Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts (i.e., via lactation) rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers breastfeed for six months or more, without the addition of infant formula or solid food. After the addition of solid food, mothers are advised to continue breastfeeding for at least a year, and can continue for two years or more.
Human breast milk is the healthiest form of milk for babies.[1] There are few exceptions, such as when the mother is taking certain drugs or is infected with human T-lymphotropic virus, HIV if not taking ARVs, or has active untreated tuberculosis. Breastfeeding promotes health and helps to prevent disease.[2][3][4] Artificial feeding is associated with more deaths from diarrhea in infants in both developing and developed countries.[5] Experts agree that breastfeeding is beneficial, and have concerns about artificial formulas but there are conflicting views about how long exclusive breastfeeding remains beneficial.[6][7][8]
The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) emphasize the value of breastfeeding for mothers as well as children. Both recommend exclusive breastfeeding for the first six months of life. The AAP recommends that this be followed by supplemented breastfeeding for at least one year, while WHO recommends that supplemented breastfeeding continue up to two years or more.[9][10][11] While recognizing the superiority of breastfeeding, regulating authorities also work to minimize the risks of artificial feeding.[7]
Not all the properties of breast milk are understood, but its nutrient content is relatively stable. Breast milk is made from nutrients in the mother's bloodstream and bodily stores. Breast milk has just the right amount of fat, sugar, water, and protein that is needed for a baby's growth and development.[12] Because breastfeeding uses an average of 500 calories a day it helps the mother lose weight after giving birth.[13] The composition of breast milk changes depending on how long the baby nurses at each session, as well as on the age of the child. The quality of a mother's breast milk may be compromised by smoking, alcoholic beverages, caffeinated drinks, marijuana, methamphetamine, heroin, and methadone.[14] Nonetheless, concerns about milk quality must be balanced with concerns about artificial baby milk. The American Academy of Pediatrics states that "Tobacco smoking by mothers is not a contraindication to breastfeeding."[15] In addition, the AAP states that, while breastfeeding mothers "should avoid the use of alcoholic beverages," an "occasional celebratory single, small alcoholic drink is acceptable, but breastfeeding should be avoided for 2 hours after the drink."[15]
Scientific research, such as the studies summarized in a 2007 review for the U.S. Agency for Healthcare Research and Quality (AHRQ)[16] and a 2007 review for the WHO,[17] has found many benefits to breastfeeding for the infant.
During breastfeeding, antibodies pass to the baby.[18] This is one of the most important features of colostrum, the breast milk created for newborns. Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections), lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria)[19][20] and immunoglobulin A protecting against microorganisms.[21]
Among the studies showing that breastfed infants have a lower risk of infection than non-breastfed infants are:
Breastfed babies have better arousal from sleep at 2–3 months. This coincides with the peak incidence of sudden infant death syndrome.[26] A study conducted at the University of Münster found that breastfeeding halved the risk of sudden infant death syndrome in children up to the age of 1.[27]
Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.[16][28] Breastfeeding also appears to protect against diabetes mellitus type 2,[16][17][29][30] at least in part due to its effects on the child's weight.[30]
Breastfeeding appears to reduce the risk of extreme obesity in children [31] The protective effect of breastfeeding against obesity is consistent, though small, across many studies, and appears to increase with the duration of breastfeeding.[16][17][32]
A study has also shown that infants who are bottle-fed in early infancy are more likely to empty the bottle or cup in late infancy than those who are breastfed. "Bottle-feeding, regardless of the type of milk, is distinct from feeding at the breast in its effect on infants' self-regulation of milk intake." According to the study, this may be due to one of three possible factors, including that when bottle feeding, parents may encourage an infant to finish the contents of the bottle whereas when breastfeeding, an infant naturally develops self-regulation of milk intake.[33] A study in Today's Pediatrics associates solid food given too early to Formula-fed babies before 4 months old will make them 6 times as likely to become obese by age 3. It does not happen if the babies were given solid foods with breast feeding.[34]
In children who are at risk for developing allergic diseases (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through exclusive breastfeeding for four months, though these benefits may not be present after four months of age.[35] However, the key factor may be the age at which non-breastmilk is introduced rather than duration of breastfeeding.[36] Atopic dermatitis, the most common form of eczema, can be reduced through exclusive breastfeeding beyond 12 weeks in individuals with a family history of atopy, but when breastfeeding beyond 12 weeks is combined with other foods incidents of eczema rise irrespective of family history.[37]
Necrotizing enterocolitis (NEC) is an acute inflammatory disease in the intestines of infants. Necrosis or death of intestinal tissue may follow. It is mainly found in premature births. In one study of 926 preterm infants, NEC developed in 51 infants (5.5%). The death rate from necrotizing enterocolitis was 26%. NEC was found to be six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, compared with exclusive breastfeeding. In infants born at more than 30 weeks, NEC was twenty times more common in infants fed exclusively on formula.[38] A 2007 meta-analysis of four randomized controlled trials found "a marginally statistically significant association" between breastfeeding and a reduction in the risk of NEC.[16]
In one study, breastfeeding did not appear to offer protection against allergies.[39] However, another study showed breastfeeding to have lowered the risk of asthma, protect against allergies, and provide improved protection for babies against respiratory and intestinal infections.[40]
A review of the association between breastfeeding and celiac disease (CD) concluded that breast feeding while introducing gluten to the diet reduced the risk of CD. The study was unable to determine if breastfeeding merely delayed symptoms or offered life-long protection.[41]
An initial study at the University of Wisconsin found that women who were breast fed in infancy may have a lower risk of developing breast cancer than those who were not breast fed.[42]
Breastfeeding may decrease the risk of cardiovascular disease in later life, as indicated by lower cholesterol and C-reactive protein levels in adult women who had been breastfed as infants.[17][43] Although a 2001 study suggested that adults who had been breastfed as infants had lower arterial distensibility than adults who had not been breastfed as infants,[44] the 2007 review for the WHO concluded that breastfed infants "experienced lower mean blood pressure" later in life.[17] A 2007 review for the AHRQ found that "there is an association between a history of breastfeeding during infancy and a small reduction in adult blood pressure, but the clinical or public health implication of this finding is unclear".[16] A 2006 study found that breastfed babies are better able to cope with stress later in life.[45]
Studies have examined whether breastfeeding in infants is associated with higher intelligence later in life. Possible association between breastfeeding and intelligence is not clear. The 2007 review for the AHRQ found "no relationship between breastfeeding in term infants and cognitive performance."[16] The 2007 review for the WHO "suggests that breastfeeding is associated with increased cognitive development in childhood." The review also states that "The issue remains of whether the association is related to the properties of breastmilk itself, or whether breastfeeding enhances the bonding between mother and child, and thus contributes to intellectual development." [17]
Some who have found a connection:
Some who have not found a connection:
Breastfeeding is a cost effective way of feeding an infant, providing nourishment for a child at a small cost to the mother. Frequent and exclusive breastfeeding can delay the return of fertility through lactational amenorrhea, though breastfeeding is an imperfect means of birth control. During breastfeeding beneficial hormones are released into the mother's body[18] and the maternal bond can be strengthened.[12] Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point.[54]
Hormones released during breastfeeding help to strengthen the maternal bond.[12] Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[55] Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.[56]
If the mother is away, an alternative caregiver may be able to feed the baby with expressed breast milk. The various breast pumps available help working mothers to feed their babies breast milk for as long as they want. To be successful, the mother must produce and store enough milk to feed the child for the time she is away, and the feeding caregiver must be comfortable in handling breast milk.
Breastfeeding releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby.[57] Breastfeeding soon after giving birth increases the mother's oxytocin levels, making her uterus contract more quickly and reducing bleeding. Pitocin, a synthetic hormone used to make the uterus contract during and after labour, is structurally modelled on oxytocin. Syntocinon, another synthetic oxytocic, is commonly used in Australia and the UK rather than Pitocin.[58]
As the fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight.[59] However, weight loss is highly variable among lactating women; monitoring the diet and increasing the amount/intensity of exercise are more reliable ways of losing weight.[60] The 2007 review for the AHRQ found "The effect of breastfeeding in mothers on return-to-pre-pregnancy weight was negligible, and the effect of breastfeeding on postpartum weight loss was unclear."[16]
Dramatic changes occur in a pregnant woman’s metabolism and body composition as she accommodates the demands of providing for the nutritional needs of the growing fetus, and metabolizing for two. In anticipation of lactation, the mother accumulates some stores of visceral fat, but most of it is stored as subcutaneous fat in the thighs, arms, buttocks, arms, and breasts. [61] This shift in fat content leads to increased insulin production, insulin resistance, and circulating lipid levels in the mother. Studies have indicated that gestational weight gain (GWG) may contribute to complications during labor and delivery and it is the most reliable factor in predicting postpartum weight retention (PPWR).[62] In general, the more weight that women put on during pregnancy, the more weight that they retain afterward. Interventions to restrain GWG in the United States and elsewhere have had mixed results in reducing PPWR.[63] The recent recognition of PPWR’s influence on later chronic diseases has brought a surge in data analysis. In fact, the proportion of US women who gain weight excessively during pregnancy is growing. In 2005, 20.6% gained 18.2 kg (40 lb), the upper limit recommended by the Institute of Medicine.[64] Recommended weight gains during pregnancy vary according to maternal baseline characteristics. The Institute of Medicine has established guidelines where women who are underweight (BMI less than 18.5) are encouraged to gain 13 to 18 kg; women who are at normal weight (BMI 18.5-24.9) are encouraged to gain 11-16 kg; those who are overweight (BMI 25-29.9) are suggested to gain 7-11 kg; and those who are obese I (BMI 30-34.9) are recommended to gain 5-9 kg.[65] These recommendations are variable and are meant to inform an obstetrician in caring for a pregnant woman. Extreme gains in visceral fat can put women at higher risk of cardiovascular and glycemic disorders later in life.
After birth, the fat stores created during pregnancy are primed to be metabolized through lactation. Several investigators have explored the relation between duration of lactation and postpartum weight change, and found a variety of outcomes. Overall, it has been observed that prolonged exclusivity of breastfeeding is associated with increased weight loss when controlling for gestational weight gain and postpartum caloric intake and expenditure.[66] Dietary intake and energy expenditure affect how much weight women lose with lactation. When nutrition is readily available, women compensate for increased energy demands by increasing intake and decreasing energy expenditure, rather than mobilizing fat stores. Fat mobilization appears to increase after the first 3 months postpartum, reflecting changes in the hormonal effects of lactation on maternal appetite as frequency of infant feeds decreases.[67] Some findings suggest that formula-feeding mothers during the first two months postpartum consume 600 to 800 fewer calories than breast-feeding mothers and lost substantially more weight. From 3 to 6 months post-partum, however, weight loss among breast-feeding women increased substantially.[68] These results suggest that in the early postpartum period, well-nourished women in developed nations tend to increase energy intake and/or decrease physical activity to meet the energy demands of lactation, whereas beyond 3 months, lactating women are more likely to mobilize fat stores. Longitudinal studies using skinfold thickness and MRI scanning of adipose tissue during pregnancy and lactation consistently show fat accumulation in the thigh and buttocks regions during pregnancy, with mobilization from these areas postpartum.[69] [70] These studies have indicated that lactation is associated with reduction in subcutaneous fat levels and overall body weight.
Recent data suggests that lactation is associated with a reduced risk in chronic diseases such as type-2 diabetes and heart disease.[71] The long-term affects of lactation on body composition vary, and seem to be influenced by socioeconomic factors.[72] Studies have consistently indicated that lactation helps prepare the mother’s body for subsequent pregnancies and reduces complications in later periods of gestation and birth. Further research is needed to examine the long-term affects of lactation on maternal body composition and risk for chronic disease.[73]
Breastfeeding may delay the return to fertility for some women by suppressing ovulation. A breastfeeding woman may not ovulate, or have regular periods, during the entire lactation period. The period in which ovulation is absent differs for each woman. This lactational amenorrhea has been used as an imperfect form of natural contraception, with greater than 98% effectiveness during the first six months after birth if specific nursing behaviors are followed.[74] It is possible for women to ovulate within two months after birth while fully breastfeeding and get pregnant again.
For breastfeeding women, long-term health benefits include:
| “ | The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative–expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat–depends on individual circumstances.[10] | ” |
The WHO recommends exclusive breastfeeding for the first six months of life, after which "infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond."[10]
| “ | Extensive research using improved epidemiologic methods and modern laboratory techniques documents diverse and compelling advantages for infants, mothers, families, and society from breastfeeding and use of human milk for infant feeding. These advantages include health, nutritional, immunologic, developmental, psychologic, social, economic, and environmental benefits.[11] | ” |
The AAP recommends exclusive breastfeeding for the first six months of life.[11] Furthermore, "breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child."[11]
There are many books and videos to advise mothers about breastfeeding. Lactation consultants in hospitals or private practice, and volunteer organisations of breastfeeding mothers such as La Leche League International also provide advice and support.
In the half hour after birth, the baby's suckling reflex is strongest, and the baby is more alert, so it is the ideal time to start breastfeeding.[83] Breastfeeding also releases hormones that contract the uterus to reduce post-partum bleeding.[84] Early breastfeeding is associated with fewer nighttime feeding problems.[85]
Breastfeeding at least every two to three hours helps to maintain milk production. For most women, eight breastfeeding or pumping sessions every 24 hours keeps their milk production high.[11] Newborn babies may feed more often than this: 10 to 12 breastfeeding sessions every 24 hours is common, and some may even feed 18 times a day.[86] Feeding a baby "on demand" (sometimes referred to as "on cue"), means feeding when the baby shows signs of hunger; feeding this way rather than by the clock helps to maintain milk production and ensure the baby's needs for milk and comfort are being met. However, it may be important to recognize whether a baby is truly hungry, as breastfeeding too frequently may mean the child receives a disproportionately high amount of foremilk, and not enough hindmilk.[87]
"Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants' sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain."[88]
"Comforting and meeting sucking needs at the breast is nature's original design. Pacifiers (dummies, soothers) are a substitute for the mother when she cannot be available. Other reasons to pacify a baby primarily at the breast include superior oral-facial development, prolonged lactational amenorrhea, avoidance of nipple confusion, and stimulation of an adequate milk supply to ensure higher rates of breastfeeding success."[88]
Most US states now have laws that allow a mother to breastfeed her baby anywhere she is allowed to be. In hospitals, rooming-in care permits the baby to stay with the mother and improves the ease of breastfeeding. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring them to go to a special area.
Correct positioning and technique for latching on can prevent nipple soreness and allow the baby to obtain enough milk.[89][90] The "rooting reflex" is the baby's natural tendency to turn towards the breast with the mouth open wide; mothers sometimes make use of this by gently stroking the baby's cheek or lips with their nipple to induce the baby to move into position for a breastfeeding session, then quickly moving the baby onto the breast while its mouth is wide open.[91] To prevent nipple soreness and allow the baby to get enough milk, a large part of the breast and areola need to enter the baby's mouth.[89][92] To help the baby latch on well, tickle the baby's top lip with the nipple, wait until the baby's mouth opens wide, then bring the baby up towards the nipple quickly, so that the baby has a mouthful of nipple and areola. The nipple should be at the back of the baby's throat, with the baby's tongue lying flat in its mouth. Inverted or flat nipples can be massaged so that the baby will have more to latch onto. Resist the temptation to move towards the baby, as this can lead to poor attachment.
Pain in the nipple or breast is linked to incorrect breastfeeding techniques. Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns. A 2006 study found that inadequate parental education, incorrect breastfeeding techniques, or both were associated with higher rates of preventable hospital admissions in newborns.[93]
The baby may pull away from the nipple after a few minutes or after a much longer period of time. Normal feeds at the breast can last a few sucks (newborns), from 10 to 20 minutes or even longer (on demand). Sometimes, after the finishing of a breast, the mother may offer the other breast.
While most women breastfeed their child in the cradling position, there are many ways to hold the feeding baby. It depends on the mother and child's comfort and the feeding preference of the baby. Some babies prefer one breast to the other, but the mother should offer both breasts at every nursing with her newborn.
When tandem breastfeeding, the mother is unable to move the baby from one breast to another and comfort can be more of an issue. As tandem breastfeeding brings extra strain to the arms, especially as the babies grow, many mothers of twins recommend the use of more supporting pillows.
Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications."[11] National and international guidelines recommend that all infants be breastfed exclusively for the first six months of life. Breastfeeding may continue with the addition of appropriate foods, for two years or more. Exclusive breastfeeding has dramatically reduced infant deaths in developing countries by reducing diarrhea and infectious diseases. It has also been shown to reduce HIV transmission from mother to child, compared to mixed feeding.[95][96][97][98]
Exclusively breastfed infants feed anywhere from 6 to 14 times a day. Newborns consume from 30 to 90 ml (1 to 3 US fluid ounces) per feed. After the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, but as it grows the amount will increase. It is important to recognize the baby's hunger signs. It is assumed that the baby knows how much milk it needs and it is therefore advised that the baby should dictate the number, frequency, and length of each feed. The supply of milk from the breast is determined by the number and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it is larger; they should, however, go by the demands of the baby rather than what they feel is necessary.
While it can be hard to measure how much food a breastfed baby consumes, babies normally feed to meet their own requirements.[99] Babies that fail to eat enough may exhibit symptoms of failure to thrive. If necessary, it is possible to estimate feeding from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours suggests an acceptable amount of input for newborns older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools. Babies can also be weighed before and after feeds.
When direct breastfeeding is not possible, a mother can express (artificially remove and store) her milk. With manual massage or using a breast pump, a woman can express her milk and keep it in freezer storage bags, a supplemental nursing system, or a bottle ready for use. Breast milk may be kept at room temperature for up to six hours , refrigerated for up to eight days or frozen for up to four to six months. Research suggests that the antioxidant activity in expressed breast milk decreases over time but it still remains at higher levels than in infant formula.[100]
Expressing breast milk can maintain a mother's milk supply when she and her child are apart. If a sick baby is unable to feed, expressed milk can be fed through a nasogastric tube.
Expressed milk can also be used when a mother is having trouble breastfeeding.
"Exclusively expressing", "exclusively pumping", and "EPing" are terms for a mother who feeds her baby exclusively on her breastmilk while not physically breastfeeding. This may arise because her baby is unable or unwilling to latch on to the breast. With good pumping habits, particularly in the first 12 weeks when the milk supply is being established, it is possible to produce enough milk to feed the baby for as long as the mother wishes.
It is generally advised to delay using a bottle to feed expressed breast milk until the baby is 4–6 weeks old and is good at sucking directly from the breast.[101] As sucking from a bottle takes less effort, babies can lose their desire to suck from the breast. This is called nursing strike or nipple confusion. To avoid this when feeding expressed breast milk (EBM) before 4–6 weeks of age, it is recommended that breast milk be given by other means such as feeding spoons or feeding cups. Also, EBM should be given by someone other than the breastfeeding mother (or wet nurse), so that the baby can learn to associate direct feeding with the mother (or wet nurse) and associate bottle feeding with other people.
Some women donate their expressed breast milk (EBM) to others, either directly or through a milk bank. Though historically the use of wet nurses was common, some women dislike the idea of feeding their own child with another woman's milk; others appreciate being able to give their baby the benefits of breast milk. Feeding expressed breast milk—either from donors or the baby's own mother—is the feeding method of choice for premature babies.[102] The transmission of some viral diseases through breastfeeding can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.[103]
Predominant or mixed breastfeeding means feeding breast milk along with infant formula, baby food and even water, depending on the age of the child. Babies feed differently with artificial teats than from a breast. With the breast, the infant's tongue massages the milk out rather than sucking. With an artificial teat, an infant will suck as long as there is milk flowing and it is easy to overfeed with a bottle. Since the flow is constant, and the baby does not have to elicit a letdown, mixing breastfeeding and bottle-feeding (or using a pacifier) before the baby is used to feeding from its mother, can result in the infant preferring the bottle to the breast. Some mothers supplement feed with a small syringe or flexible cup to reduce the risk of artificial nipple preference. When using a bottle it is important to use the slowest flow the baby will accept (and not move up to a faster flow just because the baby is getting older) and feed in a paced manner. The baby should sit almost upright and the bottle should be only tipped slightly to allow for a little bit of milk to pass to the baby. Bottle feeding should take as long as breastfeeding does. Faster feeding can easily result in overfeeding.
Feeding two children at the same time who are not twins or multiples is called tandem nursing. As the appetite and feeding habits of each baby may not be the same, this could mean feeding each according to their own individual needs and can also include breastfeeding them together, one on each breast.
In cases of triplets or more, it is a challenge for a mother to organize feeding around the appetites of all the babies. Breasts can respond to the demand and produce large quantities of milk; mothers have been able to breastfeed triplets successfully.[104][105][106]
Tandem nursing occurs when a woman has a baby while breastfeeding an older child. During the late stages of pregnancy, the milk will change to colostrum, and some older nurslings will continue to feed even with this change, while others may wean due to the change in taste or drop in supply. Breastfeeding a child while being pregnant with another can also be considered a form of tandem feeding for the nursing mother, as she also provides the nutrition for two.[107]
It used to be common worldwide, and still is in some developing nations such as those in Africa, for more than one woman to breastfeed a child. Shared breastfeeding has now been found to be a risk factor for HIV infection in infants.[108] A woman who is engaged to breastfeed another's baby is known as a wet nurse. Shared breastfeeding can sometimes incur negative reactions in the Anglosphere;[109] American feminist activist Jennifer Baumgardner has written about her experiences in New York with this issue.[110]
The World Health Organization recommends exclusive breastfeeding for the baby's first 6 months of life, and continued breastfeeding complemented with appropriate foods up to two years old and beyond.[9][10]
In many Western countries, however, breastfeeding beyond the age of 1 year old is considered "extended breastfeeding".
These movements in the West towards earlier weaning, however, are recent. Breastfeeding beyond the age of 1 year old was at one time a very common practice worldwide.[111] Dr. Martin Stein wrote in Parental Concerns about Extended Breastfeeding in a Toddler that “The discussion about extended nursing is similar to that of co-sleeping. They are both characteristics of child rearing that are closely linked to time and place. In most cultures before the 20th century, both practices were the norm. Changes in social, economical, and sexual expectations altered our views of the meaning of breastfeeding and bed sharing.” Extended breastfeeding was encouraged in Ancient Greek, Hebrew, and Muslim cultures. The Koran, the Talmud, and the writings of Aristotle all recommend breastfeeding for 2 to 3 years.[112] In Breastfeeding Beyond 6 Months: Mothers' Perceptions of the Negative and Positive Consequences, Dr. S. B. Reamer states that "Over the past 100 years of American history, the acceptance of unrestricted nursing decreased and the age acceptable for weaning dropped dramatically, until the average weaning age was 3 months in the 1970s."
In reaction to the move in the West towards earlier weaning, several organizations have been founded in Western countries to support mothers who practice extended breastfeeding. These organizations include the International Childbirth Education Association and La Leche League International.[113]
Elizabeth Baldwin says in Extended Breastfeeding and the Law, that “Because our culture tends to view the breast as sexual, it can be hard for people to realize that breastfeeding is the natural way to nurture children.” In Western countries such as The United States of America, Canada, and Great Britain, extended breastfeeding is a taboo act. It is difficult to obtain accurate information and statistics about extended breastfeeding in these countries because of the mother's embarrassment.[113] Mothers who nurse longer than the social norm sometimes hide their practices from all but very close family members and friends. This is called “closet nursing”.[113] In a study published by the Journal of Tropical Pediatrics, 24% of American and Canadian mothers nursing past 6 months felt social hostility towards them. This number grew to 42% when mothers were nursing after 1 year of age. Also, 10% of mothers claimed embarrassment when more mobile, verbal toddlers made known in public the fact that they were nursed.[113]
In the United States, breastfeeding beyond 1 year of age is considered 'extended breastfeeding, and in contrast to WHO recommendations, the American Academy of Pediatrics stated in 1997 that, “Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child”.[11][112]
In the United States overall, 43% of babies are breastfed until 6 months and 22.4% are breastfed until 12 months, though breastfeeding rates varied among the states.[114]
Breastfeeding rates in the U.S. at 6 months rose from 34.2% in 2000 to 43.5% in 2006 and the rates at 12 months rose from 15.7% in 2000 to 22.7% in 2006. The U.S. Healthy People 2010 goals were to have at least 60% of babies exclusively breastfed at 3 months and 25% of babies exclusively breastfed at 6 months so this goal has yet to be met.[115]
In the United States a study published by the Centers for Disease Control and Prevention found that 75 percent of mothers began breastfeeding. However, by 6 months, the rate fell to 43% and was just 22% after a year. Breastfeeding rates vary across the country, from nearly 90 percent initiating breastfeeding in Utah to 52.5 percent in Mississippi. The health care law now requires large employers to provide breastfeeding mothers with breaks and a private space to feed their babies.[116]
There have been several cases in the United States where children have been taken away from their mother's care because American courts or government agencies found the mother's extended breastfeeding to be inappropriate. In 1992, a New York State mother lost custody of her child for a year. She was still breastfeeding the child at age 3 and had reported experiences of sexual arousal while breastfeeding the child. The authorities took the child from the home in the fear that the mother might sexually abuse the child. Later, the social service agency that took over the case said that there was more to the case than could be released to the press due to confidentiality laws.[111] In 2000, an Illinois child was removed from the mother's care after a judge ruled that the child might suffer emotional damage because of not being weaned. The child was later returned to the mother and the judge vacated the finding of neglect.[111] A social service agency in Colorado removed a 5-year-old child from the mother because she was still breastfeeding, but the court ordered the child returned to its family immediately.[111]
In Guinea-Bissau, West Africa, the average length of breastfeeding is 22.6 months.[117]
In India, mothers commonly breastfeed their children until 3 to 4 years of age. Stein says that “In India, women often wean their 3 or 4-year-old by putting the juice of a bitter gourd or melon on their nipples.”[112]
In the Philippines, the Implementing Rules and Regulations of the Milk Code require that breastfeeding be encouraged for babies up to the age of 2 years old or beyond. Under the same code, it is prohibited to advertise infant formula or breastmilk substitutes intended for infants and young children 24 months old and below.[118] In practice, however, a 2008 WHO survey found that on average, mothers in the Philippines breastfed their babies until 14 months of age, with breastfeeding extending up to 17 months on average in rural areas. Almost fifty-eight percent of mothers surveyed around the nation were still breastfeeding their babies when the babies were a year old, and 34.2% of mothers were still breastfeeding when their babies were 2 years old.[119]
Priscilla Colletto stated in Beyond Toddlerhood: The Breastfeeding Relationship Continues, “The adverse health effects of weaning a child before or during toddlerhood are well documented for Third World countries such as Guinea-Bissau, where children who were no longer breastfed at ages 12–35 months had a 3.5 times higher mortality rate than did their peers who continued to breastfeed.”[120] Dr. Laurence Grummer-Strawn observed that breastfeeding is protective against diarrheal diseases and other infections, breastfed children aged 12 to 36 months in Indonesia have much greater mid-arm circumference than children who have been weaned, and the incidences of malnourishment in breastfed Indonesian children are 3–5% less common than generally encountered in Indonesian clinics. Studies suggest that extended breastfeeding may reduce the chances of otitis media allergies, leukemia, and lymphoma for the toddler, and premenopausal breast cancer in the mother. This is attributed to the fact that the levels of lysozyme, lactoferrin, and secretory IgA are stable and even increase in the breast milk of mothers who are breastfeeding for over 1 year. (Stein 1507). In one study, artificially-fed infants had 2 to 3 times as many episodes of significant illnesses (defined as “otitis media, lower respiratory disease, significant vomiting or diarrhea, and any illness requiring hospital admission”).[113] However, there are also some studied risks involved in extended breastfeeding. Breastfeeding could impair a child's growth if they are not taught to eat other foods as well. Breast milk alone is not enough for children over 6 months of age and some have observed that children that have been breastfed longer than the norm have less of an appetite for added foods.[121] Stein says that “As long as a toddler is eating a variety of grains, vegetables, fruits, and foods or supplements that provide adequate iron and vitamin D, nutrition will be adequate and appropriate growth and development will be ensured.”
In A Time to Wean by Katherine Dettwyler, it states that “Western, industrialized societies can compensate for some (but not all) of the immunological benefits of breastfeeding with antibiotics, vaccines and improved sanitation. But the physical, cognitive, and emotional needs of the young child persist.”[122] Many children who are breast-fed into their toddler years use the milk as a comforting, bonding moment with their mothers.[113] In a 1974 survey of 152 mothers, 17% said that the security their toddlers obtained through extended breastfeeding helped them become more independent, 14% said that extended breastfeeding created a strong mother-child bond, and 14.6% said that extended breastfeeding strengthened their abilities as a mother. Four mothers said that they felt their child was too dependent and one mother considered her child a poor eater.[113] Dr. Stein said that “A mother in my practice who breastfed 2 children until 2 years of age explained that she would slowdown and give her undivided attention to her child several times each day when breastfeeding. Her children knew that she always had time for those moments each day. This time was also important to the mother for relaxing and unwinding....For many nursing toddlers, the breast comes to serve the same function as a favorite blanket or stuffed animal in providing comfort and a sense of security.” One issue with extended breastfeeding is the ability of the mother and the child to separate. Some say that the desire for extended breastfeeding comes from the mother's inability to let go of "her baby".[112] Baldwin refutes this statement, saying that the child is the one who chooses when they are weaned, as it is very difficult to force a child to breastfeed.
Women who are breastfeeding need to be careful about what they eat and drink, since things can be passed to the baby through the breast milk. Just like during pregnancy, breastfeeding women should avoid fish that are high in mercury, and limit lower mercury fish intake. If a woman has alcohol, a small amount can be passed to the baby through breast milk. She should wait to breastfeed at least 2 hours after a single alcoholic drink to avoid passing any alcohol to the baby. Caffeine intake should be kept to no more than 300 milligrams (about one to three cups of regular coffee) per day for breastfeeding women because it may cause problems such as restlessness and irritability in some babies. A diet coke has 46 mg per 12 oz can, and a can of pepsi has 40 mg. Most drinks post their caffeine content on the can or bottle near the nutrition label and ingredients. Some infants are sensitive enough to caffeine to have problems even with smaller amounts of caffeine.
The average breastfed baby doubles its birth weight in 5–6 months. By one year, a typical breastfed baby will weigh about 2½ times its birth weight. At one year, breastfed babies tend to be leaner than formula fed babies, which is healthier, especially in the long-run. A general guide to the growth of breastfed babies is the following:
Weaning is the process of introducing the infant to other food and reducing the supply of breast milk. The infant is fully weaned when it no longer receives any breast milk. Most mammals stop producing the enzyme lactase at the end of weaning, and become lactose intolerant. Humans often have a mutation, with frequency depending primarily on ethnic background, that allows the production of lactase throughout life so they can drink milk — usually cow or goat milk — well beyond infancy.[124] In humans, the psychological factors involved in the weaning process are crucial for both mother and infant as issues of closeness and separation are very prominent during this stage.[125]
In the past bromocriptine was in some countries frequently used to reduce the engorgement experienced by many women during weaning. This is now done only in exceptional cases as it causes frequent side effects, offers very little advantage over non-medical management and the possibility of serious side effects can not be ruled out.[126] Other medications such as cabergoline, lisuride or birth control pills may occasionally be used as lactation suppressants.
While breastfeeding is a natural human activity, difficulties and complications are not uncommon. Putting the baby to the breast as soon as possible after the birth helps to avoid many problems, including mastitis.[127] The AAP breastfeeding policy says: "Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed."[11] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained midwives, doctors and hospital staff, and lactation consultants.[128] There are some situations in which breastfeeding may be harmful to the infant, including infection with HIV and acute poisoning by environmental contaminants such as lead.[40] The Institute of Medicine has reported that breast surgery, including breast implants or breast reduction surgery, reduces the chances that a woman will have sufficient milk to breast feed.[129] Rarely, a mother may not be able to produce breastmilk because of a prolactin deficiency. This may be caused by Sheehan's syndrome, an uncommon result of a sudden drop in blood pressure during childbirth typically due to hemorrhaging.
In developed countries, many working mothers do not breast feed their children due to work pressures and very short periods of maternity leave. For example, a mother may need to schedule for frequent pumping breaks, and find a clean, private and quiet place at work for pumping. These inconveniences may cause mothers to give up on breast feeding and use infant formula.
The majority of mothers intend to breastfeed when their baby is born. There are many things that happen that disrupt or intervene in this plan. Here are just a few of the barriers that women face when attempting to breastfeed.
Women whose pregnancies are unintended are less likely to breast feed their babies.[135]
As breastfeeding can transmit HIV from mother to child, UNAIDS recommends avoidance of all breastfeeding for HIV positive mothers where formula feeding is acceptable, feasible, affordable and safe.[136] The qualifications are important. Some constituents of breast milk may protect from infection. High levels of certain polyunsaturated fatty acids in breast milk (including eicosadienoic, arachidonic and gamma-linolenic acids) are associated with a reduced risk of child infection when nursed by HIV-positive mothers. Arachidonic acid and gamma-linolenic acid may also reduce viral shedding of HIV in breast milk.[137] Due to this, in underdeveloped nations infant mortality rates are lower when HIV-positive mothers breastfeed their newborns than when they use infant formula. However, differences in infant mortality rates have not been reported in better resourced areas.[138] Treating infants prophylactically with lamivudine (3TC) can help to decrease the transmission of HIV from mother to child by breastfeeding.[139] If free or subsidized formula is given to HIV-infected mothers, recommendations have been made to minimize the drawbacks such as possible disclosure of the mother's HIV status.[140]
In an effort to further refine the UN guideline for optimal infant feeding options for HIV-infected mothers, WHO held a three day convention in Geneva in 2006 to review new evidence that have been established since they last established the guideline in October 2000. Participants included UN agencies, representative from nongovernmental organizations, researchers, infant feeding experts, and WHO headquarters departments. The convention concluded with the following updated recommendations: If replacement feeding is acceptable, feasible, affordable and safe, HIV-infected mothers are recommended to use replacement feeding. Otherwise, exclusive breastfeeding is recommended. At six months, if replacement feeding is still not available, HIV-infected mothers are encouraged to slowly introduce food while continuing breastfeeding. Those with HIV-infected nfants are recommended to continue breastfeeding even after 6 months. [141]
Before the 20th century, breastfeeding was the main way of feeding babies. If for any reason the natural mother was unable to breastfeed, a wet nurse was used. Attempts were made in 15th century Europe to use cow or goat milk, but these attempts were not successful. In the 18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding, but this did not have a favorable outcome either. True commercial infant formulas appeared on the market in the mid 19th century but their use did not become widespread until after World War II. As the superior qualities of breast milk became better-established in medical literature, breastfeeding rates have increased and countries have enacted measures to protect the rights of infants and mothers to breastfeed.
Researchers have found several social factors that correlate with differences in initiation, frequency, and duration of breastfeeding practices of mothers. Race, ethnic differences and socioeconomic status and other factors have been shown to affect a mother's choice whether or not to breastfeed and how long she breastfeeds her child.
Controversy has arisen over the marketing of breast milk vs. formula; particularly how it affects the education of mothers in third world countries and their comprehension (or lack thereof) of the health benefits of breastfeeding.[142] The most famous example being the Nestlé boycott, which arose in the 1970s and continues to be supported by high-profile stars and international groups to this day.[143][144]
In 1981, the World Health Assembly (WHA) adopted Resolution WHA34.22 which includes the International Code of Marketing of Breast-milk Substitutes.
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