ABSTRACT: As reproductive health experts and advocates for women's health who work in conjunction with other obstetric and pediatric health care providers, obstetrician–gynecologists are uniquely positioned to enable women to achieve their infant feeding goals. Maternity care policies and practices that support breastfeeding are improving nationally; however, more work is needed to ensure all women receive optimal breastfeeding support during prenatal care, during their maternity stay, and after the birth occurs. Enabling women to breastfeed is a public health priority because, on a population level, interruption of lactation is associated with adverse health outcomes for the woman and her child, including higher maternal risks of breast cancer, ovarian cancer, diabetes, hypertension, and heart disease, and greater infant risks of infectious disease, sudden infant death syndrome, and metabolic disease. Contraindications to breastfeeding are few. Most medications and vaccinations are safe for use during breastfeeding, with few exceptions. Breastfeeding confers medical, economic, societal, and environmental advantages; however, each woman is uniquely qualified to make an informed decision surrounding infant feeding. Obstetrician–gynecologists and other obstetric care providers should discuss the medical and nonmedical benefits of breastfeeding with women and families. Because lactation is an integral part of reproductive physiology, all obstetrician–gynecologists and other obstetric care providers should develop and maintain skills in anticipatory guidance, support for normal breastfeeding physiology, and management of common complications of lactation. Obstetrician–gynecologists and other obstetric care providers should support women and encourage policies that enable women to integrate breastfeeding into their daily lives and in the workplace. This Committee Opinion has been revised to include additional guidance for obstetrician–gynecologists and other obstetric care providers to better enable women in unique circumstances to achieve their breastfeeding goals.

Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations:

Introduction

Although most women in the United States initiate breastfeeding, more than one half wean earlier than they desire 1. In addition, substantial disparities persist in initiation and duration of breastfeeding that affect population health 2. For example, in a sample of infants born between 2010 and 2013, there was a 17.2% difference in the rate of initiation among black and white women in the United States. Furthermore, there was a 7.8 percentage point difference in 6-month exclusive breastfeeding rates and a 13.7 percentage point difference in any breastfeeding at 12 months 3. Maternity care policies and practices that support breastfeeding are improving nationally; however, more work is needed to ensure all women receive optimal breastfeeding support during prenatal care, during their maternity stay, and after the birth occurs 4. As reproductive health experts and advocates for women's health who work in conjunction with other obstetric and pediatric health care providers, obstetrician–gynecologists are uniquely positioned to enable women to achieve their infant feeding goals. This Committee Opinion has been revised to include additional guidance for obstetrician–gynecologists and other obstetric care providers to enable women in unique circumstances achieve their breastfeeding goals.

Benefits of Breastfeeding

Clinical management of lactation is a core component of reproductive health care. However, education surrounding lactation is often lacking in graduate and postgraduate medical education 5. Enabling women to breastfeed is a public health priority because, on a population level, interruption of lactation is associated with adverse health outcomes for the woman and her child, including higher maternal risks of breast cancer, ovarian cancer, diabetes, hypertension, and heart disease, and greater infant risks of infectious disease, sudden infant death syndrome, and metabolic disease 2 6 7.

Although lactation is the physiologic norm, cultural norms for infant feeding have changed dramatically in the past century. In 1971, only 24.7% of women left the hospital breastfeeding. Since then, breastfeeding initiation rates have progressively increased. In 2014, 82.5% of women in the United States initiated breastfeeding, 55.3% were breastfeeding at 6 months, and 33.7% were breastfeeding at 1 year after giving birth 8 Table 1.

Breastfeeding confers medical, economic, societal, and environmental advantages; however, each woman is uniquely qualified to make an informed decision surrounding infant feeding. Obstetrician–gynecologists and other obstetric care providers should discuss the medical and nonmedical benefits of breastfeeding with women and families, 9 because engaging and educating fathers and significant others have been shown to improve breastfeeding success 10. Contraindications to breastfeeding are few and include those women who have an infant with galactosemia, are infected with human immunodeficiency virus (HIV) or human T-cell lymphotropic virus type I or type II, and have active untreated tuberculosis or varicella or active herpes simplex virus lesions on the nipple. Most medications and vaccinations are safe for use during breastfeeding, with few exceptions.

Use of medically indicated drugs or treatment for substance use disorders may not be a contraindication to breastfeeding. For example, women on stable doses of methadone or buprenorphine, who are not using illicit drugs, and who have no other contraindications, should be encouraged to breastfeed 11 12 13. There are insufficient data to evaluate the effects of marijuana use on infants during lactation. In the absence of data, marijuana use is discouraged 14. As the number of states legalizing and decriminalizing marijuana use increases, screening and counseling women about medicinal and recreational marijuana use during pregnancy and lactation is important and should not be overlooked. More details on marijuana use and lactation can be found in Committee Opinion No. 722, Marijuana Use During Pregnancy and Lactation 14.

The Role of Obstetrician–Gynecologists and Other Obstetric Care Providers in Supporting Breastfeeding

The American College of Obstetricians and Gynecologists strongly encourages women to breastfeed and supports each woman’s right to breastfeed. The American College of Obstetricians and Gynecologists recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced during the infant’s first year of life, or longer, as mutually desired by the woman and her infant. This recommendation is consistent with those of other medical and nursing organizations, such as the American Academy of Pediatrics 7 and the Association of Women’s Health, Obstetric and Neonatal Nurses 15. The American College of Obstetricians and Gynecologists additionally supports public health and policy efforts to enable more women to breastfeed, including Healthy People 2020 targets for increasing worksite lactation programs, reducing formula supplementation of breastfed infants in the first 2 days of life, and increasing the proportion of births that occur in facilities that provide recommended care for lactating women and their infants Table 1.

Because lactation is an integral part of reproductive physiology, all obstetrician–gynecologists and other obstetric care providers should develop and maintain skills in anticipatory guidance, support for normal breastfeeding physiology, and management of common complications of lactation. Obstetrician–gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable women to breastfeed, whether through individual patient education, change in hospital practices, community efforts, or supportive legislation.

Obstetrician–gynecologists can play an active role in breastfeeding support by helping to ensure that their office practice setting aligns with these goals. The following practices are evidence-based options that obstetricians can implement to optimize the office setting: a written breastfeeding policy to facilitate support for breastfeeding patients and employees, providing information to patients about infant feeding that is free of artificial infant formula advertising, displaying posters and pamphlets with images of women breastfeeding that reflect the diversity of the population, and partnering with regional breastfeeding support services where patients can be referred for additional breastfeeding support after delivery 16 17 18.

Prenatal Care

The advice and encouragement of the obstetrician–gynecologist and other obstetric care providers are critical in assisting women to make an informed infant feeding decision and should be free from coercion, pressure, or undue influence 19. Women and families should receive noncommercial, accurate, and unbiased information so that they can make informed decisions about their health care 20. Obstetric care providers should be aware that personal experiences with infant feeding may affect their counseling. In addition, pervasive direct-to-consumer marketing of infant formula adversely affects patient and health care provider perception of the risks and benefits of breastfeeding.

Beginning conversations about lactation early in prenatal care by asking the patient and her family, “What have you heard about breastfeeding?” sets the stage for a patient-centered discussion. When taking an obstetric history, obstetrician–gynecologists and other obstetric care providers should specifically ask about any breast surgeries, prior breastfeeding duration, and any previous breastfeeding difficulties. Prior problems leading to earlier-than-desired weaning should be discussed, anticipatory guidance should be provided, and appropriate lactation support resources should be identified. The breast examination can identify surgical scars indicating prior surgery, as well as widely spaced, tubular breasts that may indicate insufficient glandular tissue 6. A breast assessment and breastfeeding history should be obtained as part of prenatal care, and identified concerns and risk factors for breastfeeding difficulties should be discussed with the woman and communicated to the infant's health care provider, either directly or as part of shared records. A woman with a history of breast surgery usually can successfully breastfeed with the supervision of a health care provider to watch for any milk supply challenges or other anatomic issues related to the procedure. Of particular concern is a history of breast reduction, extensive wide local excision or multiple biopsies because these procedures can affect the ability to produce a full milk supply or permit normal anatomic drainage through the ducts, or both. Obstetrician–gynecologists and other obstetric care providers should engage the patient’s partner and other family members in discussions about infant feeding and address any questions and concerns. This patient-centered approach allows the health care provider, the patient, and her family to anticipate challenges, develop strategies to address them, and collaborate to develop a feeding plan that is compatible with the woman's and family's goals. Obstetrician–gynecologists and other obstetric care providers should support each woman's informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant.

Breast cancer is the most common cancer in women worldwide 21. The range of treatment options for breast cancer is wide and many of these women will go on to have children. Women who undergo lumpectomy and radiation may opt to breastfeed. The volume of milk produced after breast radiation is decreased. In addition, breast milk from an irradiated breast can have a higher sodium concentration and lower fat concentration. Infants will sometimes reject the milk from an irradiated breast or show strong preference for the nonirradiated breast, or both 22. A full milk supply may develop in the nonirradiated breast, however, counseling about nipple soreness and complications is prudent. Breastfeeding is an option for women who have undergone double mastectomy and reconstruction by feeding with a supplemental feeding tube device at the breast 23. This device has a container, often a syringe, that has a small tube attached that can be held or taped to the woman's breast. When the infant latches, the milk from the container is drawn into the infant's mouth through this tube. These women can still participate in skin-to-skin contact and should be offered alternative approaches to feeding their infants if desired. Some women in this population may choose to use donor milk if it is available. It is important to support these women and provide resources for them, including referral to lactation specialists who have experience in breastfeeding after a breast cancer diagnosis. There are specific support groups addressing these concerns 24.

As breastfeeding rates continue to increase in the United States, more than 33% of infants are breastfeeding at 12 months and beyond 8. Thus, the topics of lactation during pregnancy and tandem nursing (when an older child and newborn are both nursing) are becoming even more relevant to the obstetrician–gynecologist than in the past. Many nursing women may notice nipple soreness or a decrease in milk supply when they become pregnant, or both. Therefore, these symptoms should trigger pregnancy testing. A review of the limited literature available suggests that there is no increase in spontaneous abortion and preterm birth among low risk women who are breastfeeding during pregnancy, and most infants will wean from breastfeeding during the first or second trimester of the woman's subsequent pregnancy. There is an increased risk of anemia in women who breastfeed while pregnant, and they can expect their milk supply to diminish. They also can expect to transition to colostrum during later parts of pregnancy. Tandem nursing has not been consistently associated with diminished infant growth, with some studies showing less and others showing more growth. More data are needed to fully understand the effect of breastfeeding during pregnancy in developed countries 25.

Intrapartum Care

Maternity care practices affect breastfeeding outcomes. The World Health Organization's “Ten Steps to Successful Breastfeeding” (Ten Steps) is an evidence-based set of health care practices that support breastfeeding physiology, including early skin-to-skin care, enabling rooming-in, and feeding on demand Box 1 2. In a systematic review of randomized controlled trials, skin-to-skin care in the first hour of life increased breastfeeding duration by a mean of 64 days (95% CI, −37.96 to 89.50) 26. Rooming-in enables women to learn and respond to infant cues and facilitates early breastfeeding. It is important to communicate the rationale for rooming-in to families during prenatal care and during the maternity care stay. A woman's clinical situation, fatigue, or a specific request for alternative arrangements may necessitate different rooming options. The Ten Steps should be integrated into maternity care to increase the likelihood that a woman will initiate and sustain breastfeeding and achieve her personal breastfeeding goals 27. Cesarean birth is associated with lower breastfeeding rates, and women who undergo cesarean delivery may need extra support to establish and sustain breastfeeding. Skin-to-skin contact is feasible in the operating room and is associated with reduced need for formula supplementation 28.

As hospitals are making progress towards providing skin-to-skin care and rooming-in, which facilitate breastfeeding initiation, it is important that infants are adequately supervised to ensure safety, prevent falls, and prevent sudden unexpected postnatal collapse. Particular attention is required for breastfeeding dyads when the woman is using opioid analgesia. Practicing a standardized approach to infant monitoring, which includes optimal infant positioning and observation, is vitally important in order to avoid adverse events Box 2 29. The American College of Obstetricians and Gynecologists' Committee Opinion No. 742 and Committee Opinion No. 711 include further discussion about opioid use and breastfeeding 11 30.

Healthy People 2020 and the Joint Commission have targeted unnecessary formula supplementation as a barrier to establishing breastfeeding, and maternity care providers can provide anticipatory guidance for families regarding the rationale for avoiding early introduction of formula. Distribution of formula marketing packs reduces breastfeeding initiation and duration 31 and implies that formula is a recommended feeding method. Moreover, provision of samples implies the health care provider's endorsement of a specific brand, which encourages families to purchase more expensive brand-name products, rather than generic equivalents 32. Such marketing should not occur in inpatient or outpatient health care settings.

The adolescent birth rate continues to decrease in the United States, but it remains the highest in the developed world. Most adolescent mothers would like to breastfeed, but they face unique challenges particular to their age. This cohort breastfeeds less exclusively and for shorter duration than their older counterparts when dividing women by age 20 years or younger 33. When adolescents are exposed to more components of the Ten Steps, they also tend to breastfeed longer and more exclusively. Thus, Ten Steps care is a practice that supports females of all ages and should not be denied to adolescents. Adolescent mothers are a vulnerable population in whom the health effects of breastfeeding could be particularly beneficial 34.

Overall, the preterm birth rate in the United States is currently 9.8% and black women have a prematurity rate of 13.3%, which is 49% higher than the preterm birth rate among all other women 35. The American Academy of Pediatrics states that all preterm infants should receive human milk. If a woman's own milk is not available, pasteurized donor human milk is the next best alternative 36. When fed human milk, this fragile group of infants has a lower risk of necrotizing enterocolitis, retinopathy of prematurity, late onset sepsis, and lower readmission rates in the first year of life 37 38. Sharing this information with women who have given birth to preterm infants and who intend to formula feed can increase breastfeeding initiation without increasing maternal anxiety 39. Obstetrician–gynecologists and other obstetric care providers should collaborate with the pediatric care provider to share this information as soon as a preterm birth is anticipated because initiation of milk expression within 6 hours of birth is associated with improved milk production 40. Obstetrician–gynecologists and other obstetric care providers should support women who have given birth to preterm and other vulnerable infants to establish a full supply of milk by providing anticipatory guidance and working with hospital staff to facilitate early, frequent milk expression starting within 1 hour of delivery, if possible 41 42. It is important to recognize and support this vulnerable group of mother–infant dyads because these women have particular challenges to initiate and maintain milk supply.

Clinical Management of the Breastfeeding Dyad

The offices of obstetrician–gynecologists and other obstetric care providers should be a resource for breastfeeding assistance throughout the entire breastfeeding relationship. Breastfeeding is a two-person activity, and evaluation of breastfeeding problems requires assessment of the woman and her infant, as well as the active engagement and support of her partner, extended family, or other identified support. Management of issues such as pain, perceived or actual low milk supply, breast infections, and maternal medication safety should, therefore, be coordinated with the infant’s health care provider as appropriate. Office staff should be prepared to triage common breastfeeding concerns and to refer women, as needed, to a certified lactation professional in the community, such as an International Board Certified Lactation Consultant or other lactation provider. Embedding lactation professionals within the offices of an obstetrician–gynecologist or other obstetric care provider may be feasible with coverage of lactation services included as preventive care under the Affordable Care Act 43. The American College of Obstetricians and Gynecologists encourages each health care provider to learn his or her own community resources to best support patients. In addition, screening patients for Women, Infants, and Children eligibility during prenatal care is an important way to help provide breastfeeding and nutrition support to many women and families. This type of collaborative care model helps enable women to achieve their feeding goals 44.

Most medications are safe for use during breastfeeding. Obstetrician–gynecologists and other health care providers should consult lactation pharmacology resources for up-to-date information on individual medications 12 because inappropriate advice often can lead women to discontinue breastfeeding unnecessarily. LactMed is a free resource updated monthly from the National Institutes of Health National Library of Medicine and available online or as an app compatible with most smartphones. Information about drug safety in pregnancy should not be extrapolated to breastfeeding because the physiology of the placenta and breast are not the same. For example, warfarin crosses the placenta and can cause embryopathy, but minimal amounts enter breast milk, so it is considered to be safe during lactation 45. Counseling regarding medication use during lactation should address the risks of drug exposure through breast milk and the risks of interrupting lactation. After anesthesia for surgical procedures, women who have given birth to healthy infants generally may breastfeed as soon as they are stable, awake, and alert enough to hold the infant 46. Breastfeeding can be continued without interruption after the use of iodinated contrast during a computed tomography scan or gadolinium contrast with magnetic resonance imaging 12 47.

Low milk supply is a common concern and may reflect misinterpretation of normal infant feeding behaviors, low production, or inadequate milk transfer 48. The most common cause of low milk supply is inadequate breast stimulation. Careful evaluation by a certified lactation professional to ensure frequent breast stimulation and milk removal is the most effective strategy to increase milk production. There is limited evidence for medications and herbal galactagogues to increase milk supply 49.

Pain is a common cause of premature weaning. In one study of more than 1,300 women who stopped breastfeeding in the first month, approximately two out of three cited pain or sore, cracked, or bleeding nipples as an important reason 50. The differential diagnosis of nipple or breast pain is broad and complex. The support of the breastfeeding woman with pain requires time and knowledge. If the symptoms, history, and physical examination do not confer a diagnosis, additional evaluation with a certified lactation professional should be strongly considered 51.

Disrupted lactation is common, with one in eight women reporting early, undesired cessation of breastfeeding because of multiple problems with pain, low milk supply, or the infant being unable to latch on to the breast 48. Obstetric care providers should collaborate with certified lactation professionals and the infant's health care provider to evaluate and manage breastfeeding problems. Even with comprehensive support, some mother–infant dyads are unable to establish sustained, exclusive breastfeeding. Women who are not able to achieve their breastfeeding intentions report considerable distress, and obstetrician–gynecologists and other health care providers should validate each woman's efforts and experience. Women who experience breastfeeding difficulties are at higher risk of postpartum depression and should be screened, treated, and referred appropriately 6.

Contraception is an important topic for all women, and comprehensive discussion of methods should not be delayed for breastfeeding women. Although breastfeeding without introducing any complementary solids or formula will in most cases prevent ovulation and, thus, pregnancy for up to 6 months after giving birth, it will do so only when women are fully or nearly fully breastfeeding and there is continued amenorrhea. Contraceptive options should be explained in detail and include nonhormonal methods (copper intrauterine devices, condoms, diaphragms, lactational amenorrhea method), and hormonal methods (levonorgestrel intrauterine device, etonogestrel implant, medroxyprogesterone acetate injection, progestin-only pills, and combined hormonal contraceptive pills) 52. The American College of Obstetricians and Gynecologists endorses the Centers for Disease Control and Prevention’s evidence-based medical eligibility criteria for contraceptive use, which states that, for breastfeeding and nonbreastfeeding women, the advantages of progestin-only pills, injectable contraception, contraceptive implant, and intrauterine devices outweigh the risks for use any time in the postpartum period, including immediately after birth. Because of an increased risk of venous thromboembolism, the advantages of combined hormonal contraceptives, however, do not outweigh the risks for women until 1 month after giving birth 53. The Centers for Disease Control and Prevention and the World Health Organization diverge on recommendations for combined hormonal contraceptives beyond the early postpartum period; according to the World Health Organization, primarily breastfeeding women generally should not use combined hormonal contraceptives from 6 weeks through 6 months after giving birth 54.

Theoretical concerns exist that exogenous progesterone could prevent the onset of milk production because progesterone withdrawal after delivery of the placenta is thought to trigger onset of lactogenesis 48. Women considering immediate postpartum progestin-only contraception should be counseled about the theoretical risk of reduced duration of breastfeeding and about the preponderance of evidence that has not shown a negative effect on actual breastfeeding outcomes 55 56 57. Obstetric care providers should discuss any concerns within the context of each woman's desire to breastfeed and her risk of unplanned pregnancy, so that she can make an autonomous and informed decision.

Breastfeeding in the Community

Obstetrician–gynecologists and other obstetric care providers should support women and encourage policies that enable women to integrate breastfeeding into their daily lives and in the workplace. Before discharge from the maternity center, women should be provided with contact information for community-based lactation support. Maintaining milk supply depends largely on frequency of milk removal through breastfeeding and through expressing milk (breast pumping or manual expression) when the woman and her infant are separated. Policies that protect the right of a woman and her child to breastfeed in public and that accommodate milk expression, such as insurance coverage for breast pumps, paid maternity leave 58, on-site childcare, break time for expressing milk, and a clean, private location for expressing milk 59, are essential to sustaining breastfeeding. Obstetric care provider offices and hospitals can set an example through supportive policies for lactating staff, accommodations for nursing patients, awareness and educational materials, and staff training 15 16. Laws vary by state, and health care providers should be aware of their state and local laws to inform and empower patients to feel comfortable breastfeeding in public and supported in achieving their breastfeeding goals (see the For More Information section for more information on state and local laws) 2.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/ObBreastfeedingSupport.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource. The resources may change without notice.