Breastfeeding

Commencement

Newborn rests as a caregiver checks its breath sounds with a stethoscope

It is recommended for mothers to initiate breastfeeding within the first hour after birth.^[29][30] Breastfeeding can begin immediately after birth. The baby is placed on the mother and feeding starts as soon as the baby shows interest. According to some authorities the majority of infants do not immediately begin to suckle if placed between the mother's breasts but rather enter a period of rest and quiet alertness. During this time they seem to be more interested in the mother's face, especially her eyes, than beginning to suckle. It has been speculated that this period of infant-mother interaction assists in the mother-child bonding for both mother and baby.^[31]

There is increasing evidence that suggests that early skin-to-skin contact (also called kangaroo care) between mother and baby stimulates breastfeeding behavior in the baby.^[32] Newborns who are immediately placed on their mother's skin have a natural instinct to latch on to the breast and start nursing, typically within one hour of birth. Immediate skin-to-skin contact may provide a form of imprinting that makes subsequent feeding significantly easier. In addition to more successful breastfeeding and bonding, immediate skin-to-skin contact reduces crying and warms the baby.

According to studies cited by UNICEF, babies naturally follow a process which leads to a first breastfeed. Initially after birth the baby cries with its first breaths. Shortly after, it relaxes and makes small movements of the arms, shoulders and head. If placed on the mother's abdomen the baby then crawls towards the breast, called the breast crawl^[31] and begins to feed. After feeding, it is normal for a baby to remain latched to the breast while resting. This is sometimes mistaken for lack of appetite. Absent interruptions, all babies follow this process. Rushing or interrupting the process, such as removing the baby to weigh him/her, may complicate subsequent feeding.^[33] Activities such as weighing, measuring, bathing, needle-sticks, and eye prophylaxis wait until after the first feeding."^[34]

Current research strongly supports immediate skin-to-skin mother-baby contact even if the baby is born by Cesarean surgery. The baby is placed on the mother in the operating room or the recovery area. If the mother is unable to immediately hold the baby a family member can provide skin-to-skin care until the mother is able. The La Leche League suggests early skin-to-skin care following an unexpected surgical rather than vaginal delivery "may help heal any feelings of sadness or disappointment if birth did not go as planned."^[35]

Children who are born preterm have difficulty in initiating breast feeds immediately after birth. By convention, such children are often fed on expressed breast milk or other supplementary feeds through tubes or bottles until they develop satisfactory ability to suck breast milk. Tube feeding, though commonly used, is not supported by scientific evidence as of October 2016.^[36] It has also been reported in the same systematic review that by avoiding bottles and using cups instead to provide supplementary feeds to preterm children, a greater extent of breast feeding for a longer duration can subsequently be achieved.^[36]

Timing

Newborn babies typically express demand for feeding every one to three hours (8–12 times in 24 hours) for the first two to four weeks.^[37] A newborn has a very small stomach capacity. At one-day old it is 5–7 ml, about the size of a large marble; at day three it is 22–30 ml, about the size of a ping-pong ball; and at day seven it is 45–60 ml, or about the size of a golf ball. The amount of breast milk that is produced is timed to meet the infant's needs in that the first milk, colostrum, is concentrated but produced in only very small amounts, gradually increasing in volume to meet the expanding size of the infant's stomach capacity.^[27]

According to La Leche League International, "Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants' sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain....Comforting and meeting sucking needs at the breast is nature's original design. Pacifiers (dummies, soothers) are a substitute for the mother when she cannot be available. Other reasons to pacify a baby primarily at the breast include superior oral-facial development, prolonged lactational amenorrhea, avoidance of nipple confusion, and stimulation of an adequate milk supply to ensure higher rates of breastfeeding success."^[38]

Many newborns will feed for 10 to 15 minutes on each breast.^[4] If the infant wants to nurse for a much longer period—say 30 minutes or longer on each breast—they may not be getting enough milk.^[4]

Duration and exclusivity

Health organizations recommend breastfeeding exclusively for six months following birth, unless medically contraindicated.^{[2][39][40][41][42][3][43][44][45][46]} Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk and no foods) except for vitamins, minerals and medications."^[34] In some countries, including the United States, UK, and Canada, daily vitamin D supplementation is recommended for all breastfed infants.^[47][48][49]

After solids are introduced at around six months of age, continued breastfeeding is recommended. The AAP recommends that babies be breastfed at least until 12 months, or longer if both the mother and child wish.^[3] WHO's guidelines recommend "continue[d] frequent, on-demand breastfeeding until two years of age or beyond.^[29][50]

The vast majority of mothers can produce enough milk to fully meet the nutritional needs of their baby for six months. Breast milk supply augments in response to the baby's demand for milk, and decreases when milk is allowed to remain in the breasts.^[51] Low milk supply is usually caused by allowing milk to remain in the breasts for long periods of time, or insufficiently draining the breasts during feeds. It is usually preventable, unless caused by medical conditions that have been estimated to affect up to five percent of women.^[52] There is no evidence to support increased fluid intake for breastfeeding mothers will increase their milk production.^[53] "Drink when thirsty" is advised.^[54] If the baby is latching and swallowing well, but is not gaining weight as expected or is showing signs of dehydration, low milk supply in the mother can be suspected.^[52]

Medical contraindications

Medical conditions that do not allow breastfeeding are rare.^[3] Infants that are otherwise healthy uniformly benefit from breastfeeding,^[55] however, extra precautions should be taken or breastfeeding avoided in circumstances including certain infectious diseases. A breastfeeding child can become infected with HIV. Factors such as the viral load in the mother's milk complicate breastfeeding recommendations for HIV-positive mothers.^[56][57]

In mothers who are treated with antiretroviral drugs the risk of HIV transmission with breastfeeding is 1–2%.^[2] Therefore, breastfeeding is still recommended in areas of the world where death from infectious diseases is common.^[2] Infant formula should only be given if this can be safely done.^[2]

WHO recommends that national authorities in each country decide which infant feeding practice should be promoted by their maternal and child health services to best avoid HIV transmission from mother to child.^[58] Other maternal infections of concern include active untreated tuberculosis or human T-lymphotropic virus. Mothers who take certain recreational drugs and medications should not breastfeed.^[14]

Location

Rooming-in bassinet

Most US states now have laws that allow a mother to breastfeed her baby anywhere. In hospitals, rooming-in care permits the baby to stay with the mother and simplifies the process. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring a special area. Despite these laws, many women in the United States continue to be publicly shamed or asked to refrain from breastfeeding in public.^[59] In the United Kingdom, the Equality Act 2010 makes the prevention of a woman breastfeeding in any public place discrimination under the law.^[60] In Scotland, it is a criminal offense to try to prevent a woman feeding a child under 24 months in public.^[60]

While laws in the U.S. that passed in 2010 which required that nursing mothers who had returned to work be given a non-bathroom space to express milk and a reasonable break time to do so, as of 2016 the majority of women still did not have access to both accommodations.^[61] As of 2019, some establishments have placed small portable nursing "pods" with electrical outlets for nursing pumps to provide their places of business with a comfortable private area to nurse or express milk. The Minnesota Vikings were the first (2015) NFL franchise to implement the lactation pods. In 2019 it was reported that the pod manufacturer had placed 152 of them in 57 airports.^[62][63]

In 2014, newly elected Pope Francis drew worldwide commentary when he encouraged mothers to breastfeed babies in church. During a papal baptism, he said that mothers "should not stand on ceremony" if their children were hungry. "If they are hungry, mothers, feed them, without thinking twice," he said, smiling. "Because they are the most important people here."^[64]

Position

Correct positioning and technique for latching on are necessary to prevent nipple soreness and allow the baby to obtain enough milk.^[65]

Babies can successfully latch on to the breast from multiple positions. Each baby may prefer a particular position. The "football" hold places the baby's legs next to the mother's side with the baby facing the mother. Using the "cradle" or "cross-body" hold, the mother supports the baby's head in the crook of her arm. The "cross-over" hold is similar to the cradle hold, except that the mother supports the baby's head with the opposite hand. The mother may choose a reclining position on her back or side with the baby lying next to her.^[66]

• 
  Standing mother breastfeeding her baby, Canjambari, Guinea-Bissau, 1973
• 
  Illustration depicting correct latch-on position during breastfeeding.
• 
  Breastfeeding – Cradle hold.
• 
  Breastfeeding – Cross cradle position.
• 
  Breastfeeding – Football hold.
• 
  Breastfeeding – Incorrect vs correct latch-on.
• 
  Breastfeeding – Semi-reclining position.
• 
  Breastfeeding – Side-lying position.
• 
  Breastfeeding – Supine position.
• 
  Breastfeeding – Tease lips or cheek.
• 
  Breastfeeding – Twins, cross cradle position I.
• 
  Breastfeeding – Twins, football or clutch hold.
• 
  Breastfeeding – Twins, parallel position II.

Latching on

Latching on refers to how the baby fastens onto the breast while feeding. The rooting reflex is the baby's natural tendency to turn towards the breast with the mouth open wide; mothers sometimes make use of this by gently stroking the baby's cheek or lips with their nipple to induce the baby to move into position for a breastfeeding session. Infants also use their sense of smell in finding the nipple. Sebaceous glands called Glands of Montgomery located in the areola secrete an oily fluid that lubricates the nipple. The visible portions of the glands can be seen on the skin's surface as small round bumps. They become more pronounced during pregnancy and it is speculated that the infant is attracted to the odor of the secretions.^[67] One study found that when one of the breasts was washed with unscented soap the baby preferred the other one, suggesting that plain water would be the best washing substance while the baby is becoming accustomed to nursing.^[68]

In a good latch, a large amount of the areola, in addition to the nipple, is in the baby's mouth. The nipple should be angled towards the roof of the mouth, and the baby's lips should be flanged out.^[69][70] In some cases in which a baby seems unable to latch on properly the problem may be related to a medical condition called ankyloglossia, also referred to as "tongue-tied". In this condition a baby can't get a good latch because their tongue is stuck to the bottom of their mouth by a band of tissue and they can't open their mouth wide enough or keep their tongue over the lower gum while sucking. If an infant is unable to hold their tongue in the correct position they may chew rather than suck, causing both a lack of nutrition for the baby and significant nipple pain for the mother. If it is determined that the inability to latch on properly is related to ankyloglossia, a simple surgical procedure can correct the condition.^{[71][72][73][74]}

At one time it was thought that massage of the nipples before the birth of the baby would help to toughen them up and thus avoid possible nipple soreness. It is now known that a good latch is the best prevention of nipple pain. There is also less concern about small, flat, and even "inverted" nipples as it is now believed that a baby can still achieve a good latch with perhaps a little extra effort. In one type of inverted nipple, the nipple easily becomes erect when stimulated, but in a second type, termed a "true inverted nipple," the nipple shrinks back into the breast when the areola is squeezed. According to La Leche League, "There is debate about whether pregnant women should be screened for flat or inverted nipples and whether treatments to draw out the nipple should be routinely recommended. Some experts believe that a baby who is latched on well can draw an inverted nipple far enough back into his mouth to nurse effectively." La Leche League offers several techniques to use during pregnancy or even in the early days following birth that may help to bring a flat or inverted nipple out.^[75]

Lactation consultant

Lactation consultants are trained to assist mothers in preventing and solving breastfeeding difficulties such as sore nipples and low milk supply. They commonly work in hospitals, physician or midwife practices, public health programs, and private practice. Exclusive and partial breastfeeding are more common among mothers who gave birth in hospitals that employ trained breastfeeding consultants.^[76]

Newborn jaundice

Approximately 60% of full-term infants develop jaundice within several days of birth. Jaundice, or yellowing of the skin and eyes, occurs when a normal substance, bilirubin, builds up in the newborn's bloodstream faster than the liver can break it down and excrete it through the baby's stool. By breastfeeding more frequently or for longer periods of time, the infant's body can usually rid itself of the bilirubin excess. However, in some cases, the infant may need additional treatments to keep the condition from progressing into more severe problems.^[77]

There are two types of newborn jaundice. Breast milk jaundice occurs in about 1 in 200 babies. Here the jaundice isn't usually visible until the baby is a week old. It often reaches its peak during the second or third week. Breast milk jaundice can be caused by substances in mother's milk that decrease the infant's liver's ability to deal with bilirubin. Breast milk jaundice rarely causes any problems, whether it is treated or not. It is usually not a reason to stop nursing.^[77]

A different type of jaundice, Breastfeeding jaundice, may occur in the first week of life in more than 1 in 10 breastfed infants. The cause is thought to be inadequate milk intake, leading to dehydration or low caloric intake. When the baby is not getting enough milk bowel movements are small and infrequent so that the bilirubin that was in the baby's gut gets reabsorbed into the blood instead of being passed in bowel movements. Inadequate intake may be because the mother's milk is taking longer than average to "come in" or because the baby is poorly latched while nursing. If the baby is properly latching the mother should offer more frequent nursing sessions to increase hydration for the baby and encourage her breasts to produce more milk. If poor latch is thought to be the problem, a lactation expert should assess and advise.^[77]

Weaning

Weaning is the process of replacing breast milk with other foods; the infant is fully weaned after the replacement is complete. Psychological factors affect the weaning process for both mother and infant, as issues of closeness and separation are very prominent.^[78] If the baby is less than a year old substitute bottles are necessary; an older baby may accept milk from a cup. Unless a medical emergency necessitates abruptly stopping breastfeeding, it is best to gradually cut back on feedings to allow the breasts to adjust to the decreased demands without becoming engorged. La Leche League advises: "The nighttime feeding is usually the last to go. Make a bedtime routine not centered around breastfeeding. A good book or two will eventually become more important than a long session at the breast."^[79]

If breastfeeding is suddenly stopped a woman's breasts are likely to become engorged with milk. Pumping small amounts to relieve discomfort helps to gradually train the breasts to produce less milk. There is presently no safe medication to prevent engorgement, but cold compresses and ibuprofen may help to relieve pain and swelling. Pain should go away in one to five days. If symptoms continue and comfort measures are not helpful a woman should consider the possibility that a blocked milk duct or infection may be present and seek medical intervention.^[80]

When weaning is complete the mother's breasts return to their previous size after several menstrual cycles. If the mother was experiencing lactational amenorrhea her periods will return along with the return of her fertility. When no longer breastfeeding she will need to adjust her diet to avoid weight gain.^[81]

Drugs

Almost all medicines pass into breastmilk in small amounts. Some have no effect on the baby and can be used while breastfeeding.^[82] Many medications are known to significantly suppress milk production, including pseudoephedrine, diuretics, and contraceptives that contain estrogen.^[83]

The American Academy of Pediatrics (AAP) states that "tobacco smoking by mothers is not a contraindication to breastfeeding."^[34] Breastfeeding is actually especially recommended for mothers who smoke, because of its protective effects against SIDS.^[84]

With respect to alcohol, the AAP states that when breastfeeding, "moderation is definitely advised" and recommends waiting for 2 hours after drinking before nursing or pumping.^[85] A 2014 review found that "even in a theoretical case of binge drinking, the children would not be subjected to clinically relevant amounts of alcohol [through breastmilk]", and would have no adverse effects on children as long as drinking is "occasional".^[86] The Centers for Disease Control says "pumping and dumping", or getting rid of milk expressed or pumped, would not reduce the amount of alcohol.^[87]

Expressed milk

Manual breast pump

A mother can express (produce) her milk for storage and later use. Expression occurs with massage or a breast pump. It can be stored in freezer storage bags, containers made specifically for breastmilk, a supplemental nursing system, or a bottle ready for use. Using someone other than the mother/wet nurse to deliver the bottle maintains the baby's association of nursing with the mother/wet nurse and bottle feeding with other people.

Breast milk may be kept at room temperature for up to six hours, refrigerated for up to eight days or frozen for six to twelve months.^[88] Research suggests that the antioxidant activity in expressed breast milk decreases over time, but remains at higher levels than in infant formula.^[89]

Mothers express milk for multiple reasons. Expressing breast milk can maintain a mother's milk supply when she and her child are apart. A sick baby who is unable to nurse can take expressed milk through a nasogastric tube. Some babies are unable or unwilling to nurse. Expressed milk is the feeding method of choice for premature babies.^[90] Viral disease transmission can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.^[91] Some women donate expressed breast milk (EBM) to others, either directly or through a milk bank. This allows mothers who cannot breastfeed to give their baby the benefits of breast milk.

Babies feed differently with artificial nipples than from a breast. With the breast, the infant's tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth. Drinking from a bottle takes less effort and the milk may come more rapidly, potentially causing the baby to lose desire for the breast. This is called nursing strike, nipple strike or nipple confusion. To avoid this, expressed milk can be given by means such as spoons or cups.

"Exclusively expressing", "exclusively pumping", and "EPing" are terms for a mother who exclusively feeds her baby expressed milk. With good pumping habits, particularly in the first 12 weeks while establishing the milk supply, it is possible to express enough milk to feed the baby indefinitely. With the improvements in breast pumps, many women exclusively feed expressed milk, expressing milk at work in lactation rooms. Women can leave their infants in the care of others while traveling, while maintaining a supply of breast milk.^[92]

Shared nursing

It is not only the mother who may breastfeed her child. She may hire another woman to do so (a wet nurse), or she may share childcare with another mother (cross-nursing). Both of these were common throughout history. It remains popular in some developing nations, including those in Africa, for more than one woman to breastfeed a child. Shared breastfeeding is a risk factor for HIV infection in infants.^[93] Shared nursing can sometimes provoke negative social reactions in the English-speaking world.^[94][95]

Tandem nursing

It is possible for a mother to continue breastfeeding an older sibling while also breastfeeding a new baby; this is called tandem nursing. During the late stages of pregnancy, the milk changes to colostrum. While some children continue to breastfeed even with this change, others may wean. Most mothers can produce enough milk for tandem nursing, but the new baby should be nursed first for at least the first few days after delivery to ensure that it receives enough colostrum.^[96]

Breastfeeding triplets or larger broods is a challenge given babies' varying appetites. Breasts can respond to the demand and produce larger milk quantities; mothers have breastfed triplets successfully.^[97][98][99]

• 
  Newborn twins being breastfed
• 
  Woman breastfeeds 2 year old twins whilst reading them a book.
• 
  Woman tandem nurses an infant and a toddler.

Induced lactation

Induced lactation, also called adoptive lactation, is the process of starting breastfeeding in a woman who did not give birth.^[100] This usually requires the adoptive mother to take hormones and other drugs to stimulate breast development and promote milk production. In some cultures, breastfeeding an adoptive child creates milk kinship that built community bonds across class and other hierarchal bonds.^[100]

Re-lactation

Re-lactation is the process of restarting breastfeeding.^[100] In developing countries, mothers may restart breastfeeding after a weaning as part of an oral rehydration treatment for diarrhea. In developed countries, re-lactation is common after early medical problems are resolved, or because a mother changes her mind about breastfeeding.

Re-lactation is most easily accomplished with a newborn or with a baby that was previously breastfeeding; if the baby was initially bottle-fed, the baby may refuse to suckle. If the mother has recently stopped breastfeeding, she is more likely to be able to re-establish her milk supply, and more likely to have an adequate supply. Although some women successfully re-lactate after months-long interruptions, success is higher for shorter interruptions.^[100]

Techniques to promote lactation use frequent attempts to breastfeed, extensive skin-to-skin contact with the baby, and frequent, long pumping sessions.^[100] Suckling may be encouraged with a tube filled with infant formula, so that the baby associates suckling at the breast with food. A dropper or syringe without the needle may be used to place milk onto the breast while the baby suckles. The mother should allow the infant to suckle at least ten times during 24 hours, and more times if he or she is interested. These times can include every two hours, whenever the baby seems interested, longer at each breast, and when the baby is sleepy when he or she might suckle more readily. In keeping with increasing contact between mother and child, including increasing skin-to-skin contact, grandmothers should pull back and help in other ways. Later on, grandmothers can again provide more direct care for the infant.^[101]

These techniques require the mother's commitment over a period of weeks or months. However, even when lactation is established, the supply may not be large enough to breastfeed exclusively. A supportive social environment improves the likelihood of success.^[100] As the mother's milk production increases, other feeding can decrease. Parents and other family members should watch the baby's weight gain and urine output to assess nutritional adequacy.^[101]

A WHO manual for physicians and senior health workers citing a 1992 source states: "If a baby has been breastfeeding sometimes, the breastmilk supply increases in a few days. If a baby has stopped breastfeeding, it may take 1-2 weeks or more before much breastmilk comes."^[101]

Extended

Extended breastfeeding means breastfeeding after the age of 12 or 24 months, depending on the source. In Western countries such as the United States, Canada, and Great Britain, extended breastfeeding is relatively uncommon and can provoke criticism.^[102][103]

In the United States, 22.4% of babies are breastfed for 12 months, the minimum amount of time advised by the American Academy of Pediatrics. In India, mothers commonly breastfeed for 2 to 3 years.^[104]

Baby

Early breastfeeding is associated with fewer nighttime feeding problems.^[111] Early skin-to-skin contact between mother and baby improves breastfeeding outcomes and increases cardio-respiratory stability.^[112] Reviews from 2007 found numerous benefits. Breastfeeding aids general health, growth and development in the infant. Infants who are not breastfed are at mildly increased risk of developing acute and chronic diseases, including lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infection and necrotizing enterocolitis.^[113][114] Breastfeeding may protect against sudden infant death syndrome,^[115] insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, childhood lymphoma, allergic diseases, digestive diseases,^[34] obesity, develop diabetes, or childhood leukemia later in life.^[116] and may enhance cognitive development.^[34][117] Babies that are breastfed are able to recognize being full quicker than infants who are bottle fed. Breastmilk also makes a child resistant to insulin, which is why they are less likely to be hypoglycemic. Infants are more likely to have a normal neural and retinal development if they are breastfed.^[118]

Mother

Diabetes

Breastfeeding of babies is associated with a lower chance of developing diabetes mellitus type 1.^[114] Breastfed babies also appear to have a lower likelihood of developing diabetes mellitus type 2 later in life.^{[113][114][152]} Breastfeeding is also associated with a lower risk of type 2 diabetes among mothers who practice it.^[153]

Social support

A review found that when effective forms of support are offered to women, exclusive breastfeeding and duration of breastfeeding are increased. Characteristics of effective support includes ongoing, face-to-face support tailored to fit their needs. It may be offered by lay/peer supporters, professional supporters, or a combination of both.^[156] This review contrasts with another large review that looked at education programs alone, which found no conclusive evidence of initiation of breastfeeding or the proportion of women breastfeeding either exclusively or partially at 3 months and 6 months.^[157]

Positive social support in essential relationships of new mothers plays a central role in the promotion of breastfeeding outside of the confines of medical centers. Social support can come in many incarnations, including tangible, affectionate, social interaction, and emotional and informational support. An increase in these capacities of support has shown to greatly positively effect breastfeeding rates, especially among women with education below a high school level.^[158] Some mothers that have used lactation rooms have taken to leaving sticky notes to not only thank the businesses that have provided them but to support, encourage, and praise the nursing moms who use them.^[63]

In the social circles surrounding the mother, support is most crucial from the male partner, the mother's mother, and her family and friends.^[159] Research has shown that the closest relationships to the mother have the strongest impact on breastfeeding rates, while negative perspectives on breastfeeding from close relatives hinder its prevalence.^[158]

• Mother – Adolescence is a risk factor for low breastfeeding rates, although classes, books and personal counseling (professional or lay) can help compensate.^[160] Some women fear that breastfeeding will negatively impact the look of their breasts. However, a 2008 study found that breastfeeding had no effect on a woman's breasts; other factors did contribute to "drooping" of the breasts, such as advanced age, number of pregnancies and smoking behavior.^[161]
• Partner – Partners may lack knowledge of breastfeeding and their role in the practice.
• Wet nursing – Social and cultural attitudes towards breastfeeding in the African-American community are also influenced by the legacy of forced wet-nursing during slavery.^[162]

Healthcare

Socioeconomic status

Race, ethnicity and socioeconomic status affect choice and duration in the United States. A 2011 study found that on average, US women who breastfed had higher levels of education, were older and were more likely to be white.^[182]

The rates of breastfeeding in the African-American community remain much lower than any other race, for a variety of proposed reasons. These include the legacy of Wet nursing during slavery, higher rates of poor perinatal health, higher stress levels, less access to support, and less flexibility in the workplace.^[183] While for other races as socio-economic class raises rates of breastfeeding also go up, for the African-American community breastfeeding rates remain consistently low regardless of socio-economic class.^[184]

There are also racial disparities in access to maternity care practices that support breastfeeding. In the US, primarily African-American neighborhoods are more likely to have facilities (such as hospitals and female healthcare clinics) that do not support breastfeeding, contributing to the low rate of breastfeeding in the African-American community. Comparing facilities in primarily African American neighborhoods to ones in primarily White neighborhoods, the rates of practices that support or discourage breastfeeding were: limited use of supplements (13.1% compared with 25.8%) and rooming-in (27.7–39.4%)^[185]

Low-income mothers are more likely to have unintended pregnancies.^[182] Mothers whose pregnancies are unintended are less likely to breastfeed.^[186]

Especially the combination of powdered formula with unclean water can be very harmful to the health of babies. In the late 1970s, there was a boycott against Nestle due to the great number of baby deaths due to formula. Dr. Michele Barry explains that breastfeeding is most imperative in poverty environments due to the lack of access of clean water for the formula. The Lancet study in 2016 discovered that universal breastfeeding would prevent the deaths of 800,000 children as well as save $300 million.^[187]

Social acceptance

Sign for a private nursing area at a museum using the international breastfeeding symbol

Some women feel discomfort when breastfeeding in public.^[188] Public breastfeeding may be forbidden in some places, not addressed by law in others, and a legal right in others. Even given a legal right, some mothers are reluctant to breastfeed,^[189][190] while others may object to the practice.^[191]

The use of infant formula was thought to be a way for western culture to adapt to negative perceptions of breastfeeding.^[192] The breast pump offered a way for mothers to supply breast milk with most of formula feeding's convenience and without enduring possible disapproval of nursing.^[193] Some may object to breastfeeding because of the implicit association between infant feeding and sex.^[194] These negative cultural connotations may reduce breastfeeding duration.^{[189][195][196][197]} Maternal guilt and shame is often affected by how a mother feeds her infant. These emotions occur in both bottle- and breast- feeding mothers, although for different reasons. Bottle feeding mothers may feel that they should be breastfeeding.^[198] Conversely, breastfeeding mothers may feel forced to feed in uncomfortable circumstances. Some may see breastfeeding as, "indecent, disgusting, animalistic, sexual, and even possibly a perverse act."^[199] Advocates (known by the neologism "lactivists") use "nurse-ins" to show support for breastfeeding in public.^[188] One study that approached the subject from a feminist viewpoint suggested that both nursing and non-nursing mothers often feel maternal guilt and shame with formula feeding mothers feeling that they are not living up to the ideals of woman and motherhood and nursing mothers concerned that they are transgressing "cultural expectations regarding feminine modesty." The authors advocate that women be provided with education on breastfeeding's benefits as well as problem-solving skills,^[198] however there is no conclusive evidence that breastfeeding education alone improves initiation of breastfeeding or the proportion of women breastfeeding either exclusively or partially at 3 months and 6 months.^[157]

Language

In languages around the world, the word for "mother" is something like "mama". The linguist Roman Jakobson hypothesized that the nasal sound in "mama" comes from the nasal murmur that babies produce when breastfeeding.

Financial considerations

Breastfeeding is less costly than alternatives, but the mother generally must eat more food than she would otherwise. In the US, the extra money spent on food (about US$14 each week) is usually about half as much money as the cost of infant formula.^[206]

Breastfeeding reduces health care costs and the cost of caring for sick babies. Parents of breastfed babies are less likely to miss work and lose income because their babies are sick.^[206] Looking at three of the most common infant illnesses, lower respiratory tract illnesses, otitis media, and gastrointestinal illness, one study compared infants that had been exclusively breastfed for at least three months to those who had not. It found that in the first year of life there were 2033 excess office visits, 212 excess days of hospitalization, and 609 excess prescriptions for these three illnesses per 1000 never-breastfed infants compared with 1000 infants exclusively breastfed for at least 3 months.^[207][208]

Mobile apps

Dozens of mobile apps exist for tracking the habits of breastfeeding mothers.^[209]

Criticism of breastfeeding advocacy

"See It", a project by Fiann Paul dedicated to promoting awareness of breastfeeding in the capital city of Iceland in 2011^[210]

There are controversies and ethical considerations surrounding the means used by public campaigns which attempt to increase breastfeeding rates, relating to pressure put on women, and potential feeling of guilt and shame of women who fail to breastfeed; and social condemnation of women who use formula.^{[211][212] [213][214]} In addition to this, there is also the moral question as to what degree the state or medical community can interfere with the self-determination of a woman: for example in the United Arab Emirates the law requires a woman to breastfeed her baby for at least 2 years and allows her husband to sue her if she does not do so.^[215][216]

It is widely assumed that if women's healthcare providers encourage them to breastfeed, those who choose not to will experience more guilt. Evidence does not support this assumption. On the contrary, a study on the effects of prenatal breastfeeding counselling found that those who had received such counselling and chosen to formula-feed denied experiencing feelings of guilt. Women were equally comfortable with their subsequent choices for feeding their infant regardless of whether they had received encouragement to breastfeed.^[217]

Preventing a situation where women are denied agency and/or stigmatized for formula use is also seen as important. In 2018, in the UK, a policy statement from the Royal College of Midwives said that women should be supported and not stigmatized, if after being given advice and information, they choose to formula feed.^[218]

Social marketing

Social marketing is a marketing approach intended to change people's behavior to benefit both individuals and society.^[219] When applied to breastfeeding promotion, social marketing works to provide positive messages and images of breastfeeding to increase visibility. Social marketing in the context of breastfeeding has shown efficacy in media campaigns.^{[220][221][222][223][224][225]} Some oppose the marketing of infant formula, especially in developing countries. They are concerned that mothers who use formula will stop breastfeeding and become dependent upon substitutes that are unaffordable or less safe.^[226][227] Through efforts including the Nestlé boycott, they have advocated for bans on free samples of infant formula and for the adoption of pro-breastfeeding codes such as the International Code of Marketing of Breast-milk Substitutes by the World Health Assembly in 1981 and the Innocenti Declaration by WHO and UNICEF policy-makers in August 1990.^[226] Additionally, formula companies have spent millions internationally on campaigns to promote the use of formula as an alternative to mother's milk.^[228]

Baby Friendly Hospital Initiative

The Baby Friendly Hospital Initiative is a program launched by WHO in conjunction with UNICEF in order to promote infant feeding and maternal bonding through certified hospitals and birthing centers. BFHI was developed as a response to the influence held by formula companies in private and public maternal health care.The initiative has two core tenets: the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes.^[229] The BFHI has especially targeted hospitals and birthing centers in the developing world, as these facilities are most at risk to the detrimental effects of reduced breastfeeding rates. As of 2018, 530 hospitals in the United States hold the "Baby-Friendly" title in all 50 states. Globally, there are more than 20,000 "Baby-Friendly" hospitals worldwide in over 150 countries.^[230]

Representation on television

The first depiction of breastfeeding on television was in the children's program, Sesame Street, in 1977.^[231] With few exceptions since that time breastfeeding on television has either been portrayed as strange, disgusting, or a source of comedy, or it has been omitted entirely in favor of bottle feeding.^[231]

Islam

Ilkhanate prince Ghazan being breastfed

In some cultures, people who have been breastfed by the same woman are milk-siblings who are equal in legal and social standing to a consanguineous sibling.^[232] Islam has a complex system of rules regarding this, known as Rada (fiqh). Like the Christian practice of godparenting, milk kinship established a second family that could take responsibility for a child whose biological parents came to harm. "Milk kinship in Islam thus appears to be a culturally distinctive, but by no means unique, institutional form of adoptive kinship."^[233]