A recent report from the Centers for Disease Control and Prevention (CDC) shows significant disparities in human milk receipt based on gestational age and sociodemographic factors (Chiang, Sharma, Nelson, Olson, & Perrine, 2019). Prevalence of term infants receiving human milk was 84.6%; however, only 71.3% of extremely preterm infants, 76.0% of early preterm infants, and 77.3% of late preterm infants received any human milk. Racial and ethnic disparities were observed with infants born to black mothers and American Indian/Alaska Native mothers having the lowest exposure to human milk. Infants whose mothers were younger, less educated, unmarried, and participating in Medicaid or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were less likely to receive human milk (Chiang et al.).

These data are concerning because for preterm infants or other vulnerable infants (such as those requiring surgery at birth), human milk is a lifesaving medical intervention (Chiang et al., 2019; Davis & Spatz, 2019, Spatz, 2004, 2018). In 2004, I developed a model to improve use of human milk and breastfeeding for vulnerable infants (Spatz, 2004). If the first two steps of this model were implemented in all healthcare setting across the United States, we could realize improved human milk rates for infants who most need it.

The first step is "Informed Decision" (Spatz, 2004, 2018). Given the sociodemographic disparities noted in the CDC data, it is clear that all families are not given the same information or opportunity to make an informed feeding choice. At Children's Hospital of Philadelphia, I provide personalized prenatal nutrition counseling based on the science of human milk and the physiology of lactation for families with known congenital anomalies. Families are taught how human milk will reduce risk of sepsis and necrotizing enterocolitis and its association with improved feeding tolerance, fewer intravenous line days, and potentially a shorter length of stay. Unique components of human milk (such as lactoferrin, stem cells, white blood cells, human milk oligosaccharides, osteopontin, antibodies, and antioxidants) that are not present in infant formula are covered. The second step of the model is "Initiation & Maintenance of Milk Supply" (Spatz, 2004, 2018). "Pumping early and pumping often" is vital (Spatz, 2004, 2018). By helping families learn there is a critical window of opportunity for establishing milk supply, they can be empowered to pump milk within the first hour after birth and concentrate on the first 3 to 5 days, the first week, and the first 2 weeks to enhance production.

If we shift our emphasis to that critical window of opportunity and ensure that milk supply comes to full volume (500 to 1,000 mL per day), infants will get more than just early feeds as human milk (Spatz, 2004, 2018). Our most vulnerable infants should receive 100% human milk diet for the entire hospital stay and beyond. Antenatal care is the ideal time to focus on Steps 1 and 2 so that families can reach their personal breastfeeding goals.

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