Literature Evaluation Table



2212-2672/Copyrightª 2015 by the Academy of Nutrition and Dietetics.


Position Paper

Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding

ABSTRACT It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimal nutrition and health protection for the first 6 months of life, and that breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants. Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs. Research continues to support the positive effects of human milk on infant and maternal health, as it is a living biological fluid with many qualities not replicable by human milk substitutes. Recent research advancements include a greater understanding of the human gut microbiome, the protective effect of human milk for premature infants and those born to women experiencing gestational diabetes mellitus, the relationship of breastfeeding with hu- man immunodeficiency virus, and the increased ability to characterize cellular com- ponents of human milk. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, should continue efforts to shift the norm of infant feeding away from use of human milk substitutes and toward human milk feeds. The role of regis- tered dietitian nutritionists and nutrition and dietetics technicians, registered, in breastfeeding promotion and support, in the context of the professional code of ethics and the World Health Organization’s International Code of Marketing of Breast-Milk Substitutes, are discussed in the “Practice Paper of the Academy of Nutrition and Di- etetics: Promoting and Supporting Breastfeeding,” published on the Academy website at: J Acad Nutr Diet. 2015;115:444-449.


It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimal nutrition and health pro- tection for the first 6 months of life and that breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants. Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs.


HIS POSITION PAPER technician, registered (NDTR) in breast- mutually desired by mother and infant.3

Treaffirms and updates theAcademy of Nutrition and Di-etetics’ 2009 position paper on breastfeeding1 and supports the “Prac- tice Paper of the Academy of Nutrition andDietetics: PromotingandSupporting Breastfeeding,”2 as well as several other Academy position papers available at the Academy website (www.eatright. org/positions). Additional work has quantified the costs of, and risks related to, not breastfeeding, and federal initia- tives have continued to strengthen ef- forts to increase breastfeeding rates at the national, regional, and local level. The role of the registered dietitian nutri- tionist (RDN) and nutrition and dietetics

feeding promotion and support is touched on here and expanded on in the accompanying practice paper.2

Human milk is considered the optimal form of infant nutrition for nearly all in- fants, as the risks of not receiving human milk include increased rates of infant and maternal morbidity and mortality, increasedhealth care costs, and significant economic losses to families and em- ployers.1,3-6 Therefore, breastfeeding con- tinues to be recommended by multiple national and international health organi- zations and agencies.1,3,7 For example, in the United States, the American Academy ofPediatrics continues to recommend that infants be exclusively breastfed to 6 months of age, atwhich point appropriate complementary foods should be intro- duced and breastfeeding should continue to at least the first birthday or as long as


The World Health Organization extends this for 2years or beyond.7 Several notable advancements have occurred since publi- cation of the 2009 position paper.1 Recent research advancements include a greater understanding of the human gut micro- biome, theprotective effectofhumanmilk for premature infants and those born to womenwith gestational diabetesmellitus (GDM), the relationship of breastfeeding with human immunodeficiency virus, the increased ability to characterize cellular components of humanmilk, and the costs and risks associated with not breastfeed- ing.8-12 Similarly, the role of the RDN/ NDTR remains to promote and support breastfeeding.2

HUMAN MILK COMPOSITION Human milk contains factors that serve both nutritive and non-nutritive

015 by the Academy of Nutrition and Dietetics.


functions,1,3,8,10,11 and it has been well characterized that the relatively low protein content and high bioavailability of essential minerals are optimally suited to the immature digestive sys- tem of the young infant.1,3 Human milk provides maternal immune factors, appetite-regulating hormones, and factors thought to support develop- ment of the healthy infant gut micro- biome.10,11 Mammary-gland�derived stem cells have been discovered recently, and this is considered an extraordinary finding with great po- tential to explain some of the effects on infant health.10 In addition to factors in human milk that provide direct im- munity, milk oligosaccharides are thought to provide indirect immunity, by both serving as substrate for bene- ficial gut bacteria, stimulating infant gut production of secretory immuno- globin A, and by interfering directly with pathogen binding.8 This func- tionality of human milk oligosaccha- rides is a current focus of researchers working to improve outcomes among infants fed with human milk sub- stitutes.8 RDNs/NDTRs will continue to review the latest science to be current when working with breastfeeding families and consider completing coursework as described in the practice paper.2

Although human milk is optimal in most situations, if infant iron stores are found to be inadequate, such as in situations of low birth weight or pre- maturity, in some less-developed countries, or when maternal prenatal iron status was low, it is recommended that the addition of iron drops begin before the introduction of iron-rich complementary foods (at approxi- mately 6 months).3 In addition, breastfed infants should receive sup- plemental fluoride after 6 months of age if living in areas where the local water source is not fluoridated.3

Vitamin K injections are recom- mended for all newborns, but should be delayed until after the first breast- feed (but no more than 6 hours post- partum). Finally, although limited research suggests that relatively high doses of maternal vitamin D supple- mentation (approximately 5,000 IU/ day for 28 days or a one-time dose of 150,000 IU)13 may render direct sup- plementation of the infant unnec- essary, there is currently insufficient evidence to support deviation from

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Institute of Medicine and American Academy of Pediatrics recommenda- tions that breastfed infants receive 400 IU vitamin D per day.3,14 In addition to these micronutrient concerns, guid- ance is required in situations in which mothers are experiencing specific viral illnesses, smoking, using legal and/or illicit drugs, poor nutritional status/di- etary intake, and those who experi- enced gestational diabetes.1,3,15,16

INFANT AND MATERNAL HEALTH OUTCOMES It is important to note that it can be a challenge to rate the strength of breastfeeding research, secondary to inconsistent definitions of breastfeed- ing (eg, exclusivity, frequency, in- tensity, duration), and unethical to conduct the randomized controlled trials necessary to answer many ques- tions.3,17,18 However, systematic re- views and meta-analyses continue to indicate that infant feeding mode is associated with infant and maternal health outcomes.17-23 The Figure out- lines well-established and currently debated health outcomes related to infant feeding mode, framed to convey risks of not breastfeeding instead of benefits of breastfeeding, as it has been noted that this framing may assist with recasting human milk substitutes as being inferior to human milk.4,5 Acute infant health outcomes associated with human milk, including reduced risk of gastrointestinal infections, respiratory infections, and otitis media, are well established and continue to drive breastfeeding initiatives.1,3,18,24-28

Although a relationship between in- fant feeding mode and other health outcomes has been established, many require continued exploration. For example, preterm infants are at

increased risk of developing necro- tizing enterocolitis compared with term infants, and human milk feedings reduce the incidence.9 Studies show an absolute difference of 5% in the risk of necrotizing enterocolitis when comparing outcomes between preterm infants receiving human milk or a substitute. This is considered a mean- ingful clinical difference due to the high case-fatality rate of necrotizing enterocolitis.26 Milk from the infant’s own mother contains bioactive com- ponents and immunomodulatory fac- tors, and is the first choice for feeding


preterm infants.9,29 Although mother’s own milk is desirable, donor milk is recommended when mother’s own milk is not available9,29 (use of donor milk is expanded upon in the practice paper2). Because of the nutritional re- quirements of preterm infants for increased amounts of protein and minerals during periods of rapid growth, it is recommended that human milk provided to very-low-birth- weight infants (<1,500 g) be fortified during the hospital stay.3,9 Although commercial fortifiers are readily avail- able with standardized mixing in- structions, there is increased interest in customizing fortification based on analysis of individual mother’s milk to provide the correct amount of protein and energy for optimal growth.9

Longer-term, but less well- established, effects of not breastfeed- ing include increased risk of type 1 diabetes mellitus, celiac disease, asthma, sudden infant death syn- drome, and development of over- weight or obesity.21,26,27,30 Although unable to show cause and effect, well- designed meta-analyses of time-series data can increase confidence in the stability of associations by evaluating repetition across multiple studies. For example, secondary to the strength of the protective effect of human milk against developing sudden infant death syndrome, illustrated by a recent meta- analysis, it has been recommended that breastfeeding promotion be incorpo- rated into the US sudden infant death syndrome reduction campaign.21,27,30

For mothers, immediate and early ef- fects of breastfeeding include reduced risk of hemorrhage after delivery, stress reduction, delay in ovulation, reduced blood pressure, reduced risk of postpartum depression, greater post- partum weight loss, and possibly greater infant bonding.1,4,6,27,31 Long- term effects include reduced risk of breast and ovarian cancers, hyperten- sion, and type 2 diabetes.12,22,32,33

However, the relatively weak study designs used to evaluate some of these outcomes contribute to their continued debate.3,26

Infant Feeding Trends Although monitoring by the Center for Disease Control and Prevention in- dicates that national breastfeeding ob- jectives have not yet been met, the


Health outcomes Strong evidence

Relationship established; needs additional study

Infant health outcomes

Nonspecific gastrointestinal infections, upper and lower respiratory tract infections


Otitis media X

Atopic dermatitis X

Autoimmune disorders (type 1 diabetes mellitus, celiac disease)


Sudden infant death syndrome X

Necrotizing enterocolitis, among premature and low-birth- weight infants


Cognitive development X

Asthma X

Later overweight or obesity X

Comorbidities of excess weight (type 2 diabetes, cardiovascular disease, heart disease, hypertension, high cholesterol)


Maternal health outcomes

Postpartum hemorrhage X

Delayed ovulation X

Hypertension X

Postpartum weight status X

Infant bonding X

Postpartum depression X

Cancer (postmenopausal breast/ovarian) X

Premenopausal breast cancer X

Comorbidities of excess weight (hypertension, type 2 diabetes mellitus)


Figure. Risks associated with suboptimal breastfeeding (lack of any breastfeeding, partial breastfeeding, or short duration of any breastfeeding).


nation continues to move in a positive direction, and federal-level initiatives, such as the Break Time for Nursing Mothers law and breastfeeding-related preventative services included in the Affordable Care Act and the breast- feeding peer counselor program offered by the Special Supplemental Nutrition Program for Women, Infants, and Children, have continued to target increasing breastfeeding rates.24,25,28

The Table outlines several Healthy People 2020 breastfeeding objectives, along with the most current national rates. Although these recent data


reflect continued improvements in breastfeeding behaviors, disparities in initiation, duration, and exclusivity remain of concern, and RDNs/NDTRs continue to play a critical role in sup- port and promotion.2,28

Social Determinants Determinants of breastfeeding initia- tion, and continuation, remain largely unchanged since publication of the previous position paper.1 Women without a high school diploma, younger women, those who are obese,


low-income women, and those living in certain regions of the United States, continue to be less likely to initiate breastfeeding as compared with their peers, and are less likely to maintain breastfeeding if initiated.28 Those mothers least likely to breastfeed are also those most likely to suffer from many of the acute and chronic diseases associated with a lack of breastfeeding (Figure). For example, non-Hispanic black women are least likely to initiate breastfeeding, but they, and their children, are at higher risk for developing overweight/obesity, type 2

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Table. Healthy People 2020 breastfeeding objectives and most recent national rates

Increase the proportion of infants who are breastfed

2020 Target rates24 (%)

National breastfeeding rates, 201125 (%)

Ever 81.9 79.2

At 6 mo 60.6 49.4

At 12 mo 34.1 26.7

Exclusively through 3 mo 46.2 40.7

Exclusively through 6 mo 25.5 18.8


diabetes, cardiovascular disease, and some cancers.24

The literature is replete with exam- ples of the multiple influences on a mother’s decision to breastfeed, and evidence of these continued disparities in breastfeeding rates suggest that these influences often outweigh maternal desire.28,34 However, eme- rging research is revealing areas for targeted intervention within specific populations.35 For example, maternity care practices that align with the Baby- Friendly Hospital Initiative, a joint initiative of the World Health Organi- zation and the United Nations Chil- dren’s Fund targeting excellence in mother�baby care, were found to be differentially effective, depending on maternal race/ethnicity.35 Mothers who breastfed for at least 10 weeks were more likely to have experienced breastfeeding within the first hour postpartum, have been allowed to feed on demand, and have infants who received only human milk while in the hospital. However, when evaluating these relationships by maternal race/ ethnicity, the authors found that feeding within an hour postpartum was only associated with breastfeeding duration among black and white mothers, but not Hispanic women. Maternity practices are discussed in greater detail in the practice paper.2

Increasing breastfeeding rates by creating successful culturally relevant interventions remains a critical component of initiatives designed to address many of the nations’ health disparities. The Surgeon General’s Call to Action to Support Breastfeeding presents a set of actions developed from a body of literature that describes

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breastfeeding in the context of the socioecological model and calls for ef- forts targeting immediate family members, community groups, health care workers, employers, and mar- keters of human milk substitutes, among others.28 Specifically, initiatives that increase the acceptance of breast- feeding as the social norm and present feeding of human milk substitutes as subpar will continue to be needed to move the nation in a positive direction (see practice paper).2

Perceived Insufficient Milk Supply Prenatal maternal self-efficacy has been linked to positive breastfeeding outcomes.36 Research conducted among primiparas who initiated bre- astfeeding demonstrates the impact of critical early maternal postpartum fac- tors that can disrupt this association, including concerns about milk volume and the ability for both mothers and infants to breastfeed.36 Although it is believed that only 5% of women are physiologically incapable of producing adequate amounts of milk, approxi- mately 50% of US mothers report perceptions of insufficient milk pro- duction, leading to supplementation with human milk substitutes or to weaning completely.27 This supple- mentation reduces infant suckling at the breast, which leads to an actual reduction in milk production. Educa- tion regarding how to accurately assess insufficient milk supply, as well as encouragement to seek expert assis- tance (such as an International Board Certified Lactation Consultant) when faced with lactation issues, should continue, with efforts amplified in at-


risk populations. The practice paper expands on these and other education- related concepts.2

Gestational Diabetes Mellitus GDMisanationalpublichealth issue that is compoundedby thehighprevalenceof maternal overweight/obesity in the United States.37 In addition, GDM is present at higher rates in populations already at elevated risk for not breast- feeding (eg, non-Hispanic black women and low-income women).24 Epidemio- logic evidence indicating a protective effect of breastfeeding on later develop- ment of type 2 diabetes among women experiencing GDM has drawn attention to breastfeeding as a critical intervention in these populations.37 Limited research suggests that blood glucose levels of in- fants born to women with GDM may be more readily stabilized by breast- feeding as compared with feeding human milk substitutes, at least in the immediate postpartum period.38

Therefore, breastfeeding is recom- mended regardless of the presence of a GDM pregnancy.

COST OF NOT BREASTFEEDING A recent pediatric cost analysis was conducted to evaluate the economic burden of suboptimal breastfeeding practices.5 Both direct and indirect costs for disease and the cost of pre- mature death were included. It was determined that if 90% of families in the United States breastfed exclusively for 6 months, $13 billion per year could be saved. A similar study focused on maternal outcomes.4 In this study, direct and indirect health costs and the economic costs of premature death associated with maternal cases of pre- menopausal breast cancer, ovarian cancer, hypertension, type 2 diabetes, and myocardial infarction were considered.4 Comparing current breastfeeding rates at 1 year (23%) with a goal of 90% indicated that suboptimal breastfeeding rates might result in a cost of $17.4 billion. RDNs/NDTRs who have completed relevant course work and/or who are certified as an Inter- national Board Certified Lactation Consultant are well placed to support families to successfully establish and maintain optimal breastfeeding prac- tices, as outlined in the accompanying practice paper.2



EMERGENT TOPICS Several issues concerning breastfeed- ing and the feeding of human milk have emerged that will require addi- tional study. For example, a trending increase in providing human milk exclusively as pumped milk may in- crease the prevalence of infants receiving human milk for the optimal duration.39 However, little is known about the impact refrigeration/freezing and subsequent thawing might have on the immunologic properties of human milk. In addition, research to tease out the benefits of breastfeeding provided by human milk itself, by the direct contact with the mother, or some combination of the two, has yet to be exhaustively conducted.39 Despite these unknowns, if expressed human milk is offered in lieu of a human milk substitute, it is likely to provide sig- nificant benefit and this behavior should continue to be monitored by professionals working with this population.39

Additional emergent topics include optimal levels of maternal vitamin D supplementation to support the breastfeeding infant, the provision of human milk during disaster situations, guidelines for the use of human milk in child care settings, informal milk sharing, and social media and infant feeding (see the practice paper for discussion of these emergent issues).2

CONCLUSION/FUTURE NEEDS Research continues to support the impact of human milk on infant and maternal health outcomes and, as such, federal initiatives supporting the effort to increase national, regional, and local breastfeeding rates continue to be strengthened. Since publication of the 2009 position paper, an effort has been made to quantify the risks of not breastfeeding and to detail the eco- nomic costs associated with suboptimal breastfeeding behaviors. Information presented here and in the accompa- nying practice paper2 provides rationale for continued efforts to shift the norm away from use of human milk sub- stitutes and toward human milk feeds. Research continues to show the impor- tance of breastfeeding and the use of human milk to infant and maternal health outcomes and RDNs/NDTRs should promote and support these practices bymaintaining a current basic


level of knowledge about lactation management, as described in the accompanying practice paper.2

References 1. American Dietetic Association. Position of

the American Dietetic Association: Pro- moting and supporting breastfeeding. J Am Diet Assoc. 2009;109(11):1926-1942.

2. Academy of Nutrition and Dietetics. Prac- tice Paper of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. resources/practice/position-and-practice- papers/practice-papers. Accessed February 2, 2014.

3. Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):E827-E841.

4. Bartick M. Mothers’ costs of suboptimal breastfeeding: Implications of the maternal disease cost analysis. Breastfeed Med. 2013;8(5):448-449.

5. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5):E1048-E1056.

6. Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol. 2013;122(1):111-119.

7. World Health Organization and the United Nations Children’s Fund. Global Strategy for Infant and Young Child Feeding. publications/infantfeeding/9241562218/ en. Published 2003. Accessed October 11, 2014.

8. Donovan SM, Wang M, Li M, Friedberg I, Schwartz SL, Chapkin RS. Host-microbe interactions in the neonatal intestine: Role of human milk oligosaccharides. Adv Nutr. 2012;3(3):450S-455S.

9. Bertino E, Giuliani F, Baricco M, et al. Benefits of donor milk in the feeding of preterm infants. Early Hum Dev. 2013;89(suppl 2):S3-S6.

10. Hassiotou F, Geddes DT, Hartmann PE. Cells in human milk: State of the science. J Hum Lact. 2013;29(2):171-182.

11. Neville MC, Anderson SM, McManaman JL, et al. Lactation and neonatal nutrition: Defining and refining the critical questions. J Mammary Gland Biol Neoplasia. 2012;17(2):167-188.

12. Schwarz EB, Brown JS, Creasman JM, et al. Lactation and maternal risk of type 2 diabetes: A population-based study. Am J Med. 2010;123(9):863.e1-863.e6.

13. Oberhelman SS, Meekins ME, Fischer PR, et al. Maternal vitamin D supplementa- tion to improve the vitamin D status of breast-fed infants: A randomized controlled trial. Mayo Clin Proceed. 2013;88(12):1378-1387.

14. Institute of Medicine. Dietary reference intakes for calcium and vitamin D. http:// rence-Intakes-for-Calcium-and-Vitamin- D.aspx. Published 2011. Accessed October 11, 2014.

15. Chapman DJ, Nommsen-Rivers L. Impact of maternal nutritional status on breast


milk quality and infant outcomes: An update on key nutrients. Adv Nutr. 2012;3(3):350-352.

16. Allen LH. B vitamins in breast milk: Rela- tive importance of maternal status and intake, and effects on infant status and function. Adv Nutr. 2012;3(3):362-369.

17. Horta BL BR, Martines JC, Victora CG. Ev- idence on the long-term effects of breastfeeding. Systematic reviews and meta-analyses. publications/2007/9789241595230_eng. pdf. Published 2007. Accessed March 14, 2014.

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

19. Anothaisintawee T, Wiratkapun C, Lerdsitthichai P, et al. Risk factors of breast cancer: A systematic review and meta-analysis. Asia Pac J Public Health. 2013;25(5):368-387.

20. Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and childhood asthma: Systematic review and meta-analysis. Am J Epidemiol. 2014;179(10):1153-1167.

21. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: A meta-analysis. Pediatrics. 2011;128(1):103-110.

22. Luan NN, Wu QJ, Gong TT, Vogtmann E, Wang YL, Lin B. Breastfeeding and ovarian cancer risk: A meta-analysis of epidemi- ologic studies. Am J Clin Nutr. 2013;98(4): 1020-1031.

23. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child. 2012;97(12):1019-1026.

24. US Department of Health and Human Ser- vices.HealthyPeople2020Maternal, Infant, and Child Health Objectives. HealthPeople. gov website. http://www.healthypeople. gov/2020/topics-objectives/topic/matern al-infant-and-child-health. Publishesd 2012. Accessed October 11, 2014.

25. Centers for Disease Control and Preven- tion. Breastfeeding Report Card 2014. reportcard.htm. Published 2013. Accessed October 11, 2014.

26. Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and Quality’s Evi- dence Report on Breastfeeding in Devel- oped Countries. Breastfeed Med. 2009;4(suppl 1):S17-S30.

27. Dieterich CM, Felice JP, O’Sullivan E, Rasmussen KM. Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin N Am. 2013;60(1):31-48.

28. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. http:// astfeeding. Published 2011. Accessed October 11, 2014.

29. Menon G, Williams TC. Human milk for preterm infants: Why, what, when and how? Arch Dis Child Fetal Neonatal Ed. 2013;98(6):F559-F562.

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30. Vennemann MM, Bajanowski T, Brinkmann B, et al. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics. 2009;123(3):e406- e410.

31. Figueiredo B, Canário C, Field T. Breast- feeding is negatively affected by prenatal depression and reduces postpartum dep- ression. Psychol Med. 2014;44(5):927- 936.

32. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-982.

33. Turkoz FP, Solak M, Petekkaya I, et al. Association between common risk factors

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and molecular subtypes in breast cancer patients. Breast. 2013;22(3):344-350.

34. Bai Y, Middlestadt SE, Peng CYJ, Fly AD. Predictors of continuation of exclusive breastfeeding for the first six months of life. J Hum Lact. 2010;26(1):26-34.

35. Ahluwalia IB, Morrow B, D’Angelo D, Li RW. Maternity care practices and breastfeeding experiences of women in different racial and ethnic groups: Preg- nancy risk assessment and monitoring system (PRAMS). Matern Child Health J. 2012;16(8):1672-1678.

36. Wagner EA, Chantry CJ, Dewey KG, Nommsen-Rivers LA. Breastfeeding con- cerns at 3 and 7 days postpartum and


feeding status at 2 months. Pediatrics. 2013;132(4):E865-E875.

37. Trout KK, Averbuch T, Barowski M. Pro- moting breastfeeding among obese women and women with gestational diabetes mellitus. Curr Diab Rep. 2011;11(1):7-12.

38. Chertok IRA, Raz I, Shoham I, Haddad H, Wiznitzer A. Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. J Hum Nutr Diet. 2009;22(2):166-169.

39. Rasmussen KM, Geraghty SR. The quiet revolution: Breastfeeding transformed with the use of breast pumps. Am J Public Health. 2011;101(8):1356-1359.

This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on March 16, 1997, and reaffirmed on September 12, 1999; June 6, 2003; May 20, 2007; and March 23, 2012. This position is in effect until December 31, 2019. Requests to use portions of the position or republish in its entirety must be directed to the Academy at [email protected]

Authors: Rachelle Lessen, MS, RD, IBCLC, LDN, The Children’s Hospital of Philadelphia, Philadelphia, PA; Katherine Kavanagh, PhD, RD, LDN (The University of Tennessee at Knoxville, Knoxville, TN).

Reviewers: Virginia Carney, MPH, RD, IBCLC, FILCA, FADA (St Jude Children’s Research Hospital, Memphis, TN); Public Health Community Nutrition dietetic practice group (DPG) (Phyllis Stell Crowley, MS, RD, IBCLC, Utah Department of Health/WIC, Salt Lake City, UT); Claire Dalidowitz, MS, MA, RD, CD-N (Connecticut Children’s Medical Center, Hartford, CT); Sharon Denny, MS, RD (Academy Knowledge Center, Chicago, IL); Women’s Health DPG (Heather Goesch, MPH, RDN, LDN, Heather Goesch Nutrition, Holly Ridge, NC); Pediatric Nutrition DPG (Stephanie Howard, MPH, RDN, LD, IBCLC Saint Luke’s Hospital, Kansas City, MO); Mary Pat Raimondi, MS, RD (Academy Policy Initiatives & Advocacy, Washington, DC).

Academy Positions Committee Workgroup: Denise A. Andersen, MS, RDN, LD, CLC (Chair) (Business Consultant in Private Practice, Mendota Heights, MN); Mindy G. Hermann, MBA, RDN (The Hermann Group, Inc, Mount Kisco, NY); Alena M. Clark, PhD, MPH, RD, CLC (Content Advisor) (University of Northern Colorado, Greeley, CO).

We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the supporting paper.


  • Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding
    • Human Milk Composition
    • Infant and Maternal Health Outcomes
      • Infant Feeding Trends
      • Social Determinants
      • Perceived Insufficient Milk Supply
      • Gestational Diabetes Mellitus
    • Cost of Not Breastfeeding
    • Emergent Topics
    • Conclusion/Future Needs
    • References