A recent confluence of 3 reviews, one on breastfeeding specifically in the NICU (Hilditch C, et al. Effect of Neonatal Unit Interventions Designed to Increase Breastfeeding in Preterm Infants: An Overview of Systematic Reviews. Neonatology. 2024;121(4):411-20) another on the evidence supporting the efficacy of lactation consultants (D’Hollander CJ, et al. Breastfeeding Support Provided by Lactation Consultants: A Systematic Review and Meta-Analysis. JAMA Pediatr. 2025;179(5):508-20), and the US Preventive Services Task Force report (Preventive Services Task Force. Primary Care Behavioral Counseling Interventions to Support Breastfeeding. JAMA. 2025).

There is some overlap between the reviews, and also some important differences. The USPSTF report is primarily concerned with primary care, but, of course, most of the mothers of NICU patients start out there. The final recommendation is a bit vague, but supports interventions to increase breastfeeding, either with personal counselling, or referral to a breast feeding specialist. The recommendation is based on a total of 90 RCTs, including nearly 50,000 women, which studied a wide range of interventions. Most of the studies were in high income countries, especially the USA, where about 60% of babies are breastfed at 6 months, and 42% are exclusively breastfed.

It is hard to believe that any mother in 2025 is unaware of the benefits of breast feeding, so simply informing a pregnant woman or a new mother of the advantages of breast milk is clearly not enough. As an accompanying editorial notes “clinicians and health systems must do more than just promote the benefits of breastfeeding and provide basic education. Behavioral breastfeeding education and counseling should be considered a starting point within a broader system that requires retooling, rethinking, and innovating”. That is particularly so within the USA, which is one of only 7 countries in the world with no nationally mandated paid maternity leave, the others being The Marshall Islands, Micronesia, Nauru, Palau, Papua New Guinea, and Tonga!

The USPSTF definition of breast feeding includes provision of expressed breast milk, which is so common in the USA; many new mothers returning to work very quickly after delivery, even before breast feeding has been well established. It is bizarre that so many articles, about breast feeding support in the USA, focus heavily on helping new mothers to find privacy, support, time, and equipment for breast milk expression, so that someone else can give their breast milk to the new baby. Please don’t get me wrong, I have nothing against a mother who makes the free choice to do that; but most new mothers in the USA have little choice, they have to rapidly return to work or risk losing income or even their job.

The review of the efficacy of Lactation Consultants also uses the definition of breastfeeding as provided in the original publication, 22 of the 40 RCTs they included were performed in the USA, so will have included feeding expressed breast milk. The review demonstrates that a referral to a lactation consultant is effective in prolonging breast feeding by an average of 3.6 weeks. When the intervention commenced sooner after birth, the metaregression showed a greater impact.

Within the NICU, interventions shown to improve the proportion of mothers breast-feeding at discharge are: skin-to-skin care (but there is no clear additional advantage to starting skin-to-skin care within 24 hours); and avoiding bottles during the establishment of breast feeding, very low quality evidence supported cup-feeding as the alternative method of choice. For breast feeding rates post-discharge, the evidence base was even poorer, but supports the same interventions. What is exactly meant by “establishment of breast-feeding” is not consistent among trials, so the point at which bottles could be introduced without having a negative impact is unclear. In our NICU we try to delay the introduction of bottle feeds until there are at least 3 full nutritive breast feeds per day, and we currently use very little cup-feeding. Obviously, everything is done in partnership with the parents, who sometimes request a different approach, with some wanting bottles sooner, and others preferring their avoidance entirely.

This review, and the RCTs underlying it, do not address what is a more important outcome, at least in terms of acute NICU complications, and that is “how can we improve the amount of maternal breast milk that very preterm infants receive”? One possible adverse impact of breast milk banks, for example, is a reduction in the amount of maternal milk provided, a systematic review from a few years ago suggested that that happens sometimes, but not consistently, in some units the provision of mother’s milk increased. What is consistent, of course, is a reduction in artificial formula use. One of the best things we can do to reduce NEC, and probably LOS and mortality, is to increase the proportion of maternal breast milk received by our very preterm babies. More research in how to do that could have major benefits.

Whether prenatal intervention by a lactation consultant, for example, increases the proportion of MoM received has not been well studied, although I think it is likely to be very helpful. Observational data shows an improvement in breast milk production if milk expression is commenced very early after delivery, depending on the study this could be within 1, 2 or 3 hours. But what if we expended a small amount of resources to specifically ensure that someone with breast feeding support expertise met all the mothers of preterm infants within that 1 to 3 hour window, to ensure that they knew what to do, how to access the equipment, and how to ensure that the colostrum produced was sent immediately to the NICU? I think a randomized trial could be very useful to show whether or not that was beneficial. Many other aspects of breast-feeding support could also be better studied, so that we can develop best practices for an intervention which may not be “sexy”, but has a big impact on clinical outcomes of our patients.