What is the recommendation for exclusive breastfeeding according the American Academy of Pediatrics?

WHO actively promotes breastfeeding as the best source of nourishment for infants and young children, and is working to increase the rate of exclusive breastfeeding for the first 6 months up to at least 50% by 2025. 

WHO and UNICEF created the Global Breastfeeding Collective to rally political, legal, financial, and public support for breastfeeding. The Collective brings together implementers and donors from governments, philanthropies, international organizations, and civil society. 

WHO’s Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes, also known as NetCode, works to ensure that breast-milk substitutes are not marketed inappropriately.

Additionally, WHO provides training courses for health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children.

Key Takeaways

• Updated guidance from the American Academy of Pediatrics recommends continued breastfeeding for two years and beyond.
• The AAP focuses on public health in its guidelines and stresses that breastfeeding isn't only about nutrition for the developing infant.
• The relationship between the parent and the child is also of paramount importance.
  

For the first time in 10 years, the American Academy of Pediatrics (AAP) has updated its breastfeeding guidelines. The AAP now supports breastfeeding until age two or beyond. Previously, the AAP recommended infants be exclusively breastfed for the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer. The new guidance is in line with the recommendations of the World Health Organization (WHO), the American Academy of Family Physicians, and the Canadian Paediatric Society.

More than 80% of babies born in the U.S. are breastfed for some length of time, but most aren’t exclusively breastfed or breastfed for as long as the AAP recommends. According to a survey from the Centers for Disease Control (CDC), 56.7% of infants are breastfed at 6-months-old, while 35% of infants are still breastfed at 1-year-old. 

The updated AAP policy statement and technical report detail the medical and neurodevelopmental advantages of breastfeeding and highlight the role pediatricians play as advocates and clinicians. 

Pediatrician and international board-certified lactation consultant Jessica Madden, MD, IBCLC, the medical director at Aeroflow Breastpumps, is happy the AAP has updated its guidelines. “They are a big step towards normalizing extended breastfeeding within the general public as well as for pediatricians and health care providers,” Dr. Madden says. She points out one survey, referenced in the AAP policy statement, that more than one-third of mothers who opted to breastfeed for over a year did not feel supported by their own pediatricians. 

Leigh Anne O’Connor, IBCLC, LCCE, an international board-certified lactation consultant, agrees with the update. “I do believe it is necessary,” she says. “Parents who are nursing their toddlers need as much, if not more, support as parents of newborns. It is biologically normal for toddlers to be nursing beyond their first birthday.”  

Benefits of Extended Breastfeeding

The continued benefits of breastfeeding beyond 1 year (and up to 2 years) are associated with both maternal and infant health.

The AAP refers to studies that confirm an association between longer than 12 months of breastfeeding and lower rates of maternal type 2 diabetes mellitus, hypertension, breast cancer, and ovarian cancer.

When it comes to infant health, the benefits of breastfeeding include decreased rates of lower respiratory tract infections, severe diarrhea, ear infections, and obesity, according to the CDC. This is because human milk has a unique composition, with antimicrobial, anti-inflammatory, and immunoregulatory agents and living cells boosting the child's immune system, explains the AAP.

Breastfeeding is also associated with a lower risk of sudden infant death syndrome (SIDS), as well as other protective effects.

The AAP policy statement also looks at breastfeeding through a public health lens, making the point that breastfeeding is about far more than the nutrition for the growing child—the bond between the parent and child is also crucial.

Breastfeeding a Toddler

Breastfeeding a toddler comes with various challenges, including the social stigma that persists in relation to breastfeeding older children. 

“Mothers who breastfeed their toddlers are often ridiculed and/or judged,” says Dr. Madden. “Despite extended breastfeeding being the norm in many parts of the world, breastfeeding past 12 months has not been viewed as ‘normal’ here in the U.S.” 

Other challenges mothers who breastfeed toddlers face are time constraints. For example, if they still need protected time to take pumping breaks at work. Another challenge is tandem nursing, or breastfeeding both a toddler and an infant at the same time, Dr. Madden adds. 

Jessica Madden, MD, IBCLC

Despite extended breastfeeding being the norm in many parts of the world, breastfeeding past 12 months has not been viewed as 'normal' here in the U.S.

— Jessica Madden, MD, IBCLC

Toddlers are older and larger, and can often be active when nursing. This can make breastfeeding a toddler more difficult to “hide” in public or in the presence of company, leading to embarrassment, says O’Connor. 

“It can also be tricky setting limits for older babies and understanding their needs for nursing,” she adds. 

When older babies are teething, this can be concerning for parents. The reality is nursing is very soothing to a toddler, O'Connor says. "There is misinformation about nursing and tooth decay. The way a baby nurses is different from the way a baby sucks on a bottle. Many people are encouraged to wean their babies when teeth erupt or if there are signs of decay."

O'Connor recommends teaching your toddler social skills by setting limits on how and where to nurse. "If a toddler is jumping around then stop nursing at that moment," she says. "Some parents will have specific places in their home where they nurse."

If your baby is teething, they may need to be reminded how to latch or you may need to switch to a more comfortable position.

What If I Can't Breastfeed My Baby?

Moms who encounter problems such as sore nipples, engorged breasts, pain, and latching difficulties are less likely to continue breastfeeding unless they receive professional support.

Another common reason for stopping breastfeeding is concerns about a lack of milk. One national study found that 50% of moms cited insufficient milk supply as their primary reason for weaning.

"Other reasons that moms can’t breastfeed include certain medications (i.e., chemotherapy for cancer), infections like HIV, HTLV 1 and 2, and untreated brucellosis or metabolic diseases in babies, such as galactosemia, and illicit drug use,” she says. “Some mothers are unable to breastfeed due to time constraints and/or not having enough lactation support.” 

It's vital that moms who are unable to breastfeed don't feel guilty or bad—Dr. Madden points out that there is a connection between breastfeeding "failure" and the development of postpartum depression.

"There's a lot of pressure put on moms to breastfeed and messaging out there about 'breast is best'," she says. "It's important for us to foster an environment in which mothers know that they are good mothers, no matter how their babies are fed, and that it's not their fault if breastfeeding does not work out."

Disparity in Breastfeeding Mothers

The AAP report draws attention to significant sociodemographic and cultural differences in breastfeeding. The lowest rates of initiation are among non-Hispanic Black or African American populations. Similar disparities exist among low-income mothers, younger women, and those educated at a high school level or below.

The issue of low breastfeeding rates in Black mothers was the focus of a special issue of Breastfeeding Medicine in 2021. Maria Muzik, MD, and her colleagues from Michigan Medicine studied the relationship between several maternal risk factors, such as demographics, history of childhood trauma, postpartum depression, and lack of social support, and compared them with breastfeeding status at six months postpartum.

Leigh Anne O'Connor, IBCLC, LCCE

Parents who are nursing their toddlers need as much, if not more, support as parents of newborns.

— Leigh Anne O'Connor, IBCLC, LCCE

The researchers discovered that Black mothers had reduced rates of breastfeeding at six months, above and beyond all the other risk factors in the model. This suggests their unique societal and personal circumstances contribute to their lower breastfeeding rates.

According to the authors, the negative impacts of racism operate at several levels to shape public health behaviors and outcomes, including systemic or structural racism that is reflected in workplace policy and practice; lack of access to higher education; discriminatory housing policy; and biased healthcare.

On average, Black mothers go back to work postpartum earlier than women from other racial and ethnic populations and are more likely to experience less flexibility at work.

Support Needed for Breastfeeding Mothers

As the experts point out, there are many changes that need to be made to ensure breastfeeding moms are adequately supported in society. 

First, the standard of medical care should be for all postpartum mother and baby care to take place in the home environment. “This is because one of the best ways for mothers to recover from childbirth and establish their breast milk supplies is lots of rest, skin-to-skin contact with their babies, and uninterrupted breastfeeding time during the postpartum period,” explains Dr. Madden. “Expecting a mom to leave her home with a 3- to 5-day-old baby to go to an outpatient pediatrician's appointment is pretty ridiculous and totally goes against what is needed to establish successful breastfeeding.”  

Dr. Madden believes all mothers should have 12 weeks of fully paid maternity leave. “The fact that we do not offer this to all working mothers in the U.S., but expect them to be able to be successful at exclusively breastfeeding, boggles my mind and sets many mothers up for failure,” she says. 

She believes the answer is to re-create "villages" of support for new moms to help them with things like cooking, household chores, watching older children, etc. “We should take as much care of new mothers as they do of their newborns,” she says. 

Insurers can also do better. “All insurers, both commercial and Medicaid, should cover the purchase of a new breast pump and supplies every 12 months,” Dr. Madden says. “In some cases, i.e., the state I live in, Medicaid will only cover the cost of a new breast pump every five years.”

Clearly marked public breastfeeding and lactation rooms and spaces are also necessary to make nursing mothers feel more supported, Dr. Madden adds.

What This Means For You

Breastfeeding is a personal choice and not all mothers are able or want to nurse. If you decide to bottle feed your infant, you shouldn't feel guilty. Equally, moms who want to breastfeed their babies through toddlerhood (or beyond) deserve to feel supported in their choice. Parents of nursing toddlers can find a like-minded community of other breastfeeding moms or enlist the help of a lactation consultant.

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