Background
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.
Position
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.
Rationale
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).
Justification
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).
Barriers
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)
Download this Infant Feeding Behaviors
Chart in PDF
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* 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).
**