Steady increases in national breastfeeding rates approaching the national Healthy People 2020 benchmarks have been observed over time (1). Two articles in this issue add to the well-known benefits of breastfeeding (2,3). Interestingly, there appears to be substantial overlap between states whose breastfeeding rates are lower than Healthy People 2020 goals with those who chose not to accept the federally-funded Medicaid Expansion as part of the Affordable Care Act (ACA). Overall the total number of children benefiting from breastfeeding in these regions remains suboptimal (4)

The ACA provides several provisions aimed at supporting breastfeeding mothers. These include mandatory break time and dedicated space for mothers to express breastmilk, coverage for breastfeeding supplies (including pumps), and lactation support (5,6). These policies, which affect ~19 million women, have led to increased worksite compliance for private breastfeeding space and are associated with a 2.5% increase in initiation of breastfeeding (an estimated 47,000 more women) (7,8,9).

Breastmilk is the premium nutritional source for infants and is associated with reduced mortality, and decreased rates of infections, allergies, asthma, Type 2 diabetes, and obesity (10). In this issue of Pediatric Research, Julvez et al. report on lower rates of autistic traits and improved cognitive function in breastfed infants in early childhood (2). Gridneva and colleagues, also in this issue, reinforce the beneficial effects of breastfeeding on adiposity, a risk factor for later obesity (3).

To continue to sustain increases in breastfeeding rates, greater societal understanding that breastfeeding rates profit from a network of social policies is needed (11). Given the influence of such measures on breastfeeding rates, the health improvements infants receive from breastfeeding are thus partially socially-determined. Physicians should advocate for standard regulations which assist breastfeeding mothers including:

SUPPORTING FEDERAL, UNIVERSAL PAID FAMILY LEAVE FOR AT LEAST 14 WK TO HELP SUSTAIN BREASTFEEDING AFTER HOSPITAL INITIATION

Paid maternity leave is strongly associated with persistence of breastfeeding (11,12). No national regulations exist in the United States for paid family leave. Five states have enacted paid family leave ranging from 4–12 wk of time off at roughly half to two thirds of pay (13). Exclusive of these states, voluntary paid leave is available to ~10% of American employees, but the durations are shorter than those of other economically-similar nations who offer between 14–52 wk (13,14). Longer employment leaves are associated with improved breastfeeding outcomes (11,13). Of note, paid family leave is only one of a constellation of social policies such as on-site childcare, flexible work scheduling, access to healthcare, equal pay, and paternity leave which positively influence sustained breastfeeding (15,16,17).

MAINTAINING EXPANDED INSURANCE COVERAGE CREATED BY THE ACA SO ELIGIBLE MOTHERS CONTINUE TO OBTAIN BREASTFEEDING BENEFITS SUCH AS LACTATION CONSULTATION, BREAST PUMPS, AND SUPPLIES

Through provisions such as the Medicaid Expansion, the ACA has provided coverage for an estimated 11.6 million women of childbearing age (18). Recent threats to repeal ACA would endanger the insurance mandates related to breastfeeding and may imperil the gains achieved. Other aspects of the ACA, if modified, may impact national breastfeeding rates. The ACA penalizes hospitals which under-perform in certain quality metrics such as 30-d readmission or central line associated blood stream infections resulting in reductions of preventable conditions as well as cost (19,20). Formula feeding in the setting of a mother who could breastfeed should be considered among these preventable conditions and included in ACA sanctions (18,19).

PROVIDING ADEQUATE FINANCING FOR THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM WHICH SUPPORTS THE NUTRITIONAL NEEDS OF BREASTFEEDING MOTHERS AND ENCOURAGES SUSTAINING BREASTFEEDING OF INFANTS

WIC provides targeted nutritional support to infants whose families earn up to 185% of the Federal Poverty Level. In 2012, almost half of all infants born in the United States participated in the program (21). Reauthorization of WIC incentivizes breastfeeding by providing performance bonuses for states with improved and sustainably-high breastfeeding rates (21,22). Currently, WIC also includes stipulations for breastfeeding counseling (23). However WIC remains a discretionary program and is vulnerable to funding changes during budgetary negotiations, including assignment of a “block grant” allocation which functionally decreases funding streams.

ELIMINATING ALLOCATION OF BLOCK GRANTS TO STATES DURING THE FEDERAL APPROPRIATIONS PROCESS TO ENSURE THESE PROGRAMS ARE FUNDED TO A LEVEL APPROPRIATE TO PROVIDE BENEFITS TO ALL ELIGIBLE MOTHERS

“Block Grant” proposals limit spending to flat amount rather than funding per eligible enrollee and are a feature of House of Representatives’ Speaker Paul Ryan’s healthcare plan (24). As a result, state expenses increase by addressing fiduciary gaps between the set dollar amount and expenses for new registrants, resulting in a limitation of Medicaid-covered services, decreased payments and disincentivized enrollment in social programs. For new mothers, this has the potential to limit the number of mothers receiving breastfeeding support through Medicaid and WIC (23,25). Use of Block Grants during the upcoming federal appropriations process is estimated to result in 14 million people denied access to Medicaid (and its breastfeeding-friendly insurance coverage) over the next decade (25,26,27).

Sustainable improvement in the number of breastfed infants requires both forceful defensive advocacy for gains already realized, and a fundamental shift in societal attitudes toward supporting mothers at the federal, state, and employer level. In their role as child health experts, pediatricians can ensure federal policies exert positive influences on newborn health; ensuring programs linked to breastfeeding promotion are substantive and remain financially viable.