The National Association of Pediatric Nurse Practitioners (NAPNAP) recognizes that optimal nutrition for newborns and infants consists of exclusive breastfeeding for the first 6 months of life, ideally beginning with skin-to-skin contact and early infant-led breastfeeding within the first hour of life. At about 6 months of age, with the addition of appropriate complementary solid foods, continuation of breastfeeding is recommended until at least age 1 year and longer as mutually desired by the mother and infant (
Academy of Breastfeeding Medicine 2015
, American Academy of Pediatrics, Section on Breastfeeding 2012
, American Academy of Pediatrics 2018
, American College of Obstetricians and Gynecologists 2016
, American Dietetic Association 2009
, U.S. Breastfeeding Committee 2010
, U.S. Department of Health & Human Services 2009
, U.S. Department of Health & Human Services 2011
, United Nations Children's Fund 2017
, World Health Organization 2017
).Given the benefits of breast milk and breastfeeding to the infant, mother, society, and environment, NAPNAP affirms that exclusive feeding of breast milk represents optimal feeding for newborns and infants. Optimizing infant feeding is a key strategy for promoting health through the lifespan. Evidence suggests that breast milk provides infants and children with increased protection against infection, acute illness, and chronic conditions across the lifespan (
American Academy of Pediatrics, Section on Breastfeeding 2012
, McNiel, Labbok and Abrahams, 2010
). Suboptimal breastfeeding, defined as nonexclusive breastfeeding and/or breastfeeding for less than AAP recommendations, may jeopardize the infant's health and increase the risk of infant morbidity and mortality (Academy of Breastfeeding Medicine 2015
, American Academy of Pediatrics 2018
, World Health Organization 2017
). These risks include, but are not limited to, higher risk of sudden infant death syndrome (i.e., SIDS), neurocognitive delays, and increased incidence of diabetes, cancers, gastroenteritis, respiratory and ear infections, and dental malocclusions (Academy of Breastfeeding Medicine 2015
, American Academy of Pediatrics, Section on Breastfeeding 2012
, Binns, Lee and Low, 2016
, Rollins et al., 2016
, Victora et al., 2016
).Breast milk also plays an important role in neurodevelopment and cognitive function, especially in preterm infants (
Schwarzenberg and Georgieff, 2018
). Premature infants receive significant benefits from human milk, including lower rates of sepsis and necrotizing enterocolitis, reduced hospital admissions, lower mortality rates, reduced long-term growth failure, and fewer neurodevelopmental disabilities (American Academy of Pediatrics, Section on Breastfeeding 2012
, Bartick et al., 2017
, Sullivan et al., 2010
). Therefore, NAPNAP affirms enacting specific strategies to increase human milk intake for the premature infant (Sullivan, S., Schanler, R. J., Kim, J. H., Patel, K. A., Trawoger, R., Kiechl-Kohlendorfer, U, . . . Lucas, A. (2010). An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. Journal of Pediatrics, 156, 562--567.
Fugate et al., 2015
).Breastfeeding is remarkably beneficial for the mother, with decreased risks of metabolic and cardiovascular disease, breast cancer, ovarian cancer, and improved birth spacing (
Rollins et al., 2016
, Victora et al., 2016
). Breastfeeding also helps new mothers lose weight that was gained during pregnancy, decreasing their risk of diabetes or other chronic disorders related to obesity (Bartick et al., 2017
).Research indicates that suboptimal breastfeeding in the United States results in more than 3,340 premature maternal and child deaths (
Bartick et al., 2017
). The associated costs of suboptimal breastfeeding in the United States accounted for $3.0 billion in direct medical costs, $1.3 billion in nonmedical costs, and $14.2 billion in premature death costs (Bartick et al., 2017
). Studies have shown that breastfeeding bestows benefits to the greater society (Bartick et al., 2017
, Rollins et al., 2016
, Victora et al., 2016
). Conversely, suboptimal breastfeeding has been shown to have a significant health care burden economically, with increased rates of health care utilization and illness.Efforts to promote and support breastfeeding should be viewed as an important public health priority for health care professionals charged with the care of women, infants, and children. Exclusive breastfeeding should be encouraged for all mothers, and in the rare instance when breastfeeding is contraindicated or is significantly limited, exclusive feeding of donor breast milk should be considered through a Human Milk Banking Association of North America (i.e., HMBANA) facility (
Human Milk Banking Association of North America 2018
). Supplemental feedings should be given to infants only when medically warranted, because their use may interfere with the establishment of good maternal supply (Academy of Breastfeeding Medicine 2009
, Holmes, McLeod and Bunik, 2013
, Kellams et al., 2017
). When unique situations arise that require the need to induce lactation (or re-lactation), supportive efforts should be initiated for breast milk production to ensure the infant receives breast milk.Promoting and supporting breastfeeding is an integral component of pediatric health care offered by pediatric nurse practitioners (PNPs) and their fellow pediatric-focused advanced practice registered nurses (APRNs). An infant's nutrition, beginning with maternal nutrition in pregnancy through the child's second birthday, is critical to neurodevelopment and lifelong mental health and provides short- and long-term positive health care outcomes (
American Academy of Pediatrics 2018
, Academy of Breastfeeding Medicine 2013
). Pediatric-focused APRNs can positively influence breastfeeding practices by implementing maternal–child health evidence–based practices (EBP), including identifying barriers to breastfeeding, ensuring equitable health care with careful follow-up, providing EBP anticipatory guidance, and advocating for breastfeeding-friendly practices. All these actions in the primary care setting serve to improve breastfeeding initiation, exclusivity, and duration from the immediate postpartum period through weaning (American Academy of Pediatrics, Section on Breastfeeding 2012
, Heinig et al., 2009
, U.S. Department of Health & Human Services 2011
).Initiatives directed toward increasing the support of lactating women returning to work are paramount, because the challenge of pumping for a child while working is one of the leading causes for early cessation of breastfeeding (
Rollins et al., 2016
). Mothers who are at risk for early cessation of breastfeeding because of social health determinants must also be the focus of breastfeeding initiatives. Maternal self-efficacy is a factor that affects breastfeeding success. The Tri-Core Breastfeeding model incorporates maternal self-efficacy strategies, lactation support, and education within the patient–family medical home for the pediatric-focused APRN to incorporate in breastfeeding promotion (Busch, Logan and Wilkinson, 2014
). NAPNAP affirms the need for pediatric-focused APRNs to implement pediatric primary care breastfeeding interventions incorporating the Tri-Core conceptual model. Pediatric-focused APRNs’ positive support within the health care systems for breastfeeding-friendly workplaces, for family and community programs, and for focused strategies for populations at risk to improve breastfeeding rates aligning with the Healthy People 2020/2025 goals is encouraged (U.S. Department of Health & Human Services 2011
).NAPNAP recommends that comprehensive, evidence-based, and culturally sensitive educational and clinical experiences in lactation and breastfeeding be included in all educational programs that prepare pediatric health care providers. NAPNAP also recommends that pediatric health care providers participate in continuing education opportunities dedicated to the promotion of breastfeeding. These opportunities would include obtaining the knowledge, skills, and strategies to effectively manage the clinical care of the breastfeeding dyad. NAPNAP also supports the goals of Healthy People 2020/2025 that promote increasing breastfeeding rates nationally to contribute to improving the health of all persons (
U.S. Department of Health & Human Services 2011
). NAPNAP recognizes and affirms the significance of the WHO/UNICEF Baby-Friendly Ten Steps international strategy and encourages hospitals to incorporate these steps into mother–infant dyad care (United Nations Children's Fund & World Health Organization 2018
, World Health Organization 1998
).NAPNAP encourages all pediatric health care providers to do the following.
- 1.Promote informed choice about infant feeding practices by educating expectant parents, their family members, and society about the nutritional, neurodevelopmental, social, and economic advantages of breast milk. Educate families on the potential short- and long-term health risks of not breastfeeding for both mother and child (Academy of Breastfeeding Medicine 2013,American Academy of Pediatrics, Section on Breastfeeding 2012,Bartick et al., 2017,Binns, Lee and Low, 2016,Rollins et al., 2016). Identify and reduce the actual and perceived barriers to initiation and continuation of breastfeeding at all phases of the childbearing/childrearing cycle. Provide counsel and support for all families pursuing the use of donor milk and/or breast milk induction/re-lactation with EBP information and resources. Acknowledge that if maternal breast milk is unavailable, donor human milk as a substitute is preferred (Academy of Breastfeeding Medicine 2009,American Academy of Pediatrics, Section on Breastfeeding 2012,Kellams et al., 2017). NAPNAP emphasizes the importance of interprofessional health care team collaboration and seeks to establish joint EBP care measures with vested health care partners to promote, protect, and support the breastfeeding dyad.
- 2.Provide expert clinical care for breastfeeding families using a family-centered care approach (Academy of Breastfeeding Medicine 2013). Identify support systems necessary to promote and sustain the nutritional goals of breastfeeding families and for those who choose to feed breast milk to their babies (American Academy of Pediatrics, Section on Breastfeeding 2012,Academy of Breastfeeding Medicine 2015,U.S. Department of Health & Human Services 2011). Assess breastfeeding at all infant/child visits and provide appropriate management/care to the breastfeeding dyad. Provide lactation support onsite or refer breastfeeding families to a lactation consultant, community support group, and/or peer group when appropriate. Facilitate, support, and promote primary care support strategies that collaborate with the UNICEF/WHO's Ten Steps to Successful Breastfeeding initiative (Human Milk Banking Association of North America 2018).
- 3.Advocate for breastfeeding support and promotion by emphasizing maternal self-efficacy lactation support and education within practice settings, hospitals, communities, and at the legislative level among all populations, especially those at risk for early cessation (Academy of Breastfeeding Medicine 2009,Academy of Breastfeeding Medicine 2013;Busch, Logan and Wilkinson, 2014). Provide assistance to populations with lower breastfeeding rates who may lack access to provider and community lactation support. Populations with lower rates of breastfeeding include those who identify as African American, have lower socioeconomic status, are unmarried, are less formally educated, have young maternal age, are participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (i.e., WIC), and/or report unintended pregnancy (Jones, Power, Queenan and Schulkin, 2015). Women who are disproportionally affected by adverse social outcomes derive the most health and economic benefits of breastfeeding (Jones, Power, Queenan and Schulkin, 2015).
- 4.Serve as an educational resource for other health care professionals, employers, and the general public regarding breastfeeding. Current research indicates that there is insufficient and inconsistent lactation education among professionals and in nursing programs. Advocate for curriculum improvements to prepare the current and next generations of pediatric health care providers (Boyd and Spatz, 2013). Advocate for increased breastfeeding continuing education for all NPs who care for breastfeeding families. NAPNAP recognizes that PNPs are uniquely qualified to be leaders in providing interprofessional lactation education and care by establishing core competencies in lactation education (U.S. Breastfeeding Committee 2010).
- 5.Advocate for workplace employer/employee policies that seek to enable employed women who are breastfeeding to continue providing breast milk to their children. This includes adhering to the Patient Protection and Affordable Care Act (P.L. 111-148) workplace provisions, recommending that employers enact policies and procedures allowing for women to pump their breast milk when reasonable in safe, private, and sanitary rooms without fear of retribution (Dinour and Szaro, 2017). Current research has indicated that the duration of maternity leave and one's employment status were found to inversely affect breastfeeding exclusivity and/or duration (Dinour and Szaro, 2017). PNPs can advocate for longer maternal and paternal postpartum leave time and encourage employers to enact flexible working arrangements. These measures will reduce workplace barriers to improving breastfeeding rates and increase retention of employees long term. Breastfeeding support for employees will reduce turnover, improve business outcomes, and benefit employee health, causing a return on the investment of the employer (U.S. Department of Health & Human Services 2017).
- 6.Support and participate in the design and implementation of clinical practice, local and national policies, and local and regional breastfeeding coalitions to actively promote the continued development and implementation of appropriate breastfeeding initiatives. Advocate, practice, and contribute to specific interventions in the primary care setting that promote the Breastfeeding-Friendly Pediatric Office Practice (Meek and Hatcher, 2017). Identify breastfeeding experts to participate on organizational committees and governing boards for the purpose of ensuring that breastfeeding promotion, protection, and support concerns are addressed in the development of policies and programs affecting women and children.
- 7.Promote, protect, and support breastfeeding as a global strategy to reduce infant morbidity and mortality in both developed and developing countries (World Health Organization 2003,World Health Organization 2017). Recognize the vital role and goals set forth by both the Innocenti Declaration and the International Code of Marketing of Breastmilk Substitutes to reduce inappropriate and unethical marketing of breast milk substitutes to families worldwide and to affirm that, in the absence of true contraindications, all infants benefit from breast milk (Rollins et al., 2016). NAPNAP recognizes and affirms the importance of national and global strategies to promote gender equality and the empowerment of women and girls by increasing access to skilled care before, during, and after childbirth and during lactation and beyond for the betterment of entire communities.
- 8.Recognize that infants are especially vulnerable during times of disaster and that breast milk is the cleanest and safest food for an infant in disasters or emergencies. Providing support for women during a disaster so they can continue exclusive breastfeeding or return to exclusive breastfeeding through re-lactation after a disaster is crucial to promote the positive health outcomes that result from the intake of human milk (Academy of Breastfeeding Medicine 2009,Carothers and Gribble, 2014). Provide professional support and ensure that mothers are instructed on hand expression and paper cup feeding during disaster situations (Academy of Breastfeeding Medicine 2009;American Academy of Pediatrics;
American Academy of Pediatrics (AAP). (2015). Infant feeding in disasters and emergencies: Breastfeeding and other options. AAP Policy and Publications. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/AAP-Policy-and-Publications.aspx
U.S. Breastfeeding Committee 2011). - 9.Conduct research and quality improvement projects related to breastfeeding to formulate, generate, evaluate, and substantiate evidence-based practices for lactation support allowing nurse practitioners to be on the forefront of breastfeeding research (Boyd and Spatz, 2013). PNPs in clinical practice and academia are encouraged to disseminate research findings with a lactation focus through scholarship.
- 10.Promote family and community support of breastfeeding, including a cultural and acculturation assessment of factors affecting breastfeeding initiation and duration (Jones, Power, Queenan and Schulkin, 2015). NAPNAP recognizes the importance of identifying these factors and incorporating culturally sensitive lactation care by assessing for cultural factors that can influence the mother in her breastfeeding decisions. Pediatric-focused APRNs must assess whether there are individual family members, community leaders, or environmental and societal factors at play that may be influencing the success of breastfeeding, resulting in a direct impact on initiation and duration of breastfeeding rates (Kimani-Murage et al., 2015;Emergency Nutrition Network 2017,World Health Organization & UNICEF 2017).
In summary, NAPNAP, an organization whose mission is to empower PNPs, pediatric-focused APRNs, and their interprofessional partners to enhance child and family health through leadership, advocacy, professional practice, education, and research, acknowledges the importance of breastfeeding for infants, mothers, families, and society. Research has substantiated the significant medical, emotional, and economic benefits bestowed by breastfeeding (
Academy of Breastfeeding Medicine 2015
; American Academy of Pediatrics 2018
; World Health Organization 2017
). NAPNAP strongly supports the role of the pediatric-focused APRN in supporting lactating mothers in achieving their breastfeeding goals for their children.References
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Article info
Footnotes
Adopted by the National Association of Pediatric Nurse Practitioners’ Executive Board on August 14, 2018. This document replaces the 2012 NAPNAP Position Statement on Breastfeeding.
All regular position statements from the National Association of Pediatric Nurse Practitioners automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
