New AAP Guidelines Support Extended Breastfeeding

New breastfeeding guidelines released by the American Academy of Pediatrics (AAP) recommend that babies are breastfed for up to two years. Previously, the AAP recommended breastfeeding until the child turned one year of age.

The guidelines continue to recommend exclusive breastfeeding for about six months after birth, as the unique composition of antimicrobial, anti-inflammatory, and immunoregulatory agents and living cells in human milk all contribute to the child’s developing immune system. Research has confirmed that six months of exclusive breastfeeding is associated with decreased lower respiratory tract infections, severe diarrhea, otitis media, and obesity, and a meta-analysis showed that less than six months of exclusive breastfeeding was associated with an abnormal microbiota and that the differences in gut microbiota persist after six months of age.

After six months of age, the AAP recommends continued breastfeeding, along with the introduction of foods. Continued breastfeeding is supported as long as mutually desired by mother and child for two years or beyond. These recommendations are consistent with those of the World Health Organization (WHO).

Preliminary data reveal that human milk in the second year of life continues to be an important source of macronutrients and immunologic factors for the growing toddler, because it is composed of the same levels of lactose and fat as first-year milk, with significantly higher concentrations of protein, lactoferrin, lysozyme, and immunoglobulin A. Studies emphasize the importance of nutrition during the “first 1000 days,” the period from conception to two years of age, on a child’s neurodevelopment and lifelong health. This is the most active period of neurologic development. Child and adult health risks, including obesity, hypertension, and diabetes, are believed to be programmed during this period.

In addition, studies have documented the importance of longer breastfeeding in increasing maternal attachment. One analysis of data from 1,272 families found that longer breastfeeding duration, up to age three, predicted increases in observed maternal sensitivity (e.g., maternal responsiveness to infant, affect, flexibility, and ability to read infants’ cues) up to age 11 in children, after accounting for multiple confounding variables.

The health benefits of longer duration of breastfeeding may be most important for maternal outcomes. Research has confirmed the importance of breastfeeding for more than one year on maternal health, which is associated with decreasing maternal diabetes, hypertension, breast cancer, and ovarian cancer.

The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding or the provision of human milk a public health imperative.

The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The AAP also recommends that pediatricians need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding, as they play a critical role in hospitals, their practices, and communities as advocates of breastfeeding.

Mothers who decide to breastfeed past the first year need continued support. They often report feeling ridiculed or alienated in their choice and conceal their breastfeeding behavior to minimize unsolicited judgment and comments. There is also evidence that only half of mothers who breastfeed beyond one year discuss their decision with their pediatric primary care provider and that 38% of women who reported that their pediatric primary care provider was unsupportive of breastfeeding past the first year elected to change providers. In addition, laws protecting breastfeeding need to be extended beyond the first year.