Common Hospital Advice May Be Undermining Breastfeeding, International Review Finds

For many mothers, the first few hours after childbirth are filled with joy but also uncertainty. As newborns cry frequently and only a few drops of thick yellow colostrum are produced, many new moms are told they may not have enough milk. Formula is introduced, breast pumps are suggested, and in some hospitals, pacifiers are discouraged altogether.

A major international review has now challenged these long-standing practices, suggesting that several routine interventions during the first three days after birth may actually reduce the chances of successful breastfeeding instead of supporting it.

Published in the Journal of Maternal-Foetal & Neonatal Medicine to coincide with World Breastfeeding Week (August 1–7), the review analysed 78 studies from countries including India, the United States, Australia, Germany, Italy and Mexico. The researchers concluded that misconceptions surrounding early milk production, pacifier use and breast pumps continue to influence maternity care despite limited scientific evidence supporting many of these practices.

The findings carry particular significance for India, where improving breastfeeding remains a public health priority. Although exclusive breastfeeding has improved over the years, it continues to fall short of national and global targets. According to the National Family Health Survey-5 (NFHS-5), nearly two-thirds of Indian infants below six months are exclusively breastfed, while early initiation of breastfeeding within one hour of birth remains suboptimal.

According to paediatrics, the first 48 to 72 hours after delivery are crucial for establishing breastfeeding, making the quality of counselling mothers receive during this period extremely important.

The review, led by Dr. Maria Di Chiara, a neonatologist at Sapienza University of Rome, noted that many mothers discontinue breastfeeding not because of biological problems but because of fear, confusion and inconsistent advice.

"On the ward, I kept seeing mothers feeling overwhelmed by the fear that they did not have enough milk, despite their incredible commitment," Dr. Di Chiara said.

"My priority has always been to support the mother first, and in doing so support the baby. These mothers need consistent, evidence-based advice, not conflicting messages."

The researchers reviewed randomised clinical trials, systematic reviews, observational studies and meta-analyses to identify gaps between scientific evidence and current hospital practices.

One of the biggest myths, they said, concerns colostrum, the thick yellow milk produced immediately after birth.

Many parents and even healthcare workers mistakenly assume that because colostrum is produced in very small quantities, it is insufficient for the newborn. This often leads to the unnecessary introduction of infant formula within hours of birth.

However, the review found that in healthy full-term babies, colostrum is perfectly matched to the newborn's tiny stomach size and nutritional requirements. Rich in antibodies, immune cells and growth factors, it provides both nutrition and protection against infections.

"Perceived insufficient milk supply is the most commonly reported reason for early formula supplementation and premature breastfeeding cessation worldwide," Dr. Di Chiara said.

"But in most cases, these concerns reflect unrealistic expectations rather than genuine problems with milk production."

Researchers cautioned that unnecessary formula supplementation can become counterproductive. Since breastfeeding works on a demand-and-supply mechanism, reduced suckling lowers breast stimulation, delays mature milk production and reinforces the mother's belief that she is not producing enough milk.

The review does not oppose formula feeding when medically indicated. Babies with excessive weight loss, hypoglycaemia, dehydration or other medical complications may require supplementation. However, the researchers argued that formula should be introduced based on clear clinical protocols rather than anxiety alone.

The second misconception concerns pacifiers.

For decades, many hospitals discouraged their use because of fears that babies might develop "nipple confusion" and refuse breastfeeding.

Yet, after examining evidence from multiple randomised controlled trials, the review found no convincing evidence that pacifier use in healthy term babies shortens breastfeeding duration or reduces exclusive breastfeeding rates.

"Routine pacifier restrictions in maternity settings are not supported by current evidence and should be reconsidered," said co-author Prof. Gianluca Terrin.

Instead of blanket bans, researchers recommended balanced counselling so parents can make informed decisions based on individual circumstances.

The review also questioned the increasing reliance on electric breast pumps during the first few days after childbirth.

While breast pumps have transformed care for premature babies, mothers separated from their infants or women with medical complications, researchers found little evidence supporting their routine use immediately after birth in healthy mother-baby pairs.

In fact, seeing only a few millilitres of colostrum in a pump bottle often convinces mothers that they are producing inadequate milk, even though such volumes are completely normal.

Instead, the review recommended hand expression as the preferred method whenever milk expression is required during the first few days.

"Electric breast pumps have an important role in specific clinical situations, but they should not be considered a routine breastfeeding tool in the first days after birth," Prof. Terrin said.

Based on the available evidence, the researchers have recommended five changes in postnatal care.

These include educating expectant mothers during pregnancy about normal colostrum production and newborn stomach capacity, promoting hand expression when necessary, introducing formula only for medical reasons, and replacing routine pacifier restrictions with evidence-based counselling.

The experts also suggested that every mother must have access to trained lactation support within 48 hours of delivery.

The authors stressed that these recommendations do not contradict the World Health Organization's advice of exclusive breastfeeding for the first six months. Instead, they aim to remove persistent misconceptions that prevent mothers from successfully initiating breastfeeding.

For India, these findings resonate with ongoing efforts to strengthen breastfeeding through initiatives such as the Baby-Friendly Hospital Initiative, the Mother's Absolute Affection (MAA) programme and expanded lactation counselling under public health services.

The review also highlighted an often-overlooked issue—the emotional wellbeing of new mothers.

Repeated suggestions that their milk is inadequate can erode confidence during an already vulnerable period, making many women abandon breastfeeding much earlier than intended.

"What struck me most was how often well-meaning routine advice runs ahead of the evidence," Dr. Di Chiara said.

"Small changes in those first three days could make a real difference for families."

According to the WHO, although the South-East Asia Region has historically recorded some of the world's highest exclusive breastfeeding (EBF) rates, progress is slowing in several countries. In India, for instance, NFHS-6 (2023-24) shows exclusive breastfeeding has declined from 63.7% in NFHS-5 (2019-21) to 55.8%, even as institutional deliveries have reached nearly 95%.

Calling the trend "deeply worrying", Dr. Arun Gupta, paediatrician and Founder, Breastfeeding Promotion Network of India (BPNI), said the decline should be treated as a public health priority. "The global review reinforces what India is witnessing. Despite high institutional deliveries, only half of newborns are breastfed within the first hour. Rising caesarean deliveries, inadequate lactation support and aggressive formula marketing are undermining mothers' confidence."

“India urgently needs stronger enforcement of the IMS Act, breastfeeding-friendly hospitals and skilled counselling to protect breastfeeding and improve child nutrition," he said.