Breastfeeding Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children: A Systematic Review

Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Interventions to support breastfeeding may help individuals and families initiate breastfeeding or breastfeed exclusively or for a prolonged period of time.

Objective

To systematically review the evidence on the benefits and harms of breastfeeding interventions to support the US Preventive Services Task Force in updating its 2016 recommendation.

Data Sources

Studies included in the previous review were reevaluated for inclusion and updated searches in MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and PsycINFO through June 3, 2024. Surveillance for new evidence in targeted publications through January 24, 2025.

Study Selection

Randomized clinical trials that evaluated a primary care-relevant intervention designed to support breastfeeding. Of 290 full-text articles reviewed, 90 met inclusion criteria.

Data Extraction and Synthesis

Independent critical appraisal of all provisionally included studies. Data were independently abstracted by one reviewer and confirmed by another.

Main Outcomes and Measures

Child and maternal health outcomes, prevalence, and duration of any and exclusive breastfeeding, and harms related to interventions.

Results

Ninety trials (N = 49 597) reported in 125 publications were included. The evidence represented individuals from diverse backgrounds and interventions that varied in timing, delivery, and duration. There was limited and mixed evidence on the effectiveness of breastfeeding support interventions on infant health outcomes (10 trials [n = 6592]) and maternal symptoms of anxiety, depression, and well-being (9 trials [n = 2334]). Pooled analyses indicated beneficial associations between breastfeeding support interventions and any or exclusive breastfeeding for up to and at 6 months (any breastfeeding: risk ratio, 1.13 [95% CI, 1.05-1.22]; 37 trials [n = 13 579] and exclusive breastfeeding: risk ratio, 1.46 [95% CI, 1.20-1.78]; 37 trials [n = 14 398]). There was no relationship between interventions and breastfeeding initiation or breastfeeding at 12 months.

Conclusions and Relevance

The updated evidence confirms that breastfeeding support interventions can increase the prevalence of any or exclusive breastfeeding up to and at 6 months. Future efforts should focus on how to best provide this support consistently for all individuals making feeding decisions for their infants.

Prenatal Breastfeeding Intention Is Consistently Associated with Breastfeeding Duration Among WIC-Participating Women

BACKGROUND/OBJECTIVE

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides breastfeeding support to participating women in low-income households. This study aimed to determine the relationships between prenatal maternal and household characteristics and breastfeeding duration, as well as whether these characteristics modify associations of prenatal breastfeeding intention with breastfeeding duration.

METHODS

This is a prospective cohort study of pregnant respondents to Los Angeles County (LAC), California, WIC surveys conducted between 2005 and 2020 (n = 1014). Associations of prenatal breastfeeding intention with duration (months) of any or fully breastfeeding, determined by WIC infant food package issuance, were assessed with linear regression models.

RESULTS

Most women reported the intention to breastfeed (67.7%) and perceived breastfeeding support during pregnancy from WIC and family/friends was associated with breastfeeding intention (both p-values < 0.0001). Stronger breastfeeding intention, lower maternal BMI, greater maternal age, greater maternal education, paternal cohabitation and employment, and greater breastfeeding support from family/friends were associated with longer duration of any or fully breastfeeding in multivariable models. Stronger breastfeeding intention was more strongly associated with longer duration of any breastfeeding among women with lower BMI (interaction p-value 0.03).

CONCLUSIONS

Breastfeeding support from WIC is an important contributor to stronger breastfeeding intention. Given the robust association of breastfeeding intention with breastfeeding duration, regardless of maternal and household characteristics, WIC breastfeeding support during pregnancy represents an important mechanism to improve breastfeeding outcomes in this population. Further research is needed to understand the directionality of associations between breastfeeding support and intention among WIC participants.

Experiences accessing nutritious foods and perceptions of nutritional support needs among pregnant and post-partum mothers with low income in the United States

Access to nutritious foods, a social determinant of health, contributes to disparities in maternal and infant health outcomes such as mental health, breastfeeding intensity and cardiometabolic risk. This study explored perceived nutrition access and intake among pregnant or post-partum women eligible for Medicaid. Qualitative, semistructured interviews were conducted with 18 women who were either currently pregnant (n = 4) or up to 12 months post-partum (n = 14) in 2021-2022. Mothers spoke English (n = 11) or Spanish (n = 7) and lived in the Texas Panhandle. Interviews were audio-recorded, transcribed, translated (Spanish to English) and verified. Two or more researchers coded each interview until consensus was reached using thematic analysis with ATLAS.ti software. The study revealed five drivers for nutrition access. (1) Social factors influenced nutrition; those with less support expressed limited ability to eat healthfully. (2) The Women, Infants and Children program was perceived as a helpful resource for some, while others faced challenges obtaining it. (3) Stress was bidirectionally related to unhealthy food choices, with food sometimes used as a coping mechanism. (4) Mothers prioritized their babies and others and had limited ability and time to prepare healthy meals. (5) Most participants felt they received inadequate nutrition guidance from their healthcare providers. Participants provided positive responses to a proposed nutritious home-delivered meal intervention. Low-income women may experience nutritional challenges specific to this life stage. Interventions that reduce stress and burden of household tasks (e.g. cooking) and improve education and access to nutritious foods may improve mothers' ability to consume nutritious foods.

Awareness and Support of Responsive Bottle Feeding Among WIC Counselors and Caregivers: A Formative Qualitative Study

OBJECTIVE

To understand the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) counselor experiences discussing responsive bottle feeding during counseling and WIC participants' knowledge, understanding, and use of responsive bottle feeding.

METHODS

Qualitative descriptive, semistructured interviews with 23 participants (8 WIC counselors and 15 WIC participants) were conducted online via Zoom. The WIC counselors and mothers of WIC-enrolled bottle-fed infants were recruited through a network of WIC clinics in North Carolina. Interviews were recorded, transcribed, and collaboratively analyzed using content analysis.

RESULTS

The WIC participants received responsive infant feeding support from WIC counselors but often in the context of breastfeeding. WIC counselors provided valuable support for families but were challenged by limited training on responsive bottle feeding, balancing promoting breastfeeding with supporting mothers' feeding decisions, and time constraints.

CONCLUSIONS AND IMPLICATIONS

Findings provide preliminary support for the need to develop and pilot an intervention focused on promoting responsive feeding for parents of bottle-fed infants.

Early introduction of complementary foods/drinks and milk feeding type in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Infants younger than 4 months are not ready for complementary foods/drinks (any solid or liquid other than breast milk or infant formula). Almost half of US infants participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which provides nutrition education and support to low-income families. We describe the prevalence of early introduction (<4 months) of complementary foods/drinks and examine the association of milk feeding type (fully breastfed, partially breastfed or fully formula fed) with early introduction of complementary foods/drinks. We used data from 3310 families in the longitudinal WIC Infant and Toddler Feeding Practices Study-2. We described the prevalence of early introduction of complementary foods/drinks and modeled the association of milk feeding type at Month 1 with early introduction of complementary foods/drinks using multi-variable logistic regression. Thirty-eight percent of infants were introduced early to complementary foods/drinks (<4 months). In adjusted models, infants who were fully formula fed or partially breastfed at Month 1 were 75% and 57%, respectively, more likely to be introduced early to complementary foods/drinks compared with fully breastfed infants. Almost two in five infants were given complementary foods/drinks early. Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks. There are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health.

Global lessons for strengthening breastfeeding as a key pillar of food security

Breastfeeding is identified as a central pillar of food security by the World Health Organization, however globally significant challenges remain in achieving breastfeeding targets for early initiation, exclusive breastfeeding for 6 months, and continued breastfeeding for 2 years and beyond. Inadequate support in health systems, poor maternity protections and workplace policies, and insufficient regulation of commercial milk formulas, among other barriers, continue to undermine this key pillar across nations. This paper highlights the central importance of breastfeeding for food security across diverse global settings by examining three case studies: Honduras, Pakistan and the USA. The cases highlight the complex layering and intersections of key challenges that threaten breastfeeding in the era of pandemics, the climate crisis, conflict and global inequality. Lessons drawn from these case studies, combined with additional insights, reinforce the importance of multisectorial collaboration to scale up investment in creating equitable, enabling environments for breastfeeding. These structural and systems approaches can successfully strengthen the breastfeeding ecosystem to ensure greater first food system resilience in the face of global crises, which compound maternal and infant vulnerabilities. Additionally, the cases add urgency for greater attention to prioritizing breastfeeding and incorporating IYCF-E protocols into disaster preparedness and management into the policy agenda, as well as ensuring that first food security is considered in energy policy. An integrated approach to policy change is necessary to recognize and strengthen breastfeeding as a pivotal part of ensuring food security across the globe.