Breastfeeding

Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts (i.e., via lactation) rather than using infant formula. Babies have a sucking reflex that enables them to suck and swallow milk. Experts recommend that children be breastfed within one hour of birth, exclusively breastfed for the first six months, and then breastfed until age two with age-appropriate, nutritionally adequate and safe complementary foods.^{[2][3][4][5][6]} The American Academy of Pediatrics recommends for the U.S. that after 6 months of exclusive breastfeeding, babies should continue to breastfeed "for a year and for as long as is mutually desired by the mother and baby".^[7] Inadequate nutrition is an underlying cause of the deaths of more than 2.6 million children and over 100,000 mothers every year.^[2] Some working mothers express milk to be used while their child is being cared for by others.

Breastfeeding is a very personal decision. Many women have their own beliefs and feelings about whether or not they want to. “The American Academy of Pediatrics and the American Dietetic Associating promote breastfeeding as the BEST source of infant nutrition”.^[8] Breastfeeding is a complete nutrition that is easy for the baby to digest, which promotes to the child eating more often due to faster digestion. It also helps in the jaw development of the baby because breastfeeding is more difficult; it helps strengthen the child’s jaw. It also decreases allergies, decreases risk of diabetes and silica and decrease risk of SIDS. There are also controversial benefits of decreased risk for obesity in adulthood and improved cognitive development.^[8] There are also many benefits for the mother to breastfeed. Breastfeeding helps in uterus shrinkage, decreases risk of breast cancer, decreases depression and decreases risk of osteoporosis. It is also a bonding experience for both mother and baby and is a lot more convenient.

Breastfeeding was the rule in ancient times up to recent human history, and babies were carried with the mother and fed as required. With 18th and 19th century industrialization in the Western world, mothers in many urban centers began dispensing with breastfeeding due to their work requirements. Breastfeeding declined significantly from 1900 to 1960, due to increasingly negative social attitudes towards the practice and the development of infant formula.^[9] Under modern health care, human breast milk is considered the healthiest form of milk for babies.^[10] From the 1960s onwards, breastfeeding experienced a revival which continues to the 2000s, though some negative attitudes towards the practice still remain.

Breastfeeding promotes the health of both mother and infant and helps to prevent disease.^[11][12][13] Longer breastfeeding has also been associated with better mental health through childhood and into adolescence.^[14] Experts agree that breastfeeding is beneficial and have concerns about the effects of artificial formulas. Artificial feeding is associated with more deaths from diarrhea in infants in both developing and developed countries.^[15] There are, however, a few exceptions, such as when the mother is taking certain drugs, has active untreated tuberculosis or is infected with human T-lymphotropic virus. The World Health Organization recommends that national authorities in each country decide which infant feeding practice should be promoted and supported by their maternal and child health services to best avoid HIV infection transmission from mother to child.

History

In the Egyptian, Greek and Roman empires, women usually fed only their own children. However, breastfeeding began to be seen as something too common to be done by royalty, and wet nurses were employed to breastfeed the children of the royal families. This extended over time, particularly in western Europe, where noble women often made use of wet nurses. But lower class women breastfed their infants and used a wet nurse only if they were unable to feed their own infant. 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.

During the early 1900s breastfeeding started to be viewed negatively by Western societies, especially in Canada and the USA. These societies considered it a low class and uncultured practice, viewing it with a certain degree of disgust.^[16] This coincided with the appearance of improved infant formulas in the mid 19th century and its increased use, which accelerated after World War II. From the 1960s onwards, breastfeeding experienced a revival which continues to the 2000s, though negative attitudes towards the practice were still intrenched up to 1990s.^[16]

Organizational endorsements

World Health Organization

“	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.[17]	”

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 up to two years of age or beyond."^[17]

National Health Service

“	Exclusive breastfeeding (giving your baby breast milk only) is recommended for around the first six months (26 weeks) of your baby's life. After that, giving your baby breast milk alongside other food will help them continue to grow and develop. Any amount of breastfeeding has a positive effect. The longer you breastfeed, the longer the protection lasts and the greater the benefits.	”

^[18]

American Academy of Pediatrics

“	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.[19]	”

The AAP recommends exclusive breastfeeding for the first six months of life.^[19] 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."^[19]

United States Centers for Disease Control and Prevention

“	One of the most highly effective preventive measures a mother can take to protect the health of her infant is to breastfeed.	”

According to the CDC, "The success rate among mothers who want to breastfeed can be greatly improved through active support from their families, friends, communities, clinicians, health care leaders, employers, and policymakers. Given the importance of breastfeeding for the health and well-being of mothers and children, it is critical that we take action across the country to support breastfeeding."^[20]

Lactation

The hormonal endocrine control system drives milk production during pregnancy and the first few days after the birth. From the twenty-fourth week of pregnancy (the second and third trimesters), a woman's body produces hormones that stimulate the growth of the milk duct system in the breasts. Progesterone influences the growth in size of alveoli and lobes; high levels of progesterone, estrogen, prolactin, and other hormones inhibit lactation before birth; hormone levels drop after birth, triggering the onset of milk production.^[21] After birth, the hormone oxytocin contracts the smooth muscle layer of cells surrounding the alveoli to squeeze milk into the duct system. Oxytocin is also necessary for the milk ejection reflex, or let-down to occur. Let down occurs in response to the baby's suckling, though it also may be a conditioned response, e.g. to the cry of the baby. Lactation can also be induced by a combination of physical and psychological stimulation, by drugs, or by a combination of these methods.^[22][23]

Breast milk

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.^[24] Because breastfeeding uses an average of 500 calories a day, it helps the mother lose weight after giving birth.^[25] 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.^[26] However, the American Academy of Pediatrics states that "Tobacco smoking by mothers is not a contraindication to breastfeeding."^[19] 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."^[19]

Benefits for the infant

Scientific research, such as the studies summarized in a 2007 review for the U.S. Agency for Healthcare Research and Quality (AHRQ)^[27] and a 2007 review for the WHO,^[28] have found numerous benefits of breastfeeding for the infant. According to the American Academy of Pediatrics, research shows that breast feeding provides advantages with regard to general health, growth, and development. Not breastfeeding significantly increases risk for a large number of acute and chronic diseases including lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis.^[29] They state that there are a number of studies that show a possible protective effect of breast milk feeding against sudden infant death syndrome, insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, lymphoma, allergic diseases, digestive diseases, and a possible enhancement of cognitive development.^[19]

Immunity

During breastfeeding, approximately 0.25-0.5 grams per day of secretory IgA antibodies pass to the baby via the milk.^[30][31] This is one of the most important features of colostrum, the breast milk created for newborns.^[32] The main target for these antibodies are probably microorganisms in the baby's intestine. There is some uptake of IgA to the rest of the body,^[33] but this amount is relatively small.^[34] Also, breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria).^[35][36]

Infections

Among the studies showing that non-breastfed infants have a higher risk of infection than breastfed infants are:

• In a 1993 University of Texas Medical Branch study, a longer period of breastfeeding was associated with a shorter duration of some middle ear infections (otitis media with effusion) in the first two years of life.^[37]
• A 1995 study of 87 infants found that breastfed babies had half the incidence of diarrheal illness, 19% fewer cases of any otitis media (middle ear) infections, and 80% fewer prolonged cases of middle ear infections than formula fed babies in the first twelve months of life.^[38]
• Breastfeeding appeared to reduce symptoms of upper respiratory tract infections in premature infants up to seven months after release from hospital in a 2002 study of 39 infants.^[39]
• A 2004 case-control study found that breastfeeding reduced the risk of acquiring urinary tract infections in infants up to seven months of age, with the protection strongest immediately after birth.^[40]
• The 2007 review for AHRQ found that breastfeeding reduced the risk of acute otitis media, non-specific gastroenteritis, and severe lower respiratory tract infections.^[27]

Maternal vaccination while breastfeeding

In a review article published in the journal Pediatrics, data from 2001 to 2012 were analyzed to discern any safety issue for mothers being vaccinated while breastfeeding. The American Academy of Pediatrics (AAP) concludes that it is safe for women to receive almost all vaccines while nursing their infants. The study further found that the protected immunity of the mother obtained by vaccination against tetanus, diphtheria, whooping cough and influenza can pass on to the baby, and that breastfeeding can reduce fever rate after infant immunization. Exceptions are smallpox and yellow fever vaccines which increase the risk of infants developing vaccinia and encephalitis. In all other cases AAP recommends women continue breastfeeding after vaccination.^[41][42]

Sudden infant death syndrome

Formula fed babies have worse arousal from sleep at 2–3 months. This coincides with the peak incidence of sudden infant death syndrome.^[43] A study conducted at the University of Münster found that formula feeding doubled the risk of sudden infant death syndrome in children up to the age of 1.^[44]

Diabetes

Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than those with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.^[27][45] Breastfeeding also appears to protect against diabetes mellitus type 2,^{[27][28][46][47]} at least in part due to its effects on the child's weight.^[47]

Mental health

Breastfeeding for more than 6 months is an independent predictor of better mental health through childhood and adolescence according to a large 2009 study.^[14] The more months children were breastfed the less likely they were to suffer from depression, delinquent behavior, attention issues and other psychological problems.^[14] Breastfeeding also improves cognitive development according to a number of other studies.

The beneficial effects seem to stem in large part from the unique composition of human milk which, compared to formula milk, has been shown to lead to improved motor and cognitive development in pre-term babies as well.^[48]

Childhood obesity

Breastfeeding appears to reduce the risk of extreme obesity in children.^[49] The protective effect of breastfeeding against obesity is consistent, though small, across many studies, and appears to increase with the duration of breastfeeding.^[27][28][50]

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.^[51] 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.^[52]

Allergic diseases (atopy)

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.^[53] However, the key factor may be the age at which non-breastmilk is introduced rather than duration of breastfeeding.^[54] 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.^[55]

Necrotizing enterocolitis in premature infants

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.^[29] 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.^[27]

Other long term health effects

Although one study showed no evidence that breastfeeding offers protection against allergies, another study showed a positive correlation between breastfeeding and a lower risk of asthma. This study also showed that breastfeeding protects against allergies, and respiratory and intestinal infections.^[56][57]

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 lifelong protection.^[58]

According to the findings of a study conducted at the University of Wisconsin, women who were breastfed as infants may have a lower risk of developing breast cancer than those who were not breastfed.^[59]

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.^[28][60] 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,^[61] the 2007 review for the WHO concluded that breastfed infants "experienced lower mean blood pressure" later in life.^[28] 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".^[27] A 2006 study found that breastfed babies are better able to cope with stress later in life.^[62]

In a paper selected by UNICEF as the “Breastfeeding Paper of the Month” it was suggested that breastfed babies have a better chance of good dental health than artificially fed infants because of the effects of breastfeeding on the development of the oral cavity and airway. It was thought that with fewer malocclusions, breastfed children may have a reduced need for orthodontic intervention. The report also suggested that children with the proper development of a well rounded, "U-shaped" dental arch, which is found more commonly in breastfed children, may have fewer problems with snoring and sleep apnea in later life.^[63]

Connection to intelligence

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"^[27] and in 2006, a prospective cohort study, sibling pairs analysis, and meta-analysis, concluded that "Breast feeding has little or no effect on intelligence in children."^[64] The researchers found that "Most of the observed association between breast feeding and cognitive development is the result of confounding by maternal intelligence."^[64]

However a 2007 review for the World Health Organization "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." ^[28] A 2005 study using data on 2,734 sibling pairs from the National Longitudinal Study of Adolescent Health "provide[d] persuasive evidence of a causal connection between breastfeeding and intelligence."^[65] In another study, cited as "the largest randomized trial ever conducted in the area of human lactation," between 1996 and 1997 maternity hospitals and polyclinics in Belarus were randomized to receive or not receive breastfeeding promotion modeled on the Baby Friendly Hospital Initiative.^[66] Of 13,889 infants born at these hospitals and polyclinics and followed up in 2002–2005, those who had been born in hospitals and polyclinics receiving breastfeeding promotion had IQs that were 2.9–7.5 points higher (which was significantly higher).^[66] Since (among other reasons) a randomized trial should control for maternal IQ, the authors concluded in a 2008 paper that the data "provide strong evidence that prolonged and exclusive breastfeeding improves children's cognitive development."^[66] Further research in 2013 has supported this theory.^[67] One 2013 imaging study indicated that breastfed children experience 15-34% enhanced brain white matter development.^[68]

Genetic studies

In 2007, A. Caspi et al. published a study “Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism.” The authors noted that there is currently agreement in the scientific community that both genetic and environmental factors effect specific traits rather than one or another. This fact inspired them to try to find a gene that mediates the well-researched phenomenon that children who are breast-fed have higher IQ. In their study they found that babies with a specific version of the FADS2 gene demonstrated an IQ averaging 7 points higher if breastfed, compared with babies with a less common version of the gene who showed no improvement when breastfed.^[69] FADS2 affects the metabolism of polyunsaturated fatty acids found in human breast milk, such as docosahexaenoic acid and arachidonic acid, which are known to be linked to early brain development.^[69] The researchers said "Our findings support the idea that the nutritional content of breast milk accounts for the differences seen in human IQ. But it's not a simple all-or-none connection: it depends to some extent on the genetic makeup of each infant"^[70] and, "further investigation to replicate and explain this specific gene–environment interaction is warranted."^[69]

However, an attempt to replicate this study in 5934 eight-year-old children failed: No relationship of the common C allele to negative effects of formula feeding was apparent, and contra to the original report, the rare GG homozygote children performed worse when formula fed than other children on formula milk.^[71][72] Another study of over 700 families also criticized the Caspi et al. study. The study reported no evidence for either main or moderating effects of the original SNP (rs174575), nor of two additional FADS2 polymorphisms (rs1535 and rs174583), nor any effect of maternal FADS2 status on offspring IQ.^[73]

Benefits for mothers

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 usually delays 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^[31] and the maternal bond can be strengthened.^[24] Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point.^[74] Children who are not breastfed are almost six times more likely to die by the age of one month than children who receive at least some breastmilk.^[75]

Bonding

According to some authorities, there is a growing body of evidence that suggests that early skin-to-skin contact (also called kangaroo care) of mother and baby stimulates breast feeding behavior in the baby.^[76] Newborn infants who are immediately placed on their mother’s skin have a natural instinct to latch on to the breast and start nursing, typically within one hour of being born. It is thought that immediate skin-to-skin contact provides a form of imprinting that makes subsequent feeding significantly easier. The World Health Organization reports that in addition to more successful breastfeeding, skin-to-skin contact between a mother and her newborn baby immediately after delivery also reduces crying, improves mother to infant interaction, and keeps baby warm. According to studies quoted by UNICEF, babies have been observed to naturally follow a unique process which leads to a first breastfeed. Initially after birth the baby will cry as they take their first breaths. Shortly after, it will relax and begin to make small movements of the arms, shoulders and head. The baby will crawl towards the breast and begin to feed. After feeding, it is normal for a baby to remain attached to the breast while it rests. This is sometimes confused for the baby not being hungry, however it is a normal thing for the baby to do after finding their food source. Providing that there are no interruptions, all babies are said to follow this process and it is suggested that trying to rush the process or interruptions such as removing the baby to weigh him/her is counter-productive and may lead to problems at subsequent breastfeeds.^[77]

Hormones released during breastfeeding help to strengthen the maternal bond.^[24] Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.^[78] Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.^[79]

If the mother is away, an alternative caregiver may be able to feed the baby with breast milk expressed with a breast pump.

Hormone release

Breastfeeding releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby.^[80] This hormone release can help to enable sleep even where a mother may otherwise be having difficulty sleeping. 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.^[81]

Weight loss

As the fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight.^[82][83][84] 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.^[85] 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."^[27]

Gestational changes

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, and breasts.^[86] 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).^[87] 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.^[88] 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.^[89] 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.^[90] 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.

Postpartum changes

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.^[91] 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.^[92] 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.^[93] 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.^[94][95] These studies have indicated that lactation is associated with reduction in subcutaneous fat levels and overall body weight.

Long-term effects of lactation on health and body composition

Recent data suggests that lactation is associated with a reduced risk in chronic diseases such as type-2 diabetes and heart disease.^[96] The long-term effects of lactation on body composition vary, and seem to be influenced by socioeconomic factors.^[97] 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 effects of lactation on maternal body composition and risk for chronic disease.^[98]

Natural postpartum infertility

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.^[99] It is possible for women to ovulate within two months after birth while fully breastfeeding and get pregnant again.

Long-term health effects

For breastfeeding women, long-term health benefits include:

• Less risk of breast cancer, ovarian cancer, and endometrial cancer.^{[19][27][100][101]}
• A 2009 study indicated that lactation for at least 24 months is associated with a 23% lower risk of coronary heart disease.^[102]
• Although the 2007 review for the AHRQ found "no relationship between a history of lactation and the risk of osteoporosis",^[27] mothers who breastfeed longer than eight months benefit from bone re-mineralisation.^[103]
• Breastfeeding diabetic mothers require less insulin.^[104]
• Reduced risk of metabolic syndrome^[105][106]
• Reduced risk of post-partum bleeding.^[81]
• According to a Malmö University study published in 2009, women who breast fed for a longer duration have a lower risk for contracting rheumatoid arthritis than women who breast fed for a shorter duration or who had never breast fed.^[107]
• According to a Spanish study published in the Journal of Clinical Nursing, breastfeeding for over six months would produce a decrease in oestroegen level and protect women against breast cancer and delay the onset of the disease by 10 years.^[108]

Financial benefits

The American Academy of Pediatrics states that breast feeding also has economic health benefits because breastfeeding results in reduced health care costs. The significantly lower incidence of illness in the breastfed infant also allows the parents more time for attention to siblings and other family duties and reduces parental absence from work and lost income. Using figures for the year 1993, it was estimated that the cost of purchasing infant formula for the first year after birth was $855. During the first 6 weeks of lactation, maternal caloric intake is no greater for the breastfeeding mother than for the nonlactating mother. After that period, food and fluid intakes are greater, but the cost of the increased caloric intake is about half the cost of purchasing formula, resulting in a saving of about $400.^[109]

Methods and considerations

There are many books and videos to advise mothers about breastfeeding. Lactation consultants in hospitals or private practice, and volunteer organizations of breastfeeding mothers such as La Leche League International also provide advice and support.

Early breastfeeding

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.^[110] Breastfeeding also releases hormones that contract the uterus to reduce post-partum bleeding.^[111] Early breastfeeding is associated with fewer nighttime feeding problems.^[112] A Cochrane review found that early skin-to-skin contact between mother and baby (placing the baby at the mother's breast before dressing the baby) reduces crying, improves mother-baby interaction, keeps the baby warmer, and helps women breastfeed successfully and for a longer period of time.^[113]

Time and place for breastfeeding

Feeding a baby "on demand" (sometimes referred to as "on cue"), means feeding when the baby shows signs of hunger. Newborn babies usually express demand for feeding every 1 to 3 hours per 24 hours (resulting in 8-12 times in 24 hours) for the first two to four weeks.^[114]

"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."^[115]

"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."^[115]

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.

In 2014, newly elected Pope Francis, well-known for his liberal outlook, drew world-wide commentary when he encouraged mothers to breastfeed in church if their babies were hungry. During a special papal baptism Pope Francis said that mothers "should not stand on ceremony" if their children were hungry. "If they are hungry, mothers, feed them, without thinking twice," he said, smiling. "Because they are the most important people here."^[116]

Latching on, feeding, and positioning

Correct positioning and technique for latching on are necessary to prevent nipple soreness and allow the baby to obtain enough milk.^[117][118] 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.^[119] 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.^[117][120] 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 re-admissions of newborns.^[121]

Duration of each session

During the newborn period, most breastfeeding sessions will take from 20 to 45 minutes.^[114] After the finishing of a breast, the mother may offer the other breast.

Exclusive breastfeeding

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."^[19] 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.^{[122][123][124][125]}

While it can be hard to measure how much food a breastfed baby consumes, babies normally feed to meet their own requirements.^[126] Babies that fail to eat enough may exhibit symptoms of failure to thrive.

The La Leche League says that their most often asked question is, "How can I tell if my baby is getting enough milk?" They advise that for the first few days while the baby is receiving mostly colostrum only one or two wet diapers per day is normal. Once the mother's milk comes in, usually on the third or fourth day, the baby should begin to have 6-8 wet cloth diapers (5-6 wet disposable diapers) per day. In addition, most young babies will have at least two to five bowel movements every 24 hours for the first several months.^[127]

The La Leache League gives the following additional signs that indicate a baby is receiving enough milk:

• The baby nurses frequently averaging at least 8-12 feedings per 24-hour period.
• The baby is allowed to determine the length of the feeding, which may be 10 to 20 minutes per breast or longer.
• Baby's swallowing sounds are audible as he is breastfeeding.
• The baby should gain at least 4-7 ounces per week after the fourth day of life.
• The baby will be alert and active, appear healthy, have good color, firm skin, and will be growing in length and head circumference.^[127]

Expressing breast milk

When direct breastfeeding is not possible, a mother can express (artificially remove and store) her milk. With manual massage or by using a breast pump, a woman can express her milk and store it. It can be stored in freezer storage bags and containers made specifically for breastmilk, 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 six to twelve months.^[128] Research suggests that the antioxidant activity in expressed breast milk decreases over time but it still remains at higher levels than in infant formula.^[129]

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 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.^[130] 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.

With the improvements in breast pumps, many women are able to return to work while exclusively feeding their infants breast milk because of their ability to express milk at work. Women can also leave their infants in the care of others for vacation or other extended trips, while maintaining a supply of breast milk. This can be very convenient to the mother.^[131]

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.^[132] The transmission of some viral diseases through breastfeeding can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.^[133]

Mixed feeding

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 nipples than from a breast. With the breast, the infant's tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; with an artificial nipple, an infant must suck harder and the milk may come in more rapidly. Therefore, 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.^[134]

Tandem nursing

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.^{[135][136][137]}

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.^[138]

Shared breastfeeding

It used to be common worldwide, and still is in some developing nations such as those found 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.^[139] 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;^[140] American feminist activist Jennifer Baumgardner has written about her experiences in New York with this issue.^[141]

Duration of breastfeeding

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.^[17][142] According to a study conducted by the Centers for Disease Control and Prevention, the results of which were published in the journal Pediatrics, as of 2013 in the United States reliance on out-dated recommendations and considerations of convenience and cost sometimes resulted in inappropriate earlier attempts to switch to solid food.^[143]

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.^[144] 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, economic, 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.^[145] 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.^[146]

The US CDC recommends exclusive breastfeeding till six months of age. Their latest figures (2008) show that 76.9% of US women had ever breastfed but only 47.2% were still breastfeeding at six months and 25.5% at twelve months. Figures for exclusive breastfeeding at three months were 36% and at six months only 16.3%.^[147]

Diet during breastfeeding

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.^[148] If a woman ingests alcohol, a small amount can be passed to the baby through breast milk. Alcohol-containing breastmilk has been shown to have a detrimental effect on motor development.^[149] Caffeine intake should be kept to no more than 300 milligrams (about one to three cups of regular coffee) per day for breastfeeding women, as excess caffeine in breastmilk can cause irritability and restlessness in infants. When consumed in normal, everyday amounts, caffeine is considered to be compatible with breastfeeding by the American Academy of Pediatrics.^[150] Nursing mothers concerned about the chemical bisphenol A, which has been shown to affect a childs health, should be aware that it can be passed to their baby though breast milk; they may want to limit their dietary intake of certain foods and adjust their shopping habits to avoid as much exposure as possible.^[151][152]

Healthy infant growth

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:

• Weight gain of 4–7 ounces (112–200 grams) a week during the first month
• An average of 1–2 pounds (1/2 to 1 kilogram) per month for the first six months
• An average of one pound (1/2 kilogram) per month from six months to one year
• Babies usually grow in length by about an inch a month (2.5 cm) during the first six months, and around one-half inch a month from six months to one year.^[153]

Weaning

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. Figures vary, but worldwide, humans lose about 75 to 95 percent of birth lactase levels by early childhood, and there is a continuous decline in lactase during the course of a lifetime. However, the prevalence varies widely among ethnic backgrounds. Estimates range from 2 to 5 percent in persons from Northern Europe to nearly 100 percent in adult Asians and American Indians. Blacks and Ashkenazi Jews have prevalences of 60 to 80 percent, and Latinos have a prevalence of 50 to 80 percent.^[154][155]

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.^[156]

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.^[157] Other medications such as cabergoline, lisuride or birth control pills may occasionally be used as lactation suppressants.

Extended breastfeeding

North America

Elizabeth Baldwin says in Extended Breastfeeding and the Law, "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."^[158] 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.^[146] 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".^[146] 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.^[146]

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".^[19][145]

In the United States overall, according to a 2010 CDC "report card", 43% of babies are breastfed until 6 months and 22.4% are breastfed until 12 months, though breastfeeding rates varied among the states.^[159]

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.^[160]

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.^[161]

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.^[144] 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.^[144] 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.^[144]

Guinea-Bissau

In Guinea-Bissau, West Africa, the average length of breastfeeding is 22.6 months.^[162]

India

In India, mothers commonly breastfed their children until 2 to 3 years of age. Cows milk is given in combination with breast milk though use of formula has been on the rise.^[145]

As of November 2012,^[163] the Ministry of Women and Child Development, with UNICEF as a technical partner, have kicked off a nationwide campaign to promote exclusive breastfeeding to infants up to the age of six months - one among a series of advisories it is issuing - as part of an awareness program targeted at eradicating malnutrition in the country. Indian actor Aamir Khan serves as the brand ambassador, and has acted in numerous televised public service announcements.

The Philippines

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.^[164] 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.^[165]

In 2012, it was reported that legislation had been introduced which would narrow down the application of the Milk Code (reducing the period recommending against artificial baby foods for babies from 0 to 36 months to 0 to six months only), would lift the restriction on donations of artificial milk products in emergency situations (encouraging mothers who suffer from disabilities to shift to milk substitutes instead of encouraging them to continue breastfeeding assisted by support persons), would change the legally mandated lactation break period for breastfeeding mothers from paid to unpaid status, and would remove the prohibition against milk companies giving away free samples of artificial milk products in the health care system.^[166][167]

Health effects

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."^[168] Dr. Laurence Grummer-Strawn, widely known in the breastfeeding research and advocacy communities,^[169] observed that breastfeeding is protective against diarrheal diseases and other infections and that breastfed children aged 12 to 36 months in Indonesia have much greater mid-arm circumference than children who have been weaned at an early age. He also noted that the incidence of malnourishment in breastfed Indonesian children is 3–5% less common than generally encountered in early-weened children. 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").^[146] In traditional human societies, the lack of nutrients missing in breast milk such as iron, zinc, and vitamin b12 was supplemented through premastication and feeding of meat to the child.^[170][171]

Psychological effects

In A Time to Wean, Katherine Dettwyler 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."^[172] Many children who are breast-fed into their toddler years use the milk as a comforting, bonding moment with their mothers.^[146] 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.^[146] Dr. Stein said "A mother in my practice who breastfed 2 children until 2 years of age explained that she would slow down 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".^[145] 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.

Breastfeeding difficulties

International board certified lactation consultants

International board certified lactation consultants (IBCLCs) are an excellent source of assistance for breastfeeding mothers. IBCLCs are health care professionals certified in lactation management. They work with mothers to solve breastfeeding problems and educate families and health care professionals about the benefits of breastfeeding. Research shows that rates of exclusive breastfeeding and of any breastfeeding are higher among women who have had babies in hospitals with IBCLCs on staff.^[173]

Physiological constraints to breastfeeding

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.^[174] The AAP breastfeeding policy says: "Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed."^[19] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained midwives, doctors and hospital staff, and lactation consultants.^[175] 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.^[57] 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.^[176] Research shows that women whose pregnancies are unintended are less likely to breast feed their babies.^[177]

Barriers to breastfeeding

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.

• Birth procedures – routine separation of the baby from the mother, delayed breastfeeding initiation, vigorous routine suctioning, medications and mode of delivery all interfere with breastfeeding. A "substantial" number of hospital and facilities implemented procedures and policies that were not evidenced based and that were known to interfere with lactation.^[178]
• Nursery policies – additional separation, rooming in policies, routine bottles and pacifiers can also prevent the baby from learning to latch and establishing a supply. About a quarter of all breastfeeding infants receive formula supplementation in the first two days of life.^[179]
• Ignorance
  • Personal – breastfeeding is the biologic norm but in absence of watching others nurse their babies, it is a lost art as well. Classes, books and personal counseling (professional or lay) can be beneficial. Some women do not want to breastfeed because they fear that breastfeeding will negatively impact the look of their breasts, although medical evidence attributes "drooping" or "sagging" of the breasts to pregnancy, aging, and smoking habits. Jae Ireland reports “the idea that breastfeeding causes saggier, smaller breasts is a myth, as proven by a 2008 study published in the Aesthetic Surgery Journal. The study found that while breastfeeding had no effect on a woman's breasts, other factors did contribute to sagginess, such as a mother's advanced age, her number of pregnancies and whether or not she smoked. All three factors can result in altered breasts, but breastfeeding was not identified as a marker for a change in overall breast appearance.” ^[180]
  • Partner – Partners also lack basic breastfeeding knowledge and are typically unsure of their role in breastfeeding.
  • Practitioner – Physicians and nurses have surprisingly little training in lactation and lactation support. One of the main action items in The Surgeon General’s Call to Action to Support Breastfeeding is to help educate practitioners about breastfeeding and breastfeeding issues.^[181]
• Workforce – Returning to work is the most common cited reason for discontinuing breastfeeding.^[182] Maternity leave in the US varies widely despite the Family Medical Leave Act (FMLA), which provides most working mothers up to 12 weeks. Many mothers are forced to take unpaid time off from their job and the majority do not use FMLA for the full twelve weeks. Fathers are also allowed to use FMLA for the birth or adoption of the child. Maternity leave varies widely by state. Save the Children recently examined maternity leave laws, the right to nursing breaks at work, and several other indicators to create a ranking of 36 industrialized countries measuring which ones have the most – and the least – supportive policies for women who want to breastfeed. Norway topped the scorecard and the United States came in last.^[183]
• Poor latch - Pain caused from mis-positioning the baby on the breast or a tongue-tie in the infant can cause great pain in the mother and therefore discourage her from breastfeeding. These problems are generally easy to correct (by re-positioning or clipping the tongue-tie).^[184]

Sociological factors

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. A recent study found that on average women that breastfed their infants had higher levels of education, were older, and were more likely to be white.^[185]

The reasons for the persistently lower rates of breastfeeding among African American women are not well understood, but employment may play a role. African American women tend to return to work earlier after childbirth than white women, and they are more likely to work in environments that do not support breastfeeding. Although research has shown that returning to work is associated with early discontinuation of breastfeeding, a supportive work environment may make a difference in whether mothers are able to continue breastfeeding.^[185]

Deborah L. Dee's research found that women and children who qualify for WIC, Special Supplemental Nutrition Program for Women, Infants, and Children were among those who were least likely to initiate breastfeeding. Income level can also contribute to women discontinuing breastfeeding early. More highly educated women are more likely to have access to information regarding difficulties with breastfeeding, allowing them to continue breastfeeding through difficulty rather than weaning early. Women in higher status jobs are more likely to have access to a lactation room and suffer less social stigma from having to breastfeed or express breastmilk at work. In addition, women who are unable to take an extended leave from work following the birth of their child are less likely to continue breastfeeding when they return to work.^{[citation needed]} Low income women are more likely to have unintended pregnancies,^[185] and women whose pregnancies are unintended are less likely to breast feed their babies.^[177]

Breastfeeding in public

Breastfeeding in public is forbidden in some jurisdictions, not addressed by law in others, and a granted legal right in public and the workplace in yet others. Where it is a legal right, some mothers may nevertheless be reluctant to breastfeed,^[186][187] and some people may object to the practice.^[188]

There have been incidents of owners of premises, or people present, objecting to or forbidding breastfeeding. In some cases the mothers have left; in others, where a law guaranteeing the right to breastfeed has been broken, there has been legal action. Sometimes a company has apologised after the fact.^[189]

In 2006, the editors of US Babytalk magazine received many complaints from readers after the cover of the August issue depicted a baby nursing at a bare breast. Even though the model's nipple was not shown, readers—many of them mothers—wrote that the image was "gross". In a follow-up poll, one-quarter of 4,000 readers who responded thought the cover was negative. Babytalk editor Susan Kane commented, "There's a huge puritanical streak in Americans." In a 2004 survey conducted by the American Dietetic Association, 43% of the 3,719 respondents believed women ought to have the right to breast-feed in public.^[190]

Stigma

Sexual objectivization

Negative perception of breastfeeding in social settings has led some women to feel discomfort when breastfeeding in public.^[191] Even though many women are educated about the health benefits of breastfeeding, less than 25% choose to breastfeed their children. Western society tends to think of breasts in sexual terms instead of for their main biological purpose, to bring nourishment to infants.^[192] The sexualized image of breasts has led many to have an adverse reaction to breastfeeding because people do not like to associate feeding an infant with sexual pleasure. The consequences of Western culture’s sexualization of breasts has led women feeling embarrassed to breast feed in public, and instead, in private settings.^[193] Limitations on places in which women can breastfeed, as well as negative cultural connotations with breastfeeding may play a role in the amount of time a woman will breastfeed.^[194] The end result is often that the woman may give up breastfeeding and switch to a bottle. .^[193]

Maternal guilt and shame

Research has shown that maternal guilt and shame is often associated with how a mother feeds their infant. This guilt and shame is a result of the inability to achieve the idealized notion of what it means to be a good mother. Mothers of both bottle and breast fed babies often feel shame and/or guilt for different reasons. Mothers who bottle feed their infants may feel that they are failures at breastfeeding.^[195] On the other hand, mothers who breastfeed may feel exposed when breastfeeding in public places because of sexual connotations associated with breasts. They may also fear ridicule from emotional responses to an exposed breast. Some may see breastfeeding as, ““indecent, disgusting, animalistic, sexual, and even possibly a perverse act.^[192]” In response to scrutiny concerning public breastfeeding, advocates use nurse-ins to show others that there should be no shame in breastfeeding in public.^[191] However some advocates don’t fight the shame a woman can feel when she cannot breastfeed and must bottle-feed her baby. Shame should not be used as a tool to advocate breastfeeding, rather women should be able to individually define what a good mother is. Rather than focusing on the choice a woman has made on whether or not to breastfeed, it is suggested that there be a redirection with the emphasis of providing women with education on the benefits of breastfeeding as well as problem solving skills for women who may find it difficult.^[195]

Mobility to breast milk

The cultural context of Western society, does not always seem to advocate for breastfeeding in public.^[191] According to one study published in the Journal of American Dietetic Association, over half of the people who voted believed that women should not be allowed to breastfeed in public. This study confirms previous studies that indicate that Americans do not want to see breasts in public places. Thus the stigma associated with breastfeeding in public can guide parents to seek an alternative to breastfeeding, even though it may not be as healthy for the child.^[196] There used to be only two options for feeding infants: breastfeeding or formula. With the introduction of formula as a scientifically proven way of nourishing infants, many people chose to feed their child formula over breast milk. Formula was popular for the convenience it offered by opening care opportunities to others.^[197] When examining the invention of formula from a bio cultural perspective, one might also see the invention of formula as a way in which western culture adapted to negative cultural perceptions of breastfeeding in public.^[196] In response to negativism against breastfeeding, the La Leche League began a breastfeeding advocacy movement that aimed to educate the public about the short and long term benefits of breastfeeding for both mother and child. With the introduction of the breast pump came a “third option,” that offered the benefits of mobility associated with formula feeding and the health benefits of breastfeeding. This allowed care relationships to extend across further distances without compromising the health benefits of breast milk.^[197]

Role of marketing

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.^[198] The most famous example, the Nestlé boycott, arose in the 1970s and continues to be supported by high-profile stars and international groups to this day.^[199][200]

In 1981, the World Health Assembly (WHA) adopted Resolution WHA34.22 which includes the International Code of Marketing of Breast-milk Substitutes. Subsequently, the Innocenti Declaration was made by WHO and UNICEF policy-makers in August 1990 to protect, promote, and support breastfeeding.^[201] According to the WHO report published ahead of World Breastfeeding Week, 2013, only 37 countries (19 per cent) of 199 countries, subscribing to the International Code of Marketing of Breast-milk Substitutes, have passed laws incorporating all of the Code’s recommendations.^[202]

HIV

The central concern about breastfeeding with HIV is whether or not it places the child at risk of becoming infected. Varying factors, such as the viral load in the mother’s milk, contribute to the difficulty in creating breastfeeding recommendations for HIV-positive mothers^[203] It is also possible for the infant to be infected with HIV throughout the duration of the pregnancy or during the birthing process (intrapartum).^[204] Breastfeeding with HIV guidelines established by the WHO suggest that HIV-infected mothers (particularly those in resource-poor countries) practice exclusive breastfeeding only, rather than mixed breastfeeding practices that involve other dietary supplements or fluids.^[205] Many studies have revealed the high benefit of exclusive breastfeeding to both mother and child, documenting that exclusive breastfeeding for a period of 6 months significantly reduces transmission, provides the infant with a greater chance of survival in the first year of life, and helps the mother to recover from the negative health effects of birth much more quickly.^[206] However, a recent study conducted by researchers from the University of North Carolina School of Medicine suggests that women infected with HIV can, in fact, breastfeed without transmitting the virus to their children, because components in breast milk are understood as able to kill the virus.^[207] 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.^[208] Despite these positive indicators, other studies have determined that bottle-fed babies of HIV-infected mothers approximately has a 19 percent chance of becoming infected, in comparison to breastfed babies who had an approximate 49 percent chance of infection.^[204] Such a variance in findings makes it difficult to institute a proper set of guidelines for HIV-infected women in third-world or developing countries, where alternative forms of feeding are not always acceptable, feasible, affordable, sustainable, and safe (AFASS).^[209] Thus after much research, the benefits and/or consequences of breastfeeding with HIV are still currently under debate.

Challenges to PMTCT policy

The practice of breastfeeding for HIV positive mothers is a highly contested and controversial global public health concern. Programs for prevention of mother to child transmission (PMTCT) and other international guidelines offer preventative interventions to address mother to child transmission(MTCT) of HIV in Third World countries.^[210] PMTCT programs provide HIV-positive women with recommendations and services including antiretroviral therapy (ART), modifications in infant feeding practices (i.e., exclusive breastfeeding or exclusive replacement feeding), and counseling.^[211]

Although prevention of mother to child transmission (PMTCT) programs have been implemented across different regions, their success in resource-constrained settings is still widely debated upon.^[212] In 2008, the majority of sub-Saharan Africa as a whole had an estimate of 430,000 HIV infections among children under the age of 15.^[212] HIV-positive women’s lack of participation and adherence to PMTCT services and infant feeding guidelines has made the success of these policies difficult, despite the knowledge and technology that has been dedicated to them.^[212] Many women fear knowing their HIV status.^[212] Generally speaking, HIV-positive mothers lack support, especially from males, thus resulting in their stigmatization and exclusion by members of the community.^[212] It is because of this that most women end up losing contact with development programs, which end soon after the mother delivers.^[212] The discontinuation of these programs makes a knowledge and understanding of different feeding options difficult for these mothers, because these programs are not there to present them with the necessary information.^[212]

Cross-Cultural Experiences of Breastfeeding with HIV

Access to available resources for the prevention of MTCT of HIV varies across different cultural regions. “MTCT of HIV has been virtually eliminated in well-resourced settings such as the United States and Europe”.^[213] Available medical and therapeutic resources in developed countries can include drugs for HIV-positive mothers during pregnancy and labour, cesarean delivery to reduce the infant’s exposure to infection; and modifications in infant feeding practices.^[155] In third world settings, medical resources and technology can be very hard to find and can serve as a financial burden to HIV-positive mothers. HIV-infected mothers refer to counselors for expert knowledge and recommendations on infant feeding and health.^[214] Treatment amenities in resource-constrained settings are also available to HIV-positive mothers in the form of antiretroviral therapy (ART) which is one resource that has contributed to the elimination of MTCT of HIV in first world countries.^[155] In order to have access to resources, HIV-positive mothers must be able maintain follow up appointments regularly, however, this is problematic in resource-limited settings due to weak infrastructure in health care systems in countries such as India, Tanzania and Nigeria.^[155] This can also serve as a dilemma for HIV-positive mothers because although limited resources are available to them, financial constraint can prevent women from accessing available treatments. This can influence HIV-positive mother’s decision to rely solely on breastfeeding as a primary feeding option due to financial instability.^[215]

Anthropological research demonstrates that in contexts where breastfeeding is essential to infant survival, such as in resource poor settings, PMTCT infant feeding guidelines challenge notions of motherhood and women’s decision making power over infant care, and colour HIV positive mothers’ infant feeding experiences.^[216] In eastern Africa, infant mortality is high and breastfeeding is vital for infant survival.^[217] Here, motherhood is defined as the responsibility for ensuring the child’s proper growth and health.^[217] Breastfeeding is also seen as a cultural practice that helps create a social bond between mother and child.^[218] However, there is a disjuncture between PMTCT policy’s infant feeding guideline and what is considered to be good mothering behaviour.^[219] The PMTCT policy promotes replacement feeding because it is believed to prevent the risk of transmission of HIV. However, adhering to such guidelines are difficult for mothers in resource-limited settings who believe that not breastfeeding one’s child would be harmful to their health and survival, as well as threaten the “development of close bodily and emotional bonds between mother and child”.^[220] As such, not breastfeeding, for HIV-positive women, is perceived as failing to be a good mother.^[217] Thus, PMTCT programs impact HIV-positive women’s agency and decision-making in infant care, as well as challenge their cultural conceptions of good motherhood.

World Health Organization breastfeeding guideline for HIV-infected mothers

In an effort to further refine the United Nations guideline for optimal infant feeding options for HIV-infected mothers, the World Health Organization (WHO) held a three-day convention in Geneva in 2006 to review new evidence that had been established since they last established a guideline in 2000. Participants included UN agencies, representative from nongovernmental organizations, researchers, infant feeding experts, and WHO headquarters departments. The convention concluded with the following 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 infants are recommended to continue breastfeeding even after 6 months.^[221]

In a 2010 update the WHO stated that significant programmatic experience and research evidence regarding HIV and infant feeding had accumulated since WHO's recommendations on infant feeding in the context of HIV were last revised in 2006. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This evidence has major implications for how women living with HIV might feed their infants, and how health workers should counsel these mothers. Together, breastfeeding and ARV intervention have the potential to significantly improve infants' chances of surviving while remaining HIV uninfected.

While the 2010 recommendations are generally consistent with the previous guidance, they recognize the important impact of ARVs during the breastfeeding period, and recommend that national authorities in each country decide which infant feeding practice, i.e. breastfeeding with an ARV intervention to reduce transmission or avoidance of all breastfeeding, should be promoted and supported by their Maternal and Child Health services. This differs from the previous recommendations in which health workers were expected to individually counsel all HIV-infected mothers about the various infant feeding options, and it was then for mothers to decide between them.

Where national authorities promote breastfeeding and ARVs, mothers known to be HIV-infected are now recommended to breastfeed their infants until at least 12 months of age. The recommendation that replacement feeding should not be used unless it is acceptable, feasible, affordable, sustainable and safe remains.^[222]

Taking medication while breastfeeding

In a review article published in the journal Pediatrics, data from 2001 to 2012 were analyzed to discern any safety issue for mothers taking prescription drugs while breastfeeding. The American Academy of Pediatrics (AAP) advises that mothers can take most prescription drugs but should avoid certain painkillers, psychiatric drugs and herbal supplements. The health benefits of mother taking drugs and breastfeeding should be weighed against the risk of drug exposure to the infant. The report recommends consulting the NIH database 'LactMed' on the most up-to-date information on drugs and breastfeeding.^[41][42]

See also

Baby Friendly Hospital Initiative Baby-led weaning Breastfeeding promotion Breast shell Dairy allergy Erotic lactation

Human–animal breastfeeding Human milk banking in North America Kangaroo care Lactation room Milk line Nursing chair

References

Further reading

• Baumslag N, Michels DL (1995). Milk, money, and madness: the culture and politics of breastfeeding. Westport, Conn.: Bergin & Garvey. ISBN 0-89789-407-3. 
• Hausman B (2003). Mother's milk: breastfeeding controversies in American culture. New York: Routledge. ISBN 0-415-96656-6. 
• Huggins K (1999). The nursing mother's companion (4th ed.). Boston, Mass.: Harvard Common Press. ISBN 1-55832-152-7. 
• Pryor G (1997). Nursing mother, working mother: the essential guide for breastfeeding and staying close to your baby after you return to work. Boston, Mass.: Harvard Common Press. ISBN 1-55832-116-0. 
• Wiessinger, D., West, D., Pitman, T. (2010). The Womanly Art of Breastfeeding (8th ed.). New York, NY: Ballantine Books. 
• Weiss R (2010). Better Way to Breastfeed Your Baby. Beverly, MA: Fair Winds. ISBN 978-1-59233-422-3. 
• Palmer G (2009). The Politics of Breastfeeding: when breasts are bad for business, 3rd edition. London: Pinter & Martin. ISBN 978-1-905177-16-5. 

External links

Wikimedia Commons has media related to Breastfeeding.

Look up breastfeeding in Wiktionary, the free dictionary.

• Breastfeeding on the Open Directory Project
• Human Milk Secretion: An Overview US National Institute of Health
• Breastfeeding Resources La Leche League International
• Breast-Feeding Content Resources WHO reports on Breast Feeding
• Health risks of not breastfeeding US Department of Health & Human Services
• The World Alliance for Breastfeeding Action (WABA) is a global network of individuals & organisations concerned with the protection, promotion & support of breastfeeding worldwide.
• Breastfeeding: NHS Choices
• Center for Disease Control and Prevention Breastfeeding CDC
• LactMed, a database of the safety of drugs to which breastfeeding mothers may be exposed, by the U.S. National Library of Medicine

v t e Human physiology and endocrinology of sexual reproduction Menstrual and estrous cycle Menarche Menstruation Follicular phase Ovulation Luteal phase Gametogenesis Spermatogenesis (spermatogonium spermatocyte spermatid sperm) Oogenesis (oogonium oocyte ootid ovum) Germ cell (gonocyte gamete) Human sexual behavior Sexual intercourse Masturbation Erection Orgasm Ejaculation Insemination Fertilisation/Fertility Implantation Pregnancy Postpartum period Mechanics of sex Life span Prenatal development/Sexual dimorphism/Sexual differentiation (Feminization Virilization) Puberty (Gonadarche Pubarche Menarche Adrenarche) Maternal age / Paternal age Climacteric (Menopause Andropause) Egg (biology) Ovum Oviposition Oviparity Ovoviviparity Vivipary Reproductive endocrinology and infertility Hypothalamic-pituitary-gonadal axis Andrology Hormone Breast Thelarche Breast development Lactation Breastfeeding M: ♀ FRS anat/phys/devp noco/cong/npls, sysi/epon proc/asst, drug (G1/G2B/G3CD) M: ♂ MRS anat/phys/devp noco/cong/tumr, sysi/epon proc, drug (G3B/4BE/4C) M: BRE anat/phys/devp noco/cong/tumr proc