nutrients

Editorial
Breastfeeding: Benefits to Infant and Mother
Robert Roghair

Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA;
robert-roghair@uiowa.edu

1. Introduction
The provision of human milk to newborn infants is one of the most effective ways to
reduce infant mortality. It has been estimated that nearly one million children’s lives could
be saved every year if all children were optimally breastfed [1]. Later in life, breastfed
children perform better on intelligence tests, are less likely to be overweight or obese and
less prone to diabetes [2]. Additional benefits are seen for birthing parents that provide
their own milk for their infants, including a reduction in the rates of many types of cancer
and decreased metabolic or cardiovascular disease [3,4]. Based on this evidence, the World
Health Organization (WHO) and the United Nations International Children’s Emergency
Fund (UNICEF) recommend that children initiate breastfeeding within the first hour of
birth and be exclusively breastfed for 6 months [5]. Unfortunately, more often than not,
infants receive non-human milk feedings before 6 months, and the provision of breast
milk often ends before the evidence-based target of at least 2 years. Beyond the global
imperative, disparities in breastfeeding rates within countries are striking and the variable
rate of breastfeeding across racial or ethnic groups and among individuals with different
socioeconomic statuses is an under-appreciated public health crisis.
This Special Issue “Breastfeeding: Benefits to Infant and Mother” was created to
develop evidence-based recommendations to increase the initiation and maintenance of
breastfeeding worldwide and further expand upon the health benefits of human milk across
diverse populations. This effort was successful with dozens of submissions subjected to
rigorous peer review, resulting in twelve outstanding contributions to the medical literature
in this important area. This editorial is intended to assist in the dissemination of this
newfound knowledge and awareness. In turn, it is hoped that caregivers and care providers
will be able to use this information to increase breastfeeding rates with positive impacts on
child and adult health.
Citation: Roghair, R. Breastfeeding:
Benefits to Infant and Mother. 2. Overview of Published Articles
Nutrients 2024, 16, 3251. https://
In the first contribution, Elgzar et al. utilized a retrospective, cross-sectional study
doi.org/10.3390/nu16193251
to examine the correlation between specific components of maternal ideation on exclu-
Received: 5 September 2024 sive breastfeeding (EBF) practices in Saudi Arabia (contribution 1). The reported rate of
Accepted: 20 September 2024 EBF at 6 months within this cohort (41%) is consistent with global rates, supporting the
Published: 26 September 2024 widespread applicability of the inquiries. The investigation found that each construct of
maternal ideation, including cognitive aspects (adequate knowledge and positive beliefs),
psychological dimensions (self-efficacy) and social dimensions (social influence, descriptive
and injective norms) were positive predictors of EBF, as were traditional factors, including
Copyright: © 2024 by the author.
maternal age, mode of delivery, occupation, and education.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
Olcina Simón et al. added another layer to the investigations of Elgzar et al. by
distributed under the terms and
delving into the role of cognitive and social dimensions in the persistence of colostrum
conditions of the Creative Commons avoidance among a majority of women in rural Ethiopia (contribution 2). In their cross-
Attribution (CC BY) license (https:// sectional study, only 3% of birthing parents started breastfeeding within an hour of birth
creativecommons.org/licenses/by/ and 56% practiced colostrum avoidance. Maternal educational level, living conditions,
4.0/). beliefs about the dangers of colostrum, and attendance at delivery by relatives rather than

Nutrients 2024, 16, 3251. https://doi.org/10.3390/nu16193251 https://www.mdpi.com/journal/nutrients

Nutrients 2024, 16, 3251 2 of 5

healthcare providers predicted colostrum avoidance. Unfortunately, inaccessible health

care contributed to limited or no prenatal care for most of the study participants, and
this likely contributed to the persistence of the traditional feeding practices despite their
association with increased infant mortality.
D’Adamo et al. published a related time-course investigation into the impact time since
delivery on the breast milk content of presepsin, a truncated, soluble form of CD14 that
has been used as a short-term biomarker for infection (contribution 3). Their prospective
study demonstrated reductions in presepsin with advancing gestational age at delivery and
elapsed time since delivery with relatively minor variation seen based on mode of delivery
or infant gestation. Notably, presepsin levels are markedly higher in colostrum than
transitional or mature milk, especially among preterm infants. While the impact of breast
milk presepsin on gut health and innate immunity is an area of ongoing investigation,
these data support the importance of colostrum feedings, especially in the context of
preterm delivery.
Although it is certainly not available to all families, donor human milk can be used
as a bridge towards the provision of maternal milk or as a substitute for maternal milk
during prolonged neonatal hospitalizations. In those situations, it is important for donor
milk to replicate the characteristics of maternal milk, and in this regard, the article by Vass
et al. examined the impact of demographic parameters on the fatty acid composition of
donor milk (contribution 4). While Holder pasteurization significantly reduced the content
of multiple medium and long chain fatty acids, there were significantly increased levels
of other fatty acids. Similar changes were seen, independent of pasteurization, based on
mode of delivery with smaller effects identified in relation to the gender of the donor’s
infant. While the absolute differences in fatty acid content were relatively small, it is clear
that further research is needed to define the effects of various pasteurization methods and
donor selection strategies on the composition of donated human milk.
Returning to the investigation of the correlates of early EBF success, Verea-Nuñez et al.
performed a cross-sectional study at a certified baby-friendly hospital in Spain with an
EBF rate during admission of 73% (contribution 5). While there was an overall positive
attitude towards breastfeeding, this was further enhanced by avoidance of pacifiers and the
provision of proper breastfeeding information from healthcare providers. Beyond having
a positive attitude, having a positive prior breastfeeding experience and an infant that
did not require specialized care was associated with increased likelihood of EBF through-
out the newborn admission. These results emphasize the importance of assisting initial
breastfeeding efforts for benefits that extend beyond the current dyad to subsequent births.
A second cross-sectional contribution from Saudi Arabia by Al-Thubaity et al. focused
on the determinants of maternal self-efficacy in the ability to breastfeed satisfactorily, a key
component of EBF ideation, especially when extra effort or persistence are needed in the
context of unexpected barriers or challenges (contribution 6). Reinforcing the findings of
Elgzar et al. and Verea-Nuñez et al., maternal self-efficacy over the first 6 months following
delivery was significantly influenced by a positive maternal attitude, as well as maternal
occupation, education, and past EBF experiences. It is worth emphasizing the study’s
important, but perhaps not surprising, finding that housewives were nearly twice as likely
to have a high EBF self-efficacy compared with working mothers, highlighting a need for
improved workplace and parental leave policies.
The prospective cohort study performed in southern Brazil by Bizon et al. further
emphasized the importance of a positive maternal attitude in the maintenance of EBF
by directly correlating the level of maternal satisfaction at 1 month with ongoing EBF
(contribution 7). In a multivariate model that corrected for maternal age, maternal edu-
cation, cohabitation, and early breastfeeding difficulties, mothers with a higher level of
satisfaction at 1 month were over four times as likely to be EBF at 6 months. While the
results emphasize the importance of early interventions to achieve maternal satisfaction,
the EBF rate at 6 months of only 24% among the cohort with high levels of early satisfaction
emphasizes the need for additional and ongoing assessments and interventions.
Nutrients 2024, 16, 3251 3 of 5

In a complimentary investigation, Vila-Candel and colleagues explored the importance

of health literacy in the prevention of breastfeeding abandonment (contribution 8). Their
multicenter study across four regions of Spain prospectively assessed breastfeeding attrition
over 6 months with rates gradually declining from 82% to 43%, consistent with global rates
of breastfeeding abandonment. Health literacy, along with mobilization during labor and
spontaneous labor were significantly associated with a reduced likelihood of breastfeeding
abandonment, perhaps a reflection of improved feelings of maternal self-efficacy or control
over the perinatal events. Interestingly, unlike the results of other studies within this Special
Issue, maternal education level or economic status did not predict either health literacy or
breastfeeding discontinuation, emphasizing the need for region-specific investigations.
With multiple studies demonstrating the importance of maternal support or educa-
tion in the development of maternal self-efficacy, Rodríguez-Gallego led a remarkable
randomized clinical trial that tested the effectiveness of a monthly midwife-led postpartum
support group on breastfeeding outcomes at 4 months among 382 women from Andalusia
(contribution 9). At 6 months, the rate of EBF was significantly higher in the intervention
arm, and this appeared to be mediated by an increase in perceived self-efficacy. In a sec-
ond contribution from the same interventional study, women in the postpartum support
group also had significantly reduced Edinburgh Postnatal Depression Scale scores at 4
months (contribution 10). At both 2 months and 4 months, higher depression scores were
significantly associated with reduced EBF rates. Beyond the correlation with EBF rates,
the mitigation of maternal depression through enhanced support group participation has
implications for the long-term health of both mother and child.
Continuing the shift towards long-term outcomes, Melov et al. investigated the
association of prior breastfeeding with subsequent maternal health (contribution 11). In
their retrospective cohort, an impressive 62% of multiparous women in Sydney, Australia,
breastfed over 6 months in their prior pregnancy, although disparities were noted in
association with maternal age, ethnicity, and economic status. Overall, high intensity
breastfeeding for at least 3 months in the prior pregnancy was associated with nearly a 50%
reduction in the odds of an abnormal fasting glucose in the subsequent pregnancy and a
tendency towards a reduced likelihood of being diagnosed with gestational diabetes.
Finally, the long-term outcomes of breastfed infants were evaluated by Libuda and
colleagues (contribution 12). Their observational study allayed concerns that breastfeeding
could prevent early childhood eczema in higher-risk infants at the cost of a rebound increase
in allergic diseases through young adulthood. Overall, beyond the known protection from
early eczema, there was no association between breastfeeding and healthcare provider-
diagnosed allergic diseases. There was, however, an interesting bidirectional interaction,
based on the presence or absence of early eczema, between breastfeeding and long-term
allergic rhinitis risk in those with no family history of allergic diseases.

3. Conclusions
This compilation of articles has significantly expanded the depth of our understanding
of the factors that facilitate breastfeeding initiation and continuation, as well as the public
health implications of those efforts. The role of maternal ideation, in particular self-efficacy,
assumed a prominent role in this Special Issue, and for good reason, as multiple publi-
cations demonstrate the importance of maternal satisfaction in the decision to continue
breastfeeding with implications for the health of the infant, the mother, and potential future
pregnancies. Given the ongoing need to increase breastfeeding rates, it is encouraging that
many of the factors that contribute to a positive maternal attitude can be modifiable.
Only when healthcare providers screen for and identify suboptimal levels of maternal
knowledge or self-efficacy can discussions begin with families regarding factors that might
be contributing. Those conversations can, in turn, open the door to possible interventions
to promote a more positive experience for the mother–infant dyad and the prevention of
premature breastfeeding abandonment. As the contributions in this Special Issue attest,
there are important roles in this process for all members of the multidisciplinary healthcare
Nutrients 2024, 16, 3251 4 of 5

team, including lactation consultants, midwives, and additional community-based allies

that contribute towards our shared understanding of the benefits of human milk.
Beyond encouragement to implement expanded screenings and evidence-supported
quality improvement projects, the contributions gathered for this Special Issue identify
important areas for future research. These areas include the optimal design of breastfeeding
education programs and/or interventions in developing as well as developed countries.
While the public health importance of breastfeeding is a clear call for an overall increase in
resource allocation by policy makers, in particular an improvement in parental leave policies
and universal screenings, and because resources remain limited, there is a need to identify
ways to risk-stratify individuals for need-based and targeted educational interventions to
achieve both effective and sustainable effects in all communities.

Acknowledgments: The author acknowledges all members of the University of Iowa Health Care’s
Human Milk Equity Taskforce for their ongoing efforts to facilitate the provision of human milk for
all infants throughout their hospitalizations and within their communities.
Conflicts of Interest: The authors declare no conflicts of interest.
List of Contributions
1. Elgzar, W.; Al-Thubaity, D.; Alshahrani, M.; Essa, R.; Ibrahim, H. The Relationship between
maternal ideation and exclusive breastfeeding practice among Saudi nursing mothers: a cross-
sectional study. Nutrients 2023, 15, 1719. https://doi.org/10.3390/nu15071719.
2. Olcina Simón, M.; Rotella, R.; Soriano, J.; Llopis-Gonzalez, A.; Peraita-Costa, I.; Morales-
Suarez-Varela, M. Breastfeeding-related practices in rural ethiopia: Colostrum avoidance. Nutri-
ents 2023, 15, 2177. https://doi.org/10.3390/nu15092177.
3. D’Adamo, E.; Peila, C.; Strozzi, M.; Barolo, R.; Maconi, A.; Nanni, A.; Botondi, V.; Coscia, A.;
Bertino, E.; Gazzolo, F.; et al. Presepsin in human milk is delivery mode and gender dependent.
Nutrients 2024, 16, 2554. https://doi.org/10.3390/nu16152554.
4. Vass, R.; Zhang, M.; Simon Sarkadi, L.; Üveges, M.; Tormási, J.; Benes, E.; Ertl, T.; Vari, S. Effect
of Holder pasteurization, mode of delivery, and infant’s gender on fatty acid composition of
donor breast milk. Nutrients 2024, 16, 1689. https://doi.org/10.3390/nu16111689.
5. Verea-Nuñez, C.; Novoa-Maciñeiras, N.; Suarez-Casal, A.; Vazquez-Lago, J. Factors associated
with exclusive breastfeeding during admission to a baby-friendly hospital initiative hospital: A
cross-sectional study in Spain. Nutrients 2024, 16, 1679. https://doi.org/10.3390/nu16111679.
6. Al-Thubaity, D.; Alshahrani, M.; Elgzar, W.; Ibrahim, H. Determinants of high breastfeeding self-
efficacy among nursing mothers in Najran, Saudi Arabia. Nutrients 2023, 15, 1919. https://doi.org/
10.3390/nu15081919.
7. Bizon, A.; Giugliani, C.; Giugliani, E. Women’s satisfaction with breastfeeding and risk of
exclusive breastfeeding interruption. Nutrients 2023, 15, 5062. https://doi.org/10.3390/nu152
45062.
8. Vila-Candel, R.; Soriano-Vidal, F.; Franco-Antonio, C.; Garcia-Algar, O.; Andreu-Fernandez, V.;
Mena-Tudela, D. Factors influencing duration of breastfeeding: Insights from a prospective
study of maternal health literacy and obstetric practices. Nutrients 2024, 16, 690. https://doi.
org/10.3390/nu16050690.
9. Rodríguez-Gallego, I.; Corrales-Gutierrez, I.; Gomez-Baya, D.; Leon-Larios, F. Effectiveness of a
postpartum breastfeeding support group intervention in promoting exclusive breastfeeding
and perceived self-efficacy: A multicentre randomized clinical trial. Nutrients 2024, 16, 988.
https://doi.org/10.3390/nu16070988.
10. Rodríguez-Gallego, I.; Vila-Candel, R.; Corrales-Gutierrez, I.; Gomez-Baya, D.; Leon-Larios,
F. Evaluation of the impact of a midwife-led breastfeeding group intervention on prevention
of postpartum depression: A multicentre randomised clinical trial. Nutrients 2024, 16, 227.
https://doi.org/10.3390/nu16020227.
11. Melov, S.; Elhindi, J.; White, L.; McNab, J.; Lee, V.; Donnolley, K.; Alahakoon, T.; Padmanabhan,
S.; Cheung, N.; Pasupathy, D. Previous high-intensity breastfeeding lowers the risk of an
abnormal fasting glucose in a subsequent pregnancy oral glucose tolerance test. Nutrients 2024,
16, 28. https://doi.org/10.3390/nu16010028.
Nutrients 2024, 16, 3251 5 of 5

12. Libuda, L.; Filipiak-Pittroff, B.; Standl, M.; Schikowski, T.; von Berg, A.; Koletzko, S.; Bauer,
C.; Heinrich, J.; Berdel, D.; Gappa, M. Full breastfeeding and allergic diseases—Long-term
protection or rebound effects? Nutrients 2023, 15, 2780. https://doi.org/10.3390/nu15122780.

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