Breastfeeding: Behavioral Counseling Interventions

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including healthcare delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

The association between breastfeeding and health benefits in children has been previously well established;^1,2 health benefits have also been found for lactating persons.^1,2 However, breastfeeding rates in the United States are relatively modest; 59.8% of infants at 6 months of age are breastfed and 27.2% of infants at that age are exclusively breastfed.³ Breastfeeding rates differ according to race, age, level of education, and other sociodemographic factors.¹ Variables associated with lower breastfeeding rates include Black race, being younger than age 30 years, participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), being unmarried, living in a nonmetropolitan area, or having high school as the highest education level achieved.^1,3,4 Disparities are present by race, with 51.7% of Black infants being breastfed at 6 months compared with 73.9% of Asian infants, 63.4% of White infants, and 56.1% of Hispanic infants.³

There are important and complex historical, social, cultural, and structural factors that contribute to disparities in rates of breastfeeding, as well as inequities in access to breastfeeding support interventions. Historically, Black women were often forced to act as wet nurses for their slave owner’s children, which has had a lasting stigma and impact on attitudes towards breastfeeding in Black communities today.^5-8 In the 1950s, marketing tactics of some formula companies specifically messaged to Black communities that use of their product was associated with feelings of status.^9,10 A belief that may have a role in the lower breastfeeding rates in Hispanic and Latina communities is a perception that providing both breast milk and formula gives infants twice the benefits.^11-13 These historical actions may influence current beliefs and decisions about breastfeeding.

Structural and economic factors may also contribute to disparities in breastfeeding rates. Black and Hispanic and Latina individuals, as well as individuals with lower socioeconomic status, may work in jobs that make it difficult to continue breastfeeding while working.^8,12,14,15 There are also inequities in access to breastfeeding support, including in healthcare settings. Zip codes that have higher proportions of Black residents are less likely to have birthing facilities with supportive breastfeeding practices, such as early initiation of breastfeeding, rooming in, limited use of breastfeeding supplements, limited use of pacifiers, and post-discharge support.¹⁶ Studies also show that Black individuals may be less likely to receive breastfeeding support than White individuals,^17-22 and Black, Asian, Hispanic and Latina, and Native American/Alaska Native individuals have reported receiving inequitable perinatal care as well as reporting being ignored by, shouted at, and having requests for information denied at rates 2 times higher than that of White individuals.²³

The USPSTF concludes with moderate certainty that behavioral counseling interventions to support breastfeeding in pregnant and postpartum persons have a moderate net benefit. Therefore, clinicians should provide pregnant and postpartum persons with behavioral counseling interventions to support breastfeeding or refer them to appropriate healthcare professionals.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.²⁴

Patient Population Under Consideration

This recommendation applies to all pregnant and postpartum persons of all genders, and their infants and children. Interventions to support breastfeeding may also involve partners, other family members, and friends. This recommendation does not apply in circumstances where there are contraindications to breastfeeding (e.g., certain maternal medical conditions or infant metabolic disorders, such as galactosemia). The USPSTF did not review evidence on interventions directed at breastfeeding of preterm infants.

Definitions of Breastfeeding

For the purposes of this recommendation statement, breastfeeding includes both feeding at the breast and feeding expressed breast milk through a bottle. Rates of breastfeeding are described in terms of initiation (starting breastfeeding or introducing breast milk, at or within 1 week after birth), duration (the number of months breastfeeding or consumption of breast milk lasts), and exclusivity (consumption of only breast milk, whether from the breast or bottle, and without other liquid or food supplementation).

Behavioral Counseling Interventions and Implementation Considerations

Behavioral counseling interventions that help increase breastfeeding rates include breastfeeding education and support. Breastfeeding education typically includes a formalized program to convey general breastfeeding knowledge and focuses on the benefits of breastfeeding, practical breastfeeding skills (e.g., latching), and the management of common breastfeeding complications. These programs may also offer family members encouragement and advice on how to support the mother. Breastfeeding support can include providing information about the benefits of breastfeeding, psychological support (encouraging the mother, providing reassurance, and discussing the mother’s questions and problems), and direct support during breastfeeding observations (helping with the positioning of the infant and observing latching). Interventions are often provided by professionals such as nurses, midwives, clinicians, or lactation care providers. Support may also be provided by trained peers. Interventions that occur over multiple periods (i.e., during prenatal, peripartum, and postpartum periods) tend to have greater effects compared with those that occur over a single period (just one trimester of pregnancy). Effective interventions have varied in terms of delivery setting—in person vs. remote delivery (via video, telephone, or text), in-home visit vs. in hospital or in medical office, and delivery to an individual vs. a group.

For persons who decide to breastfeed their infant via expressed milk, under the Affordable Care Act, health insurance plans must cover the cost of a breast pump.²⁵ Additionally, under the 2022 Providing Urgent Maternal Protections for Nursing Mothers (PUMP) Act, most employees covered by the Fair Labor Standards Act (FLSA) have the right to a reasonable break time and place to express breast milk while at work.²⁶

Additional Tools and Resources

The Centers for Disease Control and Prevention (CDC) provides information on practices that support breastfeeding in maternity care settings (https://www.cdc.gov/breastfeeding/php/guidelines-recommendations/safety-in-maternity-care.html).

The U.S. Department of Labor provides a fact sheet on FLSA protections for employees to pump breast milk at work (https://www.dol.gov/agencies/whd/fact-sheets/73-flsa-break-time-nursing-mothers).

The Office of the Assistant Secretary for Health provides resources on how to support breastfeeding at work (https://www.womenshealth.gov/supporting-nursing-moms-work/resources).

Information on breast pumps and breastfeeding is available through the Food and Drug Administration (https://www.fda.gov/consumers/womens-health-topics/pregnancy#Breast%20pumps%20and%20breastfeeding).

Both the Eunice Kennedy Shriver National Institute of Child Health and Human Development (https://www.nichd.nih.gov/health/topics/breastfeeding) and the CDC provide educational materials on breastfeeding for patients and families (https://www.cdc.gov/breastfeeding/php/guidelines-recommendations/index.html).

The U.S. Department of Agriculture provides resources for WIC breastfeeding support (https://wicbreastfeeding.fns.usda.gov/).

The National Institutes of Health has created a drug and lactation database, LactMed®, that contains information on drugs and other chemicals that may pass from breast milk to the infant (https://www.ncbi.nlm.nih.gov/books/NBK501922/).

Additional resources on breastfeeding for maternal and child health professionals is available through the Health Resources and Services Administration’s Maternal and Child Health Bureau (https://mchb.hrsa.gov/programs-impact/focus-areas/maternal-health/mchb-supports-breastfeeding).

When final, this recommendation will update the 2016 recommendation statement on primary care interventions to support breastfeeding. The current draft recommendation is consistent with the 2016 recommendation; both are “B” recommendations.

Scope of Review

The USPSTF commissioned a systematic review¹ to evaluate the benefits and harms of behavioral counseling interventions to support breastfeeding in pregnant and postpartum persons. This is an update to a systematic review that was commissioned for the USPSTF in 2016. The updated review focused on interventions that were initiated in, conducted in, or referable from primary care.

Benefits of Behavioral Counseling Interventions

Ninety trials representing data on more than 49,000 pregnant or postpartum persons and their infants were reviewed.¹ Thirty-three of the trials were conducted in the United States, 23 in Europe, 17 in Asia, 10 in Australia and New Zealand, and seven in Canada.¹ The participants in the majority of the U.S.-based studies (24/33) were predominately Black and/or Hispanic and Latina women, including six studies that limited enrollment to Hispanic or Latina women or Black women.¹ Many of the U.S.-based studies also required that participants have incomes in the lower income bracket to be able to enroll.¹ Almost half of the studies limited enrollment to persons who were intending to breastfeed, and the majority of participants in the remaining studies intended to breastfeed at the beginning of the study.¹ Most of the studies delivered the intervention to individual participants, although 12 interventions included group sessions with other participants.¹ Trials varied widely in terms of when they were provided (prenatally, peripartum, or postpartum), who delivered the intervention (nurse, midwife, clinician, lactation care provider, or peer), and where the intervention was delivered (office, hospital, home, video, telephone, or text).¹ Few of the studies described whether interventions addressed use of expressed or donor breast milk; no studies reported outcomes by whether breastfeeding was at the breast vs. through use of expressed or donor breast milk.

All but one of the 90 trials reported prevalence of breastfeeding at some time point after the intervention, although the number of studies reporting at a given time point (initiation, less than 3 months, 3 to 6 months, and 6 months) varied from 27 to 51 trials (N analyzed=10,622 to 17,580).¹ Based on pooled analyses evaluating followup up to 6 months, there was a statistically significant increased prevalence of any breastfeeding and exclusive breastfeeding in the intervention group at all time points, except for initiation of any breastfeeding. Effect sizes ranged from a risk ratio of 1.06 (95% [confidence interval] CI, 1.03 to 1.08; 47 trials; N=15,663) for any breastfeeding at less than 3 months to a risk ratio of 1.46 (95% CI, 1.20 to 1.78; 37 trials; N=14,398) for exclusive breastfeeding at 6 months. Overall, at any given time point, risk ratios for exclusive breastfeeding were higher than they were for any breastfeeding, indicating that interventions may have a greater role in increasing exclusive breastfeeding. Generally, intervention effectiveness did not vary by any participant or intervention characteristic except in exploratory analyses that suggested that interventions may be more effective in women who were not initially intending to breastfeed and if they take place over multiple periods (i.e., prenatal, peripartum, or postpartum).

A much smaller number of the included trials reported on the direct impact of breastfeeding support intervention and health outcomes in infants (10 trials; n=6,592) or their breastfeeding parent (9 trials; n=2,334). Generally, the number of participants analyzed for each of these outcomes was much smaller, making it difficult to determine if any differences between control and intervention groups existed, since many of these analyses were underpowered. However, the association between breastfeeding and improved health outcomes in infants and their breastfeeding parent has been well established by observational studies. Recent reviews of these studies have found that a lower risk for acute otitis media,²⁷ asthma,²⁸ elevated blood pressure in early childhood (ages 6 to 7 years),²⁹ childhood leukemia,³⁰ type 1 diabetes,³¹ hospitalizations due to diarrhea³² and lower respiratory tract infection,³³ dental caries,³⁴ overweight and obesity,³⁵ and sudden infant death syndrome³⁶ was associated with infants who were breastfed (or consumed breast milk) compared with those who were never breastfed (or consumed breast milk). Higher all-cause mortality risk in children has also been associated with never being breastfed.³⁷ Although the evidence on improved health outcomes in persons who breastfeed is less robust, breastfeeding has been associated with reduced risk for breast and epithelial ovarian cancer,^38,39 hypertension,³⁹ and type 2 diabetes.^39,40

Harms of Behavioral Counseling Interventions

Few trials (7 trials; n=1,404) reported on harms of behavioral counseling interventions to support breastfeeding. Most reported no adverse events related to the intervention, although one trial reported greater feelings of anxiety and decreased confidence among participants in the intervention group. Twenty-two trials (n=13,815) reported that participants in the intervention group experienced fewer breastfeeding problems or difficulties (such as mastitis or sore nipples or breasts), pointing to another potential benefit of these interventions.

See Table 2 for research needs and gaps related to behavioral counseling interventions to support breastfeeding in pregnant and postpartum persons.

Several organizations, including the American Academy of Pediatrics⁴¹, the American College of Obstetricians and Gynecologists⁴², the American Academy of Family Physicians⁴³, and the 2020–2025 Dietary Guidelines for Americans⁴⁴ recommend exclusive breastfeeding for approximately the first 6 months, followed by introduction of complementary foods, and continued breastfeeding as mutually desired by mother and infant. Generally, these organizations also state that breastfeeding beyond the first^43,44 or second^41,42 year offers health benefits to both the breastfeeding parent and the child.

1. Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 242. Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication No. 24-05316-EF-1.
2. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007(153):1-186.
3. Centers for Disease Control and Prevention. Rates of Any and Exclusive Breastfeeding by Socio-Demographics Among Children Born in 2021. 2022. Accessed September 23, 2024. https://www.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem-2021.html
4. Centers for Disease Control and Prevention. Breastfeeding Among U.S. Children Born 2014–2021, CDC National Immunization Survey–Child. 2024. Accessed September 23, 2024. https://www.cdc.gov/breastfeeding/data/nis_data/results.html
5. Otarola L, Sly J, Manigat T, et al. Understanding black matriarchal role models in the U.S. Attitudes and beliefs about breastfeeding. Breastfeed Med. 2021;16(6):501-505.
6. Gyamfi A, O'Neill B, Henderson WA, Lucas R. Black/African American breastfeeding experience: cultural, sociological, and health dimensions through an equity lens. Breastfeed Med. 2021;16(2):103-111.
7. Gross TT, Powell R, Anderson AK, Hall J, Davis M, Hilyard K. WIC peer counselors' perceptions of breastfeeding in African American women with lower incomes. J Hum Lact. 2015;31(1):99-110.
8. Dauphin C, Clark N, Cadzow R, et al. #BlackBreastsMatter: process evaluation of recruitment and engagement of pregnant African American women for a social media intervention study to increase breastfeeding. J Med Internet Res. 2020;22(8):e16239.
9. Barriers to breastfeeding: supporting initiation and continuation of breastfeeding: ACOG Committee Opinion, number 821. Obstet Gynecol. 2021;137(2):e54-e62.
10. Mangun K, Parcell LM. The Pet Milk Company "Happy Family" advertising campaign: a groundbreaking appeal to the Negro market of the 1950s. Journal Hist. 2014;40:70-84.
11. Hamner HC, Beauregard JL, Li R, Nelson JM, Perrine CG. Meeting breastfeeding intentions differ by race/ethnicity, Infant and Toddler Feeding Practices Study‐2. Matern Child Nutr. 2021;17(2):1-10.
12. Rhodes EC, Damio G, LaPlant HW, et al. Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program. Int J Equity Health. 2021;20(1):128.
13. Bunik M, Clark L, Zimmer LM, et al. Early infant feeding decisions in low-income Latinas. Breastfeed Med. 2006;1(4):225-235.
14. Bartkowski JP, Kohler J, Xu X, et al. Racial differences in breastfeeding on the Mississippi Gulf Coast: making sense of a promotion-prevalence paradox with cross-sectional data. Healthcare (Basel). 2022;10(12):2444.
15. Griswold MK, Crawford SL, Perry DJ, et al. Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black Women's Health Study. J Racial Ethn Health Disparities. 2018;5(6):1180-1191.
16. Lind JN, Perrine CG, Li R, Scanlon KS, Grummer-Strawn LM; Centers for Disease Control and Prevention. Racial disparities in access to maternity care practices that support breastfeeding - United States, 2011. MMWR Morb Mortal Wkly Rep. 2014;63(33):725-728.
17. Jones KM, Power ML, Queenan JT, Schulkin J. Racial and ethnic disparities in breastfeeding. Breastfeed Med. 2015;10(4):186-196.
18. Louis-Jacques A, Deubel TF, Taylor M, Stuebe AM. Racial and ethnic disparities in U.S. breastfeeding and implications for maternal and child health outcomes. Semin Perinatol. 2017;41(5):299-307.
19. Robinson K, Fial A, Hanson L. Racism, bias, and discrimination as modifiable barriers to breastfeeding for African American women: a scoping review of the literature. J Midwifery Womens Health. 2019;64(6):734-742.
20. Johnson AM, Kirk R, Rooks AJ, Muzik M. Enhancing breastfeeding through healthcare support: results from a focus group study of African American mothers. Matern Child Health J. 2016;20(Suppl 1):92-102.
21. Kulka TR, Jensen E, McLaurin S, et al. Community based participatory research of breastfeeding disparities in African American women. Infant Child Adolesc Nutr. 2011;3(4):233-239.
22. Thomas EV. "Why even bother; they are not going to do it?" The structural roots of racism and discrimination in lactation care. Qual Health Res. 2018;28(7):1050-1064.
23. Vedam S, Stoll K, Taiwo TK, et al; GVtM-US Steering Council. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77.
24. U.S. Preventive Services Task Force. Procedure Manual. Accessed September 24, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
25. U.S. Centers for Medicare & Medicaid Services. Health Benefits & Coverage: Breastfeeding Benefits. Accessed October 2, 2024. https://www.healthcare.gov/coverage/breast-feeding-benefits/
26. U.S. Department of Labor. Fact Sheet #73: FLSA Protections for Employees to Pump Breast Milk at Work. Accessed October 2, 2024. https://www.dol.gov/agencies/whd/fact-sheets/73-flsa-break-time-nursing-mothers
27. Bowatte G, Tham R, Allen KJ, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):85-95.
28. Güngör D, Nadaud P, LaPergola CC, et al. Infant milk-feeding practices and food allergies, allergic rhinitis, atopic dermatitis, and asthma throughout the life span: a systematic review. Am J Clin Nutr. 2019;109(Suppl 7):772s-799s.
29. Güngör D, Nadaud P, Dreibelbis C, et al. Never Versus Ever Feeding Human Milk and Cardiovascular Disease Outcomes in Offspring: A Systematic Review. Alexandria, VA: U.S. Department of Agriculture; April 2019.
30. Güngör D, Nadaud P, Dreibelbis C, et al. Infant milk-feeding practices and childhood leukemia: a systematic review. Am J Clin Nutr. 2019;109(Suppl 7):757s-771s.
31. Güngör D, Nadaud P, LaPergola CC, et al. Infant milk-feeding practices and diabetes outcomes in offspring: a systematic review. Am J Clin Nutr. 2019;109(Suppl 7):817s-837s.
32. Lamberti LM, Fischer Walker CL, Noiman A, Victora C, Black RE. Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health. 2011;11(Suppl 3):S15.
33. Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Arch Pediatr Adolesc Med. 2003;157(3):237-243.
34. Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and bottle feeding as risk factors for dental caries: a systematic review and meta-analysis. PLoS One. 2015;10(11):e0142922.
35. Dewey KG, Güngör D, Donovan SM, et al. Breastfeeding and risk of overweight in childhood and beyond: a systematic review with emphasis on sibling-pair and intervention studies. Am J Clin Nutr. 2021;114(5):1774-1790.
36. Alm B, Wennergren G, Möllborg P, Lagercrantz H. Breastfeeding and dummy use have a protective effect on sudden infant death syndrome. Acta Paediatr. 2016;105(1):31-38.
37. Sankar MJ, Sinha B, Chowdhury R, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):3-13.
38. Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96-113.
39. Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Report No.: 18-EHC014-EF. Rockville, MD; Agency for Healthcare Research and Quality: July 2018.
40. Aune D, Norat T, Romundstad P, Vatten LJ. Breastfeeding and the maternal risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr Metab Cardiovasc Dis. 2014;24(2):107-115.
41. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.
42. ACOG Committee Opinion No. 756: optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2018;132(4):e187-e196.
43. American Academy of Family Physicians. Breastfeeding (Policy Statement). Accessed September 24, 2024. https://www.aafp.org/about/policies/all/breastfeeding-policy-statement.html
44. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th ed. https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. The USPSTF often needs additional evidence to create the strongest recommendations for everyone and especially for persons with the greatest burden of disease. This table summarizes key bodies of evidence needed for the USPSTF to make recommendations for behavioral counseling interventions to support breastfeeding. For each of the evidence gaps listed below, research must assess intervention effectiveness among different demographic characteristics such as race and ethnicity, geographic location, socioeconomic level, and working status.