Breastfeeding: What are the Barriers? Why Women Struggle to Achieve Their Goals

Abstract

Despite recognized health benefits for both mothers and infants, significant disparities still exist in the rates of breastfeeding in the United States. Major organizations representing the health of women and children (including the Centers for Disease Control and Prevention [CDC], American Academy of Pediatrics [AAP], American Congress of Obstetrics and Gynecology [ACOG], American Academy of Family Physicians [AAFP], United Nations International Children's Emergency Fund (UNICEF), the World Health Organization [WHO], and the United States Public Health Service [PHS]) recommend exclusive breastfeeding, but statistics show that although many women initiate breastfeeding, few meet the recommended goals for duration and exclusivity. This article reviews the evidence related to barriers (prenatal, medical, societal, hospital, and sociocultural) that many mothers face, and explore the known barriers and the impact they have on a woman's ability to breastfeed her infant. Strategies will be discussed to address (and potentially overcome) some of the most common barriers women face along with a list of resources that can be useful in this effort. Gaps in care and areas that need further research will be noted. This article is targeted toward physicians and other healthcare providers who work with women and who can assist with and advocate for the removal of barriers and thereby improve the health of women and children by increasing the rates of breastfeeding initiation, duration, and exclusivity in the United States.

Introduction

Breastmilk is the physiologic norm for infant nutrition, offering multiple health benefits and protection for mothers and babies.¹ Despite recommendations from major health organizations, such as the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), American Congress of Obstetrics and Gynecology (ACOG), American Academy of Family Physicians (AAFP), United Nations International Children's Emergency Fund (UNICEF), the World Health Organization (WHO), and United States Public Health Service (PHS) to breastfeed exclusively for the first 6 months, followed by combining breastmilk and solid foods until babies are at least 12 months of age,^2

–7 many women in the U.S. are not achieving this metric.⁸ Significant disparities exist in breastfeeding rates based on education level, maternal race/ethnicity, and socioeconomic status (Tables 1 and 2). Women with lower levels of education, who are nonwhite, non-Hispanic, or of lower socioeconomic status face significant barriers and are less likely to meet their breastfeeding goals. There are various factors that need to be considered for these disparities, such as cultural factors, financial need to return to work, as well as lack of partner and/or family support to continue breastfeeding.⁹

Table 1.

U.S. Breastfeeding Rates Versus Healthy People 2020

	Today (%)	2020 HP goals (%)
Ever BF	79.2	81.9
Any BF-6 months	49.4	60.6
Any BF-12 months	26.7	34.1
Exclusive BF-3 months	40.7	46.2
Exclusive BF-6 months	18.8	25.5
Increase No. of worksite lactation programs		38
Reduce formula in first 48 hours of life	19.4	14.2
Increase No. of birth facilities with recommended care	7.79	8.1

CDC 2014: www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf.

BF, breastfeeding; HP, Healthy People.

Table 2.

U.S. Breastfeeding Rates Versus Demographic

Race	% Initiation	% 6 months	% 12 months
White, non-Hispanic	74.3	43.2	21.4
Black, non-Hispanic	54.4	26.6	11.7
Hispanic	80.4	45.1	24.0
Asian	80.9	52.4	29.7
WIC status
WIC enrolled	66.1	32.7	16.5
WIC eligible, not enrolled	76.5	50.4	30.1
Not eligible	82.2	51.7	25.5
Mother's education
Less than HS or GED	66.2	35.9	19.9
HS or GED	65.2	31.7	15.7
Some college	74.8	40.5	19.7
College graduate	85.4	56.5	28.6
Mother's age
<20	53	19.3	8.1
20–29	69	33.8	16.2
≥30	77.5	48.5	25.4

MMWR, March 2010: www.cdc.gov/mmwr/preview/mmwrhtml/mm5911a2.htm.

GED, general equivalency diploma; HS, high school; WIC, Women, Infants, & Children Program.

By familiarizing themselves with the known barriers and identifying women who are at risk for not achieving the established feeding goals, healthcare professionals can better support women and design interventions that can help mothers overcome these challenges. Change would need to occur at all levels: sociocultural, institutional, and most importantly, at the level of the individual provider–patient relationship. Evidence has shown that healthcare provider support of breastfeeding along with patient education has a significant impact on breastfeeding rates.¹⁰ Mothers who stop breastfeeding early often demonstrate a lack of realistic expectations, suggesting a gap in knowledge and support that could have been provided by their healthcare professional.¹¹ This article reviews the evidence related to prenatal, hospital, postnatal, sociodemographic, medical, societal, and cultural barriers to successful breastfeeding that many mothers face and explore potential strategies to help mothers achieve their intended breastfeeding goals.

Prenatal Factors

Breastfeeding rates began to decrease in this country in the late 1950's. By 1971, rates reached a nadir in which only one out of every four or five women even initiated breastfeeding.¹² A generation of grandmothers, aunts, physicians, and nurses to help support and manage breastfeeding was therefore lost. Healthcare providers are well positioned to help women learn why breastfeeding is recommended, what to expect, and how to anticipate and manage common concerns. The chain of experience would be restored as more mothers breastfeed successfully and breastfeeding again becomes the norm.

Most women make their feeding decisions before conception and/or during pregnancy, making prenatal breastfeeding education and counseling vital.¹³ One recent study showed that prenatal breastfeeding education was addressed in only 29% of visits for <40 seconds, highlighting the fact that, during a busy encounter, breastfeeding may be inadequately addressed.¹⁴

Receiving breastfeeding education before delivery may add to feelings of breastfeeding self-efficacy and confidence. Women with lower confidence were more likely to stop breastfeeding within 1 week postpartum (5% vs. 27%). Prenatal confidence was one of the most significant predictors of breastfeeding duration. Women with low confidence in breastfeeding often feel that they have insufficient milk supply. As a result of this perception, many women start formula supplementation and eventually stop breastfeeding.^14,15 Prenatal classes, which addressed breastfeeding myths and concerns, showed increased rates of breastfeeding initiation and duration among lower SES black women.¹⁶ Prenatal breastfeeding education helps improve breastfeeding rates and is a recommended strategy from the United States Preventive Services Task Force and the WHO/UNICEF.^17,18 Based on the evidence, ensuring that all pregnant mothers receive breastfeeding education would result in increased rates of breastfeeding. Future studies should be designed that would maximize efficiency, effectiveness, and timing of prenatal or even preconception breastfeeding education.

Provider Knowledge, Attitudes, and Beliefs

Despite a preponderance of evidence regarding positive health outcomes, providers still report that they feel uncomfortable “telling a mother how to feed a baby.”¹⁹ Some fear that they will make mothers feel guilty if they choose not to breastfeed.^20,21 Yet, healthcare providers routinely discuss a wide variety of emotionally charged topics such as smoking cessation, obesity, birth control, immunizations, and discipline strategies. It has been shown that the manner in which such topics are addressed may determine how a mother will feel about the recommendation.²² Motivational interviewing techniques can be employed with breastfeeding counseling to maximize both the empowerment of the mother to help increase breastfeeding rates.²³ Strategies are needed to help healthcare providers feel comfortable recommending that mothers breastfeed their infant and then provide information based on a mother's knowledge level and specific concerns to help her make the best decision for herself and her family.

Many practicing physicians were trained when only about 25% of new mothers were initiating breastfeeding. Some pediatricians still recommend that mothers discontinue breastfeeding for conditions that are compatible with breastfeeding.²⁴ Over 71% of both practicing pediatricians and OB-Gyns felt they had little or no breastfeeding education or training. Due to lack of knowledge and training, many physicians report a lack of confidence in counseling their patients on infant feeding choices.²⁵

In some cases, personal experiences with breastfeeding can play a big role in a provider's attitude. These anecdotes may be generated by a provider's own breastfeeding attempts or experiences conveyed by partners, friends, and family. Many mothers who are medical professionals, struggle to overcome breastfeeding difficulties. Studies of physicians show a discrepancy between intent to breastfeed and the actual length of breastfeeding.²⁶ While many female physicians are unable to meet their breastfeeding goals due to work demands, not meeting these goals was associated with negative emotion. One study found that over 90% of pediatricians felt their breastfeeding experiences affected their clinical advice to mothers.²⁷ This study highlights the importance of healthcare providers, along with their partners, to have access to better resources so that they can meet their own individualized breastfeeding goals, and in turn, they themselves can be an advocate for their patients who want to breastfeed.

Sociocultural Influences

Women access information about breastfeeding from many nonmedical sources: media, social groups, family members, and cultural practices.^28,29 Whether on TV, social media, the news, or blogs, media is powerful in swaying its audience through marketing and popular culture.^30,31 Unfortunately, the information may not be helpful, accurate, or safe. Some of these sources continue to perpetuate the idea that bottles, rather than breastfeeding are the norm.³² Local community marketing, PSAs, and social media can be an effective way to reach at-risk populations and help shift their thinking while addressing social and cultural norms. In Vietnam, by using mass media, print ads, and social media, breastfeeding rates increased from 26% (2011) to 48% (2012).³³

The opinion of the mother's partner and family can significantly influence a mother's decision to breastfeed. Since many current grandmothers may have never breastfed, a new mother may not have someone who can help her. For some, their own personal breastfeeding experiences, especially those that resulted in poor outcomes, can negatively affect breastfeeding for the new mother.³⁴ In some families and cultures, the decision to breastfeed is not one that is made by the new mother, but instead, is heavily influenced by the baby's father. For some African American women, their decision to forgo breastfeeding is based on the fact that the baby's father discouraged it, even though the mother knew it was best for her baby.³⁵ Involving the father significantly improves breastfeeding duration, paternal self-efficacy, and general satisfaction.³⁶ Families, significant others, and friends should be included in breastfeeding counseling, support, and education. (See Supplementary Table S1. Supplementary Data are available online at www.liebertpub.com/jwh).

Myths about breastfeeding perpetuate misinformation regarding sleep, diet, and medications. These myths can undermine a woman's informed decision to breastfeed.³⁷ In addition to common misconceptions about the negative effects on sleep, restrictions on diet, or medication use, many women are nervous about what breastfeeding will physically feel like. In particular, African American women tended to be more fearful of pain (18.6%) than White (4.8%) or Hispanic (3.8%) women.^2,38,39 Healthcare providers can help dispel these myths by first asking what the patients and families have heard about breastfeeding and then giving them factual, evidence-based information.

The conflict between the sexuality of breasts, and functionality of breastfeeding for a baby's nutrition has led to many concerns about nursing in public. Women have been accosted in public places and asked to cover up or leave establishments while trying to breastfeed their infant. Lack of support for breastfeeding in public contributes to low rates of breastfeeding exclusivity and duration.⁴⁰ The general public is not supportive of women breastfeeding in public, and many are uncomfortable with a woman breastfeeding in close proximity.⁴¹ Despite laws which exempt breastfeeding women from public indecency laws and thereby allow public breastfeeding, many women are still not protected due to the large variation between states.⁴² While many women feel too embarrassed to breastfeed in public, options such as feeding in more private spaces such as bathrooms may be undesirable for both comfort and sanitation concerns. This has led to many national and international movements where hundreds or even thousands of women have nursed in public to bring awareness to the issue, with the goal of educating the general public that breastfeeding is normal infant nutrition.

Marketing also plays a role in establishing the infant feeding norm. Images of bottle-feeding babies are commonly featured on commercial “baby” items. In a study that looked at common items given as baby shower gifts, out of 2670 baby items, none had any images of breastfeeding. In contrast, baby bottle images were found in 8 out of the 11 categories of items. Thirty-five percent of baby dolls were sold with a plastic baby bottle. The prevalence of dolls sold with baby bottles is evidence that breastfeeding may still not be viewed by all as the norm for infant feeding.⁴³

The AAP and the Academy of Breastfeeding Medicine (ABM) discourages displaying any images of bottle-feeding babies, and rather, suggests that signs, brochures, and photos feature positive images of breastfeeding and encourage mothers to breastfeed.^44,45 A recent study showed that a practice that implemented this breastfeeding-friendly office protocol increased rates of breastfeeding exclusivity.⁴⁶ Providers that examine their practice environments and implement changes that are supportive of breastfeeding may also see a rise in the rates of exclusive breastfeeding in their patient population.

Infant formula or commercial, artificial breast milk substitute is a heavily marketed product—both in the United States and internationally. This occurs in the free market, as well as through the Women, Infants, & Children Program (WIC), a federally funded program that serves a vulnerable population. Although rates are rising, WIC recipients characteristically have lower breastfeeding rates compared to those not receiving WIC.⁴⁷ WIC purchases over 50% of the formula in the US, which translates into $850 million of a $7.3 billion budget. Over $90 million is spent on formulas with additives (DHA/ARA) that have not been shown to have any benefit to the baby's development.⁴⁸

Historically, the Infant Formula Council (IFC) has lobbied against the public health promotion of breastfeeding. In 2007, due to pressure from the IFC, there was poor media coverage for the Health and Human Services Blueprint for Action on Breastfeeding, as the IFC discouraged a pro-breastfeeding campaign.^49,50 The WHO's International Code of Marketing Breast Milk Substitutes clearly states that formula samples should not be given to pregnant women and new mothers; and feeding with infant formula should only be done so with a medical indication and demonstrated by healthcare workers.⁵¹

Pregnant women are commonly exposed to formula advertising in their OB's office, parenting magazines, and are sometimes offered free formula. Receiving formula, whether in maternity discharge packs or at home through the mail, may prevent women from reaching their breastfeeding goals. Peripartum breastfeeding cessation was significantly higher in women exposed to commercial formula packs in the obstetrician's office.⁵² Physician professional organizations should strive to follow the Conflict of Interest statement regarding corporate sponsorship and work as individuals to limit the amount of corporate-sponsored education material and advertising in their environments. These sponsorships may unduly influence professional judgments involving the primary interests and goals of medicine while ignoring evidence-based practices.⁵³

In 2011, Save the Children ranked the United States last out of 36 countries on the Breastfeeding Policy scorecard. The United States is “the only economically advanced country”. … “where employers are not required to provide any paid maternity leave after a woman gives birth.” Ninety-eight countries give new mothers 14 weeks or more of paid maternity leave. Expectant mothers in the United States can apply for leave under the Family and Medical Leave Act (FMLA), which provides the mother with 12 weeks of unpaid maternity leave; however, companies are not required to provide FMLA. In this economy, unpaid leave is not a feasible choice for many families.⁵⁴

Healthy People 2020 includes a goal to “increase the proportion of employer worksite lactation support programs.” The Surgeon General's Call to Action to Support Breastfeeding included a section calling for lactation support in employment settings. The Patient Protection and Affordable Care Act (ACA) states that businesses must provide reasonable break time and adequate space for a nursing mother to express milk.⁵⁵ As the importance of breastfeeding and risks of formula feeding become better known, various health and governmental organizations are taking steps to help new mothers reach their breastfeeding goals.

Many women choose to exclusively pump their breast milk to feed their infants rather than put them directly to the breast. There is also sometimes a perception that women who are breastfeeding need to pump. Often times, women receive a breast pump ($200–$300) at the baby shower, or receive a manual pump at hospital discharge. Women choose to pump for various reasons, including modesty, avoiding nursing in public, family/father involvement, and body image.⁵⁶ These decisions are made with little to no existing data to support the equivalence in health outcomes for breastfeeding at the breast compared to long-term breast milk feeding with pumped milk. The ACA now requires most health insurance plans to cover the cost of a breast pump as part of women's preventive health services. The Internal Revenue Service considers breast pumps and other lactation supplies as medical supplies, which allows these items to be eligible for tax breaks and/or flexible spending accounts.⁵⁶ Women who have Medicaid are eligible for WIC, which also provides breast pumps under certain circumstances. Many WIC programs also provide breastfeeding peer counselors, as well. Healthcare providers can ensure that pregnant women and breastfeeding mothers are aware of the provisions within their insurance plans and suggest that they call the number on their insurance card to determine what is covered under their specific health insurance plan.

Hospital/Maternity Care

It is only in the 20th century that the majority of births began to take place in hospitals. Techniques and interventions that have become standard, such as epidurals, IV/IM analgesia, IV fluids, have been associated with less effective suckling, lethargy, delay of feeding behaviors, and increased weight loss in the first few days.^57
–59 While the evidence is not completely clear, epidural analgesia likely has no effect on women who are determined to breastfeed and have good support, however, this may post a subtle challenge for women who may lack a strong intention or support to breastfeed.⁶⁰ Examining specific labor interventions and their impact on infant feeding may result in more successful initiation of breastfeeding in the hospital, and less formula supplementation for breastfeeding babies.

Hospitals that implement evidence-based best practices have higher breastfeeding initiation, duration, and exclusivity rates. Practices such as placing babies on infant warmers rather than on the mother's chest and taking the babies to another room for routine procedures such as weights, bilirubin checks, and hearing screens all can decrease rates of breastfeeding success. Studies have shown a dose–response relationship between various baby-friendly steps and breastfeeding duration and exclusivity.^61,62 Hospitals that have implemented all of the WHO/UNICEF BFHI 10 Steps can apply to become a certified Baby-Friendly hospital.⁶³ Studies show that being Baby-Friendly increases breastfeeding initiation, exclusivity, and duration at 12 months (19.7% vs. 11.4%), with higher rates of breastfeeding exclusivity at 3 months (43.3% vs. 6.4%) and 6 months (7.9% vs. 0.6%) when compared to hospitals who do not follow Baby-Friendly guidelines^64,65 (Table 3).

Table 3.

Ten Steps to Successful Breastfeeding-World Health Organization/United Nations International Children's Emergency Fund

Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff.

Step 2: Train all healthcare staff in skills necessary to implement this policy.

Step 3: Inform all pregnant women about the benefits and management of breastfeeding.

Step 4: Help mothers initiate breastfeeding within the first (half) hour of birth.

Step 5: Show mothers how to breastfeed, and how to maintain lactation.

Step 6: Give newborn infants no food or drink other than human milk, unless medically indicated.

Step 7: Practice rooming-in—that is, allow mothers and infants to remain together 24 hours per day.

Step 8: Encourage breastfeeding on demand.

Step 9: Give no artificial teats or pacifiers to breastfeeding infants.

Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

www.babyfriendlyusa.org

Currently only 7.15% of U.S. births occur at Baby-Friendly facilities. There are many potential barriers for hospitals becoming Baby-Friendly: cost of staff training, purchase of formula at fair market price, and the time investment to implement, collect, and submit data on these quality improvement strategies. Despite this, a recent analysis showed that the undertaking was relatively cost neutral.⁶⁶

The CDC conducts a biannual survey measuring how well hospitals are following evidence-based breastfeeding practices. While scores have been improving over the past several years, the average composite score of 75 out of a possible 100, indicates that the United States has a tremendous opportunity to help these mothers get off to a stronger start with infant feeding.⁸

For example, women who were randomized to have immediate skin-to-skin (S2S) time with their infant after delivery showed increased breastfeeding rates upon hospital discharge, and increased rates of breastfeeding at 1–4 months. AAP and ACOG guidelines for perinatal care state that, if the newborn is stable, the baby should be placed immediately S2S with the mother. Interventions, such as Vitamin K, height/weight, can be delayed until after the first hour.^67

–70 Healthcare providers can work with their facilities to find out their Maternity Practices in Infant Nutrition and Care (mPinc) scores and subsequently work with the administration to ensure that the 10-Steps are being implemented in their hospitals.

Postnatal Factors

Cesarean delivery is associated with delayed S2S contact between mother and baby, significant delay in breastfeeding initiation, increased supplemental feeding, and separation of mother and baby, all of which lead to suboptimal breastfeeding practices.^2,71,72 Ongoing efforts to lower the percentage of cesarean deliveries may have a positive impact on breastfeeding outcomes.

Obesity continues to be an epidemic in this country, and unfortunately women and new mothers are equally affected. Body mass index (BMI) rates continue to increase. During 2011–2012, 36% of women were obese, 32% of these women are of child-bearing age.⁷³ While there are multiple health risks for an obese mother and her baby, maternal BMI also negatively affects breastfeeding rates. Women with a BMI ≥30 are less likely to initiate breastfeeding and have a shorter duration of breastfeeding, and have psychosocial characteristics associated with poor breastfeeding outcomes, and are at risk for delayed onset of lactation.^74
–76 Providing breastfeeding care may be more challenging due to anatomical, physical mobility issues, as well as issues related to modesty and the stigma associated with being obese. Women with higher BMIs can be referred for expert breastfeeding education prenatally and provided opportunities for breastfeeding support and management postnatally to help them meet their goals.

Although the AAP recommends that mother–infant dyads be observed during breastfeeding for effectiveness,⁴ less than half of the physicians surveyed felt that evaluating breastfeeding was a primary-care physician's responsibility, and even fewer routinely observed breastfeeding dyads.²⁵ Nurses also play an integral part when helping mothers feed their new infants. Although the American Nurses Association recommends breastfeeding, breastfeeding teaching and experiential learning are inconsistent among nursing training programs.^77,78

Another consideration in the hospital is that the rates of premature births have risen since the late 1990's. Much of this increase is accounted for by late preterm infants (34 and 0/7 and 36 6/7 weeks).⁷⁹ Due to maternal–infant separation, there may be an increased need, real or perceived, for formula supplementation.⁸⁰ The Joint Commission now recommends forgoing elective inductions or caesarean sections before 39 weeks. If an infant is born early, techniques such as hand expression or pumping within the first hour and on a regular basis thereafter have been shown to facilitate and ensure adequate milk supply.^81,82

Hand expression is an extremely effective technique for removing colostrum when the infant is not able to breastfeed. Mothers who hand expressed within the first few days of postpartum were able to express an average of 955 mL/day. Mothers who hand expressed within the immediate postpartum period were more likely to be breastfeeding at 2 months (96.1%) compared to a mother who used an electric pump (72.7%)^83,84 Healthcare providers who care for mothers and their premature babies are in a position to educate staff and families about the importance of hand expression and hands-on pumping in the first hour after separation to help establish and maintain their milk supply.

In U.S. hospitals, new mothers and their babies stay in the hospital for an average of 1.6 days after delivery.⁸⁵ Within that time, there are a number of mandatory screenings and assessments that must take place within a short period of time. These interruptions can negatively influence breastfeeding.⁸⁶ Healthcare providers can coordinate and cluster care to streamline the process that will minimize hospital room visits so that the mother–baby dyad can bond and establish feeding patterns.

The fear of jaundice in newborns and the risk of progression to kernicterus in newborns is another common barrier in the hospital that often leads to increased formula use. While it is true that poor breastfeeding is associated with increased jaundice risk, frequent and effective breastfeeding can be protective against the development of nonphysiologic jaundice.⁸⁷ Breastfed babies usually have a prolonged physiologic jaundice (unconjugated) that can extend into the second week of life. Breastfed babies need to nurse at least 8–12 times per 24-hour period for adequate nutrition and hydration, which can help prevent nonphysiologic jaundice. Breastfeeding dyads can be assessed using an objective screening tool to check for optimal milk transfer.⁸⁸ If supplementation is needed beyond the mother's own milk, the baby should receive (1) expressed mother's milk, (2) pasteurized donor milk, or (3) infant formula. Hydrolyzed (elemental) protein formulas may be more effective than standard formula to inhibit the intestinal absorption of bilirubin.⁸⁹ If a baby requires phototherapy, there are methods to provide phototherapy with minimal breastfeeding interruption by keeping the infant in the mother's room for frequent feeding and providing phototherapy while the infant is held S2S.⁹⁰

Formula supplementation, which is often initiated or recommended based on an infant's weight loss, has been shown to be detrimental to breastfeeding rates.⁹¹ Since obstetrical intervention and certain infant factors can affect an infant's degree of weight loss, an evaluation to assess latch and milk transfer should be done before deciding the appropriate intervention.^59,92 A recent study shows that a subset of normal breastfeeding newborns lost >10% of their birth weight 48 hours after delivery, with babies delivered through C-section having a greater amount of weight loss for a longer duration (72 hours).⁹³ Healthcare providers can now use evidence-based guidelines and nomograms to help decide a medical need for supplementation, or whether close observation and management by a lactation specialist will suffice.⁸⁰

The incidence of ankyloglossia, or a shortened or tight lingual frenulum, often referred to as “tongue tie,” has been shown to be in the range of 3%–13%.⁹⁴ Breastfeeding difficulties were seen in 25% of mothers with infants who had ankyloglossia.⁹⁵ Signs include maternal pain, trouble sustaining latch, which may result in poor milk transfer. A physical exam as well as a functional feeding assessment to look for problems sustaining latch, problems transferring milk, or persistent maternal pain despite lactation assistance and/or the use of a tool such as the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) can identify infants who may require a frenulotomy, or frenotomy, a simple and effective bedside procedure, which can improve latch and reduce maternal pain.^96
–98 Healthcare providers can examine for tongue-tie as part of their normal admission exam, and if indicated (i.e., there is the presence of a short frenulum and a functional issue has been identified), may offer frenotomies to make breastfeeding more effective while decreasing maternal pain.

The AAP recommends that mothers breastfeed their infant in bed and then return the baby to its own sleep surface to avoid bed sharing while encouraging pacifier use and breastfeeding.⁹⁹ However, others have shown that cosleeping is associated with longer duration of breastfeeding.¹⁰⁰ Breastfeeding has also been shown to be a key protective factor for SIDS while bed sharing; this effect being stronger with exclusive breastfeeding.^101,102 However, socioeconomic factors need to be considered. Amidst all the confusing evidence, healthcare providers need to educate parents about safe sleep practices while preserving breastfeeding.

Finally, regarding hospital discharge, women who received free formula samples at discharge were less likely to be breastfeeding at 1 month and more likely to introduce solids at 2 months. In addition, the rates of initiation, exclusivity, and duration were decreased.¹⁰³ Medical providers are in a role to educate, encourage, and support mothers to breastfeed in the hospital and refrain from giving formula discharge packs. The provision of commercial hospital discharge packs (with or without formula) reduces the number of women exclusively breastfeeding at all times.¹⁰⁴ Movements to ban the bags have been successful in getting rid of formula samples within the hospital setting while improving breastfeeding success.

Conclusion

This article reviews many factors—prenatal, medical, sociocultural, hospital, and postnatal, which are all considered “Booby Traps”—putting women at risk of not meeting their personal breastfeeding goals. When mothers make the important decision about infant feeding, they need evidence-based information to make a truly informed choice. By presenting infant feeding as a health decision impacting the health of mother and baby, the healthcare team can tailor information to the mother's knowledge, goals, and concerns.

Breast milk is an exquisitely personalized medicine and every mother and her baby have the right to learn the benefits of breastfeeding when making her decision. We, as healthcare providers, all share in this responsibility.¹⁰⁵

By providing mothers, along with their partners and families, with factual and current evidence-based recommendations, healthcare professionals can educate and assist mothers at-risk. Healthcare providers, with awareness of these barriers, can work in communities, at their facilities, in their practices, and on an individual basis with women to help mothers feel more prepared and supported so that they may successfully reach their breastfeeding goals. When these challenges are effectively identified and addressed, breastfeeding rates will likely rise, thereby positively impacting the health of women and infants in the United States.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

Agency for Healthcare Research and Quality; U. S. Department of Health and Human Services. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Publication No. 07-E007, April 2007.

U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.

United States Breastfeeding Committee. Implementing The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding. Washington, DC, 2010.

Eidelman

, Schanler

. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics, 2012; 129:e827–e841.

The Academy of Breastfeeding Medicine Board of Directors. Position on breastfeeding. Breastfeed Med, 2008; 3:267–270.

Fifty-fourth World Health Assembly. Global strategy for infant and young child Feeding: The optimal duration of exclusive breastfeeding. Geneva, Switzerland: World Health Organization, 2001.

Healthy People 2020. Maternal, infant, and child health. 2012. www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=26. Accessed September 15, 2014 .

Centers for Disease Control and Prevention. Breastfeeding report card-United States, 2012. www.cdc.gov/breastfeeding/data/reportcard.htm. Accessed September 15, 2014 .

Scanlon

, Grummer-Strawn

, Li

, Chen

, Molinari

, Perrine

. Racial and ethnic differences in breastfeeding initiation and duration, by state. National Immunization Survey, United State, 2004–2008. MMWR Wkly, 2010:59; 327–334.

10.

Dyson

, McCormick

, Renfrew

. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev, 2005:CD001688.

11.

Scott

, Lander

, Hughes

, Binns

. Psychosocial factors associated with the abandonment of breastfeeding prior to hospital discharge. J Hum Lact, 2001; 17:24–30.

12.

Wright

, Schanler

. The resurgence of breastfeeding at the end of the second millennium. J Nutr, 2001; 131:421S–425S.

13.

Arora

, McJunkin

, Wehrer

, Kuhn

. Major factors influencing breastfeeding rates: Mother's perception of father's attitude and milk supply. Pediatrics, 2000; 106:E67.

14.

Demirci

, Bogen

, Holland

, et al. Characteristics of breastfeeding discussions at the initial prenatal visit. Obstet Gynecol, 2013; 122:1263–1270.

15.

Noel-Weiss

, Rupp

, Cragg

, Bassett

, Woodend

. Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. J Obstet Gynecol Neonatal Nurs, 2006; 35:616–624.

16.

Kistin

, Benton

, Rao

, Sullivan

. Breastfeeding rates among black urban low-income women: Effect of prenatal education. Pediatrics, 1990; 86:741–746.

17.

U.S. Preventive Services Task Force. Primary Care Interventions to Promote Breastfeeding. An Evidence Review for the U.S. Preventive Services Task Force, October 2008.

18.

WHO/UNICEF. Protecting, promoting and supporting breastfeeding: The special role of maternity services. Geneva, 2003.

19.

Colen

, Ramey

. Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Soc Sci Med, 2014; 109:55–65.

20.

Shah

. Is breast always best? A personal reflection on the challenges of breastfeeding?. Obstet Gynecol, 2013; 121:869–871.

21.

Labbok

. Exploration of guilt among mothers who do not breastfeed: The physician's role. J Hum Lact, 2008; 24:80–84.

22.

Opel

, Heritage

, Taylor

, et al. The architecture of provider-parent vaccines discussions in helath supervision visits. Pediatrics, 2013; 132:1037–1046.

23.

Elliott-Rudder

, Pilotto

, McIntyre

, Ramanathan

. Motivational interviewing improves exclusive breastfeeding in an Australian randomised controlled trial. Acta Paediatr, 2014; 103:e11–e16.

24.

Feldman-Winter

, Schanler

, O'Connor

, Lawrence

. Pediatricians and the promotion and support of breastfeeding. Arch Pediatr Adolesc Med, 2008; 162:1142–1149.

25.

Pound

, Williams

, Grenon

, Aglipay

, Plint

. Breastfeeding knowledge, confidence, beliefs, and attitudes of Canadian physicians. J Hum Lact, 2014; 30:298–309.

26.

Sattari

, Levine

, Neal

, Serwint

. Personal breastfeeding behavior of physician mothers is associated with their clinical breastfeeding advocacy. Breastfeed Med, 2013; 8:31–37.

27.

Dixit

, Feldman-Winter

, Szucs

. “Frustrated,” “Depressed,” and “Devastated” pediatric trainees: US Academic Medical Centers Fail to provide adequate workplace breastfeeding support. J Hum Lact, 2015; 31:240–248.

28.

Sheehan

, Schmied

, Barclay

. Complex decisions: Theorizing women's infant feeding decision in the first 6 weeks after birth. J Adv Nurs, 2010; 66:371–380.

29.

Raj

, Plichta

. The role of social support in breastfeeding promotion: A literature review. J Hum Lact, 1998; 14:41–45.

30.

Zhang

, Carlton

, Fein

. The association of prenatal media marketing exposure recall with breastfeeding intentions, initiation, and duration. J Hum Lact, 2013; 29:500–509.

31.

Brown

, Peuchaud

. Media and breastfeeding: Friend or foe?. Int Breastfeed J, 2008; 3:15.

32.

Moore

, Coty

. Prenatal and postpartum focus groups with primiparas: Breastfeeding attitudes, support, barriers, self-efficacy, and intention. J Pediatr Health Care, 2006; 20:35–46.

33.

Alive & Thrive. Strategic design of mass media, promoting breastfeeding in mass media; 2014. www.fhi360.org/sites/default/files/media/documents/eMag-VN-Mass_Media-FINAL%203%2004%202014.pdf. Accessed January 21, 2015 .

34.

Grassley

, Eschiti

. Grandmother breastfeeding support: What do mothers need and want?. Birth, 2008; 35:329–335.

35.

Alexander

, Dowling

, Furman

. What do pregnant low-income women say about breastfeeding?. Breastfeed Med, 2010; 5:17–23.

36.

Abbass-Dick

, Stern

, Nelson

, Watson

, Dennis

. Coparenting breastfeeding support and exclusive breastfeeding: A randomized controlled trial. Pediatrics, 2015; 135:102–110.

37.

Doan

, Gardiner

, Gay

, Lee

. Breast-feeding increases sleep duration of new parents. J Perinat Neonatal Nurs, 2007; 21:200–206.

38.

Hurley

, Black

, Papas

, Quigg

. Variation in breastfeeding behaviours, perceptions, and experiences by race/ethnicity among a low-income statewide sample of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants in the United States. Matern Child Nutr, 2008; 4:95–105.

39.

Office of Women's Health, U.S. Department of Health and Human Services. It's only natural: Breastfeeding myths in the African-American community. 2013. http://womenshealth.gov/itsonlynatural/addressing-myths/myths-in-the-african-american-community.html. Accessed January 21, 2015 .

40.

Sayers

. Breast is best: Just maybe in private?. Br J Gen Pract, 2014; 64:44–45.

41.

Mulready-Ward

, Hackett

. Perception and attitudes: Breastfeeding in public in New York City. J Hum Lact, 2014; 30:195–200.

42.

Nguyen

, Hawkins

. Current state of US breastfeeding laws. Matern Child Nutr, 2013; 9:350–358.

43.

Gellerson

, Hornsby

, Lowenhaupt

, et al. Prevalence of baby bottle versus breastfeeding graphics on products in national chain stores. Breastfeed Med, 2012; 7:469–472.

44.

Grawey

, Marinelli

, Holmes

; Academy of Breastfeeding Medicine. ABM Clinical Protocol #14: Breastfeeding-friendly physician's office: Optimizing care for infants and chidren, revised 2013. Breastfeed Med, 2013; 8:237–242.

45.

American Academy of Pediatrics. How to have a breastfeeding friendly practice. www2.aap.org/breastfeeding/files/pdf/AAP%20FindFriendlyPractice.pdf. Accessed October 4, 2015 .

46.

Corriveau

, Drake

, Kellams

, Rovnyak

. Evaluation of an office protocol to increase exclusivity of breastfeeding. Pediatrics, 2013; 131:942–950.

47.

CDC National Immunization Survey. Rates of any and exclusive breastfeeding by socio-demographics among children born in 2011. 2011. www.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem-2011.htm. Accessed January 21, 2015 .

48.

Oliveira

, Frazao

, Smallwood

. Rising infant formula costs to the WIC program: Recent trends in rebates and wholesale prices,” ERR-93, USDA, Economic Research Service, February 2010:3–4. www.cbpp.org/cms/?fa=view&id=3201#_ftn2. Accessed September 17, 2014 .

49.

Kaufman

, Lee

. HHS Toned Down Breast-Feeding Ads. www.washingtonpost.com/wp-dyn/content/article/2007/08/30/AR2007083002198.html Accessed February 23, 2015 .

50.

Health and Human Services Letter. 2004. http://media.washingtonpost.com/wp-srv/health/documents/yeutterletters.pdf. Accessed September 17, 2014 .

51.

International Code of Marketing of Breast-Milk Substitutes. World Health Organization, Geneva, 1981. www.who.int/nutrition/publications/code_english.pdf. Accessed January 21, 2015 .

52.

Howard

, Howard

, Lawrence

, Andresen

, DeBlieck

, Weitzman

. Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol, 2000; 95:296–303.

53.

Conflict of Interest in Medical Research, Education, and Practice. Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo

, Field

, eds. Washington, DC: National Academies Press (US), 2009. The National Academies Collection: Reports funded by National Institutes of Health.

54.

U. S. Department of Labor. Family medical leave act of 1993. 2012. www.dol.gov/compliance/guide/fmla.htm. Washington DC: U. S. Department of Labor; Office of the Assistant Secretary for Policy. Updated September 2009. Accessed September 21, 2014 .

55.

Garvin

, Sriraman

, Paulson

, Wallace

, Martin

, Marshall

. The business case for breastfeeding: A successful regional implementation, evaluation, and follow-up. Breastfeed Med, 2013; 8:413–417.

56.

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #8: Human milk storage information for home use for full-term infants (original protocol March 2004; revision #1 March 2010). Breastfeed Med, 2010; 5:127–130.

57.

Dewey

, Nommsen-Rivers

, Heinig

, Cohen

. Risk factors for suboptimal infant breastfeeding behaviora, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 2003; 112 (3 Pt 1):607–619.

58.

Noel-Weiss

, Woodend

, Peterson

, Gibb

, Grol

. An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss. Int Breastfeed J, 2011; 6:9.

59.

Chantry

, Nommsen-Rivers

, Peerson

, Cohen

, Dewey

. Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance. Pediatrics, 2011; 127:e171–e179.

60.

Academy of Breastfeeding Medicine Protocol Committee: Montgomery

, Hale

. Clinical protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother. New Rochelle, NY: Academy of Breastfeeding Medicine, 2012.

61.

Nickel

, Labbok

, Hudgens

, Daniels

. The extent that noncompliance with the ten steps to successful breastfeeding influences breastfeeding duration. J Hum Lact, 2013; 29:59–70.

62.

Taylor

, Nickel

, Labbok

. Implementing the ten steps for successful breastfeeding in hospitals serving low-wealth patients. Am J Public Health, 2012; 102:2262–2268.

63.

Baby-Friendly USA, 2012. www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps. Accessed September 16, 2014 .

64.

Kramer

, Chalmers

, Hodnett

, et al. PROBIT Study Group (Promotion of Breastfeeding Intervention Trial). Promotion of Breastfeeding Intervention Trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA, 2001; 285:413–420.

65.

Del Bono

, Rabe

. Breastfeeding and child cognitive outcomes: Evidence from a hospital-based breastfeeding support policy. ISER Working Paper Series:, 2012; 12:2012–29.

66.

DelliFraine

, Langabeer

2nd , Williams

, Gong

, Delgado

, Gill

. Cost comparison of baby friendly and non baby friendly hospitals in the United States. Pediatrics, 2011; 127:e989–e994.

67.

Academy of Breastfeeding Medicine Protocol Committee: Chantry

, Howard

, McCoy

. Clinical protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term. New Rochelle, NY: Academy of Breastfeeding Medicine, 2003.

68.

American Academy of Pediatrics [AAP] Expert Workgroup on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics, 2005; 115:496–506.

69.

American College of Obstetricians and Gynecologists [ACOG] Committee on Health Care for Underserved Women & Committee on Obstetric Practice. ACOG Committee Opinion #361, February 2007. Breastfeeding: Maternal and infant aspects. ACOG Clinical Review, 12. 2007, January–February (Suppl. 1):1S–16S.

70.

Anderson

, Moore

, Hepworth

, Bergman

. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev, 2003:CD003519.

71.

Rowe-Murray

, Fisher

. Baby-friendly hospital practices: Cesarean section is a persistent barrier to early initiation of breastfeeding. Birth, 2002; 29:124–131.

72.

Pérez-Escamilla

, Maulěn-Radovan

, Dewey

. The association between cesarean delivery and breast-feeding outcomes among Mexican women. Am J Public Health, 1996; 86:832–836.

73.

NCHS Data Brief, Number 131, Prevalence of obesity among adults: United States, 2011–2012; October 2013. www.cdc.gov/nchs/data/databriefs/db131.htm. Accessed January 21, 2015 .

74.

Amir

, Donath

. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth, 2007; 7:9.

75.

Hauff

, Leonard

, Rasmussen

. Associations of maternal obesity and psychosocial factors with breastfeeding intention, initiation, and duration. Am J Clin Nutr, 2014; 99:524–534.

76.

Nommsen-Rivers

, Chantry

, Peerson

, Cohen

, Dewey

. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr, 2010; 92:574–584.

77.

American Nurses' Association. The imperative of breastfeeding: Policy changes to promote the health and economic benefits of infant feeding, 2010. www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/Issue-Briefs/Breastfeeding.pdf. Accessed October 4, 2015 .

78.

Boyd

, Spatz

. Breastfeeding and human lactation: Education and curricular issues for pediatric nurse practitioners. J Pediatr Health Care, 2013; 27:83–90.

79.

Kugelman

, Colin

. Late preterm infants: Near term but still in a critical developmental time period. Pediatrics, 2013; 132:741–751.

80.

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med, 2009; 4:175–182.

81.

Academy of Breastfeeding Medicine Protocol Committee: Clinical Protocol #10: ABM clinical Protocol #10: Breastfeeding the late preterm infant (340/7 to 366/7 weeks gestation). Breastfeed Med, 2011; 6:151–156.

82.

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice the Society for Maternal–Fetal Medicine. Nonmedically Indicated Early-Term Deliveries. Committee opinion. April 2013:#561.

83.

Morton

. Is pumping out of hand? Why hand expression in the first 3 postpartum days is important. Lactation matters, International Lactation Consultant Association, 2011. http://lactationmatters.org/2011/09/06/is-pumping-out-of-hand-why-hand-expression-in-the-first-3-postpartum-days-is-important/ Accessed January 21, 2015 .

84.

Hand Expression of Breastmilk. Stanford School of Medicine. 2016. http://newborns.stanford.edu/Breastfeeding/HandExpression.html. Accessed January 21, 2015 .

85.

Farhat

, Rajab

. Length of postnatal hospital stay in healthy newborns and re-hospitalization following early discharge. N Am J Med Sci, 2011; 3:146–151.

86.

Morrison

, Ludington-Hoe

, Anderson

. Interruptions to breastfeeding dyads on postpartum day 1 in a university hospital. J Obstet Gynecol Neonatal Nurs, 2006; 35:709–716.

87.

Maisel

, Bhutani

, Bogen

, Newman

, Stark

, Watchko

. Hyperbilirubinemia in the newborn infant ≥35 weeks' gestation: An update with clarifications. Pediatrics, 2009; 124; 1193.

88.

LATCH Breastfeeding assessement tool. 1994. www.cdph.ca.gov/programs/breastfeeding/Documents/MO-LatchBreastfeedingAssessment.pdf. Accessed October 4, 2015 .

89.

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #22: Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks' gestation. Breastfeed Med, 2010; 5:87–93.

90.

Szucs

, Rosenman

. Family-centered, evidence-based phototherapy delivery. Pediatrics, 2013; 131:e1982–e1985.

91.

Odom

, Li

, Scanlon

, Perrine

, Grummer-Strawn

. Reasons for earlier than desired cessation of breastfeeding. Pediatrics, 2013; 131:e726.

92.

Martens

, Romphf

. Factors associated with newborn in-hospital weight loss: Comparisons by feeding method, demographics, and birthing procedures. J Hum Lact, 2007; 23:233–241.

93.

Flaherman

, Schaefer

, Kuzniewicz

, Li

, Walsh

, Paul

. Early weight loss nomograms for exclusively breastfed newborns. Pediatrics, 2015; 135:e16–e23.

94.

Ballard

, Auer

, Khoury

. Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics, 2002; 110:e63.

95.

Messner

, Lalakea

, Aby

, Macmahon

, Bair

. Ankyloglossia: Incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg, 2000; 126:36–39.

96.

Amir

, James

, Donath

. Reliability of the Hazelbaker assessment tool for lingual frenulum function. Int Breastfeed J, 2006; 1:3.

97.

Buryk

, Bloom

, Shope

. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics, 2011; 128:280.

98.

Academy of Breastfeeding Medicine. Protocol # 11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. New Rochelle, NY.

99.

American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 2011; 128:e1341–e1367.

100.

Huang

, Hauck

, Signore

, et al. Influence of bedsharing activity on breastfeeding duration among US mothers. JAMA Pediatr, 2013; 167:1038–1044.

101.

Vennemann

, Bajanowski

, Jorch

, Mitchell

. Does breastfeeding reduce the risk of sudden infant death syndrome?. Pediatrics, 2009; 123:e406–e410.

102.

Carpenter

, McGarvey

, Mitchell

, et al. Bed sharing when parents do not smoke: Is there a risk of SIDS? An individual level analysis of five major case–control studies. BMJ Open, 2013; 3, 1–11.

103.

Rosenberg

, Eastham

, Kasehagen

, Sandoval

. Marketing infant formula through hospitals: The impact of commercial hospital discharge packs on breastfeeding. Am J Public Health, 2008; 98:290–295.

104.

Donnelly

, Snowden

, Renfrew

, Woolridge

. Commercial hospital discharge packs for breastfeeding women. Cochrane Database Syst Rev, 2000:CD002075.

105.

Victoria

, Bahl

, Barros

, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet Breastfeeding Series, January 2016. Presented at The Lancet Breastfeeding Series Global Launch 2016.

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