Position Statement on Infant Feeding, Updated 2010


The first Texas Position Statement on Infant Feeding was released in 1998. Since this time, there have been advancements in scientific knowledge that have greatly increased our understanding of breastfeeding and human lactation, including about the impact of breastfeeding on maternal and infant health outcomes. This document updates and replaces the 1998 position statement.


 The Texas Department of State Health Services (DSHS) affirms that:

  • Exclusive breastfeeding for approximately the first six months of life and continued breastfeeding for one- to-two years and beyond is the physiologic norm and the optimal method of infant feeding.
  • Breastfeeding has a mediating effect on the determinants of health by promoting optimal health for infants and mothers, reducing health disparities among population groups, and decreasing health care costs.
  • Protection, promotion, and support of breastfeeding at multiple levels of society are indispensable strategies for improving public health and are integral to the DSHS mission, to improve health and well-being in Texas.


DSHS recognizes that many factors influence the infant feeding decision (see Figure 1). Parents should feel confident and comfortable with their feeding decisions. Women have the right to choose the infant feeding practices that best support the needs of their families and their circumstances. DSHS supports the principle of informed decision making, whereby infant feeding choices are made in the context of an environment that: (a) provides access to and supports consideration of full, accurate, and un-biased information about the risks and benefits of feeding options, and (b) promotes and supports a woman’s ability to carry out her choices.

DSHS recognizes breastfeeding as the optimal method for infant feeding. As the natural conclusion of the reproductive cycle, breastfeeding is the physiologic norm for mothers and their children. DSHS joins all major health authorities in recommending that infants, with rare exception[*], receive no other food or drink besides breast milk for about the first six months of life (“exclusive breastfeeding”), with continued breastfeeding for at least one to two years of life (1-18).  Further, it is recommended that initiation of breastfeeding begin immediately after birth and introduction of appropriate complementary foods begin at about six months of age. It is recognized that infants will continue to receive nutritional and immunologic benefits from human milk for as long as they receive any breast milk, with no evidence of harm associated with extended breastfeeding of any duration (2, 7).

Infants require adequate and safe nutrition to support and sustain their growth and development. Where conditions preclude direct breastfeeding, infants should be provided with suitable substitutes, including expressed milk from their mothers or banked donor milk, with or without fortifier as indicated (7, 19-20). In the absence of breast milk, FDA-regulated infant formulas, with proper instruction on handling and storage, should be available for families who choose to use them. Infant formulas should be marketed in accordance with the World Health Organization’s (WHO) International Code of Marketing of Breast-milk Substitutes (21). 


Breastfeeding is a basic, well-established, cost effective preventative health measure (22-24). Protection, promotion and support of breastfeeding is needed at all levels of society to increase breastfeeding rates, reestablish breastfeeding as the normal and predominant mode of infant feeding, and to improve the health and well-being of Texans. Breastfeeding has evolved over millions of years to meet babies’ physical, nutritional, immunologic, and emotional needs.

Breastfeeding allows all infants access to the same quality of nutrition and immune protection, regardless of social and economic resources. Infants who do not receive breast milk are at increased risk for a wide variety of childhood illnesses and adverse outcomes lasting into adulthood. In addition, the physical and social aspects of breastfeeding facilitate infant stimulation, bonding, and physiologic stability through skin-to-skin contact (25). Being breastfed is associated with reduced risk of infectious diseases, asthma, atopic dermatitis, childhood leukemia, type 1 and type 2 diabetes, obesity and sudden infant death syndrome (SIDS) (26-27). Breast milk is especially important for compromised infants, such as those born preterm or with low birth weight. Preterm infants not provided breast milk are at increased risk for necrotizing enterocolitis, a debilitating and often fatal condition common among very low birth weight infants.  Maximum risk reduction for adverse health outcomes is observed with six months of exclusive breastfeeding and a year or more of full breastfeeding. A recent cost analysis, looking at just some of the health outcomes associated with breastfeeding, found that the United States would save $13 billion dollars annually and prevent 911 deaths if 90% of infants could be exclusively breastfed for the first six months of life (28).

Maternal health is also impacted by breastfeeding. Breastfeeding helps to resolve the transition from the pregnant to postpartum state, resulting in faster recovery from birth, decreased postpartum bleeding and increased maternal iron stores. Lactational amenorrhea, the physiologic suppression of menstruation that can result from exclusive breastfeeding, results in increased child spacing (29-31). Women who breastfeed are at reduced risk for Type 2 diabetes and estrogen related cancers, including breast and ovarian cancers. Not breastfeeding or early weaning is associated with an increased risk of maternal postpartum depression (26). Research also suggests that breastfeeding has a dose-response relationship in the reduction of risk for cardiovascular disease, hypertension, and hyperlipidemia (32), and metabolic syndrome (33).

Breast milk is a renewable hygienic infant food requiring no environmental resources beyond maternal calorie reserves. Infant formulas are susceptible to manufacturing errors (34), environmental and bacterial contamination (35-36), and unsafe handling and misuse (37-38). In a natural or man-made emergency, supplies of infant formula may be diminished or inaccessible. Safe water for re-constitution of infant formula may be scarce or completely unavailable, and methods to sterilize water, bottles and teats may also be inadequate. Mother’s milk may be the only safe food available for infants during emergencies and may be life saving in dire situations (40-41).


The majority of Texas women choose to breastfeed their infants, with greater than 75% initiating breastfeeding in the early postpartum period. However, by the second day of life, up to 59% of Texas infants are receiving formula in addition to or instead of breast milk (42-43), and only 14% exclusively breastfeed at six months of life.  Many women stop breastfeeding before they want to, citing insufficient support and societal barriers as impediments to achieving their breastfeeding goals.

Despite its indisputable benefits, breastfeeding is not fully promoted and supported throughout society. Disparities in breastfeeding continue to persist across race, ethnic, age and other socioeconomic groups, as well as geographically across the United States and Texas (44-46).  Many social and institutional barriers exist to the initiation, exclusivity, and continuation of breastfeeding. Breastfeeding outcomes are influenced by: policies and practices in maternity services and within health care systems, the workplace, the community, and in government; societal and personal attitudes, beliefs, and norms; level of knowledge of and accuracy and consistency of information received from health care professionals and from family and friends about infant feeding in general and about breastfeeding specifically; type and number of effective role models and social support for breastfeeding; exposure to positive or negative portrayals of breastfeeding in the media; degree of exposure to marketing for breast milk substitutes; availability of professional and peer support for breastfeeding management, and other factors (13, 47). As a result, not all women and children in Texas receive the full array of protections incurred through breastfeeding.

DSHS encourages hospitals, health delivery systems, worksites, and communities to adopt policies and create environments that are supportive of breastfeeding. DSHS is committed to addressing barriers to breastfeeding through promotion of breastfeeding as the normal and optimal form of infant feeding and coordinated implementation of evidence-based breastfeeding activities.

Figure 1: Determinates of Breastfeeding: 

Adapted from models developed by Lutter (48) and EU Project on Promotion of Breastfeeding in Europe (49)

  Infant Feeding Behaviors Chart

Download this Infant Feeding Behaviors Chart in PDF


1.   Academy of Breastfeeding Medicine Board of Directors. 2008. Position on breastfeeding. Breastfeed Med, 3(4): 267-70. Available from ABM Statements, Position on Breastfeeding (65 kb, PDF).

2.    American Academy of Family Practitioners (AAFP). Breastfeeding. Policy Statement. [Internet]. Leawood (KS): AAFP, 2007. Available from AAFP Breastfeeding Policy Statement

3.   American Osteopathic Association. Breast-feeding exclusivity.  [Internet]. Chicago (IL): American Osteopathic Association, 2007.

4.   American Public Health Association (APHA). A call to action on breastfeeding: A fundamental public health issue. [Internet]. Washington (DC): APHA, 2007 Nov. Available from APHA Policy Statement Database.

5.   Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Breastfeeding. Position Statement. [Internet]. Washington (DC): AWHONN, 2007.

6.   Fiocchi, A.; Assa'ad, A.; Bahna, S. 2006. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol, 97(1): 10-20.

7.   American Academy of Pediatrics. 2005. Breastfeeding and the use of human milk. Pediatrics, 115(2): 496-506.

8.   American Dietetic Association. 2005. Position of the American Dietetic Association: Promoting and supporting breastfeeding. J Am Diet Assoc, 105(5):810–8.

9.   American College of Nurse Midwives. Breastfeeding. Position statement. Silver Spring (MD): American College of Nurse Midwives; 2004.

10.          American College of Obstetricians and Gynecologists. Breastfeeding. Washington (DC); 2003.

11.          World Health Organization (WHO)/UNICEF. Global strategy for infant and young child feeding. WHO, Geneva, Switzerland; 2003. 30 pp. Available from Global strategy for infant and young child feeding.

12.          National Association of Pediatric Nurse Practitioners (NAPNAP). 2001. Position statement on breastfeeding. J Pediatr Health Care, 15(5): 22A. Available from NAPNAP Position Statements.

13.          Department of Health and Human Services (US). HHS blueprint for action on breastfeeding. Washington (DC): Department of Health and Human Services (US); Office on Women’s Health, 2000.  33 pp.

14.          Department of Health and Human Services (US). Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. [Internet]. Washington (DC): U.S. Government Printing Office, 2000 Nov. Available from Healthy People.

15.          United States Breastfeeding Committee. Statement on exclusive breastfeeding. Raleigh (NC): United States Breastfeeding Committee; 2000. Available from USBC Publications & Position Statements.

16.          World Health Organization/United Nations Children Fund/United States Agency for International Development/Swedish International Development Cooperation Agency. Innocenti Declaration: On the protection, promotion and support of breastfeeding. [Internet]. 1990. Available from On the Protection, Promotion and Support of Breastfeeding.

17.          Codex Alimentarius Commission. Statement on infant feeding [Internet]. Rome, Italy: FAO/WHO Codex Alimentarius Commission, 1976. Available from CAC/MISC 2-1976 Statement on infant feeding (8 kb, PDF)

18.          Vohr B, Poindexter B, Dusick A, McKinley L, Higgins R, Langer J, Poole W; National Institute of Child Health and Human Development National Research Network. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics. 2007;120(4):e953-9.

19.          Vohr B, Poindexter B, Dusick A, McKinley L, Wright L, Langer J, Poole W; National Institute of Child Health and Human Development National Research Network. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006;118(1):e115-23. Available from Pediatrics.

20.          World Health Organization. International code of marketing of breast-milk substitutes. WHO, Geneva, Switzerland; 1981. 36 pp. Available from International Code of Marketing of Breast-Milk Substitutes

21.          Ball T, Bennett D. The economic impact of breastfeeding. Pediatr Clin North Am. 2001 Feb;48(1):253-62.

22.          Weimer, J. The Economic Benefits of Breastfeeding: A Review and Analysis. Washington (DC). Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Food Assistance and Nutrition Research; 2001 Mar. Report No. 13. 20 pp.

23.          Jones G, Steketee R, Black R, Bhutta Z, Morris S. The Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet. 2003;362:65–71.

24.          Moore E, Anderson G, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2007 Jul 18; (3): CD003519.  Available from The Cochrane Library.

25.          Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (Tufts-New England Medical Center Evidence-based Practice Center). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No. 153. Rockville (MD): Agency for Healthcare Research and Quality; 2007 Apr. AHRQ Publication No. 07-E007. Contract Nu. 290-02-0022. 415 pp. Available from Agency for Healthcare Research and Quality.

26.          World Health Organization. Horta, B, Bahl, R, Martinés J, Victoria C. Evidence on the long-term effects of breastfeeding: Systematic review and meta-analysis. Geneva, Switzerland: WHO; 2007. 52 pp. Available from WHO | Evidence on the long-term effects of breastfeeding.

27.          Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics. 2010 May; 125(5):e1048-56.

28.          Academy of Breastfeeding Medicine. Clinical Protocol #13: Contraception during breastfeeding. New Rochelle, New York: Academy of Breastfeeding Medicine; 2005. Available from BFMed | Clinical Protocol.

29.          Becker S, Rutstein O, Labbok M. Estimation of births averted due to breastfeeding and increases in levels of contraception needed to substitute for breastfeeding. J Biosoc Sci. 2003 Oct;35(4):559–574.

30.          Tommaselli G, Guida M, Palomba S, Barbato M, Nappi C. Using complete breastfeeding and lactational amenorrhea as birth spacing methods. Contraception. 2000; 61(4): 253-7.

31.          Schwarz E, Ray R, Stuebe A, Allison M, Ness R, Freiberg M, Cauley J. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-982.

32.          Gunderson EP, Jacobs DR, Chiang V, Lewis, CE, Feng, J, Quessenberry, CP, Sidney, S. Duration of lactation and incidence of the Metabolic Syndrome in women of reproductive age according to Gestational Diabetes Mellitus status: A 20-year prospective study in CARDIA—The Coronary Artery Risk Development in Young Adults Study. Diabetes. Published online before print December, 2009. Available from American Diabetes Association | Duration of Lactation and Incidence of the Metabolic Syndrome in Women of Reproductive Age According to Gestational Diabetes Mellitus Status

33.          National Alliance for Breastfeeding Advocacy, Recalls of Infant Feeding Products; 2005.

34.          Drudy D, Mullane N, Quinn T, Wall P, Fanning S. Enterobacter sakazakii: an emerging pathogen in powdered infant formula. Clin Infect Dis. 2006 Apr;42(7):996-1002.

35.          Jones TF, Ingram LA, Fullerton KE, Marcus R, Anderson BJ, McCarthy PV, Vugia D, Shiferaw B, Hauberst N, Wedel S, Angulo FJ. A case-control study of the epidemiology of sporadic salmonella infection in infants. Pediatrics. 2006;118:2380–2387.

36.          Baker R. Infant formula safety. Pediatrics. 2002 Oct;110(4):833-5. Available from Pediatrics | Infant Formula Safety.

37.          Labiner-Wolfe J, Fein S, Shealy K. Infant formula-handling education and safety. Pediatrics. 2008 Oct; 122 Suppl 2:S85-90

38.          Renfrew M, Ansell J, Macleod K. Formula feed preparation: helping reduce the risks; a systematic review. Arch Dis Child. 2003 Oct;88(10):855-8.

39.          American Academy of Pediatrics. Infant nutrition during a disaster. Elk Grove Village (IL). American Academy of Pediatrics. 2007.

40.          World Health Organization. Guiding principles for feeding infants and young children during emergencies. WHO, Geneva, Switzerland; 2004. 84 pp. Available from WHO | Guiding principles for feeding infants and young children during emergencies

41.          Texas Department of State Health Services, Newborn Screening Data, 2008.

42.          CDC National Immunization Survey, 2006 births. Available from CDC | Breastfeeding Among U.S. Children Born 1999—2007.

43.          National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services  (2009) Breastfeeding among U.S. children born 1999—2006, CDC National Immunization Survey. Available from CDC | Breastfeeding Among U.S. Children Born 1999—2007

44.          Kogan M, Singh G, Dee D, Belanoff C, Grummer-Strawn L. Multivariate analysis of state variation in breastfeeding rates in the United States. Am J of Public Health. 2008 Oct;98(10):1872-80.

45.          Texas Department of State Health Services. (2008) Breastfeeding Beliefs, Attitudes, and Practices in the Texas WIC Population: Findings from the 2007 WIC Infant Feeding Practices Survey. Available from Breastfeeding Beliefs, Attitudes, and Practices in the Texas WIC Population (2.2 mb, PDF).

46.          Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.

47.          Lutter C. Breastfeeding promotion—Is its effectiveness supported by scientific evidence and global changes in breastfeeding behaviors? Advances in Experimental Medicine and Biology, 2000;478:355–68.

48.          EU Project on Promotion of Breastfeeding in Europe. Protection, promotion and support of breastfeeding in Europe: a blueprint for action (revised). European Commission, Directorate Public Health and Risk Assessment, Luxembourg, 2008.


* Note: Classic galactosemia (galactose 1-phosphate uridyltransferase deficiency) is the only condition of the infant for which breastmilk is completely contraindicated. (AAP, 2005)  Infants with phenylketonuria require special formulas but may receive small amounts of human milk under medical supervision (Lawrence 2005). **

Last updated April 15, 2021