Despite known benefits, breastfeeding rates in the United States (U.S.) fall short of the U.S. Government's Healthy People 2030 objectives, which include increasing the percent of infants exclusively breastfed to at least six months of age to 42.4% and increasing the percentage of infants who are breastfed at 1 year to at least 54.1% (1–3). In 2025, U.S. rates are 27.7% for exclusive breastfeeding to 6 months and 39.5% for continued breastfeeding through 12 months (4). Factors contributing to the U.S. not meeting breastfeeding objectives include the effects of unrestricted infant formula marketing, the absence of comprehensive paid maternity leave and workplace lactation policies, and social norms that do not encourage breastfeeding, which are underscored by ethnic, racial, income, and educational disparities (3, 5–7).

Public health nutrition experts endorse public policies that support and promote optimal feeding of infants and young children (0–24 months) in the U.S. and globally (5, 8–10). Increasing breastfeeding behaviors would contribute to reaching both Healthy People 2030 national public health aims in the U.S. and the United Nation's Sustainable Development Goals (SDGs) (11, 12). The SDGs are a set of global priorities to improve health and education, increase economic growth, and reduce inequalities.

In 2017, the Global Breastfeeding Collective (GBC), a global partnership of agencies, including the US Agency for International Development and the U.S. Centers for Disease Control and Prevention (CDC), was launched by the World Health Organization (WHO) and the United Nations Children's Fund to speed global progress toward the achievement of breastfeeding targets by coalescing around shared policy priorities in the WHO's Global Strategy for Infant and Young Child Feeding (10, 13–15). The aim of the GBC is to increase the adoption, implementation, and enforcement of recommended policy priorities that protect, promote, and support breastfeeding. The GBC calls on governments to (1) increase funding to raise breastfeeding rates; (2) fully implement the International Code for Marketing of Breastmilk Substitutes (“the Code”), a set of legal guidelines aimed to restrict the promotion of infant formula by industry to protect breastfeeding, which the U.S. has not formally adopted (16–18); (3) enact paid family leave and workplace policies; (4) implement the “Ten Steps to Successful Breastfeeding” in maternity facilities, a package of health care programs and policies in support of breastfeeding and to follow the Code in facilities designated as Baby-Friendly (19, 20); (5) improve access to skilled breastfeeding counseling; (6) strengthen links between health facilities and communities; (7) strengthen monitoring systems that track the progress of [breastfeeding] policies, programs and funding; and [expand]; (8) infant and young child support in emergencies (13). These policy priorities are recommended for all countries, developed and developing.

The GBC uses data sources, including from the CDC and the World Breastfeeding Trends Initiative (WBTi), to track country-level implementation and performance across recommended policy priorities to monitor and assess progress toward the targets in the Global Breastfeeding Scorecard (10, 21–23). The WBTi, which is a collaborative network, follows country-level progress toward global targets to assess, monitor, and publicly display infant and young child feeding programs and policy progress using standardized metrics, and it compiles country reports that are used to update the GBC Scorecards (21–24). Based on 2019 data, the most recently available, the U.S. scored 40.5 on a 100-point scale, ranking it in the bottom quintile of countries, underscoring the need for improvements (15, 25).

Most U.S. infants are fed infant formula in the first year of life for part or all of their nutrients and infant diets globally are moving to formula feeding (26, 27). For families feeding infants with infant formula, it is an essential food (28). The COVID-19 pandemic and 2022 infant formula shortage (henceforth, “shortage”) in the U.S. affected infant formula supply chains, shifted breastfeeding and formula feeding practices, and affirmed infant formula as a critical food source to be protected (28–31). The shortage highlighted systematic inequalities, as populations with low incomes and from racial and ethnic minority groups were more likely to have to take on negative coping behaviors in response to the shortage (32–34). In light of the shortage, policymakers called for action to maintain and protect infant formula supply and public health nutrition experts urged policy responses that would support breastfeeding, in addition to protecting infant formula supply over the long-term (28, 29, 32, 35, 36).

The purpose of this study was to determine how federal U.S. infant feeding policy changes compare to the GBC policy area priorities. The extent to which U.S. federal policies, which tend to be stable and resistant to change (37), were adopted and substantively modified indicates attention to infant feeding as a public policy issue (38). A comparison of policy changes to GBC policy priorities identified through a policy scan assessing the timing and content of changes can be used to identify priorities and gaps in U.S. infant feeding policies and opportunities to enhance U.S. infant feeding policies within the highly connected and rapidly changing global food system (14, 39, 40).

Fifty-seven new or substantively modified U.S. federal infant feeding policies were identified (Table 3). Twenty-nine of the 57 policies (51%) addressed more than one infant feeding policy topic area. Seventeen of the 57 policies (30%) aligned with at least one of the seven GBC policy areas−15 with a single policy priority, one with two policy topic priorities, and one with three GBC priorities (Table 2). In total, the 57 new or substantively changed policies covered 116 topics coded into GBC and non-GBC policy areas; 10 of the 57 policies (18%) addressed both GBC and non-GBC policy areas. Of the 116 topics addressed, 20 (17%) aligned with the seven GBC policy priorities and 96 (83%) topics were outside of GBC policy priorities (Figure 2; Table 3).

The purpose of this study was to explore how changes in U.S. federal infant feeding policies compared to recommendations in the GBC policy priorities. It complements existing state and national assessments of U.S. breastfeeding policy implementation by examining changes across breastfeeding and infant formula policies and alignment with global priorities (52–57). While 17 of the 57 (30%) policies examined aligned with at least one of the GBC policy priorities, the other 70% did not align with any and the majority (49 out of 57, 86%) included changes outside the scope of the GBC priorities. Although U.S. and global progress for exclusive breastfeeding to the age of 6 months is increasing in comparison to past assessments, progress remains short of targets across multiple breastfeeding indicators (4, 22, 58). The lack of alignment between U.S. and GBC policy priorities suggests missed opportunities and challenges to promote, protect, and support breastfeeding in the U.S., which are consequential because misaligned policies can hinder the achievement of intended outcomes (59, 60). Furthermore, the GBC reported in 2025 that among 106 countries, 75 countries, including the U.S., reported increases in breastfeeding rates since 2017, but 29 countries reported decreases in breastfeeding (22).

Increasing funding to raise breastfeeding rates from birth to 2 years of age is an important GBC priority that was not compared against U.S. federal spending in this study. Assessment of funding was outside the scope and U.S. federal breastfeeding appropriations to agencies and programs is tracked by the United States Breastfeeding Collaborative, a breastfeeding support coalition (61). Modeling estimates of the costs of not breastfeeding in the U.S. document racial/ethnic breastfeeding disparities and that substantial health care costs could be prevented by improved breastfeeding rates (7, 62). A 2024 review concluded that total costs of not breastfeeding were typically calculated to be greater than approximately U.S.$100 billion in the U.S. and U.S.$300 billion globally each year, despite a diverse range of approaches and methods used (62). However, funding estimates to implement breastfeeding strategies vary and may be conservative, in part because the costs focused on health care approaches (e.g., lactation counseling) and other costs such as maternal time and/or social policies (e.g., paid leave) to protect breastfeeding were not adequately incorporated (62, 63).

Moreover, the GBC funding indicator is limited to the percentage of countries achieving a target of at least $5 USD per birth based on donor funding, a metric based on recommendations from the World Health Assembly to reach global exclusive breastfeeding targets (22). According to the 2024 GBC Scorecard report, which highlighted the need for accelerated government and donor commitments for breastfeeding, only 4% of countries globally met the GBC funding metric and already insufficient donor breastfeeding development aid contributions were dropping (22). No U.S. data was provided on the GBC funding indicator in the online GBC Scorecard (23). To help meet the GBC call to accelerate in-country and foreign-assistance donor commitments for breastfeeding worldwide, including medium and high-income countries, harmonization with and additional measures that assess progress toward funding targets across a range of GBC policy priorities, including from the Nutrition Accountability Framework of the Global Nutrition Report that monitors donor commitments (58), is warranted.

No policy changes identified in this study related to the marketing of infant formula. In the absence of Code implementation in the U.S., policies allow for the unrestrained marketing of infant formula and industry self-regulation, impeding breastfeeding and beneficial maternal, infant, and child health outcomes (3, 64–66). Researchers have identified federal policy actions that could be enacted across multiple agencies and levels to protect against deceptive infant formula marketing and health claims to align U.S. policies more closely with the Code, without formal endorsement (64, 67). Examples include ensuring that FDA infant formula labeling regulations follow those in the Code, mandating that infant formula manufacturers with WIC contracts adhere to provisions in the Code, and disallowing the distribution of free infant formula in hospital settings (17, 64, 67). Such policy changes were not identified in this study, but represent a future opportunities for research and policy.

Laws protecting workplace breastfeeding, including the provision of break times and paid maternity leave are associated with improved breastfeeding initiation and increased breastfeeding at 6 months (53, 68–70). The eight breastfeeding and work accommodation policies identified in this study suggest progress in closing the gap between U.S. and global policy priorities related to leave, breaktimes, lactation facilities, and privacy protections (23, 71). However, the U.S. policy of 12 weeks unpaid leave time falls far short on the paid family leave target in the GBC scorecard of 18 weeks of paid maternity leave, which was informed by International Labor Organization recommendations (and additionally fall short of 12-week paid family and medical leave recommendations endorsed by the U.S. Breastfeeding Committee) (23, 72, 73). This is consistent with other studies finding that the U.S. lacks comparable federal family leave policies and workplace breastfeeding protections to other high- and-middle-income countries (56, 69, 72, 74). The U.S. falls behind the number of weeks of leave benefits that are legislated in countries including the United Kingdom (52 weeks of which 39 weeks are paid), every country in Europe and Central Asia (ranging between 14 and 58 weeks), and either behind or on par with countries in the Americas (e.g., Canada has 17 weeks of leave; Uruguay 14 weeks, Jamaica and Mexico each have 12 weeks) (71).

The only policy change that specifically referenced unpaid leave policies and included language about breastfeeding support was the 2014 presidential memo to enhance workplace flexibilities and balance for families. While the 2022 PUMP Act extended breastfeeding privacy and the provision of “reasonable” break periods to a greater range of employee types, including home care workers, drivers, teachers, nurses, and agriculture workers, the PUMP Act does not require paid breaks and does not apply to all employee types (75). This highlights inequalities and persistent policy gaps in U.S. breastfeeding support.

No policy changes related to infant feeding in hospitals or supported the GBC aim to “Implement the Ten Steps to successful breastfeeding in maternity facilities”. According to the CDC, 29% of U.S. live births occur in Baby-Friendly designated hospitals, which falls short of GBC indicator target that >50% of births occur in Baby-Friendly facilities (22, 76). In comparison, the GBC reports from country-level data that none (0%) of the delivery facilities in France and 43% of facilities in Mexico are reported as Baby-Friendly, which raises country level considerations (22). In the U.S., unique factors including the absence of a nationalized health system and the fact that hospital policies are regulated and monitored at the state level may account for not meeting the GBC Ten Steps implementation goal. A 2023 review of Baby-Friendly Hospital Initiative implementation in Mexico found uneven monitoring of Baby-Friendly Hospitals and monitoring of the Ten Steps in facilities (77). Overall, following previous recommendations, these findings highlight the importance of considering country specific contexts and need for timely, publicly available, and transparent data to assess progress, enhance comparability, and evaluate possible replicability of approaches across different settings (14, 56).

Only one policy corresponded to the GBC skilled breastfeeding counseling policy, which was the 2023 amendment to military law aimed to support military spouses to become Internationally Board-Certified Lactation Consultants or doulas, indicating an opportunity for increased training and skill development. Policies that provided community-level lactation counseling included 2016 and 2022 WIC policy changes, 2014 modifications to medical benefits for military families, and 2016 lactation counseling referral changes in Head Start program services. The WIC policy changes were consistent with findings in a review by Anstey et al. (2016) that documented the redoubling of efforts by WIC to improve and expand breastfeeding counseling and address breastfeeding inequalities following the 2011 U.S. Surgeon General's Call to Action to Support Breastfeeding (5, 74). Increasing access to lactation counseling in military benefits likely reflected the influence of the 2014 TRICARE Moms Improvement Act, which was enacted to extend Affordable Care Act breastfeeding counseling and breastfeeding supplies to military members and families (78). The TRICARE program provides benefits to personnel in the U.S. Armed Forces, military retirees, and their dependents.

The GBC policy priority of infant and young child feeding support in emergencies, such as public health emergencies or disasters caused by natural catastrophes, is an overlooked but emerging U.S. policy priority (54, 72). Breastmilk is the safest source of nutrition for infants during emergencies, as infant formula supplies can be disrupted and infant formula donations can be disorganized (72, 79). The 2022 Access to Baby Formula Act included new language waiving administrative procedures during U.S. emergencies or disasters for infant formula, but breastfeeding support was not included, indicating a policy gap to promote and safeguard breastfeeding during emergencies.

Breastfeeding-forward policy changes outside of the scope of GBC policy priorities that could contribute to the achievement of breastfeeding objectives in the U.S., and possibly in other countries, were identified. A promising non-GBC policy that can promote breastfeeding was ensuring lactation spaces outside of the home in work and public spaces. Many mothers have reported feeling embarrassed to breastfeed away from home, are not universally protected from being asked to leave public spaces when lactating, and need support to breastfeed outside of the home (5, 52, 56, 74). Specific to public spaces, six policies were put in place to support breastfeeding outside of the home, including a mandate to provide lactation spaces in airports and in child care program settings. While no U.S. federal policy allows breastfeeding in all private and public locations, some local and state level policies do (52, 56).

Increasing access to breastfeeding supplies is a non-GBC policy with the potential to support breastfeeding. Two changes included language about the provision of breastfeeding supplies to improve breastfeeding outcomes. Breast pumps have been widely used to initiate and maintain breastfeeding (80). Nardella et al. (81) found that breast pump use among mothers enrolled in Medicaid was associated with an average of over 20 more weeks of breastfeeding compared to mothers not using breast pumps, with the strongest associations found among Black and Native American respondents. This suggests a potential for policies that increase breastfeeding supplies to minimize breastfeeding disparities.

This study has limitations. It focused exclusively on U.S. federal-level policy change to assess national attention to infant feeding from policymakers. While the authors cast a wide net to capture policy change across a range of infant feeding topics across GBC and non-GBC topics to detect patterns and interpret policymaker attention, there are gaps in the comprehensiveness and depth in the results. Existing federal policies that were in place but did not change within the 10-year period studied were excluded from the study design. One example is the Patient Protection and Affordable Care Act (ACA) of 2010, which includes prenatal health and workplace protections (57, 72). Formal amendments have not been made to the ACA law, and any changes in rules guiding the implementation of the ACA would have occurred at levels not included in this study. The findings in this study complement but do not replace the findings in other studies assessing the implementation or impacts of topic-specific infant feeding policies (52–54, 56, 57). Future studies could include static infant feeding policies that have been in effect with policy changes for a more complete assessment. In addition, while the focus on federal policy change allowed for an assessment of federal policy priorities, it did not account for state level changes Infant feeding laws have been shown to be variable across different states (52). In agreement with past recommendations, it is important to assess infant feeding policy implementation and changes at the state, global and other levels to determine policy coherence across multiple levels (52, 53, 59, 60, 64).

An additional limitation is that the policies included in the study were each given the same weight when they vary in scope, enforcement mechanisms, and potential for public health impact. For example, passage of the 2022 PUMP for Nursing Mothers Act (29 USC §218d)—an amendment to the 2010 Break Time for Nursing Mothers law in the Fair Labor Standards Act, which made important rule changes expanding workplace accommodations to pump breastmilk—is more significant and broader than a specific rule change in 2014 to enhance the traceability of infant formula (21 CFR §106.80). This comparison demonstrates the challenges of equating the weight the policy changes but also demonstrates the range of U.S. infant feeding policies and the stated commitment of U.S. policy makers to specific topics in infant feeding.

The GBC aim is to increase the adoption, implementation and enforcement of recommended policies to protect, promote and support breastfeeding worldwide (13). The emphasis of this study was on the adoption of U.S. infant feeding policies, by focusing on the identification of policy changes at the federal level over a 10 year period. In line with other studies calling for increased investment in implementation research and evaluation (14, 56, 77), future research should explore in more depth the implementation, enforcement, scope and effectiveness of U.S. infant feeding policies, over more time and at multiple levels to identify patterns, including when there are changes in political priorities.

Future assessment of how U.S. policies align with public health nutrition recommendations in both breastfeeding and infant formula feeding domains is needed. Given the frequent use of infant formula in the U.S., and growing transition to infant formula globally in infant diets (26, 27), there is a justification to explore breastfeeding and infant formula policies together and more comprehensively to assess policy activity, political considerations, as well as determinants and impacts using systematic and robust qualitative and quantitative methods that minimize potential bias and allow for greater comparability over time. Building on past recommendations, future research should highlight which populations benefit the most (and least) from infant feeding policies and consider implications within the global food system and for GBC adaptations (35, 39, 64, 70). To support caregivers working outside of the home in the U.S. and in other countries when appropriate, research that explores and compares the applicability of promising policies that are not GBC priorities but with the potential to support breastfeeding, such as increasing access to breastfeeding supplies, and the impacts of those policies, in various settings should be carried out.