Breastfeeding, Human Milk and Infant Feeding Alternatives: Evidence, Barriers and Global Guidance

Breastfeeding has been recognised as the gold standard for infant nutrition and maternal health. The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with complementary foods until at least 2 years of age.[1] The health benefits of breastfeeding extend across survival, immunity, neurological development and maternal outcomes.[2-6] In contrast, formula feeding, while sometimes medically indicated, introduces significant risks, particularly in resource-constrained or crisis settings.[2,7-9] This manuscript synthesises evidence confirming the superiority of breastfeeding and human milk-based alternatives over breastmilk substitutes (BMS), identifies barriers to breastfeeding continuation and explores the role of the Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) in safeguarding infant health in humanitarian contexts. THE SUPERIORITY OF BREASTFEEDING AND HUMAN MILK Breastfeeding and human milk are by far superior to any alternative that may be available at present, and the following are the advantages of breastfeeding and human milk [Figure 1].Figure 1: Display of the advantages of breastfeeding and human milk. SIDS: Sudden Infant Death Syndrome; DM: Diabetes Mellitus; IgA: Immunoglobulin A. This figure was drawn through the premium version of BioRender (https://biorender.com/), accessed on 29 August 2025, with license number NY28OU63 L2,[ 10 ] Illustration Credit: Rahnuma Ahmad.INFANT HEALTH OUTCOMES Exclusive breastfeeding reduces infant mortality by protecting against diarrhoea and pneumonia, the two leading causes of under-five deaths globally.[2,11] Meta-analyses confirm strong associations between breastfeeding and reduced Sudden Infant Death Syndrome, otitis media and necrotising enterocolitis (NEC) in preterm infants.[12-14] Long-term benefits extend to reduced risks of obesity, hypertension and type 2 diabetes mellitus (T2DM) through metabolic programming.[6,15,16] MATERNAL HEALTH Breastfeeding decreases maternal risks of breast and ovarian cancer, T2DM and cardiovascular disease.[3,5,17] Large cohort analyses observed an association between longer breastfeeding duration and improved maternal cardiometabolic outcomes.[17] Psychological benefits include reduced postpartum depression in mothers who successfully sustain breastfeeding.[18,19] NUTRITIONAL AND IMMUNOLOGICAL SUPERIORITY Human milk contains a unique composition of macro-and micronutrients, immune cells, antibodies, growth factors and bioactive molecules not reproducible in formula.[20,21] It dynamically adapts to the infant’s developmental stage and protects against infections through immunoglobulin A, lactoferrin, oligosaccharides and microbiome-modulating components.[20] ALTERNATIVES WITHIN HUMAN MILK SPECTRUM Wet nursing Wet nursing remains a viable alternative where it is culturally acceptable and medically safe. It provides unprocessed milk and eliminates risks of contamination associated with pumping or transport.[22,23] The WHO recommended wet nursing during the COVID-19 pandemic when mothers were severely ill.[24] The United Nations Children’s Fund recently issued operational guidance to promote wet nursing in humanitarian emergencies, with robust screening mechanisms to address safety.[22] Expressed mother’s own milk Expressing allows the continued provision of breastmilk during maternal separation or return to work.[20,25] While expressing breast milk requires adequate protective, safe handling, storage and hygiene are critical to avert microbial contamination.[26] Workplaces must provide conditions to make expressing feasible.[27,28] Donor human milk Donor human milk (DHM) is prioritised through human milk banks when a mother’s milk is unavailable. Evidence shows that donor milk significantly reduces the incidence of NEC in preterm infants compared with formula.[12,13,28] Studies also indicate lower sepsis and mortality, underscoring its importance in neonatal intensive care units.[29] THE RISKS OF FORMULA AND BREASTMILK SUBSTITUTES BMS poses notable risks in both high-and low-resource settings. Formula-fed infants experience higher rates of diarrhoea and respiratory infections, even with proper preparation.[30] During emergencies, supply chain disruptions, unsafe water access and a lack of sterilisation capacity escalate the danger.[31,32] Beyond infection, the formula lacks critical bioactive factors, predisposing to long-term chronic disease risk.[21] Unethical promotion of BMS undermines maternal confidence. Despite the InternationalCodeofMarketingofBreastmilkSubstitutes (1981) restricting industry promotion, violations remain widespread.[8,32] In 2017, the WHO highlighted aggressive formula marketing campaigns as key obstacles to achieving global breastfeeding targets.[8] BARRIERS TO OPTIMAL BREASTFEEDING PRACTICES Several barriers exist to optimal breastfeeding practices [Figure 2].Figure 2: Illustrates the various barriers to breastfeeding. This figure was drawn through the premium version of BioRender (https://biorender.com/), accessed on 29 August 2025, with license numer GF28OVVLNJ,[ 10 ] Illustration Credit: Rahnuma Ahmad.MATERNAL EMPLOYMENT Return to work is a principal reason for early cessation. Mothers on short or absent maternity leave often discontinue breastfeeding prematurely.[7,27] Even when mothers continue, a lack of protected breaks, private lactation rooms and storage facilities makes exclusive breastfeeding nearly impossible.[33-35] Workplace culture – such as in emergency medicine – often minimises accommodations for nursing mothers.[33] SOCIOCULTURAL NORMS Public breastfeeding stigma, misconceptions about milk insufficiency and cultural prestige associated with formula undermine breastfeeding globally.[36-38] Misleading marketing intensifies these perceptions, especially in middle-income countries where the formula is equated with modernity.[8] HOUSEHOLD DYNAMICS Support from spouses, families and peers influences decisions. Paternal support has been shown to considerably improve breastfeeding initiation and duration.[39] Conversely, misinformation or discouragement by family members contributes to premature cessation.[37,40] HEALTHCARE SYSTEM GAPS Healthcare providers often lack competency in lactation management. Studies report mothers receiving limited or incorrect advice regarding latching, frequency and supplementation.[26,41] Separation of newborns post-delivery and lack of early skin-to-skin contact further reduce success.[42] Initiatives like the Baby-Friendly Hospital Initiative[43] aim to standardise and improve practices globally. MATERNAL MENTAL HEALTH Depression and anxiety are associated with early breastfeeding cessation.[18,19] Mothers of preterm or ART-conceived infants experience additional stress, compounding vulnerabilities.[23,42] Adequate counselling and psychosocial support are therefore integral. INFANT FEEDING IN EMERGENCIES: OPERATIONAL GUIDANCE ON INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES Emergencies can compromise optimal feeding by disrupting access to essential services, including healthcare, water and safe environments. Infants displaced by disasters or conflict face extremely high risks when breastfeeding is interrupted.[31] The OG-IFE, endorsed by the World Health Assembly, provides a global framework prioritising infant feeding safety.[31] OG-IFE emphasises (i) re-lactation through counselling, (ii) wet nursing was acceptable and safe, (iii) mother’s expressed milk should be maintained with strict hygiene, (iv) DHM from recognised banks and (v) infant formula only under strict monitoring, with prohibition of donations.[31,32] Formula provision is limited to controlled instances, given that there are risks of contamination and dependency. OG-IFE also highlights the importance of complementary feeding from 6 months and creating ‘mother-baby safe spaces’ in crises to sustain breastfeeding.[19] EMERGING TRENDS: TECHNOLOGY AND DIGITAL LACTATION SUPPORT The COVID-19 pandemic highlighted the potential of telehealth in lactation support.[43] Surveys in Canada and the United States show high maternal satisfaction with online consultations, particularly among first-time mothers.[24,43] However, virtual services cannot replace physical assessments, such as correcting latch technique. Social media platforms serve as both supportive spaces and channels for the dissemination of misinformation. Hybrid models combining in-person and digital support could enhance accessibility while maintaining quality.[44] MATERNAL EDUCATION AND SUPPORT REGARDING BREASTFEEDING Breastfeeding provides significant health and developmental benefits for infants and mothers, but many women encounter practical, physical and emotional barriers when initiating and continuing breastfeeding. To overcome these challenges, enhanced education on how breastfeeding works, guidance on resolving difficulties and awareness of normal infant behaviours are essential. Mothers consistently express a desire for such knowledge, coupled with tailored emotional and practical support.[45] Evidence across a wide range of studies demonstrates that breastfeeding support, whether provided by healthcare professionals, trained volunteers or community peers, plays a crucial role in meeting public health goals to improve breastfeeding rates in the United Kingdom. Importantly, this support is most effective when delivered in a consistent, accessible and context-specific manner.[46] A key element of this provision is peer support, typically offered by mothers who have previously breastfed and can provide experiential and empathetic assistance. In some cases, peer supporters undergo formal training, while in others, support is more informal.[47] Although findings on the impact of peer support on breastfeeding initiation and continuation rates remain mixed – often due to differences in how interventions are implemented and evaluated[48] – research consistently highlights that mothers perceive such support as highly valuable.[49] When integrated with professional services and delivered across multiple environments, peer support appears to have the most substantial effect.[41,50,51] However, over recent years, multiple factors – including cuts to community health budgets and restrictions during the COVID-19 pandemic – have limited access to in-person peer support opportunities. As a result, many mothers increasingly turn to online spaces and digital peer networks to seek help with breastfeeding.[52-54] Rapid growth in smartphone use and the widespread adoption of social media (SM) platforms have transformed how new parents access health-related information.[55] Koh etal. 2024 in their scoping review reported that it was appraised ‘number of users at 4.9 billion worldwide’.[56] Nevertheless, another study revealed that ‘there were 5.41 billion SM users around the world at the start of July 2025, equating to 65.7% of the total global population’.[57] Social media platforms, therefore, represent a powerful medium for providing connection, advice and support. For many new mothers, SM networks have become an essential source of parenting knowledge and emotional reassurance, and most report that they find it beneficial during the transition into parenthood.[58] The COVID-19 pandemic further intensified reliance on online communities, as parents were socially isolated and unable to build face-to-face support networks.[59] While systematic evidence reviews suggest that traditional face-to-face breastfeeding support remains the most effective model,[46] these reviews were based on data collected before the widespread expansion of SM functionality. Since then, accessibility, interactivity and integration of online breastfeeding groups have increased substantially, and early evidence suggests that many mothers are positively engaging with these forums and reporting meaningful benefits.[60] Understanding mothers’ experiences of SM-based breastfeeding support is now a key public health priority. It is essential to explore both the reasons mothers choose online communities and which groups of women benefit most. This knowledge can help refine strategies to strengthen and target digital support services. Previous systematic reviews provide valuable insights, but with limitations. For example, some reviews have broadly evaluated internet-based interventions[61,62] while others have explicitly focused on breastfeeding outcomes.[62] Collectively, these studies underscore the importance of personalisation and interactivity in effective online interventions.[61] They also reinforce the potential of digital tools to act as valuable adjuncts to conventional care.[44,63] Despite these developments, no prior synthesis has concentrated exclusively on how women experience SM groups as a form of community-based breastfeeding support. With evolving patterns of technology use and growing recognition of peer-driven online networks, it becomes increasingly relevant to examine this dimension. By understanding women’s perspectives, future breastfeeding support services – both digital and in-person – can be designed to maximise accessibility, inclusivity and effectiveness. FUTURE DIRECTIONS Policy reform: Expansion of maternity leave and implementation of workplace lactation policies across sectors[26,34] Partner engagement: Inclusion of paternal perspectives in breastfeeding interventions[38] Emergency preparedness: Contextual adaptation of OG-IFE, including wet nursing guidelines and safe DHM expansion[30] Equity focus: Address disparities in breastfeeding that is linked to education, income and geography[9,39] Hybrid care: Evaluation of combined telehealth and on-site lactation interventions.[42,43] CONCLUSION Breastfeeding remains the safest and most effective method of feeding, conferring unmatched benefits to both infants and mothers. Alternatives within the human milk spectrum – such as wet nursing, expressed breast milk and donor milk – are superior to BMS across various contexts. Formula feeding, although necessary under strict criteria, poses significant health and survival risks, which are heightened during emergencies. Barriers such as workplace constraints, cultural stigma, inadequate healthcare support and maternal mental health challenges must be addressed systematically. The OG-IFE framework underscores the importance of protecting and promoting breastfeeding in emergencies while rigorously limiting formula use. Future directions demand multisectoral collaboration, equity-sensitive policies and innovative service delivery models. By strengthening breastfeeding promotion and human milk protection, public health gains can be maximised globally. Consent for publication The author has reviewed and approved the final version and agrees to be accountable for all aspects of the work, including any accuracy or integrity issues. Disclosure Mainul Haque works as an editorial team member of the Advances in Human Biology, India. The remaining authors declare that they do not have any financial involvement or affiliations with any organisation, association or entity directly or indirectly related to the subject matter or materials presented in this review paper. Data availability Information for this review paper is taken from freely available sources. Authorship contribution All authors contributed significantly to the work, whether in the conception, design, utilisation, collection, analysis or interpretation of data or all these areas. They also participated in the drafting, revision and critical review of the paper; gave their final approval for the version that would be published; decided on the journal to which the article would be submitted and made the responsible decision to be held accountable for all aspects of the work.

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