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.
The Texas Department of State Health Services (DSHS) affirms that:
- Exclusive breastfeeding for approximately the first 6 months of life and continued breastfeeding for 1 to 2 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 Texas Department of State Health Services mission, to improve health and well being in Texas.
The Texas Department of State Health Services (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).
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.
Position Statement on Infant Feeding Committee Members
Julie Stagg, MSN, RN, IBCLC
Maternal and Child Health Nurse Consultant
Office of Program Decision Support
Tracy Erickson, RD, LD, IBCLC
State WIC Breastfeeding Coordinator
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Hellen Sullivan, RN, IBCLC, CLE
Breastfeeding Promotion Nurse
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Lindsay Rodgers, MA, RD, LD
Obesity Prevention Specialist
Nutrition, Physical Activity, and Obesity Prevention Program
Pamela Berens, MD, FABM
Associate Professor Department of OB/GYN
UT Health Science Center Medical School
Fellow of the Academy of Breastfeeding Medicine (FABM)
Jeannette Crenshaw, MSN, RN, IBCLC, LCCE, NEA, BC
Family Educator, Texas Health Presbyterian Hospital of Dallas
Graduate Faculty, Nursing Administration Program at University of Texas at Arlington
Representative, United States Breastfeeding Committee (Lamaze International)
Representative, USDA Breastfeeding Promotion Consortium (Lamaze International)
Judy Hopkinson, PhD, IBCLC
Janet Rourke, MSHP, LD, CLE
Editor, Hale Publishing
Alisa Sanders RN, IBCLC, RLC, CCE
Breastfeeding and Outreach Coordinator
The University of Texas Medical School at Houston Department of Pediatrics WIC Program
Barbara Wilson-Clay, BSEd, IBCLC, FILCA
Private Practice Lactation Consultant and Author, The Breastfeeding Atlas
Fellow of the International Lactation Consultant Association (FILCA)
Vice President of the Board of Directors of the Mother’s Milk Bank at Austin
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 Microsoft Word Document (60 kb, DOC)
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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). **