A Call to Action: Improving Exclusive Human Milk Rates to Reduce Respiratory Illness and RSV

Diane L. Spatz, PhD RN-BC FAAN

As neonatal nurses, we have a vital role to play in public health issues. The National Association of Neonatal Nurses (NANN) endorses the use of human milk and breastfeeding for all infants, especially those requiring hospitalization (NANN, 2015).  Furthermore, in 2022, the American Academy of Pediatrics (AAP) released their updated position statement on human milk and breastfeeding and changed their recommendation that families should breastfeed for 2 years or more to align with the World Health Organization (WHO; Meek et al., 2022).

The United States faced ongoing formula shortages in 2022 and the focus of our government has been how to bring more formula into the country. There have not been initiatives to help families make an informed feeding choice for human milk and breastfeeding (Spatz, 2022). Furthermore, since the fall of 2022, hospitals have been stretched and at capacity due to high levels of the flu, respiratory illnesses, and respiratory syncytial virus (RSV). In the newspaper articles, television reports and social media postings I viewed, no one mentioned a cost-free intervention to address this public health concern: human milk and breastfeeding.

Exclusive breastfeeding for 6 months reduces the risk of lower respiratory illness by 19% compared to exclusive breastfeeding for less than 4 months (Meek et al., 2022), and exclusive breastfeeding also reduces the incidence and severity of RSV (Jang, et al 2020).

Infants who received an exclusive human milk diet were less likely to require oxygen therapy (4.3%) versus infants who received mixed human milk/formula diets (8.1%) versus infants who received an exclusive formula diet (13.5%; p = 0.042; Jang, et al 2020). The odds ratios (ORs) for infants requiring oxygen therapy were significantly higher in the formula-fed infants versus the infants exclusively fed human milk (adjusted OR, 3.807; 95% confidence interval, 1.22-11.90; P=0.021; Jang, 2020).

Thus, when considering the high rates of respiratory illness and RSV, there is considerable opportunity for we, as members of NANN, to call for and endorse strategies to improve exclusive human milk feeding rates during the first 6 months of life.

In the United States, only one out of four infants receive exclusive human milk feeds for the first 6 months (Centers for Disease Control and Prevention [CDC] Breastfeeding Report Card 2022). The AAP also reports that the disparities in human milk and breastfeeding represent significant inequity disproportionately impacting the non-Hispanic Black population (Meek et al., 2022). NANN members can and should do more to promote and protect human milk feeding, especially in at-risk groups. The AAP position statement states that implicit bias, structural racism, and structural bias must be addressed to eliminate disparities to improve human milk and breastfeeding outcomes.

Even with pediatric primary-care centers prioritizing breastfeeding interventions, it can be challenging for at-risk families to meet their personal breastfeeding goals (Kawan, Gregory & Spatz, 2022). The Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act could help. Introduced into Congress in May 2021, it wasn’t signed into law until December 23, 2022, as part of a $1.7 trillion omnibus spending bill. It extends protections to 9 million parents who were not covered by the 2010 Break Time for Nursing Mothers law, requiring employers to provide reasonable time and space to pump milk. But first, parents must make the decision to feed their child human milk.

The first step of my 10-step model, the Spatz 10-step model for human milk and breastfeeding in vulnerable infants, is informed decision-making for all families, which I know is not happening in clinical practice (Spatz, 2018). NANN members should prioritize educating families about how an exclusive human milk diet is an important strategy to reduce respiratory illness and RSV. We should call for public health campaigns that address the important role of human milk in keeping infants healthy, especially during flu and virus season.

As NANN members, we should be ensuring that ALL families (regardless of ethnicity, income, or education) can learn about the science of human milk and the physiology of lactation so that they can start and continue to provide human milk for their children. Research has demonstrated that when families learn about human milk and breastfeeding from a science-based perspective, they not only choose to initiate pumping/breastfeeding but they also provide milk at statistically significantly higher rates compared to national data (Froh et al., 2020; Froh & Spatz, 2022).

Once we help families make informed feeding choices, we also must ensure that they achieve a robust milk supply so they can provide a 100% human milk diet to their child. Step 2 of my model is initiation and maintenance of milk supply (Spatz, 2018). The first hours after birth and the first 3–5 days are critical for the conversion from secretory differentiation to secretory activation. As NANN members, we must address this critical window of opportunity for families to effectively establish milk supply. Ideally, all infants should be in skin-to-skin contact and directly breastfeed within the first hour of life. However, we know this is not feasible for many infants. Therefore, if an infant is unable to directly feed at the breast or is NOT feeding effectively, we must prioritize early, frequent pumping with a high-quality computer chip breast pump (Spatz et al., 2015).

To increase exclusive human milk rates at 6 months, we need to have a sense of urgency about milk supply in the first hours after birth, the first 3–5 days, the first week, and the first 2 weeks. Data is crystal clear that if we do not have a robust milk supply early, we will never be able to increase exclusive human milk and breastfeeding rates at 6 months.

NANN members, this is your call to action! Each day in your clinical practice, in your communities, and in your professional roles, we need you to prioritize informed decision-making and establishment of milk supply. You have an important role in protecting human milk and breastfeeding and increasing exclusive human milk rates for the first 6 months of your patients’ life. Implementing the first two steps of my model could go a long way to improving exclusive human milk rates to provide long-term protection of infants from respiratory illnesses and RSV.

Diane L. Spatz, PhD RN-BC FAAN is a professor of perinatal nursing and the Helen M. Shearer professor of nutrition at the University of Pennsylvania School of Nursing. She shares a joint appointment as a nurse scientist in lactation at the Center for Pediatric Nursing Research and Evidence Based Practice at Children’s Hospital of Philadelphia. She can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..


Centers for Disease Control and Prevention. (2022). Breastfeeding report card, 2022. https://www.cdc.gov/breastfeeding/pdf/2022-Breastfeeding-Report-Card-H.pdf

Froh, E. B., Schwarz, J., & Spatz, D. L. (2020). Lactation outcomes among dyads following participation in a model of group prenatal care for patients with prenatally diagnosed fetal anomalies. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 15(11), 698–702. https://doi.org/10.1089/bfm.2020.0061

Froh, E. B., & Spatz, D. L. (2022). Lactation outcomes after participation in a tailored prenatal nutrition consultation among women with infants with congenital anomalies. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 51(6), 590–598. https://doi.org/10.1016/j.jogn.2022.07.007

Jang, M. J., Kim, Y. J., Hong, S., Na, J., Hwang, J. H., Shin, S. M., & Ahn, Y. M. (2020). Positive association of breastfeeding on respiratory syncytial virus infection in hospitalized infants: A multicenter retrospective study. Clinical and Experimental Pediatrics, 63(4), 135–140. https://doi.org/10.3345/kjp.2019.00402

Kawan, M., Gregory, E. F., & Spatz, D. L. (2022). Improving breastfeeding care & support in a large, urban, pediatric primary care practice. Journal of Pediatric Nursing, S0882-5963(22)00253-6. Advance online publication. https://doi.org/10.1016/j.pedn.2022.10.007

Meek, J. Y., Noble, L., & Section on Breastfeeding (2022). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 150(1), e2022057988. https://doi.org/10.1542/peds.2022-057988
National Association of Neonatal Nurses. (2015, April). The use of human milk and breastfeeding in the neonatal intensive care unit (Position Statement 3065). https://nann.org/uploads/About/PositionPDFS/1.4.3_Use%20%20of%20Human%20Milk%20and%20Breastfeeding%20in%20the%20NICU.pdf

Spatz D. L. (2018). Beyond BFHI: The Spatz 10-step and breastfeeding resource nurse model to improve human milk and breastfeeding outcomes. The Journal of Perinatal & Neonatal Nursing, 32(2), 164–174. https://doi.org/10.1097/JPN.0000000000000339

Spatz, D. L., Froh, E. B., Schwarz, J., Houng, K., Brewster, I., Myers, C., Prince, J., & Olkkola, M. (2015). Pump early, pump often: A continuous quality improvement project. The Journal of Perinatal Education, 24(3), 160–170. https://doi.org/10.1891/1058-1243.24.3.160