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Breastfeeding

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A breastfeeding infant

Breastfeeding is the practice of a woman feeding an infant (or sometimes a toddler or a young child) with milk produced from her mammary glands, usually directly from the nipples. Babies have a sucking instinct allowing them to extract the milk.

While many mothers choose to breastfeed their child, there are some who do not, either for personal or medical reasons. Breast milk has been shown to be the most beneficial feeding method for a child. As with other bodily fluid transfers, some diseases, such as HIV and HTLV-1 can be passed from the mother to the infant. Medications may also transfer into breast milk; however, most medications are transferred in very small amounts and are considered safe to take during breastfeeding. Numerous governmental strategies and international initiatives have promoted breastfeeding as the preferred method of feeding the child – this supports recommendations by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) amongst others.

Beginning lactation

File:Breastfeeding(milkfinal).png
When the baby sucks, a hormone called oxytocin starts the milk flowing from the alveoli, through the ducts (milk canals) into the sacs (milk pools) behind the areola and finally into the baby's mouth

Main article: Breast milk

Throughout pregnancy a woman's body produces hormones which stimulate the growth of the milk duct system in the breasts:

By the fifth or sixth month of pregnancy, the breasts are sufficiently developed to produce milk. Near the time of birth, the breasts may begin to secrete a thick, yellowish fluid called colostrum (or "beestings"), which is the first milk the infant receives. It contains important antibodies from the mother's body providing "immunological protection." Colostrum has no fat and little sugar – these substances appear three to four days after birth when the suckling action of the infant further stimulates the breast to produce mature breast milk.

After the colostrum the breast produces milk on a basis of supply and demand in response to how often a child feeds and how much milk he or she consumes. The production, secretion and ejection of milk is called lactation. Some breastfeeding advisers recommend at least one feeding every four hours to prevent premature termination of lactation.

The exact integrated properties of breast milk are not entirely understood, but the nutrient content after this period is relatively consistent and draws its ingredients from the mother's food supply. If that supply is found lacking, content is obtained from the mother's bodily stores. The exact composition of breast milk varies from day to day, depending on food consumption and environment, meaning that the ratio of water to fat fluctuates. Foremilk, the milk released at the beginning of a feed, is watery, low in fat and high in carbohydrates relative to the creamier hindmilk which is released as the feed progresses. The breast can never be truly "emptied" since milk production is a continuous biologic process.

The let-down reflex

The let-down reflex, also known as the milk ejection reflex, is the stimulation of the muscles of the breast to squeeze out the milk by the release of the hormone oxytocin. Breastfeeding mothers describe the sensation differently, with some feeling slight tingling and others not feeling anything different.

The reflex is not always consistent, especially at the start of the breastfeeding process. The thought of nursing or the sound of any baby can stimulate the process, causing unexpected leakage. Commonly both breasts can give out milk when one infant is feeding, but this and other problems often settle after two weeks of feeding. One major cause of difficulties during breastfeeding is when the mother is in a stressed or anxious state of mind.

Causes of a poor let-down reflex:

  • Sore or cracked nipples
  • Separation from the infant
  • A history of breast surgery

When a mother has difficulties breastfeeding she may try different methods of assisting the let-down reflex, including:

  • Feeding in a familiar and comfortable location
  • Massage of the breast or back
  • Warming the breast with a cloth or shower

Benefits

The benefits of breastfeeding are both physical and psychological. Nutrients and antibodies are passed through to the baby and the process of breastfeeding releases hormones into the woman's system. The bond between the baby and its mother is also strengthened during breastfeeding.

Benefits for the infant

Breast milk consumption has been linked to a decreased risk for several infant conditions including Sudden Infant Death Syndrome (SIDS). The sucking technique required of the infant encourages the proper development of both the teeth and other speech organs.

Numerous health benefits of breastfeeding have been medically documented. According to the American Academy of Pediatrics' policy statement on breastfeeding and the use of human milk, "Extensive research, especially in recent years, documents diverse and compelling advantages to infants, mothers, families, and society from breastfeeding and the use of human milk for infant feeding. These include health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits."[1]

Breast milk helps to lower the risk of or protect against:

Recent studies show that children who have been breastfed on average score higher on IQ tests than those babies who have not been breastfed.

Breastmilk, when fed directly from the nipple, is immediately available with no wait, sterile, and served at the correct temperature.

Benefits for the mother

Breastfeeding has also been shown to be beneficial to the mother. The act of breastfeeding releases hormones which have been found to both relax the mother and cause her to experience nurturing feelings toward her infant. Breastfeeding as soon as possible after giving birth increases levels of oxytocin which encourages a more rapid contraction of the uterus and in turn decreases postpartum bleeding. Breastfeeding can also allow the mother to return to her pre-pregnant weight as the fat stores accumulated during pregnancy are utilized in milk production. Frequent and exclusive breastfeeding delays the return of menstruation and fertility (known as lactational amenorrhea) allowing for improved iron stores and the possibility of natural child spacing. Breastfeeding mothers experience improved bone re-mineralization postpartum, and a reduced risk for both ovarian and pre/post-menopausal breast cancer.

Bonding

Madonna Litta, a circa 1490 painting by Leonardo da Vinci showing the Madonna and her child

The maternal bond is strengthened through breastfeeding, with the hormonal releases giving the mother positive feelings of nurture towards the child. Building upon this bond is very important as studies show that up to 80% of mothers suffer from some form of postpartum depression, though most cases are very mild. The partner can support the mother in a variety of ways and is seen as an important factor in successful breastfeeding [2]. This can also help to establish the paternal bond in fathers.

The relationship between the partner and the child can also be greatly affected by the act of breastfeeding. While some partners may feel left out when the mother is feeding the baby, others may see the whole process as a chance to bond as a family. Breastfeeding, possibly alongside birth-related health problems, takes a lot of time. This may add pressure to the partner and the family, with them having to work harder, caring for the mother and performing tasks she would otherwise do. However, as they are often very willing to show their supportiveness, this pressure can help to strengthen the family bonds.

If looking after the child while the mother is away, the father may feed the child using expressed breast milk (EBM). Sometimes this may be impractical as the mother must produce and store enough milk to feed the child for the duration of her absence. If the parents are separated feeding the breast milk may also lead to feelings of awkwardness. These two situations may lead to a necessity to find an alternative feeding method for the child either temporarily or by switching to a permanent arrangement.

Recommendations and research

"Pediatricians and parents should be aware that exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life[...] Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child."

– The American Academy of Pediatrics (AAP) [3]

"A vast majority of mothers can and should breastfeed, just as vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother's milk be considered as unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed milk from the 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 or a teat – depends on individual circumstances"

– WHO Global Strategy for Infant and Young Child Feeding. Geneva, World Health Assembly, May 2002, page 10 [4]

"If we allow the 'breast versus bottle' argument to be reduced to a simple issue of nutrition, we ignore the much greater potential breastfeeding has to enhance the lives of parents and children."

– Gill Rapley, deputy programme director of the UNICEF UK Baby Friendly Initiative [5]

Contraindications and complications

It is not uncommon for a mother and child to have difficulties breastfeeding, with some women unable to feed their child at all. Others find it too problematic or choose not to attempt or continue breastfeeding for personal reasons.

Breast refusal

When first born the child must learn how to feed. Though babies have a natural sucking reflex they may occasionally resist feeding from the breast, often due to external factors. It is important for the baby to be fed soon after birth in order to quickly establish the routine and to become accustomed to feeding from the breast. Other causes of breast refusal include:

  • Over-handling after birth
  • Formula feeding, sometimes without the knowledge of the mother.
  • Poor feeding technique
  • The use of artificial teats leading to "nipple confusion"
  • The presence of thrush in the mouth of the baby
  • Distractions or interruptions during feeds
  • Long separations from the mother
  • Breathing difficulties, often caused by a common cold
  • Pain or discomfort; for example, due to recent surgery or medical procedures (such as circumcision [6][7])

In later stages teething could be perceived by the mother as a hindrance to breastfeeding and is seen by some as a good time to wean the infant.

Medical conditions of the infant

Reasons for the inhibition of an infant to feed include:

Premature babies have difficulties because their sucking reflex is still underdeveloped and because they tire during feeds.

Medical conditions of the mother

Damage to the breast tissue can cause problems or totally prevent manageable breastfeeding, especially women with history of breast surgery or infection. Cancer (particularly breast cancer) and chemotherapy treatments have also been shown to cause difficulties. Many women with previous surgeries, abscesses and cancer can breastfeed successfully.

Infectious diseases such as HIV, AIDS, or active, untreated tuberculosis can be passed onto the infant. A HIV-positive mother breastfeeding an infant can, in some countries, be investigated for child abuse – a 1998 case in the U.S. resulted in the HIV-positive mother being reported to social services for her continued breastfeeding and non-treatment of the child for HIV [8]. The presence of herpes lesions on the breast is also contraindicative to breastfeeding.

Mastitis, the inflammation of the mammary glands caused by the blocking of the milk ducts, can cause painful areas on the breasts or nipples and may lead to a fever or flu-like symptoms. It is not necessary to wean a nursling simply because of mastitis; in fact, nursing is the most effective way to remove the blockage and alleviate the symptoms, and is not harmful to the baby. Sudden weaning can cause or exacerbate mastitis symptoms.

Negative effects upon the infant

Breastfeeding can be harmful to the infant if the mother:

  • is taking certain medications that suppress the immune system
  • is taking certain medications which may be passed onto the child through the milk and are found to be harmful. However, the vast majority of medications are compatible with breastfeeding.
  • has had excessive exposure to heavy metals such as mercury
  • uses potentially harmful substances such as cocaine, heroin and amphetamines. Substances such as caffeine, tobacco, and alcohol, while possibly harmful to the nursling if consumed in large quantities, are safe to use in moderation while breastfeeding (see below).

Health and diet

Since the nutritional requirements of the baby must be satisfied solely by the breast milk in exclusive breastfeeding it is important for the mother to maintain a healthy lifestyle, especially with regards to her diet. If the baby is large and grows quickly, the fat stores gained by the mother during pregnancy can be quickly depleted, and she may have trouble eating well enough to keep developing sufficient milk. The diet usually involves a high calorie, high nutrition diet which follows on from that in pregnancy. The Subcommittee on Nutrition during Lactation advises approximately 1500–1800 calories per day [9]. While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of vitamins A, D, B6 and B12. She may also have a lower supply than well-fed mothers [10].

There are no foods which are absolutely contraindicated during lactation, although a baby may show a sensitivity to particular foods in the mother's diet. Some breastfeeding advisers suggest mothers avoid certain gas producing food, such as beans, if the baby starts to develop colic or gas.

Breastfeeding mothers must use caution if they regularly consume nicotine through tobacco smoking. In addition to reducing the milk supply, heavy use of cigarettes by the mother (more than 20 per day) has been shown to cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfeeding infants. Research is ongoing to determine whether the benefits of breastfeeding out-weigh the potential harm of nicotine in breast milk. The effects of a smoky environment are thought to have links to Sudden Infant Death Syndrome (SIDS). Breastfeeding mothers who smoke are counselled not to do so during or immediately before feeding their child, and are encouraged to seek advice to help them to reduce their nicotine intake or to quit.

Heavy alcohol consumption is known to be harmful to the infant, causing problems with the development of motor skills and decreasing the speed of weight gain. However, there is no consensus on how much alcohol may be safely consumed and it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother. It is unknown what level is safe. Some believe that a single daily glass of wine is sufficient to cause distress, with levels of alcohol in breast milk peaking 30 to 90 minutes after one drink of moderate alcoholic content. Considering the known dangers of alcohol exposure to the developing fetus, many medical professionals believe it is preferable to err on the side of caution with alcohol exposure to a baby and have breastfeeding women restrict or eliminate their alcoholic intake.

Excessive caffeine consumption by the mother can cause irritability, sleeplessness, nervousness and increased feeding in the breastfed infant. Moderate use (one to two cups per day) usually produces no effect. Breastfeeding mothers are advised to avoid or restrict caffeine intake.

The recreational use of marijuana in conjunction with breastfeeding is a controversial issue. The AAP Committee on Drugs lists marijuana in their table of Drugs of Abuse for Which Adverse Effects on the Infant During Breastfeeding Have Been Reported yet they reference only one study in the literature and this study reports no effect. [11] There is a lack of research on the effects of marijuana on the breastfed infant. Withdrawal from marijuana can cause some mild unpleasant effects, however these disappear in a few weeks, and the mother's body becomes almost free of the active ingredient in just a few days.

Feeding options and requirements

Exclusive breastfeeding is generally defined as feeding a baby nothing but breast milk. Predominant or mixed breastfeeding is the practice of feeding breast milk along with some form of substitute – infant formula or baby food, depending upon the age of the child, or even water. The baby's feeding method is different from artificial teats to a nipple. When feeding from a bottle an infant will suck harder than on the nipple, where the tongue is used to massage the milk out more than it is sucked, and it does not go as far into the mouth. This leads to the advice of not mixing breastfeeding and bottle-feeding (or the use of dummies) until the baby is adept at feeding from its mother. Orthodontic teats, which are generally slightly longer, can be used to greater replicate the nipple.

Exclusively breastfed infants feed, on average, 6–10 times a day. The requirements vary greatly between children, with newborns consuming in the range of one to three US fluid ounces (30 to 90 mL) and babies after the age of four weeks consuming around four US fluid ounces (120 mL) per feed. Each baby is different and as it grows this amount will increase. It is important to recognise the signs of a baby's hunger and it is advised that the baby should dictate the number, frequency, and length of each feed, based on the assumption that it knows the amount of milk it needs. The supply of milk in the breast is determined by the frequency and length of these feeds or the amount of milk expressed.

One criticism of breastfeeding is the difficulty in accurately monitoring the amount of food taken by the baby. This, however, is largely discounted because the baby will feed as per its own requirements. It is also easily possible to monitor, in an exclusively breastfed infant, output – wet and soiled nappies. An acceptable amount of output (6–8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours) indicates an acceptable amount of input.

Expression

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

When direct breastfeeding is not possible the baby may still be fed breast milk. By expressing (artificially removing and storing) her milk, a mother can allow her child to be fed while she is not present or does not have the opportunity to do so herself. With expression through manual massage or the use of a breast pump the woman can draw out her milk and keep it in a bottle ready for use. This bottle may be refrigerated for up to eight days or frozen for up to four months, though research suggests that antioxidant activity in breast milk decreases over time [12] although it still remains in levels higher than infant formula.

Expression can be used to prolong the lactation when required. This is most common if the mother and child are separated for an extended period. In cases of the baby being unable to feed, expressed milk can be fed through a nasogastric tube.

Expressed milk can also be used to assist a mother who is experiencing difficulty breastfeeding, in the later stages because of a newborn causing grazing and bruising or because of an older baby growing teeth and biting.

Some women donate their expressed breast milk (EBM) to other people, either directly or through the hospital. Though some dislike the idea of feeding their own child with another person's milk, others appreciate the ability to give their baby the benefits of breast milk.

Infant formula

If the decision is made not to feed the child with breast milk or if it is not possible, then infant formula is given to the infant, usually using a baby bottle. While proven inferior to breast milk, infant formula has in recent times been marketed as being a superior feeding solution. Such marketing has been successful in many areas, with a 2004 UK Department of Health survey showing that 34% of women believe infant formula to be very similar to or the same as breast milk. [13]

Infant formula may be introduced as a supplemental liquid drink to weaned babies and taken from a cup. It is treated for human babies and thus a healthier option to simply drinking the milk from another animal.

Infant formula has been heavily marketed and promoted to many new mothers as the preferred option to breastfeeding. In 1979 the International Baby Food Action Network (IBFAN) was formed to help raise awareness of such practices.

The World Health Organization recommends that all mothers be encouraged to breastfeed, and hospitals that are accredited by the World Health Organization are tolerant of formula feeding but do not offer it to healthy infants who can breastfeed.

Tandem, extended, and shared breastfeeding

Feeding two infants simultaneously is called tandem breastfeeding. The most common need for this is after the birth of twins whereby both babies are fed at the same time. It is not necessarily the case, however, that the appetite and feeding habits of both babies are the same. This leads to the complication of trying to feed each baby according to their individual requirements while also trying to breastfeed them both at the same time.

In cases of multiple births with three or more children it is extremely difficult for the mother to organise feeding around the appetites of all of the babies. The mammary glands can produce a high quantity of milk, according to the demand placed upon them, and many mothers have been able to successfully feed their infants [14]. It is common, however, for the woman to look to other alternatives.

Tandem breastfeeding is also convenient if a woman gives birth to a newborn while still feeding an older baby or child. Under these circumstances it is possible for the newborn baby to miss out on the beneficial colostrum.

Although some may find it controversial, some women breastfeed their offspring for as many as three to seven years from birth. This is referred to as extended breastfeeding. All the benefits of human milk–both nutritional and emotional–continue for as long as a child nurses.

In developing nations within Africa and elsewhere, it is sometimes common for more than one woman to feed a child. This shared breastfeeding has been highlighted as a source of HIV infection amongst infants born HIV-negative [15].

See also: wet nurse

Breastfeeding method

There are many texts available to new mothers to assist in the establishment of breastfeeding. The baby will usually indicate hunger by crying or moaning and fussing. When the baby's cheek is stroked, the baby will move his or her face towards the stroking and open his or her mouth, demonstrating the rooting instinct. Breastfeeding can make the mother thirsty and can last for up to an hour (usually in the early days, when both mother and baby are inexperienced) – it is therefore common for the mother to require a drink during the process.

Feeding and positioning

While for some people the process of breastfeeding seems natural there is a level of skill required for successful feeding and a correct technique to use. Incorrect positioning is one of the main reasons for unsuccessful feeding and can easily cause pain in the nipple or breast. By tickling the baby's cheek with the nipple the baby will open its mouth and turn toward the nipple, which should then be pushed in so that the baby has a mouthful of nipple and areola – the nipple should be at the back of the baby's throat. Inverted or flat nipples can be massaged to give extra area for the baby to latch onto. Many women choose to wear a nursing bra to allow easier access to the breast than normal bras.

The baby may pull away from the nipple after a few minutes or after a much longer period of time. Sometimes the baby will relatch on the same breast or mother may offer the other side. The fat content of the milk increases as the breast empties. Babies should be permitted to "finish the first breast first" before offering the second breast and without a time limit on feeding from either breast.

The length of feeding is quite variable. Regardless of the duration, it is important for the breastfeeding woman to be comfortable.

  • Upright: The sitting position with the back straight.
  • Mobile: The mother carries her nursling in a sling or other baby carrier while breastfeeding. Doing so permits the mother to incorporate breastfeeding into the varied work of daily life, such as shopping, working in the garden, housework, hiking, etc.
  • Lying down: Good for night feeds or for those who have had a caesarean section.
    • On her back: Mother is usually sitting slightly upright; particularly useful for tandem breastfeeding.
    • On her side: The mother and baby lie on their sides.
  • Hands and knees: The mother is on all fours with the baby underneath her (not usually recommended).

There are many positions and ways in which the feeding infant can be held. This depends upon the comfort of the mother and child and the feeding preference of the baby – some babies tend to prefer one breast to another. Most women breastfeed their child in the cradling position.

  • Cradling positions:
    • Cradle hold: The baby is held with its head in the woman's elbow horizontally across the abdomen, "tummy to tummy", with the woman in an upright and supported position.
    • Cross-cradle hold: As above but the baby is held with its head in the woman's hand
  • Football hold: The woman is upright and the baby is held securely under the mother's arm with the head cradled in her hands.
  • Feeding up hill: The baby lies stomach to stomach with the mother who is lying on her back; this is helpful for babies finding it difficult to feed.
  • Lying down:
    • On its side: The mother and baby lie on their sides.
    • On its back: The baby is lying on its back (cushioned by something soft) with the mother on her hands and knees above the child (not usually recommended).

When tandem breastfeeding the mother is unable to move the baby from one breast to another and comfort can be more of an issue. This brings extra strain to the arms, especially as the babies grow, and many mothers of twins recommend the use of more supporting pillows. Favoured positions include:

  • Double cradle hold
  • Double clutch hold
  • One clutched baby and one cradled baby
  • Lying down

Breast and nipple pain

Breastfeeding may hurt some women, sometimes related to an incorrect technique, but usually eases over time. Milk ducts can block up on occasion, leading to breast engorgement or mastitis, and should be addressed with massage and by encouraging the baby to suck from that side to keep it as empty as possible until the problem goes away. A new onset of pain when nursing has previously been going well may be due to a yeast infection of the nipples. Limiting feeding time does not prevent soreness.

Fair skinned mothers are most likely to experience cracked nipples, but it can happen to anyone. The baby's rough tongue can also cause grazes and the suction can cause bruising if the mother and baby have not learned to latch and unlatch. To break the suction, mothers should wait for the baby to come off the breast or insert a finger just inside the baby's mouth. Other sources of nipple and breast pain include nursing pads, tight bras, hair dryers, sun lamps, soap, alcohol, perfume, deodorant, hair spray or body powder. Bottles and nipple shields may change the way the baby sucks, and incorrect use of breast pumps can result in pain.

Taking the baby from the breast without first breaking the suction can contribute to nipple soreness. If you decide to take your baby from the breast before he comes off on his own, gently insert a finger into the corner of your baby's gums, or press down gently on your breast, to break the suction.

Some mothers apply medical grade lanolin to sooth nipples; La Leche League International has endorsed Lansinoh, an ultrapure medical grade lanolin cream designed for breastfeeding mothers. Mothers can also express milk and rub it on the nipples.[16] After six weeks of breastfeeding, the process usually becomes easier, as both mother and baby learn the best technique. Mothers can also buy or hire breast pumps to extract the milk, if nipple pain becomes unbearable.

Weaning

Weaning is the process of gradually introducing the infant to what will be its adult diet and withdrawing the supply of milk. The infant is considered to be fully weaned once it no longer receives any breast milk and begins to rely on baby food or other solid foods for all its nutrition. This often leads to lactose intolerance.

History of breastfeeding

In the early years of the human species, breastfeeding was as common as it was for other mammals feeding their young. There were no alternative foods for the infants, and the mother, along with other lactating females, would have no choice but to breastfeed the children. This process is still seen in many developing countries and is known as shared breastfeeding.

The Egyptian, Greek and Roman empires saw women only feeding their own children. However, breastfeeding began to be seen as something too common to be done by royalty and wet nurses were employed to feed the children of the royal families. This was extended over the ages, particularly in western Europe, and saw women of noble birth (or who married into nobility) making use of wet nurses.

According to some Brahminical literature, breastfeeding in 2nd century India was commonly practiced but not until the fifth day, allowing the colostrum to be discarded and the true breast milk to flow.

Developing alternatives

Alternatives first became popular in the late 15th century with many parents substituting cow or goat's milk for their own breast milk. This was particularly necessary for those families working the land whereby time could not easily be taken out to regularly breastfeed the child. Such trends soon faded when the problems associated with these milks started to show, and by the mid to late 16th century breastfeeding once again became the preferred feeding method for most families. Italian Hieronymus Mercurialis wrote in 1583 that women generally finished breastfeeding an infant exclusively after the third month and entirely after around 13 months.

Dry nursing, the feeding of flour or cereal mixed with broth or water, became the next alternative in the 19th century but once again quickly faded. Around this time there became an obvious disparity in the feeding habits of those living in rural areas and those in urban areas. Most likely due to the availability of alternative foods, babies in urban areas were breastfed for a much shorter length of time, supplementing the feeds earlier than those in rural areas.

Though first developed by Henri Nestlé in the 1860s, infant formula received a huge boost during the post World War II "Baby Boom". The aggressive marketing campaigns when business and births decreased saw Nestlé and other such companies focus on non-industrialised countries, while government strategies in industrialised countries attempted to highlight the benefits of breastfeeding.

Breastfeeding in Japan

Traditionally, Japanese babies were born at home and breastfed with the help of breast massage. Weaning was often late, with breastfeeding in rare cases continuing until early adolescence. After World War II Western medicine was taken to Japan and the women began giving birth in hospitals, where the baby was usually taken to the nursery and fed formula. In 1974 a new breastfeeding promotion by the government helped to boost the awareness of its benefits and the uptake has seen a sharp increase. Japan became the first developed country to have a Baby-friendly hospital (and has since gone on to have another 24 such facilities.

Breastfeeding in Canada

A 1994 Canadian government health survey found that 73% of Canadian mothers initiated breastfeeding, up from 38% in 1963.[17] Western Canadians are more likely to breastfeed; just 53% of Atlantic province mother breastfeed, compared to 87% in BC. More than 90% of women surveyed said the breastfed because it provides more benefits for the baby than does formula. Of women who did not breastfeed, 40% said formula feeding was easier (the most prevalent answer). Women who were older, more educated, higher income, and married were the most likely to breastfeed. Immigrant women were also more likely to breastfeed. About 40% of mothers who breastfed do so for less than three months. Women were most likely to discontinue breastfeeding if they perceived themselves to have insufficient milk. However, among women who breastfed for more than three months, returning to work or a previous decision to stop at that time were the top reasons.

A 2003 La Leche League International study found that 72% of Canadian mothers initiate breastfeeding and that 31% continue to do so past four to five months.[18]

A 1996 article in the Canadian Journal of Public Health found that, in Vancouver, 82.9% of mothers initiated breastfeeding, but that this differed by Caucasian (91.6%) and non-Caucasian (56.8%) women.[19] The article reported that just 18.2% of mothers breastfeed at nine months, and that breastfeeding practices were significantly associated with the mothers' marital status, education and family income.

Breastfeeding in Cuba

Since 1940, Cuba's constitution has contained a provision officially recognizing and supporting breastfeeding. Article 68 of the 1975 constitution reads, in part:

During the six weeks immediately preceding childbirth and the six weeks following, a woman shall enjoy obligatory vacation from work on pay at the same rate, retaining her employment and all the rights pertaining to such employment and to her labor contract. During the nursing period, two extraordinary daily rest periods of a half hour each shall be allowed her to feed her child.

Publicity, promotion and law

In response to public pressure, the health departments of various governments have recognised the importance of encouraging women to breastfeed. The required provision of baby changing facilities was a large step towards making places more accessible for parents and in many countries there are now laws in place to protect the rights of a breastfeeding mother when feeding her child in public.

The World Health Organisation (WHO), along with grassroots non-governmental organisations like the International Baby Food Action Network (IBFAN) have played a large role in encouraging these governmental departments to promote breastfeeding. Under this advice they have developed national breastfeeding strategies, including the promotion of its benefits and attempts to encourage mothers, particularly those under the age of 25, to choose to feed their child with breast milk.

Government campaigns and strategies around the world include:

However, there has been a long, ongoing struggle between corporations promoting artificial substitutes and grassroots organisations and WHO defending breastfeeding. The International Code of Marketing of Breast-milk Substitutes was developed in 1981 by WHO, but organisations, including those networked in IBFAN, claim that, in particular, Nestle took three years before it initially implemented the code, but in the late 1990s and early 2000s was again violating the code.

Developing countries

In many countries, particularly those with a generally poor level of health, malnutrition is the majority cause of death in children under 5, with 60% of all those cases being within the first year of life [20]. International organisations such as Plan International and La Leche League have helped to promote breastfeeding around the world, educating new mothers and helping the governments to develop strategies to increase the number of women exclusively breastfeeding.

Traditional beliefs in many developing countries give different advice to women raising their newborn child. In Ghana babies are still frequently fed with tea alongside breastfeeding [21]. This reduces the benefits of exclusive breastfeeding and the drink can inhibit the absorption of iron, important in the prevention of anaemia.

Rich countries

In 1981, 118 countries voted in favour of the International Code of Marketing of Breast-milk Substitutes, but the USA voted against, on the grounds that it was a violation of freedom of speech guaranteed by the First Amendment of the Constitution of the USA, since due to corporate personhood, corporations have the same human rights as individual humans. [22]

Breastfeeding in public

When in public with a breastfed baby it is often difficult to avoid the need to feed the infant. The public reaction at the sight of breastfeeding can make the situation uncomfortable for those involved. There are numerous laws around the world that have made public breastfeeding legal and companies disallowed from prohibiting it.

In the U.S. the "Right to Breastfeed Act" (HR 1848) was signed into law on September 29, 1999 affirming the right of a woman to breastfeed her child anywhere on federal property. However, not all state laws have affirmed the same right in their respective public places. Nowhere is breastfeeding in public illegal.

A survey reported by the UK Department of Health stated that most people (84%) find breastfeeding in public acceptable as long as it is done discreetly [23]. Contrastingly, 67% of mothers are worried about general opinion being against public breastfeeding. To combat these fears in Scotland, a bill [24] (pdf) safeguarding the freedom of women to breastfeed in public has been passed [25] in the Scottish Parliament [26]. The legislation sets up a fine of up to £2500 for preventing breastfeeding in legally permitted places.


In Canada, the Canadian Charter of Rights and Freedoms affords some protection under gender equality. Although Canadian human rights protection does not explicitly include breastfeeding, a 1989 Supreme Court of Canada decision (Brooks v. Canadian Safeway Ltd.) set the precedent for pregnancy as a condition unique to women and that thus discrimination on the basis of pregnancy is a form of sex discrimination. Canadian legal precedent also allows women the right to bare their breasts, just as men may. In British Columbia, the British Columbia Human Rights Commission Policy and Procedures Manual protects the rights of female workers who wish to breastfeed.

Many mothers choose to purchase pumping equipment or express milk ("milk" themselves) by hand so that they can carry a small bottle of milk with them if they plan to be out at mealtimes. This allows them the advantages of breastfeeding while avoiding possibly uncomfortable situations. Breastfed babies can have trouble transitioning to a bottle, so this may not work for everyone.

Recent global uptake

The following table shows the uptake of exclusive breastfeeding. Sources: WHO Global Data Bank on Breastfeeding and UNICEF Global Database Breastfeeding Indicators

Country Percentage Year Type of feeding
Armenia 0.7% 1993 Exclusive
20.8% 1997 Exclusive
Benin 13% 1996 Exclusive
16% 1997 Exclusive
Bolivia 59% 1989 Exclusive
53% 1994 Exclusive
Central African Republic 4% 1995 Exclusive
Chile 97% 1993 Predominant
Colombia 19% 1993 Exclusive
95% (16%) 1995 Predominant (exclusive)
Dominican Republic 14% 1986 Exclusive
10% 1991 Exclusive
Ecuador 96% 1994 Predominant
Egypt 68% 1995 Exclusive
Ethiopia 78% 2000 Exclusive
Mali 8% 1987 Exclusive
12% 1996 Exclusive
Mexico 37.5% 1987 Exclusive
Niger 4% 1992 Exclusive
Nigeria 2% 1992 Exclusive
Pakistan 12% 1988 Exclusive
25% 1992 Exclusive
Poland 1.5% 1988 Exclusive
17% 1995 Exclusive
Saudi Arabia 55% 1991 Exclusive
Senegal 7% 1993 Exclusive
South Africa 10.4% 1998 Exclusive
Sweden 55% 1992 Exclusive
98% 1990 Predominant
61% 1993 Exclusive
Thailand 90% 1987 Predominant
99% (0.2%) 1993 Predominant (exclusive)
4% 1996 Exclusive
Zambia 13% 1992 Exclusive
23% 1996 Exclusive
Zimbabwe 12% 1988 Exclusive
17% 1994 Exclusive
38.9% 1999 Exclusive

Lactation without pregnancy

Although not widely known in developed countries, women who have never been pregnant are able to lactate and therefore breastfeed as well. If their nipples are stimulated in a breastfeeding manner for a while (such as a breast pump or an actual baby suckling), eventually the breasts will begin to produce milk which can be used to feed a baby. For this reason, adoptive mothers [27], usually initially in conjuction with some form of supplementation, are able to breastfeed their infants and young children. There is also anecdotal evidence of male lactation.

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See also

References

Printed references:

  • Breastfeeding, Biocultural Perspectives; Editors Patricia Stuart-Macadam & Katherine A. Dettwyler.
  • La Leche League (2003). The Breastfeeding Answer Book.
  • Mercurialis, H. (1583). De Morbis Puerorum.
  • Minchin, M. (1985). Breastfeeding matters, Almo Press Publications, Australia. ISBN 0-86861-810-1
  • Moody, J., Britten, J. and Hogg, K. (1996). Breastfeeding your baby, National Childbirth Trust, UK. ISBN 0-72253-635-6
  • Royal College of Midwives (1991). Successful Breastfeeding: A Practical Guide for Midwives, Royal College of Midwives, London.
  • Stuart-Macadam, P. and Dettwyler, K. (1995). Breastfeeding: Biocultural Perspectives (Foundations of Human Behavior), Aldine de Gruyter. ISBN 0-20201-192-5

Website references:

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