Lactation is a robust, resilient and reliable survival mechanism, one critical to evolutionary success. Breastmilk is the bridge between the womb and the world, directing all postnatal growth. Optimised by evolution, it is necessary for unsurpassed infant development. Yet pressures stemming from the social and cultural status of breastfeeding, and women’s varying circumstances, often present barriers to breastfeeding successfully over the duration that is recommended for child and maternal health. Industrialisation, lack of medical knowledge and the changing roles of women within society have resulted in population-wide shifts away from breast milk towards commercial products. These shifts are contributing to epidemics of previously rare diseases, many of which are transmitted between generations.
However, growing awareness of the effects of different feeding modes on baby and mother has shifted the focus back towards breast milk feeding – and specifically exclusive breastfeeding from birth. Feeding modes of infants and young children affect their nutritional status, their survival, and their long-term health. Breastmilk provides a natural, complete food for growth and development during the first six months of life. It also continues to provide a substantial proportion of an infant’s nutritional needs into the second year of life , . Breastmilk supports sensory and cognitive development, safeguards against infections and chronic diseases, reduces infant morbidity and mortality, and speeds recovery from illness (see chapters 2, 4, 5, 7).
By creating gut dysbiosis and immune dysregulation, even small exposures to infant formula in the first days after birth can have long-lasting adverse effects on individual and population health. Infant formula induces measurable biological differences in growth and development, and increases the risk of many diseases (see chapter 4, 5, 16). Genomic, microbiomic and metabolic damage can result from both the absence of breastfeeding’s unique properties and components, and from the presence of formula’s very different heat-treated ingredients, metabolites, and contaminants. Further research across all body tissues and organs is needed to fully appreciate formula’s impact, past and present. To create the healthiest gut microbiome, breastfeeding needs to be exclusive from birth. Hospital staff can help by adopting and implementing evidence-based protocols that end unnecessary neonatal exposure to any food other than breast milk, and any other products affecting primary colonisation of the gut.
A normal part of the female reproductive cycle, breastfeeding also promotes the health and wellbeing of mothers, increasing their metabolic efficiency, and reducing the risk or severity of anaemia, depression, cardiovascular and other serious diseases. Women who do not breastfeed are at increased risk for lifelong and intergenerational maternal morbidity (see chapters 5, 14) as well as severe suffering, and even premature death, from uterine, ovarian and breast cancers (see chapters 1, 2, 3, 4, 5, 7, 10, 11, 13, 14, 17, 22).
Multi-country research evidence supports exclusive breastfeeding for around six months as optimal for infants, and continued breastfeeding, alongside food, for two years or longer , . Infant formula should be reserved for when suitable breast milk is unavailable, and only in the first year of life. The gradual adoption of quality complementary family foods and drinking water is important from around six months of age .
Health professionals should not be persuaded by industry marketing that formula is almost as good as breast milk. One is a living tissue, the other an unsterile industrial powder. The educational curricula of all healthcare providers should include up-to-date information about all aspects of infant feeding (including the problems of lactation and the risks and harms of infant formulas). Mothers need skilled ongoing support in establishing and maintaining breastfeeding (see chapter 11). Healthcare providers can help encourage the initiation of exclusive breastfeeding, and the continuation of appropriate breastfeeding, by providing ongoing assistance to families. Communities at large can share the information about infant feeding to help current and prospective parents make informed choices, and can also provide practical resources to enable them to implement their choices as safely as possible. To reduce potential harms, fact-based information on safer artificial feeding is needed, covering not only infant formula products, but also water sources and equipment. All parents and carers who are formula feeding infants need non-judgmental hands-on education about the process. This applies equally to those who choose to formula feed from birth, and many women who will be partly breastfeeding, or were unable to breastfeed, for whatever reason.
This infant feeding information can be extended to the workplace, so employers can ensure that all working mothers have comfortable safe areas to breastfeed or to pump breast milk for later use. Increased employer understanding of the importance of breast milk can also support paid maternity leave, or leave extensions for breastfeeding families (see chapters 2, 8, 9, 10). At every level, families and society will benefit from universal, timely and practical support that enables breast-feeding and minimises risks of bottle feeding.
Breastfeeding and breast milk need to be re-established as the desirable ‘gold standards’ for every newborn. As with blood banking, regulated human milk banks could be established (see chapter 17). Such banks would enable access to donor breast milk and help meet shortfalls if mothers are unable to supply their infants with their own breast milk. Factual advice about risks and benefits of wetnursing and informal milk sharing between women should be freely available without judgement of these valid parental choices (see chapter 12). Governments could reduce subsidies to infant formula companies, stop providing free infant formula to families, subsidise infant formula only when medically necessary for low income families, and investigate the pricing of infant formulas.
The economic impact of suboptimal breastfeeding on society is substantial . Compelling evidence suggests that national health services could significantly reduce costs through increased breastfeeding (see chapter 11). Infant formula is also expensive for families, societies and the environment. Under-utilising breast milk, a rich, natural resource, can further disadvantage many families. Consideration should be given to pragmatic strategies to encourage, enable and even reward breastfeeding for low income families, involving such families and those working with them, in consultations on the issue.
There are many challenges facing breastfeeding practices and promotion that aﬀect parents, governments, healthcare providers and advocates. All parents, whether they breast or bottle feed, should have the opportunity to learn how to do so as safely as possible, and have access to ongoing support networks. Parental autonomy and choice needs to be respected. However, parents also need to understand that health oﬃcials and professionals are legally obliged to inform society of the risks of not breastfeeding. Governmental agencies can also drive change by regulating infant formula production and marketing across all media, including social media, thereby providing some balance to the intensive marketing of infant formulas, feeding products and commercial baby foods.
To reiterate, independently funded research is warranted to further explore the lifelong and inter-generational eﬀects, across all human body organs and tissues, of both the absence of breast-feeding, and the presence of infant formulas. In addition, comparison studies on the outcomes of similar infant formulas would be welcome, so healthcare professionals and parents can, when necessary, assess the most appropriate brands for diﬀerent ages and purposes. Professional health organisations and associations have a role to play, too. By learning the outcomes of new research on infant feeding, they will be better equipped to address the deficit of knowledge often evident among healthcare providers. Additionally, interdisciplinary expert committees, featuring experienced breastfeeding counsellors and advocates, could be created to identify and propose strategies for addressing this deficit, and thus help maximise breastfeeding practices. As well, public health campaigns (see chapter 9) – similar to those that have proven eﬀective in promoting car restraints – could be additional ways to reduce unnecessary reliance on infant formula and encourage breastfeeding. Such breastfeeding promotion is not in-tended to distress anyone, but to prevent future needless harms, like other public health campaigns that trigger strong feelings among those already aﬀected.
Promoting WHO-recommended practices, where infants begin exclusive unrestricted breastfeeding immediately or within the first hour after birth, for around six months, is necessary to ensure the very best for maternal and child health . The World Health Organization (WHO) challenge in the 2025 Global Targets is increasing the rate of exclusive breastfeeding for the entire first 6 months up to at least 50% .
If this is to be achieved, funding needs to in-crease across all research disciplines, and sound networks of multidisciplinary researchers and well-supported community-based implementers need to work together. Breastfeeding is one of the health interventions with the highest return on investment, yet it continues to be relatively under-funded . For a century, Western governments have directly and indirectly subsidized the creation and spread of artificial feeding. Governments and decision-makers need to accept this WHO challenge, and move infant feeding higher on the political agenda. Investment needs to focus on capacity-building, systems-strengthening and enabling scale up of breastfeeding protection, support, and promotion programmes. It will take significant resources and structural changes (see chapter 10) to make it possible for all women to experience the joy of successful breastfeeding, and for all infants to have access to one of nature’s most valuable resources – breast milk.
Geelong (Australia), July 2018
 Summarised in chapter 3.9 of Milk Matters: Infant feeding and immune disorder (Milk Matters Pty Ltd, Geelong Australia 2015), ISBN: 9780959318319.
 WHO/UNICEF. Global Strategy for Infant and Young Child Feeding. World Health Organization; 2003
 World Health Organization. Exclusive breast feeding. Available at: http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/ [accessed December 2017]
 World Bank 2017, Investment Framework for Nutrition
 WHO. Global Targets 2025: http://www.who.int/nutrition/global-target-2025 (accessed January 2018)