PolicyLab

Editor’s Note: In light of the recent formula shortage and the highly publicized American Academy of Pediatrics updated policy statement on breastfeeding, this World Breastfeeding Week, we asked three PolicyLab and Children’s Hospital of Philadelphia (CHOP) experts from a variety of disciplines (i.e., pediatric primary care, child psychology, neonatology) to help us unpack the research behind the benefits of breastfeeding for parents and what policies provide the support working parents need to breastfeed for the duration they desire. To continue our World Breastfeeding Week blog post series, we also published a post by colleagues in CHOP’s Center for Pediatric Nursing Research & Evidence-Based Practice diving deeper into their own research behind the supportive policy of workplace protections, as well as a post giving a closer look at reducing racial disparities in breastfeeding from a recent graduate of CHOP’s Pediatrics Residency Program.

Breastfeeding Health Benefits for Parents

By Dr. Meg Kawan

This past June, the American Academy of Pediatrics (AAP) updated their policy statement, “Breastfeeding and the Use of Human Milk,” their first update on breastfeeding/chestfeeding* in 10 years. The statement and accompanying technical report reaffirm the importance of breastfeeding and, in much publicized news, extends the recommendation for breastfeeding through age 2 and beyond, if “mutually desired by mother and infant.” This recommendation aligns with World Health Organization guidance and is based on extensive evidence on the medical and neurodevelopmental benefits of breast milk to both birth parents and infants.  

While the health benefits of breastfeeding and human milk for infants are widely recognized, less is publicized about important health benefits to breastfeeding parents. The AAP technical report mentioned above reviews the data, which show parents who breastfeed for greater than 12 months have a 30% reduced risk of type 2 diabetes, 10-13% reduced risk of high blood pressure, a 26% reduced risk of breast cancer and a 37% reduced risk of ovarian cancer. The protective benefits of breastfeeding past one year are particularly strong for breastfeeding parents with gestational diabetes, with a meta-analysis of nine studies demonstrating a 78% reduction of risk of diabetes within a five-year period. The authors of this report conclude, “The health benefits of longer duration of breastfeeding may be most important for maternal outcomes.” 

The United States currently has one of the highest rates of maternal mortality among high-income countries, with unacceptable racial disparities. Current evidence suggests creating policies that support increasing breastfeeding duration are critical to addressing this crisis. 

Workplace Protections: A Supportive Policy for Increasing Breastfeeding Duration

By Dr. Marsha Gerdes

Knowing the benefits of breastfeeding is not enough to help a parent who is returning to the workplace. Parents are challenged to continue breastfeeding when they return because of the lack of facilities and time to express breastmilk, otherwise known as pumping. Pumping two to three times during a workday is necessary to provide adequate food for the baby, protecting their health and that of the parent breastfeeding. Unfortunately, many parents find their workplace does not have these accommodations, and they are forced to individually take on advocacy for requesting them. The Federal Break Time for Nursing Mothers Law ensures “reasonable break times” and a “non-bathroom” space. However, this law does not cover non-exempt employees or businesses with fewer than 50 employees and has a waiver for business for which these accommodations cause hardship.   

What is needed is fairly simple: lactation rooms that are non-bathrooms, clean and private, include a chair, small tabletop surface, electrical outlet, and clean running water, and that can be scheduled easily. Parents also need breaks that allow time for expressing milk (15-20 minutes) and time for getting to the room, setting up, and disassembling and cleaning up. However, making these accommodations takes some innovative planning and thinking outside the box. What works for a remote worker is different than a breastfeeding parent working in a factory or fast food establishment or driving a delivery truck. Kudos to the creative thinkers in Los Angeles who opened lactation rooms in fire stations for all city workers, as well as the TriMET bus company in Portland, Ore., which is using portable lactation pods made from portable restroom shells for their bus drivers. Our own institution, Children’s Hospital of Philadelphia, just set up a lactation room scheduler chat bot to ease access to rooms.     

Unfortunately, continuing breastfeeding upon return to the workplace, as is recommended by the AAP, is not possible for many parents due to the lack of workplace accommodations. The U.S. Department of Health and Human Services has a helpful toolkit with ideas for businesses to use, as it is an undue burden on individuals to be the ones to initiate these changes. It is time to expand the mandates to cover all breastfeeding parents through state regulations or through the expansion of the Federal Break Time for Nursing Mothers Law. 

Paid Family Leave: A Supportive Policy for Increasing Breastfeeding Duration

By Dr. Diana Montoya-Williams

Individual and public health goals regarding human milk provision in this country will never be achieved until there is widespread access to paid family leave for all working people. Paid family leave has been associated with improved breastfeeding initiation rates and longer duration of milk provision to infants both in the U.S. and in other countries. In the U.S., the evidence of these positive associations comes from states with paid family leave policies, particularly California in 2004 and New York in 2018. In one well-designed quasi-experimental study, the strongest association found was between paid family leave and breastfeeding at six months, which mirrors the AAP recommendation for about how long infants should be fed human milk exclusively, if at all possible.  

Increased initiation and longer periods of breastfeeding have been hypothesized as among the reasons for why paid family leave is also associated with decreased infant rehospitalization rates after birth, and critically, with improved mortality rates for infants and kids under 5 years old.  

Importantly, in socio-economically and racially diverse areas of the country like New York, paid family leave has been shown to preferentially benefit Black birthing parents’ breastfeeding rates, which is critical given known racial disparities in breastfeeding initiation and continuation in the U.S. Thus, not only is paid family leave associated with more people able to provide their infants with human milk for longer periods of time, but it may represent a policy solution to pressing racial disparities in infant health.  

Still, the U.S. Bureau of Labor recently estimated that only 23% of working people in this country have access to paid leave, likely due to a lack of federal policy guaranteeing the right to paid leave. In recent years, uptake of unpaid leave through programs like the Family and Medical Leave ACT (FMLA) has increased, but the policy gap remains for those who cannot afford to take unpaid leave or whose employers do not meet criteria that require the provision of FMLA. 

*While we use “breastfeeding” throughout this piece to align with the awareness week and for consistency, we recognize some parents prefer the terminology of “chestfeeding.” 

Meg Kawan, MD, MPH, IBCLC, is a pediatrician at Children’s Hospital of Philadelphia’s Karabots Pediatric Care Center.