Breastfeeding, Family Physicians Supporting (Position Paper)

Introduction

The American Academy of Family Physicians (AAFP) has long supported breastfeeding. All family physicians, whether they provide maternity care or not, have a unique role in the promotion of breastfeeding. They understand the advantages of family-centered care and are well positioned to provide breastfeeding support in that context. Because they provide comprehensive care to the whole family, family physicians have an opportunity to provide breastfeeding education and support throughout the course of life to all members of the family. However, despite growing evidence of the health risks of not breastfeeding, physicians—including family physicians—do not receive adequate training about supporting breastfeeding.^1-4

History
Throughout most of human history, breastfeeding was the norm, with only a small number of infants not breastfed for a variety of reasons. But over the past century and a half, the United States has struggled through periods of time when breastfeeding was not well supported by individuals, communities, or the medical field.⁵ Indeed, we are still working to increase support for breastfeeding. This has been complicated by issues of body image/fashion, social status, acceptance and support of women in the workplace, and historical exploitation of poor women and enslaved Black women as wet nurses for wealthy and slave-owning families.⁶

By the late 19^th century, infant mortality from unsafe artificial feeding became an acknowledged public health problem. Public health nurses addressed this by promoting breastfeeding and home pasteurization of cows’ milk. In the early 20^th century, commercial formula companies found a market for artificial baby milks as safer alternatives to cows’ milk. During this same period, infant feeding recommendations became the purview of the newly organized medical profession. Partially because of physician support and a vision of “scientific” infant care, the widespread promotion of formula as a breast milk substitute for healthy parents and babies emerged.^{7, 8} Throughout the mid-20^th century, most physicians did not advocate breastfeeding and most parents did not choose to breastfeed. An entire generation of parents—and physicians—grew up not viewing breastfeeding as the normal way to feed babies. Despite the resurgence of breastfeeding in the late 20^th century in the United States, breastfeeding and formula feeding continued to be considered virtually equivalent, representing merely a lifestyle choice parents could make without significant health sequelae.⁹

Currently, the AAFP, the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the World Health Organization (WHO), and others recommend that infants exclusively receive breast milk for their first six months of life, with continued breastfeeding for at least the first year and beyond.^10-13 The U.S. Public Health Service’s Healthy People 2020 initiative set national goals of 81.9% of babies breastfeeding at birth, 60.6% at six months, and 34.1% at one year.¹⁴ Targets for exclusive breastfeeding were 46.2% at three months and 25.5% at six months. The United States has not yet met all of its breastfeeding goals. Data published by the Centers for Disease Control and Prevention (CDC) for infants born in 2017 show that 84.1% of U.S. parents initiated breastfeeding; 58.3% of babies were breastfeeding—and 25.6% were exclusively breastfeeding—at six months; and 35.3% of babies were breastfeeding at 12 months. Although some subpopulations come close to Healthy People 2020 initiation goals, most do not, and few breastfeed exclusively.¹⁵ Healthy People 2030 goals have been published with two targets to increase the number of infants breastfed at six and 12 months.¹⁵ Breastfeeding rates quoted for the United States reflect data that do not always distinguish between exclusive breastfeeding, breastfeeding with supplementation, and minimal breastfeeding.

Benefits of Breastfeeding
Family physicians should be familiar with the health effects of breastfeeding on parents and children. The evidence concerning health effects continues to expand in terms of depth of understanding and quality of research, and several review articles that outline the evidence supporting the role of breastfeeding in optimal health outcomes have been published.^{11, 16-19} Not breastfeeding has been associated with increased risks of common conditions for infants, including acute otitis media, gastroenteritis, and atopic dermatitis, as well as life-threatening conditions, including severe lower respiratory infections, necrotizing enterocolitis, and sudden infant death syndrome.^{17, 18, 20} The beneficial health effects of breastfeeding persist beyond the period of breastfeeding.²¹ A WHO review showed that children who had not been breastfed had higher mean blood pressure, increased risk of type 2 diabetes, increased risk of obesity, and lower scores on intelligence tests.^{16, 22} Children who are not breastfed are also at an increased risk of type 1 diabetes, asthma, and childhood leukemia.^{11, 18} The evidence base also supports the importance of six months of exclusive breastfeeding (when compared with three to four months) as protection against gastrointestinal tract and respiratory tract infections.²³

Breastfeeding also has broader economic and social benefits. Health care costs for both children and parents are increased when breastfeeding duration is suboptimal (or a child not breastfed).^{24, 25} In addition, breastfeeding is environmentally friendly since it involves no use of grazing land for cows, no product transportation or packaging, and no waste.⁵

Health Equity and Breastfeeding
Health disparities observed with maternal morbidity and mortality are also seen in rates of breastfeeding initiation and duration. Data from 2000-2007 showed that American Indian/Alaska Native individuals had lower rates of breastfeeding compared to Asian American, Hispanic, or white individuals, and African American individuals had the lowest rates of initiation and continuation of breastfeeding compared to other racial and ethnic groups surveyed.²⁶ This trend continued among infants born in 2015, with data showing that rates of continued breastfeeding were lower for Black individuals who had initiated breastfeeding compared with rates for white individuals.²⁷ Black parents disproportionately face numerous barriers to initiating and sustaining breastfeeding, including historical exploitation and inadequate support from peers, family, health care settings, and employers.^{6, 26, 28}

For family physicians, it is important to note that there is a lower rate of evidence-based maternity care practices in health care facilities in underserved areas. ^{29, 30}  Specifically, health care facilities in areas with a higher percentage of Black residents were shown to be less likely to meet key indicators for supporting breastfeeding, including early initiation of breastfeeding, avoidance of supplementation with formula, and rooming-in for patient and infant. ^{29, 30}  These are metrics that can be addressed, as demonstrated by a quality improvement project that provided education and technical assistance to a number of hospitals in order to improve their compliance with the “Ten Steps to Successful Breastfeeding.”³⁰ This intervention resulted in increased breastfeeding initiation and exclusive breastfeeding among African American infants.³⁰

Recognizing the Diversity of Families
The AAFP recognizes that the language traditionally used around lactation and parenting is highly gendered and often presupposes a heteronormative, two-parent family structure. This can misgender, misrepresent, and isolate individuals and families, causing harm. Healthy families can have many diverse structures. Many transmasculine people use the term “chestfeeding” because it is better aligned with their gender identity. To avoid causing gender dysphoria and to promote inclusivity of all families, the AAFP encourages physicians to select language that is appropriate for each individual patient and avoid any assumptions about a patient’s gender identity, sexual orientation, partner status, or family makeup when providing lactation support and counseling.

Call to Action for Family Physicians

Physician Level

• Almost all babies should be breastfed or receive human milk exclusively for approximately six months.²³ Breastfeeding with appropriate complementary foods, including iron-rich foods, should continue through at least the first year.¹¹ Health outcomes for parents and babies are best when breastfeeding continues for at least two years.³¹ Breastfeeding should continue as long as mutually desired by parent and child.
  
• Medical contraindications to breastfeeding are rare. However, there are some situations in which additional considerations for breastfeeding management are necessary. Family physicians should keep up to date on current evidence and best practices to appropriately counsel patients who are breastfeeding. More details can be found in the appendices of this paper.
• Breastfeeding babies and parents should be seen for follow-up within a few days after birth. Family physicians and all health care professionals who regularly care for parents and babies should be able to assist with normal breastfeeding and common breastfeeding challenges. When challenges exceed the expertise of the family physician, parents should be referred to someone with specialized expertise, such as an International Board-Certified Lactation Consultant (IBCLC).

 

Practice Level

• Birthing centers and hospitals need to incorporate baby-friendly principles. Babies should be kept skin-to-skin with the parent at least until the first successful breastfeed.³² Perinatal care practices should support breastfeeding, optimally by following the “Ten Steps to Successful Breastfeeding,”³³ and patients and babies should receive care from health care professionals knowledgeable about breastfeeding.³⁴
• Formula supplementation of breastfed babies should occur only when medically indicated.³⁵ Family physicians should not undermine breastfeeding by providing formula samples or coupons to breastfeeding parents.³⁶
• Family physicians should establish a breastfeeding-friendly office, even if they do not provide maternity care.
• Family physicians should advocate for breastfeeding and provide education about breastfeeding throughout the course of life and for the entire family. Family physicians have the unique opportunity to emphasize the benefits of breastfeeding and integrate breastfeeding education and support beginning with preconception visits and continuing through prenatal care and labor support, delivery, prompt initiation and continuation of breastfeeding, and postpartum care, as well as during ongoing care of the baby and family.
• Encouragement from a physician, the health care team, and other family members is an important factor in the initiation of breastfeeding, so family physicians should remind the parent’s social support system to encourage breastfeeding.^{37, 38}

Advocacy and Education

• With all of the health advantages of breastfeeding for parents and children, as well as its economic and ecological impacts, breastfeeding is a public health issue, not merely a lifestyle choice. Family physicians should work in their communities to advocate for removal of barriers to breastfeeding. This could include overcoming cultural issues, encouraging breastfeeding-friendly workplaces, advocating for adequate paid parental leave, and protecting the right to breastfeed in public.
• Medical schools and family medicine residencies should include appropriate curricula in lactation physiology and breastfeeding management so that family physicians are adequately trained to provide care to breastfeeding parents and infants.³⁹ Medical trainees who are breastfeeding should be given support to attain their breastfeeding goals.⁴⁰

AAFP Efforts to Support Breastfeeding

Policies

The AAFP has several policies and resources available to support breastfeeding. The AAFP’s policy on breastfeeding recommends that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life.¹¹ The AAFP also supports breastfeeding beyond this time frame for as long as mutually desired. Family physicians should have the knowledge to promote, protect, and support breastfeeding.

In order to support and encourage breastfeeding, the AAFP discourages the distribution of formula or coupons for formula during hospital discharge or in physician office packets to parents who choose to breastfeed exclusively. In addition, hospital staff are encouraged to respect the decision of the breastfeeding parent and avoid offering formula, water, or pacifiers.⁴¹

Vitamin D supplementation is important for infants who are breastfeeding or receiving formula. The AAFP recommends vitamin D supplementation and supports coverage by third-party payers.⁴²

Breastfeeding has demonstrable health and economic benefits. However, many parents stop breastfeeding earlier than they intended due to lack of support from family, friends, and colleagues. Working outside the home is associated with shortened duration of breastfeeding,^43-45 and conditions in the workplace further impact this duration.^{46, 47} Medical trainees are educated about the benefits of breastfeeding and taught to encourage and support their patients in their breastfeeding efforts. However, when medical trainees and physicians choose to breastfeed, they often do not receive adequate support from their colleagues and institutions and many do not meet their breastfeeding goals.^{48, 49} The AAFP advocates for support of trainees and practicing physicians who are breastfeeding and issued a model policy outlining key recommendations for medical schools, residency and fellowship programs, and health care facilities.⁴² Key items needed include adequate lactation facilities, protected time for expression of breast milk or breastfeeding, and policies outlining roles and responsibilities to provide an environment of support for breastfeeding trainees.

Education
In the preclinical years, courses in anatomy, physiology, and biochemistry, among others, should include aspects pertinent to lactation. These include anatomy of a lactating breast and how this relates to baby’s latch-on; physiology of milk production and the milk ejection reflex; and biochemistry of human milk and the vast differences in artificial substitutes. Aspects of lactation relevant to particular disciplines could be integrated into the existing curriculum. For example, the basics of the passage of medications into human milk could be incorporated into the pharmacology course. In the introductory clinical course, students should be taught how to take a breastfeeding history (when appropriate) and how to examine lactating breasts. In the clinical years, patient care experience in family medicine, obstetrics, and pediatrics should include instruction in care for normal breastfeeding parents and babies and in common breastfeeding problems.

The family medicine residency curriculum should reinforce the concept that breastfeeding is the physiologic norm. All aspects of normal breastfeeding and management of common problems should be covered and integrated longitudinally in the three-year residency curriculum. The AAP has developed a residency curriculum that is easily modified for use in family medicine residencies.⁵⁰ This curriculum, which includes advocacy, community outreach, coordination of care, anatomy and physiology, basic skills, peripartum support, ambulatory management, and cultural competency, has been shown to improve breastfeeding outcomes for patients cared for by family medicine residents, pediatrics residents, and OB-GYN residents.³

Member Resources and National Initiatives
The United States Breastfeeding Committee (USBC) is an independent nonprofit coalition of more than 100 nationally influential organizations. Its mission is to improve the nation’s health by working collaboratively to protect, promote, and support breastfeeding. The AAFP has a liaison to the USBC, collaborates with the USBC, and supports their core competencies in breastfeeding care and services, which were developed to be used as guidance to integrate evidence-based breastfeeding into everyday practice.⁵¹

The AAFP has an established member interest group (MIG) focused on breastfeeding medicine that provides opportunities for education and peer-to-peer training and support.

Appendix 1: Specific Recommendations for Clinical Management
Appendix 2: Additional Breastfeeding Considerations
Appendix 3: Resources From External Organizations

References

Appendix 1: Specific Recommendations for Clinical Management

1.  Preconception and prenatal education

1. Ensure that all discussions take place in a culturally sensitive manner.
2. Address the infant feeding decision before conception or as early in pregnancy as possible. Prenatal intention to breastfeed affects initiation and duration of breastfeeding. Continue to bring up the issue of infant feeding and express support for breastfeeding throughout the prenatal period.⁵² Provide appropriate education and anticipatory guidance to encourage breastfeeding and determine what support is needed to make and carry out this decision.
3. Elicit any factors in the family medical history that may make breastfeeding especially important (e.g., atopic diseases, diabetes, obesity, cancers) and provide counseling and advice specific to these factors.¹⁶
4. Elicit any risk factors for potential breastfeeding problems and any medical contraindications to lactation. Provide appropriate support and education.¹¹
5. For previous births, document the duration of lactation for each infant, reasons for weaning, and any problems that occurred. (If possible, document this history and include the labor history of each infant.) For the current pregnancy, document a plan for intervention, including lactation consultation if indicated, on the patient’s prenatal record.⁵²
6. Encourage the participation of the patient’s support network and educate them as appropriate. Remember that anyone present during a patient’s prenatal visits or hospital stay is likely to have influence over breastfeeding and other health care decisions.^{53, 54}
7. Recognize the feelings of relatives who did not breastfeed or who weaned prematurely. Encourage them to learn what is known about breastfeeding for the optimal health of the parent and baby.⁵
8. Encourage the parent and people from their support network to attend breastfeeding classes and/or support group meetings during the prenatal period.^{5, 52, 54}
9. Provide accurate, noncommercial breastfeeding literature and recommend accurate lay breastfeeding resources (e.g., books, websites).⁵
10. Provide education regarding potential breastfeeding problems associated with the use of intrapartum analgesia and anesthesia. Encourage the use of a labor support person (i.e., a doula).^55-57

2.  Intrapartum support

1. Provide appropriate labor support intended to minimize use of unnecessary analgesics or anesthesia.⁵⁸
2. If parent and baby are stable, facilitate immediate postpartum breastfeeding. Minimize separation of the parent and infant and wait until after the first breastfeeding to perform routine newborn procedures such as weighing, ophthalmic prophylaxis, and vitamin K injection.^{32, 59}
3. Provide warming for the stable newborn via skin-to-skin contact with the parent, covering if necessary.³²

3.  Early postpartum education and support^{52, 60}

1. Advocate for 24-hour rooming-in for the breastfeeding parent and baby.⁶¹
2. Involve family members and others from the support network in breastfeeding education and enlist their support for breastfeeding.⁵
3. Ensure that breastfeeding is being adequately assessed on a regular basis by qualified professionals. Advocate for lactation consultation services at all hospitals where maternal and infant care is provided.^{34, 60, 62, 63}
4. Educate parents about the importance of frequent, unrestricted breastfeeding with proper positioning and latch. ⁶³
5. Help parents recognize the baby’s early feeding cues (e.g., rooting, lip smacking, sucking on fingers or hands, rapid eye movements) and explain that crying is a late sign of hunger. It is also important to help them recognize signs that the baby is satisfied at the end of a feeding (e.g., relaxed body posture, unclenching of fists).⁶⁴
6. If separation of the parent and infant is necessary, assist with maintenance of breastfeeding and/or ensure that the parent receives assistance with expressing milk. Encourage expression of milk within two hours after being separated from the infant.⁶⁴
7. Identify breastfeeding problems in the hospital and assist with these before discharge.^{63, 64}
8. At hospital discharge, provide clear verbal and written breastfeeding instructions that include information on hunger and feeding indicators, stool and urine patterns, jaundice, proper latch and positioning, and techniques for expressing breast milk.^{60, 63, 64}
9. Educate patients about the risks of unnecessary supplementation.^{60, 63, 64} The decision to use a pacifier should be based on personal preferences as the use of pacifiers has not been associated with an increased risk of not breastfeeding in motivated parents.⁶⁵
10. Avoid the use of discharge packs containing formula samples and formula company advertising or literature.⁴¹
11. Ensure appropriate follow-up within 48 hours of discharge and provide the parents with phone numbers for lactation support.^{11, 23}
12. Develop an appropriate follow-up plan for any identified problems or concerns.^{63, 64}
13. Provide the family with information about breastfeeding support groups in the community.^{63, 64}

4.  Ongoing support and management

1. Provide evaluation within 24-72 hours after hospital discharge to assess adequacy of milk intake, newborn jaundice, and any breastfeeding concerns. Evaluation may need to occur within 24 hours after hospital discharge if breastfeeding was not going well in the hospital.
2. Continue to support breastfeeding throughout the first year of life and beyond at well-child and other visits. Encourage exclusive breastfeeding for the first six months of life.¹¹
3. Be knowledgeable about prevention and management of common breastfeeding challenges.⁶⁶
4. Educate office staff on breastfeeding topics so that they can provide optimal breastfeeding triage and support.⁵
5. Develop a working relationship with professionals who have expertise in lactation issues, such as International Board Certified Lactation Consultants (IBCLCs). Consult when breastfeeding concerns exceed your level of expertise.
6. Encourage parents who are returning to work to continue to breastfeed.⁵
7. Encourage partial breastfeeding for as long as possible if exclusive breastfeeding is not feasible.

 

Appendix 2: Additional Breastfeeding Considerations

Infant Health
Ill infants benefit from breastfeeding and/or consuming breast milk. In many cases, these infants have poor suck, appetite, and alertness, and they often need supplementation. Ideally, any necessary supplementation should be with the breastfeeding parent’s own expressed milk or with pasteurized human milk from a donor, if available, and it should be given by a method least likely to interfere with breastfeeding. The breastfeeding parent’s own milk supply should be protected and/or increased by adequate pumping or manual expression.

Neonatal illnesses such as hyperbilirubinemia and hypoglycemia may be due to poor milk transfer and warrant an urgent consultation with a skilled lactation consultant. Infants born with defects such as cleft lip and palate can breastfeed in many cases, but they may require consultation with an experienced lactation professional to ensure success. Infants who have other anomalies or syndromes that cause hypotonia also will benefit from such consultation. However, infants who have type 1 galactosemia are unable to breastfeed and must be on a lactose-free diet. Infants who have phenylketonuria should breastfeed; however, if supplementation is needed, they must receive supplementation with a low-phenylalanine formula.^{67, 68} Infants who have phenylketonuria who are breastfed have better developmental outcomes compared with those exclusively fed low-phenylalanine formulas.⁶⁹

Health of the Breastfeeding Parent
Illness or the need to take medication is often cited as a reason that breastfeeding is stopped sooner than desired.⁷⁰ For most illnesses, medication issues do not prevent breastfeeding because safe medication choices almost always can be made. Exceptions include treatment of cancer, which necessitates use of antimetabolites. Some newer protocols that involve chemotherapeutic agents with short half-lives may necessitate only temporary weaning, and breastfeeding may be resumed after five half-lives. Each agent should be individually assessed.⁷¹

For most infections, breastfeeding helps protect the infant against the disease or decreases the severity of the illness because of anti-infective components in human milk. Only a few infections preclude breastfeeding.

In the United States, parents who have human immunodeficiency virus (HIV) are currently advised not to breastfeed because of the potential risk of transmission to the child. In countries with high infant mortality rates caused by infectious illnesses or malnutrition, the benefits of breastfeeding may outweigh the risk of HIV transmission.

Other infections that are less prevalent in the United States but also contraindicate breastfeeding are human T-cell lymphotropic virus (HTLV) type I and type II, and untreated brucellosis.^{72, 73}

Most infections do not preclude breastfeeding, but, in a few specific infections, certain considerations apply. In parents who have active tuberculosis, separation should be instituted until both the parent and infant are receiving appropriate anti-tuberculosis therapy, the parent wears a mask, and the parent understands and is willing to adhere to infection control measures. The breastfeeding parent’s expressed milk may be given to the infant. Once the infant is receiving isoniazid, separation is not necessary unless multidrug-resistant Mycobacterium tuberculosis is present, or the parent has poor adherence to treatment and direct-observation treatment is not possible.⁷⁴

Limited evidence suggests that SARS-CoV-2, the virus that causes COVID-19, is spread via respiratory droplets. To date, studies have not detected SARS-CoV-2 and similar coronavirus infections in breast milk. Therefore, the American Academy of Family Physicians (AAFP) recommends promotion of breastfeeding and parent-infant bonding, and avoidance of parent-infant separation whenever possible.⁷⁵ If a parent who is breastfeeding has been exposed to COVID-19, breastfeeding is a reasonable choice. The parent should use a mask and careful hand hygiene to reduce the risk of exposing the infant to respiratory secretions. If the parent is unable to breastfeed due to illness, it is an option to use expressed milk with appropriate hygiene to keep the pump and bottles free of virus.

During active herpes simplex outbreaks, it is safe to nurse unless lesions are present on the breasts. If lesions are present, it is recommended to avoid feeding from the affected breast until they resolve.⁷¹ Babies born to parents who develop chickenpox within five days antepartum or within two days postpartum are at risk of more serious chickenpox infections. It is recommended separation occur until the parent is no longer infectious, but expressed milk may be provided, as long as it does not come into contact with active lesions.⁷¹ Transmission of hepatitis C through human milk has not been established. The risk of infection from parents who has hepatitis C is the same in breast- or bottle-fed infants. However, if a parent who has hepatitis C has bleeding or cracked nipples, it may put the breastfeeding infant at risk of transmission of the virus.⁷⁶ Parents acutely infected with H1N1 virus should be isolated from their infants during the febrile period, but their milk is safe to provide.⁷⁷ Some other uncommon serious infections, such as Ebola virus may require temporary interruption or complete avoidance of breastfeeding.^{78, 79} In the event of severe trauma or acute life-threatening illness, a parent may be too ill to nurse or express milk. If illness causes separation, assistance with maintaining lactation should be provided, if desired by the breastfeeding parent.

Anesthesia rarely contraindicates breastfeeding.⁵⁸ Local anesthetics enter the bloodstream in minute quantities that are too small for significant amounts to be present in milk. Most agents used for general anesthesia have short half-lives and clear the maternal circulation rapidly. There is no need to delay breastfeeding after general anesthesia for a procedure done within the first two to three days postpartum (e.g., tubal ligation) because the amount of colostrum is too small to carry a significant quantity of the anesthetic agents. For surgical procedures done later, the decision about resuming breastfeeding depends on the condition of the infant. Parents of healthy term neonates can resume feeding once they are awake and able to hold the infant. In the case of a preterm or otherwise compromised neonate, pumping and discarding the milk for 12 to 24 hours after the procedure may be warranted.⁵⁸

It is rarely necessary to interrupt breastfeeding for radiologic procedures. The radioiodines used as intravenous contrast agents for some radiography and computed tomography scanning have an extremely short half-life and virtually no oral bioavailability.⁸⁰ Therefore, they pose an insignificant risk to a breastfed infant. Similarly, gadopentetate used as contrast for magnetic resonance imaging (MRI) has such minimal excretion in the milk—and even lower oral absorption—that only extremely small amounts are available to the nursing infant.⁸⁰ Knowledgeable family physicians can reassure patients undergoing such procedures that there is no need to interrupt breastfeeding, and they may need to intervene on a patient’s behalf if the radiologist recommends temporary cessation based on misleading manufacturer’s literature.

Similarly, most diagnostic procedures using radioisotopes do not require interruption of breastfeeding.^{81, 82} However, there are some that may require temporary interruption or— rarely—cessation of breastfeeding.⁸⁰ References are available that outline the effects of various radioisotopes.⁸³ For most diagnostic radioactive scanning, it is possible to find a radioisotope that does not require interruption, or at least to select one with the shortest half-life. The duration of breastfeeding cessation should be five times the half-life. The breastfeeding parent has the option of pumping and storing milk before the procedure. To maintain supply, the parent should continue to express milk after the procedure. This milk can be discarded until it is safe to resume breastfeeding or stored in a freezer that is not opened often. Once all of the radiation is gone, this milk can be given to the baby. The nuclear medicine radiologist can provide guidance regarding when the radioactivity would be depleted in the milk, and it may be tested for residual radioactivity.

Breast Surgery
Some parents who have had breast augmentation may not be able to produce sufficient amounts of milk.⁸⁴ Some parents may have had insufficient breast tissue before surgery.^{85, 86} However, augmentation surgery itself may cause additional breastfeeding problems.⁸⁷ Breast reduction surgery may result in insufficient production of milk,^{88, 89} although newer surgical techniques that do not disrupt neurovascular supply and ductal architecture (e.g., inferior pedicle technique) are less likely to cause problems.

Breast biopsy with circumareolar incision can interfere with milk supply and transfer in the affected breast.⁸⁸ Patients who undergo this procedure should be encouraged to breastfeed with close monitoring to ensure that the infant has an adequate milk intake. Patients who develop a suspicious breast mass during lactation should not wean for the purpose of evaluating the mass. Mammography and breast mass biopsy can be done without interfering with lactation. A milk fistula occasionally develops after breast surgery; this condition is benign and generally resolves without intervention.

Family physicians should assist their patients with decisions about breast surgery. They should communicate with the surgeon to advocate for their patient’s future breastfeeding needs and breastfeeding conservation surgeries whenever medically feasible.

Medication and Substances
Almost all prescription and over-the-counter medications taken by the breastfeeding parent are safe during breastfeeding. Several resources are available to help estimate the degree of drug exposure an infant will receive through breast milk, including LactMed, MotherToBaby, and InfantRisk Center.⁹⁰ When prescribing medications to breastfeeding parents, physicians should weigh the risks and benefits by considering the need for the drug, potential effects on milk production, the amount of drug known to be excreted into human milk, the extent of oral absorption by the infant, and any potential adverse effects on the infant.⁹¹

Contraception
Breastfeeding parents have a number of safe options for contraception, both non-hormonal and hormonal. The lactational amenorrhea method (LAM) has been shown to be effective when practiced according to three specific criteria: 1) exclusive breastfeeding takes place without routine supplements or delays in feedings; 2) infant is younger than six months; and 3) menses have not returned (i.e., no bleeding after 56 days postpartum).^92-94 A Cochrane analysis assessing the effectiveness of LAM as a contraceptive method found that the pregnancy rates at six months ranged from 0.45% to 2.45%.⁹⁵ In the absence of any one of the three criteria, this method is unreliable and additional precautions are needed.

Parents who wish to avoid hormones can be instructed in fertility awareness methods; however, menses may remain irregular during lactation, which makes use of these methods more challenging. Additional contraceptive options include barrier methods, long-acting reversible contraceptive (LARC) methods (e.g., intrauterine devices [IUDs], the implant), and other hormonal methods (e.g., pills, patches, rings). The main advantage of barrier methods (e.g., condoms, diaphragms) is the lack of potential adverse effects to milk, whereas their main disadvantage is lower effectiveness. They may have their greatest use as a complement to lactational amenorrhea or fertility awareness methods. Diaphragms must be refitted at least six weeks postpartum.

Hormonal choices for breastfeeding parents include progestin-only and estrogen-containing contraceptives. It is recommended to avoid estrogen-containing contraceptives in the initial postpartum period because of added risk of blood clots; however, this risk is significantly reduced after six weeks.⁹⁶ Clinical studies support the safety of hormonal contraceptive use during breastfeeding, with no significant effects on infant growth or health noted. Indeed, recent data suggest even immediate placement of the etonogestrel implant has no effect on the quality or quantity of breast milk.⁹⁶ Individuals who choose to use hormonal methods should be encouraged to breastfeed.

Tobacco, Alcohol, and Marijuana Use
Infants should not be exposed to cigarette smoke. Elevated levels of cotinine, a nicotine metabolite, have been detected in the urine of children of parents who smoke cigarettes when compared to children of nonsmoking parents. Breast milk can also transfer cotinine to infants, leading to higher levels than if the baby was only exposed to passive cigarette smoke.^97-99 Indeed, babies who are breastfed immediately after smoking demonstrate changes in their sleep and wake patterns.⁹⁹ Breastfeeding infants who bed share with parents who smoke also have a higher risk of sudden infant death syndrome (SIDS).¹⁰⁰ Finally, people who smoke and breastfeed are at risk of insufficient milk supply because of the negative effect of nicotine on prolactin levels.¹⁰¹

Parents who breastfeed are advised not to smoke. If parents who smoke cannot quit, it is still more valuable to breastfeed. They should be advised not to smoke in the infant’s environment, to smoke as little as possible, and to smoke immediately after nursing (rather than before) to minimize the nicotine levels in their milk. U.S. Food and Drug Administration (FDA)-approved nicotine replacement products can be used to aid in tobacco cessation, although it is best to use the lowest possible dose because of the adverse effects of nicotine on the infant and milk supply.¹⁰²

Alcohol passes easily into breast milk but is also cleared from breast milk as rapidly as it is cleared from the bloodstream. Although it is safest for nursing parents to consume no alcohol, small amounts of alcohol (e.g., one serving of wine or beer per day) appear to be safe. It is ideal to advise waiting two to two-and-a-half hours after finishing the alcoholic beverage before nursing again.¹⁰³

Similarly, breastfeeding individuals who use marijuana or CBD products should be encouraged to reduce their intake; ideally, they should stop using these products altogether. Though tetrahydrocannabinol (THC) is excreted in breast milk in small quantities, it is stored in body fat and slowly released, which could expose a breastfed infant over an extended period of time. Data are insufficient to determine the health effects on breastfed infants; however, there is concern about possible effects on nervous system development.¹⁰⁴

Toxins and Pollutants
Although the presence of toxic chemicals in humans’ fetal environment and milk signals the urgent need to reduce community exposure to these pollutants, the weight of the evidence indicates that breastfeeding remains the healthiest option for parents and babies. Infant exposure to toxins and pollutants occurs primarily through feeding and breathing. Individuals without specific occupational or other known poisonous exposures to pollutants may nevertheless be found to have a variety of polluting chemicals in their bodies.¹⁰⁵ Some of these chemicals may be transferred to fetuses in utero and possibly to infants postnatally through breast milk, as well as through formula and complementary foods.

Many people are concerned about chemicals in breast milk. Unfortunately, reporting of chemicals in breast milk may lead to early termination of breastfeeding.¹⁰⁶ It is important for family physicians to educate parents that formula contains many of the same toxins, phthalates, heavy metals, and pesticides, and potentially many more. Using formula does not reduce an infant’s exposure to environmental toxins, and the risk of cancers and less-than-optimal neurologic development remains higher in formula-fed babies compared with breastfed babies in similar environments.^{107, 108}

Individuals who have average environmental exposure do not need to have their milk screened for pollutants. On the other hand, for those who have known poisonous exposures, testing of breast milk may be necessary. Bisphenol A (BPA) is a common chemical used to make many plastics, including baby bottles. Further study is needed on the exact effects of BPA in humans. BPA-free bottles are common, and parents may choose to use those to limit exposure.¹⁰⁹ However, it is unclear whether the BPA substitutes also pose a risk.

Concerns have been raised about heavy metal toxins—primarily mercury—in fish, causing some people to reduce fish consumption during pregnancy and lactation. Given the beneficial effects of increased consumption of fish during pregnancy on cognitive development in children, the Environmental Protection Agency (EPA) now encourages those who are pregnant or breastfeeding to eat more fish that are lower in mercury.¹¹⁰ The FDA has updated its guidance for fish consumption to reflect this change.¹¹¹ The EPA maintains information on mercury levels in fish (available online at https://www.epa.gov/mercury/guidelines-eating-fish-contain-mercury), and most states, U.S. territories, and Native American tribes also provide information on mercury levels in fish.

Employment
Family physicians have an opportunity and responsibility to promote breastfeeding in the workplace as community leaders, business owners, supervisors, and/or employees. Research suggests that key reasons for low breastfeeding rates lie in employment and the lack of paid maternity leave in the United States.¹¹² American parents who plan to continue their jobs are forced to make a relatively rapid return to employment. Federal law currently requires many employers to provide reasonable break times for employees to express milk in a private, non-bathroom location for one year after the child’s birth.¹¹³

The AAFP advocates for support of trainees and practicing physicians who are breastfeeding and issued a model policy outlining key recommendations for medical schools, fellowships, and health care facilities.⁴⁰

Lactation support is highly desired by breastfeeding employees who return to work after childbirth; it also can improve a company’s return on investment by saving money in health care and employee expenses.¹¹⁴ Employer benefits include the following¹¹³:

• Lower medical costs and health insurance claims for breastfeeding employees and their infants (up to three times less for breastfeeding employees)
• Reduced turnover rates (86% to 92% of breastfeeding employees return to work after childbirth when a lactation support program is provided compared with the national average of 59%)
• Lower absenteeism rates (up to half the number of one-day absences)
• Improved productivity
• Higher employee morale and loyalty to the company

Resources to help family physicians educate employers in their communities are available. The Business Case for Breastfeeding is a comprehensive program designed by the U.S. Department of Health and Human Services to educate employers about the value of supporting breastfeeding employees in the workplace.¹¹² The program highlights how such support contributes to the success of the entire business. It also offers tools to help employers provide worksite lactation support and privacy for breastfeeding parents to express milk. In addition, it provides guidance on employees’ rights and responsibilities regarding breastfeeding and working.

Pumping, Expressing, and Storage Guidelines
Expressing milk can be accomplished in various ways. The optimal method varies with the length of the breastfeeding parent’s absence from the infant and individual preference. For occasional brief absences, hand expression and/or the use of a hand pump is usually sufficient. The longer and more frequent the separations, the more important it is to use a hospital grade double-pumping electric pump. This is especially important in cases of separation caused by illness or prematurity and when a breastfeeding parent returns to full-time work in the absence of on-site day care.⁷¹ To avoid a significantly reduced milk supply during the workweek, people who work full-time should breastfeed frequently when they are with their infants. While at work, they should pump at a frequency as close to the feeding frequency as possible. The infant caregiver should be encouraged not to feed a full bottle to the infant shortly before the breastfeeding parent is expected to pick up the infant. Parents whose milk ejection reflex is inhibited at work can be encouraged to use an item of their infant’s clothing and/or their infant’s picture as a stimulus and to ensure as comfortable an environment as possible for pumping.⁷¹

Breast milk can be stored safely for longer periods than were previously recommended.¹¹⁵ For working parents with healthy, term infants, the milk can be stored at room temperature for six to eight hours, in an insulated cooler bag with ice packs for 24 hours, and in the refrigerator for up to five days. Milk can routinely be stored in a freezer for up to six months, and storing milk in a freezer for up to 12 months may be acceptable. Small amounts of milk can be added to previously expressed milk, but the fresh milk should be chilled before it is added to already frozen milk. Room should be left in the container to allow for expansion during freezing.¹¹⁶

The best storage containers are hard plastic or glass containers. It is best to avoid clear plastic containers because of the possible leaching of BPA into the milk during warming. Warming and thawing of milk should not be done in the microwave. Thawing can be accomplished by placing the frozen milk in the refrigerator overnight, by placing it in a bowl of warm water, or by holding it under warm running water.¹¹⁶ Once thawed, the milk should not be refrozen but can be stored in the refrigerator for 24 hours. Because any thawed milk that has been partially consumed must be discarded, it is advisable to use small containers (2-4 oz) to avoid unnecessary waste.

Supplementation
Routine supplementation for healthy, term breastfeeding infants is not recommended unless medically indicated.³⁵ Supplementation with formula can lead to a decrease in milk supply caused by decreased demand. In addition to potential loss of milk, supplementation can also interfere with other psychosocial and neurodevelopmental benefits of breastfeeding. Common situations in which infant supplementation is medically indicated include infant hypoglycemia not responsive to breastfeeding, insufficient milk supply, delay in lactation, excessive infant weight loss, infant illness such that feeding at the breast is not effective, and separation of the infant from the breastfeeding parent.¹¹⁷

Supplementation may be done with expressed milk, pasteurized human milk from a donor, or infant formula. Methods of supplementation include cup feeding, finger feeding with a syringe attached to a feeding tube, using a supplemental feeding tube at the breast, and bottle feeding. One method is not necessarily more suitable than another, and the choice of method depends on individual evaluation of latch, infant feeding, and parent comfort. When supplementation is necessary, parents need professional guidance and consultation with a certified lactation consultant or other knowledgeable health care professional is recommended.

Sunlight has historically been the primary source of vitamin D for humans. However, people receive much less sun exposure in modern times because of urban/indoor lifestyles, migration, and sun avoidance or use of sunscreens to prevent skin cancer. As human breast milk contains low levels of vitamin D, the AAFP recommends that babies who are exclusively or partially breastfed be supplemented with 400 IU of vitamin D daily until one year of age.⁴² Infants given formula should also receive vitamin D supplementation until they are consuming more than 32 ounces of formula per day.⁴²

Breastfeeding and the Preterm Infant
The period following the birth of a premature infant can be overwhelming for families. The advice and support of a trusted family physician can be invaluable to parents confronted with unforeseen decisions and numerous uncertainties. Some relatively mature preterm infants may be able to breastfeed right away. Family physicians can provide immediate guidance on maintaining lactation when separation from the infant is required.

Premature infants who receive breast milk have a decreased risk of necrotizing enterocolitis, improved gut motility and maturation, improved neurodevelopmental outcomes,¹¹⁸ and reduced rates of sepsis¹¹⁹ and retinopathy of prematurity¹²⁰ compared with infants who receive milk substitutes. The decrease in necrotizing enterocolitis appears to outweigh any short-term increase in growth achieved with preterm formula feeding.¹²¹

Evidence of improved feeding tolerance, earlier full enteral feeds, and decreased risk of atopic diseases has been inconsistent to date. A meta-analysis of 20 studies concluded that breastfeeding is associated with long-term cognitive advantages and that preterm infants derive more benefits in cognitive development from breast milk than full-term infants do.¹²² Other benefits of breastfeeding for preterm infants later in life include decreased risk of metabolic syndrome and hypertension,¹²³ decreased insulin and leptin resistance,¹²⁴ and lower low-density lipoprotein levels.¹²⁵

Preterm infants who are provided human milk in the neonatal intensive care unit (NICU) have lower rates of rehospitalization.¹²⁶ Human milk also has been associated with enhanced retinal development and visual acuity in preterm infants. However, protein fortification may be necessary for smaller or more fragile preterm infants. In addition to promoting physiologic stability in premature infants, skin-to-skin contact (i.e., “kangaroo care”) increases maternal milk supply and breastfeeding rates.^{32, 127}

Parents of preterm infants should be presented with information about the benefits of breastfeeding and human milk for the premature infant. Individuals who are hesitant to make a long-term commitment to breastfeeding can be encouraged to nurse or express colostrum and milk for their infant until hospital discharge. Breastfeeding parents of preterm infants face many challenges, such as infant illness, parent-infant separation, infant feeding difficulties at the breast, the possibility of prolonged pumping, and the emotional and physical stress of juggling personal care with other commitments to family, job, and newborn. When family physicians work as part of a medical team of neonatologists, nurses, social workers, dietitians, and lactation consultants, they can be effective in supporting the successful initiation and continuation of breastfeeding the preterm infant.

Breastfeeding the Late Preterm Infant
Newborns born at 35 to 37 weeks of gestation have special nutritional needs and require extra lactation support compared with newborns who are full term. These babies tend to be sleepy and are at high risk of not feeding effectively enough at the breast to support sufficient growth.¹²⁸ This increases their risk of hypoglycemia and dehydration. Because of their relative immaturity, they are also at risk of delayed hepatic bilirubin excretion leading to jaundice. These infants require monitoring of adequate breast milk intake and often need supplementation of expressed colostrum or breast milk until they are sufficiently vigorous and alert while feeding to maintain proper growth.¹²⁸

Donor Milk
There are a number of nonprofit human milk banks in the United States and Canada that are members of the Human Milk Banking Association of North America (HMBANA), with four additional banks in the developing stage. Each milk bank carefully screens donors and then pasteurizes and distributes human milk from donors to a variety of infant and child populations in need. Banked pasteurized human milk from donors has been found to be safe and nutritionally sound for babies who do not have access to their own parent’s milk.^{129, 130} Certain premature infants, such as those weighing less than 1,500 g (3 lb, 3 oz), who are using banked donor milk generally need protein fortification of the milk in order to achieve optimal growth.^{131, 132}

In recent years, a new trend of casual milk sharing—in which unpasteurized milk is shared with or sold to other parents, without benefit of medical screening—has emerged among some people. One study found that milk purchased anonymously over the internet frequently was contaminated,¹³³ though these results may not be generalizable to situations in which donor and recipient are acquainted and shipping is not necessary.¹³⁴ Individuals accepting milk from unscreened donors should be warned of the potential dangers, including possible transmission of HIV, and other infectious diseases; unknown hygiene of collection and storage techniques; and unknown medication history of the donor. Age and health status of the recipient baby should also be considered, and parents should make a fully informed decision in their particular situation, weighing the risks of unscreened and unpasteurized human milk from a donor versus risks of infant formula.

Breastfeeding Multiples
Parents of twins and higher order multiples should be encouraged to breastfeed. In highly motivated parents and those with good support, breastfeeding initiation rates in twins have been as high as 70% to 90%.^{135, 136}

Parents of multiples will need additional support for breastfeeding. Most can exclusively breastfeed twins. Success with breastfeeding triplets and even quadruplets has been reported.¹³⁷ A consistent concern about breastfeeding multiples is whether there will be enough supply. However, simultaneous feeding may help with milk production.¹³⁸ Prior to delivery, physicians should provide education and resources for parents to support breastfeeding, including reassurance that adequate milk supply is possible although parents may need additional techniques, support, or help. Physicians should be familiar with techniques for increasing milk supply and recognize that even partial breastfeeding is beneficial.

Adoptive Breastfeeding
Family physicians often care for adoptive families. The physician should discuss options for breastfeeding their child with the adoptive parents.

A knowledgeable physician or lactation consultant may help the adoptive parent develop a milk supply before or after an adoption. The family physician who is supporting lactation induction or relactation should begin as early as possible in the adoptive process.¹³⁹

Many adoptive parents are physiologically capable of producing milk. Although the adoptive parent may not develop a full milk supply, with induced lactation techniques and the use of galactagogues, it is often possible to provide a significant amount of breast milk.¹³⁹ It is also important to be knowledgeable about the informal milk-sharing resources in communities and on the internet and to counsel adoptive parents about the potential risks of such arrangements. The opportunity to emotionally bond during nursing provides benefit of breastfeeding for adoptive parents and babies.¹⁴⁰

Breastfeeding Beyond Infancy
As recommended by the World Health Organization (WHO), breastfeeding ideally should continue beyond infancy, but this is not the cultural norm in the United States and requires ongoing support and encouragement. People who have immigrated to the United States from cultures in which breastfeeding beyond infancy is routine should be encouraged to continue this tradition. There is no evidence that extended breastfeeding is harmful to parent or child. Family physicians should be knowledgeable regarding the ongoing benefits to the child of extended breastfeeding, including continued immune protection^{141, 142} and availability of a sustainable food source in times of emergency. Emerging research on nutrient content of human milk into the second year of lactation suggests that breast milk continues to offer significant nutritional and immunological benefits.¹⁴² Furthermore, the longer a parent breastfeeds, the greater the decrease in their risk of breast cancer.¹⁴³ Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the patient is healthy, breastfeeding during pregnancy is their personal decision.

Weaning
Weaning has nutritional, behavioral, and psychosocial components. From a strictly nutritional perspective, weaning is the gradual process of transitioning infants from breast to complementary foods and, ultimately, to an older child’s diet. In this sense, weaning begins with the introduction of solids around the middle of the first year. Complete weaning (i.e., complete cessation of breastfeeding) ideally should be a gradual process accomplished over a long period. There is no evidence that a specific age of weaning is preferred. Like other developmental milestones, self-weaning takes place when a child is ready, physically and psychologically. Anthropological data suggest a wide range of normal self-weaning ages, from two-and-a-half to seven years of age.¹⁴⁴ As breast milk decreases in nutritional importance in the growing child’s diet and complementary foods are incorporated for additional needed protein, minerals, and other nutrients, behavioral and psychosocial factors become more important in the bonding and comforting aspects of nursing.

The role of the family physician involves knowing the physiologic norm for weaning and providing culturally sensitive anticipatory guidance and counseling to parents and families during the process. It is important to recognize and counsel parents about the difference between weaning and a sudden refusal to nurse (i.e., nursing strike). Medications to decrease or stop milk production are not necessary and should be avoided. Gradual or partial weaning can be encouraged. In rare cases in which abrupt weaning is necessary, the advice of a lactation consultant should be sought to minimize the risks. Regardless of the reasons for weaning, whether it is premature and abrupt or gradual and parent- or child-led, many breastfeeding parents feel a sense of grief or loss as breastfeeding ends.¹⁴⁵ The family physician can provide anticipatory guidance and support for the patient and the family during this phase.

Partner’s Role in Breastfeeding Support
In the United States, studies have shown that one of the most powerful influences on a person’s decision to breastfeed is the support of their partner.^146-148 The partner’s opinion, attitude, and knowledge about breastfeeding may have an important impact on whether someone initiates and continues breastfeeding.¹⁴⁹ Support of breastfeeding by the patient’s partner is associated strongly with the decision to breastfeed.¹⁴⁸ Individuals who perceive their partners to prefer formula or to be ambivalent about the feeding method are significantly more likely to discontinue breastfeeding before discharge from the hospital compared with those who perceive their partners as being supportive.¹⁵⁰

Five main partner attributes associated with successful breastfeeding have been identified: (1) knowledge about breastfeeding; (2) positive attitude toward breastfeeding; (3) involvement in the decision-making process; (4) practical support; and (5) emotional support.³⁸ Family physicians should be prepared to help educate partners on the benefits of breastfeeding and to dispel any myths and misperceptions they may have. Partners need to understand that what they may perceive as problems, such as the breastfeeding parent’s soreness, physiologic infant weight loss, jaundice, baby fussiness, and frequency of feedings, especially at night, do not necessitate a switch to formula.

Adolescents and Breastfeeding
The family physician is well positioned to assist pregnant and breastfeeding teenagers and their families. All adolescent parents should be encouraged to breastfeed.¹⁵¹

Although teenage parents share barriers to breastfeeding with their adult peers, they also face many unique pressures. The family physician can help pregnant teenagers cope with these issues and encourage breastfeeding. Enlisting and educating the teenager’s support system (e.g., their own parents and other relatives, peers, friends, and their partner) is important and may make a difference.¹⁵¹ Teens living with their own parents may be at especially high risk of early weaning.¹⁵² Ideally, a teen’s parents should be encouraged to participate in counseling sessions on breastfeeding. Peer counseling by other breastfeeding teenagers can be powerful. Adolescents usually are interested in learning about the practical issues of breastfeeding and learn quickly. However, they often have an incorrect understanding, so dispelling myths is key.¹⁵³

Pregnant and breastfeeding adolescents often have significant concerns about exposure of their breasts during breastfeeding. These concerns can be addressed by providing positive images of discreet breastfeeding and educating teens about changes that will occur during pregnancy and breastfeeding. Often, teenagers are disinclined to bring up such concerns, but, if asked, they are willing to discuss body image concerns, as well as issues such as sexuality and contraception. Because teenagers worry about their changing bodies, it is important to share information about proper nutrition, diet, exercise, and weight loss proactively.¹⁵⁴

Continued support of the adolescent parent will help them maintain breastfeeding. It is also important to help create environments supportive of success in breastfeeding, so the physician may need to advocate on the patient’s behalf at school and/or work to ensure time for breastfeeding and pumping is provided. In addition, anticipatory guidance about the infant’s growth and development, as well as ongoing parenting education, will further help maintain breastfeeding as part of the patient’s lifestyle.

Breastfeeding in Underserved Populations
Protections for expressing breast milk in the workplace included in the Patient Protection and Affordable Care Act (ACA) helped to equalize opportunities for breastfeeding across lines of socioeconomic status. A report from 2018 showed that the ACA policies were associated with significant increases in the durations of any breastfeeding and exclusive breastfeeding.¹⁵⁵

Unfortunately, the ACA’s requirement for coverage of breastfeeding support, supplies, and counseling applies only to private health care plans. It does not apply to Medicaid; rather, coverage decisions for Medicaid are managed at the state level. The United States Breastfeeding Committee (USBC) encourages states to go beyond current requirements to include lactation services as separately reimbursed pregnancy-related services and provides examples of current state practices.¹⁵⁶ Family physicians should understand  the specific financial, work, and time obstacles to breastfeeding, work with families to overcome them, and provide specific means to address the obstacles.

Issues of Ethnicity and Culture
Ethnic subgroups within U.S. society face significant obstacles to breastfeeding, even when economic conditions are not a factor. First-generation immigrants from countries where breastfeeding is the norm are more likely to breastfeed than are second- and later-generation parents. This may be because of convenience, belief in modern food technology, and/or attempts to acculturate into a society where bottle feeding is perceived to be the norm. Thus, breastfeeding role models are lost with successive generations. Additionally, accurate breastfeeding information is less available in the languages of ethnic minorities with smaller U.S. populations.

Family physicians can promote lactation among their patients of various ethnicities in a number of ways, including the following:

• Learning about the family structure of their patients. Support from key family members may assist greatly in the promotion of breastfeeding.
• Being aware of impact of the physician’s own personal cultural attitudes and implicit biases when interacting with patients
• Ensuring that parents from diverse cultures understand the importance of breastfeeding to their children’s growth and development
• Respecting cultural traditions and taboos associated with lactation and adapting cultural beliefs to facilitate optimal breastfeeding, while also sensitively educating patients about traditions that may be detrimental to breastfeeding
• Encouraging exclusive lactation in the hospital in a culturally sensitive manner
• Providing all information and instruction, whenever possible, in the patient’s native language in a culturally relevant manner and assessing for literacy level, when appropriate

Military Issues
As of 2021, maternal leave in the military is 12 weeks (six weeks of maternity care and six weeks of primary caregiver leave).¹⁵⁷ Deployments can be delayed up to 12 months after childbirth.¹⁵⁸  Breastfeeding parents in the military have many issues in common with other employed parents but also face some unique challenges. Family physicians should be aware of the challenges faced by military families and be actively involved in working with the military to educate commanders, supervisors, and peers about the benefits of breastfeeding and how to support initiation and maintenance of breastfeeding.

Family Physicians and Breastfeeding Advocacy
Family physicians have many opportunities to advocate for and support breastfeeding because they care for all members of the family, and often the extended family, and practice in a variety of community settings. Family physicians who provide maternity care can advocate for and support breastfeeding before conception, during pregnancy, and after the delivery; no other specialty has that unique opportunity. Family physicians should support and advocate for public health policies and research that would increase breastfeeding rates. Family physicians can serve as breastfeeding advocates in physician offices, hospitals, residency education, medical schools, birthing centers, workplaces, legislatures, and insurance companies.

The AAFP supports the “Ten Steps to Successful Breastfeeding” for making hospitals and staff more breastfeeding friendly (see Appendix 3, under “National and International Breastfeeding Initiatives”).¹⁵⁹ These 10 steps are the core of the Baby-Friendly Hospital Initiative (BFHI). While BFHI-designated facilities have been shown to increase breastfeeding rates, successful breastfeeding requires prenatal and post-delivery education and support.¹⁶⁰ Family physicians can play an important role in helping their hospital or birthing facility implement the provisions of the 10 steps.

Studies have shown that a physician’s recommendation to breastfeed increases breastfeeding initiation and duration rates.^{161, 162} Eliminating formula company literature, advertising, and distribution of samples encourages breastfeeding as normal infant feeding.¹⁶³ Family physicians need to ensure that office and hospital policies support breastfeeding patients. Family physicians can advocate for breastfeeding in their offices by making their office and staff breastfeeding friendly. The Academy of Breastfeeding Medicine (ABM) has published a clinical protocol that offers guidance for establishing a breastfeeding-friendly office.⁵²

In advocacy for breastfeeding issues related to insurance coverage and workplace changes, the economic benefits of breastfeeding are essential points. Several studies have shown a substantial increase in cost to families, communities, health care systems, and employers when babies are not breastfed.^{25, 164, 165} Physicians must be aware of these data to be effective advocates in promoting change in policies regarding breastfeeding. Family physicians have assumed many administrative roles in hospitals, managed care plans, insurance companies, and large physician organizations. In these roles, family physicians are in a position to promote breastfeeding and ensure appropriate payment for lactation services provided by physicians or lactation consultants. Family physicians should advocate for improved access to lactation services, encouraging increased availability of and payment for lactation consultants.

Family physicians are active and influential in their communities. By projecting a positive attitude toward breastfeeding in the office and the community, they can strongly affect a patient’s decision to breastfeed. The AAFP supports the U.S. Preventive Services Task Force (USPSTF) recommendations for structured breastfeeding education and counseling to improve breastfeeding rates.¹⁶⁶ Family physicians provide a wealth of patient education in their offices. As a part of their health education and promotion activities in schools, family physicians should incorporate information about breastfeeding. Making breastfeeding education available to all family and community members will help make breastfeeding the community norm.

Appendix 3: Resources From External Organizations

ORGANIZATIONS AND EDUCATIONAL RESOURCES FOR PHYSICIANS

American Academy of Family Physicians (AAFP)
www.aafp.org
The AAFP is a national organization representing more than 136,000 family physicians, family medicine residents, and students who provide comprehensive, coordinated, and continuing care to all members of the family and serve as the patient’s advocate in the changing health care system. Breastfeeding support materials and continuing medical education (CME) training are available.
Resources:

• AAFP policy statement on breastfeeding: www.aafp.org/about/policies/all/breastfeeding-policy-statement.html
• AAFP policy supporting breastfeeding and lactation for medical trainees: www.aafp.org/about/policies/all/breastfeeding-lactation-medical-trainees.html
• Breastfeeding information and resources: www.aafp.org/breastfeeding
• Courses with AAFP Prescribed credit are listed in the AAFP CME database: www.aafp.org/cme.html

Academy of Breastfeeding Medicine (ABM)
www.bfmed.org
A worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Membership is open to all physicians.
Resources:

• Clinical protocols: Evidence-based clinical guidelines for the care of breastfeeding parents and infants, as well as annotated bibliographies. Useful for hospital and clinical policies. Updated regularly, with translations in some languages available.
• Fellowship in Breastfeeding Medicine (FABM): Recognizes physicians who have additional training, experience, and knowledge in the clinical, research, academic, or public policy areas of breastfeeding medicine
• Breastfeeding Medicine: A peer-reviewed physician journal
• ABM Annual International Meeting: Offers the “What Every Physician Needs to Know About Breastfeeding” pre-conference course and a health team meeting for non-physician health professionals

American Academy of Pediatrics
www.aap.org
Resources

• Breastfeeding and the Use of Human Milk policy statement
• Breastfeeding Promotion in Physicians’ Office Practices Program (BPPOP III) provides support in effective breastfeeding promotion and management for pediatric, obstetric, and family medicine residents; practicing physicians; and other health care professionals.

American College of Obstetricians and Gynecologists (ACOG)

www.acog.org/breastfeeding

Resources:

• Clinical Guidance https://www.acog.org/clinical
• Breastfeeding: Maternal and Infant Aspects (ACOG Committee Opinion No. 361): Provides a brief introduction to concepts detailed in an ACOG special report of the same title.

Breastfeeding Basics
www.breastfeedingbasics.org
Resources:

An online short course on the fundamentals of breastfeeding; geared primarily for the medical professional

Centers for Disease Control and Prevention (CDC)
www.cdc.gov/breastfeeding
The CDC is committed to increasing breastfeeding rates throughout the United States and to promoting optimal breastfeeding practices as a means of improving the public’s health.

www.cdc.gov/growthcharts/who_charts.htm
The World Health Organization (WHO) standards establish growth of the breastfed infant as the norm for growth. Breastfeeding is the recommended standard for infant feeding. The WHO charts reflect growth patterns among children who were predominantly breastfed for at least four months and were still breastfeeding at 12 months.
Resources:

• WHO growth charts (for infants and children from birth to two years of age in the United States)
• CDC growth charts (for children age two years and older in the United States)

International Board of Lactation Consultant Examiners
www.iblce.org/
The internationally recognized certifying agency for lactation consultants

International Lactation Consultant Association
www.ilca.org
The professional association for International Board Certified Lactation Consultants (IBCLCs) and other health care professionals who care for breastfeeding families
Resources:

• Journal of Human Lactation

La Leche League International
www.llli.org
This organization’s mission is to help mothers worldwide to breastfeed through mother-to-mother support, encouragement, information, and education, and to promote a better understanding of breastfeeding as an important element in the healthy development of the baby and the mother.
Resources:

• Numerous resources on breastfeeding, the law, and education

The Joint Commission
www.jointcommission.org/perinatal_care
An independent, not-for-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States
Resources:

• Speak Up: What You Need to Know About Breastfeeding patient brochure
• Perinatal Care performance measure set: Includes a performance measurement for “exclusive breast milk feeding.” Mandatory for all hospitals with 300 or more births per year, effective January 1, 2016.

The National Women’s Health Information Center
www.womenshealth.gov/breastfeeding
A project of the U.S. Department of Health and Human Services (HHS) Office on Women’s Health
Resources:

• HHS Blueprint for Action on Breastfeeding
  
• The Business Case for Breastfeeding program

United States Breastfeeding Committee
www.usbreastfeeding.org
Composed of representatives from health care professional associations, relevant government departments, and nongovernmental organizations organized for the coordination of breastfeeding activities in the United States

Wellstart International
www.wellstart.org
A nonprofit organization that promotes maternal and child health, specializing in the area of breastfeeding. Wellstart provides educational opportunities for perinatal health care professionals, with a focus on the scientific basis for and management of human lactation.
Resources:

• Lactation Management Curriculum: A Faculty Guide for Schools of Medicine, Nursing, and Nutrition
• Lactation Management Self-Study Modules, Level 1

World Alliance for Breastfeeding Action
www.waba.org.my
A global network of individuals and organizations concerned with protecting, promoting, and supporting breastfeeding worldwide

NATIONAL AND INTERNATIONAL BREASTFEEDING INITIATIVES

The Baby-Friendly Hospital Initiative (BFHI)
www.babyfriendlyusa.org
A worldwide project of UNICEF and the World Health Organization (WHO). The goal of the initiative is to recognize hospitals and birth centers that take special steps to provide an optimal environment for breastfeeding and implement the “Ten Steps to Successful Breastfeeding.” Baby-Friendly USA (BFUSA) is the accrediting body for the BFHI in the United States. In the United States, hospitals and birth centers may take a first step toward receiving “Baby-Friendly” designation through the Certificate of Intent program.

Baby-Friendly facility designation is awarded after a comprehensive process of self-assessment, policy development, staff training, data collection, quality improvement, and BFUSA on-site assessment. The process is guided by the BFHI Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation. Baby-Friendly designation requires successful implementation of the “Ten Steps to Successful Breastfeeding” and the International Code of Marketing of Breast-milk Substitutes.

Ten Steps to Successful Breastfeeding

www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/

(Supported by the American Academy of Family Physicians)

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant [patients] about the benefits and management of breastfeeding.
4. Help [parents] initiate breastfeeding within one hour of birth.
5. Show [parents] how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in; allow [parents] and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer [parents] to them on discharge from the hospital or birth center.

International Code of Marketing of Breast-milk Substitutes
www.who.int/nutrition/publications/code_english.pdf
In 1981, the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes as a tool to protect breastfeeding. Formula marketing targets parents. New parents are given free samples of formula, babies are given bottles in hospitals, coupons or food samples arrive in the mail, and booklets and videotapes on breastfeeding and weaning are distributed. This code prohibits marketing of breast milk substitutes in these ways. It covers formula, other milk products, cereals, teas, and juices, as well as bottles and teats.

1. The code has significant provisions that require the following:
2. No advertising of any of these products to the public
3. No free samples to parents
4. No promotion of products in health care facilities, including the distribution of free or low-cost supplies
5. No company sales representatives to advise parents
6. No gifts or personal samples to health care professionals
7. No words or pictures idealizing artificial feeding or pictures of infants on labels of artificial infant milk containers
8. Information to health care professionals should be scientific and factual.
9. ALL information on artificial infant milk, including information on labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
10. Unsuitable products, such as sweetened condensed milk, should not be promoted for infants.
11. Manufacturers and distributors should comply with the code’s provisions, even if countries have not adopted laws or other measures.

References

1. Freed GL, Clark SJ, Cefalo RC, et al. Breast-feeding education of obstetrics-gynecology residents and practitioners. Am J Obstet Gynecol. 1995;173(5):1607-1613.

2. Freed GL, Clark SJ, Sorenson J, et al. National assessment of physicians' breast-feeding knowledge, attitudes, training, and experience. Jama. 1995;273(6):472-476.

3. Feldman-Winter L, Barone L, Milcarek B, et al. Residency curriculum improves breastfeeding care. Pediatrics. 2010;126(2):289-297.

4. Krogstrand KS, Parr K. Physicians ask for more problem-solving information to promote and support breastfeeding. J Am Diet Assoc. 2005;105(12):1943-1947.

5. Office of the Surgeon G, Centers for Disease C, Prevention, et al. Publications and Reports of the Surgeon General, in The Surgeon General's Call to Action to Support Breastfeeding. 2011, Office of the Surgeon General (US): Rockville (MD).

6. Green VL, Killings NL, Clare CA. The Historical, Psychosocial, and Cultural Context of Breastfeeding in the African American Community. Breastfeed Med. 2021;16(2):116-120.

7. Apple RD. The medicalization of infant feeding in the United States and New Zealand: two countries, one experience. J Hum Lact. 1994;10(1):31-37.

8. Greer FR, Apple RD. Physicians, formula companies, and advertising. A historical perspective. Am J Dis Child. 1991;145(3):282-286.

9. Wright AL. The rise of breastfeeding in the United States. Pediatr Clin North Am. 2001;48(1):1-12.

10. American Academy of Family Physicians. Breastfeeding (policy statement). 2017 https://www.aafp.org/about/policies/all/breastfeeding.html. Accessed August 10, 2018.

11. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-841.

12. American College of Obstetricians and Gynecologists. Optimizing Support for Breastfeeding as Part of Obstetric Practice. 2016 https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Support-for-Breastfeeding-as-Part-of-Obstetric-Practice. Accessed August 10, 2018.

13. World Health Organization. Breastfeeding. 2018 http://www.who.int/topics/breastfeeding/en/. Accessed August 10, 2018.

14. United States Department of Health and Human Services. Healthy People 2020, Maternal, Infant, and Child Health. 2014 http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=26. July 16, 2014.

15. Centers for Disease Control and Prevention. Key breastfeeding indicators. September 28, 2020 https://www.cdc.gov/breastfeeding/data/facts.html. Accessed March 31, 2021.

16. Horta BL, Victora CG. Long-term efects of breastfeeding:  a systematic review. 2013. http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf

17. Horta BL, Victora CG. Short-term effects of breastfeeding:  a systematic review on the benefits of breastfeeding on diarrhoea and pneumonia mortality. 2013. http://allattamento.sip.it/wp-content/uploads/2014/03/WHO_breve-termine.pdf

18. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007;(153):1-186.

19. Dieterich CM, Felice JP, O'Sullivan E, et al. Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin North Am. 2013;60(1):31-48.

20. Mitchell EA. Recommendations for sudden infant death syndrome prevention: a discussion document. Arch Dis Child. 2007;92(2):155-159.

21. Kelishadi R, Farajian S. The protective effects of breastfeeding on chronic non-communicable diseases in adulthood: A review of evidence. Adv Biomed Res. 2014;3:3.

22. Belfort MB, Rifas-Shiman SL, Kleinman KP, et al. Infant feeding and childhood cognition at ages 3 and 7 years: Effects of breastfeeding duration and exclusivity. JAMA Pediatr. 2013;167(9):836-844.

23. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;8:Cd003517.

24. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048-1056.

25. Bartick MC, Stuebe AM, Schwarz EB, et al. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol. 2013;122(1):111-119.

26. Jones KM, Power ML, Queenan JT, et al. Racial and ethnic disparities in breastfeeding. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine. 2015;10(4):186-196.

27. Beauregard JL, Hamner HC, Chen J, et al. Racial Disparities in Breastfeeding Initiation and Duration Among U.S. Infants Born in 2015. MMWR. Morbidity and mortality weekly report. 2019;68(34):745-748.

28. DeVane-Johnson S, Giscombe CW, Williams R, 2nd, et al. A Qualitative Study of Social, Cultural, and Historical Influences on African American Women's Infant-Feeding Practices. The Journal of perinatal education. 2018;27(2):71-85.

29. Lind JN, Perrine CG, Li R, et al. Racial disparities in access to maternity care practices that support breastfeeding - United States, 2011. MMWR Morb Mortal Wkly Rep. 2014;63(33):725-728.

30. Merewood A, Bugg K, Burnham L, et al. Addressing Racial Inequities in Breastfeeding in the Southern United States. Pediatrics. 2019;143(2).

31. World Health Organization UNICEF. Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding. 1990. http://www.unicef.org/programme/breastfeeding/innocenti.htm July 16, 2014.

32. Moore ER, Anderson GC, Bergman N, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012;5:Cd003519.

33. Baby-Friendly USA. The 10 Steps to Successful Breastfeeding. 2014 http://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps.

34. Renfrew MJ, McCormick FM, Wade A, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. 2012;5:Cd001141.

35. World Health Organization UNICEF. Acceptable medical reasons for use of breast-milk substitutes. . 2009. http://www.who.int/nutrition/publications/infantfeeding/WHO_NMH_NHD_09.01/en/

36. Howard C, Howard F, Lawrence R, et al. Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol. 2000;95(2):296-303.

37. Taveras EM, Capra AM, Braveman PA, et al. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics. 2003;112(1 Pt 1):108-115.

38. Sherriff N, Panton C, Hall V. A new model of father support to promote breastfeeding. Community Pract. 2014;87(5):20-24.

39. Holmes AV, McLeod AY, Thesing C, et al. Physician breastfeeding education leads to practice changes and improved clinical outcomes. Breastfeed Med. 2012;7(6):403-408.

40. American Academy of Family Physicians. Breastfeeding and Lactation Support for Trainees. https://www.aafp.org/about/policies/all/breastfeeding-accommodations-trainees.html. Accessed August 12, 2019.

41. American Academy of Family Physicians. Hospital use of infant formula in breastfeeding infants. 2017 https://www.aafp.org/about/policies/all/hospital-use-infant-formula.html. Accessed March 31, 2012.

42. American Academy of Family Physicians. Coverage of vitamin D supplementation for infants. 2020 https://www.aafp.org/about/policies/all/coverage-vitamin-d.html. Accessed January 17, 2021.

43. Calnen G. Paid maternity leave and its impact on breastfeeding in the United States: an historic, economic, political, and social perspective. Breastfeed Med. 2007;2(1):34-44.

44. Mirkovic KR, Perrine CG, Scanlon KS. Paid Maternity Leave and Breastfeeding Outcomes. Birth. 2016;43(3):233-239.

45. Mirkovic KR, Perrine CG, Scanlon KS, et al. Maternity leave duration and full-time/part-time work status are associated with US mothers' ability to meet breastfeeding intentions. Journal of human lactation : official journal of International Lactation Consultant Association. 2014;30(4):416-419.

46. Murtagh L, Moulton AD. Working mothers, breastfeeding, and the law. American journal of public health. 2011;101(2):217-223.

47. U.S. Department of Health and Human Services. Supporting nursing moms at work. February 21, 2019. https://www.womenshealth.gov/supporting-nursing-moms-work. Accessed March 31, 2021.

48. Dixit A, Feldman-Winter L, Szucs KA. "Frustrated," "depressed," and "devastated" pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding support. J Hum Lact. 2015;31(2):240-248.

49. Melnitchouk N, Scully RE, Davids JS. Barriers to Breastfeeding for US Physicians Who Are MothersBarriers to Breastfeeding for US Physician MothersLetters. JAMA Internal Medicine. 2018;178(8):1130-1132.

50. American Academy of Pediatrics. Breastfeeding Curriculum. http://www2.aap.org/breastfeeding/curriculum/ July 21, 2014.

51. United States Breastfeeding Committee. Core competencies in breastfeeding care and services for all health professionals. . 2010 http://www.usbreastfeeding.org/core-competencies. Accessed March 31, 2021.

52. Grawey AE, Marinelli KA, Holmes AV. ABM Clinical Protocol #14: Breastfeeding-friendly physician's office: optimizing care for infants and children, revised 2013. Breastfeed Med. 2013;8:237-242.

53. Maycock B, Binns CW, Dhaliwal S, et al. Education and support for fathers improves breastfeeding rates: a randomized controlled trial. J Hum Lact. 2013;29(4):484-490.

54. Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(8):560-564.

55. Newton KN, Chaudhuri J, Grossman X, et al. Factors associated with exclusive breastfeeding among Latina women giving birth at an inner-city baby-friendly hospital. J Hum Lact. 2009;25(1):28-33.

56. Hodnett ED. Caregiver support for women during childbirth. Cochrane Database Syst Rev. 2000;(2):Cd000199.

57. Mottl-Santiago J, Walker C, Ewan J, et al. A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Matern Child Health J. 2008;12(3):372-377.

58. Montgomery A, Hale TW. ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother, revised 2012. Breastfeed Med. 2012;7(6):547-553.

59. Edmond KM, Zandoh C, Quigley MA, et al. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics. 2006;117(3):e380-386.

60. Holmes AV, McLeod AY, Bunik M. ABM Clinical Protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term, revision 2013. Breastfeed Med. 2013;8(6):469-473.

61. Ball HL, Ward-Platt MP, Heslop E, et al. Randomised trial of infant sleep location on the postnatal ward. Arch Dis Child. 2006;91(12):1005-1010.

62. Meek JY, Hatcher AJ. The Breastfeeding-Friendly Pediatric Office Practice. Pediatrics. 2017;139(5):e20170647.

63. Philipp BL. ABM Clinical Protocol #7: Model Breastfeeding Policy (Revision 2010). Breastfeed Med. 2010;5(4):173-177.

64. World Health Organization UNICEF. The Baby-Friendly Hospital Initiative, Section 3: breastfeeding promotion and support in a baby-friendly hospital. 2009. https://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse_s3/en/

65. Jaafar SH, Ho JJ, Jahanfar S, et al. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016;(8):Cd007202.

66. Amir LH. Managing common breastfeeding problems in the community. Bmj. 2014;348:g2954.

67. McCabe L, Ernest AE, Neifert MR, et al. The management of breast feeding among infants with phenylketonuria. J Inherit Metab Dis. 1989;12(4):467-474.

68. Lamonica DA, Stump MV, Pedro KP, et al. Breastfeeding follow-up in the treatment of children with phenylketonuria. J Soc Bras Fonoaudiol. 2012;24(4):386-389.

69. Riva E, Agostoni C, Biasucci G, et al. Early breastfeeding is linked to higher intelligence quotient scores in dietary treated phenylketonuric children. Acta Paediatr. 1996;85(1):56-58.

70. Odom EC, Li R, Scanlon KS, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics. 2013;131(3):e726-732.

71. Lawrence RA, Lawrence RM, eds. Breastfeeding: A Guide for the Medical Profession. 7th ed. 2011, Elsevier Mosby: Maryland Heights, MO.

72. Goncalves DU, Proietti FA, Ribas JG, et al. Epidemiology, treatment, and prevention of human T-cell leukemia virus type 1-associated diseases. Clin Microbiol Rev. 2010;23(3):577-589.

73. Arroyo Carrera I, Lopez Rodriguez MJ, Sapina AM, et al. Probable transmission of brucellosis by breast milk. J Trop Pediatr. 2006;52(5):380-381.

74. Pickering LK, Baker CJ, Kimberlin DW, eds. Tuberculosis. Red Book: 2012 Report of the Committee of Infectious Diseases. 29th ed. 2012, American Academy of Pediatrics.

75. American Academy of Family Physicians. Considerations for Pregnancy, Breastfeeding, and COVID-19. 2021 https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/AAFP-COVID-Breastfeeding-Policy.pdf. Accessed March 31, 2021.

76. Centers for Disease Control and Prevention. Hepatitis B and C Infections. http://www.cdc.gov/breastfeeding/disease/hepatitis.htm.

77. Centers for Disease Control and Prevention. 2009 H1N1 Flu (Swine Flu) adn Feeding Your Baby:  What Parents Should Know. 2009 http://www.cdc.gov/h1n1flu/infantfeeding.htm. July 20, 2014.

78. Lawrence RM. Circumstances when breastfeeding is contraindicated. Pediatr Clin North Am. 2013;60(1):295-318.

79. Centers for Disease Control and Prevention. Care of a neonate born to a mother who is confirmed to have ebola, is a person under Investigation, or has been exposed to ebola. 2018 https://www.cdc.gov/vhf/ebola/clinicians/evd/neonatal-care.html. Accessed September 21, 2020.

80. Hale TW. Medications and Mothers' Milk. 15th ed, Amarillo, TX: Hale Publishing.

81. Siegel J. Guide for Diagnostic Nuclear Medicine. 2001

82. American College of Radiology Committee on Drugs and Contrast Media. Administration of contrast media to women who are breastfeeding. In ACR Manual on Contrast Media. 2021. http://www.infantrisk.com/sites/default/files/files/Radiocontrast%20Breastfeeding.pdf July 28, 2014.

83. Stabin MG, Breitz HB. Breast milk excretion of radiopharmaceuticals: mechanisms, findings, and radiation dosimetry. J Nucl Med. 2000;41(5):863-873.

84. Hurst N. Breastfeeding after breast augmentation. J Hum Lact. 2003;19(1):70-71.

85. Neifert MR, Seacat JM. Lactation insufficiency: a rational approach. Birth. 1987;14(4):182-190.

86. Neifert M, DeMarzo S, Seacat J, et al. The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain. Birth. 1990;17(1):31-38.

87. Cruz NI, Korchin L. Breastfeeding after augmentation mammaplasty with saline implants. Ann Plast Surg. 2010;64(5):530-533.

88. Brzozowski D, Niessen M, Evans HB, et al. Breast-feeding after inferior pedicle reduction mammaplasty. Plast Reconstr Surg. 2000;105(2):530-534.

89. Harris L, Morris SF, Freiberg A. Is breast feeding possible after reduction mammaplasty? Plast Reconstr Surg. 1992;89(5):836-839.

90. centers for Disease Control and Prevention. Prescription medication use. 2020 https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/prescription-medication-use.html. Accessed September 21, 2020.

91. Sachs HC. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-809.

92. Breastfeeding as a family planning method. Lancet. 1988;2(8621):1204-1205.

93. Labbok MH, Hight-Laukaran V, Peterson AE, et al. Multicenter study of the Lactational Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception. 1997;55(6):327-336.

94. Panzetta S, Shawe J. Lactational amenorrhoea method: the evidence is there, why aren't we using it? J Fam Plann Reprod Health Care. 2013;39(2):136-138.

95. Van der Wijden C, Kleijnen J, Van den Berk T. Lactational amenorrhea for family planning. Cochrane Database Syst Rev. 2003;(4):Cd001329.

96. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016;65(3):1-103.

97. Becker AB, Manfreda J, Ferguson AC, et al. Breast-feeding and environmental tobacco smoke exposure. Arch Pediatr Adolesc Med. 1999;153(7):689-691.

98. Mascola MA, Van Vunakis H, Tager IB, et al. Exposure of young infants to environmental tobacco smoke: breast-feeding among smoking mothers. Am J Public Health. 1998;88(6):893-896.

99. Primo CC, Ruela PB, Brotto LD, et al. Effects of maternal nicotine on breastfeeding infants. Rev Paul Pediatr. 2013;31(3):392-397.

100. Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a population-based survey of new mothers. Pediatrics. 2005;116(4):e530-542.

101. Bahadori B, Riediger ND, Farrell SM, et al. Hypothesis: smoking decreases breast feeding duration by suppressing prolactin secretion. Med Hypotheses. 2013;81(4):582-586.

102. Drugs and Lacatation Database (LactMed). Nicotine. https://www.ncbi.nlm.nih.gov/books/NBK501586/  Accessed March 31, 2021.

103. Drugs and Lacatation Database (LactMed). Alcohol. https://www.ncbi.nlm.nih.gov/books/NBK501586/  Accessed March 31, 2021.

104. Centers for Disease Control and Prevention. Marijuana. Breastfeeding and Special Circumstances. . https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/marijuana.html. Accessed March 3, 2021.

105. Wang RY, Needham LL. Environmental chemicals: from the environment to food, to breast milk, to the infant. J Toxicol Environ Health B Crit Rev. 2007;10(8):597-609.

106. Geraghty SR, Khoury JC, Morrow AL, et al. Reporting individual test results of environmental chemicals in breastmilk: potential for premature weaning. Breastfeed Med. 2008;3(4):207-213.

107. American Academy of Pediatrics Committee on Environmental Health. Handbook of Pediatric Environmental Health, Elk Grove Village, IL: American Academy of Pediatrics.

108. Frank JW, Newman J. Breast-feeding in a polluted world: uncertain risks, clear benefits. Cmaj. 1993;149(1):33-37.

109. Maragou NC, Makri A, Lampi EN, et al. Migration of bisphenol A from polycarbonate baby bottles under real use conditions. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2008;25(3):373-383.

110. U.S. Food and Drug Administration. FDA and EPA issue final fish consumption advice. January 18, 2014. http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm397929.htm

111. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th edition. 2015 https://health.gov/our-work/food-nutrition/2015-2020-dietary-guidelines/guidelines/. Accessed September 21, 2020.

112. Mirkovic K, Perrine C, Scanlon K. Paid Maternity Leave and Breastfeeding Outcomes. Birth (Berkeley, Calif.). 2016;43.

113. United States Department of Labor. Break Time for Nursing Mothers. 2010. http://www.dol.gov/whd/nursingmothers/ July 28, 2014.

114. United States Department of Health and Human Services OoWsH. Business Case for Breastfeeding. http://www.womenshealth.gov/breastfeeding/government-in-action/business-case.html

115. Hamosh M, Ellis LA, Pollock DR, et al. Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk. Pediatrics. 1996;97(4):492-498.

116. Eglash A. ABM clinical protocol #8: human milk storage information for home use for full-term infants (original protocol March 2004; revision #1 March 2010). Breastfeed Med. 2010;5(3):127-130.

117. ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med. 2009;4(3):175-182.

118. Isaacs EB, Fischl BR, Quinn BT, et al. Impact of breast milk on intelligence quotient, brain size, and white matter development. Pediatr Res. 2010;67(4):357-362.

119. Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula. Pediatrics. 1999;103(6 Pt 1):1150-1157.

120. DiBiasie A. Evidence-based review of retinopathy of prematurity prevention in VLBW and ELBW infants. Neonatal Netw. 2006;25(6):393-403.

121. Quigley M, Embleton N, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2019;7(7):Cd002971.

122. Anderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr. 1999;70(4):525-535.

123. Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. Lancet. 2001;357(9254):413-419.

124. Singhal A, Farooqi IS, O'Rahilly S, et al. Early nutrition and leptin concentrations in later life. Am J Clin Nutr. 2002;75(6):993-999.

125. Singhal A, Cole TJ, Fewtrell M, et al. Breastmilk feeding and lipoprotein profile in adolescents born preterm: follow-up of a prospective randomised study. Lancet. 2004;363(9421):1571-1578.

126. Vohr BR, Poindexter BB, Dusick AM, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006;118(1):e115-123.

127. Hake-Brooks SJ, Anderson GC. Kangaroo care and breastfeeding of mother-preterm infant dyads 0-18 months: a randomized, controlled trial. Neonatal Netw. 2008;27(3):151-159.

128. ABM clinical protocol #10: breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks gestation) (first revision June 2011). Breastfeed Med. 2011;6(3):151-156.

129. Henderson G, Anthony MY, McGuire W. Formula milk versus maternal breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2007;(4):Cd002972.

130. Tanaka A, Rugolo LM, Miranda AF, et al. Fractional sodium excretion, urinary osmolality and specific gravity in preterm infants fed with fortified donor human milk. J Pediatr (Rio J). 2006;82(5):335-340.

131. Arslanoglu S, Moro GE, Ziegler EE. Adjustable fortification of human milk fed to preterm infants: does it make a difference? J Perinatol. 2006;26(10):614-621.

132. Adamkin DH, Radmacher PG. Fortification of human milk in very low birth weight infants (VLBW <1500 g birth weight). Clin Perinatol. 2014;41(2):405-421.

133. Keim SA, Hogan JS, McNamara KA, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics. 2013;132(5):e1227-1235.

134. Steube AM, Gribble KD. Differences between online milk sales and peer-to-peer milk sharing. Pediatrics. 2014.

135. Flidel-Rimon O, Shinwell ES. Breast feeding twins and high multiples. Arch Dis Child Fetal Neonatal Ed. 2006;91(5):F377-380.

136. Gromada KK, Spangler AK. Breastfeeding twins and higher-order multiples. J Obstet Gynecol Neonatal Nurs. 1998;27(4):441-449.

137. Mead LJ, Chuffo R, Lawlor-Klean P, et al. Breastfeeding success with preterm quadruplets. J Obstet Gynecol Neonatal Nurs. 1992;21(3):221-227.

138. Multiple Births Foundation. Guidance for Health Professionals on Feeding Twins, Triplets and Higher Order Multiples.  . 2011 http://www.multiplebirths.org.uk/MBF_Professionals_Final.pdf. Accessed January 6, 2021.

139. Bryant CA. Nursing the adopted infant. J Am Board Fam Med. 2006;19(4):374-379.

140. Auerbach KG, Avery JL. Induced lactation. A study of adoptive nursing by 240 women. Am J Dis Child. 1981;135(4):340-343.

141. Goldman AS, Goldblum RM, Garza C. Immunologic components in human milk during the second year of lactation. Acta Paediatr Scand. 1983;72(3):461-462.

142. Perrin MT, Fogleman AD, Newburg DS, et al. A longitudinal study of human milk composition in the second year postpartum: implications for human milk banking. Maternal & Child Nutrition. 2017;13(1):e12239.

143. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet. 2002;360(9328):187-195.

144. Dettwyler KA. A Time to Wean: The Hominid Blueprint for the Natural Age of Weaning in Modern Populations. Breastfeeding: Biocultural Perspectives, New York: Aldine deGruyter.

145. Wight NE. Management of common breastfeeding issues. Pediatr Clin North Am. 2001;48(2):321-344.

146. Littman H, Medendorp SV, Goldfarb J. The decision to breastfeed. The importance of father's approval. Clin Pediatr (Phila). 1994;33(4):214-219.

147. Sharma M, Petosa R. Impact of expectant fathers in breast-feeding decisions. J Am Diet Assoc. 1997;97(11):1311-1313.

148. Scott JA, Binns CW, Aroni RA. The influence of reported paternal attitudes on the decision to breast-feed. J Paediatr Child Health. 1997;33(4):305-307.

149. Brown A, Davies R. Fathers' experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Matern Child Nutr. 2014.

150. Scott JA, Landers MC, Hughes RM, et al. Psychosocial factors associated with the abandonment of breastfeeding prior to hospital discharge. J Hum Lact. 2001;17(1):24-30.

151. Pinzon JL, Jones VF. Care of adolescent parents and their children. Pediatrics. 2012;130(6):e1743-1756.

152. Bica OC, Giugliani ER. Influence of counseling sessions on the prevalence of breastfeeding in the first year of life: a randomized clinical trial with adolescent mothers and grandmothers. Birth. 2014;41(1):39-45.

153. Nelson AM. Adolescent attitudes, beliefs, and concerns regarding breastfeeding. MCN Am J Matern Child Nurs. 2009;34(4):249-255.

154. Feldman-Winter L, Shaikh U. Optimizing breastfeeding promotion and support in adolescent mothers. J Hum Lact. 2007;23(4):362-367.

155. Gurley-Calvez T, Bullinger L, Kapinos KA. Effect of the Affordable Care Act on Breastfeeding Outcomes. Am J Public Health. 2018;108(2):277-283.

156. Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). Medicaid Coverage of Lactation Services. 2012 https://www.medicaid.gov/medicaid/quality-of-care/downloads/lactation_services_issuebrief_01102012.pdf. . Accessed March 31, 2021.

157. Army US. Military parental leave program (MPLP) benefit fact sheet. . https://myarmybenefits.us.army.mil/Benefit-Library/Federal-Benefits/Military-Parental-Leave-Program-(MPLP)?serv=122. . Accessed March 31, 2021.

158. Act FNDA. https://www.govinfo.gov/content/pkg/PLAW-116publ92/pdf/PLAW-116publ92.pdf. . Accessed March 31, 2021.

159. American Academy of Family Physicians. United States Breastfeeding Health Initiative, Ten Steps and Criteria. . AAFP Board Endorsement of Expert Panel Document 1994.

160. World Health Organization. Evidence for the ten steps to successful breastfeeding. 1998. http://www.who.int/maternal_child_adolescent/documents/9241591544/en/

161. Guise JM, Palda V, Westhoff C, et al. The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force. Ann Fam Med. 2003;1(2):70-78.

162. Valdes V, Pugin E, Schooley J, et al. Clinical support can make the difference in exclusive breastfeeding success among working women. J Trop Pediatr. 2000;46(3):149-154.

163. Howard FM, Howard CR, Weitzman M. The physician as advertiser: the unintentional discouragement of breast-feeding. Obstet Gynecol. 1993;81(6):1048-1051.

164. Ryan AS, Martinez GA. Breast-feeding and the working mother: a profile. Pediatrics. 1989;83(4):524-531.

165. Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103(4 Pt 2):870-876.

166. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Primary Care Interventions to Support Breastfeeding: US Preventive Services Task Force Recommendation Statement. Jama. 2016;316(16):1688-1693.

(2001) (January 2022 COD)