Closing the breastfeeding gap for healthier lives and a thriving planet
The incredible benefits of breastfeeding for early-life nutrition and health, as well as the environment are renowned; however, it has not yet garnered the recognition it merits.
Photo by charlesdeluvio / Unsplash
The global consumption of commercial milk formulas as breastmilk substitutes (BMS) has risen by 115% from 2005 to 2019, further displacing the powerful contribution of breastfeeding as the global standard for optimal early-life nutrition and health. While BMS is the often preferred product used by mothers and families to aid in the transition to cow’s milk and meet the constantly changing nutritional requirements at this age, they are not the best source of nutrition for infants and young children to achieve optimal health and should not replace breastfeeding. Non-exclusive breastfeeding during the first six months is a risk factor for stunting and infant mortality due to several preventable diseases, including diarrhea. In the context of food systems, breastfeeding represents the first food system and is crucial for early-life nutrition and health infants and young children have the highest chances of survival, growth, and reaching their full potential when they are fed breastmilk through breastfeeding.
The wonders of breastfeeding for infants and young children
The unique qualities of breastmilk and breastfeeding make them superior to commercial milk formulas and other infant food sources.
It begins with the production of colostrum.
Colostrum is the milk produced by mothers from before birth until about a week after delivery. This thick, yellow liquid contains immunologic components that protect babies from illness and is high in protein and low in lactose. It also triggers the first bowel movement of the newborn, lowering the risk of jaundice. After the production of colostrum ceases, mothers begin to produce a paler, more watery liquid known as mature breastmilk, which is higher in energy and adapts to meet the evolving needs of the baby.
But, what makes breastmilk truly unique is that it is delivered through breastfeeding, facilitated by a sophisticated communication system between mother and infant.
As the optimal first food, breastmilk is readily available and responsive to the infant’s needs. It provides unparalleled nutritional benefits, including proteins, fats, vitamins, and minerals that are perfectly balanced for a baby's digestive system. This liquid gold offers critical support for the immune system, helping to protect against infections and illnesses during the crucial early stages of life.
The global recommendation for breastfeeding by WHO states that, whenever feasible, exclusive breastfeeding should be provided for the initial six months of life, followed by continued breastfeeding for a minimum of 2 years, alongside the introduction of complementary foods at 6 months of age. This is because the health benefits of breastfeeding are profound and far-reaching, both for infants and mothers. Breastfeeding has the potential to prevent more than 800,000 deaths of children under the age of five worldwide. By reducing the risk of mortality caused by infectious diseases, breastfeeding plays a crucial role in saving the lives of infants.
Research shows that breastfeeding can prevent half of all diarrhea episodes and a third of respiratory infections, which are the leading causes of death in newborns.
Breastmilk, with its antibodies that protect against infections, is considered the safest, cleanest, and most nutritious food for infants.
Breastfeeding also reduces the likelihood of stunting and wasting, which are significant concerns in many parts of the world, including Indonesia.
Results of a meta-analysis of publications on breastfeeding and its correlation with stunting revealed that breastfed children had a 38% lower risk of stunting compared to non-breastfed children, indicating that breastfeeding offers protection against stunting. This is attributed to the ability of breastmilk to protect against infections and aid in the recovery from illness, thereby contributing to the healthy development of the child.
In the long term, breastfeeding is also associated with a lower risk of obesity.
Children who were never breastfed or were breastfed for less than six months show a higher prevalence of obesity. Therefore, breastfeeding could serve as a strong tool in the fight against multiple forms of malnutrition worldwide.
Regarding immunity development, breastfeeding enables mothers to pass on beneficial components of their microbiota to their children through breastmilk. These beneficial bacteria inhabit the gastrointestinal tract, contributing to disease prevention, promoting healthy digestion, and supporting the regulation of the child's developing immune system.
The wonders of breastfeeding for mothers
Breastfeeding also provides a multitude of advantages for mothers.
Prolonged breastfeeding beyond 12 months provides considerable health advantages, including a 30% decrease in the likelihood of developing diabetes and a 13% reduction in the risk of hypertension.
Breastfeeding also possesses the ability to lower cancer risk.
Global data reported that breastfeeding could prevent 20,000 annual deaths from breast cancer. The longer the duration of breastfeeding, the higher the reduction in cancer risk will be. It has been reported that for every additional 12 months of breastfeeding, there is a corresponding 4.3% decrease in breast cancer risk. Although the precise mechanisms remain somewhat unclear, some theories propose that breastfeeding may lessen exposure to the cyclic hormones associated with reproductive life due to the suppression of ovulation that occurs with extended breastfeeding.
Additionally, breastfeeding is associated with a reduced risk of ovarian cancer. A pooled analysis investigating the association between breastfeeding and ovarian cancer reported that women who breastfed had a 24% lower risk of ovarian cancer compared to those who did not. The proposed hypothesis for this protective effect is that breastfeeding suppresses ovulation, which subsequently inhibits epithelial cell division and proliferation, ultimately decreasing the likelihood of carcinogenesis. These results emphasize the substantial impact of breastfeeding in decreasing the risk of certain cancers and enhancing overall health outcomes for women.
Further, the benefits of breastfeeding extend beyond just nutrition and health aspects. Breastfeeding helps to develop and strengthen the interaction between mother and infant.
Suckling the breast releases oxytocin, prolactin, and other metabolites that foster mother–child bonding and reduce physiological stress for both. This unique nature of breastfeeding cannot be replicated artificially, emphasizing its exceptional benefits.
Breastfeeding as an environmentally sustainable infant food
Breastfeeding practices not only benefit the mother-baby dyad but also produce less negative environmental impacts than their artificial counterparts.
It is well-established that the production of commercial milk formula (CMF) is highly resource-intensive and contributes to annual global greenhouse gas (GHG) emissions ranging from 5.9 to 7.5 billion kg CO2e or an estimated 3.95 to 4.04 kg CO2e per kg of CMF.
A life cycle analysis comparing infant formula with breastfeeding found that, across five evaluated environmental impact categories, the scores for 1 kg of ready-to-feed infant formula were 24–60% higher than those for 1 kg of breastmilk.
Feeding an infant with formula for four months, as opposed to breastfeeding, resulted in a 38% increase in global warming potential, a 72% increase in terrestrial acidification, a 35% increase in freshwater eutrophication, a 59% increase in marine eutrophication, and a 53% increase in land use.
Challenges and barriers to breastfeeding
While the aforementioned facts of breastfeeding are recognized and appreciated in global health, the implementation of breastfeeding continues to encounter challenges.
There are numerous factors contributing to these issues, with one of the main ones being the lack of attention given to protecting, promoting, and supporting breastfeeding.
First, breastmilk and breastfeeding as the first food system remain absent in the Conceptual Framework of Food Systems for Diet and Nutrition, despite its direct impact on improving nutrition and health outcomes. The absence of breastfeeding in the framework makes both interventions susceptible to being overlooked in discussions around the food system.
Second, despite the increasing trend of exclusive breastfeeding nearing the global target of 50%, less than half of newborns worldwide are breastfed within one hour of birth (early initiation of breastfeeding), falling short of the 70% target.
Early initiation of breastfeeding keeps a baby warm, builds their immune system, promotes bonding, boosts a mother’s milk supply, and increases the chances of continued exclusive breastfeeding. However, one in three babies in low and middle-income countries receive prelacteal feeds—liquids or non-breastmilk foods, mostly water and animal milk—before being put to the breast. This practice delays breastfeeding, adversely affects lactation, and is associated with self-reported insufficient milk (SRIM) and premature supplementation or cessation of breastfeeding.
While SRIM can generally be prevented or addressed with appropriate support, such as increasing breastfeeding frequency, educating mothers the proper way to breastfeed, and encouraging mothers to eat nutritious foods, the influence of CMF marketing that is either promoted by doctors and healthcare providers (HCPs) or makes up the most of what is available to mothers prevents a mother perception about the sufficiency of her breastmilk. This could result in reduced suckling and actual insufficient milk production. Such advice is common globally due to a lack of adequate lactation training for HCPs combined with CMF marketing to HCPs, who are considered authorities on infant feeding.
The disparity in access to skilled breastfeeding counseling for mothers and families in healthcare services also leads to a lack of confidence in breastfeeding, as they may not have adequate knowledge of the benefits of breastfeeding and breastfeeding techniques. Common challenges include perceived insufficient milk supply, poor latching techniques, and practical difficulties in expressing breastmilk.
Third, CMF marketing exploits common infant behavior like crying, unsettled behavior, and short night-time sleep durations that are often misinterpreted as feeding problems. They also target HCPs and scientific establishments through financial support, corporate-backed research, and medicalization of feeding practices for infants and young children.
Furthermore, weak law enforcement of the International Code of Marketing of Breastmilk Substitutes in various countries leaves women and families easily exposed to CMF marketing. The Code is intended to protect infants and young children from inappropriate marketing by prohibiting the promotion of breastmilk substitutes, bottles, and teats to the public, healthcare workers, and facilities, as well as the distribution of samples or vouchers to new parents.
However, the diverse and evolving marketing strategies of the CMF industry change social norms and influence feeding decisions. These strategies include product and cross-product promotions distributed through trusted sources like health facilities and workers, along with extensive social and mass media campaigns. These aggressive marketing campaigns drastically influence both the food environment (access, availability, affordability, quality) and consumer behavior (choosing what food to purchase and prepare for young children), resulting in negative health and nutrition consequences.
Lastly, while breastfeeding is considered natural for many women, not all mothers have the privilege to breastfeed their babies.
In certain circumstances, it may be recommended that some mothers refrain from breastfeeding their infants. Such situations include mothers who are taking specific medications, such as cancer chemotherapy drugs, those undergoing radiation therapy, or those who are actively using drugs/substances and are unable to control their alcohol consumption. Additionally, women with a history of breast surgery may encounter significant challenges with breastfeeding.
Regarding infants, an absolute contraindication for breastfeeding is the presence of galactosemia—a rare metabolic issue that impedes the body’s ability to process the sugar galactose, potentially leading to liver complications and shock. In such cases, comprehensive examination, consultation, and support from professional healthcare are essential to ensure that the nutritional requirements of both mothers and infants are met without jeopardizing their health.
Closing the gap
Breastfeeding is a beautiful and natural part of nurturing a child, but it requires a supportive environment to truly thrive. It takes a village to raise a child, and every member of that village has a role to play in ensuring that mother—baby dyads receive the support they need. Individuals, communities, and policymakers must work together to create a breastfeeding-friendly world.
Policymakers have the power to implement and promote breastfeeding-friendly policies, such as paid maternity leave, workplace accommodations, and public breastfeeding protections. The law enforcement concerning CMF marketing must be carried out with greater rigor.
Recently, the Indonesian government has issued Regulation No.28/2024 on Implementing Regulations of Law No.17/2023 concerning Health (Peraturan Pemerintah RI Nomor 28 Tahun 2024 tentang Peraturan Pelaksanaan Undang-Undang Nomor 17 Tahun 2023 Tentang Kesehatan), which aligns with The International Code of Marketing of Breast-Milk Substitutes and aims to protect and support breastfeeding. Some measures mentioned in the regulation include stipulations that CMF must be provided solely based on medical indications previously determined by health workers and/or qualified health professionals. The regulation prohibits health workers from receiving or promoting CMF and restricts the provision of health services funded by CMF manufacturers or distributors.
Additionally, CMF producers and distributors are prohibited from giving free CMF samples to health workers, community health workers, pregnant women, or new mothers. They are also prohibited from offering discounts or gifts to encourage CMF purchases, collaborating with public figures or social media influencers for CMF promotion, and marketing CMF through mass media, both in print and digital platforms. The successful implementation of this comprehensive regulation will undoubtedly require diligent oversight and strong political will from various stakeholders.
Communities also play an important role in protecting and supporting breastfeeding. Communities can help with organizing support groups, providing resources for mothers, and creating public spaces that are safe and welcoming to breastfeeding mothers.
Finally, as individuals, we can offer our support to breastfeeding mothers by providing encouragement and understanding. By educating ourselves and others about the benefits and challenges of breastfeeding, we can help close the gap in breastfeeding support and ensure that every mother has the opportunity to breastfeed her child successfully.
During this World Breastfeeding Awareness Week, let’s take tangible steps to support breastfeeding families and make breastfeeding a more accessible and accepted practice for all.
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