Breastfeeding

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An infant breastfeeding

Breastfeeding is feeding of infants or young children with breast milk from female breasts (i.e. through lactation). The sucking reflex enables babies to suck and swallow milk instinctively. Some mothers express milk to be used while their child is being cared for by others by hand or by using a breast pump.

Globally, inadequate nutrition is an underlying cause of the deaths of more than 2.6 million children and over 100,000 mothers every year.[1]

The World Health Organization (WHO), UNICEF and Save the Children recommend children be breastfed within one hour of birth and exclusively breastfed for the first six months,[1][2] after which WHO recommends continued breastfeeding until age two together with age-appropriate, nutritionally adequate and safe complementary foods.[2] The American Academy of Pediatrics (AAP) 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".[3] AAP and the American Dietetic Association promote breastfeeding as the best source of infant nutrition".[4]

Breastmilk is easy for the baby to digest, which promotes more frequent eating due to faster digestion.[5] It may decrease risk of diabetes and celiac disease.[6][7] Benefits for the mother include: better uterine shrinkage, decreased risk of breast cancer, decreased postpartum depression and decreased risk of osteoporosis.[citation needed] It may also be a bonding experience[8] for mother and child, and can be less expensive than infant formula.[9] Controversially, decreased risk for obesity in adulthood and improved cognitive development have been mooted.[2][4]

Breastfeeding promotes health of both mother and infant and helps prevent disease.[2][10] Consensus holds that breastfeeding is beneficial and superior to infant formula. Formula feeding is associated with more deaths from diarrhea in infants in both developing and developed countries.[2][11] Exceptions include periods when the mother is taking certain drugs, has active untreated tuberculosis or is infected with human T-lymphotropic virus. WHO recommends that national authorities in each country decide which infant feeding practice should be promoted by their maternal and child health services to best avoid HIV transmission from mother to child.

History[edit]

Ilkhanate prince Ghazan being breastfed.

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. 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 was also unsuccessful.

During the early 1900s breastfeeding started to be viewed negatively by Western societies, especially Canada and the US. These societies considered it a low class and uncultured practice.[12] 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 continued into the 2000s, though negative attitudes towards the practice were still entrenched up to 1990s.[12]

Lactation[edit]

Main article: 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 breast's milk duct system. 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 milk production.[13] 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.[14][15]

Breast milk[edit]

Two 25ml samples of human breast milk. The sample on the left is foremilk, the watery milk coming from a full breast. To the right is hindmilk, the creamy milk coming from a nearly empty breast.[16]
Himba woman and child
Main article: Breast milk

Not all of breast milk's properties are understood, but its nutrient content is relatively consistent. Breast milk is made from nutrients in the mother's bloodstream and bodily stores. Breast milk has an optimal balance of fat, sugar, water, and protein that is needed for a baby's growth and development.[17] Breastfeeding triggers biochemical reactions which allows for the enzymes, hormones, growth factors and immunologic substances to effectively defend against infectious diseases for the infant. The breastmilk also has long-chain polyunsaturated fatty acids which help with normal retinal and neural development.[18] Because breastfeeding requires an average of 500 calories a day, it helps the mother lose weight after giving birth.[19] The composition of breast milk changes depending on how long the baby nurses at each session, as well as on the child's age.

Milk quality may be compromised by smoking, alcoholic beverages, caffeinated drinks, marijuana, methamphetamine, heroin and methadone.[20] However, AAP states that "tobacco smoking by mothers is not a contraindication to breastfeeding."[21] In addition, 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."[21]

Methods[edit]

Books and videos 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 commencement[edit]

Early breastfeeding is associated with fewer nighttime feeding problems.[22] A systematic review of thirty four trials found that early skin to skin contact between mother and baby improves breastfeeding outcomes, cardio-respiratory stability and decreases infant crying.[23]

Time and place[edit]

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.[24]

According to La Leche League International, "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....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."[25]

Rooming-in bassinet

Most US states now have laws that allow a mother to breastfeed her baby anywhere. In hospitals, rooming-in care permits the baby to stay with the mother and simplifies the process. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring a special area.

In 2014, newly elected Pope Francis drew world-wide commentary when he encouraged mothers to breastfeed hungry babies in church. During a special papal baptism he 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."[26]

Technique[edit]

Illustration depicting correct latch-on position during breastfeeding.

Correct positioning and technique for latching on are necessary to prevent nipple soreness and allow the baby to obtain enough milk.[27] 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.[28] 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.[29][30] Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns.

Babies can successfully latch on to the breast from multiple positions. Each baby may prefer a particular position. The "football" hold places the baby's legs next to the mother's side with the baby facing the mother. Using the "cradle" or "cross-body" hold, the mother supports the baby's head in the crook of her arm. The "cross-over" hold is similar to the cradle hold, except that the mother supports the baby's head with the opposite hand. The mother may choose a reclining position on her back or side with the baby laying next to her.[31][unreliable medical source?]

Duration[edit]

During the newborn period, most breastfeeding sessions take from 20 to 45 minutes.[24] After one breast is empty, the mother may offer the other breast.

Ways of feeding babies[edit]

Exclusive breastfeeding[edit]

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."[21] National and international guidelines recommend that all infants be breastfed exclusively for the first six months of life. Thereafter 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 also reduces HIV transmission from mother to child, compared to mixed feeding.[32][33][34][35]

While it can be hard to measure how many calories a breastfed baby consumes, babies normally attempt to meet their own requirements.[36] 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, one or two wet diapers per day is normal. Once the mother starts producing milk, usually on the third or fourth day, the baby should 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.[37]

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

  • The baby averages at least 8-12 feedings per 24-hour period.
  • The baby determines the length of the feeding, which may be 10 to 20 minutes per breast or longer.
  • The baby's swallowing sounds are audible.
  • The baby gains at least 4-7 ounces per week after the fourth day.
  • The baby is alert and active, appears healthy, has good color, firm skin and is growing in length and head circumference.[37]

Expressing breast milk[edit]

Manual breast pump

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 and store her milk. 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 six to twelve months.[38] Research suggests that the antioxidant activity in expressed breast milk decreases over time, but remains at higher levels than in infant formula.[39]

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.

Expressing milk can help a mother who is having trouble breastfeeding. Hand expression of breast milk, together with manual massage while pumping has been shown to maximize milk supply.[40]

"Exclusively expressing", "exclusively pumping", and "EPing" are terms for a mother who feeds her baby exclusively expressed breastmilk. 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.

Expressed breast milk (EBM) or infant formula can be fed to an infant by bottle

Authorities generally advise delaying using a bottle to feed expressed breast milk until the baby is 4–6 weeks old and is successful at sucking directly from the breast.[41] Drinking from a bottle takes less effort, potentially causing the baby to lose desire for the breast. This is called nursing strike or nipple confusion. To avoid this when bottle feeding before 4–6 weeks of age, it is recommended that breast milk be given by other means such as spoons or cups. Also, the bottle should be delivered by someone other than the mother (or wet nurse), so that the baby associates direct feeding with the mother (or wet nurse) and bottle feeding with other people.

With the improvements in breast pumps, many women exclusively feed breast milk, expressing milk at work. Women can leave their infants in the care of others while traveling, while maintaining a supply of breast milk.[42]

Some women donate their expressed breast milk (EBM) to others, either directly or through a milk bank. Historically the use of wet nurses was common, although some women dislike the idea of feeding their child with another woman's milk, while mothers who cannot breastfeed can give their baby the benefits of breast milk. Expressed breast milk—either from donors or the baby's own mother—is the feeding method of choice for premature babies.[43] Viral disease transmission can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.[44]

Mixed feeding[edit]

Formula and pumped breastmilk, side-by-side. Note that the formula is of uniform consistency and color, while the milk exhibits properties of an organic solution, separating into the creamline layer of fat at the top, milk and a watery blue layer at the bottom.

Predominant or mixed breastfeeding means feeding breast milk along with infant formula, baby food and even water, depending on the child's age. 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 express more rapidly. Therefore, mixing breastfeeding with bottle-feeding (or using a pacifier) before the baby is used to breastfeeding can result in nipple strike. Some mothers supplement feed with a small syringe or flexible cup to reduce the risk of artificial nipple preference.[45]

Shared breastfeeding[edit]

Main article: Wet nurse

Wet nursing was common throughout history. It remains popular in some developing nations including in Africa, for more than one woman to breastfeed a child. Shared breastfeeding is a risk factor for HIV infection in infants.[46] A woman who is engaged to breastfeed another's baby is known as a wet nurse. Shared breastfeeding can sometimes provoke negative reactions in the Anglosphere.[47][48]

Tandem nursing[edit]

Feeding two children at the same time who are not twins or multiples is called tandem nursing. Appetite and feeding habits of each baby may differ, so they may feed at the same or different times, which may involve breastfeeding them together, one on each breast.

Breastfeeding triplets or larger broods is a challenge given babies' varying appetites. Breasts can respond to the demand and produce larger milk quantities; mothers have breastfed triplets successfully.[49][50][51]

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. While some children continue to breastfeed even with this change, others may wean due to the change. Breastfeeding a child while being pregnant with another may be considered a form of tandem feeding for the nursing mother, as she provides nutrition for two.[52]

Relactating[edit]

Re-lactation is the process of restarting breastfeeding after stopping.[53] In developing countries, mothers may restart breastfeeding after a weaning as part of an oral rehydration treatment for diarrhea. In developed countries, re-lactation is common after early medical problems are resolved, or because a mother changes her mind about breastfeeding.

Re-lactation is most easily accomplished with a very young newborn or with a baby that was previously breastfeeding; if the baby was initially bottle-fed, then the baby may refuse to suckle. If the mother has recently stopped breastfeeding, then she is more likely to be able to re-establish her milk supply, and more likely to have an adequate supply. Although some women successfully re-lactate after interruptions of several months, success is higher for shorter interruptions.[53]

Induced lactation, also called adoptive lactation, is the process of starting breastfeeding in a woman who did not give birth.[53] This usually requires the adoptive mother to take hormones and other drugs to stimulate breast development and promote milk production. In some cultures, breastfeeding an adoptive child creates milk kinship that built community bonds across class and other hierarchal bonds.[53]

Techniques to promote re-lactation and induced lactation both use frequent attempts to breastfeed, extensive skin-to-skin contact with the baby, and frequent, long pumping sessions to express breastmilk.[53] Suckling may be encouraged with a tube filled with infant formula, so that the baby associates suckling at the breast with food. Or a dropper or syringe without the needle may be used to place milk onto the breast while the baby suckles.[54] Milk-producing drugs, such as domperidone, may also be given. All of these techniques require the mother's commitment of time and energy over a period of weeks or months. Success is likely, but not guaranteed. However, even when lactation is established, the supply may not be large enough to breastfeed exclusively. A supportive social environment improves the likelihood of success.[53] As the mother's milk production increases, other feeding can decrease. Parents and other family members should watch the baby's weight gain and urine output to assess nutritional adequacy.[54]

Extended breastfeeding[edit]

Extended breastfeeding means breastfeeding after the age of 12 or 24 months, depending on the source. In Western countries such as the United States, Canada, and Great Britain, extended breastfeeding is relatively uncommon. For example, in the United States overall, only 22.4% of babies are breastfed for 12 months.[55] By contrast, in India, mothers commonly breastfeed until the child reaches 2 to 3 years.[56]

Mother's diet[edit]

Some pollutants in the mother's food and drink are passed to the baby through the breast milk, including mercury (found in some carnivorous fish),[57] alcohol,[58] caffeine[59] and bisphenol A.[60][61]

Duration[edit]

The World Health Organization recommends exclusive breastfeeding for the baby's first 6 months of life, and continued breastfeeding complemented with appropriate foods for up to two years and beyond.[62][63] The US Centers for Disease Control and Prevention (CDC) recommends exclusive breastfeeding for six months.[64] A 2012 Cochrane review found that infants exclusively breastfed for six months had less gastrointestinal infection-related morbidity than infants who switched from exclusive to partial breastfeeding at three to four months.[65]

Weaning[edit]

Main article: Weaning

Weaning is the process of replacing breast milk with other food. The infant is fully weaned after the replacement is complete. 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 lactase continues to decline with age. However, the prevalence varies widely among ethnic backgrounds. Estimates range from 2 to 5 percent in those with Northern European ancestry to nearly 100 percent in adult Asians and American Indians. Africans and Ashkenazi Jews have prevalences of 60 to 80 percent, while Latinos have a prevalence of 50 to 80 percent.[66][67]

In humans, psychological factors crucially affect the weaning process for both mother and infant, as issues of closeness and separation are very prominent.[68]

In the past bromocriptine was in some countries frequently used to reduce the common engorgement experienced during weaning. This is now done only in exceptional cases due to frequent side effects and slight benefits.[69] Other medications such as cabergoline, lisuride or birth control pills may occasionally be used to suppress lactation.

Health effects[edit]

For the baby[edit]

A 2007 review for the U.S. Agency for Healthcare Research and Quality (AHRQ)[70] and a 2007 review for the WHO,[71] found numerous benefits of breastfeeding for the infant. According to AAP breast feeding aids general health, growth and development. Infants who are not breastfed are at a significantly increased risk for acute and chronic diseases, including lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infection and necrotizing enterocolitis.[72] Breastfeeding may protect against sudden infant death syndrome, insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, lymphoma, allergic diseases, digestive diseases and may enhance cognitive development.[21]

Growth[edit]

The average breastfed baby doubles its birth weight in 5 to 6 months. By one year, a typical breastfed baby weighs about 2½ times its birth weight. At one year, breastfed babies tend to be leaner than formula-fed babies, which improves long-run health.[73]

The Davis Area Research on Lactation, Infant Nutrition and Growth (DARLING) study reported that breastfed and formula-fed groups had similar weight gain during the first 3 months, but the former began to drop below the median beginning at 6 to 8 months and were significantly lower weight than the formula-fed group between 6 and 18 months. Length gain and head circumference values were similar between groups, suggesting that the breastfed babies were leaner.[74]

Immunity[edit]

During breastfeeding, approximately 0.25-0.5 grams per day of secretory IgA antibodies pass to the baby via milk.[75][76] This is one of the most important features of colostrum.[77] The main target for these antibodies are probably microorganisms in the baby's intestine. The rest of the body displays some uptake of IgA,[78] but this amount is relatively small.[79] Beast 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).[80][81]

Infections[edit]
Maternal vaccination while breastfeeding[edit]

In a 2013 review data from 2001 to 2012 were analyzed to assess the safety of maternal vaccinations while breastfeeding. AAP concluded that the practice is safe for almost all vaccines. The study further found that the mother's immunity obtained by vaccination against tetanus, diphtheria, whooping cough and influenza can protect 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.[82][83]

Infant mortality[edit]

Children who are not breastfed are almost six times more likely to die by the age of one month than those who receive at least some breastmilk.[84]

Diabetes[edit]

Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than those with a shorter duration of breastfeeding.[70] Breastfed infants appear to have a lower likelihood of developing diabetes mellitus type 2 later in life.[70][71][85]

Childhood obesity[edit]

The protective effect of breastfeeding against obesity is consistent, though small, across many studies.[70][71][86] A 2013 longitudinal study reported less obesity at ages two and four among 4-month breastfed infants.[87]

Allergic diseases (atopy)[edit]

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 4-month exclusive breastfeeding, though these benefits may not persist.[88]

Necrotizing enterocolitis in premature infants[edit]

A 2007 meta-analysis of four randomized controlled trials found "a marginally statistically significant association" between breastfeeding and a reduction in the risk of Necrotizing enterocolitis (NEC).[70]

Other long-term health effects[edit]

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 did not address whether breastfeeding delayed symptoms or offered lifelong protection.[89]

Breastfeeding may decrease the risk of cardiovascular disease in later life, as indicated by lower cholesterol and C-reactive protein levels in breastfed adult women.[71] A 2007 review for WHO concluded that breastfed infants "experienced lower mean blood pressure" later in life.[71] A 2007 review for AHRQ found that "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".[70]

In a 1998 study it was suggested that breastfed babies have a better chance of good dental health than formula-fed infants because of the developmental effects of breastfeeding on the oral cavity and airway. It was thought that with fewer malocclusions, breastfed children may have a reduced need for orthodontic intervention. The report suggested that children with 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.[90]

Connection to intelligence[edit]

It is unclear whether breastfeeding improves intelligence later in life. Several studies found no relationship after controlling for confounding factors like maternal intelligence (smarter mothers were more likely to breastfeed their babies).[70][91] However, other studies concluded that breastfeeding was associated with increased cognitive development in childhood, although the cause may be increased mother–child interaction rather than the breastmilk itself.[71]

For the mother[edit]

Breastfeeding is a cost-effective feeding strategy, providing nourishment for a child at a small maternal cost. Exclusive breastfeeding usually delays the return of fertility through lactational amenorrhea, although it does not provide reliable birth control. Breastfeeding releases beneficial hormones into the mother's body[76] and can strengthen the mother/child bond.[17]

Bonding[edit]

Newborn rests as caregiver checks breath sounds

According to some authorities, a growing body of evidence suggests that early skin-to-skin contact (also called kangaroo care) of mother and baby stimulates breastfeeding behavior in the baby.[8] 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 birth. It is thought that immediate skin-to-skin contact provides a form of imprinting that makes subsequent feeding significantly easier. WHO reports that in addition to more successful breastfeeding, skin-to-skin contact between a mother and her newborn immediately after delivery also reduces crying, improves mother to infant interaction, and warms the baby. According to studies cited by UNICEF, babies naturally follow a process which leads to a first breastfeed. Initially after birth the baby cries with its first breaths. Shortly after, it relaxes and makes small movements of the arms, shoulders and head. The baby crawls towards the breast and begins to feed. After feeding, it is normal for a baby to remain latched to the breast while resting. This is sometimes mistaken for lack of appetite. Absent interruptions, all babies follow this process. Rushing or interrupting the process, such as removing the baby to weigh him/her, may complicate subsequent feeding.[92]

Hormones released during breastfeeding help to strengthen the maternal bond.[17] Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[93] Support for a breastfeeding mother can strengthen familial bonds and help build a paternal bond.[94]

Hormonal[edit]

Breastfeeding releases oxytocin and prolactin, hormones that relax the mother and increase her nurturing response.[95] This hormone release can help to enable sleep. Breastfeeding soon after 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.[96]

Weight loss[edit]

It is unclear whether breastfeeding causes mothers to lose weight after giving birth.[70]

Gestational changes[edit]

Postpartum weight retention (PPWR) has significant effects on later chronic diseases. 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 (IOM).[97] Recommended weight gains during pregnancy vary according to maternal baseline characteristics. IOM established guidelines recommending that underweight women (BMI less than 18.5) are encouraged to gain 13 to 18 kg; normal weight women (BMI 18.5-24.9) 11–16 kg; overweight women (BMI 25-29.9) 7–11 kg; and obese women (BMI 30-34.9) 5–9 kg.[98] These recommendations are relative and meant to inform obstetricians. Extreme gains in visceral fat can put women at higher risk of cardiovascular and glycemic disorders later in life.

Natural postpartum infertility[edit]

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 non-ovulating period varies by individual. This lactational amenorrhea has been used as natural contraception, with greater than 98% effectiveness during the first six months after birth if specific nursing behaviors are followed.[99]

Long-term health effects[edit]

For breastfeeding women, long-term health benefits include reduced risk of breast cancer, ovarian cancer, and endometrial cancer.[21][70]

Concerns[edit]

Infants that are otherwise healthy uniformly benefit from breastfeeding. "No known disadvantages" stem from breastfeeding.[100] However extra precautions should be taken or breastfeeding be avoided entirely in circumstances including certain infectious diseases, or use of certain medications.[101] In some cases it may not be feasible for the mother to continue breastfeeding.[102]

HIV[edit]

The central concern about breastfeeding in the presence of maternal HIV is whether or not it risks the child becoming infected. Factors such as the viral load in the mother’s milk complicate breastfeeding recommendations for HIV-positive mothers.[103]

Medications[edit]

A 2013 review article assesses safety issues for breastfeeding mothers taking prescription drugs. AAP advises that mothers can take most prescription drugs, but should avoid certain painkillers, psychiatric drugs and herbal supplements. The maternal health benefits must be weighed against the risk of infant drug exposure. The report recommends consulting the NIH database 'LactMed' for up-to-date information.[82][83]

Financial considerations[edit]

Breastfeeding is cheaper than alternatives, but it is not free of cost. The mother generally must eat more food than otherwise. In the US, the extra money spent on food (about US$13 each week) is usually about half as much money as the cost of infant formula.[104]

Breastfeeding represents an opportunity cost, as the mother must spend hours each day breastfeeding instead of engaging in activities, such as paid work or home production (such as growing food). In general, the higher the mother's earning power, the less likely she is to save money by breastfeeding.[105]

Breastfeeding reduces health care costs and the cost of caring for sick babies. Parents of breastfed babies are less likely to miss work and lose income because their babies are sick.[104]

Difficulties[edit]

Physiological constraints[edit]

AAP breastfeeding policy says: "Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding."[21] In some situations breastfeeding may be harmful to the infant, including infection with HIV and acute poisoning by environmental contaminants such as lead.[106] IOM reported that breast surgery, including breast implants or breast reduction surgery, reduces the chances that a woman will have sufficient milk to breastfeed.[107] Women whose pregnancies are unintended are less likely to breast feed their babies.[108]

Barriers[edit]

The majority of mothers intend to breastfeed at birth. Many things can disrupt this intent. Barriers that women face when attempting to breastfeed include:

  • Birth procedures – routine mother/baby separation, delayed initiation, vigorous routine suctioning, medications and delivery mode all interfere. A "substantial" number of hospital and facilities employed procedures and policies that were known to interfere with lactation.[109]
  • Knowledge and social support
    • Mother – breastfeeding is the biological norm but in absence of examples, mothers may opt out,[110] although classes, books and personal counseling (professional or lay) can help compensate. Some women fear that breastfeeding will negatively impact the look of their breasts.However, a 2008 study found that breastfeeding had no effect on a woman's breasts, other factors did contribute to "drooping" of the breasts, such as advanced age, number of pregnancies and smoking behavior.[111]
    • Partner – Partners may lack knowledge of breastfeeding and their role in the practice.
    • Practitioner – Primary physicians and nurses have little training in lactation and lactation support and are often unprepared to provide the information that mothers need.[110] The Surgeon General’s Call to Action to Support Breastfeeding attempts to educate practitioners about breastfeeding.[112]
  • Workforce – Work is the most common cited reason for not breastfeeding.[113] Maternity leave in the US varies widely despite the Family Medical Leave Act (FMLA), which provides most mothers up to 12 weeks unpaid leave although the majority of mothers resume work earlier. 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, ranking 36 industrialized countries according to their support for breastfeeding, such as the right to nursing breaks at work. Norway ranked first, while the US came in last.[114]
  • Technique - Pain caused from mis-positioning the baby on the breast or a tongue-tie in the infant can cause pain in the mother and discourage her. These problems are generally easy to correct (by re-positioning or clipping the tongue-tie).[115]
Famille d’un Chef Camacan se préparant pour une Fête ("Family of a Camacan chief preparing for a celebration") by Jean-Baptiste Debret shows a woman breastfeeding a child in the background.

Society and culture[edit]

Organizational endorsements[edit]

WHO states, "Breast milk is the ideal food for the healthy growth and development of infants; breastfeeding is also an integral part of the reproductive process with important implications for the health of mothers.",[116] and together with UNICEF recommends exclusive breastfeeding for the first six months of life,[2] after which the WHO's guidelines recommend "continue[d] frequent, on-demand breastfeeding until two years of age or beyond."[2] Similar recommendations hold for both developed and developing countries, and focus on preventing gastrointestinal infections as well as providing optimal conditions for maintaining the child's normal weight and cognitive development.[2] Save the Children also endorses breastfeeding saying, "Six months of exclusive breastfeeding increases a child’s chance of survival at least six-fold."[117]

The European Commission supports breastfeeding to ensure "optimal growth, development and health." They state that "Low rates and early cessation of breastfeeding have important adverse health and social implications for women, children, the community and the environment, [resulting] in greater expenditure on national health care provision, and [increased] inequalities in health.[118][119]

American Academy of Pediatrics also supports six months of exclusive breastfeeding and asserts "breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child."[120] According to 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."[121]

The UK-based National Health Service advises exclusive breastfeeding for around the first six months, stating, "Any amount of breastfeeding has a positive effect. The longer you breastfeed, the longer the protection lasts and the greater the benefits."[122] In a joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada to provide recommendations for parents and caregivers, they advise, "Breastfeeding - exclusively for the first six months, and sustained for up to two years or longer with appropriate complementary feeding - is important for the nutrition, immunologic protection, growth, and development of infants and toddlers."[123] The Australian Department of Health states, "Breastfeeding provides babies with the best start in life and is a key contributor to infant health. Australia’s dietary guidelines recommend exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months – and beyond, if both mother and infant wish."[124]

Sociological factors[edit]

Social factors correlate with differences in initiation, frequency, and duration of breastfeeding practices. Race, ethnic differences, socioeconomic status and other factors affect a mother's breastfeeding choice and duration. A recent study found that on average, US women who breastfed had higher levels of education, were older, and were more likely to be white.[125] The reasons for the persistently lower rates of breastfeeding among African American women are not well understood, but employment may play a role. They tend to return to work earlier after childbirth than white women, and are more likely to work in unsupportive environments. Although returning to work is associated with early discontinuation of breastfeeding, a supportive work environment may make a difference in whether mothers continue.[125]

Low income women are more likely to have unintended pregnancies.[125] Women whose pregnancies are unintended are less likely to breast feed.[108]

Breastfeeding in public[edit]

Public breastfeeding is forbidden in some jurisdictions, not addressed by law in others, and a granted legal right in others. Even given a legal right, some mothers may nevertheless be reluctant to breastfeed,[126][127] and others may object to the practice.[128]

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.[129] Recently, when these incidents have occurred, breastfeeding mothers have protested by organizing a "nurse-in" or a breastfeeding flash-mob, where groups of nursing mothers have gathered at the offending premise and all nursed their babies simultaneously.

Sign for a private nursing area at a museum

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.[130]

In some public places and workplaces, rooms for mothers to nurse in private have been designated.

Stigma[edit]

Sexual objectification[edit]

Negative perception of breastfeeding in social settings has led some women to feel discomfort when breastfeeding in public.[131] 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.[132] 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.[126] 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.[133] The end result is often that the woman may give up breastfeeding and switch to a bottle.[126] Society has related showing one's breast as sexual, and rejects breastfeeding in public for the most part.[134] Before bottles and formula were invented, wet nursing used to be the typical replacement if a mother could not breastfeed her own child.[135] In the 1800s however, wet nursing was looked down upon and formula feeding was a sign of wealth and status.[136]

Maternal guilt and shame[edit]

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.[137] 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.[132]” In response to scrutiny concerning public breastfeeding, advocates use nurse-ins to show others that there should be no shame in breastfeeding in public.[131] 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.[137]

Mobility to breast milk[edit]

The cultural context of Western society, does not always seem to advocate for breastfeeding in public.[131] 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.[138] 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.[139] 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.[138] 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.[139]

Advocacy[edit]

International board certified lactation consultants (IBCLCs) may be a 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.[140]

Marketing of infant formula[edit]

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.[141] 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.[142][143]

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.[144]

Commercial infant formula costs more than low-income families can afford to pay.[145]

A 2013 Save the Children report states regarding formula companies giving free samples: "If new mothers are given free samples to feed to their babies it can start a vicious circle that undermines their own ability to breastfeed. An infant satiated with formula may demand less breast milk, so the mother produces less, and that can result in her losing confidence in her ability to breastfeed."[146]

See also[edit]

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Further reading[edit]

  • Baumslag, Naomi; Michels, Dia L. (1995). Milk, money, and madness: the culture and politics of breastfeeding. Westport, Conneticut: Bergin & Garvey. ISBN 9780313360602. 
  • Cassidy, Tanya and Abdullahi El Tom, eds. Ethnographies of Breastfeeding: Cultural Contexts and Confrontations (Bloomsbury Academic; 2015) 255 pages; Scholarly essays on a variety of topics such as networks of milk sharing through Facebook, public-health guidelines on infant feeding and HIV in Malawi, and dilemmas involving breastfeeding and bonding for babies born from surrogate mothers.
  • Halili, Hassan Kamal; Che, Musa Norsuhaida (June 2014). "Women’s right to breastfeed in the workplace: legal lacunae in Malaysia". Asian Women (Research Institute of Asian Women (RIAW)) 30 (2): 85–108. doi:10.14431/aw.2014.03.30.2.85. 
  • Hausman, Bernice L. (2003). Mother's milk: breastfeeding controversies in American culture. New York, New York: Routledge. ISBN 9780415966573. 
  • Huggins, Kathleen (2010) [1987]. The nursing mother's companion (6th ed.). Boston, Massachusetts: Harvard Common Press. ISBN 9781558327207. 
  • Palmer, Gabrielle (2009) [1988]. The politics of breastfeeding: when breasts are bad for business (3rd ed.). London: Pinter & Martin. ISBN 9781905177165. 
  • Pryor, Gale (1997). Nursing mother, working mother: the essential guide for breastfeeding and staying close to your baby after you return to work. Boston, Massachusetts: Harvard Common Press. ISBN 9781558321175. 
  • Weiss, Robin (2010). The better way to breastfeed: the latest, most effective ways to feed and nurture your baby with comfort and ease. Beverly, Massachusetts: Fair Winds Press. ISBN 9781592334223. 
  • Wiessinger, Diane (2010) [1988]. The womanly art of breastfeeding (8th ed.). London: Pinter & Martin. ISBN 9781905177400. 

External links[edit]