12th September, 2010 - Posted by Drboo - 14 Comments
When does breastfeeding become “extended”?
6 months? 12 months? 2 years?
This was not one of the questions I asked in my recent survey about thoughts about breastfeeding (doh!) but what I found is this – many people don’t know the actual recommendations about how long to breastfeed your child for, or, in fact, why you would breastfeed for very long at all….
Back in July (2010) I sent out a survey to 50 or so friends and family. This was forwarded and Facebooked until 75 people had filled it in.
How long did people breastfeed for?
Of the 61 mothers who responded, the spread of length of breastfeeding was vast, from less than a month to 52 months. An equal majority either fed for a month or less or for 6 months. The next most common was to stop at 12 months. This graph breaks it down:
So, as you can see, a lot of people stopped breastfeeding within 6 months (18). But more were breast feeding, beyond that time. However, very few people were following the World Health Organisation recommendation of breastfeeding (alongside solid foods after 6 months) to 2 years and beyond (11).
Why did people stop breastfeeding?
These were the main reasons people stopped breastfeeding:
- Going back to work or being away from home
- Problems (tongue-tie, pain, illness, mastitis) and/or lack of support or information
- Baby self-weaned
- Lack of milk or milk “drying up”
What did people think about breastfeeding in public?
All the participants thought babies of 6 months, fed in public, was “great”. But by the time they hit 12 months, 3 people stopped feeling positive and just felt neutral about it.
3 people did not think babies over 18 months should be breastfed – although this question was geared towards attitudes to seeing these babies fed in public.
7 did not think babies of 2 years should be fed in public, with 2 people being strongly against this. Despite the fact that these babies would still be being fed well within WHO recommendations.
By the time the babies were 3 years, 17 did not think they should be breastfed, with 5 being strongly against it.
At 4 years, 28 did not think breastfeeding should happen, with 7 feeling strongly about it.
5 year olds being breastfed evoked strongly negative reactions in 10 people, with a further 22 being against it.
As for older children, 11 were strongly against them being breastfed, and 35 in total were against it.
Of the respondents, 14 were Doulas or worked in the breastfeeding arena (i.e. breastfeeding counsellors). For this reason they were analysed separately. However, it was surprising to see that 2 of these thought that the WHO recommendation was 1 year, and 4 thought it was 2 years.
However, all the Doula responses to extended breastfeeding were positive, with the themes of “natural”, “normal”, “bonding”, “comfort” and “nutrition”, and benefits for both mother and child being noted.
That said, one thought that she didn’t think breastfeeding over 4 years should happen, and another 2 (making 3 in total) thought breastfeeding at 5 years should not happen.
What did people know about the recommendations?
So, who out of the rest of the participants knew those WHO recommendations?
Of those outside the breastfeeding world (60 participants) 71.6% got the answer wrong. 17 were correct (2 years or more) but another 20 were close (2 years). 6 thought 6 months, 11 thought 1 year and 2 thought the answer was 18 months. 1 thought 3 years and 3 thought 5 years.
So, to be fair, 37 were close or totally correct (61%).
In total 41 people, then, thought that the recommendation was at least 2 years if not more. This ties in with 46 people being neutral or positive about seeing babies of this age being breastfed. It seems likely, then, that lack of knowledge of the guidelines promotes negative feelings about babies of a certain age being breastfed.
Attitudes towards breastfeeding
Let’s move on to looking at attitudes towards breastfeeding. Those who were not employed in the “breastfeeding world” had a mixture of feelings.
|Health benefits||Beneficial / nutritional/health benefits/Illness/immunity|
|Emotional benefits||Closeness with child/bond(ing)/contact/settling for child /Comfort (for mother and for the child)/emotional benefit / both enjoy it|
|None of my business!||“Live and let live” / none of my business/I would not judge / personal choice|
|Natural weaning||Best thing is for the child to give up when they are ready/wean naturally|
|Mother’s needs||Mum doesn’t want to let go/wants to baby the child or not let him grow up/”needy mother”/Mother’s attachment issues/doing it for the mother’s needs , not the child’s/evangelical mothers proving a point|
|Detrimental to the child||Promotes physical dependency in the child /confusing signals to the child/attachment issues|
|Child’s needs||Child doesn’t want to stop and mother doesn’t want to upset the child/”needy” child/comfort for the child (negative – i.e. shouldn’t use this for comfort if going to school)|
|Society’s needs||I feel uneasy/ don’t feel comfortable seeing an older child breastfed / society is not comfortable with it/taboo/ Boobs are too sexual in our society/like sex…it’s not for public consumption|
|Nutritionally unnecessary||Nutritionally not necessary beyond a certain age/not necessary in a developed country/if she is in a country where food was an issue I could understand|
|Just plain wrong!||Inappropriate / “if they can speak, bite or climb into Mummy’s lap and help themselves then perhaps it is time to stop”.|
This survey was prompted by a chapter in Ann Sinnott’s book “Breastfeeding Older Children” where she interviews psychologists and therapists and concludes that most, if not all, consider extended breastfeeding to be “pathologic”. So, what did the 5 psychologists or therapists in this survey think?
|1.||I think that breastfeeding has numerous nutritional and emotional values but I am pro choice when it comes to breast v bottle feeding. Having been bottle fed myself I don’t feel that it hindered either my physical or emotional development or my bond with my mother. If anything i think the fact that feeding was spread more evenly between my parents served to strengthen my bond with my father and helped him feel more attached to me. I have also had a lot of conversations with male friends whose partners are breastfeeding and noticed how ‘left out’ some of them feel not to be able to bond with their child this way too.
I think that there is a societal expectation as to when breastfeeding becomes inappropriate (eg extended) and I really feel that it depends upon the parents choice.
However, I would worry whether the breastfeeding is for the benefit of the child or the mother’s emotional needs once the child is of school age. I also think that parents have a responsibility to be mindful of societal expectations once their child is socialising on their own (eg. school, nursery). Whilst I am pro parents challenging stereotypes and perceptions I think they need to be mindful of the potential negative impact this could have on their child (eg. being deemed ‘strange’ or rejected by peers).
I dont have a problem seeing mothers breast feed children in public and have never understood some people object.
|2.||to retain the attachment, though this may not always be a healthy attachment from either side.
|3.||In some cultures, where food scarcity and purity has been/is a problem children have been breast fed as the best option to meet their nutritional needs. Also social side-effects, in many countries it is believed that you should not have sex with a woman who is breastfeeding – and without access to contraception that can be a way for women to regulate their child bearing in patriarchal societies.
I think that breast feeding for too long may result in overly dependent attachment to the mother, and difficulty meeting the developmental challenges of separation. I also wonder about the impact on the relationship of the child with their father, and the parents’ relationship.
(I think the gap between when you should stop breast feeding owing to that, and where you shouldn’t breast feed because the child is becoming sexually mature are sufficiently far apart to be a non-issue.)
|4.||i personally think it’s more about the mother then than the child, although i can see how some mums will see emotional benefits to comforting a child with breastfeeding.
|5.||because this may be the only way of getting nutrients into the child|
An interesting mix of responses, with some clear concerns raised about attachment, which is what Sinnott found in her interviews.
Are the psychologists – and others – right to be concerned about the child’s attachment to the mother if breastfeeding is prolonged?
What about those nutritional benefits? Are they needed in infants from developed
What does the research say?
When an infant reaches his second year, 448ml of breast milk provides:
43% of protein requirement1
36% of calcium requirement1
75% of vitamin A requirement1
94% of vitamin B12 requirement1
60% of vitamin C requirement1
And 35-45% of their energy requirements2
This is regardless of whether the child is in a country of ample food supplies or not. It really comes into its own if an infant is ill and cannot eat as they will often nurse – so continuing to breastfeed ensures that they get adequate nutrition as well as fluids. This may be why illnesses in children over 1 year who are breastfed are shorter than for those who are not (and they are said to get ill less often – but I haven’t found evidence to back this up yet).
Studies have shown that continued breastfeeding around 1 year of age makes it less likely that a child will get various illnesses. For instance, one study that is an example of this (and there aren’t many from the developed world) found that the chances of getting an episode of a middle ear inflammation was much less in children who were breastfeeding after 11 months of age, and less still (but not very significantly) after 18 months.3 This may be because concentrations of lysozyme, lactoferrin, and secretory IgA are stable and even increase in the breast milk of mothers who are breastfeeding for longer than 1 year.4 From the emphasis the researchers put on these, I am guessing they are good. The researchers concluded that breastfeeding for 11 months is great, and up to 18 months is also handy. But they didn’t go further than that.
It is well documented that babies who are breastfed in the first year of life are less likely to contract several types of infections and are less likely than formula fed babies to develop allergies.5 However, there is also some evidence (limited, but increasing) that breastfeeding beyond 1 year is also beneficial to the health of the child and the mother. Several studies suggest that babies who are breastfed for over 6 months are less likely to develop childhood lymphoma and leukemia.6,7 Sounds fantastical? That’s what I thought too, but the studies are sound. This is what the researchers of an analysis of 9 case control studies say:
human milk may make the breast-fed infant better able to negotiate future carcinogenic insults by modulating the interaction between infectious agents and the developing infant immune system or by directly affecting the long-term development of the infant immune system
To balance the argument, however, other studies have not found a link between breastfeeding (ever) and childhood leukemia10, and still other meta-studies have found that the duration of breastfeeding made no difference11 (but that children who had been breastfed were less likely to get childhood leukemia). A more recent, well controlled study found that the length of breastfeeding did matter (but so did low age and low education of the mother).
Confused yet? Me too.
Finally, there is well established evidence that breastfeeding mothers are less likely to get breast cancer, and the evidence now suggests that the longer you breastfeed, the less and less likely you are to get this.8,9
I am tempted to just leave this section blank. Nowhere could I find any research on the effects of breastfeeding (from a psychological point of view) for longer than 6 months to a year at the most.
I know this research would be difficult – separating the consequences of breastfeeding from other factors such as socio-economic status, education of parents etc etc makes it really hard to draw reliable conclusions with this kind of data. But, let’s face it, it hasn’t stopped this research being carried out looking at breastfed children who have been fed this way for 12 months or less.
Dorothy Rowe, a Psychologist, writing in The Times (May 5 2005) had this to say :
“The question we must ask is whether extended breast-feeding is more about the mother than it is the needs of the child. Certainly, in physical terms, once a child is eating an ordinary, varied diet (ie, well after weaning on to first solid foods), they don’t need their mother’s milk. …
Psychologically, there is little evidence to support long-term breast-feeding. In the first couple of months it is important to the bonding relationship, but you can still have this with mothers who can’t breast-feed. It is not exclusive to breast-feeding. It’s very easy to become a martyr to breast-feeding — and it’s not necessary to do this to yourself…
To function in the adult world, you have to feel you are competent and able to look after yourself, and to be able to rely on your own judgment — your mother has to give you the confidence to believe this, and this comes from all those encouragements she offered — “Aren’t you clever?”, “You did that really well” — when you tried things yourself. Lots of mothers love to see that independence, but there are others who don’t believe their children can function without them, and that may include extended breast-feeders.
The more tricky question about extended breast-feeding is what is appropriate in physical terms. All parents have to start thinking quite early about what kind of physical closeness they have with their children — what is “inappropriate” is very difficult to define; it can only be defined from a child’s point of view as anything that makes the child feel disturbed and uncomfortable, or intrudes on their privacy.
Of course breast-feeding is to be encouraged because it does confer long-term health benefits. But breastfeeding in the long term may not be best for the child.”
Rowe does not cite one study that supports her ideas on extended breastfeeding, or those who breastfeed their children for over 1 year (i.e. that they do not believe their children can function without them). But her attitude seems to be shared by many in the mental health professions (although, I hasten to add, not all).
Looking at the studies available, there is evidence that, rather than fostering a dependant attachment, as some psychologists seem to be concerned about, longer breastfeeding (in this case, Horwood’s long-range study13 (following 999 children from birth to 18), which refers in this case to babies breastfed for 8 months or more) breastfed children were rated as more cooperative and socially better students the longer they were breastfed. Drop-out rates were higher among children who had been bottle-fed and lowest among those who had been breastfed equal to or longer than eight months, even when the data were adjusted for maternal demographics.
One study that looked at babies nursed for over one year (Ferguson et al. 1987) found that, at 6-8 years of age, both teachers and parents rated less conduct disorders – the researchers stated: “There are statistically significant tendencies for conduct disorder scores to decline with increasing duration of breastfeeding.” That said, this study did not take into account mother-child interaction, which could also account for this effect.
So, the research is not great – but I am not looking for evidence that breastfeeding over 1 year is beneficial – I am looking to see whether the fear some have that it harms can be substantiated. Even with the shortcomings of the available studies there seems to be no evidence to support Rowe and others’ idea that long-term breastfeeding has negative psychological consequences.
What do the professional bodies say is an appropriate length of time to breastfeed?
WHO – “up to two years or beyond. ”
American Association of Paediatricians – “there is no upper limit to the duration of breastfeeding and no evidence of psychological or developmental harm from breastfeeding into the third year of life and longer.”
American Academy of Family Physicians – “As recommended by the WHO, breastfeeding should ideally continue beyond infancy, but this is not the cultural norm in the United States and requires ongoing support and encouragement. It has been estimated that a natural weaning age for humans is between two and seven years. Family physicians should be knowledgeable regarding the ongoing benefits to the child of extended breastfeeding, including continued immune protection, better social adjustment, and having a sustainable food source in times of emergency. The longer women breastfeed, the greater the decrease in their risk of breast cancer… “If the child is younger than two years of age, the child is at increased risk of illness if weaned.” (AAFP 2008)
The NHS – “The Department of Health supports the World Health Organization’s (WHO) advice that: Breastfeeding (or breast milk substitutes) should continue for a minimum of the first six months, and continue as solid food is introduced. WHO recommends that mothers breastfeed for two years or longer.”
There is a lot of judgement around breastfeeding – and where there is judgement there is usually guilt – whether you do it or not, whether you do it exclusively or not, whether you enjoy it or not, whether you do it in public and if so how discreetly, and how long you do it
Everyone has a position, an opinion, and some take it very firmly. However, a lot of the basis for these opinions comes from a lack of information. There seems to be an information deficit around breastfeeding in our society generally – how to breastfeed, how to wean, how to go back to work, how to breastfeed in public and your rights about this*, when to stop breastfeeding…
This is just really, really sad. No-one should feel judged about how they give their child nourishment. And no-one should make another person feel guilty because they follow a different path.
If you chose to wean earlier than a year, later than a year, if you chose to not breastfeed at all, so be it – as long as you made that decision based on the facts and without pressure, then great. Sadly, the survey did not reflect this happening. A lot of people gave up breastfeeding when it seems that they may not have done so with better information given at the right time. There was also an apparent correlation between people’s attitudes towards “older” babies being breastfed and a lack of knowledge of current guidelines.
Psychologists seem, from the (admittedly very few) in this survey, the opinions of Rowe, and the information found by Ann Sinnott for her book, to hold strong beliefs about the meaning and possible consequences of “extended” breastfeeding without the evidence base to back up these theories.
Psychologists were not alone in feeling that breastfeeding older babies or children is somehow wrong – that it is nutritionally not needed, it made them feel uncomfortable, some feared it was more for the mother’s benefit than the child’s, others that the child could be harmed.
In fact the evidence base suggests that, nutritionally, breastfeeding a toddler has advantages, and psychologically there is no evidence if harm and possibly some evidence of benefit.
If everyone is armed with the facts – including that there is absolutely no harm in breastfeeding a child for as long as the mother and baby are comfortable (and many health organisations believe that it should be encouraged) – perhaps there would be less judgement.
As the t-shirt says “Still breastfeeding – still none of your business”.
- 1. Dewey, 2001. Nutrition, growth and complementary feeding of the breastfed infant. Pediatr Clin North Am. 2001 Feb;48(1):87-104.
- 2. WHO. Guiding Principles for Complementary Feeding of the Breastfed Child.
- 3. Heinig J. Host defense benefits of breastfeeding for the infant.Pediatr Clin North Am. 2001;48 :105 –123
- 4. Dewey K, Heinig J, Nommsen-Rivers L. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126 :696 –702
- 5. Goldman A, Goldblum R. Immunologic components in human milk during the second year of lactation. Acta Paediatr Scand. 1983;72 :461 –462
- 6. Davis M. Review of the evidence for an association between infant feeding and childhood cancer.Int J Cancer Suppl. 1998;11 :29 –33
- 7. Xiao S, Linet M, Steinbuch M, et al. Breast-feeding and risk of childhood acute leukemia. J Natl Cancer Inst. 1999;91 :1765 –1772
- 8. Labbok M. Effects of breastfeeding on the mother. Pediatr Clin North Am. 2001;48 :143 –158
- 9. Newcomb P, Storer B, Longnecker M, et al. Lactation and a reduced risk of premenopausal breast cancer. N Engl J Med. 1994;330 :81 –87
- 10. Kwan et al., 2005. Breastfeeding patterns and risk of childhood acute lymphoblastic leukaemia. Br J Cancer. 2005 8;93(3):379-84.
- 11. Kwan et al, 2004. Breastfeeding and the risk of childhood leukemia: a meta-analysis. Public Health Rep. 119(6):521-35
- 12. Berner et al. 2008. Does prolonged breastfeeding reduce the risk for childhood leukemia and lymphomas? Minerva Pediatr. 60(2):155-61.
- 13. Horwood LJ, Fergusson DM. 1998 Breastfeeding and later cognitive and academic outcomes. Pediatrics 101(1):E9.
- 14. Ferguson, D. M. et al. 1987 Breastfeeding and subsequent social adjustment in six- to eight-year-old children. J Child Psychol Psychiatr Allied Discip 28:378-86.
* The 1975 Sexual Discrimination Act created legal protection for a woman under the provision of goods, facilities and services section. This protection covered a woman breastfeeding a child, of any age, by implication, and meant that she could not be discriminated against for breastfeeding in places such as restaurants, cafes, surgeries, libraries etc.