Position Statement of the Academy of Breastfeeding Medicine, 2025

Recommendations for Exclusive Breastfeeding and Prevention of Underfeeding and Overfeeding in Breastfed Infants

This document aims to guide healthcare professionals in supporting exclusive breastfeeding, recognising situations where breast milk alone is insufficient, and limiting unjustified use of commercial infant formula.

Background and General Position of the Academy of Breastfeeding Medicine

The Academy of Breastfeeding Medicine (ABM) affirms that breast milk is the reference food for infants, providing optimal nutrition and numerous health benefits for both the child and the breastfeeding parent, particularly in terms of survival and protection in crisis and disaster settings. The central position of this document is to recommend exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with appropriate complementary foods until at least 2 years of age, or beyond according to the family's wishes. This recommendation is based on evidence showing that the benefits of breastfeeding are proportional to the volume of breast milk received and the duration of breastfeeding.

Definition and Implications of Exclusive Breastfeeding

Exclusive breastfeeding is defined as feeding the infant only breast milk (preferably directly at the breast), with no other food or drink, with the exception of medications, vitamins, or minerals. The document emphasises that this practice is associated with the best health outcomes for both the infant and the breastfeeding parent, and that it supports a longer duration of breastfeeding compared with feeding expressed breast milk.

The ABM states that, as a general rule, supplementation with other foods before 6 months for reasons such as allergy prevention or improvement of iron status is not justified in healthy infants. Nevertheless, the organisation acknowledges the existence of clinical situations in which breast milk alone or direct breastfeeding is insufficient, while emphasising that the majority of commercial formula use is not based on genuine medical indications.

Role and Hierarchy of Supplementation

For the rare cases in which supplementation is necessary (insufficient intake, inadequate milk transfer, medical constraints), the ABM establishes an order of preference: expressed milk from the mother, donor human milk, and only as a last resort, commercial infant formula. The volume of supplementation should be adjusted to the infant's estimated needs, taking into account age, gestational age, and mode of delivery, in order to avoid overfeeding.

The document stresses that the introduction of supplements must always be accompanied by an assessment and support of lactation, with the goal of returning to exclusive breastfeeding as soon as possible. Supplementation is presented as a transitional tool to be used with caution, as it can disrupt the physiological supply-and-demand relationship that regulates lactation.

Prevention of Underfeeding

The ABM recalls that the initial period following birth is a time of great vulnerability for exclusive breastfeeding, especially when birth practices do not adhere to the WHO's "Ten Steps to Successful Breastfeeding". To prevent underfeeding, the ABM recommends close monitoring of all newborns: feeding frequency, wet and dirty nappies, weight curve, and active assistance in initiating and maintaining effective latch (positioning, attachment, comfort).

The document lists risk factors for low milk production or insufficient intake: history of breast surgery, infertility, metabolic conditions such as insulin resistance, polycystic ovary syndrome, hypothyroidism or diabetes, hypertension, advanced maternal age, late preterm or early term birth, and infant ankyloglossia (tongue-tie). In these at-risk dyads, enhanced monitoring of nipple pain, milk transfer, and infant growth is strongly recommended.

Warning Signs and Clinician Competencies

The ABM identifies several signals that should raise concern about possible underfeeding in the first days: excessive weight loss, failure to regain birth weight, insufficient wet or soiled nappies, lethargic behaviour, or conversely, marked agitation related to hunger. Clinicians should be trained in the direct observation of a feeding to assess its effectiveness.

The document also discusses the early use of breast pumps, which may indicate a perceived concern about milk production or transfer, or a problem with painful latch, and which should prompt clinical evaluation rather than simply increasing supplementation. The central principle is to prioritise resolution of breastfeeding difficulties (latch, pain management, maternal support) before concluding that ongoing supplementation is necessary.

Overfeeding and Unnecessary Supplementation

On the other hand, the document emphasises the frequency of overfeeding associated with unjustified supplementation, particularly via commercial infant formula. According to the ABM, this over-supplementation often results from a misinterpretation of normal newborn behaviours (crying, frequent waking, cluster feeding) and from a lack of qualified breastfeeding support.

Excessive use of commercial infant formula disrupts the physiological supply-and-demand regulation of lactation, increases the risk of early weaning and raises the likelihood of overweight and obesity later in childhood. The document notes that the provision of infant formula without medical indication is among the most common reasons why mothers do not meet their exclusive breastfeeding goals.

Maximising Breast Milk and Respecting Autonomy

The ABM underscores that all efforts should aim to maximise the proportion of breast milk in the infant's diet, even when exclusive breastfeeding is not possible or not desired. This involves also supporting families who choose mixed feeding, in order to increase the proportion of infants receiving at least part of their nutrition in the form of breast milk.

The document emphasises respect for family autonomy in their real-life context: level of antenatal education, socioeconomic constraints, cultural norms, previous experiences, and capacity to access breastfeeding support. Recommendations must therefore be adapted and family-centred, aiming to inform and accompany rather than impose choices.

The Role of Hospital Practices and Marketing

The ABM advocates for the implementation of birth and maternity care practices aligned with WHO recommendations, such as early skin-to-skin contact, 24-hour mother-infant rooming-in, and the elimination of free distribution of commercial infant formula. These practices promote breastfeeding initiation, limit unnecessary supplementation, and strengthen parental confidence in their ability to breastfeed.

The document also calls for strict enforcement of the International Code of Marketing of Breast-milk Substitutes, in order to protect families and healthcare providers from aggressive marketing strategies that normalise or encourage the unjustified use of commercial infant formula. By reducing the influence of this industry, more supportive care environments for exclusive breastfeeding can be created.

Conclusion of the Position Statement

In summary, this statement positions exclusive breastfeeding as the recommended standard for the first 6 months, while providing a precise framework for identifying and preventing both underfeeding and overfeeding. It emphasises clinician competence, organisational support (hospital practices, public policies), limitation of unnecessary supplementation, and respect for family choices, with the ultimate goal of increasing the number of infants benefiting from a maximum intake of human milk in conditions of safety and respect.

Feldman-Winter L, Ware J, Schreck P, Kellams A, Rosen-Carole C, Rouw E. ABM Position Statement: Recommendation for Exclusive Breastfeeding: Avoidance of Underfeeding and Overfeeding (October 2024). Breastfeeding Medicine. 2025;20(2):81-84. doi:10.1089/bfm.2024.85389.bess