REVIEW

CURRENT
OPINION Breastfeeding: uncovering barriers and
offering solutions
Stephanie Sayres a and Lisa Visentin b

Purpose of review
The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend
exclusive breastfeeding for 6 months after an infant is born. Although the recommendations are well
known, mothers face barriers that make breastfeeding difficult. This article reviews the recent literature on
barriers to breastfeeding as well as strategies for pediatricians to use to help women overcome them.
Recent findings
The mode of delivery, mother’s socioeconomic status, return to work, and prenatal breastfeeding education
have been reported as factors that influence breastfeeding. Family-centered models for breastfeeding, peer
support groups, and technology have been studied as potential ways to help women meet their
breastfeeding goals.
Summary
Pediatricians are the first providers to care for babies after hospital discharge and are likely the first
doctors that mothers see after childbirth. These early visits create opportunities for pediatricians to learn
about the barriers that their patients face and open the doors to addressing these barriers.
Keywords
barriers, breastfeeding, general pediatrics, infant feeding, parenting

INTRODUCTION lower rates of asthma, obesity, gastrointestinal tract

The American Academy of Pediatrics (AAP) and the
Centers for Disease Control and Prevention (CDC)
recommend exclusive breastfeeding for the first
6 months of a baby’s life, and then a combination
of breastfeeding with other food introduction until
the baby is at least 1 year old [1]. The Ten Steps to
Successful Breastfeeding are a set of guidelines devel-
oped by experts at the WHO and the United Nations
International Children’s Emergency Fund that con-
sists of steps hospitals can take to encourage breast-
feeding [1]. With these recommendations and
guidelines in place, the Healthy People targets for
the year 2020 include a breastfeeding initiation rate
of 81.9%, with 60.6% continuation at 6 months and
34.1% at 1 year in the United States [2]. The most
recent data from the CDC tell us that 81.1% of
babies born in 2013 initiated breastfeeding; 51.8%
continued breastfeeding through 6 months, and
30.7% continued throughout the 1st year. Although
the initiation rate reflects an increase from 73% in
2004, the CDC also reports that 60% of mothers stop
breastfeeding before they want to [2].
Breastfeeding has numerous benefits for both
mother and baby. Babies who are breastfed have
infections, necrotizing enterocolitis, type 2 diabetes,
ear infections, respiratory infections, and sudden
infant death syndrome. For mothers that breastfeed,
the risk of heart disease, type 2 diabetes, and certain
cancers such as ovarian and breast cancer are low-
ered [3,4].
Once a mother and child leave the hospital, the
first provider seen is most commonly the general
pediatrician. According to the AAP recommenda-
tions, an infant is examined at least seven times
during the 1st year of life [5]. This gives pediatricians
multiple windows of opportunity to inquire about
infant feeding, offer recommendations, and provide
solutions.
a
Pediatrics Department at Cohen Children’s Medical Center, New Hyde
Park and bPeconic Pediatrics and Breastfeeding Medicine, Riverhead,
New York, USA
Correspondence to Stephanie Sayres, DO, Department of Pediatrics at
Cohen Children’s Medical Center, 269-01 76th Ave., New Hyde Park,
New York, USA. Tel: +1 718 470 3204; e-mail: ssayres@northwell.edu
Curr Opin Pediatr 2018, 30:591–596
DOI:10.1097/MOP.0000000000000647

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Office pediatrics
KEY POINTS
! The current breastfeeding rate in the United States falls
short of the Healthy People 2020 Goals.
! Mothers face a number of barriers to breastfeeding,
which include delivery via cesarean section, low
socioeconomic status, the need to return to work, and
poor breastfeeding education.
! General pediatricians can work closely with their
patients, the patients’ families, obstetricians, and their
communities to help mothers continue to breastfeed
by providing family and peer support, using mobile
devices, and making better prenatal
education available.
Our review of the current literature compiles the
most recent studies that discuss barriers to breast-
feeding and solutions that have been offered.
BARRIERS TO BREASTFEEDING
General pediatricians are the providers that spend
the most time with a mother and infant during the
1st year of life. During visits, the provider not only
examines the baby and ensures the baby’s health,
but also has the opportunity to learn about the
family, the mother’s feeding goals, and the culture
in which the child is being raised. In learning about
the patient, the pediatrician may uncover barriers to
exclusive breastfeeding and can work with the
mother and family to address and overcome these
obstacles. Barriers generally come in two broad cat-
egories: those that can be externally influenced and
those intrinsic factors that are out of the control of
the mother and pediatrician. It is important that
pediatricians understand that there is power in
knowledge of all of these barriers, despite the inabil-
ity to modify the preexisting risk factors.
One of the risk factors studied throughout mul-
tiple populations is the mode of delivery; women
who give birth via cesarean section or assisted vagi-
nal delivery are less likely to exclusively breastfeed.
Fernandez et al. studied factors associated with
exclusive breastfeeding cessation in a population
of 529 mothers who gave birth at a baby-friendly
hospital in Spain. Of mothers who gave birth via
cesarean section, 51% were exclusively breastfeed-
ing at 3 months and 25% at 6 months, versus 67.6
and 33% of mothers who gave birth vaginally at 3
and 6 months, respectively [6 ]. A Swedish study
&&
had a shorter follow-up period of 2 months, but
found similar results. Vaginal delivery was associ-
ated with a 79.8% rate of exclusive breastfeeding,
whereas the cesarean section rate was 58.1% [7]. A
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large Australian study of 17 564 mothers found that
24% of women who had a cesarean section and
11.4% of women who had assisted vaginal deliveries
versus 64.6% of women who had a normal vaginal
delivery were exclusively breastfeeding at the time
of follow up, between 1 and 4 weeks [8 ]. These three
&
studies specifically examined determinants of
breastfeeding cessation and highlighted the mode
of delivery as a major factor for nonexclusive breast-
feeding. Despite inability to control for the method
of delivery, pediatricians should obtain this infor-
mation in postpartum visits to better understand
which mothers might be at risk for not meeting
their goals.
Return to work was another common theme
amongst studies that examined barriers to breast-
feeding. Each country has its own regulations for
maternity and paternity leave. In the United States,
federal law permits women to take 3 months of
maternity leave. Some states have expanded upon
this law, allowing for a longer leave; however, in
many states it is up to the company’s discretion
whether the leave is paid. Mothers in the United
States often return to work earlier so that they can
continue to provide financially for their families.
This can leave the mother with less time to breast-
feed. In Spain, where women are given 16 weeks
paid maternity leave, a significant difference was
found in exclusive breastfeeding rates between
women who did and did not return to work at
6 months; 18.4% of mothers who were working at
6 months versus 49.1% who were not working con-
tinued to exclusively breastfeed during this time
[6 ]. Snyder et al. [9] found that women who worked
&&
in the service industry were less likely to meet their
breastfeeding goals and felt less support from their
supervisors than those in a professional industry
[10]. Pediatricians can help with the transition back
to work by talking to mothers about these rights so
they feel empowered to ask for break time, pump at
work, and store their milk appropriately.
Yourkavitch et al. [11 ] weighed poverty and
&&
neighborhood disadvantage on rates of breastfeed-
ing upon hospital discharge. A set of neighborhoods
was assigned an ‘affluence’ or ‘disadvantage’ index
that incorporated income, occupation, education,
home values, and public assistance. The authors
found that most of the women who exclusively
breastfed or provided ‘some breast milk’ at the time
of discharge were from areas with a higher ‘afflu-
ence’ index and were more commonly married or
separated, US born, employed, Hispanic or white,
and college-educated [11 ]. The study found a sig-
&&
nificant positive association between affluence and
breastfeeding and a negative, though not statisti-
cally significant, relationship between disadvantage
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 Uncovering barriers and offering solutions Sayres and Visentin
and breastfeeding [11 ]. This study was striking in
&&
that it evaluated breastfeeding rates only at the time
of discharge; this tells us that the 24–72 h that a
baby spends in the hospital, and likely the time
leading up to birth, are extremely important in
determining who goes home breastfeeding.
Breastfeeding education in the prenatal period
can positively influence breastfeeding rates. Many
women prefer to have information available prena-
tally, when they have more time to review it [12].
Zielinska and Hamulka [13 ] studied 446 mothers in
&
Poland with infants aged 0–6 months and found
that 57% of infants were exclusively breastfed, and
80% of infants were breastfed at all. The highest
rates of exclusive breastfeeding existed amongst
women aged 26–30, with prepregnancy intent to
breastfeed, and with very good breastfeeding knowl-
edge [13 ]. This study found that mothers who
&
assessed themselves to have inadequate knowledge
of breastfeeding had three times lower odds of exclu-
sively breastfeeding [13 ].
&
Barriers to breastfeeding are many, including
factors that may be out of one’s control such as
the mode of delivery and socioeconomic back-
ground; however, they also include elements that
pediatricians can influence, such as breastfeeding
education and assistance with returning to work. In
knowing what the mother’s background and inten-
tions are, we can better educate our patients and
help them provide what is best for their baby.
FAMILY-CENTERED BREASTFEEDING
Traditionally, breastfeeding has been thought of as
exclusively a mother’s job, as she is the natural
source of breast milk. This tends to place a burden
on the mother. Some solutions have been posed to
help more evenly distribute this responsibility. It is
helpful for pediatricians to learn the strength of
each mother’s support system, so they can better
care for their patients.
One reason mothers may feel alone when it
comes to breastfeeding is that family members often
do not know how to get involved. Ke et al. [14 ]
&&
aimed to promote breastfeeding education for entire
Chinese families to better support the mother.
The women in their study lived with other family
members, mainly fathers and grandmothers, who
attended prenatal breastfeeding lectures and post-
partum home visits with a breastfeeding and lacta-
tion education specialist [14 ]. Although the
&&
authors’ results did not reach statistical significance,
the experimental group was more likely to exclu-
sively breastfeed during the first 6 months and
family support was perceived to be higher [14 ].
&&
The study size was small, and education only began
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in the third trimester, but it highlights the impor-
tance of incorporating family support into breast-
feeding.
Men often times do not view breastfeeding as
something they can take part in, but pediatricians
can help teach how they can help. Abbass-Dick and
Dennis [12] included fathers in discussions about
breastfeeding in the hospital. They provided resour-
ces that contained images of fathers, websites with
information on coparenting and breastfeeding, a
workbook, DVD, and supportive emails to fathers
and mothers alike [12]. In doing this, a significant
difference was found in the number of mothers
breastfeeding at 12 weeks, self-efficacy scores
reported by fathers at 6 weeks, the percentage of
partners involved with breastfeeding, and satisfac-
tion with partners’ roles in breastfeeding [12].
Fathers have found that distinct roles arise when
they are included in the breastfeeding discussion
[15]. They assist in decision-making, take on respon-
sibility for family function, and provide emotional
support [14 ]. Men reported feeling a need to help
&&
with household chores, spend time with the baby,
change diapers, and ensure the mother was comfort-
able while feeding [15]. These examples of how
males and partners can help should be shared with
families to demonstrate ways in which the mother
can be supported.
Pediatricians can help give a greater voice to the
father. Fathers should be encouraged to participate
in prenatal care and to join infant well visits. Pedia-
tricians’ offices can have breastfeeding education
material that specifically includes fathers. Some of
the previously mentioned articles touch on pater-
nity leave, which not only entitles fathers to spend
time with the child but also allows them to help the
mother. Ultimately, the home environment and the
type of support system the mother has is an impor-
tant piece of information for the pediatrician to
have when discussing infant feeding at well child
visits.
PEER SUPPORT GROUPS
Breastfeeding demands time and energy, and many
mothers feel they are going through the process
alone. In addition to help from the family, recent
studies have examined different types of peer sup-
port groups, including ‘support coaches’, visiting
‘family support workers’, and ‘drop-in centers’
(e.g., Baby Cafes) with the aim of promoting a
supportive method for nursing mothers.
One private practice obstetrician’s office trained
women with personal breastfeeding experience to
be ‘support coaches’ that provided pre and postpar-
tum guidance [16 ]. They made five home visits and
&
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Office pediatrics
ten phone calls throughout the 1st year of life so
that the mothers had contact with their coaches at
least once a month [16 ]. The authors found that
&
100% of women breastfed at some point during the
1st year, 85% were still breastfeeding at 6 months,
and 64.6% continued breastfeeding for the entire
year [16 ]. Most of these women were white, mar-
&
ried, 30–34 years old and had originally planned to
breastfeed [16 ]. Although this study neither exam-
&
ine exclusivity nor have a study population repre-
sentative of the United States population, the study
reported rates higher than the national average. This
type of frequent one-on-one support may help
mothers keep their goals aligned, discuss issues
and roadblocks, and obtain support and advice.
On the other hand, McGinnis et al. [17 ] dis-
&
cussed a cohort of 3521 pregnant mothers who were
at risk of having poor child health and developmen-
tal outcomes given some of the barriers described
above. Healthy Families New York, a home visita-
tion program, made biweekly visits prenatally and
weekly visits postnatally until 6 months of age. They
provided information on the postnatal period with
about one-third of the visits included discussions on
breastfeeding [17 ]. This study found that 71.5% of
&
mothers initiated breastfeeding, 65% continued
breastfeeding for the 1st month, and 21.6% contin-
ued to breastfeed for 6 months [17 ]. Those who
&
were younger than 18 years old, had not graduated
high school, and were unmarried had the lowest
rates [17 ]. Although the rates of breastfeeding in
&
this population were lower than the national aver-
age, the likelihood of breastfeeding increased in
concert with the number of breastfeeding discus-
sions and women in this program had higher rates
than those without support [17 ].
&
In Australia, ‘drop-in centers’ were provided for
women who were breastfeeding [18]. Normally
when a mother gives birth in Australia, she is enti-
tled to a home visit by a skilled clinician, followed by
subsequent office visits. In addition, centers were
established with the intent of providing a safe,
private place for women to connect with other
breastfeeding mothers and nurses to discuss con-
cerns in a private setting [18]. Overall, few women
attended the sessions and as such, there was no
difference in outcomes [18]. This particular study
may have had poor turnout, but this intervention is
not the first of its kind. Similar drop-in centers, such
as ‘Baby Cafes’, have been established throughout
the world and have been studied in areas such as
New York, Massachusetts, and the United Kingdom
[19–21]. Previous literature has cited strengths of
these programs including social support for families,
ability to have discussions with a breastfeeding
professional, gaining confidence in hearing others’
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successes, similarly to those mentioned in the afore-
mentioned study in Australia [19–21]. A shared
limitation cited by all of the authors is that these
locations might not be easily accessible to many,
thus drastically limiting the patient population to
which these centers can help [18–21]. Pediatricians
can point their patients in the right direction and be
knowledgeable about ways to get them there.
Women respond well to one-on-one support,
especially from a professional that can listen to their
difficulties and provide advice. There are many
topics to cover during a well child visit and breast-
feeding should be the major one addressed. If
significant concerns arise, additional visits may be
helpful and pediatricians ought to be aware of the
resources in the community.
MOBILE PROGRAMS
Pregnant women in this generation have grown up
with technology that was not previously available.
The majority of women of childbearing age in the
United States have a cell phone and many practices
around the world are using this technology to
improve communication between practitioners and
patients.
With the advent of cell phones and text messag-
ing, new doors are opening to communication.
Harari et al. [22 ] looked at the effect of breastfeed-
&&
ing-promoting text messages on rates of exclusive
breastfeeding and goal-meeting at 2 weeks. The
messages were sent to 52 women in their study,
were personalized, addressed barriers and beliefs
about breastfeeding, and were sent prenatally and
immediately postpartum [22 ]. Depending on the
&&
responses by mothers a phone call or in-person visit
was sometimes made [22 ]. The researchers found
&&
that 50% of mothers receiving the text messages
versus 31.8% of mothers in the control group con-
tinued to exclusively breastfeed at 2 weeks [22 ]. In
&&
addition, these mothers more often met their goals
[22 ]. This was a small sample and reported overall
&&
low rates of breastfeeding; however, the positive
effect found shows that this may be an area worth
further exploring. Developing countries are also
beginning to utilize cell phones in this regard. A
promising study out of Myanmar, where exclusive
breastfeeding at 6 months is 24%, is providing
breastfeeding support three times a week via text
message [23]. The messages are sent with respect
to gestational age and include ways to address
obstacles, words of support, and information about
health conditions previously thought to be contra-
indications to breastfeeding [23]. The researchers are
following with monthly phone calls and results are
expected to be available soon.
Volume 30 ! Number 4 ! August 2018
 Uncovering barriers and offering solutions Sayres and Visentin
Another way in which technology is being used
to encourage breastfeeding is by use of mobile appli-
cations (apps). There are breastfeeding apps in
which mothers can watch videos of breastfeeding,
view images of different positions, determine if their
medications cross over into breast milk, and log
their feedings. One such app, Baby Connect, is
a diary through which women can track their
thoughts, breastfeeding patterns, and experiences
[24 ]. In a study using this app, 35 women were
&
instructed to track each feeding and each expression
of milk along with any thoughts, frustrations, or
successes that they met [24 ]. In the first few weeks
&
after birth, multiple feelings arose including anxi-
ety, frustration, uncertainty, and surprise [24 ].
&
Many moms reported physical and mental exhaus-
tion, feeling that their sleep and care for themselves
suffered [20]. The evaluation of the app in this study
alone was limited – the sample size was small and
the women did not always successfully record each
feeding; however, some mothers may prefer track-
ing through an app versus on paper [24 ].
&
Throughout the world, people are realizing the
extent and capability of technology as an adjunct to
healthcare. Whether it be text message reminders
providing words of encouragement, an app-based
diary to record thoughts, or breastfeeding trouble-
shooting videos, cell phones are gaining popularity
in terms of breastfeeding support. Pediatricians can
do their best to learn about the different resources
available and provide their patients with the links.
When asking about feeding, documentation of
thoughts and questions would prevent recall bias
and may more effectively help the pediatrician
address issues. For those technologically-inclined
mothers an app-based diary would be a useful way
to document.
CONCLUSION
Despite recommendations from the AAP and CDC,
we are falling short of these goals locally and glob-
ally. We know that multiple barriers exist to breast-
feeding, some of which we can control and others
we cannot. Early cessation of breastfeeding has been
attributed to cesarean birth, returning to work, a
lack of knowledge about breastfeeding, low socio-
economic status, and inadequate support. Pediatri-
cians can work with patients to help overcome
modifiable barriers, along with keeping in mind
those barriers not easily managed to help identify
their at-risk patients.
A family-centered approach, especially one that
focuses on breastfeeding education for the partner,
has been shown to increase rates of breastfeeding.
Pediatricians can encourage mothers to bring the
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father or other family member to visits for discus-
sion and education. They also can collaborate with
obstetricians to educate the mother and family early
in pregnancy, perhaps during the first and second
trimester. Having informative material geared
toward men, including partners in the decision to
breastfeed, and coming up with ways for partners to
support the breastfeeding mothers are some ways
that pediatricians can help mothers meet their goal.
With respect to community support, pediatri-
cians can partner with nurses and home healthcare
providers or can train their own staff in making
home visits to check up on women after birth.
The first few days are often the most troublesome
for breastfeeding mothers, and they may have some
questions that cannot wait until the baby’s first visit
with the pediatrician. Pediatricians can ensure their
own comfort level with these discussions and can
work with lactation consultants in their area to
provide ample guidance at the baby’s visit. Moms
can also be pointed in the right direction for forums
where other mothers share and discuss their
thoughts and ideas. Technology can make a differ-
ence, too. For example, text messaging is a great,
simple way to communicate with patients and send
words of encouragement. In expanding the lines of
communication, patients may feel more comfort-
able discussing their own worries and problems. For
some women, app-based recording of breastfeeding
may be helpful; they can then bring their device
with them to each visit and recall the various emo-
tions they felt through each experience.
General pediatricians have great influence on
their patients and families. By utilizing these meth-
ods and keeping in mind the barriers that each
patient may be encountering, we hope that the
Healthy People 2020 breastfeeding goals will be met.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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& of special interest
&& of outstanding interest
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Unique concept of breastfeeding-promoting text messages that provide tips and
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Provides a useful tool in tracking breastfeeding thoughts and emotions.
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