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Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women's Health (US). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011.

Cover of The Surgeon General's Call to Action to Support Breastfeeding

The Surgeon General's Call to Action to Support Breastfeeding.

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The Importance of Breastfeeding

Health Effects

The health effects of breastfeeding are well recognized and apply to mothers and children in developed nations such as the United States as well as to those in developing countries. Breast milk is uniquely suited to the human infant’s nutritional needs and is a live substance with unparalleled immunological and anti-inflammatory properties that protect against a host of illnesses and diseases for both mothers and children.1

In 2007, the Agency for Healthcare Research and Quality (AHRQ) published a summary of systematic reviews and meta-analyses on breastfeeding and maternal and infant health outcomes in developed countries.2 The AHRQ report reaffirmed the health risks associated with formula* feeding and early weaning from breastfeeding. With regard to short-term risks, formula feeding is associated with increases in common childhood infections, such as diarrhea3 and ear infections.2 The risk of acute ear infection, also called acute otitis media, is 100 percent higher among exclusively formula-fed infants than in those who are exclusively breastfed during the first six months (see Table 1).2

Table 1. Excess Health Risks Associated with Not Breastfeeding.

Table 1

Excess Health Risks Associated with Not Breastfeeding.

The risk associated with some relatively rare but serious infections and diseases, such as severe lower respiratory infections2,4 and leukemia2,5 are also higher for formula-fed infants. The risk of hospitalization for lower respiratory tract disease in the first year of life is more than 250 percent higher among babies who are formula fed than in those who are exclusively breastfed at least four months.4 Furthermore, the risk of sudden infant death syndrome is 56 percent higher among infants who are never breastfed.2 For vulnerable premature infants, formula feeding is associated with higher rates of necrotizing enterocolitis (NEC).2 The AHRQ report also concludes that formula feeding is associated with higher risks for major chronic diseases and conditions, such as type 2 diabetes,6 asthma,2 and childhood obesity,7 all three of which have increased among U.S. children over time.

As shown in Table 1, compared with mothers who breastfeed, those who do not breastfeed also experience increased risks for certain poor health outcomes. For example, several studies have found the risk of breast cancer to be higher for women who have never breastfed.2,8,9 Similarly, the risk of ovarian cancer was found to be 27 percent higher for women who had never breastfed than for those who had breastfed for some period of time.2 In general, exclusive breastfeeding and longer durations of breastfeeding are associated with better maternal health outcomes.

The AHRQ report cautioned that, although a history of breastfeeding is associated with a reduced risk of many diseases in infants and mothers, almost all the data in the AHRQ review were gathered from observational studies. Therefore, the associations described in the report do not necessarily represent causality. Another limitation of the systematic review was the wide variation in quality among the body of evidence across health outcomes.

As stated by the U.S. Preventive Services Task Force (USPSTF) evidence review,10 human milk is the natural source of nutrition for all infants. The value of breastfeeding and human milk for infant nutrition and growth has been long recognized, and the health outcomes of nutrition and growth were not covered by the AHRQ review.

Psychosocial Effects

Although the typical woman may cite the health advantages for herself and her child as major reasons that she breastfeeds, another important factor is the desire to experience a sense of bonding or closeness with her newborn.12–14 Indeed, some women indicate that the psychological benefit of breastfeeding, including bonding more closely with their babies, is the most important influence on their decision to breastfeed.12 Even women who exclusively formula feed have reported feeling that breastfeeding is more likely than formula feeding to create a close bond between mother and child.13

In addition, although the literature is not conclusive on this matter, breastfeeding may help to lower the risk of postpartum depression, a serious condition that almost 13 percent of mothers experience. This disorder poses risks not only to the mother’s health but also to the health of her child, particularly when she is unable to fully care for her infant.15 Research findings in this area are mixed, but some studies have found that women who have breastfed and women with longer durations of breastfeeding have a lower risk of postpartum depression.16–18 Whether postpartum depression affects breastfeeding or vice versa, however, is not well understood.19

Economic Effects

In addition to the health advantages of breastfeeding for mothers and their children, there are economic benefits associated with breastfeeding that can be realized by families, employers, private and government insurers, and the nation as a whole. For example, a study conducted more than a decade ago estimated that families who followed optimal breastfeeding practices could save more than $1,200–$1,500 in expenditures for infant formula in the first year alone.20 In addition, better infant health means fewer health insurance claims, less employee time off to care for sick children, and higher productivity, all of which concern employers.21

Increasing rates of breastfeeding can help reduce the prevalence of various illnesses and health conditions, which in turn results in lower health care costs. A study conducted in 2001 on the economic impact of breastfeeding for three illnesses—otitis media, gastroenteritis, and NEC—found that increasing the proportion of children who were breastfed in 2000 to the targets established in Healthy People 2010 22 would have saved an estimated $3.6 billion annually. These savings were based on direct costs (e.g., costs for formula as well as physician, hospital, clinic, laboratory, and procedural fees) and indirect costs (e.g., wages parents lose while caring for an ill child), as well as the estimated cost of premature death.23 A more recent study that used costs adjusted to 2007 dollars and evaluated costs associated with additional illnesses and diseases (sudden infant death syndrome, hospitalization for lower respiratory tract infection in infancy, atopic dermatitis, childhood leukemia, childhood obesity, childhood asthma, and type 1 diabetes mellitus) found that if 90 percent of U.S. families followed guidelines to breastfeed exclusively for six months, the United States would save $13 billion annually from reduced direct medical and indirect costs and the cost of premature death. If 80 percent of U.S. families complied, $10.5 billion per year would be saved.24

Environmental Effects

Breastfeeding also confers global environmental benefits; human milk is a natural, renewable food that acts as a complete source of babies’ nutrition for about the first six months of life.25 Furthermore, there are no packages involved, as opposed to infant formulas and other substitutes for human milk that require packaging that ultimately may be deposited in landfills. For every one million formula-fed babies, 150 million containers of formula are consumed;26 while some of those containers could be recycled, many end up in landfills. In addition, infant formulas must be transported from their place of manufacture to retail locations, such as grocery stores, so that they can be purchased by families. Although breastfeeding requires mothers to consume a small amount of additional calories, it generally requires no containers, no paper, no fuel to prepare, and no transportation to deliver, and it reduces the carbon footprint by saving precious global resources and energy.

Endorsement of Breastfeeding as the Best Nutrition for Infants

Because breastfeeding confers many important health and other benefits, including psychosocial, economic, and environmental benefits, it is not surprising that breastfeeding has been recommended by several prominent organizations of health professionals, among them the American Academy of Pediatrics (AAP),25 American Academy of Family Physicians,27 American College of Obstetricians and Gynecologists,28 American College of Nurse- Midwives,29 American Dietetic Association,30 and American Public Health Association,31 all of which recommend that most infants in the United States be breastfed for at least 12 months. These organizations also recommend that for about the first six months, infants be exclusively breastfed, meaning they should not be given any foods or liquids other than breast milk, not even water.

Regarding nutrient composition, the American Dietetic Association stated, “Human milk is uniquely tailored to meet the nutrition needs of human infants. It has the appropriate balance of nutrients provided in easily digestible and bioavailable forms.”30

The AAP stated, “Human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding. Exclusive breastfeeding is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.”25

While breastfeeding is recommended for most infants, it is also recognized that a small number of women cannot or should not breastfeed. For example, AAP states that breastfeeding is contraindicated for mothers with HIV, human T-cell lymphotropic virus type 1 or type 2, active untreated tuberculosis, or herpes simplex lesions on the breast. Infants with galactosemia should not be breastfed. Additionally, the maternal use of certain drugs or treatments, including illicit drugs, antimetabolites, chemotherapeutic agents, and radioactive isotope therapies, is cause for not breastfeeding.25

Federal Policy on Breastfeeding

Over the last 25 years, the Surgeons General of the United States have worked to protect, promote, and support breastfeeding. In 1984, Surgeon General C. Everett Koop convened the first Surgeon General’s Workshop on Breastfeeding, which drew together professional and lay experts to outline key actions needed to improve breastfeeding rates.32 Participants developed recommendations in six distinct areas: 1) the world of work, 2) public education, 3) professional education, 4) health care system, 5) support services, and 6) research. Follow-up reports in 1985 and 1991 documented progress in implementing the original recommendations.33,34

In 1990, the United States signed onto the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, which was adopted by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). This declaration called upon all governments to nationally coordinate breastfeeding activities, ensure optimal practices in support of breastfeeding through maternity services, take action on the International Code of Marketing of Breast-milk Substitutes (the Code),35 and enact legislation to protect breastfeeding among working women.36

In 1999, Surgeon General David Satcher requested that a departmental policy on breastfeeding be developed, with particular emphasis on reducing racial and ethnic disparities in breastfeeding. The following year, the Secretary of the U.S. Department of Health and Human Services (HHS), under the leadership of the department’s Office on Women’s Health (OWH), released the HHS Blueprint for Action on Breastfeeding.37 This document, which has received widespread attention in the years since its release, declared breastfeeding to be a key public health issue in the United States.



The term “formula” is used here to include the broad class of human milk substitutes that infants receive, including commercial infant formula.


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