- The UK has one of the lowest rates of breastfeeding in Europe. There are limited data available to compare trends in breastfeeding internationally, particularly at age 6-8 weeks when current UK data are recorded. An analysis of global breastfeeding prevalence found that in the UK only 34% of babies are receiving some breast milk at 6 months compared with 49% in the US and 71% in Norway.1
- Breastfeeding rates in the UK decrease markedly over the first weeks following birth. In the 2010 UK Infant Feeding Survey, 81% of mothers in the UK initiated breastfeeding, but only 34% and 0.5% were breastfeeding at 6 and 12 months respectively.2
- While around two-thirds of mothers start breastfeeding,3 4 this falls by 6-8 weeks after birth;5 48.0% of mothers were breastfeeding in England,6 43.9% in Scotland,7 39% in Wales8 and 29.8% in Northern Ireland.9
- Breastfeeding rates are generally reported as mixed (partially breastfeeding) or exclusive breastfeeding (infants only receiving breastmilk). Across the UK, the way in which rates are reported and the denominators used, vary slightly across the four nations, so care should be taken in comparisons between nations.
- The prevalence of breastfeeding is particularly low among very young mothers and disadvantaged socio-economic groups, potentially widening existing health inequalities and contributing further to the cycle of deprivation. Data from the 2010 Infant Feeding Survey showed that 46% of mothers in the most deprived areas were breastfeeding, compared with 65% in least deprived areas.2
- Explanations why the prevalence of breastfeeding in the UK is low are complex and multiple. Mothers may experience practical problems in establishing breastfeeding, and fail to access or receive adequate practical support. Maternal concern about whether an infant is receiving sufficient milk may result in reinforcement from friends, family and health professionals, to “supplement” with formula which undermines maternal milk production and is strongly associated with secondary lactation failure and premature cessation of breastfeeding.2 Societal attitudes may lead to women feeling uncomfortable about breastfeeding in public or in the presence of peers and family members.10
- Investigating the effect of breastfeeding on health outcomes is challenging as it is not feasible to randomise healthy term infants to be breast or formula fed. Consequently, data largely come from observational studies with a high risk of confounding. Hence caution must be exercised in interpreting data, and care taken to reflect uncertainties accurately.
Robust research analyses11 suggest that breastfeeding is likely to be causally related to reduced risk of gastro-intestinal, respiratory and ear infections and reduced need for hospitalisation for infections, in all settings.7 This protection is seen whilst the infant is receiving breast-milk, and is greater with exclusive than with partial breastfeeding. The protective benefits are large and the evidence consistent and biologically plausible.
- Breastfeeding is associated with increased scores on tests of intelligence, and might also protect against deaths in high and low income countries; evidence of reduced overweight, obesity and diabetes in childhood is less secure.
- Breastfeeding is associated with reduced risk of malocclusion. Longer periods of breastfeeding have been associated with an increase in tooth decay, emphasising the importance of tooth-brushing twice a day with fluoride toothpaste once the first tooth has erupted.
- For mothers, breastfeeding provides protection against breast cancer and improves birth spacing;3 breastfeeding may protect against ovarian cancer and type 2 diabetes, but the evidence for these benefits is less certain.
- A systematic review reported that it is possible to improve breastfeeding substantially with the use of interventions to support women in their homes and communities and through health services.12 Support may be offered by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed.13
- There is currently no evidence to suggest that SARS-CoV2 can be passed on in breast milk.14 The well-recognised benefits of breastfeeding outweigh any potential risks of transmission of coronavirus through breastmilk and mothers should be supported to breastfeed. The main risk is the close contact between mother and baby during feeding. Mothers with suspected or confirmed COVID-19 should pay particular attention to handwashing and avoiding coughing or sneezing on the baby.
- A report commissioned by UNICEF15 estimated that moderate increases in breastfeeding would save up to £40 million in NHS expenditure based on fewer General Practitioner consultations and hospital admissions; the report also highlighted savings to the family as there would be no need to buy formula.
- If 45% of babies were breastfed exclusively for four months and 75% of babies in neonatal care were discharged home breastfeeding, an estimated £17 million could be saved by reducing the costs of treating four conditions alone: infection of the lungs, gut, ears (approximately £11 million) and necrotising enterocolitis (approximately £6 million);10 this would also result in 50,000 fewer General Practitioner consultations.
What have children and young people said
Children and young people have shared their views about the education to promote the benefits and normalisation of breastfeeding.
Some of us are embarrassed when people talk about breastfeeding or we see pictures of it. There are some things we think might help like have more education in schools and youth centres about it and to just tell people it is natural and normal – ideally education should start from the age of 10.
Key messages for health professionals
- RCPCH strongly supports breastfeeding, the promotion of breastfeeding, the provision of advice and support for women, and national policies, practices, and legislation that are conducive to breastfeeding.
- All child health professionals should be trained to deliver simple breastfeeding advice. They should make it their responsibility to be aware of specialist advice and local services to support breastfeeding, in order to signpost mothers effectively.
- Make every contact count: mothers may see any encounter with a trusted health professional as an opportunity to discuss breastfeeding. Professionals should take the opportunity to proactively explore and promote breastfeeding practices, in a sensitive manner.
- Breastfeeding is a natural process, however mothers and fathers may require support, knowledge and education. With such support, the expectation is that most women will be able to breastfeed.
- Mothers should be advised that the use of infant formula “supplements” or combined breast and formula feeding may make it more difficult to establish exclusive breastfeeding.
- Mothers should be supported to breastfeed their healthy term infant exclusively for up to 6 months.
- All infants require solid foods from 6 months for adequate nutrition. Solid food should not be introduced before 4 months (17 weeks).16 17
- We recommend that mothers should be encouraged to breastfeed beyond 6 months, alongside giving solid food. Mothers should be supported to continue breastfeeding for as long as they wish; in countries such as the UK evidence is lacking to recommend any particular duration of breastfeeding.
- 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.
- Some women cannot or choose not to breastfeed; this should be respected by healthcare professionals and appropriate support and education on infant feeding provided.
- The promotion of infant formula and the provision of free formula samples to mothers or health professionals are banned under the WHO Code on the marketing of breast milk substitutes, to which the RCPCH adheres. The RCPCH does not condone the promotion of follow-on formulas or non-evidenced claims of health benefits from infant formula and other nutritional products.
- Infant formula and other nutritional products must be based on rigorous, high quality research, development, and clinical evaluation, to ensure babies receive products that improve incrementally; this requires transparent, collaborative engagement between paediatricians, scientists, other healthcare professionals, and industry.
1. Increase initiation and continuation of breastfeeding
RCPCH calls on:
- Public Health England to deliver a public health messaging campaign on initiation and continuation of breastfeeding. Campaigns should be targeted in areas with high maternal deprivation.
- The Northern Ireland Public Health Agency should build on the ‘#NotSorryMums campaign, including promoting information on initiation and continuation of breastfeeding.
- We welcomed the Welsh Government’s launch of the All Wales Breastfeeding Five Year Action Plan in 2019. Resource should be provided to ensure implementation of actions within the Plan.
- The Scottish Government should continue to annually review and monitor the objectives set out in “Improving Maternal and Infant Nutrition: A Framework for Action” (2011) and take appropriate action based on this evaluation.
- The NHS in England and the Welsh Government to require all maternity services to achieve and maintain UNICEF Baby Friendly Initiative accreditation. Accreditation should include compliance with “10 Steps to Successful Breastfeeding” (for maternity units), the “7 Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings”, provision of antenatal education and breastfeeding promotion to both parents, and availability of staff skilled in delivering breastfeeding advice and support.
- Public Health England and the Public Health Agency in Northern Ireland should ensure that all actions implemented to promote, support and protect women to breastfeed are evidence-based.
- Local authorities in England, Health Boards in Wales and the Public Health Agency in Northern Ireland along with Health Trusts to provide local pathways, agreed by multi-agencies, which improve access to support, resources and services for women seeking to breastfeed. These pathways should include provision of local breastfeeding peer support networks. Funding for these services should be ringfenced within areas with high maternal deprivation.
- Scottish Government should continue with the expansion of peer support services across Scotland and the training of additional volunteers and establishing new groups in areas where breastfeeding rates are low.
- The NHS in England, Wales, Scotland and Northern Ireland to ensure the preservation of universal midwifery services.
- UK Government and the Governments in Wales, Scotland and Northern Ireland to commit to adequate resourcing to preserve universal health visiting services.
- Governments in each nation to ensure evidence based, standardised and consistent breastfeeding education is included as part of statutory personal, health and social education in schools.
- Employers to ensure career or life-time salaries are not adversely effected by a woman’s choice to breastfeed.
- UK Government to legislate for breastfeeding breaks and facilities suitable in all workplaces for breastfeeding or expressing breast milk.
- The Department of Health and Social Care should introduce legislation to support and protect breastfeeding infants and their mothers in public places.
2. Data on breastfeeding
RCPCH calls on:
- UK and devolved Governments to ensure reliable, comparable data are recorded across the UK, to measure breastfeeding initiation, at 6-8 weeks, and at suitable intervals up until 12 months of age with data analysed centrally to ensure that local, regional and national comparisons and monitoring of trends are conducted using consistent, comparable definitions and methods.
- Public Health England should conduct the UK-wide Infant Feeding Survey to ensure improved data collection on rates of breastfeeding continuation at birth, 10-14 days, 6-8 weeks and 6 months and beyond. We welcome the commitment within the Department for Health and Social Care’s Prevention Green paper to support this.
3. Further research
RCPCH calls on:
- The National Institute for Health Research to commission research to improve the evidence-base for several aspects of breastfeeding, including optimal duration/exclusivity for different groups of infants, approaches to encourage continuation, the long-term health effects for mother and baby, differences in infant outcomes between breast-feeding and feeding expressed breast milk, and methods to promote a supportive societal culture.
RCPCH activity to promote breastfeeding
- The RCPCH training curriculum for General Paediatricians18 and all paediatric sub-specialties requires trainees to understand the importance of breastfeeding and lactation physiology, be able to recognise common breastfeeding problems, have knowledge of formula and complementary feeding and be able to advise mothers or refer for support.
- RCPCH is committed to working with relevant authorities and agencies across the UK to progress the recommendations listed in this position statement, with the aim of achieving steady improvement in UK prevalence of breastfeeding.
- As an organisation and employer committed to breastfeeding, RCPCH will ensure that breastfeeding is actively promoted and supported in our facilities, events and other organisational policies.
Role and responsibilities of paediatricians
- All paediatricians should be aware of the RCPCH position on breastfeeding and encourage and support mothers, including those with preterm or sick infants, to breastfeed. They should avoid undermining breastfeeding through the inappropriate use of infant formula “top-ups”, and advise women that the use of infant formula may make it more difficult to establish exclusive breastfeeding.
- Paediatricians not directly involved in advising women who are breastfeeding can contribute by supporting colleagues who undertake this role, and ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. This includes ensuring that breastfeeding women are not separated from their infant when either party needs hospital admission, unless this is necessary for medical reasons.
- Paediatricians should be aware of local and national support for breastfeeding mothers (see “External links” below).
Date for review: March 2024
- 1. The Lancet. Web appendix 4: Lancet breastfeeding series paper 1. data sources and estimates: countries without standardized surveys. 2016. Available from www.thelancet.com/cms/attachment/2047468706/2057986218/mmc1.pdf
- 2. a. b. c. 2.McAndrew F, Thompson J, Fellows L et al Infant Feeding Survey 2010. NHS Health and Social Care Information Centre. Copyright © 2012, Health and Social Care Information Centre
- 3. a. b. Public Health England. National Public Health Profiles: Child and Maternal Health 2018/19. Available from fingertips.phe.org.uk/profile/child-health-profiles/data#page/1/gid/1938133226
- 4. Scottish Government. 2018. Scottish Maternal and Infant Nutrition Survey. Available at: www.gov.scot/publications/scottish-maternal-infant-nutrition-survey-2017
- 5. Public Health England. Official Statistics Breastfeeding prevalence at 6-8 weeks after birth (Experimental Statistics). Available from www.gov.uk/government/uploads/system/uploads/attachment_data/file/563003/2015_16_Annual_Breastfeeding_Statistical_Commentary.pdf
- 6. Public Health England. 2021. Breastfeeding prevalence at 6-8 weeks after birth, 2019 to 2020 annual (February 2021 release). Available at: www.gov.uk/government/statistics/breastfeeding-at-6-to-8-weeks-after-birth-annual-data
- 7. a. b. Information Services Division Scotland. 2020. Infant Feeding Statistics Scotland 2019/20. Available at: beta.isdscotland.org/find-publications-and-data/population-health/child-health/infant-feeding-statistics
- 8. Welsh Government. 2020. Breastfeeding, quarterly rates by age and LHB. Available at: statswales.gov.wales/Catalogue/Health-and-Social-Care/NHS-Primary-and-Community-Activity/Breastfeeding/breastfeedingquarterlyrates-by-age-lhb
- 9. Public Health Agency. 2020. Breastfeeding in Northern Ireland. Available at: www.publichealth.hscni.net/sites/default/files/2020-05/Hi%20Brief%20Breastfeeding%20February%202020%20FINAL_0.pdf
- 10. a. b. Public Health England. 2017. New survey of mums reveals perceived barriers to breastfeeding. www.gov.uk/government/news/new-survey-of-mums-reveals-perceived-barriers-to-breastfeeding. (Accessed 2 June 20177 April 2021)
- 11. Victora CG, Bahl R, Barros AJD, et al, for The Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475-90
- 12. Rollins NC, Bhandari N, Hajeebhoy N, et al, on behalf of The Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016; 387: 491-504
- 13. Cleminson J, Oddie S, Renfrew MJ, McGuire W. Being baby friendly: evidence-based breastfeeding Support. Arch Dis Child Fetal Neonatal Ed 2015;100: F173–F178
- 14. RCPCH COVID-19 – research evidence summaries www.rcpch.ac.uk/resources/covid-19-research-evidence-summaries (last accessed 7 April 2021)
- 15. Renfew, M.J., Pokhrel, S., Quigley, M., McCormick, F., Fox-Rushby, J., Dodds, R., Duffy, S., Trueman, P., Williams, A. 2012. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resources.pdf (Accessed 7 April 2021)
- 16. EFSA Panel on Nutrition, Novel Foods and Food Allergens. Appropriate age range for introduction of complementary feeding into an infant’s diet. Dietetic Products, Nutrition and Allergies. EFSA Journal (2019) 17 (9):5780
- 17. Fewtrell M, Bronsky J, Campoy C, et al Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. JPGN 2017 Jan; 64(1):119-132
- 18. RCPCH Progress Curriculum. Paediatric Speciality: Postgraduate Training. Approved by the GMC for implementation as of 1 August 2018