Maresa Smith / Stocksy
When the American Academy of Pediatrics (AAP) released updated feeding guidelines in June—extending the recommended duration for providing human milk to children from 1 to 2 years—it drew swift backlash for being unrealistic.
Other agencies, like the World Health Organization, have long recommended providing human milk to children for at least two years. The AAP's updated guidelines also called for support, including paid family leave, to change the reality for American families and support longer chestfeeding.
Why the backlash? Cecília Tomori, Ph.D., the director of global public and community health at Johns Hopkins University School of Nursing, says it's because the recommendations may come off as a directive to individuals to figure out a way to meet these guidelines. But that's not the point.
"Recommendations facilitate policy change," says Dr. Tomori, who wrote Nighttime Breastfeeding: An American Cultural Dilemma. "They are written for that purpose. Individuals are not responsible for the system. We need to fix the system."
A new survey from Aeroflow Breastpumps further highlights what little supports exist for lactating parents. Nearly two-thirds of the 1,600-plus respondents said that more support would have allowed them to lactate longer, and more than half said there wasn't enough awareness about support services.
But what does support mean? Dr. Tomori says it takes a village.
Lactation Data, At a Glance
Breastfeeding rates have increased in the last century. In the mid to late 1940s, only 25% of people ever initiated breastfeeding. But new programs, such as the Baby-Friendly Hospital Initiative (BFHI), have helped. According to 2018 data from the Centers for Disease Control and Prevention (CDC), 83.9% of children born that year were breastfed as newborns. However, there was a significant drop to 57.7% still breastfeeding by the six-month mark and 35% at one year. Rates may rise amid an ongoing formula shortage. Nearly 2-in-5 respondents to the Aeroflow survey said they were planning to breastfeed longer due to the formula shortage, and 18% said they were planning to seek lactation support.
For many, choosing to chestfeed or not is a personal decision. For others, the decision is complicated by systemic inequities. Chestfeeding is not easy or free, and those in historically oppressed communities are not given the support or access to succeed at chestfeeding if they do want to do so. "Privilege becomes a part of breastfeeding," says Dr. Tomori. According to the CDC, nearly 86% of non-Hispanic white people ever breastfeed and 69.4% of non-Hispanic Black people breastfeed. "Only people able to mobilize these resources are able to breastfeed," adds Dr. Tomori.
In order to increase rates and help people meet their goals, access to resources and support is essential.
What Lactating Parents Need
Medical experts acknowledge the benefits of human milk, such as the reduced risk of some cancers in lactating people and respiratory and gastrointestinal issues in babies. But the system doesn't provide the necessary structure to help families meet the recommendations. Then individuals blame themselves if it does not work out.
"In most instances, women believe that these struggles are their own fault and that they or their bodies have failed," Dr. Tomori writes in a recent paper on breastfeeding. "This is, of course, not the case. The majority of breastfeeding challenges are attributable to structural drivers rather than individual physiology or even personal decisions."
Here's what needs to change.
Paid parental leave
Dr. Tomori says access to paid leave is an anchor in setting families up for success with lactation and, frankly, should be given regardless of how a family is feeding their child. The United States remains the only developed nation without federal paid leave. In March of 2021, fewer than 25% of civilian, private-sector, and state and local government workers had access to paid family leave, according to the U.S. Bureau of Labor Statistics.
"It's a right," says Dr. Tomori. And when it comes to the lactation, it's essential. Lactation relies on proximity, supply, and demand. The more milk removed from a lactating person, the more the person will make. "Babies feed very frequently, especially early on," Dr. Tomori explains. "If you interfere with that, you undermine lactation."
One 2016 study showed that individuals with at least 12 or more weeks of paid leave were more likely to initiate and still be breastfeeding after six months. Research shows that Black and Latinx birthing people are significantly less likely to have access to paid leave, so it's not surprising they are less likely to breast/chestfeed.
Dr. Tomori recommends at least one year of paid leave. "Societies that value raising the next generation understand the significance," she says. "Of course, people could return earlier if desired. At the minimum, we should be complying with International Labour Organization recommendations of 14 weeks."
Workplace support doesn't end when any applicable leave does. To continue providing milk to a child, a lactating person who has returned to work will need to express milk at least as often as the baby eats, says Sheila Janakos, IBCLC, and founder of Healthy Horizons Breastfeeding Centers and Corporate Lactation Services. In an eight-hour workday, that may be about two to four times. It can take about 20 minutes or more with a double-electric pump, which insurance provides for free under the Affordable Care Act.
Under federal labor laws, most employers must provide pumping breaks and a space other than the bathroom. Those breaks can be unpaid. The PUMP Act, which would have clarified that pump breaks need to be paid, failed to pass in July. The lack of paid pump breaks expands inequity for individuals who must clock out to pump. "People who don't have to clock out don't have to stress about not getting paid," says Janakos.
Jankos adds workplace support for breast/chestfeeding parents should include a clean place to pump, a refrigerator to store milk, and paid shipment of milk if a person has to travel for business while pumping.
Acknowledgement of the effects of systemic racism
Access to paid leave and other resources, such as money to pay for lactation support, are key cogs in the low breastfeeding rates in Black communities. But centuries of trauma also play a role, notes Lydia Boyd, IBCLC, CBE, CLE, BPC, of The Lactation Network and The B.L.A.C.K. Course.
Black enslaved women were often forced to be wet nurses or, after giving birth, sent back to work in the fields while someone else may or may not have cared for their child. Boyd says the Black body has also been demonized—called unhygienic, used for medical experimentation, including by James Marion Sims, the "Godfather of Modern Gynecology."
"It makes it difficult for us to embrace the natural beauty of our nakedness, much less during breastfeeding," says Boyd.
And because rates of Black breastfeeding have historically lagged, Boyd says that new parents may not have the same village that may be able to offer advice, such as on effective latching. It doesn't help that many of the images in gynecology offices, on international board-certified lactation consultant (IBCLC) exams, and in other literature are of white people. "The fact is in 2022...we center white anatomy so much that people don't know what [Black anatomy] looks like," says Boyd.
Nekisha Killings, MPH IBCLC, from The Melanated Mammary Atlas, agrees. "Starting at the top, the organizations that drive education and testing for lactation professionals must prioritize inclusion and cultural humility in their curriculums and examination," says Killings. "This would force those entering the field and renewing certifications to have some level of acumen regarding engagement with and assessment of [Black, Indigenous, and people of color]."
Killings also calls for people in health care and lactation professionals to reach out to historically oppressed communities about what they need to be successful. "We cannot effectively meet the education and support needs of marginalized and historically oppressed communities without inviting them to the table to have input on creating solutions that are relevant to them," says Killings.
Education before birth
There's an idea out there that breastfeeding is natural—mammals do it in the wild, after all. But Janakos says that prenatal education is critical. Courses exist, often through hospitals and OB-GYN offices, but Janakos said there needs to be an increased priority in raising awareness about them.
Overall, education should cover how lactation works, what's normal, and what support is available while also dispelling myths and offering support with creating a birth plan that includes immediate skin-to-skin. Studies show that skin-to-skin within the first hour of life increases breastfeeding initiation.
Jessica Madden, M.D., IBCLC, the medical director at Aeroflow Breastpumps, says education should include a plan for a support person's role. "The breastfeeding parent has to be able to breastfeed the baby," says Dr. Madden. "That's it. That partner can take on everything else like laundry, cooking, and diaper changes."
More education for health care providers
Pediatricians are only required to have three hours of lactation education to care for newborns. International Board Certified Lactation Consultants (IBCLCs) need a minimum of 95 hours of lactation education. Dr. Madden says that many pediatricians have improved at referring individuals to IBCLCs if they flag a potential feeding problem, such as slow weight infant gain. Others have them on staff. The AAP suggests pediatricians consider the latter.
There isn't data on how many have taken this suggestion. Dr. Madden believes it's rare, and Dr. Tomori thinks that's problematic. "Physicians will state they are supportive," Dr. Tomori says. "The words are there. The practices aren't. They aren't understanding the way lactation works or babies need to feed frequently…and may encourage practices that interfere with lactation, such as not feeding during the night [which hurts supply], supplementing without moving milk, limiting time on the breast, and interval feedings [rather than on-demand feedings]."
The solution when something goes wrong is too often formula rather than support.
"Whenever something goes wrong with breastfeeding, they don't fix the underlying issue with breastfeeding," says Dr. Tomori. "They go to formula."
One program developed in part to curb this issue is the Baby Friendly Hospital Initiative (BFHI), launched by the WHO and UNICEF. It aims to give people the education, information, and support to initiate chestfeeding in the hospital, starting with their Ten Steps to Successful Breastfeeding guide.
Offering options is critical. According to the CDC's Maternity Practices in Infant Nutrition and Care, 76% of people wishing to formula feed say they received information in the hospital on how to safely prepare formula, which is higher than the 70% of lactating people who say they were shown or taught techniques, like latching and hand expression.
Access to lactation consultants
IBCLCs are highly trained in lactation, but they may also be expensive and not always covered by insurance. Costs vary, but visits can be $100 or more, and many parents need multiple visits for appropriate support. Boyd and Madden believe policies requiring insurance companies to cover these visits would help make IBCLCs more accessible and increase equity in chestfeeding rates.
There has been progress in providing support to more families. For example, WIC, a supplemental income program for lower-income women, infants, and children, has peer counselors available to help individuals who qualify
Advocating for structural support, as the AAP has done, is essential in helping people meet their feeding goals. But those supports do not currently exist, particularly in historically oppressed communities. Until—and even when—they are in place, Boyd says it's important to remember chestfeeding may look different for everyone.
Also, in rare cases, the lactating person is biologically unable to produce enough milk. "We have to meet people where they are," says Boyd. "We may have a better chance at getting people to breastfeed for two years if we tell them that you can pump, give donor milk, or if we have to give them a little formula, that's OK. You should still get credit for breastfeeding."
Dr. Tomori wants individuals to understand that it's not a lactating person's fault if chestfeeding doesn't work out. "People succeed in systems or fail in systems because of the system," says Tomori.
In other words, parents are doing their best, and it's long past time for the system to follow suit.