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Position of the American Dietetic Association:

Promoting and Supporting Breastfeeding
ABSTRACT This American Dietetic Association (ADA) position paper includes the
It is the position of the American Di- authors’ independent review of the literature in addition to systematic
etetic Association that exclusive review conducted using ADA’s Evidence Analysis Process and information
breastfeeding provides optimal nutri- from ADA’s Evidence Analysis Library. Topics from the Evidence Analysis
tion and health protection for the first Library are clearly delineated. The use of an evidence-based approach
6 months of life and breastfeeding provides important added benefits to earlier review methods. The major
with complementary foods from 6 advantage of the approach is the more rigorous standardization of review
months until at least 12 months of criteria, which minimizes the likelihood of reviewer bias and increases the
age is the ideal feeding pattern for ease with which disparate articles may be compared. For a detailed descrip-
infants. Breastfeeding is an impor- tion of the methods used in the Evidence Analysis Process, go to http://
tant public health strategy for im- adaeal.com/eaprocess/.
proving infant and child morbidity Conclusion Statements are assigned a grade by an expert work group
and mortality, improving maternal based on the systematic analysis and evaluation of the supporting research
morbidity, and helping to control evidence. Grade I⫽Good; Grade II⫽Fair; Grade III⫽Limited; Grade
health care costs. Breastfeeding is as- IV⫽Expert Opinion Only; and Grade V⫽Not Assignable (because there is no
sociated with a reduced risk of otitis evidence to support or refute the conclusion). Evidence-based information for
media, gastroenteritis, respiratory ill- this and other topics can be found at www.adaevidencelibrary.com and sub-
ness, sudden infant death syndrome, scriptions for nonmembers are purchasable at www.adaevidencelibrary.com/
necrotizing enterocolitis, obesity, and store.cfm.
hypertension. Breastfeeding is also
associated with improved maternal
outcomes, including a reduced risk of
POSITION STATEMENT chronic diseases. Federal agencies
breast and ovarian cancer, type 2 di-
It is the position of the American Die- and national professional associa-
abetes, and postpartum depression.
tetic Association that exclusive breast- tions in the United States recommend
These reductions in acute and chronic
feeding provides optimal nutrition infants be exclusively breastfed for
illness help to decrease health care-
and health protection for the first 6 the first 6 months of life, and continue
related expenses and productive time
months of life and breastfeeding with to breastfeed at least through the first
lost from work. Overall breastfeeding
complementary foods from 6 months year of life (1-6). In addition, the
rates are increasing, yet disparities
until at least 12 months of age is the World Health Organization (WHO)
persist based on socioeconomic sta-
ideal feeding pattern for infants. and United Nations Children’s Fund
tus, maternal age, country of origin,
Breastfeeding is an important public (UNICEF) recommend that every in-
and geographic location. Factors such
health strategy for improving infant fant should be exclusively breastfed
as hospital practices, knowledge, be-
and child morbidity and mortality, for the first 6 months of life, with
liefs, and attitudes of mothers and
and improving maternal morbidity, breastfeeding continuing for up to 2
their families, and access to breast-
and helping to control health care years of age or longer (7-9). Exclusive
feeding support can influence initia-
tion, duration, and exclusivity of costs. breastfeeding is defined as feeding
the infant only breast milk, with no
W
breastfeeding. As experts in food and ith rare exceptions, breast-
nutrition throughout the life cycle, it feeding, or lactation, is the op- supplemental liquids or solids except
is the responsibility of registered timal method for feeding and for liquid medicine and vitamin/min-
dietitians and dietetic technicians, nurturing infants. Extensive research eral supplements (9). The Bellagio
registered, to promote and support documents the significant advantages Child Survival Study Group identi-
breastfeeding for its short-term and of breastfeeding for infants, mothers, fied breastfeeding during the first
long-term health benefits for both families, and the environment. year as one of the most important
mothers and infants. Breastfeeding involves primary and, strategies for improving child sur-
J Am Diet Assoc. 2009;109: to a lesser extent, secondary preven- vival (10-12). There also are extensive
1926-1942. tion of acute and chronic diseases. health benefits for breastfeeding
The benefits of breastfeeding include mothers (7,8). The growth and devel-
decreased infant and child morbidity opment of breastfeeding infants is the
and mortality, protection against standard by which all infants and
0002-8223/09/10911-0013$36.00/0
common childhood infections, and de- children should be measured. New
doi: 10.1016/j.jada.2009.09.018
creased risk for certain acute and growth charts available from WHO
1926 Journal of the AMERICAN DIETETIC ASSOCIATION © 2009 by the American Dietetic Association
are based on breastfed infants as the 80
normative growth model constituting 70
good nutrition, health, and develop- 60
ment (13). This is in contrast to the 50 Initiation
Centers for Disease Control and Pre- 40 6 months
vention (CDC) growth charts that % 30 12 months
represent the growth patterns of 20
breast- and formula-fed infants (14). 10
Portions of this position paper used 0
the American Dietetic Association’s 1999 2000 2001 2002 2003 2004 2005
(ADA’s) Evidence Analysis Library Initiation 68.3 70.9 71.6 71.4 72.7 73.8 74.2
(EAL) to address three questions: 6 months 32.62 34.2 36.9 37.6 39.1 41.5 43.1
12 months 15 15.7 18.2 19 19.6 20.9 21.4
● Which dietary factors would affect Figure 1. Percentage of US children who were breastfed by birth year, 1999-2005. Data adapted
breast milk production, breast milk from: National Immunization Survey, 2005 Births, Centers for Disease Control and Prevention,
supply, or established lactation? Department of Health and Human Services. http://www.cdc.gov/breastfeeding/data/NIS_data/.
● What are the effects of an artificial Accessed April 24, 2009.
nipple on the duration of breast-
feeding? moted as being more convenient for According to provisional 2007 NIS
● What are the effects of maternal the mothers and being more nutri- data for infants born in 2005, 23
diet or dietary supplements of n-3 tious than human milk. Breastfeed- states achieved the national Healthy
fatty acids on breast milk composi- ing rates reached an all-time low in People 2010 objectives of 75% of
tion and infant health outcomes? the United States in 1971 with only mothers initiating breastfeeding. In
24% of mothers initiating breastfeed- addition, 10 states achieved the objec-
For a detailed description of the ing (19). tive of 50% of mothers breastfeeding
methods used in the evidence analy- The US Department of Health and at 6 months, 12 states achieved the
sis process, access ADA’s Evidence Human Services (HHS) set goals for objective of 25% of mothers breast-
Analysis Process information page at breastfeeding initiation and duration feeding at 12 months, and eight states
http://adaeal.com/eaprocess/. rates in the late 1970s, and the achieved all three initiation and du-
United States has since seen a steady ration objectives (16). It should be
increase in breastfeeding rates (1). noted that many of the mothers
BREASTFEEDING TRENDS IN THE UNITED Data from the 2007 National Immu- counted as “breastfeeding” were sup-
STATES nization Survey (NIS) indicate that plementing their infants with for-
Breastfeeding initiation and duration the rate of initiation and duration of mula or other products and the de-
rates in the United States are lower breastfeeding are improving, but are gree of breastfeeding was not actually
than in most nations. Globally, about still below the Healthy People 2010 measured.
79% of infants are breastfed for 12 goals (16). Breastfeeding initiation Breastfeeding initiation rates paint a
months, compared to 21.4% in the rates increased from a low of about much more positive picture of breast-
United States (7,15,16). Currently, 20% in the early 1970s to a high of feeding practices in the United States
one out of three infants in the devel- 61.9% in 1982 (19,20). After a decline than do breastfeeding exclusivity rates.
oping world is exclusively breastfed in breastfeeding rates through 1990, Although data about breastfeeding ex-
for the first 6 months of life, compared breastfeeding initiation rates in hos- clusivity are limited, the available data
to 11.9% in the United States (16,17). pitals have increased yearly, exceed- provide important insight. In 2007,
Almost all newborns in the United ing 70% from 2000. The 2007 NIS Healthy People 2010 objectives were
States were breastfed before 1880. In data indicate a high of 74.2% in 2005 updated to include two new objectives
the 1880s, women began to supple- (16) (see Figure 1). Breastfeeding that address exclusive breastfeeding
ment breastfeeding with cow’s milk rates are expected to continue in- (ie, feeding an infant only breast milk,
soon after giving birth and to wean creasing as a result of several na- with no additional liquids or solids)
their infants before they were 3 tional efforts, including Healthy Peo- (9,24). These two new objectives are to
months old. Infants fed cow’s milk ple 2010 (1) and Blueprint for Action increase the proportion of women who
died at much higher rates than on Breastfeeding (2), the US Depart- exclusively breastfeed their infants for
breastfed infants until the 1920s ment of Agriculture’s Loving Support 3 months to 40%, and to increase the
when pasteurization made cow’s milk Makes Breastfeeding Work campaign proportion of mothers who exclusively
safe and readily available for infant (21), the US Breastfeeding Commit- breastfeed their infants for 6 months to
feeding. Breastfeeding rates declined tee’s Breastfeeding in the United 17% (24). The national rates for exclu-
sharply because of the widespread be- States: A National Agenda (22), and sive breastfeeding at 3 and 6 months
lief that pasteurized cow’s milk elim- the HHS’s The Business Case for for infants born in 2005 were 31.5%
inated the differences between hu- Breastfeeding: Steps for Creating a and 11.9%, respectively. These rates
man and cow’s milk feeding (18). The Breastfeeding Friendly Worksite (23). are significantly lower than the targets
decline continued when other milk The US Breastfeeding Committee’s set by Healthy People 2010. More de-
substitutes such as evaporated cow’s strategic plan is supported by the tailed information can be found on the
milk and infant formula became HHS and more than 20 professional CDC Web site (16). Furthermore, 10
widely available. These were pro- and public health organizations. states met the objective of 40% exclu-
November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1927

Table. Provisional breastfeeding (BF) rates by sociodemographic factors among children born in 2005 (percent⫾half 95% confidence interval),
n⫽15,014 (exclusive), n⫽15,269 (any)a
BF at 6 BF at 12 Exclusive BFb Exclusive BFb
Demographic factor Ever BF months months at 3 months at 6 months
US national 74.2⫾1.2 43.1⫾1.3 21.4⫾1.1 31.5⫾1.3 11.9⫾0.9

Marital status
Married 79.6⫾1.2 49.8⫾1.5 25.1⫾1.4 36.9⫾1.5 14.0⫾1.1
Not married 62.4⫾2.6 28.0⫾2.5 13.3⫾2.0 19.5⫾2.2 7.1⫾1.5
Age
⬍20 51.2⫾8.3 18.6⫾6.9 9.2⫾5.1 14.9⫾5.8 7.4⫾5.2
20-29 y 70.6⫾2.0 36.0⫾2.2 15.5⫾1.6 26.7⫾2.0 10.8⫾1.5
⬎30 y 78.5⫾1.4 49.9⫾1.7 26.6⫾1.6 36.1⫾1.7 12.9⫾1.2
Education
⬍ High school 65.7⫾3.4 37.1⫾3.7 20.4⫾3.2 23.9⫾3.5 8.6⫾2.4
High school 67.8⫾2.5 33.6⫾2.8 15.5⫾2.1 25.2⫾2.6 10.2⫾1.9
Some college 75.2⫾2.1 39.7⫾2.5 18.7⫾2.1 31.5⫾2.4 11.3⫾1.7
College grad 85.9⫾1.3 58.8⫾1.9 29.9⫾1.8 43⫾1.9 16.2⫾1.3
Race/ethnicity
American Indian or Alaskan Native 65.5⫾8.5 42.3⫾6.9 24.3⫾5.8 25.7⫾5.7 7.9⫾2.8
Asian or Pacific Islander 83.6⫾4.9 51.8⫾4.4 29.1⫾3.9 34.5⫾5.9 13.4⫾3.7
Native Hawaiian and other 87.5⫾7.4 43.7⫾12.7 26.5⫾10.8 35.6⫾11.4 12.1⫾7.0
Black/African American 61.4⫾3.2 29.3⫾2.5 13.4⫾1.8 19.2⫾2.4 6.5⫾1.5
White 76.8⫾1.3 43.2⫾1.3 21.9⫾1.1 33.9⫾1.5 12.9⫾1.1
Hispanic/Latino 80.6⫾2.3 45.1⫾2.5 24.1⫾2.2 32.6⫾3.1 12.6⫾2.3
Receiving WICc
Yes 67.8⫾1.9 34.2⫾1.6 16.9⫾1.6 23.8⫾1.8 8.2⫾1.3
No, but eligible 76.2⫾5.2 56.4⫾6.5 32.9⫾6.8 40.6⫾7.2 16.1⫾4.5
No, ineligible 82.3⫾1.5 52.7⫾1.9 25.7⫾1.7 40.4⫾1.8 15.9⫾1.4
Poverty Income Ratiod
⬍100% 67.0⫾2.9 36.2⫾3.1 19.3⫾2.7 25.8⫾3.0 8.9⫾2.0
100% to ⬍185% 71.4⫾3.1 38.8⫾3.7 20.0⫾3.0 27.2⫾3.4 10.2⫾2.4
185% to ⬍350% 74.9⫾2.4 43.3⫾2.6 21.5⫾2.0 32.6⫾2.4 12.7⫾1.8
350% or higher 82.8⫾1.7 52.1⫾2.2 24.5⫾2.0 40.1⫾2.2 15.1⫾1.6
Residence
MSAe, Central City 76.2⫾1.8 45.4⫾2.1 23.8⫾1.8 31.7⫾2.0 12.3⫾1.4
MSA, Non-Central City 75.8⫾1.8 44.4⫾2.2 21.4⫾1.8 32.7⫾2.0 12.3⫾1.5
Non-MSA 64.6⫾2.9 33.1⫾2.7 15.3⫾1.9 27.5⫾2.6 9.4⫾1.7
a
Source: National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services. http://www.cdc.gov/breastfeeding/data/NIS_data/2005/
socio-demographic_any.htm. Accessed April 26, 2009.
b
Exclusive breastfeeding is defined as only breast milk—no solids, no water, and no other liquids.
c
WIC⫽Special Supplemental Nutrition Program for Women, Infants, and Children.
d
Ratio of self-reported family income to the federal poverty threshold value.
e
MSA⫽Metropolitan Statistical Area; defined by the US Census Bureau.
sively breastfeeding through 3 months the Mountain or Pacific regions of the old, living in the South Atlantic region,
of age and eight states met the objec- country (15,16) (see the Table). Among participating in WIC, and mothers
tive of 17% of mothers who exclusively women eligible for the Special Supple- with low-birth-weight infants (15,16).
breastfeeding through 6 months (16). mental Nutrition Program for Women,
Achieving all of the Healthy People Infants, and Children (WIC), those not
2010 objectives for breastfeeding could receiving WIC benefits have higher ini- BENEFITS OF BREASTFEEDING FOR
lead to a significant decrease in pediat- tiation and duration rates, and twice as INFANTS
ric health care costs in the United many are exclusively breastfeeding at 6 According to the American Academy
States (25). months (15). Whereas all demographic of Pediatrics, breastfed infants are
Breastfeeding initiation rates and groups reported increases in breast- the reference against which all alter-
exclusive breastfeeding at 3 and 6 feeding initiation since 1990, the larg- native feeding methods must be mea-
months are highest among women who est increases occurred among mothers sured with regard to growth, health,
are white or non-Hispanic, college edu- who have historically been less likely to development, and other outcomes (4).
cated, married, living in urban areas, breastfeed—women who are African Human milk has many beneficial ef-
older than 30 years, employed part- American, Hispanic, less educated, em- fects on the health of infants, espe-
time, have higher incomes, or living in ployed full-time, younger than 24 years cially premature and low birth weight
1928 November 2009 Volume 109 Number 11

1. Which dietary factors would affect breast milk production (or breast milk supply, established lactation)?
EAL Conclusion Statement: Current available evidence shows no significant effects or relationships between any of the following dietary
factors and breast milk production in healthy, adult, lactating women (mean⫾standard deviation body mass index ranged from 21.4⫾0.9 to
25.2⫾4.2): short periods (⬍10 weeks) of reduced energy intake (25% to 35% energy deficit), increased or decreased fluid intake (⫾25%
to 50%), increased protein intake (1.5 g/kg/d), three types of nutrition supplement (ie, Coleus amboinicus soup, Fenugreek seed capsules;
sugar-coated Moloco⫹B-12 tablets), and calcium intake (Evidence Grade II⫽Fair ).
2. What are the effects of artificial nipple on the duration of breastfeeding?

EAL Conclusion Statement: Overall, evidence suggests a negative influence of artificial nipple on the duration of all types of breastfeeding
(from partial to exclusive). Observational evidence consistently showed an association between use of pacifier before 3 months of age and
shorter breastfeeding duration in healthy term or full-term infants, after controlling for potential confounding. Data are insufficient to
determine whether increasing frequencies of pacifier use or introduction of pacifier use beyond 3 months of age has differential influences
on breastfeeding duration. Well-designed randomized control tests with blinded assessments of breastfeeding outcomes are needed to
further support the validity of the findings from the observational studies concerning negative influence of pacifier use on the duration of
breastfeeding. Data are insufficient to make a conclusion regarding the effects of artificial nipple on the duration of breastfeeding among
preterm infants (Evidence Grade II⫽Fair ).
Supplemental feeding in term or full-term Infants
Data from both randomized control trials and observational studies also consistently suggested that supplemental feedings to term
infants, regardless of method (bottle or cup), had a detrimental effect on breastfeeding duration, compared to no supplemental feeding.
Preterm Infants
Data are insufficient to make a conclusion regarding the effects of artificial nipple on the duration of breastfeeding among preterm
infants.
3. What are the effects of maternal diet or dietary supplements of n-3 fatty acids on the breast milk composition and infant
health outcomes?
EAL Conclusion Statement: Consistent results from randomized control trials have shown that n-3 fatty acid supplementation (fish oil, cod
liver oil, or docosahexaenoic acid [DHA]-rich oil) to pregnant women or breastfeeding mothers can increase n-3 FA levels in both breast
milk and infants’ plasma phospholipids. There is a dose-response relationship between doses of DHA supplementation and breast milk DHA
levels, but the saturation dose remains unclear. Currently there is no study directly examining the dose-response relationship for other types
of n-3 fatty acid supplementation.
These positive changes in breast milk n-3 fatty acid compositions, however, do not always show a positive affect on children’s visual
acuity and cognitive development at long-term follow-up. (Evidence Grade⫽Good ).
Figure 2. American Dietetic Association Evidence Analysis Library (EAL) conclusion statements for dietary effects on lactation and the effects of
artificial nipples on duration of breastfeeding.
infants and young children. These that n-3 fatty acids supplementation interfere with pathogens binding to
benefits are magnified with exclusive to pregnant and breastfeeding women host cell receptors (28). Human milk
breastfeeding and breastfeeding be- can increase n-3 fatty acid levels in has a relatively low sodium content,
yond 6 months of age (9,10). breast milk and infant plasma phos- allowing the fluid requirements of ex-
pholipids. However, there do not ap- clusively breastfed infants to be met
Optimal Nutrient Composition pear to be any long-term clinical ben- while keeping the renal solute load
efits in children (Evidence Grade low. Minerals in breast milk are
Human milk is uniquely tailored to
IⴝGood). See Figure 2 for the EAL largely protein bound and balanced to
meet the nutrition needs of human
conclusion statement. enhance bioavailability. The 2:1 ratio
infants. It has the appropriate bal-
The relatively low protein content of calcium to phosphorus is ideal for
ance of nutrients provided in easily
digestible and bioavailable forms of human milk presents a relatively the absorption of calcium and both of
(7,26,27). The milk changes its com- modest nitrogen load to immature these minerals, and, along with mag-
position—from colostrum for new- kidneys. The protein is largely alpha- nesium, are present in appropriate
borns to mature milk for older in- lactalbumin—a whey protein that amounts for growth and develop-
fants—to meet the nutrient needs of forms a soft, easily digestible curd. ment. The limited amount of iron and
growing infants. It provides adequate There are more than 100 major milk zinc is highly absorbable (26). Given
amounts of carbohydrates, essential oligosaccharides in human milk that the nutrient content of human milk,
fatty acids, saturated fatty acids, me- are thought to have protective prop- supplements are not necessary, with
dium-chain triglycerides, long-chain erties against respiratory and enteric the exception of vitamin D and possi-
polyunsaturated fatty acids, and cho- diseases. These oligosaccharides pass bly fluoride (1,4,8). Due to insufficient
lesterol. An EAL report indicates that through the infant undigested, con- levels of vitamin D in human milk
there is consistent evidence to show centrate in feces, and are thought to and decreased exposure to sunlight, a

clusively breastfed 4 months or longer
Benefits for infants Benefits for mothers have a 72% reduction in hospitaliza-
tion for a lower respiratory tract in-
● Optimal nutrition for infant ● Strong bonding with infant fection during the first year of life
● Strong bonding with mother ● Increased energy expenditure, which may than infants who are formula-fed
● Safe, fresh milk lead to faster return to prepregnancy (32). In addition, breastfeeding may
● Enhanced immune system weight reduce the risk of nonspecific gastro-
● Reduced risk for acute otitis media, ● Faster shrinking of the uterus enteritis by 64% when compared to
nonspecific gastroenteritis, severe ● Reduced postpartum bleeding and delays infants who are not breastfed (33).
lower respiratory tract infections, and the menstrual cycle Breastfeeding for at least 6 months
asthma ● Decreased risk for chronic diseases such is associated with a 15% to 19% re-
● Protection against allergies and as type 2 diabetes, breast, and ovarian duction in the risk of developing
intolerances cancer childhood leukemia (33,34). Exclusive
● Promotion of correct development of ● Improved bone density and decreased breastfeeding has a positive effect on
jaw and teeth risk for hip fracture the development of the oral cavity by
● Association with higher intelligence ● Decreased risk for postpartum depression improving shaping of the hard palate
quotient and school performance ● Enhances self-esteem in the maternal resulting in proper alignment of the
through adolescence role teeth and fewer problems with maloc-
● Reduced risk for chronic disease such ● Time saved from preparing and mixing clusions (35). For families with a his-
as obesity, type 1 and 2 diabetes, formula tory of atopic dermatitis, breastfeed-
heart disease, hypertension, ● Money saved from not buying formula ing for at least 3 months is associated
hypercholesterolemia, and childhood and increased medical expenses with a 42% reduction in the condition
leukemia associated with formula feeding
(33). Studies on the effects of breast-
● Reduced risk for sudden infant death
feeding on the development of asthma
syndrome
are less clear. Some studies have
● Reduced risk for infant morbidity and
shown a moderate protective effect
mortality
whereas other studies demonstrate
conflicting results including an in-
Figure 3. Potential benefits of breastfeeding for infants and mothers. Data adapted from creased risk associated with breast-
references 1-3, 6, 7, 9, 26, 27, 33, and 42. feeding. Children without a family
history of asthma who breastfeed at
vitamin D supplement is recom- lies and malignancies (31) and exclu- least 3 months have been shown to
mended. The American Academy of sive breastfeeding is associated with have a 27% reduction in the risk for
Pediatrics recommends that all lower rates of hospitalization from in- asthma compared to children who do
healthy infants and children have at fections in the first year of life (32). not breastfeed (33). For those with a
least 400 IU of vitamin D daily. Sup- Evidence suggests that breastfeeding family history of asthma, there is a
plementation should be given to may reduce the risk for a large num- 40% reduction in the risk of asthma in
breastfeeding infants within the first ber of acute and chronic diseases (see children younger than 10 years old if
few days of life and continued Figure 3). A report by the Agency for they are breastfed for at least 3
throughout childhood regardless of Healthcare Research and Quality months (33). However, it is not clear if
whether or not the child is receiving there is a reduction in older children
(AHRQ) provides an extensive sum-
supplemental formula as it is un- and adolescents (33).
mary of meta-analyses, randomized
likely that a breastfed infant would Breastfeeding is associated with a
and nonrandomized comparative tri-
consume 1 L formula, the amount reduced risk of sudden infant death
als, prospective cohort, and case-con-
needed to supply 400 IU vitamin D syndrome (SIDS). According to the
trol studies to examine the effects of AHRQ report, a meta-analysis of
(29). Breastfed infants who are aged 6 breastfeeding on certain infant and
months and older may need a fluoride case-control studies found that receiv-
maternal health outcomes (33). Evi- ing breast milk is associated with a
supplement if the total amount of flu- dence suggests a significant reduction
oride from the local water supply or 36% reduction in the risk of SIDS
in the risk of acute otitis media, non- compared to infants who never
other sources available to the infant
specific gastroenteritis, childhood leu- breastfed (33). A German case-control
is inadequate (30).
kemia, and in hospitalizations from study compared 333 infants who died
lower respiratory tract disease for as a result of SIDS to 998 age-
Reduction in Infant Morbidity and breastfed infants compared to their matched controls and found that ex-
Mortality formula-fed counterparts (33). Com- clusively breastfeed infants at 1
Breastfeeding, especially exclusive pared to infants who are exclusively month of age had half the risk, and
breastfeeding, during the first 6 formula-fed, there is a 23% reduction that both partial and exclusive
months of life is an important factor in the risk of otitis media in infants breastfeeding were associated with a
for reducing infant and childhood ever breastfed and a 50% reduction in reduced risk of SIDS (36).
morbidity and mortality (12). Breast- infants exclusively breastfed for at Breast milk feedings for premature
feeding is associated with a reduction least 3 months (33). Breastfeeding infants may reduce the incidence of
in postneonatal deaths from all may decrease morbidity from respira- necrotizing enterocolitis (NEC). Stud-
causes other than congenital anoma- tory tract infections and infants ex- ies show an absolute risk difference of

Disease AHRQ WHO
Obesity Three meta-analyses of good and moderate methodological Updated meta-analyses concluded that the evidence
quality report an association of breastfeeding and a suggests that breastfeeding may have a small
reduction in the risk of obesity in adolescence and adult protective effect on the prevalence of obesity.
life compared with those not breastfed.
Blood pressure Two moderate quality meta-analyses concluded there was a Updated meta-analyses showed a small but significant
small reduction in systolic and diastolic pressure in protective effect of breastfeeding on systolic and
adults who were breastfed compared to those formula- diastolic blood pressure.
fed.
Figure 4. Findings of the Agency for Healthcare Research and Quality (AHRQ) and the World Health Organization (WHO) analyses of breastfeeding
and obesity and blood pressure. Data adapted from references 13 and 33.
5% in the risk of NEC between pre- have long-term effects on the reduc- obese in adolescence and adulthood
term infants receiving human milk tion of blood pressure possibly due to (44). Bottle-fed full-term infants who
and formula. This is considered a the lower sodium content of breast are appropriate for gestational age
meaningful clinical difference due to milk compared to infant formula, the have a 3.2 times greater risk of rapid
the high case-fatality rate of NEC long-chain polyunsaturated fatty acid weight gain between ages 2 and 6
(33,37,38). The value of human milk content of breast milk, and the re- years when compared to breastfed in-
in reducing the incidence of NEC has duced incidence of obesity, which is a fants (45). This effect may be related
influenced the growing use of pas- risk factor for hypertension (42). to factors such as the higher protein
teurized donor human milk for in- Studies have suggested that adults intake of formula-fed infants, greater
fants at high risk for NEC (37-41). who were breastfed are more likely to insulin response to formula resulting
When mother’s milk is not available, have lower serum cholesterol than in fat deposition, or an easier transi-
providing pasteurized donor milk their formula-fed counterparts. How- tion among breastfed infants to some
from appropriately screened donors ever, the AHRQ reports that a meta- new foods such as vegetables, which
from an approved milk bank offers analysis of cohort and case-control may lead to a more healthful diet in
immunoprotection and bioactive fac- studies included studies with serious later life (42).
tors not found in infant formula and methodological flaws and that the re- Breastfeeding is also associated with
is the next best option particularly for lationship between breastfeeding and a decreased risk of type 2 diabetes later
ill or preterm infants (4,39,41). Only cholesterol levels cannot be deter- in life after adjusting for birth weight,
human milk from facilities that mined at this time (33). Nonetheless, parental diabetes, socioeconomic sta-
screen and approve donors and pas- a meta-analysis published by WHO tus, and body size (42). Studies report
teurize the milk should be used be- reports that the evidence suggests that formula-fed infants have higher
cause there is risk of disease trans- that the association between breast- glucose concentrations and higher
mission to the recipient from donors feeding and total cholesterol varies by basal and post-prandial concentrations
who are not screened and from the age, with significant effects in adults of insulin and neurotensin when com-
use of unpasteurized milk. who were breastfed, but not among pared to breastfed infants (42,46). Chil-
children or adolescents who were dren and adults who were not breastfed
Long-Term Outcomes breastfed. The study also concluded have higher serum insulin levels. WHO
In addition to a significant reduction that the association was not due to and AHRQ identified studies that
in acute illnesses, breastfeeding can publication bias or residual confound- found breastfed infants were less likely
affect the development of chronic dis- ing (42) (see Figure 4). to present with type 2 diabetes later in
eases later in life. WHO conducted Breastfed infants are less likely to life compared to formula-fed infants,
systematic reviews of 33 observa- become overweight or obese as adults but also report other studies that failed
tional and randomized studies to as- (42-44). Some studies have found an to show an association (33,42). WHO
sess the long-term consequences of association of breastfeeding and a re- and AHRQ concluded that it is not cur-
breastfeeding on blood pressure, obe- duction in the risk of obesity in ado- rently possible to draw conclusions
sity/overweight, total cholesterol, lescence and adulthood compared about the long-term effects of breast-
type 2 diabetes, and intellectual per- with those who were not breastfed. feeding on the risk of type 2 diabetes.
formance (42). Nearly all the studies Breastfeeding may reduce the risk of (33,42).
were conducted in countries with high overweight or obesity in adolescence Although evaluating the effect of
income and in predominantly white and adulthood by 7% to 24% (43,44). breastfeeding on cognitive develop-
populations. The systematic review Another study found a 4% reduction ment is problematic, as it is difficult
found a small but significant protec- in the risk of being overweight in to control for factors such as maternal
tive effect of breastfeeding on systolic adulthood for each additional month intelligence, maternal education, the
and diastolic blood pressure and a re- of breastfeeding in infancy (44). Over- home environment, and socioeco-
duction in cholesterol levels among all, there is an association between a nomic status, a WHO meta-analysis
adults who were breastfed in infancy history of breastfeeding and a reduc- report indicated that infants who
(42). Breastfeeding has been found to tion in the risk of being overweight or were breastfed for at least 1 month

performed higher on intelligence tests ternal neglect, the odds were nearly with a lifetime breastfeeding of more
than their formula-fed counterparts. four times greater for nonbreastfed in- than 12 months (56-58). Women with
Furthermore, infants who are exclu- fants compared to infants breastfed breast cancer are less likely to have
sively formula-fed have an average more than 4 months, after adjustment ever breastfed and their average life-
intelligence quotient that is 4.9 points for confounding variables (48). time duration of breastfeeding is
lower than infants who breastfeed at shorter (9.8 vs 15.6 months) compared
least 1 month, even when studies con- to women without breast cancer. For
trol for the home environment. BENEFITS OF BREASTFEEDING FOR each year a woman breastfeeds in her
Breastfeeding for less than 6 months WOMEN lifetime there is a 4.3% reduction in the
is associated with decreased test In addition to the numerous benefits of risk of breast cancer (56). Women who
scores and impaired school perfor- breastfeeding for the infant, there are have breastfed three or more children
mance when compared to infants who many benefits for the mother (see Fig- have a decreased risk for breast cancer
breastfeed for a longer duration. The ure 3). The degree to which some of (57), and for each 6-month increase in
report also suggests that breastfeed- these health benefits may be realized breastfeeding there is further reduc-
ing is associated with increased cog- depends on breastfeeding duration, tion in breast cancer risk (58). Breast-
nitive development in childhood. breastfeeding frequency, breastfeeding feeding has been also found to be effec-
However, the practical significance is exclusivity, and other personal factors tive in reducing ovarian cancer risk.
unknown. The report also reviewed a (49). Women choosing to breastfeed can This protection is attributed to the par-
few studies that examined school per- feel confident that their choice of infant tial inhibition of ovulation in lactating
formance and found higher educa- feeding improves not only the health of women (59). One systematic review of
tional achievement in late adoles- their child but also their own long-term 31 studies found that there was no
cence and young adulthood among health and well-being. emerging consensus regarding breast-
those who were breastfed compared feeding and protection against breast
to their formula-fed counterparts cancer for either ever vs never breast-
(42). In addition, AHRQ reviewed one Family Planning feeding or for the duration of breast-
well-performed sibling analysis and Women who exclusively breastfeed feeding as only about half of the studies
three prospective cohort studies con- their infants are more likely to be am- reviewed found a significant protective
ducted in developed countries with enorrheic, which conserves iron stores effect (60).
term infants that were adjusted for and decreases the risk for iron defi- A longer duration of lifetime breast-
maternal intelligence and found little ciency, at 6 months postpartum (50). feeding is also associated with a de-
or no evidence of a relationship be- Extended breastfeeding also sup- creased risk for developing type 2 dia-
tween breastfeeding and cognitive presses ovulation, which delays the betes among women with no history of
performance (33). menstrual cycle and in turn may in- gestational diabetes, although for
A high concentration of long-chain crease spacing between pregnancies. women with a history of gestational di-
polyunsaturated fatty acids in breast The lactational amenorrhea method abetes the increased risk of developing
milk and enhanced maternal-child (LAM) has been promoted for more type 2 diabetes is not ameliorated by
bonding may be responsible for im- than two decades by family planning lactation (33,46). Breastfeeding may be
proved cognitive development (27,30) advocates, especially in developing associated with a reduced risk of hip
and researchers are still trying to un- countries that have difficulty obtaining fractures in postmenopausal women
derstand which of them is the deciding contraceptive (50-53). LAM advocates (61) and improve bone mineral density
factor. However, the results from one purport that the method provides more during young adulthood in adolescent
large randomized trial suggest that the than 98% protection from pregnancy in mothers (62). However, others report
nutritional properties of breast milk the first 6 months postpartum. A Co- there is little evidence to show an asso-
have a positive independent effect (47). chrane Database of Systematic Review ciation between lifetime breastfeeding
The EAL reports that although mater- of LAM also concluded that exclusively and a reduced risk of fractures due to
nal supplementation with n-3 fatty ac- breastfeeding women who stay amen- osteoporosis (33). There also is a de-
ids increases plasma phospholipids in orrheic (regardless of whether they creased risk for developing rheumatoid
infants there is an apparent dose-re- used LAM) have a very small risk of arthritis, especially if a mother breast-
sponse relationship. Furthermore, the getting pregnant (54). LAM can be im- feeds for more than 12 months (63).
increases in breast milk n-3 fatty acid plemented with minimal counseling or
compositions do not always show a pos- follow-up and is an effective family
itive influence on children’s visual acu- planning method with a high level of Weight Loss
ity and cognitive development at long- user satisfaction that can be used in a The studies on breastfeeding and
term follow-up, indicating that other variety of cultures and health care set- weight loss have produced mixed find-
factors are involved. (Evidence Grade tings (55). However, this method is not ings. Studies estimating postpartum
IⴝGood). See Figure 2 for the EAL promoted by US federal agencies and weight changes are less likely to detect
conclusion statement. national professional assocations (54). weight or fat loss than studies directly
Although there is limited research, measuring postpartum weight changes
breastfeeding may also help to protect (64). In the short term, breastfeeding
against maternal neglect and maltreat- Reduction in Disease women experience greater weight and
ment. An Australian longitudinal co- Several studies have found that breast- fat loss than non-breastfeeding women.
hort study spanning 15 years found feeding is associated with a decreased Furthermore, women who breastfeed
that in children with substantiated ma- risk for breast cancer that is magnified for longer than 6 months and those who

do so exclusively are more likely to mended by the US Surgeon General for less than 3 months report barriers
achieve greater weight loss (65-68). (74). These savings could be much such as: unsure if the infant is getting
Some studies report that lactation may higher since this figure only repre- enough milk, perception of not produc-
be associated with increased weight sents cost savings from the treatment ing enough milk, nipple or breast prob-
gain, or that any observed weight dif- of three childhood illnesses: otitis me- lems, mother or infant not liking
ference may not be sustained past 18 dia, gastroenteritis, and necrotizing breastfeeding, maternal fatigue, em-
months (69). It should be noted that enterocolitis (74). It also is estimated barrassed to breastfeed in public, going
weight loss and body composition that $30 million would be saved if all back to work, concern about weight loss
changes are highly variable among women participating in WIC breast- or dietary restrictions, and being the
postpartum women (69). In addition, fed for one month. An additional $48 only one who can feed the infant (81-
prepregnancy weight, total pregnancy million could be saved if 75% of the 85). In a study of WIC participants who
weight change, and parity all greatly mothers in the WIC program breast- did not initiate breastfeeding, African
impact postpartum weight loss (69,70). fed for 3 months (74-76). Changes to American and white mothers were
the WIC food packages have recently more likely to report perceptions of
been tailored to better promote and pain and Hispanic mothers were more
Maternal Well-Being support the establishment of success- likely to report perceptions of infant
An unexpected benefit of exclusive ful long-term breastfeeding (77). In breast rejection (82).
breastfeeding is improved sleeping at addition to the savings in direct med-
night. Mothers who supplement with ical costs, data are emerging that doc-
formula at night even when the fa- ument the economic benefits of Support, Education, and Cultural
ther takes over the nighttime feed- breastfeeding support to employers, Influences
ings to allow the mother to get more including lower maternal absentee-
The support that a mother receives
sleep have been found to sleep 40 to ism due to infant illness, increased
can influence her success with breast-
45 minutes less and to have more employee loyalty, improved produc-
feeding. Mothers rate social support
sleep disturbances than mothers who tivity, lower insurance premiums and
as more important than health ser-
exclusively breastfeed their infants, enhanced public image (74,78,79).
Health care payers or insurers would vice support due to a lack of availabil-
including overnight feedings (71).
reap benefits from savings in physi- ity of health professionals, promotion
Breastfeeding also lowers blood pres-
cian fees, emergency room visits, pre- of unhelpful practices, and conflicting
sure in breastfeeding mothers before,
during, and after breastfeeding ses- scriptions, and laboratory procedures advice (84). They also report dissatis-
sions. Oxytocin release during breast- with increased breastfeeding rates faction with their breastfeeding expe-
feeding is thought to be responsible (78). Costs that are equally important rience when they do not receive
for this effect (72). but more difficult to measure are adequate help from their health pro-
Consistently studies have shown long-term health concerns such as fessionals (84). Adolescent mothers
that breastfeeding is associated with a chronic diseases, a reduction in adult report that they are not informed by
decrease in depressive symptoms in the productivity due to decreased cogni- physicians or nurses about the health
postpartum period and some studies tive development and increases in benefits of breastfeeding and that it is
have reported lower mean depression chronic illnesses leading to higher ideally suited for infants (86). Many
scores in breastfeeding mothers com- health insurance rates related to not mothers who intend to exclusively
pared to those who bottle-feed (73). A breastfeeding (78). breastfeed often give formula earlier
shorter duration or no breastfeeding is than anticipated either because of dif-
associated with increased rates of post- ficulty with breastfeeding or because
partum depression although it is diffi- FACTORS THAT AFFECT INITIATION, formula was given at the hospital
cult to determine whether depression DURATION, AND EXCLUSIVITY OF (87,88). Often mothers believe that
leads to a reduced duration of breast- BREASTFEEDING breastfeeding is beneficial for their
feeding as opposed to breastfeeding re- Despite an abundance of reasons to infants, but also believe that early in-
ducing the risk for the development of breastfeed, a large number of women troduction of formula and solid food is
depression. These outcomes might oc- still choose not to initiate breastfeed- necessary and often unavoidable, es-
cur concurrently (33). ing, to only partially breastfeed, or to pecially if the infant is fussy, does not
breastfeed for a short duration. Al- sleep well, or if formula supplementa-
though the factors that determine tion was started in the hospital
ECONOMIC BENEFITS OF BREASTFEEDING whether a mother will choose breast- (87,89). Although WIC is seen as sup-
Breastfeeding provides significant feeding or formula feeding for her new- portive of breastfeeding, it is also
economic benefits to the family and born are numerous, unsupportive hos- seen as supportive of formula supple-
society, such as reduced health care- pital practices, lack of knowledge, mentation for breastfeeding mothers,
related expenses and reduced time off personal beliefs, and family attitudes which discourages mothers from ex-
from work and loss of income to take are likely to influence the mother’s de- clusive breastfeeding (87). Whereas
care of a sick infant or child (74-76). cision (80,81). Popular mother-related many mothers exclusively breastfeed
The US Department of Agriculture reasons for breastfeeding include: the initially, this number drops dramati-
estimates that at least $3.6 billion low cost, convenience, enjoyment, and cally over time. Early introduction of
could be saved in health care costs if not wanting to prepare formula and formula (1 week after hospital dis-
breastfeeding rates were increased sterilize bottles (80). Women who do charge) by breastfeeding women is in-
from current levels to those recom- not initiate breastfeeding or who do so fluenced by the hospital of delivery,

previous breastfeeding experience, by using dietary supplements or eat- there are insufficient data to deter-
and residing with a smoker (90). ing certain foods. However, the EAL mine if increasing the frequency of
The decision to breastfeed an infant found limited evidence to suggest pacifier use or introducing a pacifier
is usually made before a woman dis- that there are specific dietary com- after 3 months of age has differential
covers she is pregnant. Women with a ponents that can boost a woman’s effects on breastfeeding duration. The
positive intention to breastfeed usu- breast milk production (Evidence EAL did conclude that there are in-
ally initiate breastfeeding, but they Grade IIⴝFair). See Figure 2 for sufficient data regarding the influ-
do not necessarily have plans to the EAL conclusion statement. ence of pacifier and breastfeeding
breastfeed for a longer duration (91). duration among preterm infants (Ev-
Attending a prenatal breastfeeding idence Grade IIⴝFair). See Figure
class offered at the birth hospital has Hospital Practices 2 for the EAL conclusion statement
been shown to increase breastfeeding Hospitals provide a unique and criti- and grade. However, in a systematic
rates and improve exclusive breast- cal link between the breastfeeding review of the literature from 1950-
feeding for longer periods of time (92). support provided before and after de- 2006, results from four randomized
Classroom education on infant feed- livery. Hospital practices can influ- controlled trials do not support an ad-
ing has been shown to increase ence not only the success of breast- verse relationship between pacifier
knowledge and improve attitudes of feeding during the hospital stay but use and breastfeeding duration or ex-
adolescents towards breastfeeding also the exclusivity and duration of clusivity. The researchers assert that
and result in greater intention to breastfeeding. The CDC conducted the association between shortened
breastfeed their children in the future the Maternity Practices in Infant Nu- duration of breastfeeding and pacifier
(93). trition and Care Survey to determine use in observational studies likely re-
The intention to breastfeed can also if hospital and birth practices were flects several factors such as breast-
be influenced by country of origin. supportive of breastfeeding during a feeding difficulties or intent to wean
Foreign-born women living in the critical time when lactation is being (99).
United States are more likely to in- established (97). The study found that Formula supplemental feedings to
tend to breastfeed when compared to most hospitals offer breastfeeding as- breastfed infants occur frequently in
women born in the United States (94). sistance and instruct mothers on hospitals. As a general practice, 24%
On the other hand, the influence of breastfeeding technique. Women who of facilities give supplements to more
family members not born to the deliver in a hospital that employs than half of all healthy, full-term
United States can have a negative in- board-certified lactation consultants breastfeeding infants, 30% offer glu-
fluence on exclusive breastfeeding. It have increased breastfeeding success cose water, and 15% offer water (97).
may be accepted within some cultures at hospital discharge, especially In 17% of the facilities, healthy full-
or groups of people to supplement women at high risk for not breast- term breastfeeding infants born in
breastfeeding with formula feeding. A feeding such as Medicaid recipients, uncomplicated cesarean births are
study of Puerto Rican women in Hart- adolescent mothers, and mothers of fed something other than breast milk
ford, CT, suggests that mothers are preterm or low birth weight babies for their first feeding. Discharge
less likely to exclusively breastfeed (98). Support after hospital discharge packs containing infant formula are
when the maternal grandmother re- is also important. Adolescent mothers distributed to breastfeeding mothers
sides in the United States (95). The believe that more support and phone in 70% of facilities, giving the mother
grandmothers may be discouraging contact with nurses would have mixed messages about the value of
exclusive breastfeeding in favor of helped them overcome breastfeeding exclusive breastfeeding (97). The
mixed feedings of breast milk and for- difficulties after they are discharged CDC recommends that these prac-
mula (96). Researchers in Denver, from the hospital (86). Several hospi- tices be discontinued to provide more
CO, found that it is not uncommon for tal practices were found not to be sup- positive support for breastfeeding ini-
Latina mothers to initiate breastfeed- portive of breastfeeding. Some hospi- tiation and duration (97). The EAL
ing with combination feedings of tals advise women to limit the concludes that there is consistent ev-
breast and formula known as “Los duration of suckling at each breast idence to suggest that supplemental
Dos,” or “best of both,” a practice that and pacifiers are routinely given to feedings to term infants, regardless of
inevitably leads to a low milk supply more than half of all healthy, full- method (bottle or cup), had a detri-
and eventual refusal of the infant to term breastfed infants (97). mental effect on breastfeeding dura-
latch on to the breast (96). Mothers Most observational studies report tion, compared to no supplemental
may believe that giving both breast an association between pacifier use feeding (Evidence Grade IIⴝFair).
milk and formula will assure that the and shortened duration of breastfeed- See Figure 2 for the EAL conclusion
infant is getting the health benefits of ing (99). The EAL concludes that statement.
breast milk along with the vitamins there is a negative impact of artificial The Baby-Friendly Hospital Initia-
in the formula (96). Other studies nipple on breastfeeding duration (Ev- tive (BFHI) is a global program spon-
have shown that Hispanic mothers idence Grade IIⴝFair). See Figure sored by WHO and UNICEF to encour-
have high rates of partial breastfeed- 2 for the EAL conclusion statement. age hospitals and birthing centers that
ing at both discharge from the hospi- Observational studies show an asso- offer an optimal level of care for lacta-
tal and at 1 month postpartum ciation between pacifier use before 3 tion. There are 10 steps to becoming a
(16,88,95). Some breastfeeding moth- months of age and a shorter duration “baby-friendly” facility and those that
ers may seek to enhance the quality of breastfeeding in healthy term in- accomplish them are officially desig-
and quantity of their milk production fants. However, the EAL reports that nated as such. The BFHI assists hospi-

tals in giving breastfeeding mothers formula and the mother is assisted Maternal Employment
information, confidence, and skills with breastfeeding (103). Even with sufficient family and com-
needed to successfully initiate and con- munity support, many women discon-
tinue breastfeeding infants and gives tinue or reduce breastfeeding when
special recognition to hospitals that fol- Formula Marketing they return to employment outside the
low “baby-friendly” pratices (100). A Formula company marketing is a home. Evidence suggests that return to
mother’s perception of the hospital’s common institutional practice in pub- employment does not necessarily re-
compliance with the Ten Steps of the lic health clinics, physician offices, duce initiation of breastfeeding except
BFHI influences the rate of exclusive and hospitals that reduces the rates for those mothers returning to work
breastfeeding during the hospital stay. of breastfeeding initiation, duration, within the first 6 weeks after delivery
Mothers are more likely to exclusively and exclusivity. Marketing of formula (115,116). However, there is evidence
breastfeed when they feel that the hos- is evident in the provision of formula to suggest that breastfeeding duration
pital is compliant with the BFHI (101). company-produced infant feeding lit- is significantly reduced when the
Having a written breastfeeding policy erature and free formula offers at pre- mother returns to work in less than 12
(Step 1) that is communicated to all natal care visits, free formula pro- weeks (117). It has been suggested that
staff improves breastfeeding rates 2 vided at hospital discharge, and when offering paid maternity leave may en-
weeks after delivery (101). Training of hospitals feed breastfed infants for- courage more women to extend the du-
perinatal and neonatal nurses and mula when it is not medically indi- ration of breastfeeding (115). Studies
medical staff in breastfeeding guidance cated (106). Concerned about the suggest that paid leave may result in
(Step 2) can have a significant influ- effects of formula marketing on more positive health outcomes for both
ence on breastfeeding initiation, dura- breastfeeding rates, the New York mother and infant (118).
tion, and exclusivity as well as improv- City Department of Health and Men- Paid maternity leave is not re-
ing satisfaction with lactation support tal Hygiene and its partners collabo- quired by federal law in the United
(102). Mothers who experience “baby- rated to change hospital and health States, and industrialized nations
friendly” hospital practices are also professionals’ practices and to edu- with exemplary paid maternity cover-
more likely to continue breastfeeding cate professionals and the public that age include: Norway, with 42 weeks
beyond 6 weeks (103). at 100% of salary or 52 weeks at 80%
breastfeeding is the normative and
Hospital practices found to have a of salary; France, with 16 weeks at
accepted method of infant feeding
positive effect on breastfeeding dura- 100% of salary; Germany, with 14
(107).
tion include breastfeeding in the first weeks at 100% of salary; Italy, with 5
hour after birth, feeding only breast months at 80% of salary; and Ireland,
milk in the hospital, infant rooming- with 18 weeks at 70% of salary (119).
Peer Counselors
in, providing a phone number for The only law related to maternity
breastfeeding help after discharge, Ongoing support is essential to assure leave in the United States is the Fam-
and not using a pacifier (103,104). breastfeeding success. Peer counselor ily and Medical Leave Act of 1993,
Mothers who experience these hospi- programs are an effective strategy to and it provides 12 weeks of unpaid
tal practices are less likely to wean improve breastfeeding rates among leave annually, allows for continued
due to difficulties establishing breast- WIC participants and empower both health insurance, and guarantees a
feeding such as insufficient milk sup- the peer counselor and the client (108- return to the same, or an equivalent
ply, an unsatisfied infant, and diffi- 113). Counselors are capable of identi- job (120). Five states (California, Ha-
culties with latching (104). Mothers fying and discussing barriers to breast- waii, New Jersey, New York, and
who breastfeed within 120 minutes of feeding, recognizing situations that Rhode Island) and Puerto Rico have
birth are 2.5 times more likely to be require referrals to a health profes- gone beyond the Family and Medical
exclusively breastfeeding at 4 months sional, and are able to increase a wom- Leave Act and offer postpartum
than mothers who breastfeed for the an’s self-confidence in her ability to women temporary disability insur-
first time at more than 120 minutes breastfeed. Proactive interactions are ance. The insurance is funded by the
(105). Mothers who hold their infants important as it is known that few employee, employer, or both and the
skin to skin are more likely to initiate mothers will call for help even when weeks covered vary by state (121).
breastfeeding sooner after birth (105). provided with a referral contact num- The HHS offers guidelines for em-
In-hospital feeding of newborns can ber upon discharge from the birth hos- ployers to create a supportive work
influence the modality of infant feed- pital (109). Counselors manage client’s environment for breastfeeding em-
ing at one month of age. Of the moth- questions through telephone counsel- ployees (23).
ers who are exclusively breastfeeding ing and individual clinic visits, and Four components have been shown
in the hospital, 50.9% continue to ex- many also visit clients in their homes. to provide the greatest financial re-
clusively breastfeed during the first Fathers are also an important source of turn for employer investments: pri-
month compared to 20.3% of women support for breastfeeding women. A vacy for milk expression, flexible
who partially breastfeed and 4.2% of “peer dad” program can offer fathers an breaks and work options, breastfeed-
mothers who do not breastfeed before opportunity to serve as role models and ing education, and support (121). The
hospital discharge (82). Mothers are to share information and support with International Lactation Consultant
more likely to fulfill their intention to other new fathers. WIC sites where Association recommends three strat-
exclusively breastfeed when the hos- peer dads are available have increased egies for protection of breastfeeding
pital staff does not supplement with breastfeeding initiation rates (114). in the workplace. First, arrange-

ments should be considered to keep about the effects of artificial nipple on from the early prenatal to postpar-
mother and infant together such as the duration of breastfeeding among tum period (27).
working from home, bringing the in- preterm infants. (Evidence Grade Most prescribed and over-the-
fant to the workplace and extended IIⴝFair). See Figure 2 for the EAL counter medications are safe for the
maternity leave. If that is not feasible conclusion statement and grade. breastfed infant and resources are
then intermittent contact to allow for Despite the many benefits of breast- available to assist in evaluating the
breastfeeding breaks by having the feeding, there are some situations in safety of drug use in lactation (27,128).
mother visit her child or having the which the infant should not be breast- However, there are a few medications
child brought to the workplace will fed. These include an infant with galac- that are not compatible with breast-
allow breastfeeding to continue while tosemia (4), and an infant whose feeding. They include radioactive iso-
the mother is at work. If mother and mother uses illegal drugs (4), has active topes, antimetabolites, cancer chemo-
infant must be separated, protection tuberculosis (4,124), is infected with therapy agents, lithium, ergotamine,
of breastfeeding can be provided by the human immunodeficiency virus and a small number of other medica-
offering the mother adequate breaks (HIV), has acquired immunodeficiency tions (4). Breastfeeding mothers should
and appropriate facilities to express syndrome (AIDS), or other diseases be encouraged to discuss any use of
and store her breast milk for later use where the immune system is compro- prescription drugs, over-the-counter
while the child is at the child care mised (4,124). In countries with high drugs, and herbal medications with
provider (122). Legislation protecting prevalence of HIV/AIDS, the infant their primary care health profes-
the rights of breastfeeding mothers to mortality risks associated with not sional. Although herbal products are
breastfeed in public and in the work- breastfeeding may outweigh the possi- widely used in the United States,
place has been enacted in many ble risks of acquiring HIV (125). data are lacking about the safety of
states and is an important strategy to Breastfeeding is not contraindicated their use during lactation.
extend the duration of breastfeeding. when the mother has hepatitis, is fe- With the exception of maternal
brile, has been exposed to low-level en- chemical poisoning, human milk re-
vironmental agents, or is positive for mains a safe feeding method for in-
SPECIAL CONSIDERATIONS fants and young children. Con-
cytomegalovirus (4). Women who
The advantages of breastfeeding and smoke cigarettes or are exposed to cig- tamination of breast milk with
the use of human milk are particularly arette smoke should attempt to quit environmental pollutants is a con-
salient for premature infants and low and avoid smoke exposure, but for cern when mothers have had specific
birth weight infants. If these infants exposure to heavy metals or insecti-
breastfeeding women with tobacco
are unable to feed directly at the cides (129,130). In situations where
smoke exposure, breastfeeding is still
breast, the mother’s milk can be ad- maternal exposure and probability
the best and preferred feeding method
ministered through various feeding of transfer in breast milk lipids are
(4).
routes (27). Human milk has also been determined to be significant, analy-
A mother’s physical and mental
successfully used with infants with sis of milk is recommended with de-
health status can affect her ability to
cleft palate; cystic fibrosis (with pancre- cisions regarding safety made from
successfully breastfeed her infant. estimated average intake. Environ-
atic enzyme replacement); Down syn-
Maternal obesity is linked to lower mental contaminants get into hu-
drome; congenital heart disease; and
inborn errors of metabolism, especially rates of breastfeeding initiation (126). man milk when mothers have had
phenylketonuria (with supplementa- Women with obesity who initiate lac- geographical, occupational, or acci-
tion of low-phenylalanine formula) tation are less likely to maintain a dental exposure. Dioxins produced
(27). In each of these situations, the full supply and are more likely to during industrial processes, organo-
major challenge remains the achieve- have infants with slower weight gain chlorine pesticides, polybrominated
ment and maintenance of an ade- who require supplementation. Moth- diphenyl ethers and polychlorinated
quate milk supply. Health profes- ers with obesity face more breastfeed- biphenyls are of greatest concern due
sionals should provide anticipatory ing challenges, yet are less likely to to their long half-lives and bioaccu-
support and be alert to early signs or seek support (127). Depression in the mulative nature in human tissues of
symptoms of feeding difficulties so ef- early postpartum period has been mothers and infants (129,131). Stud-
fective early intervention can be ini- shown to be linked to lower breast- ies have shown that even when levels
tiated. Mothers who desire to breastfeeding rates. The observation that of environmental chemicals are high,
feed and are unable to produce a depressed women who stop breast- beneficial effects of breastfeeding
sufficient milk supply can augment feeding by 6 weeks have greater im- have been observed (131). Research
the milk the infant receives from the provement in their symptoms than shows that the greatest risk period
breast with the assistance of a supple- women who continue to breastfeed for adverse effects from exposure is
mental feeding device, allowing them leads to speculation that unresolved prenatally (132).
to experience the closeness of breast- nipple pain or soreness may be a fac- Breastfeeding mothers should be
feeding while providing adequate tor in depression (127). Medical ad- encouraged to reduce their exposure
supplemental nutrition (123). Moth- vances have improved the health out- to known chemical contaminants. For
ers may have concerns about the long- comes of many pregnant women with example, women who may become
term effects of offering their preterm chronic diseases. The key to success- pregnant, who are pregnant, or who
infants feedings by bottle on breast- ful breastfeeding for these women is are breastfeeding should reduce their
feeding success. The EAL found insuf- appropriate choice of medications, exposure to methylmercury (133).
ficient evidence to make a conclusion treatments, and lactation support Large bottom-dwelling fish are the

most common food source of methyl- ● Provide pregnant women and their sires and needs of each breastfeed-
mercury so the US Food and Drug families with practical information ing dyad. Ideally, weaning should
Administration and the US Environ- about breastfeeding that addresses be gradual and solid foods should be
mental Protection Agency recom- their specific questions and con- offered based on the age and devel-
mend the following guidelines for eat- cerns. A family-centered approach opmental stage of the child. Evalu-
ing fish: avoid shark, swordfish, may help identify potential breast- ate client education materials and
mackerel, and tilefish; eat up to 12 oz feeding problems early and prevent service delivery sites for product
of other kinds of fish every week with unnecessary or premature wean- bias. Changes should be made to
a maximum of 6 oz albacore tuna per ing. the counseling environment to
week; and check local advisories ● Limit or discontinue the use of ed- clearly communicate that breast-
about eating locally caught fish. If no ucational materials provided by for- feeding is the norm for infant
advice is posted, limit intake of locally mula companies, because they often feeding.
caught fish to 6 oz per week and con- contain subtle messages that may
sume no other fish in that same week discourage breastfeeding.
(133). ● Target women who are less likely to Involve Family and Friends
breastfeed (eg, ethnic minority
● Identify support networks as early
groups, low education, and adoles-
ROLES AND RESPONSIBILITIES OF FOOD in pregnancy as possible and de-
cents) and counsel in a culturally
AND NUTRITION PROFESSIONALS velop programs and materials
relevant and sensitive manner.
REGARDING PROMOTING AND aimed at specific groups such as ad-
● Identify women who are at risk for
SUPPORTING BREASTFEEDING olescent mothers, partners, and
early cessation. The first 6 weeks
As experts in food and nutrition grandmothers.
are especially crucial. Predictors of
throughout the life cycle, it is the re- ● Include fathers in breastfeeding ed-
early cessation include education
sponsibility of registered dietitians ucation and counseling sessions.
level, working intentions, work-
(RDs) and dietetic technicians, regis- Support from a woman’s partner
place support, social support, and
tered (DTRs) to promote and support and her mother significantly in-
previous breastfeeding experience
breastfeeding for its short- and long- crease her chances of breastfeeding
(134).
term health benefits for both mother and continuing to breastfeed. Fa-
● Encourage breastfeeding mothers
and infants. ADA emphasizes the es- thers need to learn how to be part of
with overweight and obesity to
sential role of RDs and DTRs in pro- a successful breastfeeding family
achieve a healthful weight. These
moting and supporting breastfeeding and adolescents need to hear that
women may have a lower prolactin
by providing up-to-date, practical in- breastfeeding strengthens the bond
response, which may result in de-
formation to pregnant and postpar- with their infants. Mothers and
creased milk production and early
tum women, involving family and grandmothers of pregnant adoles-
cessation of breastfeeding (135).
friends in breastfeeding education cent mothers should also be in-
● Refer new mothers to a woman-to-
and counseling, advocating for the re- cluded if possible.
woman breastfeeding support
moval of institutional barriers to ● Encourage women to identify and
group. Women who are members of
breastfeeding, collaborating with enlist help and support of women in
these peer networks act as volun-
community organizations and others their family or community who
teer counselors and receive specific
who promote and support breastfeed- have previously breastfed success-
training on supporting and encour-
ing, and advocating for policies that fully.
aging new mothers. Peer support
position breastfeeding as the norm for ● Compile a list of resources to give to
may represent a cost-effective
infant feeding. ADA recommends the clients such as breast pump rentals,
method to promote and support
following strategies to promote and breastfeeding-friendly places in the
breastfeeding, especially where lac-
support breastfeeding: community, and contact informa-
tation consultants or professional
tion for lactation consultants and
breastfeeding support is not widely
breastfeeding support groups and
Counsel and Educate Pregnant and available.
agencies.
Postpartum Women ● Encourage women who are return-
ing to work or school to explore
● Counsel clients enthusiastically their options for continuing to Enhance Professional Development
about the benefits of breastfeeding, breastfeed. Discuss on-site arrange-
with emphasis that breastfeeding is ments to pump and store milk ● Be familiar with and comply with
more than a lifestyle choice. safely for later use. For women who all aspects of the International
● Recognize and respect that breast- cannot pump on-site, discuss how to Code of Marketing of Breast-milk
feeding is an individual and per- supplement breastfeeding with for- Substitutes in particular as it ap-
sonal decision. Effective educa- mula while apart and continuing to plies to health professionals (136).
tional strategies that strike a breastfeed when with their infant. ● Participate in continuing education
balance of support, respect, and ed- ● Discuss appropriate weaning foods, activities to keep up-to-date with
ucation result in informed decisions and clean and safe feeding of breast the art and science of lactation. In-
about infant feeding. milk substitutes when indicated. tensive courses in lactation training
● Discuss the challenges of breast- ● Provide appropriate and timely in- and education are available
feeding and suggest ways to mini- formation on weaning. The decision through various organizations.
mize or eliminate. to wean should be based on the de- ● Consider obtaining the professional

credential, International Board nor milk from a milk bank for sick breastfeeding promotion campaigns
Certified Lactation Consultant, or preterm infants when mother’s to adolescent mothers, men, and
through the International Board of own milk is not available. grandmothers.
Lactation Consultant Examiners ● Encourage lactating mothers to ● Initiate and support campaigns
(137,138). consider donating surplus milk to a that promote breastfeeding exclu-
● Participate in continuing education milk bank. sivity for the first 6 months of life
programs that sharpen skills in ● Advocate for hospitals and clinics to and continued breastfeeding be-
counseling and brief motivational provide training for all health care yond 6 months. Emphasize that
interviewing. staff, including physicians. breastfeeding is more than meeting
● Participate in continuing education ● Encourage hospitals to have lacta- the nutrition needs of young in-
programs on cultural competence. tion consultants available. fants. It offers health, physical, and
Cultural, ethnic, linguistic, and eco- ● Ensure that commercial infant for- psychological benefits to infants
nomic differences impact how indi- mula and feeding products are not that influence health outcomes
viduals access and use health, edu- inadvertently being promoted later in life.
cation, and social services. These through the display of formula com- ● Initiate campaigns that promote
differences also present barriers to pany logos on lanyards, badge hold- breastfeeding as part of a broader
effective education and health care ers, pens, and note pads. strategy to eliminate health dispar-
interventions (139,140). The low ● Support the removal of discharge ities among vulnerable groups.
prevalence of breastfeeding among packs in hospitals provided by for- ● Organize and participate in World
racial/ethnic minority groups de- mula companies to breastfeeding Breastfeeding Week activities an-
mands ongoing training in cultural mothers. nually in the first week of August.
competence. Ask questions and in- ● Advocate for the use of nurse home-
vite dialogue to identify and under- visitation programs that promote
stand the specific barriers for a and support breastfeeding among Advocate for Policy Change
group, then design or refine ser- low-income pregnant and postpar-
● Support legislation to eliminate
vices and messages to address those tum women.
barriers. Focusing on hands-on in- barriers to breastfeeding. More
terventions, skill building and prob- than half of the states have enacted
lem-solving can begin the process of Collaborate with Others Who Promote legislation to address breastfeeding
social change. Breastfeeding in public, on the job, and on jury
duty (141).
● Conduct critical internal review of
● Participate in professional and vol- ● Advocate for other policy changes
undergraduate and graduate die-
tetic training programs to ensure unteer activities with other health affecting a woman’s ability to con-
that lactation physiology, breast- professionals and community-based tinue breastfeeding including
feeding management, and cultural agencies. Collaborative opportuni- longer family leave, paid family
competence are incorporated into ties exist for ADA members to work leave, facilities for child care and
curriculums. with the International Lactation breastfeeding at the worksite or
Consultant Association; La Leche nearby in the community, paid
League International; Nursing nursing breaks, lactation rooms for
Initiate Institutional Change Mothers’ Counsel; Healthy Mothers milk expression, flexible work ar-
Healthy Babies coalitions; WIC; rangements, breastfeeding support
home visitation programs such as personnel/lactation consultation,
● Encourage hospitals and birthing the Nurse-Family Partnership Pro- and third party reimbursement for
centers to adopt the “Ten Steps to gram, the Community Health lactation consultation and manage-
Successful Breastfeeding” as out- Workers Program, and the Healthy ment services.
lined by UNICEF/WHO (100). Families Program; the African ● Encourage school boards to review
● Initiate and create institutional American Breastfeeding Alliance; their curriculums to ensure that
and organizational policies to re- and breastfeeding task forces at all breastfeeding is presented as the
duce or eliminate institutional bias levels to promote and support norm in texts, other resources, and
in hospitals and clinics for infant breastfeeding. classroom discussion at elementary
formula and incorporate appropri-
● Work with other health profession- and secondary schools. Volunteer to
ate lactation promotion and sup-
als to recruit and train successful work with curriculum committees;
port policies in their place. Food
breastfeeding women to be mem- science fair committees; and guest
and nutrition professionals must
bers of woman-to-woman breast- lecture in classes such as social
present the breastfed infant as the
feeding peer support groups. studies, life management, and
standard against which infants fed science.
human milk substitutes are com-
pared. Initiate and Support Breastfeeding
● Encourage public health agencies Campaigns Conduct Empirical Research
and health professionals to use the
WHO reference standards for ● Work with pro-breastfeeding orga- ● Initiate or partner with researchers
growth assessment of all infants nizations to promote breastfeeding in the conduct of empirical research.
and children. as the social norm. Research is needed on topics such as
● Promote the use of pasteurized do- ● Support extending the reach of breastfeeding older children, cultural

influences on infant feeding, milk have an important role in promoting clinical_charts.htm. Accessed August 28,
banking, social marketing of breast- and supporting breastfeeding for its 2009.
15. Abbot Nutrition Mother’s Survey: Breast-
feeding, breastfeeding in the work- short- and long-term health benefits feeding Trends 2003. Abbot Nutrition Web
place, media portrayal of infant feed- for both mother and infants. RDs and site. Web site. http://abbottnutrition.com/
ing, effectiveness of breastfeeding DTRs also have an important role in resources/en-US/news_and_media/media_
promotion programs, cost-effective- conducting empirical research on center/BF_Trends_2003.pdf. Published
2003. Accessed January 10, 2009.
ness of breastfeeding, hospital/clinic breastfeeding-related topics. Re- 16. Breastfeeding practices: Results from the
use rates, oral health and breastfeed- search is especially needed on the ef- National Immunization Survey. Centers
ing, eliminating barriers to extended fectiveness of breastfeeding promo- for Disease Control and Prevention Web
breastfeeding, and nutrient needs for tion campaigns. site. http://www.cdc.gov/breastfeeding/data/
women and children with special NIS_data/index.htm. Accessed August 28,
2009.
needs. In addition, research should 17. Progress for children: A report card on nu-
be theory-based and have policy im- References trition. 2006; No 4. United Nations Chil-
plications. 1. Healthy People 2010 [conference edition]. dren’s Fund Web site. http://www.unicef.
● Encourage all public and private Washington, DC: US Department of Health org/progressforchildren/2006n4/index_
funding sources to target breast- and Human Services; 2000. introduction.html. Published May 2006.
2. HHS Blueprint for Action on Breastfeeding. Accessed January 10, 2009.
feeding as an important topic in Washington, DC: US Department of Health 18. Wolf JH. Low breastfeeding rates and pub-
grant funding. and Human Services, Office on Women’s lic health in the United States. Am J Public
● Develop and/or advocate for a con- Health; 2000. Health. 2003;93:2000-2010.
sistent definition of breastfeeding 3. National Center for Education in Maternal 19. Ryan AS, Rush D, Krieger FW. Recent de-
and Child Health, eds. Followup Report: clines in breastfeeding in the United
in research studies to include fre- The Surgeon General’s Workshop on Breast- States, 1984 through 1989. Pediatrics.
quency and duration of breastfeed- feeding and Human Lactation. Rockville, 1991;88:719-727.
ing as well as timing of introduction MD: US Department of Health and Human 20. Ryan, AS. The resurgence of breastfeeding
of solid foods to improve the under- Services, Division of Maternal and Child in the United States. Pediatrics. 1997;99:
Health; 1985. E12. http://pediatrics.aappublications.org/
standing of the benefits of exclusive 4. American Academy of Pediatrics. Breast- cgi/content/full/99/4/e12%20. Accessed Au-
breastfeeding. feeding and the use of human milk. Pediat- gust 28, 2009.
● Submit applications for training rics. 2005;115:496-506. 21. US Department of Agriculture; Food and
grants to promote and support 5. National WIC Association. Breastfeeding Nutrition Service. Loving Support Makes
promotion and support in the WIC program Breastfeeding Work Campaign. Food and
breastfeeding at the local level. [position paper]. Washington, DC: National Nutrition Service Web site. http://www.fns.
These grants could focus on activ- WIC Association; 2004. usda.gov/wic/Breastfeeding/lovingsupport.
ities such as developing woman- 6. A call to action on breastfeeding: A funda- htm. Accessed January 10, 2009.
to-woman breastfeeding network, mental public health issue. American Public 22. US Breastfeeding Committee. Breastfeed-
Health Association Web site. http://www. ing in the United States: A National
providing stipends for women in apha.org/advocacy/policy/policysearch/default.
the woman-to-woman network, de- Agenda. Rockville, MD: US Breastfeeding
htm?id⫽1360. Published November 6, 2007. Committee; 2001.
veloping culturally relevant breast- Accessed July 29, 2008. 23. US Department of Health and Human
feeding materials, providing work- 7. Global Strategy for Infant and Young Child Services. The business case for breast-
Feeding. Geneva, Switzerland: World
shop training for health Health Organization; 2003.
feeding: Steps to creating a breastfeed-
professionals, and establishing tele- ing-friendly worksite. Womenshealth.gov
8. Community-Based Strategies for Breast- Web site. http://www.womenshealth.gov/
phone hotlines. feeding Promotion and Support in Develop- breastfeeding/programs/business-case/. Ac-
● Support a national policy to track ing Countries. Geneva, Switzerland: World
cessed April 10, 2009.
Health Organization; 2003.
breastfeeding trends using nonpro- 9. The optimal duration of exclusive breast-
24. US Department of Health and Human Ser-
prietary data. Policies are also vices, Office of Public Health and Science.
feeding: A systematic review World Health
needed to centralize national infant Hp 2010 midcourse review. Healthypeople.
Organization Web site. http://www.who.int/
gov Web site. http://www.healthypeople.
and child morbidity and mortality nutrition/publications/optimal_duration_of_
gov/data/midcourse. Accessed April 20,
data. exc_bfeeding_review_eng.pdf. Published
2002. Accessed April 9, 2009. 2009.
10. Black RE, Morris SS, Bryce J. Child sur- 25. Weimer J. The Economical Cost of Breast-
CONCLUSIONS vival I: Where and why 10 million children feeding: A Review and An Analysis. Wash-
die every year? Lancet. 2003;361:226-2234. ington, DC: Economic Research Service, US
Human milk has many beneficial ef- Department of Agriculture. ERS Food As-
11. Jones G, Steketee R, Black R, Bhutta Z,
fects on the health of infants, espe- Morris S, and the Bellagio Child Survival sistance and Nutrition Research Report
cially premature and low birth weight Study Group. Child survival II: How many No. 13; 2001.
infants and young children. These child deaths can we prevent this year? Lan- 26. Riordan J. Breastfeeding and Human Lac-
cet. 2003;362:65-71. tation. Boston, MA: Jones and Bartlett;
benefits are magnified with exclusive 2004:108-109.
12. Bellagio Child Survival Study Group. Child
breastfeeding and breastfeeding be- survival V: Knowledge into action for child 27. Lawrence RA, Lawrence RM. Breastfeeding:
yond 6 months of age (7,12). Breast- survival. Lancet. 2003;362:323-327. A Guide for the Medical Profession. St Louis,
feeding also provides several health 13. WHO Child Growth Standards: Length/ MO: Mosby-Year Book; 2005:105-170.
Height-For-Age, Weight-For-Age, Weight- 28. Flanders Stepans MB, Wilhelm SL, Hert-
benefits for the breastfeeding woman.
For-Length, Weight-For-Height, and Body zog M, Callahan Rodehorst TK, Blaney S,
ADA recognizes the various factors Mass Index-For-Age: Methods and Develop- Clemens B, Polak JJ III, Newburg DS.
that influence women and their fam- ment. Geneva, Switzerland: World Health Early consumption of human milk oligosac-
ilies to choose a particular infant Organization; 2006. charides is inversely related to subsequent
feeding method, but ADA supports 14. National Center for Health Statistics, Cen- risk of respiratory and enteric disease in
ters for Disease Control and Prevention. infants. Breastfeed Med. 2006;1:207-215.
and advocates the position that 2000 CDC growth charts: United States 29. Wagner CL, Greer FR, Section on Breast-
breastfeeding is the optimal feeding Centers for Disease Control and Prevention feeding and Committee on Nutrition. Pre-
method for the infant. RDs and DTRs Web site. http://www.cdc.gov/growthcharts/ vention of rickets and vitamin D deficiency

in infants, children, and adolescents. infancy and early childhood on subsequent the association between breastfeeding and
Pediatrics. 2008;122:1142-1152. fat mass development: Results from the breast cancer. J Women’s Health. 2008;17:
30. Kleinman RE, ed. Pediatric Nutrition Multicenter Allergy Study 90. Am J Clin 1635-1645.
Handbook. 6th ed. Elk Grove Village, IL: Nutr. 2008;87:1356-1364. 61. Huo D, Lauderdale DS, Liming L. Influence
American Academy of Pediatrics; 2008: 46. Owen CG, Martin RM, Whincup PH, Smith of reproductive factors in hip fracture risk
1046-1052. GD, Cook DG. Does breastfeeding influence in Chinese women. Osteoporos Int. 2003;14:
31. Chen A, Rogan W. Breastfeeding and the risk of type 2 diabetes in later life? A quan- 694-700.
risk of postneonatal death in the United titative analysis of published evidence. 62. Chantry CJ, Auinger P, Byrd RS. Lactation
States. Pediatrics. 2004;113:e435-e439. Am J Clin Nutr. 2006;84:1043-1054. among adolescent mothers and subsequent
32. Talayero JMP, Lizán-Garacia M, Puime 47. Lucas A, Morley R, Cole TJ, Lister G, Lee- bone mineral density. Arch Pediatr Adolesc
AO, Muncharaz MJB, Soto BB, Sánchez- son-Payne C. Breast milk and subsequent Med. 2004;158:650-656.
Palomares M, Serrano LS, Rivera LL. Full intelligence quotient in children born pre- 63. Pikwer M, Bergström U, MNilsson J-Å, Ja-
breastfeeding and hospitalization as a re- term. Lancet. 1992;339:261-264. cobsson L, Berglund G, Turesson C. Breast-
sult of infections in the first year of life. 48. Strathearn L, Mamun A, Najman JM, feeding, but not oral contraceptives, is as-
Pediatrics. 2006;118:e92-e99. O’Callahan MJ. Does breastfeeding protect sociated with a reduced risk of rheumatoid
33. Ip S, Chung M, Raman G, Chew P, Magula against substantiated child abuse and ne- arthritis. Ann Rheum Dis. 2009;68:526-
N, DeVine D, Trikalinos T, Lau J. Breast- glect? A 15-year cohort study. Pediatrics. 530.
feeding and Maternal and Infant Health 2009;123:483-493. 64. Dewey KG. Impact of breastfeeding on ma-
Outcomes in Developed Countries. Evidence 49. Steyn NP, Mann J, Bennet PH, Temple N, ternal nutritional status. Adv Exp Med
Report/Technology Assessment. AHRQ Zimmet P, Tuomilehto J, Lindstrom J, Lou- Biol. 2004;554:91-100.
Publication No. 07-E007. Rockville, MD: heranta A. Diet, nutrition and the preven- 65. Kac G, Benicio M, Velasquez-Melendez G,
Agency for Healthcare Research and Qual- tion of type 2 diabetes. Public Health Nutr. Valente J, Struchiner CJ. Breastfeeding
ity; 2007. 2004;7:147-167. and postpartum weight retention in a co-
34. Bener A, Hoffmann GF, Afify Z, Rasul K, 50. Dewey KG, Cohen RJ, Brown KH, and hort of Brazilian women. Am J Clin Nutr.
Tewfik I. Does prolonged breastfeeding re- Rivera LL. Effects of exclusive breastfeed- 2004;79:487-493.
duce the risk for childhood leukemia and ing for 4 vs 6 months on maternal nutri- 66. Rooney BL, Schauberger CW. Excess
lymphomas? Minerva Pediatr. 2008;60:155- tional status and infant motor develop- weight gain and long-term obesity: One de-
161. ment: Results of two randomized trials in cade later. Obstet Gynecol. 2002;100:245-
35. Palmer B. The influence of breastfeeding on Honduras. J Nutr. 2001;131:262-267. 252.
the development of the oral cavity: A com- 51. Family Health International. Consensus 67. Olson CM, Strawderman MS, Hinton PS,
mentary. J Hum Lact. 1998;14:93-98. statement. Breastfeeding as a family plan- Pearson TA. Gestational weight gain and
36. Vennemann MM, Bajanowski T, Brink- ning method. Lancet. 1998;ii:1204-1205. postpartum behaviors associated with
mann B, Jorch G, Yücesan, Sauerlan C, 52. Kennedy KI, Vissness CM. Contraceptive weight change from early pregnancy to 1 y
Mitchell EA, the GeSID Study Group. Does efficacy of lactational amenorrhoea. Lancet postpartum. Int J Obes. 2003;27:117-127.
breastfeeding reduce the risk of sudden in- 1992;339:227-230. 68. Hatsu IE, McDougald DM, Anderson AK.
fant death syndrome? Pediatrics. 2009;123: 53. Labbok MH, Perez A, Valdes V, Sevilla F, Effect of infant feeding on maternal body
e406-e410. Wade K, Laukaran VH, Cooney KA, Coly S, composition. Int Breastfeed J. 2008;3:18.
37. Schanler R, Shulman R, and Lau C. Feed- Sanders C, Queenan JT. The lactational 69. Sichieri R, Field AE, Rich-Edwards J, Wil-
ing strategies for premature infants: Bene- amenorrhea method (LAM): A postpartum lett WC. Prospective assessment of exclu-
ficial outcomes of feeding fortified human introductory family planning method with sive breastfeeding in relation to weight
milk vs preterm formula. Pediatrics. 1999; policy and program implications. Adv Con- change in women. Int J Obes Relat Metab
103:1150-1157. tracept. 1994;10:93-109. Disord. 2003;27:815-820.
38. Sisk PM, Lovelady CA, Dillard RG, Gruber 54. Van der Wijden C, Brown J, Kleijnen J. 70. Coitinho DC, Sichieri R, D’Aquino BMH.
KJ, O’Shea TM. Early human milk feeding Lactational amenorrhea for family plan- Obesity and weight change related to par-
is associated with a lower risk of necrotiz- ning. Cochrane Database System Rev. 2008; ity and breast-feeding among parous
ing enterocolitis in very low birth weight 3:CD001329. women in Brazil. Public Health Nutr. 2001;
infants. J Perinatal. 2007;27:428-433. 55. Peterson AE, Perez-Escamilla R, Labbok 4:865-870.
39. Tully MR, Lockhart-Borman L, Updegrove M, Hight V, von Hertzen H, Van Look P. 71. Doan T, Gardiner A, Gay C, Lee K. Breast-
K. Stories of success: The use of donor milk Multicenter study of lactational amenor- feeding increases sleep duration of new
is increasing in North America. J Hum rhea method (LAM) III: Effectiveness, du- parents. J Perinat Neonatal Nurs. 2007;21:
Lact. 2004;20:75-77. ration and satisfaction with reduced client- 200-206.
40. Updegrove K. Necrotizing enterocolitis: provider contact. Contraception. 2000;62: 72. Jonas W, Nissen E, Ransjö-Arvidon, Wik-
The evidence for use of human milk in pre- 221-230. lund I, Henriksson P, Uvnas-Moberg K.
vention and treatment. J Hum Lact. 2004; 56. Collaborative Group on Hormonal Factors Short- and long-term decrease of blood
20:335-339. in Breast Cancer. Breast cancer and pressure in women during breastfeeding.
41. Tully D, Jones F, and Tully MR. Donor breastfeeding: Collaborative reanalysis of Breastfeed Med. 2008;3:103-109.
milk: What’s in it and what’s not. J Hum individual data from 47 epidemiological 73. Dennis CL, McQueen K. The relationship
Lact. 2001;17:152-155. studies in 30 countries, including 50,302 between infant-feeding outcome and post-
42. Horta BL, Bahl R, Martines JC, Victora women with breast cancer and 96,973 partum depression: A qualitative system-
CG. Evidence on the long-term effects of women without the disease. Lancet. 2002; atic review. Pediatrics. 2009;123:e736-
breastfeeding. Systematic reviews and 360:187-195. e751.
meta-analyses. http://whqlibdoc.who.int/ 57. Zheng T, Holford TR, Mayne ST, Owens 74. Weimer J. The economic benefits of breast-
publications/2007/9789241595230_eng.pdf. PH, Zhang Y, Zhang B, Boyle P, Zahm SH. feeding: A review and analysis. US Depart-
Accessed August 28, 2009. Lactation and breast cancer risk: A case- ment of Agriculutre Economic Research
43. Owen CG, Martin RM, Whincup PH, Smith control study in Connecticut. Br J Cancer. Service Web site. http://www.ers.usda.gov/
GD, Cook DG. Effect of infant feeding on 2001;84:1472-1476. publications/fanrr13/fanrr13.pdf. Accessed
the risk of obesity across the life course: A 58. Trggvadóttir L, Tulinius J, Jórunn EE, Sig- April 20, 2009.
quantitative review of published evidence. urvinsson T. Breastfeeding and reduced 75. Montgomery DL, Splett PL. The economic
Pediatrics. 2005;115:1367-1377. risk of breast cancer in an Icelandic cohort benefit of breast-feeding infants in the WIC
44. Arenz S, Ruckerl R, Koletzko B, von Kries study. Am J Epidemiol. 2001;154:37-42. program. J Am Diet Assoc. 1997;97:379-
R. Breastfeeding and childhood obesity: A 59. Tung KH, Wilkens LR, Wu AH, McDuffie 385.
systematic review. Int J Obes Relat Metab K, Nomura AMY, Kolonel LN, Terada KY, 76. Splett PL, Montgomery DL. The Economic
Disord. 2004;28:1247-1256. Goodman MT. Effect of anovulation factors Benefits of Breastfeeding an Infant in the
45. Karaolis-Danckert N, Buyken AE, Kulig M, on pre-and postmenopausal ovarian cancer WIC Program: Twelve Month Follow-up
Kroke A, Forster J, Kamin W, Schuster A, risk: Revisiting the incessant ovulation hy- Study. Final Report submitted to USDA
Hornberg C, Keil T, Bergmann RL, Wahn pothesis. Am J Epidemiol. 2005;161:321- Food and Consumer Service. 1998.
U, Lau S. How pre- and postnatal factors 329. 77. US Department of Agriculture, Food and Nu-
modify the effect of rapid weight gain in 60. Yang L, Jacobsen K. A systematic review of trition Service. Special Supplemental Nutri-

tion Program for Women, Infants and 93. Walsh A, Moseley J, Jackson W. The effects tional WIC survey. J Hum Lact. 2001;17:
Children (WIC): Revisions in the WIC food of an infant-feeding classroom activity on 135-141.
packages; interim rule. Food and Nutrition the breast-feeding knowledge and inten- 109. Martens P. Increasing breastfeeding initi-
Service Web site. http://www.fns.usda.gov/ tions of adolescents. J Sch Nurs. 2008;24: ation and duration at a community level:
WIC/regspublished/wicfoodpkginterimrulepdf. 164-169. An evaluation of Sagkeeng First Nation’s
pdf. Published December 6, 2007. Accessed 94. Bonuck K, Freeman K, Trombley M. Coun- Community Health Nurse and peer coun-
May 22, 2009. try of origin and race/ethnicity: Impact on selor programs. J Hum Lact. 2002;18:236-
78. Ball T, Bennett D. The economic impact of breastfeeding intentions. J Hum Lact. 246.
breastfeeding. Ped Clin North Am. 2001;48: 2005;21:320-326. 110. Meier E, Olson BH, Benton P, Eghtedary
253-262. 95. Anderson A, Damio G, Chapman D, Peréz- K, Song WO. A qualitative evaluation of a
79. Cohen R, Mrtek MB, Mrtek RG. Compari- Escamilla R. Differential response to an breastfeeding peer counselor program. J
son of maternal absenteeism and infant ill- exclusive breastfeeding peer counseling in- Hum Lact. 2007;23:262-268.
ness rates among breastfeeding and formu- tervention: the role of ethnicity. J Hum 111. Bronner Y, Barber T, Davis S. Breastfeed-
la-feeding women in two corporations. Lact. 2007;23:16-23. ing peer counseling: policy implications. J
Am J Health Promot. 1995;10:148-153. 96. Bunik M, Clark L, Marquiz Zimmer L, Hum Lact. 2001;17:105-109.
80. Brodribb W, Fallon AB, Hegney D, O’Brien Jiminez LM, O’Connor ME, Crane LA, 112. Bronner Y, Barber T, Vogelhut J, Kovar
M. Identifying predictors of the reasons Kempe A. Early infant feeding decisions in Resnick A. Breastfeeding peer counseling:
women give for choosing to breastfeed. J low-income Latinas. Breastfeed Med. 2006; Results from the National WIC Survey. J
Hum Lact. 2007;23:338-344. 1:225-235. Hum Lact. 2001;17:119-125.
81. McCann MF, Baydar N, Williams RL. 97. Centers for Disease Control and Preven- 113. Merewood A, Philipp B. Peer counselors for
Breastfeeding attitudes and reported prob- tion. Breastfeeding-related maternity prac- breastfeeding mothers in the hospital set-
lems in a national sample of WIC partici- tices at hospitals and birth centers— ting: Trials, training, tributes, and tribula-
pants. J Hum Lact. 2007;23:314-324. United States, 2007. MMWR Morbid tions. J Hum Lact. 2003;19:72-76.
82. Hurley KM, Black MM, Papas MA, Quigg Mortal Wkly Rep. 2008;57:621-625. 114. Stremler J, Lovera D. Insights from a
AM. Variation in breastfeeding behaviors, 98. Castrucci BC, Hoover KL, Lim S, Maus KC. breastfeeding peer support pilot program
perceptions, and experiences by race/eth- A comparison of breastfeeding rates in an for husbands and fathers of Texas WIC
nicity among a low-income statewide sam- urban birth cohort among women deliver- participants. J Hum Lact. 2004;20:417-
ple of Special Supplemental Nutrition Pro- ing infants at hospital that employ and do 422.
gram for Women, Infants, and Children not employ lactation consultants. J Public 115. Calnen G. Paid maternity leave and its im-
(WIC) participants in the United States. Health Manag Pract. 2006;12:578-585. pact on breastfeeding in the United States:
Maternal Child Nutr. 2008;4:95-105. 99. Connor NR, Tanabe KO, Siadaty MS, An historic, economic, political, and social
83. Li R, Fein SB, Chen J, Grummer-Strawn Hauch FR. Pacifiers and breastfeeding. perspective. Breastfeed Med. 2007;2:34-44.
LM. Why mothers stop breastfeeding: Arch Pediatr Adolesc Med. 2009;163:378- 116. Berger L, Hill J, Waldfogel J. Maternity
Mother’s self-reported reasons for stopping 382. leave, early maternal employment and
during the first year. Pediatrics. 2008; 100. Protecting, promoting, and supporting child health and development in the US.
122(suppl):S69-S76. breastfeeding: The special role of maternity Econ J. 2005;2:F29-F47.
84. McInnes RJ, Chambers JA. Supporting services—A joint WHO/UNICEF state- 117. Guendelman S, Kosa JL, Pearl M, Graham
breastfeeding mothers: Qualitative synthe- ment. World Health Organization Web S, Goodman J, Kharrazi M. Juggling work
sis. Adv Nurs. 2008;62:407-427. site. http://www.who.int/nutrition/publica- and breastfeeding: Effects of maternity
85. Amir LH, Cwikel J. Why do women stop tions/infantfeeding/9241561300/en/print. leave and occupational characteristics. Pe-
breastfeeding? Breastfeed Rev. 2005;13:7- html. Accessed August 28, 2009. diatrics. 2009;123:e38-e46.
13. 101. Rosenberg KD, Stull JD, Adler MR, Kas- 118. McGovern P, Dowd B, Gjerdingen D,
86. Spear H. Breastfeeding behaviors and ex- ehagen LJ, Crivelli-Kovach A. Impact of Moscovice I, Kochevar L, Murphy, S. The
periences of adolescent mothers. MCN hospital policies on breastfeeding out- determinants of time off work after child-
Am J Matern Child Nurs. 2006;31:106-113. comes. Breastfeed Med. 2008;3:110-116. birth. J Health Politics Policy Law. 2000;
87. Holmes AV, Chin NP, Kaczorowski J, 102. Shinwell ES, Churgin Y, Shlomo M, Shani 25: 528-564.
Howard C. A barrier to exclusive breast- M, Flidel-Rimon O. The effect of training 119. United Nations Statistics Division: Demo-
feeding for WIC enrollees: Limited use of nursery staff in breastfeeding guidance on graphic and Social Statistics, Table 5c—
exclusive breastfeeding food package for the duration of breastfeeding in healthy Maternity leave benefits. United Nations
mothers. Breastfeeding Med. 2009;4:25-30. term infants. Breastfeed Med. 2006;1:247- Web site. http://unstats.un.org/unsd/demo-
88. Petrova A, Hegyi T, Mehta R. Maternal 252. graphic/products/indwm/ww2005/tab5c.
race/ethnicity and one-month exclusive 103. DiGirolamo AM, Grummer-Strawn LM, htm. Accessed April 20, 2009.
breastfeeding in association with the in- Fein SB. Effect of maternity-care practices 120. Family and medical leave act. Department
hospital feeding modality. Breastfeed Med. on breastfeeding. Pediatrics. 2008; of Labor Web site. http://www.dol.gov/esa/
2007;2:92-98. 122(suppl):S43-S49. whd/fmla/. Accessed April 8, 2009.
89. Heinig MJ, Follett JR, Ishii KD, Kavanagh- 104. Murray EK, Ricketts S, Dellaport J. Hospi- 121. Lovell V, Rahmanou H. Paid family and
Prochaska K, Cohen R, Panchula J. Barri- tal practices that increase breastfeeding medical leave: Essential support for work-
ers to compliance with infant-feeding rec- duration: Results from a population-based ing women and men. Washington, DC: In-
ommendations among low-income women. study. Birth. 2007;34:202-211. stitute for Women’s Policy Research; 2000.
J Hum Lact. 2006;22:27-33. 105. Nakao Y, Moji K, Honda S, Oishi K. Initi- 122. International Lactation Consultant Associa-
90. Clifford TJ, Campbell MK, Speechley KN, ation of breastfeeding within 120 minutes tion position paper on breastfeeding and
Gorodzinsky F. Factors influencing full after birth is associated with breastfeeding work [monograph]. International Lactation
breastfeeding in a southwestern Ontario at 4 months among Japanese women: A Consultant Association Web site. http://www.
community: Assessments at 1 week and at self-administered questionnaire survey. Int ilca.org/files/resources/ilca_publications/
6 months postpartum. J Hum Lact. 2006; Breastfeed J. 2008;3:1. BreasfeedingandWorkPP.pdf. Accessed July
22:292-304. 106. Breastfeeding: Some strategies used to 15, 2009.
91. Gijsbers B, Mesters I, Knottnerus JA, Van market infant formula may discourage 123. Borucki L. Breastfeeding mothers’ experi-
Schayck CP. Factors associated with the breastfeeding; state contracts should better ences using a supplemental feeding tube
initiation of breastfeeding in asthmatic protect against misuse of WIC name. US device: Finding an alternative. J Hum
families: The Attitude-Social Influence- Government Accountability Office Web Lact. 2005;21:429-438.
Self-Efficacy Model. Breastfeed Med. 2006; site. http://www.gao.gov/new.items/d06282. 124. Shealy KR, Li R, Benton-Davis S, Grummer-
1:236-246. pdf. Accessed April 20, 2009. Strawn LM. The CDC guide to breastfeeding
92. Rivero-Lugo M, Parrilla-Rodriguez AM, 107. Kaplan DL, Graff KM. Marketing breast- interventions. Centers for Disease Control
Davila-Torres RR, Albizu-Garcia C, Rios- feeding—Reversing corporate influence on and Prevention Web site. http://www.cdc.
Motta R. Full breastfeeding during the infant feeding practices. J Urban Health. gov/breastfeeding/pdf/breastfeeding_
postpartum hospitalization and mothers’ 2008;85:486-504. interventions.pdf. Accessed April 19, 2009.
report regarding Baby-Friendly practices. 108. Bronner Y, Barber T, Miele L. Breastfeed- 125. American Academy of Pediatrics, Commit-
Breastfeed Med. 2007;2:19-26. ing peer counseling: Rationale for the Na- tee on Pediatric AIDS. Human milk,

breastfeeding, and transmission of human healthcare providers and new parents. 137. Certification information. International
immunodeficiency virus in the United Breastfeeding Med. 2008;3:251-259. Board of Lactation Consultant Examiners
States. Pediatrics. 1995;96:977-979. 132. Przyrembel H, Heinrich-Hirsch B, Vieth B. Web site. http://www.iblce.org. Accessed
126. Mok E, Multon C, Piguel L, Barroso E, Exposition to the health effects of residues August 19, 2008.
Goua V, Christin P, Perez MJ, Hankard R. in human milk. In: Koletzko B, Michaelsen 138. Diamond L. Lactation consulting: Is it for
Decreased full breastfeeding, altered prac- KF, Nernell O, eds. Short and Long Term you? J Am Diet Assoc. 1997;97:591-592.
tices, perceptions, and infant weight Effects of Breastfeeding on Child Health. 139. US Department of Health and Human Ser-
change of prepregnant obese women: A New York, NY: Kluwer Academic/Plenum vices, Office of Minority Health. Assuring
need for extra support. Pediatrics. 2008; Publishers; 2000; 478:307-325. cultural competence in health care: Recom-
121:e1319-e1324. 133. Backgrounder for the 2004 FDA/EPA con- mendations for national standards and an
127. Hatton DC, Harrison-Hohner J, Coste S, sumer advisory: What you need to know outcomes-focused research agenda. Office
Dorato V, Curet LB, McCarron DA. Symp- about mercury in fish and shellfish. US of Minority Health Web site. http://www.
Food and Drug Administration Web site.
toms of postpartum depression and breast- omhrc.gov/clas/cultural1a.htm. Accessed
http://www.fda.gov/oc/opacom/hottopics/
feeding. J Hum Lact. 2005;21:444-449. April 22, 2009.
mercury/backgrounder.html. Accessed
128. Hale T. Medications and Mothers’ Milk. 140. Getting started . . . and moving on . . . plan-
April 20, 2009.
Amarillo, TX: Pharmasoft Medical Publish- ning, implementing, and evaluating cultural
134. Kronborg H, Vaeth M. The influence of psy-
ing; 2004. chosocial factors on the duration of breast- and linguistic competence for comprehensive
129. Schecter A, Pavuk M, Päpke O, Ryan JJ, feeding. Scan J Pub Health. 2004;32:210- mental health services for children and fam-
Birnbaum L, Rosen R. Polybrominated di- 216. ilies: Implications for systems of care. Na-
phenyl ethers (PBDEs) in US mother’s 135. Rasmussen K, Kjolhede CL. Prepregnant tional Center for Cultural Competence Web
milk. Environ Health Perspect. 2003;111: overweight and obesity diminish the pro- site. http://gucchd.georgetown.edu/nccc/
1723-1729. lactin response to suckling in the first week documents/Getting_Started_SAMHSA.pdf.
130. Etzel RA, Balk S, eds. Pediatric Environ- postpartum. Pediatrics. 2004;113;465-471. Accessed May 20, 2009.
mental Health. Elk Grove Village, IL: 136. International code of marketing breast 141. 50 state summary of breastfeeding laws.
American Academy of Pediatrics; 2003. milk substitutes. International Baby Food National Conference of State Legislatures
131. LaKind JS, Berlin C, Mattison D. The Action Network Web site. http://www. Web site. http://www.ncsl.org/programs/
heart of the matter on breast milk and en- ibfan.org/site2005/Pages/article.php?art_ health/breast50.htm. Updated April 2009.
vironmental chemicals: Essential points for id⫽52&iui⫽1. Accessed April 26, 2009. Accessed April 27, 2009.
American Dietetic Association (ADA) position adopted by the House of Delegates Leadership Team on March 16,
1997, and reaffirmed on September 12, 1999; June 6, 2003; and May 20, 2007. This position is in effect until
December 31, 2013. ADA authorizes republication of the position, in its entirety, provided full and proper credit is
given. Readers may copy and distribute this position paper, providing such distribution is not used to indicate an
endorsement of product or service. Commercial distribution is not permitted without the permission of ADA.
Requests to use portions of the position must be directed to ADA headquarters at 800/877-1600, ext 4835, or
[email protected].
Authors: Delores C. S. James, PhD, RD, LD/N, FASHA (University of Florida, Gainesville, FL); Rachelle Lessen,
MS, RD, LDN, IBCLC (The Children’s Hospital of Philadelphia, PA).
Reviewers: Pediatric Nutrition dietetics practice group (DPG) (Amy Brandes, RD, LD, IBCLC, Seaton Family of
Hospitals, Austin, TX); Sharon Denny, MS, RD (ADA Knowledge Center, Chicago, IL); Nutrition Education for the
Public DPG (Laura Graney, MS, RD, Sheboygan County WIC Project, Sheboygan, WI); Mary H. Hager, PhD, RD,
FADA (ADA Government Relations, Washington, DC); Lisa S. Hamlett, MS, RD, IBCLC (Virginia Department of
Healthy, Richmond, VA); Public Health/Community Nutrition DPG (Karen Klein, MPH, RD, LD, FADA, Johnson
County Public Health, Iowa City, IA); Esther Myers, PhD, RD, FADA (ADA Research & Strategic Business
Development, Chicago, IL); Women’s Health DPG (Kathleen Pellechia, RD, USDA Food and Nutrition Information
Center, Beltsville, MD); Patricia Markham Risica, DrPH, RD (Brown University, Providence, RI); Jennifer A. Weber,
MPH, RD (ADA Government Relations, Washington, DC).
Association Positions Committee Workgroup: Carol Berg Sloan, RD (chair); Alana Cline, PhD, RD; Egondu M.
Onuoha, MS, RD, IBCLC (content advisor).
We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to
endorse this position or the supporting paper.

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from the association

Position of the American Dietetic Association:

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1927

US national 74.2⫾1.2 43.1⫾1.3 21.4⫾1.1 31.5⫾1.3 11.9⫾0.9

1928 November 2009 Volume 109 Number 11

2. What are the effects of artificial nipple on the duration of breastfeeding?

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1929

1930 November 2009 Volume 109 Number 11

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1931

1932 November 2009 Volume 109 Number 11

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1933

1934 November 2009 Volume 109 Number 11

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1935

1936 November 2009 Volume 109 Number 11

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1937

1938 November 2009 Volume 109 Number 11

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1939

1940 November 2009 Volume 109 Number 11

November 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1941

1942 November 2009 Volume 109 Number 11

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