Policies for sustainable health systems often focus on the carbon footprint of technologies and buildings. The 2023 National Health and Climate (NHC) Strategy¹ goes beyond these initiatives, with a package of climate change mitigation and adaptation measures that cover nutrition standards, waste reduction, supply chains and models of care. These measures include attention to regional and preventative health, emergency and disaster planning, food security and communicable disease risks, including antimicrobial resistance. Breastfeeding is relevant to most of these measures, but often overlooked as a powerful means to build climate-resilient health systems. This article summarises the contribution of breastfeeding to sustainability, using recent evidence. However, lifting rates of breastfeeding nationally requires institutional support and investment from the top, not more pressure on individual mothers. Health professionals interested in sustainable health systems can influence government in two key areas: funding for the 2019 Australian National Breastfeeding Strategy² and the regulation of marketing of infant formula and toddler milks³, currently before the Australian Competition and Consumer Commission⁴.

O&Gs have key leadership roles to champion breastfeeding and models of maternity care that protect and support it. In doing so, they contribute to “the highest quality, local, sustainable first-food system for generations to come”.⁵

Breastfeeding as climate change adaptation

Increasing breastfeeding builds national capacity to adapt to climate change. At the population level, breastfeeding prevents infant and maternal illness ⁶, reduces health system costs^7-9, and builds a climate-resilient health sector. Breastfeeding provides antibodies and other immunologically protective factors that reduce the incidence of infections in infants and young children^6,10  — issues that are relevant to the threat of antimicrobial resistance. However, many mothers do not live and work in environments that provide the social and institutional support necessary to breastfeed. Despite the intentions to breastfeed by the vast majority of Australian mothers (over 90%), many face multiple obstacles^11-16. For example, only 21% of Australian maternity hospitals are Baby Friendly Hospital Initiative (BFHI)-accredited^17-19. The reasons for inadequate breastfeeding are complex and include under-investment in breastfeeding support for mothers²⁰ and insufficient protection from inappropriate marketing of commercial milk formulas²¹. These problems are compounded by inadequate health professional training in breastfeeding and unsupportive social, childcare and workplace environments^20,22,23. Consequently, more than two thirds of Australia’s infants and young children are fed commercial milk formulas^24,25. These products include infant formula (for ages 0–6 months) and follow-on formula (6–12 months), toddler formula (13–36 months) and special requirements formula (0–6 months).

Breastfeeding is disrupted whenever infants are separated from their mothers. In addition to unsupportive work environments, breastfeeding is threatened by separation through medical emergencies, hospitalisation and incarceration²⁶, and hospital protocols, as seen in the early stages of the COVID-19 pandemic²⁷. Breastfeeding is disrupted when models of maternity care or medical conditions limit breastfeeding, for example maternal obesity, diabetes type 2 and premature or caesarean birth^28,29. Many of these conditions are associated with social disadvantage, compounding the first food insecurity of these communities^11-16.

Barriers to breastfeeding follow social gradients, and mothers of higher socioeconomic status are better equipped to sustain breastfeeding than mothers in lower socioeconomic groups, culturally and linguistically diverse communities and regional areas^30-32. For Australian Aboriginal and Torres Strait Islander mothers, rates of breastfeeding may vary with cultural knowledge, remoteness, culturally safe models of maternity care and breastfeeding support within Aboriginal controlled health services³³. Social inequities explain why poor households are the least likely to breastfeed, despite having the least capacity to afford commercial milk formula, a situation referred to as the ‘breastfeeding paradox’ in the food security literature^34,35.

Infant feeding in natural disasters & emergencies

Climate change is predicted to increase the frequency and intensity of natural disasters, wars and civil unrest. Health districts and communities with high rates of breastfeeding are better placed to withstand these challenges. Community resilience to emergencies and disasters requires the short supply chain and health benefits of breastfeeding. Breastfeeding provides the shortest possible food ‘supply chain’ for infants and young children. However, this supply chain is readily disrupted when breastfeeding is not protected, promoted and supported. Emergencies and natural disasters highlight the extreme vulnerability of infants and young children to acute food insecurity and infection if they are not fed properly, and disadvantaged population groups are more exposed to harm. Breastfed infants are food secure as long as they are with their mothers, and the mother’s health and wellbeing are prioritised. In bushfires, cyclones, floods and other disasters supplies of commercial milk formula and their hygienic preparation may be compromised by disruptions to transport, clean water and electricity. These hazards make bottle feeding unsafe and rapidly create conditions that expose non-breastfed infants to increased risks of infection, which may be life threatening.

However, Australian disaster management plans have been slow to include policies for feeding infants and young children, despite extensive international guidelines³⁶. These plans need to include protocols to protect and support breastfeeding and ensure that non-breastfed infants are fed safely. In contrast to the short ‘supply chain’ of breastfeeding, supply chains for commercial milk formula are complex, globalised and highly vulnerable. These supply chains are subject to logistic disruptions and recalls that affect availability^37,38. For instance, in the United States in 2022 a recall of a major infant formula brand and reported deaths of three infants resulted in a crisis arising from shortages of milk formula products³⁹.

Breastfeeding is a secure, sustainable way to feed infants and children as long as they’re with their mothers and the mother’s health is prioritised. Photo: Australian Breastfeeding Association

Breastfeeding can lower carbon footprints

Breastfeeding has long been recognised as an environmentally sustainable way to feed infants and young children, because it does not generate the substantial greenhouse gas emissions, water and fertiliser consumption, contamination and other environmental degradation, (including land fill) associated with the dairy industry and the manufacture, transport and packaging of commercial milk formulas^40,41. The production of commercial milk formulas doubles the ‘carbon footprint’ of breastfeeding. Annual emissions for commercial milk formulas range from 4-14 kg CO₂ eq across the full life cycle of product production and use^1,5,42. In addition, each kilogram of formula requires 6280L of water (including 699L of ‘blue’ water and rainwater for fodder for raw milk production⁴³.

The sustainability of diets is a new initiative in the current review of the Australian Dietary Guidelines, with the NHMRC forming a Sustainability Working Group⁴⁴, to advise on “accessible, affordable and equitable diets with low environmental impacts.” Priority areas in the review includes the effects of maternal diet on pregnancy and breast milk production and food security⁴⁵. While the review’s scope excludes infant feeding, it includes children older than 12 months and the effects of diet on children’s allergies, growth (including overweight/obesity) and development, in which breastfeeding plays a role. The review will also examine evidence surrounding ultra-processed foods, a classification applied in some countries to infant formula and “toddler milk”^46,47.

‘First food security’ recognises the centrality of breastfeeding to food security of infants and young children in households every day and during emergencies³⁷, based on concepts of breastfeeding as the ‘first food system^48,49. Breastfeeding has the potential to fulfil every aspect of food security, defined by the United Nations and others in terms of appropriateness, (a crucial factor for developing infants), and food availability, accessibility (which includes affordability), utilisation, stability and sustainability³⁷. Food security came to national attention during the recent bushfires, floods and COVID-19 pandemic, which disrupted the labour force and food supply chains and was investigated in a recent parliamentary Inquiry into Food Security in Australia⁵⁰. The relevance of breastfeeding to national food security was argued in a detailed submission to the inquiry by the World Breastfeeding Trends Initiative Australia and the Australian Breastfeeding Association⁵¹. Breastfeeding was recognised as ‘first food security’ in the inquiry’s recommendations for a National Food Security Strategy⁵², and food security is prioritised in the scope of the current review of the Australian Dietary Guidelines⁵³. Global reporting on food security now includes breastfeeding⁵⁴.

Decarbonising the health system

To ‘decarbonise the health system’ and help build community and health system resilience to climate change, we need the government to take urgent action and invest in Australia’s national capacity to breastfeed. How? By protecting breastfeeding from the influence of commercial milk formula companies in policy making, the health system and homes by strengthening, in law, Australia’s implementation of the WHO International Code of Marketing of Breastmilk Substitutes and subsequent World Health Assembly resolutions. This action is critical, following the review of the Marketing in Australian of Infant Formula (MAIF) Agreement, (a report released on 11 April 2024)⁵⁵, in response to the Australian Competition and Consumer Commission (ACCC)’s concerns about the marketing toddler milks⁵⁶.

Rolling out the 2019 Australian National Breastfeeding Strategy. This is long overdue: we need an implementation plan and funding for all sections of the strategy in federal budgets. Single actions are not enough: a national boost to breastfeeding needs coordinated investment over ten policy areas, not “cherry-picked” policy and funding. The importance of breastfeeding to climate health, makes it highly relevant to planning the implementation of the National Health and Climate Strategy ¹ and consistent with the National Women’s Health Strategy 2020-2030⁵⁷ – a ‘win’ for all.

Libby Salmon BVSc, MVCS, PhD, Australian Research Centre for Health Equity (ARCHE) School of Regulation and Global Governance, The Australian National University, Canberra.