The World Health Organization (WHO) strongly recommends exclusive breastfeeding for the first six months of life. WHO states that at six months, other foods should complement breastfeeding for up to two years or more. However, the European Food Safety Authority (EFSA) advises that for infants across the EU, complementary foods may be introduced safely between four and six months.Breastfeeding has an important role in addressing health inequality.
Incidence of breastfeeding
In the UK the incidence of initial breastfeeding in 2010 was 81% (an increase from 76% in 2005). The incidence of breastfeeding in 1990 was only 62%. One in three mothers are still breastfeeding at six months although only 1% are doing so exclusively for the first six months.
Mothers are more likely to breastfeed if they:
- Are from a minority ethnic group (97% for Chinese or other ethnic group, 96% for black and 95% for Asian.
- Are in managerial and professional occupations.
- Live in England compared to Scotland, Wales and Northern Ireland (which has the lowest breastfeeding rate).
- Are aged over 30 (rates are 87% compared to 58% in mothers aged under 20).
- Are first-time mothers.
- Left full-time education when they were over 18 years of age (91%).
Breastfeeding mothers are more likely to stop breast-feeding within two weeks if they have not been breast-fed themselves or if their friends mainly formula fed their babies.
Social benefits of breastfeeding
Breast milk is free and available without preparation. There is no need to buy a steriliser, bottles or formula milk. It does not need to be pre-warmed.
Social detractions of breastfeeding
Breastfeeding in public can be socially taboo. There is a joint initiative from the United Nations Children's Fund (UNICEF)and the WHO to increase public awareness and encourage certain environments to be more welcoming to breastfeeding mothers - eg, surgery waiting rooms and restaurants.
Medical advantages of breastfeeding
- Immunity/infection protection: there is overwhelming evidence that infants who are breast-fed have lower rates of otitis media and lower respiratory tract infections as well as fewer episodes of gastroenteritis, with a consequent reduction in hospitalisations for these conditions.
- There is a protective effect of breastfeeding on more severe eczema. However, there is no evidence that exclusive breastfeeding for four months or longer actually protects against eczema.
- Breastfeeding may be protective against childhood asthma but this may be due to confounding factors.
- Sudden infant death syndrome (SIDS): a meta-analysis of six high-quality studies has shown that ever having been breast-fed is associated with a 36% reduction in SIDS.
- Intelligence: studies have shown that breastfeeding has a positive effect on the child's general intelligence, even when controlled for confounding factors such as maternal intelligence and home stimulation.
- Obesity: neither total time of breastfeeding nor duration of exclusive breastfeeding has been shown to be associated with obesity in children and the evidence is growing that having been breast-fed can protect against later risks of being overweight and obesity.
- Diabetes: breastfeeding confers protection from future type 2 diabetes and possibly also from type 1 diabetes.
- Breast cancer: for every 12-month increase in breastfeeding over a woman's lifetime, there is an associated 4.3% reduction in invasive breast cancer.
- Diabetes: breastfeeding reduces the chances of developing type 2 diabetes by about one third.
- Ovarian cancer: longer periods of breastfeeding are associated with a reduction in ovarian cancer of about 18%.
- Breastfeeding has also been suggested to reduce the incidence of metabolic syndrome and cardiovascular disease but the evidence is not conclusive.
- Contraception: the lactation amenorrhoea method can be recommended to mothers if:
- The child is up to 6 months old.
- The mother is amenorrhoeic.
- The child is exclusively breast-fed.
Medical disadvantages of breastfeeding
There are, in general, no medical disadvantages to breastfeeding, except in the vertical transmission of human immunodeficiency virus (HIV).
- Breast milk is low in vitamin D. Vitamin D supplements are recommended for all pregnant women and for breast-feeding women.
- Breast-fed infants may need to receive drops containing vitamin D from 1 month of age if their mother has not taken vitamin D supplements throughout pregnancy.
- The advice is particularly important for those mothers and their babies at high risk of vitamin D deficiency (including those who have limited skin exposure to sunlight, or who are of South Asian, African, Caribbean or Middle Eastern descent, or who are obese). In the UK there is inadequate sunlight for skin synthesis of vitamin D from mid-October to early April.
- Vitamin supplements which contain vitamin D are available free in the UK for pregnant women and families who are on a low income, through a government scheme called 'Healthy Start'.
- Breastfeeding mothers should have appropriate nutritional advice, including advice on vitamin D supplementation, to ensure that their breast milk provides good nutrition for their babies.
Transmission of HIV
An HIV-infected mother can pass the infection to her infant during pregnancy and delivery and through breastfeeding. Antiretroviral (ARV) drug interventions, either to the mother or to the HIV-exposed infant, reduce the risk of transmission of HIV through breastfeeding. Together, breastfeeding and ARV interventions have the potential to improve infants' survival chances significantly while remaining HIV-uninfected. The WHO recommends that when HIV-infected mothers breastfeed, they should receive ARVs and follow WHO guidance for breastfeeding and complementary feeding.
However, current recommendations in the UK are that mothers known to be HIV-infected, regardless of maternal viral load and ARV therapy, should refrain from breastfeeding from birth. Nevertheless, if a woman is going to be moving to a country where safe infant formula milk feeding is unavailable, breastfeeding may be the safer option.
Hepatitis B and hepatitis C
- Breastfeeding is not a risk factor for mother-to-child transmission of hepatitis B virus (HBV) provided the infant has received appropriate HBV immunoprophylaxis. HBV-infected mothers should be encouraged to breastfeed their infants.
- Although the hepatitis C virus (HCV) can be found in maternal milk, breastfeeding is not contra-indicated.
- Certain bacterial infections in the mother may be transmitted through breast milk; temporarily stopping breastfeeding may be appropriate for a limited time: 24 hours for Neisseria gonorrhoeae, Haemophilus influenzae, group B streptococci and staphylococci, and longer for others - for example, Borrelia burgdorferi, Treponema pallidum, and Mycobacterium tuberculosis.
- Most anti-tuberculosis drugs appear to be safe for use with breastfeeding.
- In certain situations, prophylactic therapy may be advisable for the infant - eg, T. pallidum, M. tuberculosis and H. influenzae.
- Decisions about stopping breast milk because of infection should balance the potential risk with the huge benefits of breastfeeding.
Nipple soreness is very common during the first weeks of breastfeeding. Some breastfeeding mothers describe nipple soreness as a pinching, itching, or burning sensation. It may be caused by:
- Improper position of the baby: altering feeding positions may help to reduce soreness, providing good attachment is maintained.
- Improper feeding techniques: nipple soreness may be caused by incomplete suction release at the end of baby's feeding. Gently inserting a finger into the side of the mouth to break the suction may help.
- Improper nipple care: excessively dry (or excessively moist) skin can cause nipple soreness. Moisture can be caused by bras made of synthetic fabrics. Ointments containing lanolin may be helpful. Olive oil and expressed milk may also be effective for soothing uncomfortable nipples. Regardless of treatment, for most women, initial nipple pain reduces to mild levels after 7-10 days postpartum.
Blocked duct and breast engorgement
- These are caused by poor drainage of the breast. The breasts feel swollen, hard and painful. There may be redness or systemic symptoms. The nipples cannot protrude to allow the baby to 'latch on', and feeding becomes difficult.
- Common causes are: pressure on the breast (from, for example, a poorly fitting bra or a seatbelt) and prolonged gaps between feeds.
- Advise the mother to nurse eight times or more in 24 hours, for at least 15 minutes for each feed, to prevent engorgement. To relieve it, express milk manually or with a pump. Alternate warm showers followed by cold compresses may help to relieve the discomfort.
- If engorgement persists, mastitis may develop and milk or milk products can get into the bloodstream, leading to flu-like symptoms similar to those of incompatible blood transfusion.
Mastitis (inflammation of the breast) occurs in 20% of breastfeeding women; nipple damage, over-supply of milk, use of nipple shields and nipple carriage of Staphylococcus aureus increase the risk of mastitis. It may be infectious or non-infectious and is part of a continuum from blocked duct or engorgement to mastitis to breast abscess.
- An infectious cause is more likely in the presence of a cracked nipple. If infectious, puerperal mastitis and abscesses are usually caused by S. aureus. The infection takes place in the parenchymal (fatty) tissue of the breast and causes swelling which pushes on the milk ducts. This results in pain and swelling.
- Treatment may include antibiotics - eg, flucloxacillin - if symptoms haven't resolved within 24 hours. An abscess may require aspiration or incision and drainage. Breastfeeding (or pumping to relieve breast engorgement) should continue while receiving treatment.
Thrush and breastfeeding/ductal candidiasis
- The diagnosis of candidal infections of the breast is controversial. It is thought to be the cause of deep radiating breast pain and burning nipple pain in the absence of any signs of mastitis and with pain out of proportion to any nipple damage present. Diagnosis relies on subjective signs and symptoms.
- Nipple vasospasm may be mistaken for breast thrush.
- Treatment of the surface of the nipple and the baby's mouth, and occasionally oral treatment for the mother (when necessary to treat deep breast pain), should be considered if no other cause is obvious, especially if it follows antibiotic treatment of either the mother or the infant.
NB: commonly used dosing schedules and further information can be obtained from The Breastfeeding Network (see references below).
Insufficient milk/hungry baby
- Not producing enough milk is the most common reason women give for giving up breastfeeding. However, usually there is adequate milk but the woman may lack confidence in her ability to maintain her milk supply and she may not be aware that her breasts will soften as feeding becomes established and that it is perfectly normal for some breast-fed babies to feed as often as 10 times per day.
- Frequent feedings, offering both breasts at each feed, adequate rest, good nutrition and adequate fluid intake, can help maintain a good milk supply. Expressing after feeds will increase milk supply.
- Checking weight and growth will determine whether the baby is taking enough milk.
The WHO recommends:
- Breastfeeding should begin within an hour of birth.
- Breastfeeding should be 'on demand', as often as the child wants day and night.
- Bottles or pacifiers should be avoided if possible (although evidence is lacking that it has a negative effect on prevalence or duration of breastfeeding).
Mothers need to be given support, confidence and encouragement for successful breastfeeding, including immediate breastfeeding support at delivery, even if that is by caesarean section[21, 22]. Proactive telephone care delivered by a dedicated feeding team has shown promise as a cost-effective intervention for improving breastfeeding outcomes.
A pathway and standards guide has been produced which reflects the WHO/UNICEF best practice for hospital and community healthcare settings. This is a guide for all healthcare professionals who are involved with the care of women who are breastfeeding and the UNICEF Baby Friendly accreditation is the first ever national intervention to have a positive effect on breastfeeding rates in the UK.
Reducing barriers for mothers to breastfeed at work, by providing breaks and breastfeeding rooms, are low-cost interventions that employers can make; they reduce absenteeism and improve workforce performance, commitment and retention. Such initiatives have been shown to increase breastfeeding rates by 25%.
- Well infants aged >34 weeks are usually able to co-ordinate sucking, swallowing and breathing. They can usually establish breastfeeding or bottle-feeding.
- Extremely preterm babies, or those expected to have a prolonged stay in neonatal intensive care, may require total parenteral nutrition.
- Preterm human breast milk, compared with artificial formula milk, may not provide sufficient nutrition for preterm or low birth-weight infants and may need fortification.
- Multinutrient fortifiers can be added to human milk.
- Many mothers of preterm infants struggle to achieve a full milk production for many reasons, the mechanisms of which are still unclear. Strategies to enhance milk volume include early, frequent simultaneous expression of milk combined with breast massage and a reduction of stress.
Breastfeeding after augmentation
Mothers who have had surgery may have problems providing adequate milk, especially where babies are preterm. The success rate of breastfeeding has been shown to decrease by approximately 25% in young women with hypoplastic breasts following augmentation mammoplasty compared with similar women who had not had surgery; furthermore, the need to supplement breastfeeding increases by 19%.
Infant formula is the only alternative to breast milk. It is available ready-made in cartons or as powder to be made up as directed.
Cow's milk is not suitable until a baby is 1 year old, because it contains too much salt and protein but insufficient iron. Cow's milk infant formulas are the alternative to breast milk and should be given until the baby is at least 1 year old. Follow-on milks can be given from the age of 6 months, although this is not usually necessary.
- Hydrolysed protein infant formulas can be prescribed if the baby has an allergy to cow's milk.
- Soya-based infant formulas can also be used; however, babies who are allergic to cow's milk may also be allergic to soya.
- Goat's milk infant formulas are approved for use in Europe but the proteins are similar to cow's milk so it unlikely to be helpful in cow's milk protein allergy.
Weaning is the process of expanding the diet to include foods and drinks other than breast milk or infant formula. The timing of the introduction of solid food to an infant's diet is important for nutritional and developmental reasons.
There is still a debate regarding the recommendations for the optimal time of weaning infants.
The WHO recommendations state that exclusive breastfeeding for six months confers several benefits on the infant and the mother and complementary (solid) foods should be introduced at 6 months of age (26 weeks), while the mother continues to breastfeed. In the UK the Department of Health (DH) guidelines recommend the introduction of solid food 'at around six months'.
A recent Cochrane review has summarised that although infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided, the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed country settings. However, the EFSA's panel on dietetic products, nutrition and allergies has concluded that for infants across the EU, complementary foods may be introduced safely between four to six months, and six months of exclusive breastfeeding may not always provide sufficient nutrition for optimal growth and development.
The British Dietetic Association recommends that:
- Exclusive breastfeeding from birth, until the introduction of solid foods, is the optimal way to feed young infants.
- Breastfeeding should continue throughout complementary feeding.
- The introduction of solid food should commence 'at around 6 months of age' in line with DH guidance. However, as individual development of babies varies widely, some may be ready for solid food before, or after, this time.
- The introduction of solid food should commence no later than 6 months (26 weeks) of age but not before 4 months (17 weeks) of age.
- Preterm infants require special consideration and advice should be sought from the dietician and medical team caring for them.
Although there is little evidence that complementary feeding before the age of 6 months is harmful, some studies have shown that there is a higher risk of iron-deficiency anaemia which is known to be linked to irreversible adverse mental, motor and psychosocial outcomes.
A systematic review looking at infant feeding and the risk of developing coeliac disease has found no evidence to recommend avoiding either early (before 4 months) or delayed (after 6-12 months) introduction of gluten. This suggests that the age of infants at exposure to gluten during weaning does not influence the triggering of coeliac disease in those who are predisposed to it; however, the authors proposed that it may be the amount rather than the timing of gluten introduction that is important.
Canadian guidance on allergy prevention concludes that there is no evidence that delaying the introduction of certain 'trigger' foods protects against future allergy and that regular, frequent oral consumption of a food may be just as important as when it is introduced.
Further reading and references
Exclusive breastfeeding, Nutrition Topics; World Health Organization, 2016
Scientific Opinion on the appropriate age for introduction of complementary feeding of infants; European Food Safety Authority, 2009
Hansen K; Breastfeeding: a smart investment in people and in economies. Lancet. 2016 Jan 30387(10017):416. doi: 10.1016/S0140-6736(16)00012-X.
F McAndrew et al; Infant Feeding Survey 2010, Health and Social Care Information Centre, November 2012
The Baby Friendly Initiative; UNICEF UK
Victora CG, Bahl R, Barros AJ, et al; Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016 Jan 30387(10017):475-90. doi: 10.1016/S0140-6736(15)01024-7.
Flohr C, Nagel G, Weinmayr G, et al; Lack of evidence for a protective effect of prolonged breastfeeding on childhood eczema: lessons from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two. Br J Dermatol. 2011 Dec165(6):1280-9. doi: 10.1111/j.1365-2133.2011.10588.x. Epub 2011 Nov 2.
Postnatal Sexual and Reproductive Health; Faculty of Sexual and Reproductive Healthcare (2009)
Vitamin D: increasing supplement use among at-risk groups; NICE Public Health Guidance, November 2014
Jamieson DJ, Chasela CS, Hudgens MG, et al; Maternal and infant antiretroviral regimens to prevent postnatal HIV-1 transmission: 48-week follow-up of the BAN randomised controlled trial. Lancet. 2012 Jun 30379(9835):2449-58. doi: 10.1016/S0140-6736(12)60321-3. Epub 2012 Apr 26.
10 facts on breastfeeding; World Health Organization, July 2012
Taylor GP, Anderson J, Clayden P, et al; British HIV Association and Children's HIV Association position statement on infant feeding in the UK 2011. HIV Med. 2011 Aug12(7):389-93. doi: 10.1111/j.1468-1293.2011.00918.x. Epub 2011 Mar 21.
Chen X, Chen J, Wen J, et al; Breastfeeding is not a risk factor for mother-to-child transmission of hepatitis B virus. PLoS One. 20138(1):e55303. doi: 10.1371/journal.pone.0055303. Epub 2013 Jan 28.
Cottrell EB, Chou R, Wasson N, et al; Reducing risk for mother-to-infant transmission of hepatitis C virus: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013 Jan 15158(2):109-13.
Amir LH; Managing common breastfeeding problems in the community. BMJ. 2014 May 12348:g2954. doi: 10.1136/bmj.g2954.
Dennis CL, Jackson K, Watson J; Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev. 2014 Dec 15(12):CD007366. doi: 10.1002/14651858.CD007366.pub2.
Cullinane M, Amir LH, Donath SM, et al; Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Fam Pract. 2015 Dec 1616:181. doi: 10.1186/s12875-015-0396-5.
Irusen H, Rohwer AC, Steyn DW, et al; Treatments for breast abscesses in breastfeeding women. Cochrane Database Syst Rev. 2015 Aug 17(8):CD010490. doi: 10.1002/14651858.CD010490.pub2.
Amir LH, Donath SM, Garland SM, et al; Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia. BMJ Open. 2013 Mar 93(3). pii: e002351. doi: 10.1136/bmjopen-2012-002351.
Jaafar SH, Jahanfar S, Angolkar M, et al; Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2012 Jul 117:CD007202. doi: 10.1002/14651858.CD007202.pub3.
Rollins NC, Bhandari N, Hajeebhoy N, et al; Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016 Jan 30387(10017):491-504. doi: 10.1016/S0140-6736(15)01044-2.
Demirtas B; Strategies to support breastfeeding: a review. Int Nurs Rev. 2012 Dec59(4):474-81. doi: 10.1111/j.1466-7657.2012.01017.x. Epub 2012 Jul 12.
Hoddinott P, Craig L, Maclennan G, et al; The FEeding Support Team (FEST) randomised, controlled feasibility trial of proactive and reactive telephone support for breastfeeding women living in disadvantaged areas. BMJ Open. 2012 Apr 242(2):e000652. doi: 10.1136/bmjopen-2011-000652. Print 2012.
Guide to the Baby Friendly Initiative Standards; UNICEF UK, December 2012
Rochow N, Fusch G, Choi A, et al; Target Fortification of Breast Milk with Fat, Protein, and Carbohydrates for Preterm Infants. J Pediatr. 2013 Jun 12. pii: S0022-3476(13)00517-9. doi: 10.1016/j.jpeds.2013.04.052.
Geddes D, Hartmann P, Jones E; Preterm birth: Strategies for establishing adequate milk production and successful lactation. Semin Fetal Neonatal Med. 2013 Apr 25. pii: S1744-165X(13)00023-1. doi: 10.1016/j.siny.2013.04.001.
Cruz NI, Korchin L; Breastfeeding after augmentation mammaplasty with saline implants. Ann Plast Surg. 2010 May64(5):530-3. doi: 10.1097/SAP.0b013e3181c925e4.
Suitability of goats milk infant formula and follow-on formula for infants who are allergic to cows’ milk; Food standards agency (FSA), 2014
Fewtrell M, Wilson DC, Booth I, et al; Six months of exclusive breast feeding: how good is the evidence? BMJ. 2010 Jan 13342:c5955. doi: 10.1136/bmj.c5955.
The influence of maternal, fetal and child nutrition on the development of chronic disease in later life; Scientific Advisory Committee on Nutrition (SACN), 2011
Kramer MS, Kakuma R; Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012 Aug 158:CD003517. doi: 10.1002/14651858.CD003517.pub2.
Complementary Feeding: Introduction of Solid Food to an Infant's Diet; The British Dietetic Association, April 2013
Silano M, Agostoni C, Sanz Y, et al; Infant feeding and risk of developing celiac disease: a systematic review. BMJ Open. 2016 Jan 256(1):e009163. doi: 10.1136/bmjopen-2015-009163.
Chan ES, Cummings C; Dietary exposures and allergy prevention in high-risk infants: A joint statement with the Canadian Society of Allergy and Clinical Immunology. Paediatr Child Health. 2013 Dec18(10):545-54.