Highlights of, and thoughts regarding the AAP’s Policy Statement “Breastfeeding and the Use of Human Milk”.

On Monday, February 27, 2012, the American Academy of Pediatrics (AAP) published its revised policy statement, Breastfeeding and the Use of Human Milk.  Since presenting the best, evidence based information to our students, clients and patients is paramount, we suggest you read the publication thoroughly.  In this article I will highlight some of the key things to note.

“The AAP reaffirms its recommendation of exclusive breastfeeding for about 6 months, allowed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.”

This is current to what we’ve been teaching.  However the note at the end about “as mutually desired by the mother and infant” is encouraging with regards to the WHO’s recommendations: “Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.”   So, the AAP doesn’t go as far with regards to extended breastfeeding as does the WHO, but they acknowledge that there are benefits to breastfeeding longer than one year.

Breastfeeding rates over all have increased slightly over the last decade, but we still have a huge disparity with regards to the age of the mother, as well as the racial and socio-economic background of the mother.  Strikingly:

“Furthermore, 24% of maternity services provide supplements of commercial infant formula as a general practice in the first 48 hours after birth. These observations have led to the conclusion that the disparities in breastfeeding rates are also associated with variations in hospital routines, independent of the populations served. As such, it is clear that greater emphasis needs to be placed on improving and standardizing hospital based practices to realize the newer 2020 targets.”

That said, it would appear that we need to encourage our hospitals to become Baby Friendly.  In the policy statement, they give us the statistics on the lack of Baby Friendly compliance in the U.S.  The AAP encourages hospitals to practice the 10 Steps and says “the rate of exclusive breastfeeding during the hospital stay has been confirmed as a critical variable when measuring the quality of care provided by a medical facility.”

The publication addresses a wide range of illnesses ameliorated by breastfeeding.  It is noted whether the percent lower risk was with regards to any breastfeeding, or by number of months of breastfeeding.  Unsurprisingly, a fair number of conditions had reduced risk the longer the mother breastfed.  Please refer back to the policy statement for details.


“…note that breastfeeding is associated with a 36% reduced risk of SIDS.” 

Pacifier Use: 

“Given the documentation that early use of pacifiers may be associated with less successful breastfeeding, pacifier use in the neonatal period should be limited to specific medical situations. These include uses for pain relief, as a calming agent, or as part of structured program for enhancing oral motor function. Because pacifier use has been associated with a reduction in SIDS incidence, mothers of healthy term infants should be instructed to use pacifiers at infant nap or sleep time after breastfeeding is well established, at approximately 3 to 4 weeks of age.”

Is your baby smarter because you breastfed her? The short answer is yes for infants exclusively breastfed for 3 months or longer as well as for preterm infants, however:

“Consistent differences in neurodevelopmental outcome between breastfed and   commercial infant formula–fed infants have been reported, but the outcomes are confounded by differences in parental education, intelligence, home environment, and socioeconomic status.”

Guidelines for premature infants include:

“The potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.”

Maternal outcomes are also discussed – everything from breastfeeding aiding the involoution of the uterus after birth, to reduced rates of many diseases, including breast cancer and ovarian cancer:

“Cumulative duration of breastfeeding of longer than 12 months is associated with a 28% decrease in breast cancer (OR: 0.72; 95% CI: 0.65–0.8) and ovarian cancer (OR: 0.72; 95% CI: 0.54–0.97). Each year of breastfeeding has been calculated to result in a 4.3% reduction in breast cancer.”

With regards to vitamin and mineral supplements, the AAP recommends the Vit. K shot over the oral version because “the oral dose is variably absorbed and does not provide adequate concentrations or stores for the breastfed infant”.  They do, however, recommend delaying the shot until after the baby’s first breastfeeding.

Vit. D supplements are suggested for all breastfed infants upon release home because:

“Vitamin D deficiency/insufficiency and rickets has increased in all infants as a result of decreased sunlight exposure secondary to changes in lifestyle, dress habits, and use of topical sunscreen preparations.” 

Supplementary fluoride is not recommended under 6 months of age.

There are many other good data points of note in this policy statement, including information on the economic benefits of breastfeeding, contraindications to breastfeeding, charting normal infant growth and specific data points on individual diseases, etc.

I’ll leave you with this concluding statement:

“Pediatricians also should serve as breastfeeding advocates and educators and not solely delegate this role to staff or nonmedical/lay volunteers. Communicating with families that breastfeeding is a medical priority that is enthusiastically recommended by their personal pediatrician will build support for mothers in the early weeks postpartum.”


“Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue.”

How do we as educators and birth professionals address this?  We support evidence-based practices, yet at the same time we say we support a parent’s right to make an informed choice.  How will you incorporate what you’ve read here, and in the AAP’s policy statement, into your classes?

Baby Friendly Initiative, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Practice Guidelines , , , ,

  1. | #1

    Thanks for this look at the new recommendations – great summary of the highlights!

    Next step for those of who work with women in the childbearing year: working towards positioning breastfeeding as the norm in our culture. For example, instead of looking at the benefits of breastfeeding, let’s start examining the risks of formula feeding!

    Great piece on the concept here: http://www.bobrow.net/kimberly/birth/BFLanguage.html

  2. | #2

    Jeanette ~ Ah, but the risks of formula feeding are outlined in the AAP’s policy statement. If you say that breastfeeding reduces the risk of a disease by a certain percentage, then by not formula feeding you are increasing the risk of that disease. It comes down to how you choose to phrase the information… in a word, “spin”.

  3. | #3

    Check out this great and FREE service I found for expecting or nursing mothers!
    The Texas Pregnancy Riskline Information Service will counsel and give you potential risks if your baby has had any toxic exposures! Check out their website: http://www.ttis.unt.edu
    or call 1.800.733.4727

  4. | #4

    Thank you for sharing this resource. For those outside of the Texas area, many states and provinces have similar services. They will provide accurate and up-to-date information on environmental exposures. It is a great resource to share with those especially in pre-conception classes.

  5. avatar
    | #5

    Thank you for sharing this article. I was waiting on the AAP to update its policy.
    Encouraging mothers to delay pacifier use has been quite a challenge. Even after sharing the evidence based information, we must leave the decision up to the parents to discuss with their providers.
    African American mothers have some unique challenges in regards to breastfeeding. I am learning creative ways to share evidence based information in a culturally competent manner with mothers in my community. Those that market formula are quite crafty and often play on old racially charged misconceptions. In addition, immigrant mothers feel the pressure to assimilate into American culture as well and that can include formula feeding to appear “modern” and not to stand out. Still, I am hopeful that if we continue this good work, breastfeeding will be viewed as the norm and not the exception for all women including those from at risk communities.

  6. avatar
    Milena Ruzkova, MD,IBCLC
    | #6

    Does anybody have any info as to why in the new policy statement there is major “step down” as far as extended breastfeeding is concerned. The previous statement had “until 3 years and beyond” (don’t have it here to give exact wording) and in the new statement this has been left out and the statement speaks only of “one year or longer”???

  7. | #7

    Actually, the recomendation is more or less the same as the 2005 Policy statement. “Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child.” and “There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer.” http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496

    I believe you are thinking of the World Health Organization’s recommendations – but even that is 2 years of age, not three. “Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.” http://www.who.int/topics/breastfeeding/en/

  8. avatar
    Milena Ruzkova, MD,IBCLC
    | #8

    @Deena Blumenfeld
    I am comparing the two statemenst – the one from 2005 which has the phrase
    “There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer.”
    which is missing from the new statement – the biggest durating that it mentions specifically is “for one year or longer as mutually desired by mother and child” . I see this as a step backward.
    Please correct me if I am mistaken.

  9. | #9

    @Milena Ruzkova, MD,IBCLC
    I’m not sure I see this as a “step backwards”. The statement “…for as long as mutually desired by mother and child.” I believe, is inclusive. I think it covers the bases, and lets a mother choose for herself how long to breastfeed after the recommended 12 months.

    The statement “There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer.” Is not a recommendation by the AAP. It is a statement of fact. There is no harm in extended breastfeeding, but they make no note of the benefits.

    The 2012 AAP Policy statement also speaks over and over again about how statistically, longer breastfeeding duration provide more benefits to mother and child. So, this can be seen as a step forward.

    The other huge step forward is presenting breastfeeding as a public health issue. “Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue.” This statement encourages pediatricians not to have formula samples in the office, to press their local hospitals to become baby friendly and to support and encourage mothers to breastfeed till at least 12 months.

    I think the 2012 policy statement presents a change in attitude and the direction at which pediatricians should approach breastfeeding. It’s not “breast is best”, it’s “breast is necessary for the health and well being of both mother and baby.”

  10. avatar
    Milena Ruzkova, MD,IBCLC
    | #10

    @Deena Blumenfeld

    Thank you for your comments, I see the positive points you mention. But let me tell you more.
    I was in the audience of a round table session with dr Lawrence Gartner, the lead author of the 2005 statement at one of the congresses of the European Lactation Consultant Association -VELB somewhere in Austria several years back. One of the members of the round table was an Austrian ob-gyn and he was very vocal with his annoyance with this reference to bfeeding until 3 years and beyond and dr Gartner defended it, saying that policy statements must go and take lead. After the end of the roundtable session I walked up to dr Gartner and thanked him for his stand and expresseed my full support with his ideas. I think all this is connected with my own experience of breastfeeding beyond 3 years of age of my son and hearing again and again from pediatricians that it offers nothing to the child.
    So maybe you can understand my satisfaction with seeing it advocated in an official document and my saddness now, seeing that it is not continued to be mentioned… I would really like to know if this “change” is intentional or not…
    Thank you for your patience.

  11. avatar
    Milena Ruzkova, MD,IBCLC
    | #11

    Others have noticed this “discrepancy”, please see
    I don’t think it is an oversight.

  12. avatar
    | #12

    Now how to get pediatricians educated enough about breastfeeding that they do not fall back on formula for every little issue that arises with baby. Jaundice? Give that baby some formula. Baby seems to be nursing non-stop? Cut baby off after x number of minutes and supplement with some formula. The AAP can talk all day about the benefits of breastfeeding (or it should be talking about the risks of formula feeding) but until there is a concerted effort towards educating pediatricians about breastfeeding I don’t see how there can be much improvement.

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