Breastfeeding Handbook for Physicians 3rd Edition 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 11 99//1144//2222 1122::2266 PPMM 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 Mary Louise Carr, MBA, Marketing Manager, Clinical Publications Published by the American Academy of Pediatrics 345 Park Blvd Itasca, IL 60143 Telephone: 630/626-6000 Facsimile: 847/434-8000 www.aap.org 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 responsible for the content of external resources. Information was current at the time of publication. The persons whose photographs are depicted in this publication are professional models. They have no relation to the issues discussed. Any characters they are portraying are fictional. The publishers have made every effort to trace the copyright holders for borrowed materials. If they have inadver- 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 [email protected] for more information. © 2023 American Academy of Pediatrics and The American College of Obstetricians and Gynecologists All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior permis- sion from the publisher (locate title at https://publications.aap.org/aapbooks and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or email [email protected]). First edition published 2006; second, 2014. Printed in the United States of America 4-99/1122 1 2 3 4 5 6 7 8 9 10 MA0980 ISBN: 978-1-61002-442-6 eBook: 978-1-61002-443-3 Library of Congress Control Number: 2020932408 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 22 99//1144//2222 1122::2266 PPMM 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 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 33 99//1144//2222 1122::2266 PPMM 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 Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC Lawrence Noble, MD, FAAP, FABM, IBCLC 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 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 44 99//1144//2222 1122::2266 PPMM 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 v 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 55 99//1144//2222 1122::2266 PPMM 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 Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC Florida State University College of Medicine Orlando, FL Edward R. Newton, MD, FABM, FACOG East Carolina University Brody School of Medicine Greenville, NC Lawrence Noble, MD, FAAP, FABM, IBCLC 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 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 66 99//1144//2222 1122::2266 PPMM 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 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 77 99//1144//2222 1122::2266 PPMM 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 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 88 99//1144//2222 1122::2266 PPMM 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 0000 FFrroonntt MMaatttteerr BBHHFFPP ii--xxiivv..iinndddd 99 99//1144//2222 1122::2266 PPMM