Of babies born in the United States in 2023, 86.1 percent were breastfed at least once. By six months, 29.8 percent were still being fed breast milk and nothing else. Both numbers come from the CDC’s National Immunization Survey, and the distance between them is the real story of American infant feeding.
Most families don’t land cleanly on one side of the line. They start one way, hit something they didn’t plan for, and end up doing some of both. Then a lot of them feel like they failed.
This article is about what the evidence supports, what it doesn’t, and how a family decides. It isn’t about what kind of parent you are. The arc of the whole first year, the mechanics of starting solids, and supplements each have their own article in this library.
What the recommendation says, and who says it
Two federal sources state it a little differently, and the difference is worth seeing up front.
The Eunice Kennedy Shriver National Institute of Child Health and Human Development, in material last reviewed in October 2022, cites the American Academy of Pediatrics recommending only breast milk for the first six months after birth, with solid foods then introduced slowly while breastfeeding continues until age one.
CDC’s breastfeeding page, updated in July 2026, cites the Dietary Guidelines for Americans, the AAP and the World Health Organization recommending exclusive breastfeeding for about the first six months, then complementary foods around six months while breastfeeding continues to age two or beyond.
The first six months is the part they all agree on. The far end has moved outward over the years, and where your family lands on it is a conversation with your clinician, not a pass-fail test.
One practical note before the evidence. CDC says breastfed infants need extra vitamin D starting at birth and may need iron. That belongs to this library’s article on supplements for children, and the amount for your baby is a question for your baby’s doctor.
What the evidence supports, and where it gets shaky
Read NICHD’s own benefits page closely and you can watch a federal agency sorting its claims by confidence.
Three things are stated flat. Breast milk provides essential nutrition. It offers some protection against common childhood infections. Breastfeeding is linked to better survival in the first year, including lower risk of sudden infant death syndrome.
Then the verbs change. Allergic disease, asthma, obesity, type 2 diabetes and cognitive development all arrive carrying “may” and “suggest.” NICHD closes that section with a sentence most popular coverage skips: “more research is needed to confirm these findings.”
The largest American evidence synthesis points the same direction. Ip and colleagues published a summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries in 2009, drawing on roughly 400 individual studies. A history of breastfeeding was associated with lower risk of ear infections, gastroenteritis, severe lower respiratory infections, atopic dermatitis, asthma in young children, obesity, type 1 and type 2 diabetes, childhood leukemia and SIDS. For mothers, a history of lactation was associated with lower risk of type 2 diabetes, breast cancer and ovarian cancer, and the report linked no breastfeeding or early cessation to higher risk of postpartum depression.
Two findings in that report get much less airtime. The reviewers found no relationship between breastfeeding and cognitive performance in term infants, and found the data insufficient to say anything useful about cardiovascular disease or infant mortality.
Why “associated with” is doing so much work
Almost all of that evidence is observational. Researchers compare children who were breastfed with children who weren’t, then adjust for the differences they can measure.
The trouble is who breastfeeds. In the United States, breastfeeding tracks income, education, job type, paid leave, and race. Those same factors track a child’s later health through a dozen other routes: housing, air quality, food security, access to care. Compare the two groups and you aren’t only comparing milk.
The AHRQ reviewers said as much. They recommended that future work use matched designs such as sibling analysis, specifically to control for hereditary and household factors.
The sibling study that rattled the field
Someone did exactly that. Cynthia Colen and David Ramey of Ohio State University published a 2014 analysis in Social Science and Medicine using 25 years of data from the National Longitudinal Survey of Youth.
Their method was simple and clever. Instead of comparing breastfed children to formula-fed children across different families, they compared siblings inside the same family who had been fed differently. Same parents, same household, same income, same neighborhood.
Run the standard models and breastfed children aged four to fourteen did significantly better on 10 of 11 outcomes. Restrict the comparison to siblings and add within-family fixed effects, and the estimates dropped sharply. All but one lost statistical significance. The authors concluded that much of the long-term benefit usually credited to breastfeeding may instead reflect who breastfeeds, along lines of race and socioeconomic status.
That’s one study with one design and real limitations. It doesn’t erase the infection findings, which involve short-term outcomes measured close to the exposure. What it does is put a ceiling on how confidently anyone should talk about breast milk and a child’s test scores at age ten.
The trial you can’t run
You cannot randomize families to feed their babies one way or the other. The closest anyone has come is PROBIT, a cluster-randomized trial in Belarus that enrolled 17,046 mother-infant pairs at 31 maternity hospitals in the mid-1990s. Hospitals, not mothers, were randomized to receive breastfeeding promotion training. It worked: exclusive breastfeeding at three months hit 43.3 percent in the intervention group against 6.4 percent in the control group.
The follow-ups are where it gets interesting. Kramer and colleagues reported in Pediatrics in 2008 that at age six and a half there was no measurable effect on child behavior, emotional symptoms, conduct problems, hyperactivity, peer problems or maternal adjustment. A separate follow-up in the International Journal of Epidemiology in 2014 did find something: at age eleven and a half, children in the intervention group had lower rates of problematic eating attitudes.
So the strongest design in the field produced a mixed picture. Some outcomes moved. Many did not. That’s what honest evidence usually looks like.
Formula is a regulated food, and that isn’t a consolation prize
Infant formula sold in the United States is one of the most tightly specified foods in the grocery store. The Food and Drug Administration sets regulations naming 30 nutrients that every infant formula sold here must contain. A manufacturer has to submit a new infant formula submission to FDA before marketing a product, and FDA reviews it against nutritional and safety requirements. FDA inspects formula plants annually. Products must be tested for Salmonella and Cronobacter. Water used in manufacturing has to meet Environmental Protection Agency safety standards. Labels must carry preparation directions, a pictogram of the main steps, and a use-by date.
FDA doesn’t approve infant formulas the way it approves drugs. It sets the floor, polices it, and can pull a product that fails. Every formula on the shelf, domestic or imported, has to clear that bar.
CDC adds the practical layer. Iron-fortified formula is the recommended choice, and most commercial formulas sold here contain iron. CDC states that standard iron-fortified formula, at 12 milligrams of iron per liter, can meet a baby’s iron needs for the first twelve months, and that a baby fed only formula generally doesn’t need a vitamin D supplement if they’re drinking at least 32 ounces a day. Those are the agency’s published figures, and whether they describe your baby is a question for your baby’s clinician.
Two shelf warnings are worth carrying. Products labeled for toddlers are not infant formula, and CDC says young children don’t need them and they typically contain added sugars. And formula imported through third-party online sellers may never have been reviewed by FDA or stored correctly, which is why both FDA and the AAP warn against it.
Two things to never do
Never make infant formula at home. In a February 2021 advisory, FDA said it had received adverse event reports of infants hospitalized with hypocalcemia, meaning dangerously low calcium, after being fed homemade formula. Recipes circulating online have not been evaluated, may deliver too little or too much of critical nutrients, and carry contamination risk. CDC warns that homemade infant formula “can lead to serious health problems for your baby.”
Never stretch formula with extra water. CDC states both sides of the error: too much water and the formula may not meet your baby’s nutritional needs, too little and it can overwork a baby’s kidneys and digestive system and lead to dehydration. If money is the reason you’re considering it, that’s a phone call, not a measuring cup. The USDA’s WIC program provides food at no cost, breastfeeding support, nutrition counseling and referrals for pregnant and postpartum women and children under five, and your pediatrician’s office knows what else is available locally.
Why it often doesn’t go to plan
Nobody plans for this part, and it’s where most of the guilt is manufactured.
Bodies. CDC says breastfeeding shouldn’t hurt once a baby is well latched, though tenderness in the early weeks is common. Pain can come from an improper latch, a plugged duct, or mastitis, which is a breast infection. CDC says pain with a fever warrants a prompt call, and that cracked skin, or pain that hasn’t improved in one to two weeks, needs professional help. Milk typically comes in around day three, later for some first-time mothers, and worry about supply is one of the most common reasons families reach for a bottle.
Mental health. Postpartum depression is more intense and longer-lasting than the “baby blues,” which usually fades within days. CDC says mothers with postpartum depression can usually keep breastfeeding and that safe treatment options exist, including medications. Contact a clinician right away if you suspect it. If you’re having thoughts of harming yourself or your baby, call or text 988 for the Suicide and Crisis Lifeline, or call 911.
Medicine. There are real medical reasons breastfeeding doesn’t happen, and they aren’t failures of effort. CDC’s list, updated in December 2025, includes classic galactosemia in the infant, maternal HIV without sustained viral suppression, HTLV-1 or HTLV-2 infection, and suspected or confirmed Ebola. Others mean a temporary pause: untreated brucellosis, certain medications, imaging with radiopharmaceuticals, active herpes lesions on the breast, and mpox. With untreated tuberculosis or chickenpox around delivery, CDC’s guidance allows expressed milk while direct feeding waits. None of this is a decision to make from a list. It’s a conversation with the clinician who knows the diagnosis.
Work. The PUMP for Nursing Mothers Act became law on December 29, 2022. Under it, most nursing employees get reasonable break time each time they need to express milk, plus a space that is not a bathroom, is shielded from view, and is free from intrusion, for up to one year after the birth. The Department of Labor says the law reached workers previously left out, including agricultural workers, nurses, teachers, truck drivers, home care workers and managers. Notice what it gives: time and a room. It does not give paid leave, and it does not help the worker who can’t step away from a line or a classroom on an unpredictable schedule.
Hard starts. A NICU admission, a preterm birth, an adoption, or a complicated delivery changes the whole equation. Fleurant and colleagues followed 362 mothers of very-low-birth-weight infants and published their findings in Breastfeeding Medicine in 2016. A mother’s own feeding goal near discharge strongly predicted whether her baby went home on human milk. So did WIC eligibility, in the other direction. For Black mothers in the study, lower perceived support from the infant’s maternal grandmother predicted lower rates of human milk feeding at discharge. Support is a resource, and it isn’t distributed evenly.
Combination feeding is a choice, not a compromise
Look again at the national numbers. In the 2023 birth cohort, 62.8 percent of babies were getting at least some breast milk at six months, while 29.8 percent were getting breast milk alone. A large share of American families are doing both.
CDC treats that as normal. Its FAQ page has a question about feeding both breast milk and formula, and the answer is simply that patterns differ and parents should talk with their baby’s doctor or nurse.
There’s research on what all-or-nothing framing does to people. Scott and Bute interviewed 20 women who had used formula in the first six months and published their analysis in Health Communication in 2024. The women described absorbing the breast-is-best message so completely that it shaped how they saw themselves as mothers, including as shameful ones. What they wanted was messaging that moved away from all-or-nothing framing and showed the range of ways families feed babies. The paper’s title takes one participant’s phrase, that it doesn’t have to be all or nothing.
A fed baby who is gaining weight is the outcome. The route is logistics.
How families decide
Skip the pros-and-cons list. Four questions do the work. Answer them honestly.
- What does my baby’s clinician say about growth right now? This is the only one with an objective answer, and it outranks the other three. A baby gaining well on any feeding method is a baby who is fine.
- What is the current plan costing me, truthfully? Count pain, sleep, time spent pumping, and hours you aren’t spending with your other children. A plan that is wrecking you isn’t sustainable, and an exhausted parent is a safety issue in its own right.
- What support can I get in the next three days? Not in theory. A lactation consultant with an opening, a WIC appointment, a partner who takes the night shift. Most feeding crises are solvable with help that arrives soon enough.
- What is my plan B, and have I said it out loud? Families who decide in advance what they’ll do if supply drops or leave ends handle the switch better than families who treat it as a collapse.
You can change the answer later. Plenty of families switch more than once in a year.
Signs that need a clinician right away
Know these cold, whichever way you’re feeding.
CDC lists several signs that a newborn may not be getting enough: continued weight loss after day five, fewer than six wet diapers and fewer than three stools by day five, feeding fewer than eight times in 24 hours on most days, no visible or audible swallowing during feeds, trouble staying latched or clicking sounds while feeding, fussiness after a feed, and mild yellowing of the skin. CDC’s instruction with that list is to contact your baby’s health care provider right away.
MedlinePlus, from the National Library of Medicine, lists the signs of dehydration in infants and young children: a dry mouth and tongue, crying without tears, no wet diaper for three hours or more, a high fever, unusual sleepiness, irritability, and sunken eyes. It says dehydration can be life-threatening.
Add two. A baby who refuses feeds repeatedly or is unusually hard to wake needs to be seen that day. A baby who is struggling to breathe is a 911 call, not a phone-tree call.
For the parent: breast pain with a fever gets a prompt call. So does any suspicion of postpartum depression.
What to take from all this
The recommendation and the guilt are two different objects, and it helps to stop treating them as one.
The recommendation is a population-level target built on evidence that is strong for some outcomes, thin for others, and honestly uncertain for the long-term claims that get the most attention. Federal agencies say so in their own documents. The guilt isn’t evidence of anything. It’s the residue of a message that got flattened on its way to you.
This is the useful version. Breast milk is a good default where it’s working. Formula is a regulated, nutritionally complete food, and a baby raised on it isn’t starting behind. Combination feeding is what a large share of American families already do. Never make formula at home and never water it down. And the question that matters in any given week of the first year is whether your baby is growing, which belongs to the person with the scale.
Sources
- Eunice Kennedy Shriver National Institute of Child Health and Human Development. “Breastfeeding and Breast Milk.” nichd.nih.gov
- Eunice Kennedy Shriver National Institute of Child Health and Human Development. “What are the benefits of breastfeeding?.” nichd.nih.gov
- Centers for Disease Control and Prevention. “Breastfeeding Fast Facts.” cdc.gov
- Centers for Disease Control and Prevention. “What to Expect While Breastfeeding.” cdc.gov
- Centers for Disease Control and Prevention. “Newborn Breastfeeding Basics.” cdc.gov
- Centers for Disease Control and Prevention. “National Breastfeeding Rates: Results (National Immunization Survey-Child).” cdc.gov
- Centers for Disease Control and Prevention. “When Breastfeeding or Feeding Expressed Breast Milk Is Not Recommended.” cdc.gov
- Centers for Disease Control and Prevention. “Choosing an Infant Formula.” cdc.gov
- Centers for Disease Control and Prevention. “Infant Formula Preparation and Storage.” cdc.gov
- Centers for Disease Control and Prevention. “Frequently Asked Questions: Infant and Toddler Nutrition.” cdc.gov
- U.S. Food and Drug Administration. “Infant Formula.” fda.gov
- U.S. Food and Drug Administration. “FDA Advises Parents and Caregivers to Not Make or Feed Homemade Infant Formula to Infants.” fda.gov
- U.S. Department of Labor, Wage and Hour Division. “Pump at Work: Break Time for Nursing Employees.” dol.gov
- U.S. Department of Agriculture, Food and Nutrition Service. “WIC: Special Supplemental Nutrition Program for Women, Infants, and Children.” fna.usda.gov
- PubMed. “Ip S et al. "A summary of the Agency for Healthcare Research and Quality's evidence report on breastfeeding in developed countries." Breastfeeding Medicine, 2009. DOI: 10.1089/bfm.2009.0050.” doi.org
- PubMed. “Colen CG, Ramey DM. "Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons." Social Science & Medicine, 2014. DOI: 10.1016/j.socscimed.2014.01.027.” doi.org
- PubMed. “Kramer MS et al. "Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: evidence from a large, randomized trial." Pediatrics, 2008. DOI: 10.1542/peds.2007-1248.” doi.org
- PubMed. “Skugarevsky O et al. "Effects of promoting longer-term and exclusive breastfeeding on childhood eating attitudes: a cluster-randomized trial." International Journal of Epidemiology, 2014. DOI: 10.1093/ije/dyu072.” doi.org
- PubMed. “Scott SF, Bute JJ. "'It Doesn't Have to Be All or Nothing': How Individuals Who Use Infant Formula Understand the Breastfeeding Master Narrative." Health Communication, 2024. DOI: 10.1080/10410236.2024.2344284.” doi.org
- PubMed. “Fleurant E et al. "Barriers to Human Milk Feeding at Discharge of Very-Low-Birth-Weight Infants: Maternal Goal Setting as a Key Social Factor." Breastfeeding Medicine, 2016. DOI: 10.1089/bfm.2016.0105.” doi.org