An evidence review of international research suggests widespread misconceptions within the medical community about early milk production, pacifiers and breast pumps may be undermining breastfeeding success in the critical first days after birth.
Several common clinical practices and beliefs surrounding breastfeeding in the first days after birth are also not supported by current evidence, the findings indicate.
The results of the paper are published today in the peer-reviewed Journal of Maternal-Fetal & Neonatal Medicine , as people internationally mark World Breastfeeding Week – a global campaign coordinated by the World Alliance for Breastfeeding Action, alongside the World Health Organization (WHO) and UNICEF, every year from August 1 to 7 to protect, promote, and support breastfeeding.
Ultimately, the outcomes of the study – led by experts at the Sapienza University of Rome – challenge three common misconceptions encountered on maternity wards during the critical 48-72 hours after birth:
- the perception that early milk production is insufficient, leading to premature formula supplementation
- routine restrictions on pacifier (dummy) use
- and the early introduction of electric breast pumps
The researchers found that these longstanding clinical practices may inadvertently hinder breastfeeding establishment in healthy full-term babies.
"On the ward, I kept seeing mothers feeling overwhelmed by the fear that they did not have enough milk, despite their incredible commitment," explains lead author of the study, Maria Di Chiara a pediatric doctor at Sapienza University of Rome, who specialises in neonatology (the medical care, development, and treatment of newborn infants).
"My priority has always been to support the mother first, and in doing so to support the baby. These mothers need consistent, evidence-based advice, not conflicting messages, and that is what made me want to look carefully at what the evidence actually says.
"And, what our review suggests is that colostrum – the first, highly concentrated milk produced after giving birth – is usually sufficient to meet newborn needs; pacifier use does not reduce breastfeeding duration or exclusivity; and electric breast pumps should not be introduced routinely in the first days after birth."
The outcomes of the review come at a time when breastfeeding rates remain below global targets. The WHO recommends exclusive breastfeeding for the first six months of a baby's life. However, fewer than half of infants worldwide are exclusively breastfed for that long, and in many high-income countries the proportion is substantially lower.
Dr Di Chiara adds: "Because these first few days are so important for establishing breastfeeding, ensuring that parents receive advice and support that reflects the best available evidence could help improve breastfeeding outcomes."
To seek this best available evidence, Dr Di Chiara – who was joined in the study by co-author Professor Gianluca Terrin, from the Department of Mother and Child, at the same university – reviewed 78 published sources. These ranged from countries including USA, Italy, Germany, Australia, India and Mexico. The studies assessed included randomised controlled trials, systematic reviews, meta-analyses, and observational cohort studies.
Each paper addressed evidence–practice gaps relevant to the first 48–72 hours postpartum, either: the physiology of colostrum production and the mismatch between normal volumes and maternal/professional expectations; or the effect of pacifier use on breastfeeding outcomes in term infants; or the impact of breast pump use in the first days of life on breastfeeding duration and exclusivity.
The evidence of the review demonstrated a series of myths, commonly held across different healthcare systems:
Myth 1: Colostrum is not enough for newborn babies
A common reason for introducing formula in the first days after birth is the belief that colostrum is insufficient to meet a newborn baby's needs. However, the review found that in healthy full-term infants, colostrum production is physiologically matched to newborn stomach capacity and nutritional requirements.
"Perceived insufficient milk supply is the most commonly reported reason for the early introduction of formula and premature breastfeeding cessation worldwide," says Dr Di Chiara. "But in most cases, these concerns reflect unrealistic expectations rather than a genuine problem with milk production."
The authors note that structured early formula supplementation may be appropriate in situations where there is a clear medical need. However, unnecessary supplementation may reduce breast stimulation, lower milk production and reinforce concerns about inadequate supply, creating a cycle that may undermine breastfeeding establishment.
Myth 2: Pacifiers interfere with breastfeeding
Many maternity wards continue to restrict pacifier use due to concerns that it may interfere with breastfeeding. However, the evidence from randomised controlled trials shows that the use of pacifiers in healthy full-term babies does not reduce breastfeeding duration or exclusivity.
While earlier international guidance recommended avoiding artificial teats or pacifiers, more recent recommendations focus on informed parental choice rather than blanket restrictions.
"Routine pacifier restrictions in maternity settings are not supported by current evidence and should be reconsidered," adds Professor Terrin.
Myth 3: Electric breast pumps should be introduced early to support breastfeeding
Electric breast pumps are widely used in postnatal care and are often recommended to help stimulate milk supply, assess milk production or build milk stores. However, the review found little evidence supporting the routine introduction of electric pumps in the first days after birth. In some cases, early pump use may worsen breastfeeding outcomes by reinforcing perceptions of low milk supply.
Instead, when milk expression is needed – for example, because of a poor latch or temporary mother-baby separation – hand expression is generally the preferred approach.
"While electric breast pumps have an important role in specific clinical situations, they should not be considered as a routine breastfeeding tool in the first days after birth," states Professor Terrin.
Evidence-based breastfeeding support
From their results, the authors propose five priorities for supporting breastfeeding in healthy full-term babies during the first 72 hours after birth:
- Provide realistic prenatal information about colostrum volumes, newborn stomach capacity, and expected weight loss patterns.
- Use hand expression as the first-line method when milk expression is needed.
- Implement structured protocols for formula supplementation when medically necessary.
- Replace routine pacifier restrictions with balanced, evidence-based counselling.
- Ensure early access to lactation support with a trained professional within the first 48 hours after birth.
According to the researchers, these suggested adaptations to current practice do not contradict existing WHO guidance for exclusive breastfeeding. These recommendations, instead, address persistent misconceptions affecting breastfeeding initiation and continuation that are particularly common in high-income healthcare settings.
"What struck me most was how often well-meaning, routine advice runs ahead of the evidence. Small changes in those first three days could make a real difference for families," concludes Dr Di Chiara.
"Our findings do not challenge the goal of exclusive breastfeeding for the first six months.
"Rather, they identify practical opportunities to better align postnatal maternity care with the best available evidence and support families during the critical days after birth, which could lead to better breastfeeding outcomes.
"My hope is that this review gives clinicians the confidence to reassure
mothers, rather than reach for formula, a pacifier ban or a pump by default, and that postnatal care is shaped by the evidence and by listening to parents."
