other high-risk infants either by direct breastfeeding and/or using the mother's own expressed milk (Schanler 2001). Maternal support and education on breastfeeding and milk expression should be provided from the earliest possible time. Mother-infant skin-to-skin contact and direct breastfeeding should be encouraged as early as feasible (Charpak et al. 1997; Hurst et al. 1997). Fortification of expressed human milk is indicated for many very low birth weight infants (Schanler 2001). Banked human milk may be a suitable feeding alternative for infants whose mothers are unable or unwilling to provide their own milk. Human milk banks in North America adhere to national guidelines for quality control of screening and testing of donors and pasteurize all milk before distribution (Hughes 1990; Human Milk Banking Association of North America 2003; Arnold 1990). Fresh human milk from unscreened donors is not recommended because of the risk of transmission of infectious agents
• Precautions should be followed for infants with glucose-6-phosphate dehydrogenase (G6PD) deficiency. G6PD deficiency has been associated with an increased risk of hemolysis hyperbilirubinemia and kernicterus (Kaplan & Hammerman 1998). Mothers who breastfeed infants with known or suspected G6PD deficiency should not ingest fava beans or medications such as nitrofurantoin primaquine phosphate or phenazopyridine hydrochloride which are known to induce hemolysis in deficient individuals (Kaplan et al. 1998; Gerk et al. 2001).

Conclusions

Although economic cultural and political pressures often confound decisions about infant feeding the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health growth and development.

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Adair SM Bowen WH Burt BA Kumar JV Levy SM Pendrys DG Rozier RG Selwitz RH Stamm JW Stookey GK Whitford GM. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 2001 Aug 17;50(RR-14):1-42. PubMed



• Ahn CH MacLean WC Jr. Growth of the exclusively breast-fed infant. Am J Clin Nutr 1980 Feb;33(2):183-92. PubMed



• American Academy of Family Physicians. American Academy of Family Physicians. AAFP policy statement on breastfeeding. Leawood (KS): American Academy of Family Physicians; 2001.



• American Academy of Pediatrics American College of Obstetricians and Gynecologists. Care of the neonate. In: Gilstrap LC Oh W editor(s). Guidelines for perinatal care. 5th ed. Elk Grove Village (IL): American Academy of Pediatrics; 2002. p. 222.



• American Academy of Pediatrics Committee on Fetus and Newborn American College of Obstetricians and Gynecologists. Nutritional need of preterm neonates. In: Guidelines for perinatal care. 5th ed. Washington (DC): American Academy of Pediatrics American College of Obstetricians and Gynecologists; 2002. p. 259-63.



• American Academy of Pediatrics Committee on Nutrition. Breastfeeding. In: Kleinman RE editor(s). Pediatric nutrition handbook. Elk Grove Village (IL): American Academy of Pediatrics; 2004. p. 55-85.



• American Academy of Pediatrics Committee on Nutrition. Nutritional needs of the preterm infant. In: Kleinman RE editor(s). Pediatric nutrition handbook. Elk Grove Village (IL): American Academy of Pediatrics; 2004. p. 23-54.



• American Academy of Pediatrics Committee on Practice and Ambulatory Medicine. Recommendations for preventive pediatric healthcare. Pediatrics 2000;105:645-6.



• Anderson GC. Risk in mother-infant separation postbirth. Image J Nurs Sch 1989 Winter;21(4):196-9. [62 references] PubMed



• Arnold LD. Clinical uses of donor milk. J Hum Lact 1990 Sep;6(3):132-3. PubMed



• Ashraf RN Jalil F Aperia A Lindblad BS. Additional water is not needed for healthy breast-fed babies in a hot climate. Acta Paediatr 1993 Dec;82(12):1007-11. PubMed



• Bachrach VR Schwarz E Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Arch Pediatr Adolesc Med 2003 Mar;157(3):237-43. PubMed



• Blair PS Fleming PJ Smith IJ Platt MW Young J Nadin P Berry PJ Golding J. Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group. BMJ 1999 Dec 4;319(7223):1457-61. PubMed



• Brown KH Dewey KG Allen LH. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Publication no. WHO/NUT/98.1. Geneva Switzerland: World Health Organization; 1998.



• Butte NF Lopez-Alarcon MG Garza C. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva Switzerland: World Health Organization; 2002.



• Chantry CJ Howard CR Auinger P. Breastfeeding fully for 6 months vs.4 months decreases risk of respiratory tract infection [abstract 1114]. Pediatr Res 2002;51:191A.



• Charpak N Ruiz-Pelaez JG Figueroa de C Z Charpak Y. Kangaroo mother versus traditional care for newborn infants less than or equal to 2000 grams: a randomized controlled trial. Pediatrics 1997 Oct;100(4):682-8. PubMed



• Christensson K Siles C Moreno L Belaustequi A De La Fuente P Lagercrantz H Puyol P Winberg J. Temperature metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot. Acta Paediatr 1992 Jun-Jul;81(6-7):488-93. PubMed



• Cohen RJ Brown KH Canahuati J Rivera LL Dewey KG. Determinants of growth from birth to 12 months among breast-fed Honduran infants in relation to age of introduction of complementary foods. Pediatrics 1995 Sep;96(3 Pt 1):504-10. PubMed



• Controversies concerning vitamin K and the newborn. American Academy of Pediatrics Committee on Fetus and Newborn. Pediatrics 2003 Jul;112(1 Pt 1):191-2. [16 references] PubMed



• Dallman PR. Progress in the prevention of iron deficiency in infants. Acta Paediatr Scand Suppl 1990;365:28-37. PubMed



• Dettwyler KA. A time to wean: the hominid blueprint for the natural age of weaning in modern human populations. In: Stuart-Macadam P Dettwyler KA editor(s). Breastfeeding: biocultural perspectives. Hawthorne (NY): Aldine de Gruyter; 1995. p. 39-73.



• Dewey KG Cohen RJ Brown KH Rivera LL. Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras. J Nutr 2001 Feb;131(2):262-7. PubMed



• Dewey KG Cohen RJ Rivera LL Brown KH. Effects of age of introduction of complementary foods on iron status of breast-fed infants in Honduras. Am J Clin Nutr 1998 May;67(5):878-84. PubMed



• Domellof M Lonnerdal B Abrams SA Hernell O. Iron absorption in breast-fed infants: effects of age iron status iron supplements and complementary foods. Am J Clin Nutr 2002 Jul;76(1):198-204. PubMed



• Eidelman AI. Hypoglycemia and the breastfed neonate. Pediatr Clin North Am 2001 Apr;48(2):377-87. [58 references] PubMed



• Gartner LM Greer FR American Academy of Pediatrics Section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003 Apr;111(4 Pt 1):908-10. [20 references] PubMed



• Gartner LM. Introduction. Breastfeeding in the hospital. Semin Perinatol 1994;18:475.



• Gerk PM Kuhn RJ Desai NS McNamara PJ. Active transport of nitrofurantoin into human milk. Pharmacotherapy 2001 Jun;21(6):669-75. PubMed



• Goldberg NM Adams E. Supplementary water for breast-fed babies in a hot and dry climate--not really a necessity. Arch Dis Child 1983 Jan;58(1):73-4. PubMed



• Griffin IJ Abrams SA. Iron and breastfeeding. Pediatr Clin North Am 2001 Apr;48(2):401-13. [76 references] PubMed



• Gunther M. Instinct and the nursing couple. Lancet 1955 Mar 19;268(6864):575-8. PubMed



• Hall RT Mercer AM Teasley SL McPherson DM Simon SD Santos SR Meyers BM Hipsh NE. A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age. J Pediatr 2002 Nov;141(5):659-64. PubMed



• Hansen KN Ebbesen F. Neonatal vitamin K prophylaxis in Denmark: three years' experience with oral administration during the first three months of life compared with one oral administration at birth. Acta Paediatr 1996 Oct;85(10):1137-9. PubMed



• Heinig MJ Nommsen LA Peerson JM Lonnerdal B Dewey KG. Intake and growth of breast-fed and formula-fed infants in relation to the timing of introduction of complementary foods: the DARLING study. Davis Area Research on Lactation Infant Nutrition and Growth. Acta Paediatr 1993 Dec;82(12):999-1006. PubMed



• Hospital stay for healthy term newborns. American Academy of Pediatrics Committee on Fetus and Newborn. Pediatrics 1995 Oct;96(4 Pt 1):788-90. PubMed



• Howard CR Howard FM Lanphear B deBlieck EA Eberly S Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics 1999 Mar;103(3):E33. PubMed



• Howard CR Howard FM Lanphear B Eberly S deBlieck EA Oakes D Lawrence RA. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003 Mar;111(3):511-8. PubMed



• Huffman SL Ford K Allen H Streble P. Nutrition and fertility in Bangladesh: breastfeeding and post partum amenorrhoea. Popul Stud (Camb) 1987;41:447-62.



• Hughes V. Guidelines for the establishment and operation of a human milk bank. J Hum Lact 1990 Dec;6(4):185-6. PubMed



• Human Milk Banking Association of North America. Guidelines for establishment and operation of a donor human milk bank. Raleigh (NC): Human Milk Banking Association of North America Inc.; 2003.



• Hurst NM Valentine CJ Renfro L Burns P Ferlic L. Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. J Perinatol 1997 May-Jun;17(3):213-7. PubMed



• Iron fortification of infant formulas. American Academy of Pediatrics. Committee on Nutrition. Pediatrics 1999 Jul;104(1 Pt 1):119-23. PubMed



• Kaplan M Hammerman C. Severe neonatal hyperbilirubinemia. A potential complication of glucose-6-phosphate dehydrogenase deficiency. Clin Perinatol 1998 Sep;25(3):575-90 viii. [65 references] PubMed



• Kaplan M Vreman HJ Hammerman C Schimmel MS Abrahamov A Stevenson DK. Favism by proxy in nursing glucose-6-phosphate dehydrogenase-deficient neonates. J Perinatol 1998 Nov-Dec;18(6 Pt 1):477-9. PubMed



• Kramer MS Barr RG Dagenais S Yang H Jones P Ciofani L Jane F. Pacifier use early weaning and cry/fuss behavior: a randomized controlled trial. JAMA 2001 Jul 18;286(3):322-6. PubMed



• Kramer MS Kakuma R. The optimal duration of exclusive breastfeeding. A systematic review. Geneva Switzerland: World Health Organization; 2002.



• Kron RE Stein M Goddard KE. Newborn sucking behavior affected by obstetric sedation. Pediatrics 1966 Jun;37(6):1012-6. PubMed



• Lemons P Stuart M Lemons JA. Breast-feeding the premature infant. Clin Perinatol 1986 Mar;13(1):111-22. [70 references] PubMed



• Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004 Jul;114(1):297-316. [28 references] PubMed



• Mikiel-Kostyra K Mazur J Boltruszko I. Effect of early skin-to-skin contact after delivery on duration of breastfeeding: a prospective cohort study. Acta Paediatr 2002;91(12):1301-6. PubMed



• Naylor AJ Morrow AL. Developmental readiness of normal full term infants to progress from exclusive breastfeeding to the introduction of complementary foods: reviews of the relevant literature concerning infant immunologic gastrointestinal oral motor and maternal [trunc]. Washington (DC): Wellstart International and the LINKAGES project/Academy of Educational Development; 2001.



• Pisacane A De Vizia B Valiante A Vaccaro F Russo M Grillo G Giustardi A. Iron status in breast-fed infants. J Pediatr 1995 Sep;127(3):429-31. PubMed



• Popkin BM Adair L Akin JS Black R Briscoe J Flieger W. Breast-feeding and diarrheal morbidity. Pediatrics 1990 Dec;86(6):874-82. PubMed



• Position of the American Dietetic Association: breaking the barriers to breastfeeding. J Am Diet Assoc 2001 Oct;101(10):1213-20. PubMed



• Procianoy RS Fernandes-Filho PH Lazaro L Sartori NC Drebes S. The influence of rooming-in on breastfeeding. J Trop Pediatr 1983 Apr;29(2):112-4. PubMed



• Ransjo-Arvidson AB Matthiesen AS Lilja G Nissen E Widstrom AM Uvnas-Moberg K. Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding temperature and crying. Birth 2001 Mar;28(1):5-12. PubMed



• Righard L Alade MO. Effect of delivery room routines on success of first breast-feed. Lancet 1990 Nov 3;336(8723):1105-7. PubMed



• Riordan J Bibb D Miller M Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact 2001 Feb;17(1):20-3. PubMed



• Schanler RJ Hurst NM. Human milk for the hospitalized preterm infant. Semin Perinatol 1994 Dec;18(6):476-84. [79 references] PubMed



• Schanler RJ. The use of human milk for premature infants. Pediatr Clin North Am 2001 Feb;48(1):207-19. [70 references] PubMed



• Schubiger G Schwarz U Tonz O. UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Neonatal Study Group. Eur J Pediatr 1997 Nov;156(11):874-7. PubMed



• Shrago L. Glucose water supplementation of the breastfed infant during the first three days of life. J Hum Lact 1987;3:82-6.



• Sosa R Kennell JH Klaus M Urrutia JJ. The effect of early mother-infant contact on breast feeding infection and growth. In: LLoyd JL editor(s). Breast-feeding and the mother. Amsterdam Netherlands: Elsevier; 1976. p. 179-93.



• Sugarman M Kendall-Tackett KA. Weaning ages in a sample of American women who practice extended breastfeeding. Clin Pediatr (Phila) 1995 Dec;34(12):642-7. PubMed



• van den Bosch CA Bullough CH. Effect of early suckling on term neonates' core body temperature. Ann Trop Paediatr 1990;10(4):347-53. PubMed



• Wiberg B Humble K de Chateau P. Long-term effect on mother-infant behaviour of extra contact during the first hour post partum. V. Follow-up at three years. Scand J Soc Med 1989;17(2):181-91. PubMed



• Widstrom AM Thingstrom-Paulsson J. The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle. Acta Paediatr 1993 Mar;82(3):281-3. PubMed



• Wolf L Glass RP. Feeding and swallowing disorders in infancy: assessment and management. San Antonio (TX): Harcourt Assessment Inc.; 1992.

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Potential Benefits

Child Health Benefits

• Human milk-fed premature infants receive significant benefits with respect to host protection and improved developmental outcomes compared with formula-fed premature infants.
• Research in developed and developing countries of the world including middle-class populations in developed countries provides strong evidence that human milk feeding decreases the incidence and/or severity of a wide range of infectious diseases including bacterial meningitis bacteremia diarrhea respiratory tract infection necrotizing enterocolitis otitis media urinary tract infection and late-onset sepsis in preterm infants. In addition postneonatal infant mortality rates in the United States are reduced by 21% in breastfed infants.
• Some studies suggest decreased rates of sudden infant death syndrome in the first year of life and reduction in incidence of insulin-dependent (type 1) and non-insulin-dependent (type 2) diabetes mellitus lymphoma leukemia and Hodgkin disease overweight and obesity hypercholesterolemia and asthma in older children and adults who were breastfed compared with individuals who were not.
• Breastfeeding has been associated with slightly enhanced performance on tests of cognitive development. Breastfeeding during a painful procedure such as a heel-stick for newborn screening provides analgesia to infants.

Maternal Health Benefits

Important health benefits of breastfeeding and lactation are also described for mothers. The benefits include decreased postpartum bleeding and more rapid uterine involution attributable to increased concentrations of oxytocin decreased menstrual blood loss and increased child spacing attributable to lactational amenorrhea earlier return to prepregnancy weight decreased risk of breast cancer decreased risk of ovarian cancer and possibly decreased risk of hip fractures and osteoporosis in the postmenopausal period.

Health Care Costs

There is a potential for decreased annual health care costs of $3.6 billion in the United States; decreased costs for public health programs such as the Special Supplemental Nutrition Program for Women Infants and Children (WIC); decreased parental employee absenteeism and associated loss of family income; more time for attention to siblings and other family matters as a result of decreased infant illness; decreased environmental burden for disposal of formula cans and bottles; and decreased energy demands for production and transport of artificial feeding products. These savings for the country and for families would be offset to some unknown extent by increased costs for physician and lactation consultations increased office-visit time and cost of breast pumps and other equipment all of which should be covered by insurance payments to providers and families.

Potential Harms

Not stated

Contraindications

Breastfeeding is contraindicated in infants with classic galactosemia (galactose 1-phosphate uridyltransferase deficiency); mothers who have active untreated tuberculosis disease or are human T-cell lymphotropic virus type I- or II-positive; mothers who are receiving diagnostic or therapeutic radioactive isotopes or have had exposure to radioactive materials (for as long as there is radioactivity in the milk); mothers who are receiving antimetabolites or chemotherapeutic agents or a small number of other medications until they clear the milk; mothers who are using drugs of abuse ("street drugs"); and mothers who have herpes simplex lesions on a breast (infant may feed from other breast if clear of lesions). In the United States mothers who are infected with human immunodeficiency virus (HIV) have been advised not to breastfeed their infants.

Qualifying Statements

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations taking into account individual circumstances may be appropriate.

Description of Implementation Strategy

Role of Pediatricians And Other Health Care Professionals In Protecting Promoting and Supporting Breastfeeding

Many pediatricians and other health care professionals have made great efforts in recent years to support and improve breastfeeding success by following the principles and guidance provided by the American Association of Pediatrics (AAP) the American College of Obstetricians and Gynecologists the American Academy of Family Physicians and many other organizations. The following guidelines summarize these concepts for providing an optimal breastfeeding environment.

General

• Promote support and protect breastfeeding enthusiastically. In consideration of the extensively published evidence for improved health and developmental outcomes in breastfed infants and their mothers a strong position on behalf of breastfeeding is warranted.
• Promote breastfeeding as a cultural norm and encourage family and societal support for breastfeeding.
• Recognize the effect of cultural diversity on breastfeeding attitudes and practices and encourage variations if appropriate that effectively promote and support breastfeeding in different cultures.

Education

• Become knowledgeable and skilled in the physiology and the current clinical management of breastfeeding.
• Encourage development of formal training in breastfeeding and lactation in medical schools in residency and fellowship training programs and for practicing pediatricians.
• Use every opportunity to provide age-appropriate breastfeeding education to children and adults in the medical setting and in outreach programs for student and parent groups.

Clinical Practice

• Work collaboratively with the obstetric community to ensure that women receive accurate and sufficient information throughout the perinatal period to make a fully informed decision about infant feeding.
• Work collaboratively with the dental community to ensure that women are encouraged to continue to breastfeed and use good oral health practices. Infants should receive an oral health-risk assessment by the pediatrician between 6 months and 1 year of age and/or referred to a dentist for evaluation and treatment if at risk of dental caries or other oral health problems.
• Promote hospital policies and procedures that facilitate breastfeeding. Work actively toward eliminating hospital policies and practices that discourage breastfeeding (e.g. promotion of infant formula in hospitals including infant formula discharge packs and formula discount coupons separation of mother and infant inappropriate infant feeding images and lack of adequate encouragement and support of breastfeeding by all health care staff). Encourage hospitals to provide in-depth training in breastfeeding for all health care staff (including physicians) and have lactation experts available at all times.
• Provide effective breast pumps and private lactation areas for all breastfeeding mothers (patients and staff) in ambulatory and inpatient areas of the hospital.
• Develop office practices that promote and support breastfeeding by using the guidelines and materials provided by the AAP Breastfeeding Promotion in Physicians' Office Practices program.
• Become familiar with local breastfeeding resources (e.g. Women Infants and Children (WIC) clinics breastfeeding medical and nursing specialists lactation educators and consultants lay support groups and breast-pump rental stations) so that patients can be referred appropriately. 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 to be clarified for parents.
• 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 rental of breast pumps.
• Develop and maintain effective communication and coordination with other health care professionals to ensure optimal breastfeeding education support and counseling. AAP and WIC breastfeeding coordinators can facilitate collaborative relationships and develop programs in the community and in professional organizations for support of breastfeeding.
• Advise mothers to continue their breast self-examinations on a monthly basis throughout lactation and to continue to have annual clinical breast examinations by their physicians.

Society

• Encourage the media to portray breastfeeding as positive and normative.
• Encourage employers to provide appropriate facilities and adequate time in the workplace for breastfeeding and/or milk expression.
• Encourage child care providers to support breastfeeding and the use of expressed human milk provided by the parent.
• Support the efforts of parents and the courts to ensure continuation of breastfeeding in separation and custody proceedings.
• Provide counsel to adoptive mothers who decide to breastfeed through induced lactation a process requiring professional support and encouragement.
• Encourage development and approval of governmental policies and legislation that are supportive of a mother's choice to breastfeed.

Research

• Promote continued basic and clinical research in the field of breastfeeding. Encourage investigators and funding agencies to pursue studies that further delineate the scientific understandings of lactation and breastfeeding that lead to improved clinical practice in this medical field.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• Gartner LM Morton J Lawrence RA Naylor AJ O'Hare D Schanler RJ Eidelman AI. Breastfeeding and the use of human milk. Pediatrics 2005 Feb;115(2):496-506. [216 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Academy of Pediatrics

Guideline Committee

Section on Breastfeeding

Composition of Group that Authored the Guideline

Section on Breastfeeding 2003-2004: *Lawrence M. Gartner MD Chairperson; Jane Morton MD; Ruth A. Lawrence MD; Audrey J. Naylor MD DrPH; Donna O'Hare MD; Richard J. Schanler MD; *Arthur I. Eidelman MD Policy Committee Chairperson

Liaisons: Nancy F. Krebs MD Committee on Nutrition; Alice Lenihan MPH RD LPN National WIC Association; John Queenan MD American College of Obstetricians and Gynecologists

Staff: Betty Crase IBCLC RLC

*Lead authors

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline. It is intended to replace the previously issued policy statement of the American Academy of Pediatrics (AAP).

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body at which time a recommendation is made that the policy be retired revised or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation or retires a statement the current policy remains in effect.

Guideline Availability

Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site.

Print copies: Available from the American Academy of Pediatrics 141 NW Point Blvd PO Box 927 Elk Grove Village IL 60009-0927; Web site http://www.aap.org/

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This summary was completed by ECRI on April 27 1999. The information was verified by the guideline developer on July 13 1999. This NGC summary was updated by ECRI on February 23 2005. The information was verified by the guideline developer on May 2 2005.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor American Academy of Pediatrics (AAP) 141 Northwest Point Blvd Elk Grove Village IL 60007.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.