Breastfeeding: More Than Just Good NutritionRobert M. Lawrence, MD,

FAAP,* Ruth A. Lawrence,

MD, DD (HON), FAAP†

Author Disclosure

Drs Lawrence and

Lawrence have

disclosed no financial

relationships relevant

to this article. This

commentary does not

contain a discussion

of an unapproved/

investigative use of a

commercial

product/device.

Objectives After completing this article, readers should be able to:

1. Discuss the nutritional benefits of breastfeeding and its effects on growth anddevelopment.

2. Delineate the advantages to the baby of breastfeeding.3. Describe the benefits to the mother of breastfeeding.4. Explain the role that breastfeeding plays in the bonding process.5. List the differences in composition of human milk, colostrum, cow milk, and formula.6. Describe the effects of maternal infection and medication on human milk and infant

health.7. List the few contraindications to breastfeeding.8. Review the use of human milk in feeding preterm babies.9. Discuss current recommendations for breastfeeding, including the role of hospitals in

promoting the practice.

IntroductionOver the past 50 to 60 years, human milk has been described and recognized as the bestfirst food for human infants; breast is best! Human milk provides substantial nutritional,cognitive, emotional, and immunologic benefits for the infant. Such ongoing acclamationis based on the observations and experiences of mothers, families, midwives, doulas,

nutritionists, nurses, physicians, and scientists.Over the past 30 years, scientific study and research have

accumulated and now constitute a large body of evidencedocumenting the actual benefits of breastfeeding for theinfant and the mother. This article examines and referencesmuch of this evidence-based data in describing human milkand how it contributes to the health and well-being of infantsand mothers.

Current Evidence: Health Benefits ofBreastfeedingThe Agency for Healthcare Research and Quality (AHRQ)Report on Breastfeeding in Developed Countries summa-rizes evidence (published in English through May 2006) onbreastfeeding in maternal and infant health. (1) More than9,000 abstracts were considered, and data from more than400 individual studies were included after evidence-basedreview of meta-analyses, updated systematic review of thedata, and newly performed systematic reviews. It is importantto emphasize that this report included data from developedcountries only. Table 1 presents definitions of breastfeedingthat are particularly useful in “quantification” as standarddefinitions used in clinical studies.

Nineteen specific outcomes were reviewed by the AHRQ

*Clinical Associate Professor, Pediatric Immunology and Infectious Diseases, University of Florida – Health Science Center,Gainesville, FL.†Professor, Department of Pediatrics and Obstetrics/Gynecology; Director, Human Lactation Study Center, University ofRochester School of Medicine, Rochester, NY.

Abbreviations

AAP: American Academy of PediatricsAHRQ: Agency for Healthcare Research and QualityARV: antiretroviralBFHI: Baby Friendly Hospital InitiativeCI: confidence intervalCMV: cytomegalovirusDHA: docosahexaenoic acidFFA: free fatty acidGBS: group B StreptococcusGI: gastrointestinalHIV: human immunodeficiency virusHTLV: human T-lymphotrophic virusIg: immunoglobulinNEC: necrotizing enterocolitisRID: relative infant doseTB: tuberculosisTH: T-helper cellWHO: World Health OrganizationWNV: West Nile virus

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research team, including 13 for term infants and six formothers. The outcomes for infants were: incidence ofacute otitis media, atopic dermatitis, gastrointestinal(GI) infections, lower respiratory tract infections,asthma, obesity, type 1 and 2 diabetes, childhood leuke-

mia, infant mortality, and suddeninfant death syndrome as well ascognitive development and the riskof cardiovascular disease. Factorsstudied in mothers were: return toprepregnancy weight and incidenceof type 2 diabetes, osteoporosis,postpartum depression, breast can-cer, and ovarian cancer.

For infants, the meta-analyses orsystematic reviews strongly favoredbreastfeeding over not breastfeed-ing for a reduced risk of acute otitismedia,GI infections, asthma (regard-less of whether there was a familyhistory of asthma), type 2 diabetes,leukemia, and sudden infant deathsyndrome. The meta-analysis ofGI infections reported a crude oddsratio for 14 cohort studies of0.36 (95% confidence interval [CI]

0.32 to 0.41) strongly favoring breastfeeding(ever) in reducing the risk of GI infection in infantsyounger than 1 year of age (Fig. 1). Another analysisreported on two case-control studies demonstrating asummary odds ratio of 0.54 (95% CI 0.36 to 0.80)

again favoring breastfeeding. A sep-arate analysis demonstrated thatinfants breastfeeding exclusively forgreater than 3 months’ or greaterthan 6 months’ duration had sig-nificant reductions in the risk ofacute otitis media compared withinfants who were never breastfed.The analysis of infants developingatopic dermatitis (who had a familyhistory of atopic disease) demon-strated that the risk for atopic der-matitis was lower in infants breast-fed exclusively for longer than 3months compared with childrenwho were breastfed for less than 3months. An analysis examininglower respiratory tract infectionsshowed an overall reduced risk ofhospitalization due to lower respi-ratory tract infections in infants(�1 year of age) who were breast-fed exclusively for 4 months orlonger compared with infants whowere never breastfed (Fig. 1).

Figure 1. The relationship between breastfeeding (BF) and infant outcomes: meta-analysis (MA) results. adjOR�adjusted odds ratio, AOM�acute otitis media,DM�diabetes mellitus, FH�family history, GI�gastrointestinal, LRTI�lower respiratorytract infection, OR�odds ratio, SIDS�sudden infant death syndrome. Adapted withpermission from Figure 4 in Ip S, Chung M, Raman G, et al. A summary of the Agency forHealthcare Research and Quality’s Evidence Report on Breastfeeding in DevelopedCountries. Breastfeed Med. 2009;4:S17–S30, published by Mary Ann Liebert, Inc., NewRochelle, NY.

Table 1. Breastfeeding DefinitionsAny Breastfeeding

• Full Breastfeeding–Exclusive: Human milk only; no other nutrients, supplements, or liquids–Almost Exclusive: No milk other than human milk; minimal amounts ofother substances provided infrequently

• Partial Breastfeeding–High Partial: Nearly all feedings are human milk (>80%)–Medium Partial: A moderate amount of feedings are human milk incombination with other nutrient foods and nonhuman milk (20% to 80% ofnutritional intake is human milk)

–Low Partial: Very few feedings are human milk (<20% of nutritional intake)–Token: Breastfeeding is primarily for comfort (minimal % of total nutritionalintake)

Never Breastfed

• Infant has never ingested any human milk

Modified from Lawrence RM, Pane CA. Human breast milk: current concepts of immunology andinfectious diseases. Pediatr Adolesc Health Care. 2007;37:1-44.

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The report presented two meta-analyses and a system-atic review demonstrating a reduced risk of breast cancerassociated with breastfeeding primarily in premenopausalwomen. One meta-analysis that included 45 studiesshowed a 4.3% reduction in risk for each year of breast-feeding. A second meta-analysis that included 23 studiesdemonstrated a 28% reduced risk of breast cancer for12 months or more of breastfeeding. The AHRQ teamperformed a meta-analysis of 9 “fair” quality studiesthat included 4,387 cases of ovarian cancer and morethan 10,000 controls. This new meta-analysis showedan association between breastfeeding and a reduced riskof ovarian cancer. Cumulative lifetime breastfeedingduration of more than 12 months was associated signif-icantly with a decreased risk of ovarian cancer comparedwith never breastfeeding. This benefit was not seen forcumulative duration of breastfeeding of less than 12months (Fig. 2). Additional data are needed to confirm adose-response relationship between breastfeeding and areduced risk of ovarian cancer.

The analysis for type 2 diabetes, involving two verylarge cohort studies, showed that breastfeeding was as-sociated with a reduced risk of developing type 2 diabetesin women who did not have a history of gestationaldiabetes. Each additional year of lifelong breastfeedingwas associated with a 4% to 12% risk reduction in thetwo different cohorts. Breastfeeding did not appear tolead to a reduced risk of developing type 2 diabetes inwomen who had gestational diabetes. The studies onreturn to prepregnancy weight, osteoporosis, and post-partum depression were unable to demonstrate an asso-ciation between breastfeeding and these specific maternalhealth outcomes due to methodologic issues and theeffect of other contributing factors or confounders.

These high-quality, evidence-based data from the AHRQ Reportsupport breastfeeding as provid-ing significant health benefits toboth the mother and infant, even indeveloped countries. A larger bodyof evidence from developing coun-tries examines the benefits ofbreastfeeding in locales where therisk of infection in infants and chil-dren is high due to poor sanitation,low water quality, contaminatedfood sources, and other variables.This benefit is well documented fordiarrheal disease, respiratory infec-tions, and otitis media.

Beyond the evidence-basedmedicine measures is the realm of attachment and bond-ing between infant and mother and the psychologicaland developmental benefits of breastfeeding for themother and infant. How these spheres are influenced bybreastfeeding has been studied extensively in many dif-ferent countries and cultures. Close and frequent contactbetween the mother and infant, especially skin-to-skincontact, affects the mother’s attachment to the infantpositively. The positive feelings affected by the close(skin-to-skin) and frequent early contact facilitate suc-cessful breastfeeding, longer duration of breastfeeding,and more attachment behavior (fondling, kissing, andcaressing the infant). Recognition of these effects has ledto more direct contact between the infant and his or herparents in the delivery and postpartum areas. Such rec-ognition has supported the recommendation to allowplacement of the infant in direct skin-to-skin contactwith the mother in the first hour after birth to encouragesuccessful breastfeeding. The multiple contributory fac-tors to infant development makes it difficult to demon-strate a causative connection between early skin-to-skincontact or breastfeeding and overall infant and childdevelopment, emotional stability, personality, attach-ment, or person-to-person interactions.

Breastfeeding to Avoid AllergyThe impact of different methods of feeding infants on theonset of allergy has been researched. A meta-analysis of18 prospective studies involving term infants who had afamily history of atopy found a reduction of 42% (95%CI, 8% to 59%) in the risk of atopic dermatitis for infantsbreastfed for at least 3 months compared with those whowere breastfed for less than 3 months. (1)

Studies on asthma were less definitive. The AHRQ

Figure 2. The relationship between breastfeeding (BF) and maternal outcomes: Meta-analysis (MA) results. adjOR�adjusted odds ratio. OR�odds ratio. Adapted with permis-sion from Figures 2 and 3 in Ip S, Chung M, Raman G et al. A summary of the Agency forHealthcare Research and Quality’s Evidence Report on Breastfeeding in DevelopedCountries. Breastfeed Med. 2009;4:S17–S30, published by Mary Ann Liebert, Inc., NewRochelle, NY.

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reported that breastfeeding for at least 3 months wascalculated to provide a 27% (95% CI, 8% to 41%) reduc-tion in the risk of asthma in children who had no familyhistory of asthma compared with children who were notbreastfed. Children who had a family history of asthmahad a 40% risk (95% CI, 18% to 57%) reduction in theoccurrence of asthma before 10 years of age if breastfedfor 3 months compared with those not breastfed. Therisk for children older than 10 years is less clear. Exclusivebreastfeeding for the first 6 months is recommended bythe American Academy of Pediatrics (AAP) for manyreasons, including reducing the risk of allergy. Furtherif supplementation is necessary, an amino acid-basedformula is recommended (hypoallergenic formula).

Physiologic Consequences of the Differencesbetween Colostrum and Mature MilkThe milk available in the breast after 16 weeks’ gestationis called prepartum milk. When the infant delivers and isplaced at the breast (or is allowed to find his or her way)to suckle, the milk is colostrum for the next few days.A gradual change from this transition milk to maturemilk usually occurs by 14 days. Postpartum colostrumis called “the first immunization” because it containshigh concentrations of antibodies and other infection-protective elements, including cells. Colostrum is high intotal protein, low in carbohydrate, and lower in fat thanmature milk. The amount of milk produced in the first24 hours after birth is approximately 50 g, with 190 g

produced by the second 24 hours, 400 g by the third24 hours, and 1,100 g/24 hours by the fourteenth day(800 to 1,000 mL). Human milk and cow milk differsubstantially in their composition (Table 2).The proteinsdiffer in quality and quantity. In its unaltered form, cowmilk contains too much protein, too much casein, toomuch sodium, and too much phosphorus and has toohigh a solute load for a human infant. Formulas havebeen designed to improve these issues. Cow milk doesnot contain any taurine, an amino acid that has highconcentrations in human milk and is essential to infantbrain growth. The profile of amino acids in cow milkdiffers significantly from human milk, especially phenyl-alanine and tyrosine, which are at high concentrationsin cow milk and formula and contribute to problems inphenylketonuria.

The effect of higher protein in infant formula recentlyhas been questioned by investigators of the obesity epi-demic. It has been suggested that a constant intake ofhigh protein in infancy stimulates the metabolic rateand contributes to the long-term obesity of formula-fedinfants. After processing, cow milk and infant formulascontain no cells, no enzymes, and no antibodies or otheractive protective agents and do not support the mainte-nance of physiologic flora of the infant’s GI tract.

Docosahexaenoic acid (DHA) has received consider-able attention because studies in preterm infants havedemonstrated improved visual acuity and auditory acuityin those fed human milk compared with those fed regular

Table 2. Comparison of Human Milk, Cow Milk, and Infant FormulaComponent Human Milk Similac®/Enfamil® Formulas Cow Milk

Calories (kcal/L) 747 700 701Protein (g/100 mL) 1.1 1.5 2.8Casein 3.7 25.0Taurine (mM/100 mL) 25 to 30 Added artificially <1.0Phenylalanine (mg/100 mL) 48 390 mM/100 mL 172Tyrosine 61 179Fat (g/1,000 mL) 4.5 2.6 4.4Cholesterol (mg/L) 139 0 120Carbohydrate (g/1,000 mL) 6.8 7.2 4.7Minerals ash (weight %) 0.2 0.33 0.7Calcium (mg/dL) 34 55 118Phosphorus (mg/dL) 14 44 93Calcium/phosphorus ratio 2.4:1 1.2:1 1.3:1Sodium (g/L) 0.512 (7 mL Eq/L) 1.1 (6 mL Eq/L) 0.768 g/LVitamin D 4 to 40 IU/L 400 IU 47 to 100 IUVitamin K 0.9 to 6.9 mg/L 4 mg/100 kcal 19 mg/L

Similac® is a product of Abbot Laboratories, North Chicago, IL, Enfamil® is a product of Mead Johnson & Co, Evansville, IN.Data from American Academy of Pediatrics. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009; Walker WA,Watkins JB. Nutrition in Pediatrics. Boston, MA: Little, Brown and Co; 1985; and Jensen RG. Handbook of Milk Composition. New York, NY: AcademicPress; 1995.

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preterm formula. When DHA was added to formula, theacuity improved but did not reach the scores achieved bybreastfed infants. DHA and omega-3 fatty acids derivedfrom bacterial culture are added to many formulas,although a benefit has not been proven.

Vitamin concentrations in human and cow milk arecomparable, except for vitamin C, which is significantlyhigher in human milk (100 mg/d). Vitamins in infantformula exceed the concentrations found naturally. Vita-min D has become an important issue because the vita-min D generated in human skin from exposure to sun-shine has diminished through the use of sunscreen,wearing of clothing to shade from the sun, pollution ofthe air by industrial waste, and migration of dark-skinnedpopulations to climates with less sun. Pregnant womenhave been documented in recent decades to pass lessvitamin D to the fetus, so newborns lack sufficient storesat birth. As a result, breastfed infants now are given400 U daily from birth. Investigative work continues onthe benefits of providing pregnant and lactating womenwith 1,000 U of vitamin D daily. Most, but not all, infantformulas contain 400 U of vitamin D in 26 to 32 oz ofreconstituted formula.

Vitamin K content presents an important issue for thenewborn who is born with low concentrations, evenwhen the mother receives extra doses at the time ofdelivery. Hemorrhagic disease of the newborn, with GIor intracranial hemorrhage and generalized bleeding, canpresent early or up to several weeks after birth and is dueto relative deficiencies of vitamin K-dependent coagula-tion factors. Such deficiency has resulted in all newbornsreceiving 1 mg of vitamin K intramuscularly at birth,regardless of the proposed mode of feeding. If vitamin Kis administered orally, multiple doses should be pro-vided. Formula has extra vitamin K, so an infant whoreceives 26 to 32 oz per day of formula receives 4 mg ofvitamin K orally daily. Concentrations in human milk andcow milk are lower.

Immunologic Considerations of Human MilkNeonates and infants are immunologically immatureand at increased risk for infection. Such developmentalimmune defects are only some of the factors that placeinfants at greater risk of infection. In the first 6 postnatalmonths, phagocyte function is immature, with limitedability to migrate to the site of infection, and reserveproduction of phagocytes in response to infection islimited. Cell-mediated immunity develops throughoutchildhood. Defects are particularly apparent in the first6 months after birth, including decreased cytokine pro-duction, decreased natural killer cell function, poor stim-

ulation of B cells for antibody production, and limitednumbers of mature functioning T cells. In addition,function of the classical and alternative pathways of com-plement formation and activation is decreased. Immuno-globulin (Ig) production is limited in amount and reper-toire, including poor isotype switching, limited IgGsubclass production, and low serum IgA concentrationsthrough 7 to 8 years of age.

Bioactive FactorsHuman milk not only bolsters the infant’s immature

immune response by providing numerous bioactive fac-tors that dynamically affect the innate, adaptive, andmucosal immunity against specific infectious agents butalso by influencing immune system development andmaturation of the mucosal barrier. A very clear dose-response relationship has been documented between theamount (full [exclusive], partial, token) and duration ofbreastfeeding and the benefits gained by the infant andmother. (See Table 1 for the definitions.) Most bioactivefactors exert their effects at the level of the mucosalimmune system. Igs are the best recognized and studiedbioactive components in human milk. Igs in human milkare predominantly secretory IgA, with much smalleramounts of IgM and IgG. Colostrum contains higheramounts of Igs and immunologically competent mono-nuclear cells than transitional or mature milk. The Igsfunction by binding directly to specific microbial anti-gens, blocking binding and adhesion to host cells,enhancing phagocytosis, and modulating local immuneresponse. Table 3 in the online edition of this article listsspecific antibodies that have been identified in humanmilk.

The actual antibodies against specific microbial agentspresent in an individual woman’s milk depends on herexposure and response to the particular agents. Notevery mother has antibodies in her milk against everymicrobe. The predominant action of Igs in humanmilk is seen at the mucosal level of the infant’s mouth,nasopharynx, and GI tract, where they bind to and blockthe infectious entry of microbial agents through themucosal barrier. Although best recognized and remem-bered in association with “specific” protection againstindividual infectious agents, Igs provide only a smallportion of the overall immunologic benefit of humanmilk.

Other important individual bioactive proteins includelactoferrin, lysozyme, alpha-lactalbumin, and casein.Lactoferrin exerts its effects via iron chelation, whichcontributes to limiting bacterial growth, blocking adsorp-tion and penetration of viruses and adhesion of bacteria,

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and enhancing intestinal cell growth and repair. Lyso-zyme binds to endotoxin, increases macrophage activa-tion, and contributes to bacterial cell wall lysis. Lactalbu-min transports calcium and enhances the growth ofBifidobacterium, and a modified lactalbumin (in the gut)affects immune modulation. Casein limits adhesion ofbacteria and facilitates the growth of Bifidobacterium.Carbohydrates are an important nutritional componentin human milk, and the specific carbohydrates lactose,oligosaccharides, and glycoconjugates act as bioactivefactors. Oligosaccharides act as prebiotics, enhancing thegrowth of specific probiotic bacteria in breastfed infants,and both oligosaccharides and glycoconjugates bindspecific microbial antigens.

Lipids in the form of triglycerides, long-chain polyun-saturated fatty acids, and free fatty acids (FFAs) have alytic effect on many viruses and are active against Giardiaas well. Nucleotides, nucleosides, and nucleic acids com-prise more than 15% of the nonprotein nitrogen inhuman milk. Nucleotides serve many crucial roles inenergy metabolism, nucleic acid production, and signaltransduction, processes of increased importance duringthe cellular activation and replication related to an activeimmune response. Research related to the “essential”nature of nucleotides in protection against infection hasled to the addition of nucleotides to some infant formu-las. Cytokines and soluble receptors of cytokines areother examples of bioactive factors that serve severalfunctions. Cytokines can act as functional growth fac-tors and have both inflammatory and anti-inflammatoryeffects in different situations.

Hormones and growth factors, including erythropoi-etin, epidermal growth factor, insulin, insulin-likegrowth factor, nerve growth factor, and transforminggrowth factor-alpha, stimulate the growth and matura-tion of the GI tract and, to a degree, systemic growth.These bioactive factors are less specific than Igs, but byacting in concert with multiple factors, they provide themajor portion of protective effects from human milk.

Anti-inflammatory FactorsThe concept of immune protection without an extensiveand potentially damaging inflammatory response is gain-ing in significance in general medicine and in breastfeed-ing medicine. Many of the same protective bioactivefactors act at the mucosal level without stimulatinga significant inflammatory response, which indirectlydecreases inflammation and possible local tissue damage.Certain factors limit further inflammatory stimulation:lactoferrin blocks activation of complement, and lyso-zyme inhibits neutrophil chemotaxis and limits for-

mation of toxic oxygen radicals. Various enzymes inhuman milk break down inflammatory molecules: cata-lase destroys hydrogen peroxide, histaminase destroyshistamine, and arylsulfatase degrades leukotrienes. Vari-ous soluble receptors in human milk (IL-1Ra, STNF-alpha R1 and R2) bind to specific cytokines, blockingtheir inflammatory action.

Vitamins A, C, and E, which are present in higherconcentrations in human milk than in cow milk, scavengeoxygen radicals. Catalase and glutathione peroxidase aswell as lactoferrin serve multiple purposes and have anti-oxidant properties. Prostaglandins in human milk limitsuperoxide production. The sum total of these anti-inflammatory effects of human milk occurring at themucosal level limits damage to the mucosal barrier andfacilitates its ongoing growth and development to fur-ther enhance human milk’s protection of the infant.

Infant Microflora, Probiotics, and PrebioticsThe concept that “normal” intestinal microflora influ-ence the development of the local mucosal immunity andeven “prime” systemic immunity is being supported bynew research. Pathogen-associated molecular patterns inthe microflora are recognized by toll-like receptors andmay contribute to the expression of toll-like receptors onintestinal epithelial cells as well as lead to “program-ming” of systemic T-helper cell type 1 (TH1), TH2, andTH3-like T-cell responses. Probiotic bacteria are organ-isms that live symbiotically in the intestine, conferringadditional benefits on the host, which include competi-tion with pathogenic organisms, strengthened tightjunctions between cells, production of antimicrobial bac-teriocidins, increased mucin production, stimulated peri-stalsis, increased production of specific nutrients (argi-nine, glutamine, small-chain fatty acids), and enhanceddevelopment of the mucosal immune system.

Prebiotics usually are nondigestible oligosaccharidesthat, after fermentation, lower the pH of the local envi-rons and increase the amount of available FFAs. Prebiot-ics enhance the growth of probiotic bacteria in the intes-tine. Oligosaccharides are the third most commoncomponent in human milk in terms of quantity. Cowmilk and formula contain less than one tenth of theoligosaccharides in human milk by weight. The micro-flora of breastfed infants include Lactobacillus bifidusand Bifidobacterium, which comprise up to 95% of theculturable organisms. The remaining small portion ofbacteria include Streptococcus, Bacteroides, Clostridium,Micrococcus, and Enterococcus as well as Escherichia coliand other organisms in even smaller numbers. Themicroflora of formula-fed infants are composed primarily

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of gram-negative organisms (coliforms, Bacteroides, Clos-tridium, Enterobacter, and Enterococcus) in much largernumbers than in breastfed infants and include very smallamounts of Lactobacillus and Bifidobacterium. Lactoba-cillus and Bifidobacterium ferment oligosaccharides, pro-ducing various acids, including FFAs, which lower thepH in the intestine and limit the growth of potentialpathogens such as E coli, Bacteroides, and Staphylococcus.New molecular techniques that analyze stool by detect-ing ribosomal RNA sequences of microbes are expandingthe understanding of GI microflora and factors influenc-ing intestinal and immunologic development at the levelof the gut. Multiple studies have suggested a protectiverole of specific intestinal microflora against the risk ofdeveloping necrotizing enterocolitis (NEC) in pretermand very low-birthweight infants.

Infectious Disease ConsiderationsDespite all the evidence for the immunologic benefits ofhuman milk and the protection afforded infants againstspecific organisms and separate clinical illnesses, data alsodocument the transmission of specific infections throughhuman milk or direct contact with an infected maternalbreast. Although only a few infections are transmittedeasily through human milk (human immunodeficiencyvirus [HIV-1], human T-lymphotrophic viruses 1 and 2[HTLV-1 and -2], and cytomegalovirus [CMV]), theseviruses are important because of their potential for caus-ing morbidity or mortality in the infant. In addition,other infections that are uncommonly transmitted byhuman milk or breast contact should be considered inspecific situations.

Transmission of infection through human milk isexceedingly rare compared with the more commonmechanisms of transmission for neonates and infants.Prenatal infection is congenital, occurring across theplacenta; perinatal infection is due to passage throughthe birth canal; and postnatal infection occurs via air-borne, droplet, or contact transmission other than withthe breast. The predominant modes of transmission andthe usual timing of infection are important consider-ations in different clinical situations. (2) Review of theconsiderations for transmission via human milk forselected organisms can be divided into bacterial, viral,and other. See Tables 4 and 5 in the online edition of thisarticle for summaries of the considerations for selectedbacteria and viruses.

Viral InfectionsChronic infection of the mother with HTLV-1 or -2 isconsidered a contraindication to breastfeeding. Studies

on transmission have documented approximately a 30%transmission rate in breastfed infants, 10% rate in“mixed-feeding” infants, and 0% rate in exclusivelyformula-fed infants. Researchers estimate that 1 mL ofhuman milk can contain 1,000 T cells infected withHTLV-1. Epidemiologic studies from areas of Japan thathave high rates of HTLV-1 have reported significantreductions in transmission of the virus from mother toinfant with avoidance of breastfeeding or limiting breast-feeding to less than 6 months’ duration.

HIV-1 infection in the mother is another chronicinfection that can be transmitted readily via human milkto the infant. In the United States and other areas of theworld where HIV perinatal transmission prevention ishighly successful and safe alternatives to breastfeedingare available, acceptable, feasible, affordable, sustainable,and safe, mothers who have HIV infection have beenadvised not to breastfeed their infants. In areas of theworld where there is an increased risk of infectious dis-eases, nutritional deficiencies, and significant morbidityand mortality for infants who are not breastfed andreplacement feeding is not available, exclusive breast-feeding by an HIV-positive mother can afford the infantthe best chance of survival. HIV DNA is detectable easilyin human milk and can be categorized as cell-free andcell-associated virus. Factors associated with an increasedrisk of HIV transmission via breastfeeding include mixedfeeding versus exclusive breastfeeding, duration ofbreastfeeding, maternal illness and high viral loads,lower CD4 lymphocyte counts in the mother, and mas-titis or nipple lesions in the mother. Recent studies havedocumented that effective antiretroviral (ARV) treat-ment of the HIV-positive mother along with exclusivebreastfeeding can lead to lower transmission rates forinfants and lower mortality for both mothers and infants.Prophylactic ARV treatment of the infant along withexclusive breastfeeding also has been associated withdecreased HIV transmission to the infant. Additionalcarefully controlled research on exclusive breastfeeding,ARV therapy, and optimizing the infant’s nutrition andgrowth are needed before an optimal regimen can bedevised.

Latent CMV infection or even recent CMV infectionin a breastfeeding mother is not a contraindication tobreastfeeding. Postnatal CMV infection via human milkoccurs readily, but viral presence is rarely, if ever, clini-cally significant in the term infant. In fact, breastfeedinghas been described as “natural CMV immunization” inthe term infant. Preterm, low-birthweight, and very low-birthweight infants are at risk for clinically significantpostnatal CMV infection via breastfeeding. This post-

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natal infection is more likely to occur between 3 and12 weeks postpartum, when virolactia occurs commonly.Pasteurization and freezing-thawing milk can decreasethe CMV load in human milk. A reasonable protocol hasbeen outlined for protecting susceptible infants whileusing human milk in nurseries that include preterm andvery low-birthweight infants. (3) The protocol includesscreening mothers for CMV before providing humanmilk to their infants, pasteurizing or freezing-thawinghuman milk from CMV-positive mothers before its use,and observing infants in the nursery for evidence of acuteCMV infection.No prospective, controlled trials docu-ment the protective effects of such a protocol.

West Nile virus (WNV) is the only other virus forwhich there has been evidence for transmission viahuman milk with any frequency. Several studies docu-ment the presence of WNV DNA as well as IgM and IgGantibodies against WNV in human milk, but no clearevidence documents clinically significant illness in infantsexposed through breastfeeding by mothers who haveWNV infection. The concern about viruses such as her-pes simplex virus, varicella-zoster virus, vaccinia virus(smallpox vaccine virus), or variola virus (smallpox virus)is transmission through contact with skin lesions thatcontain the virus on the mother’s nipple or breast, notthrough virus excreted in the milk. Temporary avoidanceof breastfeeding and milk from the mother’s breast thathas an identified lesion due to one of these viruses may bereasonable. Prophylactic antiviral treatment for the infantalong with maternal antiviral treatment usually is ade-quate to allow breastfeeding to continue.

Viruses commonly transmitted via the respiratoryroute (influenza, respiratory syncytial virus, severe acuterespiratory syndrome-associated coronavirus) are nottransmitted through human milk. Most frequently, bythe time a specific respiratory illness is diagnosed in themother, the infant has already been exposed via respira-tory secretions. There is no reason to suspend breastfeed-ing or the use of expressed human milk, except whensevere disease in the mother prevents the ability to obtainhuman milk. The numerous bioactive factors (not Igs ifit is early in the maternal infection) in human milk canprovide the infant some ongoing protection.

Bacterial InfectionsThe concern about bacterial infections in the motheris infection of the nipple or breast (mastitis or breastabscess) that introduces the bacteria into the milk ordirectly into the infant’s mouth. (See Table 4 for selectedbacterial infections in the mother.) The risk of pulmo-nary tuberculosis (TB) in the mother is related to trans-

mission via respiratory droplets, which is the same forbreastfeeding or formula-fed infants in contact with theirmothers. TB mastitis or TB lesions of the breast are rare.Breastfeeding or use of expressed human milk from themother who has TB can continue once the mother isreceiving appropriate antituberculous therapy and theinfant is receiving isoniazid prophylactically.

Staphylococcus or group A Streptococcus infection ofthe breast can interfere with breastfeeding. Breastfeedingor use of expressed human milk can continue when themother is physically comfortable with the process, aftera temporary suspension during the mother’s initial24 hours of effective antibacterial therapy. Prophylacticantibiotic therapy for the infant in conjunction with thematernal treatment often allays additional fear.

In general, the same antibiotics used to treat a specificinfection in the mother are used and are safe in the infantand in the mother’s milk. Antibiotics do enter humanmilk, but usually in very low concentrations, exposingthe infant to a daily dose well below the commonly usedtherapeutic dose prescribed for infants and children. Theexceptions to this principle are doxycycline or tetracy-cline because of a concern for dental staining or alteredbone growth in the infant (short duration of therapy inthe mother [�3 wk] generally is considered acceptable)and erythromycin, which has been associated with theoccurrence of infantile hypertrophic pyloric stenosis inyoung infants. Quinolone use has been increasing inchildren due to the absence of significant adverse effects,and the use of levofloxacin or ofloxacin in breastfeedingmothers appears to be without significant concerns,other than the potential for changing the gut flora of theinfant and perhaps bacterial overgrowth with a resistantpathogen.

Additional considerations for group B Streptococcus(GBS) infection or colonization of the mother and trans-mission to the infant include adherence to proposedguidelines for prevention of GBS disease in the infant,the frequent and “back and forth” nature of colonizationin mother-infant dyads, the difficulty in eradicating col-onization in the mother or infant, and the fact thattransmission of GBS from mothers to infants occurs withand without evidence of mastitis in the mother. Acquisi-tion of GBS infection via breastfeeding or human milkremains uncommon compared with transmission viaclose direct contact between mothers and infants. Closeadherence to the guidelines for prevention of early GBSdisease in the infant is effective and important.

Other recommendations to decrease possible GBStransmission between mother and infant via human milkinclude careful instruction of mothers and medical staff

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on the appropriate techniques for expression, collection,and storage of expressed milk and on the signs andsymptoms of mastitis to facilitate early recognition andinitiation of effective interventions. Breastfeeding or theuse of expressed human milk can continue after a tem-porary suspension during the initial 24 hours of anti-bacterial treatment for the mother. Preventive or earlyempiric antimicrobial therapy for the infant may be indi-cated in specific clinical situations, along with the contin-uation of breastfeeding.

Fungal InfectionsCandida infection of the breast and mucocutaneousCandida infection in the infant are the only pertinentfungal infections related to breastfeeding and humanmilk. In general, antifungal therapy administered simul-taneously to the infant and the mother is the mosteffective and appropriate treatment because of the easeof colonization or recolonization in both mother andinfant. Numerous topical and systemic therapies areeffective. Occasionally, persistent or recurrent Candidainfection adversely affects ongoing breastfeeding. Can-dida infection of the breast is overdiagnosed. Consulta-tion with a professional or physician who has extensiveexperience supporting and caring for the breastfeedingmother-infant dyad can facilitate effective treatment andongoing breastfeeding.

Parasitic InfectionsTransmission of parasites through breastfeeding orhuman milk is not a significant concern. Although hook-worm infection occurs commonly in young children, andtransmammary spread of helminths has been describedin veterinary medicine, little substantiated evidence sup-ports the presence of hookworms in human milk orsignificant infection in the infant due to a hookwormpassed via human milk. Giardiasis in infants younger than6 months of age is rare, and given the various factorsactive against Giardia in human milk, transmission viathis route is highly unlikely. There is no evidence fortransmission of malaria via human milk, but the motherand infant both need to be protected from contact withinfected mosquitoes. Maternal treatment or prophylaxisfor malaria during breastfeeding can be accomplishedsafely with various agents, such as chloroquine, quinine,pyrimethamine-sulfadoxine, tetracycline, mefloquine,and primaquine, with some attention to the age of thechild, the duration of exposure, and short periods of“pumping and dumping” of expressed milk during theuse of mefloquine. Transmission of Toxoplasma gondii orTrichomonas via human milk has not been demonstrated.

Breastfeeding and Maternal MedicationsThe risk of maternal medication to the breastfed infantis a frequent question for the physician. The answerdepends on a number of factors that involve the infant,including gestational age at birth, current age, weight,feeding pattern, and total oral intake, and the mother,such as medication dose and dosing pattern, route ofadministration, drug absorption, peak plasma concentra-tion and timing of that peak, volume of distribution,molecular size of the drug, degree of ionization, pH,solubility in water or lipids, degree to which the drug isprotein bound, and oral bioavailability.

A number of questions must be clarified to make aninformed decision about the use and the potential risk ofthe medication. If the drug passes into the milk, what isthe concentration in the milk? Is it absorbed by the infantor is it not orally bioavailable as are many drugs that areeffective only by the intravenous or intramuscular routes?Is the infant able to detoxify and excrete the drug or doesit accumulate in the infant’s system? The milk/plasmaratio has been determined for a number of drugs bymeasuring the concentration in the milk and maternalplasma simultaneously. A single point in time milk/plasma ratio does not give an accurate determination ofhow much the infant will receive. A concentration mea-sured in the milk at the time of feeding is the only reliablemeasure of what the infant receives.

Despite these questions, reliable measures of manycommon medications have been documented. Consider-able research has resulted in valuable estimations of thesafety of many, but not all, drugs. The determination ofthe relative infant dose (RID) has been used to standard-ize the method that estimates the amount of a given drugthat the infant receives. The formula is:

RID (%)�absolute infant dose (mg/kg per day)�maternal dose (mg/kg per day �100)

These calculations assume average metabolism and amaternal dose in the usual therapeutic range. The accept-able RID of a drug is 10% or less for term infants, whohave a clearing capacity about one third that of the adult.Preterm infants are less efficient at clearing drugs, withcapacity only 5% of the adult capacity at 24 to 28 weeks’gestation and only 10% at 28 to 34 weeks’ gestation.After 7 months of age, however, the infant can handlemost drugs at adult concentrations. The RID is avail-able for many medications from reference data bankssuch as the Library of Medicine data bank at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Otherresources are Medications and Mother’s Milk (4) and the

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University of Rochester Breastfeeding and Human Lac-tation Study Center Drug Line (585/275-0088).

The AAP Committee on Drugs has published catego-ries of drugs and their safety for use while breastfeeding.If the drug is prescribed normally for term or preterminfants, it is considered safe via human milk. If the infantalso needs a drug such as an antibiotic, it must beadministered directly to the infant. If the medication isnot bioavailable orally, the infant cannot absorb it fromthe stomach. Large molecules such as insulin, heparin,and many Igs do not pass into milk from maternalplasma.

Drugs of abuse or street drugs are considered contra-indicated, and breastfeeding is not recommended. For amother actively participating in a methadone mainte-nance program, the potential benefits of breastfeedingand human milk for the mother and infant should beconsidered strongly. Breastfeeding can be recommendedin certain situations in which there has been good pre-natal care, maternal compliance with a drug addictionrecovery program before birth, and negative maternalurine toxicology screens for 12 weeks before and atdelivery. Women who have been stable on a methadonemaintenance program should be permitted to breastfeed.Evidence suggests that methadone-exposed infants mayhave less severe symptoms of neonatal abstinence syn-drome when maintained after delivery on human milk.

Immunosuppressant drugs, such as methotrexate, arecontraindicated. However, some newer antimetabolitesor cancer drugs have very short half-lives. A drug isconsidered to clear the body within 5 times the half-life.If the half-life is 2 hours, it will clear in 10 hours, duringwhich time the mother can pump and discard her milk.The infant can be fed previously pumped milk or asuitable substitute during that interim period.

Radioactive compounds have been studied widely.The clearance half-life has been measured for most of theradioactive compounds used diagnostically or therapeu-tically. The same formula (5�half-life�clearance time)can be used to determine how long a mother needs topump and discard her milk. However, when the half-lifeis longer than 3 days, it is impractical to have a motherpump and discard for 15 days or longer, although thisdetermination is an individual decision. Radioactive iodinefalls in this category. Iodine 131 in therapeutic doses takes3 to 5 weeks to clear the maternal system.

In summary, drugs that are administered routinely toinfants are safe to prescribe for the breastfeeding mother.Important considerations for minimizing the amount ofmedication to which the breastfeeding infant is exposedinclude choosing the drug present in the lowest amount

in human milk, using a medication in the same classifica-tion of drugs that have the lowest RID, avoiding long-acting preparations of medications, scheduling dosingso the medication concentration in the milk is lowestwhen the infant feeds, taking the medication immedi-ately after breastfeeding or breastfeeding just before thenext dose when the medication is taken several times aday, and observing the infant for changes in behaviorwhile administering the medication to the mother.

Use of Human Milk in Preterm InfantsAll of the benefits of human milk are magnified in thepreterm infant. If the infant can receive oral feeding,mother’s milk is the safest and best tolerated of all theavailable feedings. Human milk can be introduced earlierthan the foreign protein of formula. All of the infectionprotection qualities and the antibodies found naturally inhuman milk protect against infection, especially NEC.The limitations are the ability of the mother to pump hermilk and make it available. Milk banks are availablethroughout the country that can provide pasteurizedhuman milk from approved donors. The concerns of theneonatologist stem from the inability to measure thevolume consumed when the infant is at the breast and theneed for additional calories in the limited volumes toler-ated by extremely immature infants. The quick solutionis to add concentrated formula from powder or liquidmade from bovine milk, known by the misnomer“human milk supplementer.” This preparation containsnone of the protective factors of human milk and inter-feres with those present in any human milk provided.One commercially available supplementer made exclu-sively from human milk has been shown to promotegrowth in preterm infants as well as protect againstinfection, especially NEC.

Because women today commonly are deficient in vita-min D, even while taking prenatal vitamins during preg-nancy, their infants have inadequate stores at birth, espe-cially if born preterm. Vitamin D supplementation isrequired if the preterm infant is receiving mother’s milk(400 U daily).

Ideally, preterm nurseries have nursing staff who arealso certified lactation consultants and can assist motherswho wish to pump and provide their milk. The consul-tants can advocate for the mother who is ready and eagerto feed her preterm infant at the breast. All neonatalintensive care units should provide electric breast pumpsand private accommodations to pump. Freezers andrefrigerators should be designated for sole storage ofhuman milk. Pumped milk should be stored in freezer-safe containers that can be sealed and labeled with name,

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unit number, date, and time of collection, so milk can befed sequentially, beginning with the antibody-rich colos-trum. Most neonatal intensive care units have feedingprotocols geared to the gestational age and weight of theinfant. Mother’s milk can be used if these guidelines arefollowed.

At the time of discharge, some preterm infants stillneed added calories, which can be provided by “bioen-gineering,” in which the mother pumps 5 mL of milkfrom the breast first (and saves it frozen for weeks to beused later). She then feeds just the hind milk, which ishigher in calories and fat than the foremilk. Some nurs-eries have the ability to measure the caloric content ofmother’s milk from a sample taken from each pumpingfor 24 hours. The average caloric measure is 20 kcal/oz,with a range of 15 to 24 kcal/oz. The milk can besupplemented as necessary or, in the case of high-calorieproducers, not at all. The initial milk produced by moth-ers who deliver preterm has been demonstrated to behigher in protein, calcium, sodium, and calories for thefirst few weeks. Although an advantage to the infant, lackof bedside technology does not permit factoring in thisnutrient variation in the feeding orders.

Current RecommendationsThe World Health Organization (WHO), United NationsChildren’s Fund, AAP Section on Breastfeeding, Amer-ican College of Obstetricians and Gynecologists, Amer-ican Academy of Family Physicians, Academy of Breast-feeding Medicine, and many other health organizationsrecommend exclusive breastfeeding for the first 6 post-natal months. Numerous obstacles to the initiation andcontinuation of breastfeeding remain within health-caresettings, the workplace, communities, and the media.

The goals for Healthy People 2010 for breastfeedingin the United States were: 1) initiation of any breastfeed-ing in 75% of infants in the early postpartum period,2) continuation of any breastfeeding in 50% of infantsat 6 months of age, 3) continuation of any breastfeedingin 25% of infants at 1 year of age, 4) exclusive breast-feeding in 40% of infants at 3 months of age, and 5) exclu-sive breastfeeding in 17% of infants at 6 months of age.The Centers for Disease Control and Prevention havereported preliminary survey data on breastfeeding ratesin the United States for infants born in 2006. Althoughrates have improved since 1999, they still fall below theHealthy People 2010 goals. For infants born in 2006,74% initiated breastfeeding, 43% continued breastfeed-ing at 6 months, and 23% continued at 12 months of age.An estimated 33% of infants were exclusively breastfedthrough 3 months of age and 14% through 6 months of

age. The Healthy People 2020 goals for breastfeeding werereleased in late 2010 (http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid�26)and show some changes. Anticipated rates are changed,and methods to reduce barriers are included. The goalsare:

● Infants ever breastfed: 82%● Infants breastfeeding at 6 months: 60.6%● Infants exclusively breastfed through 3 months: 46.2%● Infants exclusively breastfed through 6 months: 25.5%

The WHO multicenter growth reference was conductedin six countries (Brazil, Ghana, India, Norway, Oman,and the United States) between 1997 and 2003. Thestudy consisted of a longitudinal follow-up of 882 infantsfrom birth to 24 months of age and a cross-sectionalstudy of 6,669 children ages 18 to 71 months. Childrenincluded in the study were healthy infants living in socio-economic situations favorable to growth, who werebreastfed exclusively for at least 4 months and wereintroduced to complementary foods at 6 months of age,with breastfeeding continuing up through 12 months ofage. The tables and charts (www.who.int/childgrowth/en) created through this study depict normal humangrowth under optimal environmental conditions. Thecurves for the six different countries were virtually super-imposable on each other for height and weight growththrough 60 months of age. These standards now identifybreastfeeding as the biologic norm for growth and devel-opment and add further evidence for the recommenda-tions of exclusive breastfeeding through 4 to 6 monthsof age.

Pediatricians and other health-care professionalsacross the United States should continue to recommendthe use of human milk for all infants, with few exceptions(Table 6). A balanced presentation of up-to-date infor-mation on the benefits and process of breastfeedingshould be provided to all parents to assist them in makingan informed decision for the feeding of their infants.Pediatricians and other health-care professionals shouldadopt and promote the “Ten Steps to Successful Breast-feeding” in all maternity services and facilities providingcare to infants and children (Table 7).

In-hospital Breastfeeding Policies: Early andFrequent Contact of Mother and InfantHospital management of the mother-infant dyad whoplan to breastfeed are clearly spelled out by the WHO-UNICEF ten steps that have been endorsed by the AAP(Table 7). The AAP did take exception to the recommen-

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dation on pacifier use with the following footnote: “TheAAP does not support a categorical ban on pacifiers dueto their role in sudden infant death syndrome risk reduc-tion and their analgesic benefit during painful procedureswhen breastfeeding cannot provide the analgesia.” (6)Pacifier use in the hospital in the neonatal period shouldbe limited to specific medical indications, such as painreduction or for calming in a drug-exposed infant.Mothers of healthy term breastfed infants should be

instructed to delay pacifier use untilbreastfeeding is well-established,usually about 3 to 4 weeks afterbirth.

Every effort should be made atbirth and while in the hospital tokeep mother and infant in proximity.Labor-delivery-recovery-postpartumrooms allow care for the dyad to con-tinue in the same room. Birth centersand rooming-in provide the bestenvironment in which to establishlactation. The infant should be putto breast as soon as possible afterdelivery, ideally in fewer than 30 min-utes or, as recommended in theUnited States, within the first hourafter birth. When a mother has herbaby nearby, the proximity offers heran opportunity to learn her baby’scues before they are discharged from

the hospital. The Baby Friendly Hospital Initiative (BFHI)promotes the ten steps, and The Joint Commission hasintroduced them in their review of hospitals that providedelivery services. This support, as recommended by theBFHI, should continue through infancy until weaning.

Weaning involves the introduction of safe and appro-priate complementary foods to the infant, beginning at6 months of age. Weaning is a process, and breastfeed-ing continues with the introduction of other foods. The

overall duration of breastfeedingvaries significantly according tothe mother’s and family’s beliefsand cultural practices. The end ofbreastfeeding is most frequently“decided” by the mother and infant(together or separately), and thereis no predetermined ideal time forstopping breastfeeding.

Human Milk BanksHuman milk banking operates inmany countries. Ten approvednot-for-profit banks are membersof the Human Milk BankingAssociation of North America(www.HMBANA.org). All thebanks follow the associationguidelines for collecting and pas-teurizing human milk. Womenwho donate milk are carefully

Table 6. Contraindications to BreastfeedingInfant Conditions

• Classic galactosemia (galactose 1-phosphate uridyltransferase deficiency)• Maple syrup urine disease• Phenylketonuria (partial breastfeeding is possible with careful monitoring)

Maternal Conditions

• Human immunodeficiency virus 1 infection (if replacement feeding isacceptable, feasible, affordable, sustainable, and safe)

• Human T-lymphotropic virus 1 and 2 infection (varies by country; in Japan,breastfeeding is initiated)

• Tuberculosis (active, untreated pulmonary tuberculosis, until effective maternaltreatment for the initial 2 weeks or the infant is receiving isoniazid)

• Herpes simplex virus infection on a breast (until the lesions on the breast arecleared)

• Medications (those of concern)–Most medications are considered safe because little gets into the milk–A few select compounds drugs of abuse and some radioactive compounds thathave long half-lives require cessation of lactation

Table 7. Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should:1. Have a written breastfeeding policy that is communicated routinely to all

health-care staff.2. Train all health-care staff in skills necessary to implement this policy.3. Inform all pregnant women about the benefits and management of

breastfeeding.4. Help mothers initiate breastfeeding within 30 minutes of birth.5. Show mothers how to breastfeed and how to maintain lactation even if they

should be separated from their infants.6. Give newborns no food or drink other than human milk, unless medically

indicated.7. Practice rooming-in, that is, allow mothers and infants to remain together

24 hours a day.8. Encourage breastfeeding on demand.9. Give no artificial teats or pacifiers (also called dummies or soothers) to

breastfeeding infants.10. Foster the establishment of breastfeeding support groups and refer mothers

to them on discharge from the hospital or clinic.

From Evidence for the Ten Steps to Successful Breastfeeding. (5)

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tested and screened. Milk is available by doctor’sprescription for a fee that covers processing, shipping,and handling. Donors are not paid. At least one for-profit milk bank has investigated the variations inhuman milk and has produced a concentrated fluidhuman milk supplementer made only of human milk.The company also provides regular human milk, thecalorie and protein content of which is available at 20,24, and 26 kcal/oz. This milk is also available for a fee.

References1. Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary ofthe Agency for Healthcare Research and Quality’s Evidence Reporton Breastfeeding in Developed Countries. Breastfeed Med. 2009;4:S17–S302. American Academy of Pediatrics. Pickering LK, Baker CJ, Kim-berlin DW, Long SS, eds. Red Book: 2009 Report of the Committeeon Infectious Diseases. 28th ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics; 2009

3. Lawrence RM. Cytomegalovirus in human breast milk: risk tothe premature infant. Breastfeed Med. 2006;1:99–1074. Hale TW. Medications and Mother’s Milk. 12th ed. Amarillo TX:Pharmasoft Publishing; 20105. Division of Child Health and Development, Family and Repro-ductive Health, World Health Organization. Evidence for the TenSteps to Successful Breastfeeding. Geneva, Switzerland: World HealthOrganization; 1998. Accessed April 2011 at: http://www.who.int/child_adolescent_health/documents/9241591544/en/6. American Academy of Pediatrics. Tayloe DT. AAP endorse-ment to the WHO/UNICEF ten steps to successful breastfeed-ing. Accessed May 2011 at: http://www.aap.org/breastfeeding/files/pdf/TenStepswosig.pdf

Suggested ReadingAmerican Academy of Pediatrics Section on Breastfeeding. Policy

statement: breastfeeding and the use of human milk. Pediatrics.2005;115:496–506

Briggs GE, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lacta-tion. 8th ed. Philadelphia, PA: Lippincott, Williams & Wilkins;2010

Centers for Disease Control and Prevention. Breastfeeding AmongU.S. Children Born 1999 – 2006, CDC National ImmunizationSurvey. March 16, 2010. Accessed April 2011 at: http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm

de Onis M, Garza C, Onyango AW, Rolland-Cachera MF andle Comite de nutrition de la Societe Francaise de Pediatrie.WHO growth standards for infants and young children. ArchPediatr. 2009;16:47–53. Accessed April 2011 at: www.who.int/childgrowth/en

Ip S, Chung M, Raman G, Chew P, et al. Breastfeeding andMaternal and Infant Health Outcomes in Developed Countries.Evidence Report/Technology Assessment No. 153. AHRQ Publi-cation No. 07-E007. Rockville, MD: Agency for HealthcareResearch and Quality; 2007

Ito S. Drug therapy for breastfeeding women. N Engl J Med.2000;343:118–126

Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medi-cal Profession. 7th ed. Philadelphia, PA: Elsevier Mosby; 2010

Lawrence RM, Lawrence RA. Breast milk and infection. ClinPerinatol. 2004;31:501–528

Lawrence RM, Pane CA. Human breast milk: current concepts ofimmunology and infectious diseases. Curr Probl Pediatr AdolescHealth Care. 2007;37:1–44

National Library of Medicine Lactation Data Base. Accessed April2011 at: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

United States Department of Health and Human Services. HealthyPeople 2010: Conference Edition – Volumes I and II. Washing-ton, DC: United States Department of Health and HumanServices, Public Health Service, Office of the Assistant Secretaryfor Health; 2000:47–48

ResourceBreastfeeding and Human Lactation Study Center located at the

University of Rochester, School of Medicine. Phone Number:585–275-0088

Summary• Ample evidence documents the clear benefits of

breastfeeding for both the mother and the infant.• Among the very few contraindications to

breastfeeding are galactosemia, medications or drugsof concern, and HIV and HTLV infection.

• Pediatricians should recognize that human milk issuperior to formula in optimizing each infant’spotential for early growth and development.

• Pediatricians should recommend exclusive/fullbreastfeeding as superior to formula feeding throughthe first 6 postnatal months and the subsequenttimely introduction of adequate, safe, andappropriate complementary foods in combinationwith continued breastfeeding as optimal nutrition inthe first postnatal year.

• Pediatricians should be knowledgeable aboutimportant issues concerning breastfeeding and themanagement of the breastfeeding mother-infantdyad in situations of infant prematurity or illnessand maternal illness, infection, and medicationexposure.

• Families should be provided with appropriateinformation about breastfeeding and infant feedingbefore as well as throughout the pregnancy andinfancy.

• Mothers should receive ongoing support forbreastfeeding in the hospital, in medical offices andfacilities, and throughout communities, parallelingthe BFHI.

• Ongoing lifelong education about support for andmanagement of the breastfeeding mother-infantdyad is essential for pediatricians in the 21stcentury.

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PIR QuizQuiz also available online at http://pedsinreview.aappublications.org.

1. Skin-to-skin contact between an infant and mother in the first hour after birth has been associated with:

A. Calmer personality.B. Earlier attachment.C. Faster infant development.D. Greater emotional stability.E. More successful breastfeeding.

2. The most definitive studies showing a reduction in atopic dermatitis following at least 3 months ofbreastfeeding involved:

A. Children younger than 10 years of age who had a family history of asthma.B. Children older than 10 years of age who had with a family history of asthma.C. Children who had no family history of asthma.D. Infants who had a family history of atopy.E. Infants who had no family history of atopy.

3. Vitamin K has been administered routinely to newborns for many years. Which of the following vitaminshas also been recommended for supplementation from birth?

A. A.B. B.C. C.D. DE. E.

4. In the United States, infection with which of the following viruses is a contraindication to breastfeeding?

A. Cytomegalovirus.B. Human immunodeficiency virus.C. Respiratory syncytial virus.D. Varicella-zoster virus.E. West Nile virus.

5. The earliest age at which most infants can metabolize drugs at adult rates is:

A. 1 week.B. 1 month.C. 4 months.D. 8 months.E. 1 year.

HealthyChildren.org Parent Resources from AAPThe reader is likely to find material to share with parents that is relevant to this articleby visiting this link: http://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/default.aspx.

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Robert M. Lawrence and Ruth A. LawrenceBreastfeeding: More Than Just Good Nutrition

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