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Breastfeeding
Handbook
for Physicians
3rd Edition
00 Front Matter BHFP i-xiv.indd 1 9/14/22 12:26 PM

American Academy of Pediatrics Publishing Staff
Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing
Mark Grimes, Vice President, Publishing
Heather Babiar, MS, Senior Editor, Professional/Clinical Publishing
Jason Crase, Senior Manager, Production and Editorial Services
Theresa Wiener, Production Manager, Clinical and Professional Publications
Peg Mulcahy, Manager, Art Direction and Production
Linda Smessaert, Director, Marketing
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Published by the American Academy of Pediatrics
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Telephone: 630/626-6000
Facsimile: 847/434-8000
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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical
subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of all infants, chil-
dren, adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of
medical care. Variations, taking into account individual circumstances, may be appropriate.
Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of
Pediatrics.
While the terminology used in this publication often reflects the dyad of “mother” and newborn or infant, the
intent is to be inclusive of all parents, regardless of sex, gender, or sexual orientation.
Any websites, brand names, products, or manufacturers are mentioned for informational and identification
purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not
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tently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity.
This publication has been developed by the American Academy of Pediatrics. The contributors are expert
authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in
development of the content of this publication. Disclosures: Pamela Berens discloses a speaker bureau relationship
with the Texas Department of State Health Services and a site principal investigator relationship with a Duke
University study. Susan Crowe discloses a previous advisory board relationship with Sage Therapeutics. Gabriela
Maradiaga Panayotti discloses a consulting relationship with Aveeno, a speaker’s bureau relationship with Carolina
Global Breastfeeding Institute, and a spouse/partner with a speaker relationship with Boehringer Ingelheim and an
advisory board relationship with Genentech.
Every effort has been made to ensure that the drug selection and dosages set forth in this text are in accordance
with the current recommendations and practice at the time of publication. It is the responsibility of the health
care professional to check the package insert of each drug for any change in indications or dosage and for added
warnings and precautions.
Every effort is made to keep Breastfeeding Handbook for Physicians consistent with the most recent advice and
information available from the American Academy of Pediatrics.
Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication.
Special discounts are available for bulk purchases of this publication. Email Special Sales at
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© 2023 American Academy of Pediatrics and The American College of Obstetricians and Gynecologists
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Printed in the United States of America
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ISBN: 978-1-61002-442-6
eBook: 978-1-61002-443-3
Library of Congress Control Number: 2020932408

Editorial Committee
Editor in Chief
Richard J. Schanler, MD, FAAP, FABM
Coeditors
Lori Feldman-Winter, MD, MPH, FAAP, FABM
Sharon B. Mass, MD, FACOG
Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC
Lawrence Noble, MD, FAAP, FABM, IBCLC
Staff
American Academy of Pediatrics
Mark Grimes
Jeff Mahony
Sunnah Kim, MS, RN, CPNP
Ngozi Onyema-Melton, MPH, CHES
Heather Babiar, MS
The American College of Obstetricians and Gynecologists
Christopher M. Zahn, MD
Jennifer Walsh
Ije Obidegwu, MPH
Syeda Lamiya Ahmed
Martha Hawley-Bertsch
Jennifer Hicks, MS
iii

Committees
American Academy of Pediatrics Section on Breastfeeding
Executive Committee, 2019–2020
Lori Feldman-Winter, MD, MPH, FAAP, FABM (Chair)
Maya Bunik, MD, MPH, FABM, FAAP
Ann Kellams, MD, IBCLC, FAAP, FABM
Lisa Stellwagen, MD, FAAP
Jennifer Thomas, MD, MPH, IBCLC, FABM, FAAP
Julie Ware, MD, MPH, FAAP, FABM, IBCLC
Committee Chairpersons
Margaret G. Parker, MD, MPH, FAAP
Rose St. Fleur, MD, FAAP, FABM, IBCLC
The American College of Obstetricians and Gynecologists
Breastfeeding Expert Work Group, 2020–2021
Lauren E. Hanley, MD, IBCLC, FACOG (Chair)
Pamela D. Berens, MD, IBCLC, FABM, FACOG
Meredith Lee Birsner, MD, FACOG
Andrea Braden, MD, IBCLC, FACOG
Susan D. Crowe, MD, FABM, FACOG
Victoria L. Green, MD, JD, MBA, FACOG
Gail Herrine, MD, IBCLC, FABM, FACOG
Adetola F. Louis-Jacques, MD, FABM, FACOG
Sharon Mass, MD, FACOG
Edward R. Newton, MD, FABM, FACOG
Victoria Nichols-Johnson, MD, MS, FACOG
Susan D. Rothenberg, MD, IBCLC, FACOG, FABM
Alison Stuebe, MD, MSc, FACOG
Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC (AAP Liaison)
Jamie H. Bardwell, MPP (Public Member)
iv

Contributors
Philip O. Anderson, PharmD, FCSHP, FASHP
University of California, San Diego, Skaggs School of Pharmacy and
Pharmaceutical Sciences
La Jolla, CA
Pamela D. Berens, MD, FACOG, IBCLC, FABM
McGovern Medical School at UT Health
Houston, TX
Maya Bunik, MD, MPH, FABM, FAAP
University of Colorado School of Medicine
Children’s Hospital Colorado
Aurora, CO
Cindy Calderon, MD, FAAP
Past President, Puerto Rico Chapter, American Academy of Pediatrics
Clinical Director, COVID-19 Vaccination, Puerto Rico College of Physicians
San Juan, PR
Susan D. Crowe, MD, FACOG
Stanford University School of Medicine
Stanford, CA
Lori Feldman-Winter, MD, MPH, FAAP, FABM
Cooper University Health Care
Cooper Medical School of Rowan University
Camden, NJ
Lauren Hanley, MD, FACOG, IBCLC, FABM
Harvard Medical School
Massachusetts General Hospital
Boston, MA
Daniel S. Hirsch, MD, FAAP
Columbia University Irving Medical Center
New York, NY
Ann Kellams, MD, IBCLC, FAAP, FABM
University of Virginia School of Medicine
Charlottesville, VA
Michelle L. Leff, MD, FAAP, IBCLC
University of California, San Diego, School of Medicine
San Diego, CA

Contributors
Adetola F. Louis-Jacques, MD, FABM, FACOG

University of Florida College of Medicine
Gainesville, FL
Sharon Mass, MD, FACOG
Sidney Kimmel Medical College of Thomas Jefferson University
Philadelphia, PA
Kathryn S. McLeod, MD, FAAP, IBCLC
Medical College of Georgia at Augusta University
Augusta, GA
Florida State University College of Medicine
Orlando, FL
Edward R. Newton, MD, FABM, FACOG
East Carolina University Brody School of Medicine
Greenville, NC
Icahn School of Medicine at Mount Sinai and New York City
Health+Hospitals/Elmhurst
Elmhurst, NY
Gabriela Maradiaga Panayotti, MD, FAAP, IBCLC
Duke University Medical Center
Durham, NC
Margaret G. Parker, MD, MPH, FAAP
Boston Medical Center
Boston University School of Medicine
Boston, MA
Susan Rothenberg, MD, IBCLC, FACOG, FABM
Icahn School of Medicine at Mount Sinai
New York, NY
Richard J. Schanler, MD, FAAP, FABM
Cohen Children’s and Northwell Health
Zucker School of Medicine at Hofstra/Northwell
New Hyde Park, NY
Emily K. Scott, MD, MS, FAAP, IBCLC
Indiana University School of Medicine
vi

Contributors
Indianapolis, IN
Rose St. Fleur, MD, FAAP, FABM, IBCLC
Jersey Shore University Medical Center
Neptune, NJ
Lisa Stellwagen, MD, FAAP
University of California, San Diego, School of Medicine
San Diego, CA
Jennifer Thomas, MD, MPH, IBCLC, FABM, FAAP
Advocate Aurora Healthcare
Milwaukee, WI
Julie Ware, MD, MPH, FAAP, FABM, IBCLC
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH
Michal A. Young, MD, FAAP, FABM
Howard University College of Medicine/Howard University Hospital
Washington, DC
vii

American Academy of Pediatrics Reviewers
Board of Directors Reviewer
Michelle D. Fiscus, MD, FAAP
Committees, Councils, and Sections
Committee on Child Health Financing
Committee on Drugs
Committee on Fetus and Newborn
Committee on Infectious Diseases
Committee on Medical Liability and Risk Management
Committee on Nutrition
Committee on Pediatric and Adolescent HIV
Committee on Practice and Ambulatory Medicine
Committee on Psychosocial Aspects of Child and Family Health
Council on Children and Disasters
Council on Children With Disabilities
Council on Community Pediatrics
Council on Environmental Health and Climate Change
Council on Genetics
Council on Injury, Violence, and Poison Prevention
Council on Quality Improvement and Patient Safety
Section on Administration and Practice Management
Section on Allergy and Immunology
Section on Early Career Physicians
Section on Endocrinology
Section on Epidemiology, Public Health, and Evidence
Section on Gastroenterology, Hepatology, and Nutrition
Section on Hospital Medicine
Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness
Section on Neonatal-Perinatal Medicine
Section on Nicotine and Tobacco Prevention and Treatment
Section on Obesity
Section on Oral Health
Equity, Diversity, and Inclusion Statement

The American Academy of Pediatrics is committed to principles of equity,
diversity, and inclusion in its publishing program. Editorial boards, author
selections, and author transitions (publication succession plans) are designed to
include diverse voices that reflect society as a whole. Editor and author teams are
encouraged to actively seek out diverse authors and reviewers at all stages of the
editorial process. Publishing staff are committed to promoting equity, diversity,
and inclusion in all aspects of publication writing, review, and production.
viii

Contents
Preface....................................................................................................................xiii
1 Evidence for Breastfeeding: Importance for Newborns and Infants,
Mothers, and Society...........................................................................1
Risk Reductions in Breastfeeding Newborns and Infants........................1
Risk Reductions of Breastfeeding for the Mother..................................13
Societal Effects of Breastfeeding.............................................................17
2 The Scope of Breastfeeding...................................................................23
Categories of Breastfeeding.....................................................................24
Breastfeeding in the United States.........................................................25
Breastfeeding Education..........................................................................36
Ethics.......................................................................................................44
Custody Rights........................................................................................47
Recommended Practices.........................................................................52
3 Composition of Human Milk................................................................55
Nutritional Components........................................................................55
Nitrogen...................................................................................................59
Whey and Casein....................................................................................60
Carbohydrates..........................................................................................60
Lipids........................................................................................................60
Variability of Fat Content.......................................................................61
Components of the Lipid System...........................................................61
Fat Absorption.........................................................................................61
Bile Salt-Stimulated Lipase.....................................................................61
Fatty Acids...............................................................................................62
Too Much Foremilk.................................................................................62
Minerals and Trace Elements..................................................................62
Vitamins...................................................................................................63
4 Nonnutritive Components in Human Milk........................................65
Bioactive Proteins...................................................................................65
Osteopontin.............................................................................................68
Bioactive Lipids.......................................................................................69
Bioactive Carbohydrates.........................................................................69
Cellular Elements....................................................................................70
Human Milk Microbiota.........................................................................70
Nucleotides..............................................................................................72
MicroRNA..............................................................................................72
Hormones and Growth Factors..............................................................72
Entero-mammary and Broncho-mammary Immune Pathways.............73
ix

Contents
5 Anatomy and Physiology of Lactation.................................................75

Anatomy of the Breast............................................................................75
Physiology of Lactation...........................................................................80
6 Breastfeeding: Management Before and After Conception...............87
Initial Visit...............................................................................................87
History.....................................................................................................88
Physical Examination..............................................................................90
Education.................................................................................................92
7 Breastfeeding Initiation.........................................................................99
Before Delivery........................................................................................99
After Delivery........................................................................................103
Breastfeeding Basics in the First Days..................................................105
Establishment of Breastfeeding.............................................................111
Newborn Safety and Fall Prevention...................................................116
8 Breastfeeding in the Hospital..............................................................121
Newborn Assessments...........................................................................121
Breastfeeding Patterns and Newborn and Infant Behaviors................125
Common Hospital Issues and Challenges............................................129
Hospital Discharge Planning................................................................139
9 Maintenance of Breastfeeding: The Newborn and Infant...............145
Newborn Jaundice.................................................................................145
The Association of Breastfeeding and Jaundice...................................147
Growth Spurts.......................................................................................148
Nursing Refusal (“Nursing Strike”)......................................................149
Ankyloglossia........................................................................................150
Growth Patterns of Breastfed Newborns and Infants..........................150
Vitamin and Mineral Supplementation...............................................151
Duration of Exclusive Breastfeeding and Introduction of
Complementary Feedings.................................................................152
Sleep Patterns........................................................................................153
Dental Health........................................................................................154
Newborn and Infant Illness..................................................................155
Readmission to the Hospital.................................................................155
Breastfeeding Guidance During Preventive Pediatric
Health Care Visits.............................................................................156
Breastfeeding in the Second Year and Beyond.....................................156
Weaning.................................................................................................156
10 Maintenance of Breastfeeding: The Mother.....................................167
Postpartum Visits...................................................................................167
Short-term Maternal Breastfeeding Issues............................................169
x

Contents
Postpartum Mood Changes: Postpartum Blues and Depression..........178

Long-term Maternal Breastfeeding Issues.............................................179
Maternal Nutrition, Energy Needs, and Weight Management...........180
Breast Evaluation While Nursing.........................................................184
11 The Breastfeeding-Friendly Medical Office.......................................189
A Breastfeeding-Friendly Environment...............................................189
The Business Aspect of Breastfeeding..................................................194
National Initiatives...............................................................................195
Strategies for Implementation..............................................................196
12 Breastfeeding and Human Milk for Preterm Newborns and Infants.....201
Newborns With Very Low Birth Weight.............................................202
Hospital Routines..................................................................................202
Late Preterm Newborns........................................................................209
13 Breastfeeding in Special Circumstances.............................................213
Cleft Lip and Cleft Palate.....................................................................213
Pierre Robin Sequence..........................................................................216
Down Syndrome....................................................................................217
Multiple Births......................................................................................217
Tandem Nursing....................................................................................219
Feeding Human Milk Without Birthing..............................................220
Relactation............................................................................................221
Additional Resources............................................................................221
14 Lactation Support Technology............................................................225
Manual and Mechanical Milk Expression............................................225
Supplemental Feeding Methods...........................................................232
Test Weighing........................................................................................236
Milk Storage..........................................................................................236
Donor Human Milk..............................................................................239
Bacteriologic Surveillance of a Mother’s Milk.....................................240
15 Supporting Breastfeeding During Mother-Infant Separation..........243
Maternal Employment and School Attendance..................................243
Separation Because of Newborn or Infant Illness................................247
Separation Because of Maternal Illness or Surgery..............................247
Milk Expression.....................................................................................248
Bottle-feeding........................................................................................248
16 Medications and Breastfeeding...........................................................255
Drug Passage Into Milk.........................................................................255
Clinical Factors.....................................................................................257
Adverse Reactions.................................................................................258
Phases of Breastfeeding.........................................................................259
xi

Contents
Informative Resources...........................................................................260
Drug Categories.....................................................................................260
17 Contraception and the Breastfeeding Mother...................................287
Contraceptive Counseling....................................................................287
Contraceptive Options.........................................................................288
18 Complications and Contraindications to Breastfeeding...................295
Physical Conditions of the Breast.........................................................295
Absolute and Relative Maternal Contraindications to Breastfeeding.... 297
Newborn and Infant Contraindications to Breastfeeding...................304
19 Breastfeeding Issues During Disasters...............................................307
Disaster Preparation..............................................................................309
Breastfeeding Support During a Disaster..............................................310
Relactation............................................................................................313
COVID-19 Pandemic...........................................................................314
Radiation...............................................................................................315
Appendix A
Breastfeeding and the Use of Human Milk..........................................323
Appendix B
Donor Human Milk for the High-Risk Infant: Preparation, Safety,
and Usage Options in the United States.........................................339
Appendix C
ACOG Bulletin No. 821: Barriers to Breastfeeding: Supporting
Initiation and Continuation of Breastfeeding..................................345
Appendix D
ACOG Bulletin No. 756: Optimizing Support for Breastfeeding as
Part of Obstetric Practice..................................................................355
Appendix E
The Breastfeeding-Friendly Pediatric Office Practice..........................365
Appendix F
The Physician’s Role in Human Milk Feeding....................................375
Appendix G
The Transfer of Drugs and Therapeutics Into Human Breast Milk....379
Appendix H
Promoting Human Milk and Breastfeeding for the
Very Low Birth Weight Infant..........................................................393
Index ....................................................................................................................409
Technical Report Available Online
Breastfeeding and the Use of Human Milk: https://doi.org/10.1542/peds.2022-057989
xii

Preface
As with prior editions, this third edition of the Breastfeeding Handbook for Physi-
cians is written to provide physicians in all specialties with a concise and inex-
pensive teaching and reference aid on breastfeeding and human lactation. The
overall goal of the handbook is to enhance physicians’ knowledge of lactation
physiology and clinical practice so that they become comfortable promoting and
supporting breastfeeding.
The Breastfeeding Handbook for Physicians can be used as a guide to teach breast-
feeding and lactation theory and practice to medical students, residents, and
fellows. Similarly, postgraduate continuing medical education programs can be
built around its contents. It is hoped that this handbook will encourage physi-
cians to become teachers of breastfeeding and lactation medicine.
Because this handbook is written jointly, to represent the collaborative efforts
of the American Academy of Pediatrics and the American College of Obste-
tricians and Gynecologists, it addresses collaboration among physicians and
between physicians and other health care professionals—especially lactation
specialists. To recognize the physician as the coordinator of a health care team
that consists of a large number of other professionals, the concept of a medical
home for baby and mother is stressed in the book, to help provide a framework
on which to build hospital and office policies.
While the book is designed primarily for physicians, use by other health care
professionals, including nurses, dietitians, and lactation specialists, is welcomed;
its use may serve as a bridge between these health care professionals and physi-
cians in achieving coordinated and optimal care.
This edition of the handbook contains updates on important evidence for
breastfeeding, as well as clinical practices. The first chapters deal with the
evidence behind the rationale for breastfeeding and the epidemiology of breast-
feeding in the United States. Risk reduction data are provided to give readers
estimates of effects. The section on milk composition has been enhanced with a
separate chapter on nonnutritive components in human milk, to provide physi-
cians with additional information on how bioactive factors and the microbiome
may explain some of the protective effects of breastfeeding. The chapters that
follow are organized in a life-cycle format to allow for quick reference. These
chapters contain expanded sections on contemporary issues in breastfeeding
management, such as the recently revised World Health Organization/United
Nations Children’s Fund Ten Steps to Successful Breastfeeding, skin-to-skin
contact and safe sleep, assessment of newborn and infant weight changes,
xiii

Preface
medications and vaccine use during lactation, and plans for return to work and
workplace lactation.
Breastfeeding awareness is increasing in the United States. Current data indicate
that 83.9% of women initiate breastfeeding in the hospital, which just surpassed
national targets set for 2020. The proportion of women delivering their new-
borns in a breastfeeding-friendly facility has more than tripled over set targets,
and nearly one-half of all women have a lactation program at their workplace.
The US Centers for Disease Control and Prevention data (Breastfeeding Report
Card, National Immunization Surveys, and Maternity Practices in Infant
Nutrition and Care Survey data) remain extremely useful in guiding clinical
approaches to breastfeeding and emphasize the need to continue working toward
eliminating disparities in breastfeeding rates among women.
The data provided in the handbook underscore the importance of breastfeeding
as a public health imperative, and clinicians should support attempts to remove
barriers to its success. The recommendations for exclusive breastfeeding for
about 6 months, followed by the addition of complementary foods and contin-
ued breastfeeding for 2 years or beyond as mutually desired by mother and child,
should be advocated with a knowledge base that can be found in these chapters.
The development of the Breastfeeding Handbook for Physicians is the product of
numerous experts in the field of breastfeeding and human lactation. We hope
you will find the reference useful for breastfeeding education.
The Editors
xiv

CHAPTER 1
Evidence for Breastfeeding:

Importance for Newborns and
Infants, Mothers, and Society
A
woman’s decision to breastfeed has far-reaching effects, not only for her
newborn and infant and her own health but also for the economic and
environmental benefits to society. These short- and long-term effects
are secondary to the dynamic composition of human milk, which contains anti-
infective and anti-inflammatory factors, oligosaccharides that promote a healthy
gut microbiome, growth factors, microRNA that are important in modulating
epigenetic regulators, and cells such as neutrophils, leukocytes, stem cells, and
bacteria—including Bifidobacterium and Lactobacillus (see Chapter 4, Nonnutri-
tive Components in Human Milk). These factors establish the neonatal immune
system and gut microbiome, which serve to decrease the incidence and severity of
infections and inflammatory reactions. Recent studies emphasize the importance
of the “early critical window” in the first year after birth, during which establishing
a healthy gut microbiome through breastfeeding can induce long-term effects.1
Given the well-documented short- and long-term medical and neurodevelop-
mental advantages, breastfeeding should be considered a public health priority.
This chapter outlines the risk reductions for acute and chronic illness for baby
and mother, as well as the economic effects of breastfeeding.
Ū Risk Reductions in Breastfeeding

Newborns and Infants
Extensive evidence continues to accumulate and confirm that many acute and
chronic pediatric conditions, such as otitis media, acute diarrheal disease, lower
respiratory illnesses, sudden infant death syndrome (SIDS), inflammatory bowel
disease, childhood leukemia, diabetes mellitus, obesity, asthma, and atopic
1
01 Chapter BHFP 001-022.indd 1 8/18/22 10:50 AM

dermatitis, occur less frequently among children who were breastfed as newborns
and infants and more frequently in those who are not breastfed.
The newest published evidence, including meta-analyses and systematic reviews,
is included in this chapter (Tables 1-1 and 1-2); however, these studies are
only as reliable as the individual studies they are based on and the outcome
measures selected. The most recently updated information is highlighted in the
US Department of Agriculture (USDA) Pregnancy and Birth to 24 Months
(P/B-24) project systematic review, which was conducted to evaluate selected
newborn, infant, and child outcomes with breastfeeding,26 and the Agency for
Healthcare Research and Quality (AHRQ) systematic review, which was per-
formed to evaluate maternal health outcomes.27
Acute Illness
Breastfeeding provides numerous immunologic and biochemical factors that
prevent infections and enhance the newborn’s and infant’s host defenses (see
Chapter 3, Composition of Human Milk, and Chapter 4, Nonnutritive Com-
ponents in Human Milk). At the population level, not only are rates of acute
illness lower in breastfed infants, but the duration and severity of illness are
shortened as well. Breastfed newborns and infants experience the same infec-
tions but are generally asymptomatic or have milder symptoms than formula-fed
newborns and infants. These effects are observed in upper- and lower-income/
resource countries. Breastfed newborns and infants also have significantly higher
responses to bacille Calmette-Guérin, Haemophilus influenzae type b, poliovirus,
tetanus, and diphtheria toxoid immunizations.28
Gastrointestinal Infection
The severity of gastrointestinal infection is attenuated if not prevented in
breastfed newborns and infants, with specific effects against enteric patho-
gens such as rotavirus, Giardia, Shigella, Campylobacter, and enterotoxigenic
Escherichia coli. The recent Millennium Cohort Study in the United Kingdom
demonstrated that exclusive breastfeeding for 6 months provided a 30% reduced
risk of severe/persistent diarrhea, while adjusting for confounding factors.7
Respiratory Illnesses
Wheezing and lower respiratory tract disease, among other respiratory illnesses,
are reduced in frequency and duration in breastfed newborns and infants. It has
been estimated that 21,000 hospitalizations and 40 deaths caused by lower respi-
ratory tract infections could be prevented through breastfeeding if 90% of babies
were exclusively breastfeeding through 6 months of age.29 The incidence rate of
lower respiratory tract infection from respiratory syncytial virus has been shown
2

Table 1-1. Breastfeeding and Infant Outcomesa
Outcome and Reference % Lower Risk Breastfeedinga Compared to Commentsb OR, RR, or HR 95% CI
01 Chapter BHFP 001-022.indd 3

SIDS2 40% 2–4 mo None Breastfeeding at least 2 OR 0.60 0.44-0.82
mo to reduce SIDS
60% 4–6 mo None OR 0.40 0.26-0.63
64% > 6 mo None OR 0.36 0.22-0.61
Infant mortality, US3 19% Ever Never US cohort OR 0.81 0.68-0.97
Neonatal mortality (8-27 d)3 51% Ever Never US cohort OR 0.49 0.34-0.72
Postneonatal mortality4 21% Ever Never US nationally OR 0.79 0.67-0.93
3
representative sample
38% > 3 mo Never OR 0.62 0.46-0.82
Infant mortality (7-365 days)77 26% Ever Never US national cohort OR 0.74 0.70-0.79
Neonatal mortality (7-27 days)77 40% Ever Never US national cohort OR 0.60 0.54-0.67
Postneonatal mortality (28-364 days)77 19% Ever Never US national cohort OR 0.81 0.76-0.87
Infant mortality, limited-income 33% Exclusive Predominant RR 0.67 0.52-0.88

countries5
79% Exclusive Partial RR 0.21 0.20-0.22
93% Exclusive None RR 0.07 0.03-0.16

Chapter 1: Evidence for Breastfeeding: Importance for Infants, Mothers, and Society
Infant mortality, limited-income countries6 25% Initiated in first h > first h RR 0.75 0.64-0.88
Lower respiratory tract infection7 19% Exclusive 6 mo Exclusive < 4 mo Cohort RR 0.81 0.69-0.95
(continued )
8/18/22 10:50 AM
Table 1-1 (continued )
Severe/persistent diarrhea7 30% Exclusive 6 mo Exclusive < Cohort RR 0.70 0.52-0.94

4 mo
Otitis media8 33% Ever Never OR 0.67 0.56-0.80
33% More Less OR 0.67 0.59-0.76
43% Exclusive 6 mo None OR 0.57 0.44-0.80

Asthma, 5–18 y9 10% More Less OR 0.90 0.84-0.97
12% Ever Never OR 0.88 0.82-0.95
4
Asthma, ever, all ages10 22% Longer Shorter Most protective for OR 0.78 0.74-0.84
wheezing in first 2 y
Eczema, first 2 y9 26% Exclusive 3–4 mo Shorter OR 0.74 0.57-0.97
Crohn disease11 29% Ever Never OR 0.71 0.59-0.85
80% 12 mo 3–6 mo OR 0.20 0.08-0.50
Ulcerative colitis12 22% Ever Never OR 0.78 0.67-0.91
79% 12 mo 3–6 mo OR 0.21 0.10-0.43
Childhood obesity12 22% Ever Never OR 0.78 0.74-0.81
10% < 3 mo Never OR 0.90 0.84-0.95
12% 3–5 mo Never OR 0.88 0.79-0.97
17% 5–7 mo Never OR 0.83 0.76-0.90
21% > 7 mo Never OR 0.79 0.70-0.88
8/18/22 10:50 AM
Table 1-1 (continued )

Childhood and adult obesity13 23% Ever Never OR 0.77 0.69-0.86
26% Greater Less OR 0.74 0.68-0.80
31% Exclusive Nonexclusive OR 0.69 0.61-0.79
Childhood obesity14 18% > 6 mo Never European pooled OR 0.82 0.78-0.86

analysis
11% > 6 mo OR 0.89 0.86-0.93
20% Exclusive 6 mo Nonexclusive OR 0.8 0.74-0.85
5
Type 1 DM15 57% Full breastfeed- Never Cohort HR 0.43 0.21-0.90
ing 6 mo
56% 12 mo Never Cohort HR 0.44 0.22-0.88
Type 2 DM16 33% Ever Never OR 0.67 0.56-0.80
Leukemia17 11% Ever Never OR 0.89 0.84-0.94
19% 6 mo None or shorter OR 0.81 0.73-0.89
Abbreviations: CI, confidence interval; DM, diabetes mellitus; HR, hazard ratio; OR, odds ratio; RR, relative risk; SIDS, sudden infant death syndrome.
a
Not necessarily exclusively breastfed unless specifically indicated.
b
Data are from meta-analyses, unless another type of study is indicated.
From Meek JY, Noble L; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988.
8/18/22 10:50 AM
Table 1-2. Breastfeeding and Maternal Outcomes

(From Meta-analyses)
Condition and % Lower
Reference Risk Breastfeedinga Compared to OR or RR 95% CI
Type 2 DM18 32% Longer Shorter RR 0.68 0.57-0.82
DM19 30% > 12 mo Less RR 0.70 0.62-0.78
Gestational DM 78% Longer Shorter OR 0.22 0.13-0.36

and type 2 DM20
58% Exclusive None OR 0.42 0.22-0.81
Hypertension21 8% None OR 0.92 0.88-0.96
11% 6–12 mo None OR 0.89 0.86-0.92
12% > 12 mo None OR 0.88 0.84-0.93
Hypertension19 13% > 12 mo Less RR 0.87 0.78-0.97
Premenopausal 14% Any None RR 0.86 0.80-0.93

breast cancer22
Postmenopausal 11% Any None RR 0.89 0.83-0.95

breast cancer22
Breast cancer22 28% Exclusive None RR 0.72 0.58-0.90
Breast cancer23 22% Any None OR 0.78 0.74-0.82
7% < 6 mo None OR 0.93 0.88-0.99
9% 6–12 mo None OR 0.91 0.87-0.96
26% > 12 mo None OR 0.74 0.69-0.79
Ovarian cancer23 30% Ever Never OR 0.70 0.64-0.77
17% < 6 mo None OR 0.83 0.78-0.89
28% 6–12 mo None OR 0.72 0.66-0.78
37% > 12 mo None OR 0.63 0.56-0.71
Endometrial 11% Ever Never OR 0.89 0.81-0.98

cancer24
Thyroid cancer25 9% Ever Never RR 0.91 0.83-0.99
Abbreviations: CI, confidence interval; DM, diabetes mellitus; OR, odds ratio; RR, relative risk.
a
Not necessarily exclusively breastfed unless specifically indicated.
From Meek JY, Noble L; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of
human milk. Pediatrics. 2022;150(1):e2022057988.

to be doubled in infants who were not breastfed.30 The Millennium Cohort

Study also indicated that infants who exclusively breastfed for 6 months had a
decreased risk of lower respiratory tract infections when compared with infants
who exclusively breastfed for fewer than 4 months.7
Otitis Media
A recent meta-analysis of 24 studies from the United States and Europe demon-
strated a protective effect of breastfeeding over the first 2 years after birth in a
dose-response fashion. Exclusive breastfeeding for the first 6 months after birth
showed a risk reduction of 43%, whereas “more versus less” breastfeeding and
“ever versus never” breastfeeding were associated with a 33% risk reduction.8
Sudden Infant Death Syndrome and Infant Mortality

Breastfeeding is associated with a reduced risk of SIDS. Breastfeeding for longer
than 2 months has been associated with a reduction in SIDS by 40%, by 60% if
breastfeeding duration was at least 4 months, and by 64% if breastfeeding dura-
tion was longer than 6 months.2 Exclusive breastfeeding was tracked and similarly
showed a duration-dependent effect, with the greatest protection for 4 to 6 months,
a 63% reduction. However, data were insufficient to analyze the effects of 6-month
exclusive breastfeeding. Public health messaging should therefore stress the
importance of breastfeeding for at least 2 months for the risk reduction of SIDS and
highlight that longer durations will result in even lower incidence rates of SIDS
and infant mortality. Statistical modeling indicates that optimizing breastfeeding in
the United States could prevent 492 infant deaths from SIDS every year.29
By using US national data linking birth and death certificates, it is estimated
that ever breastfeeding is associated with a 26% lower risk of infant mortality
(7–365 days) and 40% lower risk of neonatal mortality (7–27 days), and 19%
lower risk of postneonatal mortality (28–364 days). The major causes of infant
mortality lowered by breastfeeding initiation in these adjusted models included
infections, sudden unexpected infant death, and necrotizing enterocolitis. In
terms of infant mortality in lower-income/resource countries, exclusive breast-
feeding and early breastfeeding in the first hour after birth are especially impor-
tant.5,6 It has been estimated that improving global breastfeeding could prevent
823,000 annual deaths in children younger than 5 years.31
Chronic Diseases of Childhood

Diabetes
A recent Scandinavian population cohort study noted a 200% increase in risk of
developing type 1 diabetes in children who were never breastfed, compared with

those breastfeed for 12 months or longer, as well as a similar increase in risk when
compared with those fully breastfed for at least 6 months.15 In the USDA P/B-24
project, the systematic review of infant feeding and the development of diabetes
showed that never being fed human milk is associated with a higher risk of type 1
diabetes mellitus, and a shorter duration of breastfeeding is also associated with
an increased risk, when compared with a longer duration of breastfeeding.32 The
putative mechanism in the development of type 1 diabetes mellitus is postulated
to be the infant’s exposure to cow milk β-lactoglobulin, which stimulates an
immune-mediated process that cross-reacts with pancreatic β cells.33
The USDA P/B-24 systematic review had insufficient evidence to determine
whether or not there is a relationship between ever and never feeding human
milk and the development of type 2 diabetes mellitus, insulin resistance, and
other associated metabolic abnormalities.32 However, another meta-analysis did
find a protective effect of breastfeeding for the development of type 2 diabetes,
which was even higher for adolescents, with a 51% risk reduction, and extended
to adulthood, with a 23% risk reduction.16
Cardiovascular Disease
The USDA P/B-24 review indicated that breastfeeding decreased blood pressure at 6
to 7 years of age but was not associated with other cardiovascular disease outcomes.26
Obesity
A mounting body of evidence indicates that breastfeeding provides some level
of protection against overweight and obesity.34 Because breastfeeding may lower
the risk of obesity, national campaigns to prevent obesity should begin with
breastfeeding support. Although complex factors may confound studies of obesity,
there is a modest reduction in adolescent and adult obesity rates if any breastfeed-
ing occurred in infancy, compared with no breastfeeding. A 22% reduced risk of
obesity has been shown with breastfeeding, as well as a dose-response effect with
breastfeeding duration (breastfeeding for < 3 months reduced risk by 10%; 3–5
months, 12%; 5–7 months, 17%; and ≥ 7 months, 21%).12 Additionally, a 26%
reduced risk of both overweight and obesity with breastfeeding has been dem-
onstrated in children and adults.13 In another meta-analysis, breastfed and non-
breastfed infants were compared, and a 15% decrease in the odds of childhood
overweight was found.35 A European pooled analysis confirms these findings.14
Investigators also evaluated breastfeeding promotion efforts, and although they did
not find significant changes in child weight or length, they did find a reduction in
body mass index (BMI), which highlights the importance of adding breastfeeding
promotion to public health strategies for obesity prevention.36 The Early Nutrition
Project recently concluded that breastfeeding should be promoted, protected,

and supported, because—in addition to many other benefits—breastfeeding may

contribute to risk reduction for later overweight and obesity.37
The protective effect of breastfeeding against overweight and obesity appears to
be greater for exclusively breastfed newborns and infants, when compared with
those who are fed formula or who receive combined breastfeeding and formula
feedings. Mothers who use combined breastfeeding and formula feeding or
exclusive formula feeding may be less attuned to feeding and satiety cues in their
newborns and infants. Other postulated mechanisms for this association relate
to how nursing newborns and infants self-regulate milk intake volume, irrespec-
tive of maneuvers that increase available milk volume; the early programming
of self-regulation, in turn, affects adult weight gain. This concept is supported
by the observations that infants who are fed by bottle, who are fed formula, and
who are fed expressed breast milk will demonstrate increased bottle emptying,
poorer self-regulation, and excessive weight gain in later infancy (> 6 months)
when compared with infants who only nurse from the breast.38
Asthma
Recent studies continue to highlight the importance of breastfeeding to reduce
the risk of asthma. An asthma risk reduction of 10% has been shown in more
breastfeeding versus less; similarly, a 12% asthma risk reduction was found in any
breastfeeding versus never breastfeeding in children 5 to 18 years of age.9 It has
also been shown that a longer duration of breastfeeding is associated with a 22%
decreased risk of developing asthma across all age groups and is most protective
against asthma for the first 2 years after birth and until at least 3 to 6 years of
age.10 Moreover, the American Academy of Pediatrics (AAP) recently con-
cluded that breastfeeding for at least 3 to 4 months is protective against wheez-
ing in the first 2 years after birth. There is also some evidence that longer versus
shorter duration of any breastfeeding is associated with a reduced risk of asthma,
even after 5 years of age. The USDA P/B-24 systematic review indicated that
any breastfeeding is associated with lower risk of childhood asthma.
Allergic Rhinitis and Eczema

Breastfeeding has been shown to reduce the risk of allergic rhinitis for children
up to 5 years of age, and exclusive breastfeeding has been shown to reduce the
risk of eczema within the first 2 years after birth.9 However, according to the
P-B/24 systematic review, limited evidence did not indicate an association
between breastfeeding and atopic dermatitis or allergic rhinitis.39 More research
in this area is clearly needed.
Exclusive breastfeeding for at least 3 to 4 months decreases the cumulative
incidence of eczema in the first 2 years after birth.40 There was no evidence that

breastfeeding or hydrolyzed formula decreased food allergies; however, studies

may be imprecise in combining exclusive breastfeeding at the breast versus
feeding human milk, because direct breastfeeding may be important in the
mechanism of protection. The USDA P/B-24 systematic review also indicated
that longer durations of breastfeeding offered more protection, but no relation-
ship was found with atopic dermatitis or food allergies.26
For the prevention of allergic disease, the AAP continues to endorse exclusive
breastfeeding for about 6 months, followed by the introduction of complemen-
tary foods, with the only possible exception being infants at high risk for peanut
allergy, in whom introduction of peanut protein at 4 to 6 months of age may
confer protection.40
Inflammatory Bowel Disease

A meta-analysis showed that breastfeeding is associated with a reduced risk
of Crohn disease by 29% and for ulcerative colitis by 22%. This association is
dose dependent in that the strongest decrease in risk occurs when breastfeeding
duration is at least 12 months for Crohn disease (80% reduced risk) and 79%
for ulcerative colitis, compared with only 3 or 6 months of breastfeeding.11
The USDA systematic review indicates that longer duration of breastfeeding
is also associated with lower rates of inflammatory bowel disease.26 The protec-
tive effect may result from the interaction of the immune-modulating effect of
human milk and the underlying genetic susceptibility of the newborn or infant
or from an altered microbiome in formula-fed newborns and infants.
Celiac Disease
Although it has not been shown that breastfeeding or introducing gluten while
breastfeeding reduces the risk of celiac disease,41,42 the USDA P/B-24 project
yielded limited evidence to suggest that never being fed human milk is associ-
ated with a higher risk of celiac disease, when compared with ever being fed
human milk.26
Childhood Leukemia
When compared with no breastfeeding or shorter duration of breastfeeding, any
breastfeeding for at least 6 months after birth is associated with a 20% lower
risk of childhood leukemia, and any breastfeeding when compared with never
breastfeeding is associated with a 9% lower risk of childhood leukemia.17 Indeed,
14% to 20% of all childhood leukemia cases may be prevented by breastfeeding
for 6 months or more. The evidence for prevention of childhood lymphomas,
however, is inconclusive.17,43 The investigators of the P/B-24 project similarly
concluded that never being breastfed is associated with a slightly higher risk of
10

childhood leukemia when compared with ever being breastfed and that a longer
duration of breastfeeding (≥ 6 months) was the most protective.44
Neurodevelopmental Outcomes
IQ
According to 16 observational studies that controlled for several confounding fac-
tors, being breastfed in early life is associated with a higher mean IQ of 3.44 points
(95% CI, 2.30–4.58). Even after controlling for maternal IQ, the relationship was
maintained, although somewhat attenuated (mean difference, 2.62 points [95% CI,
1.25–3.98]).45 A prospective, population-based birth cohort study of neonates in
Brazil followed participants for 30 years. In the adjusted analysis, participants who
were breastfed for 12 months or longer had higher IQ scores (mean difference,
3.76 points [95% CI, 2.20–5.33]), more years of education (mean, 0.91 years
[95% CI, 0.42–1.40]), and higher monthly incomes than those who were breastfed
for less than 1 month. This analysis also indicated that adult IQ was responsible
for 72% of the effect of breastfeeding on income.46
Attention-Deficit/Hyperactivity Disorder
A recent meta-analysis demonstrated that children with attention-deficit/
hyperactivity disorder had significantly less breastfeeding duration than control
subjects (mean, −2.44 months [95% CI, −3.17 to −1.71]) and were 31% less
likely to have been breastfed for 6 to 12 months and 42% less likely to have
been breastfed for longer than 12 months. They were 48% less likely to have
been exclusively breastfed for longer than 3 months and were 3.7 times more
likely to not have been breastfed at all.47
Autism Spectrum Disorder

A meta-analysis of 7 studies showed that children with autism spectrum disorder
were 39% less likely to have been breastfed. Subgroup analyses showed that
results remained significant for children who were breastfed with additional
supplementation.48 In both attention-deficit/hyperactivity disorder and autism
spectrum disorder, there may be a possibility of reverse causality, in that infants
with these diagnoses may have poor oral motor skills, have difficulty with social-
emotional interaction, and be inattentive at breastfeeding skills, which can lead
to earlier weaning.
Neglect and Abuse

According to the National Longitudinal Study of Adolescent to Adult Health,
when compared with adolescents who were never breastfed, adolescents who
11

were breastfed for 9 months or longer had a 46% reduced risk of having expe-
rienced neglect and a 53% reduced risk of sexual abuse, after controlling for
covariates.49
Dental Health
It has been well documented that breastfeeding decreases the development
of malocclusion.50–52 Additionally, breastfeeding for up to 12 months has also
demonstrated a reduced risk of infant caries, but breastfeeding for longer than
12 months has shown an increased risk of caries when compared with children
who were breastfed for fewer than 12 months. For children who were breastfed
for longer than 12 months, those who fed nocturnally or more frequently
had a 7-times increased risk of caries. In addition, children who are breastfed
for 24 months or longer have a 2.4-times higher risk of having severe early
childhood caries than those who are breastfed up to 12 months of age, while
breastfeeding between 13 and 23 months of age has no effect on dental car-
ies.53 In summary, there is a benefit of decreased caries with breastfeeding up to
12 months, but more caries occur in children who are breastfed for longer than
2 years, or longer than 1 year if there is a higher rate of feeding at night.
Preterm Newborns and Infants
Neonatal Morbidity
Providing human milk to neonates with very low birth weight (≤ 1,500 g) in
the neonatal intensive care unit offers short- and long-term health benefits and
should be considered lifesaving medical therapy (see Chapter 12, Breastfeeding
and Human Milk for Preterm Newborns and Infants). A mother’s own milk
contains macronutrients, micronutrients, and an array of active biological
components, such as immunoglobulins, cytokines, growth factors, hormones,
antimicrobial agents, probiotic bacteria, immune cells, stem cells, and prebiot-
ics such as oligosaccharides (see Chapter 3, Composition of Human Milk, and
Chapter 4, Nonnutritive Components in Human Milk).
A clear protective effect in human milk has been found against necrotizing
enterocolitis (NEC), as well as decreased incidence of late-onset sepsis, severe
retinopathy of prematurity, and bronchopulmonary dysplasia (BPD).54 Particu-
larly for NEC, receiving any volume of human milk is better than none, and the
higher the dose of human milk received, the greater the protection afforded.55 A
diet of exclusive human milk reduces BPD by 23%, and a diet of partial human
milk reduces BPD by 17%.56
A mother’s own milk should be the primary diet of preterm neonates and
infants. Pasteurized donor human milk should be provided when a mother’s own
12

milk is not available or when it is contraindicated. Fortification of a mother’s

own milk or pasteurized donor human milk with bovine-based or human milk–
based fortifiers is necessary for growth optimization.
Very premature neonates and infants who are fed donor milk as a sole diet or as
a supplement to their mother’s own milk have been shown to receive protec-
tion against NEC, have slower in-hospital growth, and have no difference in
long-term growth or neurodevelopment, when compared with very premature
neonates and infants who are fed formula.57 The use of donor milk has been
associated with increased use of a mother’s own milk, possibly because of height-
ened awareness of the importance of human milk.58
Ū Risk Reductions of Breastfeeding

for the Mother
Bonding and Stress Reduction
For the mother, the psychological advantages to breastfeeding include creating
a quiet time for the nursing mother and fostering bonding with her newborn or
infant. It has been shown that lactating women have decreased levels of steroid
hormones. The blunted response of stress hormones is thought to be an adaptive
mechanism for negotiating the stressful time of the puerperium. In addition to
decreasing the stress response, oxytocin also may foster maternal-infant bonding
and play a role in blunting the perception of pain via the dopaminergic pathway.
Postpartum Weight Retention

Postpartum weight loss may be facilitated in breastfeeding women. However,
studies of the overall effect of breastfeeding on the return of mothers to their
prepregnancy weight are inconclusive, given the large numbers of confounding
factors on weight loss (ie, diet, activity, baseline BMI, and ethnicity). It has been
shown that mothers who breastfed had significantly lower postpartum weight
retention of −0.38 kg (95% CI, −0.64 to −0.11). However, subgroup analysis
showed that breastfeeding for fewer than 3 months did not show a significant
effect, breastfeeding for 3 to 6 months had a minimal decrease (−0.20 kg),
breastfeeding for 6 to 12 months the largest decrease (−1.58 kg), and breastfeed-
ing for longer than 1 year a smaller decrease (−0.97 kg).59 In addition, breastfeed-
ing may be more effective in promoting weight loss for lactating women who
are younger than 30 years, those who are primipara, or those who have a normal
prepregnancy BMI. The AHRQ review of 16 cohort studies showed an unclear
association between breastfeeding and postpartum weight change but also noted
that postpartum weight change varied according to exposure to breastfeeding.27
13

Cancer
Breast Cancer
Breastfeeding has long been associated with a decrease in the risk of breast
and ovarian cancers. Breastfeeding has been shown to decrease breast cancer
rates by 16% when compared with parous and nulliparous women who never
breastfed, in both premenopausal (14%) and postmenopausal women (11%).
Exclusive breastfeeding had a stronger protective effect against breast cancer,
with a reduced risk of 28%.22 Breastfeeding duration is likewise very important.
A meta-analysis of 24 studies involving 13,907 breast cancer cases demonstrated
that breastfeeding decreased breast cancer rates by 39% and longer breastfeeding
durations decreased breast cancer rates more than shorter breastfeeding dura-
tions (with 53% reduced risk).60 Indeed, breastfeeding for fewer than 6 months
decreased breast cancer rates by 7%; 6 to 12 months, 9%; and longer than
12 months, 26%.23 Maximum protection is offered by longer than 24 months of
continuous or sequential breastfeeding.
It is also important to consider breast cancer subtype when evaluating the
association between breast cancer and breastfeeding. Breastfeeding decreases the
risk of developing estrogen receptor (ER)–negative and progesterone receptor
(PR)–negative breast cancer subtypes by 10% and reduces the risk of develop-
ing triple-negative breast cancer by 12%, but it does not decrease the risk of
developing ER+/PR+ or ER+ and/or PR+ breast cancers.61 Breastfeeding has
also been associated with a 23% reduced risk of developing luminal subtype
cancer and a 21% reduced risk of triple-negative subtype cancer.62 Among
BRCA1 mutation carriers, breastfeeding for at least 1 year is associated with a
32% reduction in risk (OR, 0.68; 95% CI, 0.52–0.91; P = .008); breastfeeding
for 2 years or longer confers a greater reduction in risk (OR, 0.51; 95% CI,
0.35–0.74). Among BRCA2 mutation carriers, there is no significant associa-
tion between breastfeeding for at least 1 year and breast cancer risk (OR, 0.83;
95% CI, 0.53–1.31; P = .43).63
Likewise, the AHRQ systematic review demonstrated a consistent association
between ever breastfeeding and lower rates of breast cancer with a reduced risk
by 22% when compared with never breastfeeding; longer durations of breast-
feeding were associated with lower rates of breast cancer. An unclear association
was noted between breastfeeding and breast cancer mortality.27 However, other
investigators have estimated that improving global breastfeeding rates could
prevent 20,000 annual deaths from breast cancer.31
14

Ovarian Cancer
Breastfeeding decreases the risk of ovarian cancer by 30% to 34%, and for every
1 month increase in breastfeeding duration, the risk of ovarian cancer decreases
by 2%.23,64 A dose-dependent association has been noted, as breastfeeding for
fewer than 6 months decreases ovarian cancer rates by 17%; breastfeeding for 6
to 12 months decreases ovarian cancer rates by 28%; and breastfeeding for lon-
ger than 12 months decreases ovarian cancer rates by 37%.23 Breastfeeding for
longer than 12 months is associated with a 38% reduced risk of ovarian cancer
for carriers of the BRCA1 mutation and a 50% reduced risk for carriers of the
BRCA2 mutation.65 The anovulation associated with lactation also may protect
against ovarian cancer, which has been shown to increase with greater frequency
of ovulation.
Endometrial Cancer
Breastfeeding reduces the risk of endometrial cancer by 26%. A linear relation-
ship has been found to indicate that cancer risk decreased by 1.2% for every
1-month increment of breastfeeding.66 In addition, according to the Epidemiol-
ogy of Endometrial Cancer Consortium, any breastfeeding is associated with an
11% reduction in endometrial cancer, and longer durations are associated with
lower risks of endometrial cancer.24
Thyroid Cancer
Breastfeeding has been found to decrease thyroid cancer incidence rates by
9%, and a linear relationship has been noted; an increment of 1-month of
breastfeeding decreased the risk of thyroid cancer by 2%.25 A longer duration of
breastfeeding has been found to decrease the risk of thyroid cancer by 30%.67
Type 2 Diabetes, Cholesterol, and Blood Pressure

A meta-analysis of 4 studies demonstrated that breastfeeding for longer than
12 months decreased diabetes rates by 30%, compared with breastfeeding for a
shorter duration.19 Breastfeeding (longer vs shorter duration) has been shown to
decrease the risk of type 2 diabetes by 32% in mothers who breastfeed.18 Every
year of lifetime breastfeeding decreases the risk of type 2 diabetes by 4% to 12%.
In mothers with gestational diabetes, longer lactation (> 4–12 weeks vs shorter
duration of lactation) reduces the risk of type 2 diabetes in the next 5 years by
78%, and exclusive lactation for longer than 6 to 9 weeks lowers the risk of
type 2 diabetes when compared with exclusive formula feeding by 58%.20 The
AHRQ review demonstrated a consistent association between any breastfeeding
and longer durations of breastfeeding with a decreased risk of type 2 diabetes
15

among women with and without gestational diabetes, with the magnitude vary-
ing according to breastfeeding exposure.27
Cholesterol
The nationally representative Korea National Health and Nutrition Examina-
tion Survey showed that breastfeeding duration of longer than 24 months
decreased the risk of having a low-density lipoprotein cholesterol disorder by
16% and decreased the risk of having a non–high-density lipoprotein cholesterol
disorder by 25%.68
Blood Pressure and Cardiovascular Disease

Breastfeeding offers a reduced risk of hypertension, which varies according to
the number of months of breastfeeding: longer than 0 to 6 months, 8% reduced
risk; longer than 6 to 12 months, 11% reduced risk; and longer than 12 months,
12% reduced risk, when compared with non-breastfeeding mothers.21 A meta-
analysis of 5 studies showed that breastfeeding for longer than 12 months
decreased rates of hypertension by 13%, when compared with breastfeeding for
a shorter duration.19 A consistent association has also been found between a
longer duration of breastfeeding (> 6–12 months) and lower rates of hyperten-
sion. There is an unclear association between breastfeeding duration and lower
cardiovascular disease rates, however. Likewise, an unclear association has been
found between breastfeeding and cardiovascular-related mortality.27
Osteoporotic Fractures
Losses in bone density (of approximately 5%) are seen during lactation, with
remineralization occurring during weaning of the infant. Breastfeeding does not
increase the risk of osteoporotic and forearm fractures in women and may reduce
the risk of hip fracture by 28%. In a subgroup analysis, the beneficial effect of
breastfeeding on hip fracture was remarkable, with a 48% reduced risk among
postmenopausal women. In dose-response analysis, hip fracture risk decreased by
1.2% for each 1-month increment of breastfeeding.69
Rheumatoid Arthritis
Breastfeeding has been reported to decrease the risk of maternal rheumatoid
arthritis by 32% in a meta-analysis of 6 studies. In subgroup analysis, breastfeed-
ing for 1 to 12 months was found to decrease the risk of rheumatoid arthritis
by 22% and decrease the risk by 48% when breastfeeding for longer than
12 months.70 However, a more recent Swedish epidemiological investigation
with 2,641 cases and 4,251 control subjects demonstrated no association
between breastfeeding and rheumatoid arthritis.71
16

Ū Societal Effects of Breastfeeding

Breastfeeding has been called the most environmentally friendly food avail-
able. It is a natural, renewable food that produces no pollution or greenhouse
gases and requires no packaging or transportation. By contrast, human milk
substitutes require energy to produce, packaging materials, fuel for transport,
water for use, and cleaning solutions for daily preparation and use—all of which
generate pollution. A report on the carbon footprint of baby formula in the
Asia-Pacific region noted that the total greenhouse gas emissions from milk
formula sold in just 6 countries in 2012 was 2.89 million tons, which is roughly
the equivalent of a car driving 6.9 billion miles or burning 3,107 million
pounds of coal.72 In the United States, 550 million cans, 86,000 tons of metal,
and 364,000 tons of paper used annually to package infant formula ends up in
landfills.73 The contribution of breastfeeding to environmental sustainability
and food security year-round should be considered in development goals at
national and global levels.
It has been estimated that lost income potential due to lower IQ scores from
not being universally breastfed for 6 months results in a global economic loss
of $300 billion a year or 0.49% of world gross national income.74 In addition,
a 10% increase in IQ with exclusive breastfeeding for up to 6 months or con-
tinued breastfeeding for up to 1 to 2 years after birth would reduce treatment
costs of childhood disorders by at least $312 million every year in the United
States. According to an analysis of maternal and childhood treatment costs in
the United States, it has been estimated that if 90% of newborns and infants
were breastfed according to medical recommendations, treatment costs would
decrease by $3.0 billion a year—79% of which are maternal treatment costs.
In addition, the cost of premature maternal and infant death every year totals
$14.2 billion.29 Keith Hansen, the former vice president of the World Bank,
has stated: “If breastfeeding did not already exist, someone who invented it
today would deserve a dual Nobel Prize in medicine and economics. For while
‘breast is best’ for lifelong health, it is also excellent economics.”75
The economic advantages of breastfeeding can be calculated at the personal
level. The obvious personal advantage is in the savings accrued by not purchas-
ing infant formula, a figure conservatively estimated to range from $750 to
$1,200 per year, per infant.76 Studies conducted by managed care organizations
indicate that breastfeeding for 3 months significantly reduces the direct costs
of medical care (for medicines and doctor visits) when compared with no
breastfeeding.
17

In summary, breastfeeding results in reduced burden of acute and chronic

infant illnesses; reduced burden of maternal illness; reduced annual health care
costs; reduced Special Supplemental Nutrition Program for Women, Infants,
and Children costs for formula; reduced employer costs and parental employee
absenteeism (with associated loss of family income); reduced environmental
burden for disposal of formula cans and bottles; and reduced energy demands
for production and transport of artificial feeding products. Breastfeeding is more
than simply a lifestyle choice—it is a public health priority, and families need
our support to make breastfeeding a success.
Ū Selected References
1. Stiemsma LT, Michels KB. The role of the microbiome in the developmental origins of health
and disease. Pediatrics. 2018;141(4):e20172437 PMID: 29519955 https://doi.org/10.1542/peds.
2017-2437
2. Thompson JMD, Tanabe K, Moon RY, et al. Duration of breastfeeding and risk of SIDS: an
individual participant data meta-analysis. Pediatrics. 2017;140(5):e20171324 PMID: 29084835
https://doi.org/10.1542/peds.2017-1324
3. Ware JL, Chen A, Morrow AL, Kmet J. Associations between breastfeeding initiation and
infant mortality in an urban population. Breastfeed Med. 2019;14(7):465–474 PMID: 31210534
https://doi.org/10.1089/bfm.2019.0067
4. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States.
Pediatrics. 2004;113(5):e435–e439 PMID: 15121986 https://doi.org/10.1542/peds.113.5.e435
5. Sankar MJ, Sinha B, Chowdhury R, et al. Optimal breastfeeding practices and infant and child
mortality: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):3–13 PMID:
26249674 https://doi.org/10.1111/apa.13147
6. Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM; Neovita Study Group.
Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis.
PLoS One. 2017;12(7):e0180722 PMID: 28746353 https://doi.org/10.1371/journal.
pone.0180722
7. Quigley MA, Carson C, Sacker A, Kelly Y. Exclusive breastfeeding duration and infant
infection. Eur J Clin Nutr. 2016;70(12):1420–1427 PMID: 27460268 https://doi.org/10.1038/
ejcn.2016.135
8. Bowatte G, Tham R, Allen KJ, et al. Breastfeeding and childhood acute otitis media: a
systematic review and meta-analysis. Acta Paediatr. 2015;104(467):85–95 PMID: 26265016
https://doi.org/10.1111/apa.13151
9. Lodge CJ, Tan DJ, Lau MX, et al. Breastfeeding and asthma and allergies: a systematic
review and meta-analysis. Acta Paediatr. 2015;104(467):38–53 PMID: 26192405 https://doi.
org/10.1111/apa.13132
10. Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and
childhood asthma: systematic review and meta-analysis. Am J Epidemiol. 2014;179(10):1153–
1167 PMID: 24727807 https://doi.org/10.1093/aje/kwu072
11. Xu L, Lochhead P, Ko Y, Claggett B, Leong RW, Ananthakrishnan AN. Systematic review
with meta-analysis: breastfeeding and the risk of Crohn’s disease and ulcerative colitis. Aliment
Pharmacol Ther. 2017;46(9):780–789 PMID: 28892171 https://doi.org/10.1111/apt.14291
12. Yan J, Liu L, Zhu Y, Huang G, Wang PP. The association between breastfeeding and childhood
obesity: a meta-analysis. BMC Public Health. 2014;14(1):1267 PMID: 25495402 https://doi.
org/10.1186/1471-2458-14-1267
18

13. Horta BL, Loret de Mola C, Victora CG. Long-term consequences of breastfeeding on
cholesterol, obesity, systolic blood pressure and type 2 diabetes: a systematic review and
meta-analysis. Acta Paediatr. 2015;104(467):30–37 PMID: 26192560 https://doi.org/10.1111/
apa.13133
14. Rito AI, Buoncristiano M, Spinelli A, et al. Association between characteristics at birth,
breastfeeding and obesity in 22 countries: the WHO European Childhood Obesity Surveillance
Initiative – COSI 2015/2017. Obes Facts. 2019;12(2):226–243 PMID: 31030194 https://doi.
org/10.1159/000500425
15. Lund-Blix NA, Dydensborg Sander S, Størdal K, et al. Infant feeding and risk of type 1 diabetes
in two large scandinavian birth cohorts. Diabetes Care. 2017;40(7):920–927 PMID: 28487451
https://doi.org/10.2337/dc17-0016
16. Horta BL, de Lima NP. Breastfeeding and type 2 diabetes: systematic review and meta-analysis.
Curr Diab Rep. 2019;19(1):1 PMID: 30637535 https://doi.org/10.1007/s11892-019-1121-x
17. Amitay EL, Keinan-Boker L. Breastfeeding and childhood leukemia incidence: a meta-analysis
and systematic review. JAMA Pediatr. 2015;169(6):e151025 PMID: 26030516 https://doi.
org/10.1001/jamapediatrics.2015.1025
18. Aune D, Norat T, Romundstad P, Vatten LJ. Breastfeeding and the maternal risk of type
2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr
Metab Cardiovasc Dis. 2014;24(2):107–115 PMID: 24439841 https://doi.org/10.1016/j.
numecd.2013.10.028
19. Rameez RM, Sadana D, Kaur S, et al. Association of maternal lactation with diabetes and
hypertension: a systematic review and analysis. JAMA Netw Open. 2019;2(10):e1913401 PMID:
31617928 https://doi.org/10.1001/jamanetworkopen.2019.13401
20. Tanase-Nakao K, Arata N, Kawasaki M, et al. Potential protective effect of lactation against
incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus:
a systematic review and meta-analysis. Diabetes Metab Res Rev. 2017;33(4):e2875 PMID:
28072911 https://doi.org/10.1002/dmrr.2875
21. Qu G, Wang L, Tang X, Wu W, Sun Y. Association between duration of breastfeeding and
maternal hypertension: a systematic review and meta-analysis. Breastfeed Med. 2018;13(5):318–
326 PMID: 29698055 https://doi.org/10.1089/bfm.2017.0180
22. Unar-Munguía M, Torres-Mejía G, Colchero MA, González de Cosío T. Breastfeeding mode
and risk of breast cancer: a dose–response meta-analysis. J Hum Lact. 2017;33(2):422–434
PMID: 28196329 https://doi.org/10.1177/0890334416683676
23. Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and maternal health outcomes: a
systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96–113 PMID: 26172878
24. Jordan SJ, Na R, Johnatty SE, et al. Breastfeeding and endometrial cancer risk: an analysis from
the Epidemiology of Endometrial Cancer Consortium. Obstet Gynecol. 2017;129(6):1059–1067
PMID: 28486362 https://doi.org/10.1097/AOG.0000000000002057
25. Yi X, Zhu J, Zhu X, Liu GJ, Wu L. Breastfeeding and thyroid cancer risk in women: a dose-
response meta-analysis of epidemiological studies. Clin Nutr. 2016;35(5):1039–1046 PMID:
26732028 https://doi.org/10.1016/j.clnu.2015.12.005
26. Stoody EE, Spahn JM, Casavale KO. The Pregnancy and Birth to 24 Months Project: a series
of systematic reviews on diet and health. Am J Clin Nutr. 2019;109(suppl 1):685S–697S PMID:
30982878 https://doi.org/10.1093/ajcn/nqy372
27. Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding Programs
and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries.
Comparative Effectiveness Review No. 210. (Prepared by the RTI International–University of
North Carolina at Chapel Hill Evidence-based Practice Center under contract no. 290–2015–
00011-I.) AHRQ Publication No. 18–EHC014-EF. Rockville, MD: Agency for Healthcare
Research and Quality; 2018
28. Anderson PO. Maternal vaccination and breastfeeding. Breastfeed Med. 2019;14(4):215–217
PMID: 30888205 https://doi.org/10.1089/bfm.2019.0045
19

29. Bartick MC, Schwarz EB, Green BD, et al. Suboptimal breastfeeding in the United States:
maternal and pediatric health outcomes and costs. Matern Child Nutr. 2017;13(1):e12366
PMID: 27647492 https://doi.org/10.1111/mcn.12366
30. Shi T, Balsells E, Wastnedge E, et al. Risk factors for respiratory syncytial virus associated
with acute lower respiratory infection in children under five years: systematic review and
meta–analysis. J Glob Health. 2015;5(2):020416 PMID: 26682048 https://doi.org/10.7189/
jogh.05.020416
31. Victora CG, Bahl R, Barros AJ, et al; Lancet Breastfeeding Series Group. Breastfeeding in the
21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–490
PMID: 26869575 https://doi.org/10.1016/S0140-6736(15)01024-7
32. Güngör D, Nadaud P, LaPergola CC, et al. Infant milk-feeding practices and diabetes outcomes
in offspring: a systematic review. Am J Clin Nutr. 2019;109(suppl 1):817S–837S PMID:
30982877 https://doi.org/10.1093/ajcn/nqy311
33. Chia JSJ, McRae JL, Kukuljan S, et al. A1 beta-casein milk protein and other environmental
pre-disposing factors for type 1 diabetes. Nutr Diabetes. 2017;7(5):e274 PMID: 28504710 https://
doi.org/10.1038/nutd.2017.16
34. World Health Organization. Exclusive breastfeeding to reduce the risk of childhood overweight
and obesity: biological, behavioural and contextual rationale. https://www.who.int/elena/bbc/
breastfeeding_childhood_obesity/en. Published September 2014. Accessed June 2, 2020
35. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-
analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child.
2012;97(12):1019–1026 PMID: 23109090 https://doi.org/10.1136/archdischild-2012-302263
36. Giugliani ERJ, Horta BL, Loret de Mola C, Lisboa BO, Victora CG. Effect of breastfeeding
promotion interventions on child growth: a systematic review and meta-analysis. Acta Paediatr.
2015;104(467):20–29 PMID: 26361071 https://doi.org/10.1111/apa.13160
37. Koletzko B, Godfrey KM, Poston L, et al. EarlyNutrition Project Systematic Review Group.
Nutrition during pregnancy, lactation and early childhood and its implications for maternal
and long-term child health: the early nutrition project recommendations. Ann Nutr Metab.
2019;74(2):93–106 PMID: 30673669 https://doi.org/10.1159/000496471
38. Azad MB, Vehling L, Chan D, et al; CHILD Study Investigators. Infant feeding and
weight gain: separating breast milk from breastfeeding and formula from food. Pediatrics.
2018;142(4):e20181092 PMID: 30249624 https://doi.org/10.1542/peds.2018-1092
39. Güngör D, Nadaud P, LaPergola CC, et al. Infant milk-feeding practices and food allergies,
allergic rhinitis, atopic dermatitis, and asthma throughout the life span: a systematic review.
Am J Clin Nutr. 2019;109(suppl 1):772S–799S PMID: 30982870 https://doi.org/10.1093/ajcn/
nqy283
40. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition,
Section on Allergy and Immunology. The effects of early nutritional interventions on the
development of atopic disease in infants and children: the role of maternal dietary restriction,
breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
Pediatrics. 2019;143(4):e20190281 PMID: 30886111 https://doi.org/10.1542/peds.2019-0281
41. Pinto-Sánchez MI, Verdu EF, Liu E, et al. Gluten introduction to infant feeding and risk of
celiac disease: systematic review and meta-analysis. J Pediatr. 2016;168:132–43.e3 PMID:
26500108 https://doi.org/10.1016/j.jpeds.2015.09.032
42. Szajewska H, Shamir R, Chmielewska A, et al; PREVENTCD Study Group. Systematic review
with meta-analysis: early infant feeding and coeliac disease—update 2015. Aliment Pharmacol
Ther. 2015;41(11):1038–1054 PMID: 25819114 https://doi.org/10.1111/apt.13163
43. Wang KL, Liu CL, Zhuang Y, Qu HY. Breastfeeding and the risk of childhood Hodgkin
lymphoma: a systematic review and meta-analysis. Asian Pac J Cancer Prev. 2013;14(8):4733–
4737 PMID: 24083735 https://doi.org/10.7314/APJCP.2013.14.8.4733
44. Güngör D, Nadaud P, Dreibelbis C, et al. Infant milk-feeding practices and childhood leukemia:
a systematic review. Am J Clin Nutr. 2019;109(suppl 1):757S–771S PMID: 30982871 https://
doi.org/10.1093/ajcn/nqy306
20

45. Horta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: a systematic
review and meta-analysis. Acta Paediatr. 2015;104(467):14–19 PMID: 26211556 https://doi.
org/10.1111/apa.13139
46. Victora CG, Horta BL, de Mola CL, et al. Association between breastfeeding and intelligence,
educational attainment, and income at 30 years of age: a prospective birth cohort study from
Brazil. Lancet Glob Health. 2015;3(4):e199–e205 PMID: 25794674 https://doi.org/10.1016/
S2214-109X(15)70002-1
47. Tseng PT, Yen CF, Chen YW, et al. Maternal breastfeeding and attention-deficit/hyperactivity
disorder in children: a meta-analysis. Eur Child Adolesc Psychiatry. 2019;28(1):19–30 PMID:
29907910 https://doi.org/10.1007/s00787-018-1182-4
48. Tseng PT, Chen YW, Stubbs B, et al. Maternal breastfeeding and autism spectrum disorder in
children: a systematic review and meta-analysis. Nutr Neurosci. 2019;22(5):354–362 PMID:
29046132 https://doi.org/10.1080/1028415X.2017.1388598
49. Kremer KP, Kremer TR. Breastfeeding is associated with decreased childhood maltreatment.
Breastfeed Med. 2018;13(1):18–22 PMID: 29125322 https://doi.org/10.1089/bfm.2017.0105
50. Peres KG, Cascaes AM, Nascimento GG, Victora CG. Effect of breastfeeding on malocclusions:
a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):54–61 PMID: 26140303
51. Boronat-Catalá M, Montiel-Company JM, Bellot-Arcís C, Almerich-Silla JM, Catalá-Pizarro
M. Association between duration of breastfeeding and malocclusions in primary and mixed
dentition: a systematic review and meta-analysis. Sci Rep. 2017;7(1):5048 PMID: 28698555
https://doi.org/10.1038/s41598-017-05393-y
52. Doğramacı EJ, Rossi-Fedele G, Dreyer CW. Malocclusions in young children: does breast-
feeding really reduce the risk? A systematic review and meta-analysis. J Am Dent Assoc.
2017;148(8):566–574.e6 PMID: 28754184 https://doi.org/10.1016/j.adaj.2017.05.018
53. Peres KG, Nascimento GG, Peres MA, et al. Impact of prolonged breastfeeding on dental
caries: a population-based birth cohort study. Pediatrics. 2017;140(1):e20162943 PMID:
28759394 https://doi.org/10.1542/peds.2016-2943
54. Miller J, Tonkin E, Damarell RA, et al. A systematic review and meta-analysis of human milk
feeding and morbidity in very low birth weight infants. Nutrients. 2018;10(6):707 PMID:
29857555 https://doi.org/10.3390/nu10060707
55. Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated
with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based
products. J Pediatr. 2010;156(4):562–567.e1 PMID: 20036378 https://doi.org/10.1016/
j.jpeds.2009.10.040
56. Huang J, Zhang L, Tang J, et al. Human milk as a protective factor for bronchopulmonary
dysplasia: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed.
2019;104(2):F128–F136 PMID: 29907614 https://doi.org/10.1136/archdischild-2017-314205
57. Quigley M, Embleton ND, McGuire W. Formula versus donor breast milk for feeding preterm
or low birth weight infants. Cochrane Database Syst Rev. 2019;7(7):CD002971 PMID: 31322731
https://doi.org/10.1002/14651858.cd002971.pub5
58. Williams T, Nair H, Simpson J, Embleton N. Use of donor human milk and maternal
breastfeeding rates: a systematic review. J Hum Lact. 2016;32(2):212–220 PMID: 26887844
https://doi.org/10.1177/0890334416632203
59. Jiang M, Gao H, Vinyes-Pares G, et al. Association between breastfeeding duration and
postpartum weight retention of lactating mothers: a meta-analysis of cohort studies. Clin Nutr.
2018;37(4):1224–1231 PMID: 28606701 https://doi.org/10.1016/j.clnu.2017.05.014
60. Zhou Y, Chen J, Li Q, Huang W, Lan H, Jiang H. Association between breastfeeding and
breast cancer risk: evidence from a meta-analysis. Breastfeed Med. 2015;10(3):175–182 PMID:
25785349 https://doi.org/10.1089/bfm.2014.0141
61. Islami F, Liu Y, Jemal A, et al. Breastfeeding and breast cancer risk by receptor status—a
systematic review and meta-analysis. Ann Oncol. 2015;26(12):2398–2407 PMID: 26504151
https://doi.org/10.1093/annonc/mdv379
21

62. Lambertini M, Santoro L, Del Mastro L, et al. Reproductive behaviors and risk of developing
breast cancer according to tumor subtype: a systematic review and meta-analysis of
epidemiological studies. Cancer Treat Rev. 2016;49:65–76 PMID: 27529149 https://doi.
org/10.1016/j.ctrv.2016.07.006
63. Kotsopoulos J, Lubinski J, Salmena L, et al; Hereditary Breast Cancer Clinical Study Group.
Breastfeeding and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers. Breast
Cancer Res. 2012;14(2):R42 PMID: 22405187 https://doi.org/10.1186/bcr3138
64. Feng LP, Chen HL, Shen MY. Breastfeeding and the risk of ovarian cancer: a meta-analysis.
J Midwifery Womens Health. 2014;59(4):428–437 PMID: 25066743 https://doi.org/10.1111/
jmwh.12085
65. Kotsopoulos J, Lubinski J, Gronwald J, et al; Hereditary Breast Cancer Clinical Study Group.
Factors influencing ovulation and the risk of ovarian cancer in BRCA1 and BRCA2 mutation
carriers. Int J Cancer. 2015;137(5):1136–1146 PMID: 25482078 https://doi.org/10.1002/
ijc.29386
66. Zhan B, Liu X, Li F, Zhang D. Breastfeeding and the incidence of endometrial cancer: a meta-
analysis. Oncotarget. 2015;6(35):38398–38409 PMID: 26384296 https://doi.org/10.18632/
oncotarget.5049
67. Cao Y, Wang Z, Gu J, et al. Reproductive factors but not hormonal factors associated with
thyroid cancer risk: a systematic review and meta-analysis. BioMed Res Int. 2015;2015:103515
PMID: 26339585 https://doi.org/10.1155/2015/103515
68. Cho S, Han E. Association of breastfeeding duration with dyslipidemia in women aged over
20 years: Korea National Health and Nutrition Examination Survey 2010-2014. J Clin Lipidol.
2018;12(2):437–446 PMID: 29452892 https://doi.org/10.1016/j.jacl.2018.01.009
69. Duan X, Wang J, Jiang X. A meta-analysis of breastfeeding and osteoporotic fracture risk in the
females. Osteoporos Int. 2017;28(2):495–503 PMID: 27577724 https://doi.org/10.1007/s00198-
016-3753-x
70. Chen H, Wang J, Zhou W, Yin H, Wang M. Breastfeeding and risk of rheumatoid arthritis: a
systematic review and meta-analysis. J Rheumatol. 2015;42(9):1563–1569 PMID: 26178286
https://doi.org/10.3899/jrheum.150195
71. Orellana C, Saevarsdottir S, Klareskog L, Karlson EW, Alfredsson L, Bengtsson C. Oral
contraceptives, breastfeeding and the risk of developing rheumatoid arthritis: results from the
Swedish EIRA study. Ann Rheum Dis. 2017;76(11):1845–1852 PMID: 28818831 https://doi.
org/10.1136/annrheumdis-2017-211620
72. Dadhich JP, Smith J, Iellamo A, Suleiman A. Carbon footprints due to milk formula. A
study from selected countries of the Asia Pacific region. ResearchGate website. https://www.
researchgate.net/publication/301289819_Carbon_Footprints_Due_to_Milk_Formula_A_study_
from_selected_countries_of_the_Asia_Pacific_region. Published 2015. Accessed June 2, 2020
73. US Department of Health and Human Services. Executive Summary: The Surgeon General’s
Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and
Human Services, Office of the Surgeon General; 2011. https://www.hhs.gov/sites/default/files/
breastfeeding-call-to-action-executive-summary.pdf. Accessed June 2, 2020
74. Rollins NC, Bhandari N, Hajeebhoy N, et al; Lancet Breastfeeding Series Group. Why invest,
and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491–504
PMID: 26869576 https://doi.org/10.1016/S0140-6736(15)01044-2
75. Hansen K. Breastfeeding: a smart investment in people and in economies. Lancet.
2016;387(10017):416 PMID: 26869553 https://doi.org/10.1016/S0140-6736(16)00012-X
76. Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics.
1999;103(4 Pt 2):870–876 PMID: 10103324
77. Li R, Ware J, Chen A, et al. Breastfeeding and post-perinatal infant deaths in the United
States, a national prospective cohort analysis. Lancet Reg Health-Amer. 2022;5:100094
22

CHAPTER 2
The Scope of Breastfeeding
B
reastfeeding is the normative standard for newborn and infant feeding
and nutrition. More than 80% of women initiate breastfeeding in the
United States (according to US Centers for Disease Control and Pre-
vention National Immunization Surveys data) and both federal and state laws
protect a woman’s right to breastfeed, as well as the right to breastfeed in public
and to continue breastfeeding or expression of milk in the workplace. With the
vast majority of women choosing to breastfeed, it is clear that breastfeeding
has been established as the cultural norm in the United States. Furthermore,
breastfeeding, or the provision of human milk, should be considered the refer-
ence standard when compared to all forms of infant feeding from a biological,
medical, and scientific standpoint. As such, it should be considered a national
and international public health priority and not only a lifestyle choice.
Physicians of all specialties benefit by understanding the biology and physiology
of breastfeeding, as well as the prevalence and social behaviors associated with
breastfeeding. The American Academy of Pediatrics (AAP) and the American
College of Obstetricians and Gynecologists (ACOG) recommend that all moth-
ers and infants, with rare exceptions, breastfeed exclusively for about 6 months
after birth. Furthermore, the AAP supports continued breastfeeding, along with
the appropriate introduction of complementary foods at about 6 months, as
long as mutually desired by mother and child for 2 years or beyond. The United
States has been tracking rates of breastfeeding among different populations and
uses these data to set national goals. The United States also tracks multiple
process indicators for breastfeeding protection, promotion, and support. These
indicators help health care professionals design interventions to overcome per-
sistent disparities in breastfeeding within the United States.
Successful breastfeeding requires education, support, and an environment that
values and understands breastfeeding. This need for support may derive from
the fact that our modern culture has evolved a series of messages that inhibit
automatic and natural behaviors related to breastfeeding. Because breastfeeding
23

is rarely observed in our society, health care professionals must supply the appro-
priate education, support, and encouragement necessary for breastfeeding to
occur and to help mothers meet their breastfeeding goals. In addition, there is a
growing database for defining the beneficial effects of the use of human milk for
preterm neonates and infants. These effects are reviewed in Chapter 1, Evidence
for Breastfeeding: Importance for Newborns and Infants, Mothers, and Society,
and Chapter 14, Lactation Support Technology.
Ū Categories of Breastfeeding
Breastfeeding intensity (exclusivity) has been categorized in various ways, and
clarity with regard to these terms can facilitate teaching, research, and clinical
evaluation (Box 2-1). The term any breastfeeding may be confusing, although it
is often used to describe a population that includes those who exclusively breast-
feed and those who combine formula feeding and breastfeeding. Furthermore,
the actual prevalence of exclusive breastfeeding for 6 months in the United
Box 2-1. Breastfeeding Categories
Exclusive breastfeeding: Human milk is the only food provided. Medicines, miner-
als, and vitamins may also be given in this category, but no water, juice, or other
preparations are given to the neonate or infant. Neonates and infants who are fed
expressed breast milk from their own mothers or from a milk bank via gavage tube,
cup, or bottle also can be included in this category if they have no nonhuman milk
or foods.
Almost or predominantly exclusive breastfeeding: Human milk is the predomi-
nant food provided in this category, with rare feeding of other milk or foods. The
neonate or infant may have been given a volume of 1 to 2 oz or 20 to 40 mL/day of
formula during the first few days after birth but none after that.
Partial or mixed breastfeeding: This diet may vary, from neonates and infants
receiving mostly human milk with small amounts or infrequent feedings of nonhu-
man milk or foods (a high-partial diet), to neonates and infants receiving significant
amounts of nonhuman milk or foods, as well as human milk (a medium-partial diet),
to neonates and infants receiving predominantly nonhuman milk or food with some
human milk (a low-partial diet).
Token breastfeeding: The neonate or infant is fed almost entirely with nonhuman
milk and foods but has had some breastfeedings shortly after birth or continues to
breastfeed occasionally. This type of breastfeeding may be seen late in the weaning
process.
Any breastfeeding: This category includes all of the above categories.
Never breastfed: This neonate or infant has never received any human milk, either
via direct breastfeeding or via expressed milk with artificial means of delivery.
24

Chapter 2: The Scope of Breastfeeding
States is low and accounts for the difficulties in interpreting health outcomes
that are tied to exclusivity of human milk (ie, the absence of any other food or
fluid intake). Many women may be exclusively breastfeeding for some or even
most of the first 6 months, although there may be temporary interruptions when
formula or foods are given. Yet, these mothers may report at any point that
they are exclusively breastfeeding, thereby confusing the actual prevalence of
exclusive breastfeeding and rendering the health research outcomes difficult to
interpret.
It is also important to define the duration of breastfeeding to best understand
health outcomes, as well as to fully describe the experience of the mother and
baby. Other factors, such as the number of feedings in a 24-hour period, help
identify the adequacy of feeding schedules and support the analysis of weight
patterns in the newborn. There has been a shift away from describing the fre-
quency of feeding (eg, every so many hours) and the length of feedings at each
breast toward supporting the concept that babies feed in irregular patterns and
are best supported by cue-based, or on-demand, feeding. Some feedings may be
very short and others long, and this variable pattern is unique to the behaviors
and needs of each baby. This pattern also reflects the variability in mothers’ milk
production throughout the days, weeks, or months of lactation.
Ū Breastfeeding in the United States

The United States tracks breastfeeding rates by using the National Immunization
Surveys, a national surveillance system of the Centers for Disease Control and
Prevention (CDC) National Center for Immunization and Respiratory Diseases,
in partnership with the CDC National Center for Health Statistics. The National
Immunization Surveys use random-digit dialing to survey households with children
aged 19 to 35 months about breastfeeding. Mothers are asked a series of retrospec-
tive questions that include whether the child was ever breastfed or fed breast milk,
when the child stopped breastfeeding or being fed breast milk, and the age at which
formula was first given to the child, if the child was not exclusively breastfed.
Initiation rates are improving, and in 2018 the initiation rate of 83.9% exceeded
the Healthy People 2020 goal (Figure 2-1). Other measures, such as the rate
of supplementation in the first 2 days after birth, were lower in 2015 (16.9%)
than in 2009 and went up again in 2018 (19.4%) and have not met the 2020
goal of 14%. Being born at a United Nations Children’s Fund (UNICEF)/World
Health Organization (WHO)–designated Baby-Friendly Hospital provides the
best opportunity to decrease formula supplementation, and as of June 2020, the
percentage of US hospitals acheiving this designation has risen to more than
25

1
Data from 2011 to 2015 births were based on landline and cellular telephone sampling
and data for 2016 births were based on cellular telephone sampling only.
2
Data from US territories are excluded from national breastfeeding estimates to be con-
sistent with the analytical methods for the establishment of Healthy People 2030 targets
on breastfeeding.
3
Exclusive breastfeeding is defined as only breast milk—no solids, water, or other liquids.
From Centers for Disease Control and Prevention. Breastfeeding among U.S. children
born 2011–2018, CDC National Immunization Survey. https://www.cdc.gov/breastfeeding/
data/nis_data/results.html. Accessed May 16, 2022.
Figure 2-1. Breastfeeding rates among US children born from 2011 to 2018, according to the
Centers for Disease Control and Prevention National Immunization Surveys.
28%, exceeding the 2020 goal of 8% and accounting for almost 30% of births in
the United States in 2020. Employers report that nearly 50% of mothers have
provisions for breastfeeding support in the workplace, which is largely due to the
federal legislation in the Patient Protection and Affordable Care Act (PPACA).
Rates of any breastfeeding and exclusive breastfeeding continue to slowly
increase in infants at 3 months of age (47.5%) and 6 months of age (25.4%), as
well as 64.7% of newborns who are exclusively breastfeeding at 7 days of age.
Moreover, the continuation of breastfeeding in infants at 12 months of age
(36.2%) in 2016 surpassed the 2020 goal of 34.1%. However, there was a slight
downward trend from 2017 to 2018 for 6- and 12-month breastfeeding rates.
Healthy People goals for breastfeeding have been met for all but 3 measures,
as have any breastfeeding and exclusive breastfeeding at 6 months and supple-
mentation within the first 2 days (Table 2-1). There has also been a resurgence
of exclusive breastfeeding at initiation. Compared with 2003, when 62.5% of
US newborns were exclusively breastfed at 7 days of age, merely 53.9% were
exclusively breastfeeding at 7 days of age in 2009; in 2015 this figure increased to
26

Table 2-1. Breastfeeding Rates in 2016-2017 According to

Healthy People 2020 Goals
Healthy People 2020 Objectives Target Current Ratesa
MICH-21.1 Increase the proportion of infants who are 81.9% 83.2%

breastfed:
Ever ✔
breastfed:
At 6 mo

breastfed:
At 1 y ✔
breastfed:
Exclusively through 3 mo ✔
breastfed:
Exclusively through 6 mo
MICH-22 Increase the proportion of employers that have 38.0% 49.0%

work site lactation support programs.
✔
MICH-23 Reduce the proportion of breastfed newborns 14.2% 17.2%
who receive formula supplementation within the
first 2 days after birth.
MICH-24 Increase the proportion of live births that occur 8.1% 26.1%
in facilities that provide recommended care for
lactating mothers and their babies. ✔
Abbreviation: MICH, maternal infant and child health.
a
MICH-21 and MICH-23 current rates represent babies born in 2015, National Immunization Survey 2016–2017;
MICH-22 current rates represent employers providing an on-site lactation/mother’s room, Society for Human
Resource Management, 2018 survey; MICH-24 current rates represent babies born in Baby-Friendly Hospitals and
Birth Centers designated as of June 2018, Baby-Friendly USA.
Reported in Centers for Disease Control and Prevention. Breastfeeding report card. United States, 2018. https://
www.cdc.gov/breastfeeding/data/reportcard.htm. Reviewed December 31, 2019. Accessed June 3, 2020.
There is only one breastfeeding objective in the Healthy People 2030 proposal, proposed as of July 2019, comment
period open with this publication.
MICH-2030–15 increases the proportion of infants who are breastfed exclusively through 6 months.
64.7% (Table 2-2). Despite this increase, less than 50% of infants were exclusively
breastfed through 3 months of age, and about 25% of infants were exclusively
breastfed through 6 months of age. The CDC continually updates its website for
most recent breastfeeding data (https://www.cdc.gov/breastfeeding/data/index.
htm), and each year a Breastfeeding Report Card is produced (https://www.cdc.
gov/breastfeeding/data/reportcard.htm).
27

Table 2-2. Provisional Rates of Any and Exclusive Breastfeeding

by Age Among Children Born in 2018
Any Breastfeeding Exclusive Breastfeeding
Child Age (n = 21,428)a (n = 20,760)a
At birth 83.9 ± 0.9 —
7d 83.1 ± 0.9 63.3 ± 1.2
14 d 82.4 ± 1.0 61.0 ± 1.2
21 d 80.9 ± 1.0 58.9 ± 1.2
28 d 80.2 ± 1.0 58.2 ± 1.2
1 mo 79.9 ± 1.0 57.8 ± 1.2
2 mo 75.6 ± 1.0 51.9 ± 1.2
3 mo 70.9 ± 1.1 46.3 ± 1.2
4 mo 64.5 ± 1.2 39.4 ± 1.2
5 mo 59.3 ± 1.2 31.2 ± 1.1
6 mo 56.7 ± 1.2 25.8 ± 1.0
7 mo 49.1 ± 1.2 —
8 mo 46.4 ± 1.2 —
9 mo 42.9 ± 1.2 —
10 mo 39.5 ± 1.2 —
11 mo 36.9 ± 1.1 —
12 mo 35.0 ± 1.1 —
18 mo 14.8 ± 0.8 —
a
Data are percentage ± half 95% CI. According to the National Immunization Surveys. Exclusive breastfeeding is
defined as only human milk—no solids, water, or other liquids.
Adapted from Centers for Disease Control and Prevention. Breastfeeding rates. National Immunization Survey
(NIS). https://www.cdc.gov/breastfeeding/data/nis_data/results.html. Accessed May 16, 2022.
28

Disparities in Breastfeeding
Despite the seemingly impressive increase in breastfeeding rate in the United
States, there are still considerable disparities in breastfeeding rates among racial
and ethnic groups, as well as several other important sociodemographic vari-
ables. The breastfeeding initiation rate for the Hispanic or Latino population in
2015 was 84.6%, but for the non-Hispanic Black or African American popula-
tion, it was 58.1%. Disparities improved by 2018, with 85% of the Hispanic
or Latino populations initiating breastfeeding and 75.5% of the non-Hispanic
Black population initiating breastfeeding. Among mothers in low-income
households (ie, participants in the Special Supplemental Nutrition Program
for Women, Infants, and Children [WIC]), the breastfeeding initiation rate
was 69.4%, but for those in a higher-income household who were ineligible for
WIC, the initiation rate was 91.7%. The breastfeeding initiation rate was 37%
for low-income non-Hispanic Black mothers. Similar disparities are age related,
because mothers younger than 20 years initiated breastfeeding at a rate of 60%,
as compared with the rate of 83.5% in mothers older than 30 years. Exclusive
breastfeeding and continuation of breastfeeding are also low among mothers
younger than 20 years, in whom the exclusive breastfeeding rate at 6 months
was only 7.3% and for any breastfeeding at 12 months was 8.7% (Tables 2-3 and
2-4).
In 2011, the US Surgeon General issued a call to action to support breastfeeding
to address obstacles and strategies to overcome in the United States (Table 2-5).
Obstacles identified include
• Lack of experience or understanding among family members on how to best

support mothers and babies
• Not enough opportunities to communicate with other breastfeeding mothers
• Lack of up-to-date instruction and information from health care
professionals
• Hospital practices that make it hard to get started with successful breastfeeding
• Lack of accommodation to breastfeed or express milk at the workplace
Opportunities for health care professionals to help include
• More hospitals can incorporate the recommendations of the UNICEF/

WHO Baby-Friendly Hospital Initiative.
• Provide breastfeeding education for health care practitioners who care for
women and children.
• Ensure access to lactation specialists, such as those credentialed as Interna-
tional Board Certified Lactation Consultants (IBCLCs) or Fellows of the
Academy of Breastfeeding Medicine (FABM).
(continued on page 36)
29

Table 2-3. National Prevalence of Breastfeeding Initiation, Exclusive Breastfeeding Through 6 Months of
Age, and Duration of Breastfeeding at 12 Months of Agea Among Children 19 Through 35 Months of Age,
According to Selected Demographic Characteristicsb
Initiated Breastfeeding % Breastfed Exclusively Breastfed at 12 Mo %
Characteristic No. of Respondentsc (95% CI) Through 6 Mo % (95% CI) (95% CI)

Total 88,436–90,692 79.2 (78.7–79.7) 20.0 (19.5–20.5) 27.8 (27.2–28.4)
Child’s Race/Ethnicityd,e
White, non-Hispanic 49,868–51,359 81.5 (80.9–82.1) 22.5 (21.9–23.1) 30.8 (30.1–31.5)
Black, non-Hispanic 9,091–9,255 64.3 (62.7–65.9) 14.0 (12.7–15.3) 17.1 (15.8–18.4)

Hispanic 17,775–18,075 81.9 (80.8–83.0) 18.2 (17.0–19.4) 26.3 (24.9–27.7)
30
Percentage of Poverty Levelf
< 100 22,840–23,232 70.7 (69.6–71.8) 14.7 (13.8–15.6) 20.3 (19.3–21.3)
100–199 17,735–18,184 77.6 (76.5–78.7) 18.9 (17.9–19.9) 26.0 (24.8–27.2)
200–399 22,579–23,193 84.9 (84.1–85.7) 23.9 (22.9–24.9) 33.1 (32.0–34.2)
400–599 13,727–14,149 88.0 (87.1–88.9) 26.5 (25.1–27.9) 36.7 (35.2–38.2)
≥ 600 11,555–11,934 90.1 (89.2–91.0) 25.8 (24.1–27.5) 36.8 (35.0–38.6)
Recipient of WIC
Yes 40,182–40,925 72.1 (71.3–72.9) 14.5 (13.8–15.2) 19.7 (18.9–20.5)
No (but eligible) 6,265–6,461 81.9 (79.9–83.9) 27.6 (25.6–29.6) 37.9 (35.7–40.1)
No (not eligible) 41,576–42,865 89.6 (89.1–90.1) 27.2 (26.4–28.0) 38.3 (37.4–39.2)
8/18/22 10:48 AM
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Title: Nerve enough
Author: Richard Howells Watkins
Release date: April 26, 2024 [eBook #73469]
Language: English
Original publication: New York, NY: The Ridgway Company, 1925
Credits: Roger Frank and Sue Clark
*** START OF THE PROJECT GUTENBERG EBOOK NERVE

ENOUGH ***
An air pilot and the field of broken wings
NERVE ENOUGH
By Richard Howells Watkins
The time was when the T. M. O. Transportation Co. occupied a proud

position in the latest infant industry—aerial passenger carrying.
The T., who was Jim Tyler; the M., Burt Minster; and the O.,
Delevan O’Connell, each had a plane of his own. The company
leased a field on the edge of a sizable little city and erected hangars.
No less than three mechanics labored to keep the ships in the air.
The three partners had a bank account and a growing clientele
among the more progressive members of the community. They had
carried doctors to patients, ministers to congregations and judges to
court. Yes, undoubtedly the T. M. O. Transportation Co. was the peer
of any aeronautical outfit in the country.
As Del O’Connell put it, in one of his prophetic moods—
“The day will come when T. M. O. means as much in this country
as C. O. D.”
That was rather strong, perhaps too strong, for not three days
later, quite without reason, Del’s motor threw a connecting rod clean
through the crankcase. In the consequent forced landing in a pasture
some distance from the field, he cracked two struts of his landing
carriage in a successful effort to save the wings.
FALLS THREE THOUSAND FEET;
LIVES
was what the morning paper shouted to the city at large, and the
growing clientele shriveled like a violet on a griddle, and the bank
account was not slow in following it. Of course Del O’Connell hadn’t
fallen an inch; he had merely glided down without motor; but how are
you going to explain that to a headline-reading public. It worried him,
however, that the cracking of two struts should split their little
business to its foundations. And he prophesied no more.
At last the T. M. O. Transportation Co. loaded itself into the two
good ships remaining, left two of the mechanics behind and departed
for fresh fields.
At another town, smaller than the first, they had pitched their tents
and taken a field—by the month. The hard work of building up
reputation in a business generally considered the apex of the risky
was begun again. They carried hundreds of passengers in safety.
Not once did one of the pilots yield to the desire for a jazz ride and
tailspin a ship or even roll it over once or twice. The strict
aeronautical aristocrats consider such antics in commercial flying
equivalent to the employment of a puller-in outside the store in the
retail clothing business.
Prospects were good, though the company was not yet
prosperous. Then, one morning when Burt Minster took off alone to
test-hop his ship, he banked a bit too much just after leaving the
ground and came down in a side-slip that completely washed out his
plane and left him in the wreckage with a split ear and a bad
headache.
That reduced the T. M. O. Transportation Co.’s assets to Jim
Tyler’s ancient training-ship. They moved on, minus the last
mechanic. They were no longer an organization with a fixed base, a
reputation and a bank. They had descended in the world to the low
estate of gipsy fliers, winging hither and yon, picking up such
business as presented itself and landing in more cornfields than in
airdromes.
Yes, they learned about flying from those cornfields—more than a
pilot will ever know who always has four hundred yards or so of
neatly groomed turf in front of him to set his ship down on, but it
didn’t help their self-esteem any.
And in Burt Minster’s big head grew the conviction that if he
hadn’t side-slipped his bus in that silly way, the company wouldn’t
have dropped so low in the scale. He had made them aeronautical
hoboes.
The day arrived when an offer came from the Baychester Fair for
a stunt-flying, wing-walking, parachute-dropping exhibition. The three
partners grasped it eagerly. Stunting a ship, walking around on wings
and fuselage with a desert of space under you and dropping
overboard with only thin silk between you and the next world are all
hazardous propositions, but not nearly so hazardous as consistently
going without food. It was hard on their pride, of course, for they
remembered the time, only days behind them, when no money
would have tempted them to descend so low as to indulge in thrillers
to drag a crowd into a fair grounds. They were—had been—in the
transportation, not the Desperate Desmond, business.
The contract was couched in terms that permitted them to kill
themselves without incurring the animosity of one Jenkins, manager
of the fair, provided that they did it in a spectacular and public
manner. In return for this concession, they extracted sufficient cash
from Jenkins to buy two parachutes and three square meals.
And here they were, in an old shack within the mile track of the
Baychester Fair Grounds on the evening before opening day, with
discord rampant in their ranks, and threatening to blow the company
into its three component parts.
At one end of the rickety table sat Delevan O’Connell, a slender,
animated young man. His wiry body was so short that he was
compelled to lean forward on his elbows in order to raise his angry
blue eyes above the two brand new parachute packs on the table
and focus them on the big form of Burt Minster. Burt scowled back at
him.
“Oh, shut your traps, both of you,” growled Jim Tyler, bestowing
an impartial glare on his two partners. “What difference does it make
which of you does the first jump?”
The gist of the trouble was this: Both O’Connell and Minster felt
responsible for the straits in which the company found itself, and
therefore each man aspired to go over the side in the new
parachutes. Now a chute jump is nothing much; but when you
haven’t made one before, and haven’t even a man alongside you
who has and knows something about the sensation and the harness,
it is somewhat lacking in dullness.
Delevan O’Connell was swift to answer Jim Tyler’s question.
Already the discussion had gotten well within the bounds of plain
speaking.
“It makes this much difference,” he snapped, keeping his eyes
fixed on Burt, although he spoke to Jim. “The first jump must not be
botched.”
“And therefore you must make it!” exclaimed Burt Minster, with a
great laugh.
Del O’Connell flared up.
“I can not have this outfit broken up because this great oaf lacks a
little nerve at the crucial moment.”
Burt Minster leaned backward in his chair to give his chest room
for the discharge of another roar of mirth.
“Why, you poor insect, you, I’m only about twice your size, but
I’ve three times your grit, at least.”
Jim Tyler thumped Del O’Connell on the back in time to halt the
fiery little man’s response.
“It isn’t nerve but nerves that both of you have,” he asserted
emphatically. “You’re both worried about those crashed ships, and
you both want to take the first risk, in consequence.”
The truth does not belong in an argument. This theory of their
conduct was drowned in a combined shout of protest, but Del
O’Connell was a bit faster on the tongue than Burt.
“I’ll make that first jump; I’ve got to!” he cried, springing to his feet
and thumping a quick fist on the parachute packs. “You can’t trust
this fellow, and if he bungles it, we’re gone!”
“I’ll not bungle it,” retorted Burt Minster stubbornly. “And as for
nerve, I’ve more nerve than he has language, which is some.”
Jim Tyler slumped wearily against the side wall of the shack and
waited for the argument to subside.
“I stand ready to prove you a liar in any way you want to pick,”
Del O’Connell declared heatedly.
Burt Minster did not answer at once. His face reddened at the
challenge, but his eyes, as they dwelt upon the parachutes, were
merely thoughtful. Jim Tyler plunged into the lull.
“Since none of us has ever gone over, perhaps we’d better
rehearse a jump this evening, before we try it on the crowd,” he
suggested, in the hope that action would halt dissension.
But Burt Minster had by no means given up the controversy. He
had merely been planning.
“This Jenkins who is running the fair intimated to-day that he
might raise the ante if we pulled something particularly spectacular
the first day,” he said slowly. “And we need the money, if we’re ever
to get back where we started. Well, I have a scheme that’ll settle this
nerve question once and for all, and give us a big lift toward buying
another plane as well.”
“Out with it, then,” snapped Del O’Connell. “I’m willin’ already.”
Burt Minster laid a hand on the parachute packs.
“We have two of them, and we planned that the jumper should
wear both, as is customary. Well, instead of that, we’ll both jump, you
and I, at the same time.”
“And what would that prove?” snorted Del.
“I’m not through yet,” Burt rebuked him. “We’ll announce the thing
as a race to earth, the man landing first winning. You see, you don’t
have to pull the rip-cord that opens the parachute the minute you
leave the ship. You can fall free—an army expert fell almost two
thousand feet before he opened his ’chute—”
Del O’Connell’s eyes glinted.
“’Tis not a bad idea at all,” he admitted, and looked upon Burt
Minster with less rancor. “I like it fine.”
“Wait a minute,” interposed Jim Tyler. “You mean you’ll both jump,
and let yourselves fall a quarter of a mile or more? Why, that’s the
craziest—”
“And the man who pulls his rip-cord last wins, for he’ll land first,”
Del O’Connell explained. “As good a test of nerve as ever I heard
of.”
“Well, you can fly yourselves, then, for I’ll not have a hand in it,”
Jim Tyler announced firmly. “It isn’t necessary for you two to kill
yourselves to prove you’re fools. I’ll believe it now.”
His statement made no impression on his partners. This was no
sudden quarrel. Each, feeling guilty, was consequently touchy, and
doggedly set on doing his utmost to retrieve their misfortunes. And
from this attitude it was only a short step, in the ragged state of their
nerves, to an open conflict over the issue of courage—or any other
issue about which they could contend.
“Well, Jim,” said Burt Minster at last, as Tyler continued to stand
his ground unswervingly, “there’s another plane here at the fair, you
know. That fellow will take us both up if you won’t.”
Jim Tyler gave in at that, for he saw that his opposition to the plan
was only making them more eager to try it. Secretly he nursed the
hope that next day would bring them back to rational behavior.
But the opening hour of the fair found them still fixed in their resolve
to carry on perhaps the strangest duel of nerve that had ever been
devised. The three partners kept apart, since talk only led to
acrimony, and each at his post of observation watched the crowds
gathering.
They came in battered tin automobiles, and they came on foot,
and they came in ancient horse-drawn vehicles, from Baychester
County and from the county across the Baychester River which
flowed past the Fair Grounds. Jim Tyler’s airworn but still airworthy
Burgess training-plane was the center of a milling mob, for
Baychester was not so sophisticated as some of its neighbors, and a
flying machine was still an object of doubt and an object of awe. The
ropes about it strained under the pressure of the curious, and the
voices of the guards who reinforced the ropes grew hoarse and
querulous. And word of the race to the ground through the thin air
spread through the murmuring crowds.
The time of the flight came.
“Now boys, be sure and give us a good treat,” Jenkins, a stout,
harassed, badge-encrusted gentleman instructed, as he bustled up
to the shack wherein the partners had come together again.
“You’ll get it,” returned Burt Minster grimly.
“Two of them,” promised Del O’Connell, buckling the harness of
his ’chute about him, and taking a final glance at the dangling rip-
cord and the ring attached to it.
“I’ll make it worth your while,” the official declared, and dashed
away.
At the plane the three men waited, while space for a takeoff in the
infield was cleared of spectators. Jim Tyler warmed up his motor,
and then, throttling down, left the cockpit and confronted his
partners.
“If you’re set on going through with this fool thing I suppose I’ll
have to stand by,” he said briefly. “Where are you jumping from—
wing or cockpit?”
“Since we’re not pulling the rip-cords at once we might as well
jump from the cockpit,” said O’Connell. “You can signal to us better
from there and it will look more spectacular.”
“That suits me,” replied Burt Minster curtly.
“I won’t be able to get this bus up over six or seven thousand feet
with the weight of three men in her,” Jim calculated. “Suppose we
make it five thousand, to be sure?”
“A mile is plenty, since it’s going to be a sprint,” Del O’Connell
said, with a chuckle. “Though of course,” he added, looking sideways
at Minster, “one of us may not do much sprinting.”
“Speak for yourself,” growled the other man. “You’ll probably
starve to death before you get to the ground.”
“Remember, when I turn and put up five fingers, get ready,” Tyler
broke in hastily. “And when I nod, jump! One from each side. And
jump hard, so you’ll clear the tail.”
“Right,” assented Del O’Connell eagerly, and Burt Minster nodded
agreement.
The infield was clear at last. With a final glance at the fastenings
of their harness and the rip-cords that would release the parachutes,
the two men silently climbed into the rear cockpit. They wedged
themselves into the narrow seat. Then both turned automatically and
studied the direction and force of the wind, as revealed by the
whipping flags on the grandstand.
Jim Tyler gave the ship the throttle. Bouncing and lurching, it
charged into the wind, the propeller flickering as it cut the air and
flung it back upon the tense faces of pilot and ’chute jumpers. Far
across the infield the plane raced. Finally the wings took the burden
from the rubber-tired wheels. The ship, with a final jolt, parted
company with the ground, hung poised above the grass, and began
its upward climb.
Though it was an old story to them, the two men in the rear
cockpit looked downward, each upon his side, and the plane climbed
in great circles above the fair ground below. The green of the
countryside prevailed, but the brown of the oval racetrack cut
through it, and just outside this ellipse was a speckled band of many
indistinguishable colors that is the indication of people in masses.
Beyond that, behind the cigar-box grandstand, stretched a tightly
packed section of black and gray-black, where the automobiles of
the crowd were parked. Booths and buildings, gay with bunting,
displayed their tiny square outlines in regular patterns around the
ground.
And then, as the plane rose higher, the fair grounds contracted
until they were a mere detail of the landscape below—the great
green and brown squares and oblongs, with larger irregular patches
of woodland, interspersed here and there by tracts of well-watered
pasture land, of a lush green. Across it all, as if dividing all the world
into two parts, ran the almost straight course of the Baychester river.
Del O’Connell and Burt Minster at just the same time turned their
attention from the earth to the back of Jim Tyler’s head. They were
approaching their mark and both sensed it, although there was no
altimeter in their compartment.
The motor labored on, and both men thrust feet out straight, and
moved shoulders tentatively, as if to drive away any incipient
stiffness that might hinder action in that one swift leap into space.
Both were entirely at home in the air, as seamen are at home on the
water, but neither had ever gone out, deserting their craft for the
impalpable element in which it swam.
Suddenly Jim Tyler turned a grim face toward the rear cockpit and
raised his left hand, with fingers outstretched. Five thousand! For an
instant little Del O’Connell and big Burt Minster turned and looked at
each other. Determination was imprinted in the lines of both
countenances, and together they squirmed to their feet in that
cramped compartment, standing full in the buffeting stream of air
flung back by the whirling propeller. Del O’Connell, with an agile
twist, got one foot up on the rim of the cockpit and gripped the edge
with both his hands. His head turned forward, and his eyes fixed
themselves on the stern face of the pilot.
Burt, a little slower, slung a foot over his side of the machine, and
with one hand fumbled for the ripcord and dangling ring at the end of
it. Tyler nodded.
Del O’Connell, with a quick spring, brought his other foot up out of
the cockpit and, clinging with his hands, crouched on the edge of the
fuselage. His legs bent more sharply for the leap that would carry
him far out into space.
But just then the eyes of Jim Tyler caught a sudden flash of white
from the pack on Del’s back. The next instant the great silken
parachute whipped out of its confining envelop. Del’s rip-cord had
fouled on something inside the cockpit, and his eager jump to the rim
had jerked it.
The great spread of cloth billowed open instantly and whisked
backward in the grip of the wind. For just an instant Del, entirely
unconscious of what had occurred, held his place on the fuselage.
Then, like a stone from a catapult, he was whipped off his feet and
flung toward the tail of the racing plane.
The open parachute swept into the tail assembly. The
tremendous force of the wind ripped it from skirt to vent as it caught.
Shroud lines parted like threads. Then the silken cloth wrapped itself
about elevators, and several of the shrouds that did not snap
became entangled over the point of the balance of the rudder.
O’Connell’s whirling body struck the tail of the machine. Then it
swept past, dropping out into space. But the remaining shroud lines
were securely held by the rudder. O’Connell’s fall was checked by a
bone-jarring jerk. His body dangled below the tail of the plane,
swaying in the rush of the wind.
The plane wavered in the air, its flying speed dropping fast under
the resistance of the silken cloth whipping backward from the tail
assembly, and the drag of the man’s body swinging behind. Jim Tyler
opened the throttle full, and thrust the stick forward for a steep glide.
The elevators responded. They had been unhurt by the lashing
parachute. The nose of the plane turned earthward; its speed
increased.
The sudden catastrophe had come before Burt Minster had gone
over the side. He drew back in the cockpit and stared over at the
figure of Del O’Connell, dragging behind the plane by the precarious
strength of a few unsevered shroud lines. As he watched, he caught
sight of the white face of his partner, and saw that O’Connell, dazed
by the suddenness of the accident and his whip-like snap from the
cockpit, was just coming to a realization of what had occurred.
Jim Tyler turned and stared backward, too, and then the eyes of
Jim and Burt met. Speech was impossible in the fury of the motor’s
roar, but their eyes appealed to each other for help—for some way
out. The plane was diving sharply earthward; to check that dive
meant losing control of the ship; not to check it meant to crash at
terrific speed into the ground. There was no way of getting O’Connell
back into the ship; that was utterly impossible.
That communion of eyes lasted but a brief second; then both men
turned despairingly to the doomed man trailing behind the plunging
plane. They, too, were doomed in that headlong dash, but somehow
their plight seemed as nothing compared to his.
O’Connell had not lost his senses. They perceived that with both
hands he was fumbling, working at his right hip. Even as they
watched, his hand went to his left side in the same peculiar
movement. Then they comprehended.
O’Connell was unbuckling his harness. Already he had unclasped
the snap buckles that fastened the heavy webbing straps about his
thighs; now but one more buckle remained—the one across his
chest. He did not look toward the plane; his whole attention was
absorbed in his task, exceedingly difficult in that lashing wind,
dangling there in space at the end of the cords. But in an instant he
would no longer be dangling. The ship would be saved—at a price.
Jim Tyler watched, paralyzed by the horrible fascination of the
thing. In another instant O’Connell would have cast himself off from
the plane—and from life. His dry throat framed at last an inarticulate
sound of protest at the sight of that sacrifice. The wind swept it away
unheard.
Burt Minster, too, was watching. The breast buckle came apart.
Del O’Connell was free of the harness. He hung there by his hands,
and his face turned briefly toward them. A strained, twisted grin was
on it.
A pain shot through Jim Tyler’s shoulder; it was a blow from Burt
Minster’s heavy fist. The big man was squatting on top of the
fuselage.
“Right turn!”
His voice blared in the pilot’s ear, audible even above the thunder
of the motor. Jim obeyed automatically. The plane swerved sharply
to the right.
As the machine swung around, O’Connell’s body whipped
sidewise, no longer directly behind and below the tail. In that instant
Burt Minster leaped out into the air, all the strength of his powerful
muscles concentrated in the thrust of his legs. His body, its
momentum aided by the rush of air, shot through space. He crashed
like a plunging bull into the lean, small body of Del O’Connell.
The two men dropped together as the long arms of Burt wrapped
themselves about his partner.
The plane disappeared instantly from their view; they plunged
downward in a free drop, locked together, face to face. Air was all
about them; the thunder of the machine died away in their ears.
Beneath, the countryside was slowly expanding, opening up before
them like a magically blossoming flower.
“R-r-r-r-rip-cord!” roared Burt Minster. His own arms tightened
their clutch on Del O’Connell until the little man’s breath was
squeezed out of his chest. But even before Burt had spoken the
quick right hand of Del was wriggling downward, between Burt’s
shoulder and his own, toward the release ring. He found it. He
pulled.
Burt Minster’s breath followed Del O’Connell’s out of his body as
an iron band tightened across his breast; his thighs were squeezed
as if a boa had wrapped his constricting merciless folds about them.
Del felt a repetition of that shock that had hurled him from the
fuselage.
Burt emitted a sound, half expiration, half grunt. His parachute
had opened.
It spread above them like a shield. The country below ceased its
eerie expansion. Burt Minster’s grip about Del O’Connell’s chest
relaxed slightly, and the smaller man breathed again—deep, lung-
distending mouthfuls of sweet air. There was no longer any rush of
wind or roar of motor; nothing but a gentle, lulling sway from side to
side under that great canopy of silk.
Burt Minster spoke first.
“These things are supposed to handle up to four hundred pounds,
so I guess we’re all right,” he remarked, with an effort at a casual
tone.
Del blinked.
“If you’ll loosen up on those arms of yours, I’ll be able to get a grip
myself,” he answered. They adjusted their positions, and Del took
some of his weight from his hands by fastening his belt about Burt’s
harness. They continued to drift downward. The sudden cessation of
hubbub and speed made this gentle movement dreamlike.
Del O’Connell cleared his throat—and cleared it again. Finally he
muttered:
“That stuff about nerve, Burt—I’m a liar of the first water. Nerve?
You’re nothing else.”
“I saw what you were doing, yourself,” mumbled Burt Minster,
equally shamefaced and uncomfortable. “That certainly took guts,
Del.”
“I’m glad to be out of that mess,” said Del fervently. “Look! Here
comes Jim!”
Jim it was, and he was not above but below them. He was
climbing fast, and it was plain to see that he had complete control of
the ship. As they craned their necks toward the ascending plane he
banked sharply, and went circling under them, waving his hand
toward the tail. Nothing but a few tatters of silk and several shroud
lines trailed from the control surfaces of the tail assembly. Jim had
dived his encumbrance into ribbons.
With the plane whistling around them, they were wafted
downward almost directly over the fair grounds. A gentle wind was
drifting them toward it, for Jim had calculated well before signaling
for the jump. The earth was coming upward now with greater speed,
as their horizon drew in upon them. No longer could they survey half
the county.
Legs dangling, they waited. Past the eastern end of the racetrack
they drifted, and then, suddenly, the ground thudded up against their
feet, and down they went in a heap together. The parachute slipped
sideways, and lay billowing on the ground.
“We finished together, Del. It’s a dead heat,” said Burt Minster,
climbing to his feet and lifting the smaller man with him.
“Dead enough,” answered Del O’Connell emphatically. “But I’ve a
hunch this last little stunt has broken our run of bad luck, Burt. See!
Here comes Jenkins on the run, and I’m crashed if he hasn’t got his
checkbook in his hand!”
THE END
Transcriber’s Note: This story appeared in the December 30,

1925 issue of Adventure magazine.
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Breastfeeding Handbook for Physicians

Third Edition American Academy Of

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00 Front Matter BHFP i-xiv.indd 1 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 2 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 3 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 4 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 5 9/14/22 12:26 PM

Adetola F. Louis-Jacques, MD, FABM, FACOG

00 Front Matter BHFP i-xiv.indd 6 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 7 9/14/22 12:26 PM

Equity, Diversity, and Inclusion Statement

00 Front Matter BHFP i-xiv.indd 8 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 9 9/14/22 12:26 PM

5 Anatomy and Physiology of Lactation.................................................75

00 Front Matter BHFP i-xiv.indd 10 9/14/22 12:26 PM

Postpartum Mood Changes: Postpartum Blues and Depression..........178

00 Front Matter BHFP i-xiv.indd 11 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 12 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 13 9/14/22 12:26 PM

00 Front Matter BHFP i-xiv.indd 14 9/14/22 12:26 PM

Evidence for Breastfeeding:

Ū Risk Reductions in Breastfeeding

01 Chapter BHFP 001-022.indd 1 8/18/22 10:50 AM

01 Chapter BHFP 001-022.indd 2 8/18/22 10:50 AM

01 Chapter BHFP 001-022.indd 3

60% 4–6 mo None OR 0.40 0.26-0.63

64% > 6 mo None OR 0.36 0.22-0.61

Infant mortality, US3 19% Ever Never US cohort OR 0.81 0.68-0.97

Postneonatal mortality4 21% Ever Never US nationally OR 0.79 0.67-0.93

38% > 3 mo Never OR 0.62 0.46-0.82

Infant mortality, limited-income 33% Exclusive Predominant RR 0.67 0.52-0.88

93% Exclusive None RR 0.07 0.03-0.16

Severe/persistent diarrhea7 30% Exclusive 6 mo Exclusive < Cohort RR 0.70 0.52-0.94

01 Chapter BHFP 001-022.indd 4

Otitis media8 33% Ever Never OR 0.67 0.56-0.80

33% More Less OR 0.67 0.59-0.76

43% Exclusive 6 mo None OR 0.57 0.44-0.80

Asthma, 5–18 y9 10% More Less OR 0.90 0.84-0.97

12% Ever Never OR 0.88 0.82-0.95

Eczema, first 2 y9 26% Exclusive 3–4 mo Shorter OR 0.74 0.57-0.97

Crohn disease11 29% Ever Never OR 0.71 0.59-0.85

80% 12 mo 3–6 mo OR 0.20 0.08-0.50

Ulcerative colitis12 22% Ever Never OR 0.78 0.67-0.91

79% 12 mo 3–6 mo OR 0.21 0.10-0.43

Childhood obesity12 22% Ever Never OR 0.78 0.74-0.81

10% < 3 mo Never OR 0.90 0.84-0.95

12% 3–5 mo Never OR 0.88 0.79-0.97

17% 5–7 mo Never OR 0.83 0.76-0.90

21% > 7 mo Never OR 0.79 0.70-0.88

01 Chapter BHFP 001-022.indd 5

26% Greater Less OR 0.74 0.68-0.80