Consensus Study Report

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International Standard Book Number-13: 978-0-309-99192-6
Digital Object Identifier: https://doi.org/10.17226/29118
Library of Congress Control Number: 2025946879

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Breastfeeding in the United States: Strategies to Support Families and Achieve National Goals. Washington, DC: National Academies Press. https://doi.org/10.17226/29118.

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COMMITTEE ON UNDERSTANDING BREASTFEEDING PROMOTION, INITIATION AND SUPPORT ACROSS THE UNITED STATES: AN ANALYSIS

IFEYINWA ASIODU (Co-Chair), University of California, San Francisco

JULIE A. CASWELL (Co-Chair), University of Massachusetts Amherst

SARA N. BLEICH, Harvard University

KIMARIE BUGG, Reaching Our Sisters Everywhere

LORI B. FELDMAN-WINTER, Rowan University

ALLISON S. GABRIEL, Purdue University

JEFF NIEDERDEPPE, Cornell University

MARIANNE E. PAGE, University of California, Davis (as of May 7, 2024)

RAFAEL PÉREZ-ESCAMILLA, Yale University

VENA A-DAE ROMERO-BRIONES, First Nations Development Institute

DIANE L. SPATZ, University of Pennsylvania

ALISON M. STUEBE, The University of North Carolina at Chapel Hill

CECÍLIA TOMORI, Johns Hopkins University

JULIE WARE, Cincinnati Children’s Hospital

SHANNON E. WHALEY, Public Health Foundation Enterprises WIC

Study Staff

MEREDITH YOUNG, Study Director

TINA WINTERS, Program Officer

LIBBY TILTON, Research Associate

TARA NAZARI, Senior Program Assistant (as of June 17, 2024)

BRIANNA SMITH, Senior Program Assistant (until May 10, 2024)

EMILY P. BACKES, Deputy Board Director

NATACHA BLAIN, Senior Board Director

DANIEL J. WEISS, Board Director

BOARD ON CHILDREN, YOUTH, AND FAMILIES

JONATHAN TODRES (Chair), Georgia State University College of Law

TAMMY CHANG, University of Michigan

DEBRA FURR-HOLDEN, New York University

ANDREA GONZALEZ, McMaster University

NIA HEARD-GARRIS, Northwestern University Feinberg School of Medicine

NANCY E. HILL, Harvard University

CHARLES HOMER, Economic Mobility Pathways

MARGARET KUKLINSKI, University of Washington

MICHAEL C. LU, University of California, Berkeley School of Public Health

STEPHEN W. PATRICK, Vanderbilt University Medical Center

JENNY S. RADESKY, University of Michigan Medical School

STEPHEN RUSSELL, The University of Texas at Austin

JANE WALDFOGEL, Columbia University School of Social Work

JOANNA L. WILLIAMS, Search Institute

Staff

NATACHA BLAIN, Senior Board Director

EMILY P. BACKES, Deputy Board Director

BOARD ON BEHAVIORAL, COGNITIVE, AND SENSORY SCIENCES

ELIZABETH A. PHELPS (Chair), Harvard University

MIGUEL ECKSTEIN, University of California, Santa Barbara

WILSON S. GEISLER, The University of Texas at Austin

MICHELLE J. GELFAND, Stanford University

MARA MATHER, University of Southern California

ULRICH MAYR, University of Oregon

KATHERINE L. MILKMAN, The University of Pennsylvania

MARY C. MURPHY, Indiana University

ELISSA L. NEWPORT, Georgetown University

DON OPERARIO, Emory University

DAVID E. POEPPEL, New York University

KARL W. REID, Northeastern University

MO WANG, University of Florida

DUANE WATSON, Vanderbilt University

Staff

DANIEL J. WEISS, Board Director

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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ROSEMARY CHALK, Independent Consultant, and SUZANNE P. MURPHY, Emeritus, University of Hawaii at Manoa. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

This report would not have been possible without the contributions of many people. First, we thank the sponsor of this study—the Department of Health and Human Services. We would also like to thank the following organizations and individuals for their support of the mission of the Board on Children, Youth, and Families: The Burke Foundation, the New Venture Fund, the Renaissance Charitable Foundation/RCF Giving Fund, the Robert Wood Johnson Foundation, David V. B. Britt, Tammy Chang, Greg J. Duncan, Daniel Menelly, Sherry Glied, Andrea Gonzalez, Nia HeardGarris, Nancy Hill, Charles J. Homer, Kay Johnson, Margaret Kuklinski, Michael Lu, Linda A. Nelson, Stephen Patrick, Jenny Radesky, Stephen Russell, Nisha Sachdev, Jonathan Todres, Jane Waldfogel, Joanna Williams, and Barbara L. Wolfe.

Many individuals volunteered significant time and effort to address and educate the committee during our public information-gathering sessions. Their willingness to share their perspectives, research, and personal experiences was essential to the committee’s work. We thank: Joy Burkhard, Wesley Bugg, Elizabeth (Betsy) Collins, Reginald Day, Monica Esparza, Brandi Gates-Burgess, Jennifer Gil, Camie Goldhammer, Rita Hamad, Tanay Harris, Briana Jegier, Mudiwah Kadeshe, Julietta Ladipo, Tonya Lang, Jessica Lee, Glenis Liz-Decuir, Kay Matthews, Jennifer Moore, Kimberly Moore-Salas, Jessica Nash, Ora Nez, Chauntel Norris, Talita Oseguera, John James Parker, Kelly Quinn, Brenda Reyes, Katheryn Russ, Tina Sherman, Amanda Singer, Karen Tabb Dina, Camille Abbe, Cheryl Lebedevitch, and Yontii Wheeler.

The committee thanks the numerous National Academies staff for their support over the study process. We thank the staff members who worked directly with the committee: Meredith Young, Emily Backes, Tina Winters, Libby Tilton, and Tara Nazari, as well as Briana Smith, who contributed to the early stages of working with the committee. Throughout the project, Natacha Blain, director of the Board on Children, Youth, and Families, provided valuable oversight and guidance.

The committee is also grateful to Elise Mialou, Pamella Atayi, Faye Hillman, and Lisa Alston for their administrative and financial assistance on this project. Kirsten Sampson Snyder, Douglas Sprunger, and Kimberly Halperin shepherded the report through the review and the production process and assisted with its communication and dissemination. We thank Clair Woolley of the National Academies Press and Bea Porter for their assistance with the production of the final report, as well as Rebecca Morgan and Christopher Lao-Scott, in the National Academies research library, for their assistance with literature searches.

Finally, special thanks go to the members of the committee, who dedicated extensive time, expertise, and energy to drafting the report, and to the committee co-chairs, Ifeyinwa Asiodu and Julie Caswell, for their expert leadership in guiding the committee.

Contents

Acronyms and Abbreviations

Summary

1 Introduction

CURRENT BREASTFEEDING RATES AND NATIONAL GOALS

PURPOSE AND SCOPE OF THIS STUDY

Report Terminology

Study Scope

STUDY METHODS

Public Information-Gathering Sessions

Strength of Evidence

REPORT ORGANIZATION

REFERENCES

2 The Importance of Breastfeeding Across the Life Course

THE HEALTH BENEFITS OF BREASTFEEDING

Maternal Health Benefits

Health Benefits for Infants and Children

Health Benefits for Sick or Vulnerable Infants and Children

HOW BREASTFEEDING WORKS

BREASTFEEDING ACROSS THE LIFE COURSE

Preconception

Prenatal

Birth

Immediate Postpartum

Additional Considerations for the Sick or Vulnerable Infant

Post-Discharge from Birth Setting

Infancy

Childcare

Return to Work or School

Toddler

Childhood

Adulthood

CURRENT STATUS OF BREASTFEEDING IN THE UNITED STATES

Breastfeeding Initiation

Breastfeeding Exclusivity and Duration

Variances in Breastfeeding Rates

THE COST OF INACTION

REFERENCES

3 Breastfeeding in the Community Context

THE SOCIAL ECOLOGY OF BREASTFEEDING

Structural

Policy

Communities, Institutions, and Organizations

Interpersonal and Individual-Level Influences

Social Media Influences

HISTORY OF BREASTFEEDING IN THE UNITED STATES

19th- to Mid-20th Centuries

1970s–1980s

1990s–2000s

2010s to Today

CONFLICTING CULTURAL PERCEPTIONS OF BREASTFEEDING

COMMUNITY SUPPORTS FOR BREASTFEEDING FAMILIES

National and State Organizations

Interpersonal Support

The Role of Family Members

PROMISING COMMUNITY APPROACHES

REFERENCES

ANNEX

4 Federal and State Policies and Programs: Coordinating Public Health Approaches and WIC

FEDERAL AND STATE PROGRAMS THAT PROMOTE BREASTFEEDING

HHS

USDA

DOD

State-Level Programs

Opportunities for Coordination

LEGISLATION AND POLICIES THAT SUPPORT BREASTFEEDING

State and Territory Breastfeeding Laws

Tribal Policies for Supporting Breastfeeding

PUBLIC HEALTH SURVEILLANCE OF BREASTFEEDING INDICATORS

Breastfeeding Data Collection Systems

Future Public Health Surveillance Needs

THE WIC PROGRAM

WIC Breastfeeding Education and Support

The WIC Food Package

Commercial Milk Formula and WIC

BUILDING RESILIENCE IN EMERGENCIES, DISASTERS, AND SUPPLY CHAIN DISRUPTIONS

FUTURE DIRECTIONS

REFERENCES

5 Messaging, Media, and Marketing

BREASTFEEDING MESSAGING, MEDIA, AND CAMPAIGNS

Evaluation of Breastfeeding Promotion Campaigns: Global Examples of Success

Previous National Breastfeeding Promotion Campaigns in the United States

Current Breastfeeding Promotion Campaigns in the United States

DIGITAL AND SOCIAL MEDIA AND ONLINE SUPPORT

THE MARKETING AND REGULATION OF COMMERCIAL MILK FORMULA

The International Code of Marketing of Breast-Milk Substitutes

Potential Approaches to Adopting the Marketing Principles of the Code in the United States

Regulation of the Labeling and Advertising of Commercial Milk Formula in the United States

REFERENCES

6 Breastfeeding and the U.S. Health Care System

INTERVENTIONS TO IMPROVE BREASTFEEDING OUTCOMES IN THE HEALTH CARE SETTING

BFHI

QUALITY IMPROVEMENT INITIATIVES AND MEASURES

INTEGRATING BREASTFEEDING SUPPORT IN PRIMARY CARE

PROVIDER EDUCATION AND TRAINING

Physician Education and Training

Certified Nurse Midwife Education and Training

Nurse Education and Training

Access to Other Lactation Support Providers: Lactation Consultants, Doulas, and Registered Dietitians

USBC Core Competencies

DOCUMENTATION OF BREASTFEEDING OUTCOMES

HEDIS Measures

REFERENCES

7 Payment and Financing of Breastfeeding Services and Supplies

PAYERS: AN OVERVIEW

PRIVATE INSURANCE

Private Insurance Payment for Breastfeeding Services

Private Insurance Payment for Breastfeeding Equipment and Supplies

PUBLIC INSURANCE

Medicaid

U.S. MILITARY HEALTH SYSTEM

INDIAN HEALTH SERVICE

CHILDREN’S HEALTH INSURANCE PLAN (CHIP)

CONSIDERATIONS RELATED TO UNINSURED POPULATIONS

PROMISING APPROACHES FOR PAYERS

REFERENCES

8 Return to Work and School

TIMING OF RETURN TO WORK

SUPPORTING BREASTFEEDING THROUGH LEAVE POLICIES

Unpaid and Paid Family and Medical Leave

Evidence on Leave-Taking

Evidence of Paid Family Leave’s Impacts on Breastfeeding Outcomes

Evidence on Outcomes Related to Child Health and Well-Being

Evidence on Maternal Outcomes

FEDERAL RETURN TO WORK PROTECTIONS FOR BREASTFEEDING

Break Time for Nursing Mothers Act

PUMP for Nursing Mothers Act

STATE-LEVEL RETURN TO WORK PROTECTIONS FOR BREASTFEEDING

EMPLOYER-LED RETURN TO WORK SUPPORTS FOR BREASTFEEDING

Job Autonomy

Physical Work Conditions

Job-Related Supports

BREASTFEEDING SUPPORTS FOR STUDENTS RETURN TO SCHOOL

CHILDCARE

REFERENCES

9 Exploring Research Needs and Future Implementation

PRIORITIES FOR FUTURE RESEARCH

IMPLEMENTATION CONSIDERATIONS

Scaling Up Effective Programs

Measuring the Benefits and Costs of Interventions to Support Breastfeeding

Data Needs

REFERENCES

Appendix A Committee and Staff Biosketches

Appendix B State Laws

Appendix C Public Meeting Agendas

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Boxes, Figures, and Tables

BOXES

S-1 Statement of Task

1-1 Statement of Task

1-2 Report Definitions and Terminology

1-3 Common Themes Across Listening Session Perspectives

2-1 Physiological Infant Care

2-2 Measuring the Costs of Current Suboptimal Breastfeeding Rates

4-1 An Overview of Federal Breastfeeding Laws

4-2 The Evolution of WIC Breastfeeding Services

4-3 Other Promising Approaches to WIC Breastfeeding Support

5-1 Highlighting Success: Lessons from Brazil

5-2 A Summary of the Principles of The International Code of Marketing of Breast-Milk Substitutes

6-1 Applying Prevention Levels to Breastfeeding Care

6-2 BFHI: WHO/UNCIEF Ten Steps to Successful Breastfeeding

6-3 Actions to Support the Implementation of the Ten Steps

6-4 Follow Up Within 24-48 Hours of Hospital Discharge for the Following

6-5 Features of a Breastfeeding-Friendly Health Care Office

6-6 Pathways to Qualify to Sit for the IBCLC Exam

7-1 Breastfeeding Services and Supplies: Women’s Preventive Services Initiative

7-2 Billing for Breastfeeding Services and Supplies: Women’s Preventive Services Initiative

7-3 Proposed Payer Solutions from the U.S. Breastfeeding Committee

8-1 Leave Policies and Supports

8-2 Impacts of the PUMP Act

8-3 Return on Investment for Supporting Breastfeeding

8-4 Features of a Lactation Room

8-5 A Breastfeeding Initiative to Support Expecting and Parenting Students with Lactation

9-1 Research Priorities for Improving Breastfeeding Rates, by Setting

FIGURES

S-1 Percentage of babies receiving any and exclusive breastmilk during the first 12 months, among children born in 2021

S-2 The life course journey of the breastfeeding dyad

S-3 Timeline of key actions and challenges on the road to reverse the decline of breastfeeding in the United States

1-1 Percentage of babies receiving any and exclusive breast milk during the first 12 months, among children born in 2021

2-1 The life course journey of the breastfeeding dyad

2-2 Hospitals reporting mother-infant skin-to-skin contact for at least 30 minutes within 1 hour of uncomplicated vaginal birth

2-3 U.S. birth certificate breastfeeding initiation data by county, 2018–2019

2-4 Percentage of U.S. children who were breastfed, by birth year, 2014–2021

2-5 Exclusive breastfeeding percentage by birth year, 2014–2021

2-6 Percent of infants breastfed at 6 months

3-1 The social ecology of breastfeeding in the United States

3-2 Timeline of key actions and challenges on the road to reverse the decline of breastfeeding in the United States

3-3 Graph data from the mother’s survey, Ross Products Division of Abbott

4-1 Percentage change in infant WIC participation, October 2021-September 2023

7-1 Percentage of adults ages 18–64 who were uninsured or had public or private coverage, by year, United States, 2019–2023

7-2 Percentage of children ages 0–17 years who were uninsured or had public or private coverage, by year, United States, 2019–2023

7-3 Trends in breastfeeding initiation rates, by source of payment (for delivery)

7-4 State Medicaid coverage for breastfeeding services

7-5 State Medicaid coverage for breastfeeding pumps

7-6 Reasons for being uninsured among uninsured nonelderly adults, 2022

7-7 Eligibility for coverage among the nonelderly uninsured population, 2022

9-1 The breastfeeding gear model

TABLES

2-1 Overall Findings by Patnode et al. (2025) on Strength of Evidence (SOE) and Direction of Association

2-2 Definition and Description of Costing Approaches

3-1 Lactation Support Provider (LSP) Descriptions

3-2 Effectiveness of Breastfeeding Peer Counseling at Improving Breastfeeding Outcomes, Reported by Systematic Reviews

4-1 WIC Breastfeeding Curriculum

4-2 Current Schedule of Minimum Required Contacts from Breastfeeding Peer Counselors

5-1 Key Components of Public Health Communication Campaigns

8-1 Opportunities for Employers to Support Employees Who Are Lactating

8-2 Supporting Breastfeeding in Childcare Settings: Barriers, Concerns, and Solutions

B-1 State Laws

Acronyms and Abbreviations

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