Breastfeeding: a round up of Cochrane evidence

On this page, you can find lots of resources which summarise Cochrane evidence on breastfeeding and aim to make it easy to access. The content is based on this Cochrane Special Collection of systematic reviews on breastfeeding, as well as later Cochrane Reviews. You can either scroll through this page, or click on the topics below to jump straight to a particular section. Click on a graphic to enlarge it. This page is part of a series of blogs called ‘Maternity Matters’, you can read the rest here.

Support for breastfeeding women

Health promotion and an enabling environment

Care for breastfeeding women and their babies

Treating breastfeeding problems

Breastfeeding babies with additional needs, including preterm babies

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Support for breastfeeding women

Compared with usual care, breastfeeding support provided by a healthcare worker or a layperson probably reduces the number of women who stop either partial or exclusive breastfeeding by four to six weeks or by six months after birth (moderate‐certainty evidence). Not enough information is available about possible harms of support during breastfeeding. Cochrane Review (published February 2017); 100 studies with data from 73 studies involving 74,656 healthy breastfeeding mothers with healthy term babies. Studies compared support (such as reassurance, praise, information, and discussion of the mother's questions) with usual care in outpatient settings.

Read the full Cochrane Review: ‘Support for healthy breastfeeding mothers with healthy term babies’

 Read the Cochrane Clinical Answer: “What are the effects of breastfeeding support in healthy mothers with healthy term babies?”

 Listen to the podcast with the Cochrane authors.

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Read the full Cochrane Review: Breastfeeding education and support for women with twins or higher order multiples

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Health promotion and an enabling environment

Health promotion and enabling environment
Compared with standard care, antenatal breastfeeding (BF) education makes little or no difference to the initiation of breastfeeding (high-certainty evidence) and probably makes little or no difference to the proportion of women exclusively breastfeeding at three or six months (moderate-certainty evidence). It makes little or no difference to the proportion of women giving any breastfeeding at six months (high-certainty evidence) and this may be the same at three months (low-certainty evidence). Antenatal BF education probably makes little or no difference to breastfeeding complications (moderate-certainty evidence). Cochrane Review (published December 2016). 24 studies; with data from 20 studies with 9,789 women. Studies compared antenatal breastfeeding education with standard (routine) care.

Read the full Cochrane Review: Antenatal breastfeeding education for increasing breastfeeding duration

Read the Cochrane Clinical Answer: “For pregnant women, how effective is antenatal breastfeeding education in increasing initiation and duration of breastfeeding?”

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Breastfeeding education and support, either led by a healthcare professional or a non-healthcare professional, may improve the rate of women starting to breastfeed (low-certainty evidence). Effects on the rate of women starting to breastfeed early (within one hour after birth) are uncertain (very low-certainty evidence or no data available). Not enough information is available about the possible harms of interventions for promoting the initiation of breastfeeding. Cochrane Review (published November 2016); 28 studies, with data from 23 studies with 104,238 women. Studies compared breastfeeding education and support either led by a healthcare professional or a non-healthcare professional with ‘standard care’, which differed between settings.

Read the full Cochrane Review: Interventions for promoting the initiation of breastfeeding

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Read the full Cochrane Review: Interventions in the workplace to support breastfeeding for women in employment 

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Care for breastfeeding women and their babies

Care for breastfeeding women and their babies

Early skin-to-skin contact (SSC) probably increases the number of women breastfeeding at one to four months (moderate-certainty evidence) and probably increases the number exclusively breastfeeding up to six months (moderate-certainty evidence). After birth, babies held in SSC may be better stabilized and have higher blood glucose levels, but similar temperature to babies with standard care (low-certainty evidence). Not enough information is available about the possible harms of SSC. Cochrane Review (published November 2016); 46 studies, with data from 38 studies with 3472 mothers and their healthy babies after vaginal or caesarean birth, at 35 weeks to full term. Studies compared early SSC with standard care that did not involve SSC.

Read the full Cochrane Review: Early skin‐to‐skin contact for mothers and their healthy newborn infants

Listen to the podcast with the lead author of the review.

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Newborn infants unable to fully breastfeed may be more likely to be exclusively breastfeeding at hospital discharge when they have supplemental feeds by cup, rather than by bottle (low-certainty evidence). Whether newborns are cup- or bottle-fed may make little or no difference to weight gain (low-certainty evidence). Effects on length of hospital stay or breastfeeding rates at six months are uncertain (low and very low-certainty evidence). Not enough information is available about the possible harms of different forms of supplemental feeding. Cochrane Review (published August 2016); 5 studies with 971 newborn infants, most of them preterm. Studies compared supplemental feeding by cup with bottle feeding. Mothers’ or nurses’ dislike of cup feeding meant that many infants who should have received cup feeding were fed in other ways.

Read the full Cochrane Review: Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed

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Whether infants’ use of a pacifier is restricted or unrestricted probably makes little or no difference to the proportion of infants exclusively breastfeeding at four months of age (moderate-certainty evidence). There is not enough information about the effects of pacifier use on duration of exclusive breastfeeding or on maternal satisfaction and confidence in parenting. Not enough information is available about possible harms of pacifier use, such as breastfeeding difficulties or effects on infants’ health. Cochrane Review (published August 2016). Three studies; with data from two studies with 1302 healthy full‐term infants whose mothers had started breastfeeding and intended to exclusively breastfeed. Studies compared restricted pacifier use with unrestricted use.

Read the full Cochrane Review: Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding

Read the Cochrane Clinical Answer: “Does not using a pacifier help to increase the duration of breastfeeding for term infants?”

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Keeping mother and infant together in the same room after birth until discharge from hospital (known as ‘rooming-in’) may increase the rate of exclusive breastfeeding at four days after birth, but may make little or no difference to the proportion of infants breastfeeding at six months of age (low-certainty evidence). Not enough information is available on the effects of rooming-in on the duration of breastfeeding, frequency of breastfeeding or maternal level of confidence in breastfeeding. EVIDENCE GAP. Not enough information is available about possible harms of rooming-in compared with separate care. Cochrane Review (published August 2016); one study with 176 women, comparing the effects of keeping mother and infant together (rooming‐in) or separating them after birth (separate care).

Read the full Cochrane Review: Rooming‐in for new mother and infant versus separate care for increasing the duration of breastfeeding

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Read the full Cochrane Review: Early additional food and fluids for healthy breastfed full‐term infants

Read the Evidently Cochrane blog: ‘Exclusive breastfeeding or extra food and fluids: evidence and practice’

Other relevant Cochrane Reviews:

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Treatment of breastfeeding problems

In breastfeeding women with painful nipples, applying various treatments (including glycerine gel, breast shells with lanolin, expressed breast milk, lanolin or all-purpose nipple ointment) may make little or no important difference to nipple pain (low-certainty evidence). For most women, regardless of treatment used, pain may reduce to mild levels by about 7 to 10 days after giving birth (low certainty-evidence). There is not enough information available about the possible harms of interventions for painful nipples. Cochrane Review (published December 2014); four studies with 656 breastfeeding women with sore nipples. Studies compared applied lanolin (alone or with breast shells), glycerine pads, breast milk, all-purpose nipple ointment with each other, with routine care (education only) or with no treatment.

Read the full Cochrane Review: Interventions for treating painful nipples among breastfeeding women

Read the Evidently Cochrane blog: Simple help for painful nipples in breastfeeding women

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It is uncertain whether breastfeeding women who have developed a breast abscess are more likely to continue to breastfeed if treated with needle aspiration or with incision and drainage. It is also uncertain whether abscesses heal more quickly with one approach or the other (very low-certainty evidence). EVIDENCE GAP. Not enough information is available about the possible harms of needle aspiration compared with incision and drainage. Cochrane Review (published August 2015). Six studies; with data from four studies with 325 breastfeeding women with abscesses. Studies compared needle aspiration with incision and drainage.

Read the full Cochrane Review: Treatments for breast abscesses in breastfeeding women

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The effects of different treatments for breast engorgement (overfull, hard, painful breasts) during lactation are uncertain (low- and very-low certainty evidence). EVIDENCE GAP. Not enough information is available about the possible harms of different treatments for breast engorgement during lactation. Cochrane Review (published June 2016); 13 studies with 919 women with breast engorgement during lactation. The studies looked at a range of medical and non-medical treatments.

Read the full Cochrane Review: Treatments for breast engorgement during lactation

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Read the full Cochrane Review: Antibiotics for mastitis in breastfeeding women

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Feeding practices for preterm babies, or babies with additional needs

Compared with conventional neonatal care, kangaroo mother care (KMC) probably reduces infants’ risk of mortality, hypothermia and severe infection/sepsis at discharge or at 40 to 41 weeks' postmenstrual age (moderate‐certainty evidence). KMC probably also increases weight gain (moderate-certainty evidence) and breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (moderate‐certainty evidence) and at one to three months’ follow up (low‐certainty evidence). KMC compared with conventional neonatal care may make little or no difference to infants’ psychomotor development (low‐certainty evidence). Cochrane Review (published August 2016); 21 studies with 3042 infants with low birthweight comparing kangaroo mother care (defined as ‘skin‐to‐skin contact between mother and newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital’) with conventional neonatal care.

Read the full Cochrane Review: Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

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Preterm infants whose feeding is supplemented with an alternative to a bottle (such as a cup) may be more likely to fully breastfeed at discharge (low-certainty evidence), at three months after discharge (moderate-certainty evidence) and at six months after discharge (low-certainty evidence). At discharge, the rate of any breastfeeding may also be higher in infants supplemented with an alternative to bottle (low-certainty evidence), although effects at three and six months are uncertain (very low-certainty evidence). It is uncertain whether bottle feeding compared with an alternative affects length of hospital stay (very low-certainty evidence). Feeding with an alternative to bottle probably makes little or no difference to the rate of infant infection (moderate-certainty evidence). Cochrane Review (published October 2016); seven studies with 1152 preterm infants establishing breastfeeding, comparing supplementary feeds with a cup (five studies), special teat (one study) or tube with conventional bottle feeds (one study).

Read the full Cochrane Review: Avoidance of bottles during the establishment of breast feeds in preterm infants

Read the Cochrane Clinical Answer: “For preterm infants, does avoidance of bottles during establishment of breast-feeding help to increase the extent and duration of breast-feeding?”

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Compared with standard care, oral stimulation interventions for preterm infants may shorten the transition to oral feeding but may make little or no difference to weight gain (low-certainty evidence). Effects on length of hospital stay, time spent on parenteral nutrition or on breastfeeding are uncertain (very low-certainty evidence). Compared with non-oral interventions, oral stimulation may reduce the time to exclusive feed, time spent on parenteral nutrition and length of hospital stay (low-certainty evidence) but probably makes little or no difference to the rate of exclusive direct breastfeeding at discharge (moderate-certainty evidence). Not enough information is available about possible harms of oral stimulation compared to standard care or non-oral interventions. Cochrane Review (published September 2016); 19 studies with 823 preterm infants, comparing oral stimulation by finger stimulation with standard care or with non-oral stimulation interventions.

Read the full Cochrane Review: Oral stimulation for promoting oral feeding in preterm infants

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Feeding preterm infants in response to their hunger and satiation cues (responsive, cue‐based, or infant‐led feeding), rather than at scheduled intervals, may reduce the time taken for infants to transition from enteral tube to oral feeding but may result in slightly slower rates of weight gain (low certainty-evidence). There is not enough information available about the potential harms of responsive compared with scheduled feeding. Cochrane Review (published August 2016); 9 studies with 593 preterm infants comparing responsive feeding with scheduled feeding.

Read the full Cochrane Review: Responsive versus scheduled feeding for preterm infants

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When a mother's own milk is not available, there is not enough information available about the effects of feeding very low birth weight infants with banked term milk (milk expressed from donors with term babies) compared with banked preterm milk (milk expressed from donors with preterm babies) on infants’ growth and developmental outcomes. EVIDENCE GAP. There is not enough information available about the possible harms of banked donor term milk compared with banked preterm milk. Cochrane Review (published June 2019); no eligible studies found comparing feeding on banked donor preterm milk with banked term milk in infants with very low birth weight.

Read the full Cochrane Review: Banked preterm versus banked term human milk to promote growth and development in very low birth weight infants

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Exclusively formula‐fed preterm or low birth weight infants fed on dilute formula (half‐strength, double‐volume) may experience fewer episodes of feeding intolerance and achieve adequate energy intake earlier than infants fed full‐strength formula (low-certainty evidence). None of the studies reported on infants’ risk of mortality, infection or serious gastrointestinal problems. There is not enough information about possible adverse effects of dilute formula compared with full-strength formula. Cochrane Review (published June 2019); three studies comparing dilute formula milk (half‐strength, double‐volume) with full‐strength formula milk in exclusively formula‐fed preterm or low birth weight infants in neonatal intensive care units (NICUs).

Read the full Cochrane Review: Dilute versus full‐strength formula in exclusively formula‐fed preterm or low birth weight infants

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When a mother's own breast milk is not available, feeding preterm or low birth weight infants with formula rather than donor breast milk probably increases rates of weight gain, linear growth and head growth (moderate-certainty evidence) but probably makes little or no difference to survival or longer‐term growth and development (moderate-certainty evidence). Infants fed with formula rather than donor breast milk probably have a higher risk of developing necrotising enterocolitis, a severe gut disorder (moderate-certainty evidence). Cochrane Review (published July 2019); 12 studies with 1871 preterm or low birth weight infants, comparing feeding on formula (term or preterm) with donor breast milk (unfortified or fortified).

Read the full Cochrane Review: Formula versus donor breast milk for feeding preterm or low birth weight infants

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Feeding preterm infants nutrient‐enriched formula, compared with standard formula, may increase rates of weight gain and head growth but not length gain (low-certainty evidence). Only limited data are available for growth and developmental outcomes beyond infancy, and these do not show consistent effects. Feeding preterm infants with nutrient-enriched compared with standard formula probably makes little or no difference to their risk of developing necrotising enterocolitis, a severe gut disorder (moderate-certainty evidence). Cochrane Review (published July 2019); 7 studies with 590 preterm infants comparing feeding with nutrient‐enriched formula (extra energy and protein) to standard formula.

Read the full Cochrane Review: Nutrient‐enriched formula versus standard formula for preterm infants

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Feeding preterm infants with protein hydrolysate compared with standard (non‐hydrolysed) cow's milk formula may make little or no difference to their feed intolerance (low-certainty evidence). Feeding on protein hydrolysate rather than standard formula may make little or no difference to preterm infants’ risk of developing necrotising enterocolitis, a severe gut disorder (low-certainty evidence). Cochrane Review (published July 2019); 11 studies with 665 preterm infants in neonatal units, comparing feeding with hydrolysed to non‐hydrolysed formula.

Read the full Cochrane Review: Protein hydrolysate versus standard formula for preterm infants

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For preterm infants who are exclusively breastfed, nutrients (multi-nutrient fortifiers) are often added to the breast milk to give more energy and protein to help growth. Whether these nutrients are made from human milk or from cow's milk may make little or no difference to infants’ growth. It may also make little or no difference to infants’ risk of necrotizing enterocolitis (a severe gut disorder), feeding problems, infections, or death (all low-certainty evidence). Cochrane Review (published November 2019); one study with 127 preterm infants fed exclusively with breast milk in Neonatal Intensive Care Units or healthcare settings. The study compared feeding infants with multi‐nutrient fortifier made from human milk with multi-nutrient fortifier made from cow’s milk. Read the full Cochrane Review: Human milk‐derived fortifier versus bovine milk‐derived fortifier for prevention of mortality and morbidity in preterm neonates

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Read the full Cochrane Review: Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation

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Preterm infants who are fed fortified breast milk, compared with unfortified breast milk, probably grow in head size more quickly (moderate-certainty evidence) and may put on weight and grow in length slightly more quickly while they are in hospital (low-certainty evidence). However, there is probably little or no effect on neurodevelopment later in the baby’s life (moderate-certainty evidence). Whether preterm infants are fed with fortified or unfortified breast milk may make little or no difference to their risk of developing necrotising enterocolitis, a severe gut disorder (low-certainty evidence). Cochrane Review (published May 2020); 18 studies with 1456 preterm infants, comparing feeding preterm infants multi‐nutrient fortified human breast milk with unfortified human breast milk.

Read the full Cochrane Review: Multi‐nutrient fortification of human milk for preterm infants.

See also:

An influential series on breastfeeding in the Lancet and an Evidently Cochrane blog reflecting on it.

Editors note: updated June 2020.


Selena Ryan-Vig

About Selena Ryan-Vig

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Selena Ryan-Vig is the Communications and Engagement Officer at Cochrane UK. Her role primarily entails disseminating Cochrane evidence in accessible ways, managing Cochrane UK's website and social media accounts, and producing newsletters and infographics. With a colleague, Selena delivers interactive sessions to students from Years 10 to 13 to teach about evidence-based practice and to encourage critical thinking, particularly around healthcare claims made in the media. She also co-delivers talks for students to raise awareness of Cochrane and reliable, evidence-based resources. She has a psychology degree from the University of Bath. During her degree, she spent a placement year working in a national charity which provides support for young women affected by self-injury and training for professionals working with individuals who self-injure.

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