Role of Pediatricians in Promoting and Supporting Breastfeeding: A Position Paper of the International Pediatric Association Strategic Advisory Group on Infant, Child, and Adolescent Nutrition

Background: Promoting and supporting breastfeeding is an important public health intervention with multiple benefits for both infants and mothers. Even modest increases in the prevalence and duration of breastfeeding could significantly reduce healthcare costs and improve maternal and child health outcomes. However, widespread adoption of breastfeeding recommendations remains poor in most settings, which contributes to widening health and social inequalities. Pediatricians have a duty to advocate for improving child health, including promoting and supporting breastfeeding. Summary: This paper, from the International Pediatric Association Special Advisory Group on Nutrition, considers common barriers to breastfeeding and addresses how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy. All pediatricians need to understand the basics of breastfeeding, including lactation physiology, recognize common breastfeeding problems, and advise mothers or refer them for appropriate support; training curricula for general pediatricians and all pediatric subspecialties should reflect this. Even in the situation where their day-to-day work does not involve direct contact with mothers and infants, pediatricians can have an important influence on policy and practice. They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. Pediatricians and pediatric organizations should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels. Key Messages: Pediatricians have a duty to promote and support breastfeeding, regardless of their day-to-day role and responsibilities. Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers in their personal practice but also influence breastfeeding practice and policy at a local, regional, national, and international level.


Introduction
Why Should Pediatricians Promote and Support Breastfeeding?Promoting and supporting breastfeeding is an important public health intervention, which has multiple benefits for both infants and mothers [1].Even modest increases in the prevalence and duration of breastfeeding could significantly improve health outcomes, including a reduced risk of infant gastrointestinal and respiratory infections and reduced risk of breast cancer in the mother [2].This in turn could significantly reduce healthcare costs.The World Health Organization (WHO) recommends that mothers exclusively breastfeed their infant for 6 months, followed by continued breastfeeding alongside complementary feeding until the age of 2 years or more [3].However, despite numerous initiatives to improve breastfeeding initiation and duration over many years in different locations, widespread adoption of these recommendations remains poor in most settings, and economic, ethnic, and population subgroup trends in breastfeeding rates are unfortunately noted in many studies.In 2015-2021, 47% of newborns initiated breastfeeding against a global target of 70% [4], and breastfeeding initiation and duration are low in many countries despite regional variation [1,5].Despite positive trends in exclusive breastfeeding, with 47% of infants under 6 months of age exclusively breast-fed compared to 37% a decade earlier, the rate of improvement is insufficient for reaching the global target of at least 70% global prevalence by 2030 [4,6].Infant feeding and behavior problems are also frequent reasons for consultation with a health professional.
There are many potential explanations for low breastfeeding rates, and they are likely to vary in different settings.They include the following [2,[6][7][8][9][10]: • Practical problems in establishing breastfeeding with lack of adequate practical support; • Maternal concern about whether her infant is receiving sufficient milk.This may lead to advice from friends, family, and health professionals to "supplement" with formula which can undermine maternal milk production and is strongly associated with secondary lactation failure and early discontinuation of breastfeeding; • Inappropriate promotion of human milk substitutes, in part related to targeted marketing strategies of the infant formula industry, may undermine breastfeeding by normalizing or idealizing infant formula; • Societal attitudes may lead women to feel uncomfortable about breastfeeding in public or even in the presence of peers and family members; • Lack of support for women to continue breastfeeding when they re-enter the workforce, including psychological support but also practical issues such as time, private space, and equipment for milk expression; • Lack or inadequate duration of paid maternity leave.
The International Pediatric Association (IPA) has endorsed the 1990 Innocenti Declaration [11] which stated that countries would commit to establish a national coordination committee for breastfeeding, implement the "10 steps to successful breastfeeding" (which were recently updated and revised based on current information [12]) in all maternity hospitals, implement the International Code of Marketing of Breast-Milk Substitutes, and adopt legislation to protect breastfeeding women at work.Pediatricians have a duty to advocate for improving child health.This includes promoting and supporting breastfeeding, regardless of whether their day-to-day activities include direct involvement with breastfeeding women and infants.The aim of this article is to consider how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy.

How can Pediatricians Promote and Support Breastfeeding?
All Pediatricians Need to Understand the Basics of Breastfeeding Training curricula for general pediatricians and all pediatric subspecialties should require trainees to understand the importance of breastfeeding and lactation physiology, be able to recognize common breastfeeding problems, have knowledge of infant formula and complementary feeding, and be able to advise mothers and/or refer them for appropriate support.They should understand the importance of encouraging and supporting mothers with preterm or sick infants to breastfeed or provide human milk.Some key points are summarized below: • Lactation is a fundamental mammalian characteristic.Humans, in common with all other mammals, have evolved to provide milk for their offspring.In this sense, breastfeeding is a "natural" process.However, whereas lactation in many mammalian species is an instinctive process, in non-human primates and in humans it has evolved to have a greater reliance on learning and cultural/social factors [13,14].Thus, in practice, breastfeeding may not come naturally to all mothers, especially if the prevailing culture is not supportive of breastfeeding and if they lack personal experience of breastfeeding among family and friends.Mothers therefore need knowledge, education, and support.With such support, most women should be able to successfully breastfeed.
• A description of the key elements in the physiology of breastfeeding is provided in Figure 1.Human milk production generally follows a supply-and-demand process.Breast/nipple stimulation is essential to initiate and maintain the secretion of prolactin which is required

Role of Pediatricians in Supporting Breastfeeding
for milk synthesis.The release of milk from the breast is initiated by the pulsatile release of oxytocin in response to nipple stimulation or, once lactation is established, conditioned to factors such as the sight, sound, or smell of the infant.Both prolactin and oxytocin are essential for successful breastfeeding.If milk is not removed from the breast, further synthesis is prevented by build-up of the feedback inhibitor of lactation in the breast.From this overview, it is clear that breastfeeding will be compromised or prevented by factors that interfere with the removal of milk (for example, if the baby is not feeding effectively or frequently or if formula supplements are used so the baby is not hungry) or with milk production or let-down (including absent or inadequate breast stimulation, maternal stress, anxiety, or lack of confidence).These factors are summarized in Figure 1.
• For healthy full-term infants, breastfeeding should be initiated as soon as possible after delivery alongside skinto-skin contact.Exclusive breastfeeding should be encouraged, avoiding the introduction of human milk substitutes in the first days.Mothers benefit primarily from guidance, encouragement, strengthening of selfconfidence, and practical support, which cannot be substituted for by only recommending or prescribing supplements or presumed galactogogues intended to stimulate milk secretion.
• Pediatricians should avoid undermining breastfeeding by unintentionally implying that the milk supply may be inadequate (for example, in discussions about infant weight gain) or through inappropriate advice to use infant formula supplements or "top-ups."Where there is concern that the milk supply is sub-optimal, they should offer advice to increase milk supply with follow-up so the mother has the chance to maintain breastfeeding.It is important to advise women that the use of infant formula during the early postnatal period may make it more difficult to establish exclusive breastfeeding.
Clinical protocols on the management of common infant problems should pay attention to the protection of breastfeeding so that practices do not interfere with breastfeeding without good evidence.
• The use of human milk should be encouraged for all infants, including those who are sick or born preterm.If the baby is too immature or sick to feed directly from the breast, the mother should be supported to express her milk either manually or using a breast pump.Preterm infants should be offered colostrum from day one, and breast milk should be provided as the only food during the first days for these infants and continued with the added breast-milk fortifiers if required to support adequate growth.Separation of breastfeeding mothers and their infants should be avoided unless indicated for medical reasons.Donor human milk can be used, if available, where maternal milk is insufficient or unavailable, prioritizing use for high-risk newborn infants.
• Mothers should be supported to exclusively breastfeed their healthy term infant for 6 months and to then continue breastfeeding alongside complementary feeding for as long as they wish.The WHO recommends continued breastfeeding for 2 years or beyond.
• All infants require solid foods from about 6 months of age for adequate nutrition and progressive transition to family foods, alongside human milk or a breast-milk substitute.Solid food and non-milk liquids should never be introduced before 4 months (17 weeks).We are aware that national and regional recommendations differ, and the appropriate age to introduce complementary foods should consider factors such as the health risks faced by the population including the prevalence of food allergy and morbidity and mortality from infection, as well as maternal preference [15,16].Importantly, two trials investigating the introduction of specific allergenic foods before 6 months of age reported no adverse effect on breastfeeding rates [17,18].
• Mothers need to feel confident in their ability to breastfeed and to feel comfortable breastfeeding in public; this requires support from family, friends, professionals, the workplace, and society at large so that breastfeeding is regarded as normal and natural.

Even in the Situation Where Their Day-To-Day Work Does Not Involve Direct Contact with Mothers and Infants, Pediatricians Can Have an Important Influence on Policy and Practice
They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression.Depending on their role, they should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels.
Specific recommendations and suggestions include the following: Pediatricians should strongly support breastfeeding, the promotion of breastfeeding, the provision of advice and support for women, and local and national policies, practices, and legislation that are conducive to breastfeeding.Examples include the following: • Ensuring that women and their partners receive adequate prenatal care which includes guidance on how to prepare for breastfeeding, encourages exclusive breastfeeding, and provides realistic expectations, including an explanation of the difficulties that may occur in the first few days and where women can obtain advice and support.Engagement with colleagues in obstetrics can be critical here, as studies have noted that mother's decisions about infant feeding are often made during pregnancy [19].
• Organizing a support team of healthcare professionals with experience in breastfeeding who can address breastfeeding difficulties and offer solutions to mothers in a timely manner.
• Ensuring that breastfeeding women are not separated from their infant when either party needs hospital admission, unless this is necessary for medical reasons.This is particularly relevant in the context of the COVID-19 pandemic.A systematic review including 49 studies found no association between infection of COVID-19 and feeding method or maternal proximity [20].The World Health Organization (WHO) also recommended that mothers with COVID-19 (or suspected COVID-19) breastfeed as long as they take appropriate precautions [21,22].
• Not condoning or encouraging the promotion of human milk substitutes, the provision of free formula samples to mothers or health professionals, or nonevidenced claims of health benefits from infant formula and other nutritional products.Pediatricians should oppose all inappropriate marketing activities for breastmilk substitutes.Pediatricians should be aware of and recommend alternatives to avoid introducing infant formula as a supplement to breastfeeding infants unless it is medically indicated.
• Being aware of local and national support for breastfeeding mothers so they can refer women appropriately.Pediatricians can also support breastfeeding via pediatric associations, professional organizations and by lobbying elected representatives in government.Such measures could include the following: • Supporting paid parental leave to allow women to exclusively breastfeed for 6 months.
• Supporting policies that encourage women to be able to breastfeed or express milk in public and in their working environment.
• Recognizing that breastfeeding practices in some industrialized countries are inequitably distributed among economic and other population subgroups [23] and that interventions are needed to reduce this imbalance [24].
• Supporting policies to promote and facilitate breastfeeding which can reduce inequalities in countries where informal work is more prevalent and where women are forced to return to work without paid maternity leave.
• Supporting publicity and media campaigns to highlight the benefits of breastfeeding and encourage breastfeeding in all situations, showing breastfeeding as a natural part of life.This could include showing breastfeeding in TV shows and films and encouraging celebrities and influencers (singers, artists, politicians) to share their personal experiences of breastfeeding.
• Ensuring that education on infant feeding, including breastfeeding, is mandatory in the training curriculum for pediatricians and all healthcare professionals.
• Promoting the inclusion of education on infant feeding, including breastfeeding, in school curricula, regularly including breastfeeding topics in the program of scientific congresses and educational activities for all healthcare professionals in contact with pregnant women and families, and promoting discussions regarding the importance of breastfeeding for infant health and the practical difficulties faced by parents.
• Supporting implementation of binding and effective standards and practices for marketing and promotion of breast-milk substitutes based on the International Code of Marketing of Breast-Milk Substitutes and considering the related subsequent resolutions, given that unacceptable marketing practices continue in many parts of the world and new challenges arise through rapid expansion of unacceptable and uncontrolled marketing strategies through digital marketing and social media influencers [25][26][27].Pediatricians should also be aware that professional and ethical incongruities can lead to a failure to protect breastfeeding in a competitive, commercial world.
While supporting and promoting breastfeeding and acknowledging that breast-milk substitutes cannot match the numerous nutritional and non-nutritional benefits of breastfeeding, pediatricians should understand that breastmilk substitutes of high quality are required for infants that do not receive full or any breastfeeding, including a very small number of infants where full breastfeeding is not indicated for medical reasons, such as rare inborn errors of metabolism or maternal HIV infection, in settings where breast-milk substitutes are available and can be safely used [28,29].It is important for pediatricians to recognize that the use of breast-milk substitutes and other nutritional products for children should be based on rigorous, high-quality research, development, and clinical evaluation to ensure incremental improvement of such products.This requires appropriate, transparent, collaborative engagement between pediatricians, scientists, other healthcare professionals, and commercial actors based on broadly accepted and high scientific, ethical, and societal standards.Individual pediatricians and their organizations should work toward implementation of such standards around the world.

Conclusion
Pediatricians have a duty to promote and support breastfeeding as a public health intervention with benefits not only for individual mothers and infants but also for society, regardless of their day-to-day role and responsibilities.Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers and families in their personal practice and also influence breastfeeding practice and policy at a local, regional, national, and international level.

Fig. 1 .
Fig. 1.Physiology of lactation and common factors that may compromise successful breastfeeding.