Breastfeeding

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]

## Overview

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An infant breastfeeding International Breastfeeding Symbol

Breastfeeding is the feeding of an infant or young child with breast milk directly from a woman's breasts, not from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is possible for most mothers to nourish their infant (or infants in the case of twins and multiple births) by breastfeeding for the first six months, without the supplement of infant formula milk or solid food.

According to a 2001 WHO report,[1] alternatives to breastfeeding include:

* expressed breast milk from an infant’s own mother
* breast milk from a healthy wet-nurse or a human-milk bank
* a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat

In most situations human breast milk is the best source of nourishment for human infants,[2] preventing disease, promoting health and reducing health care costs[3] (exceptions include situations where the mother is taking certain drugs or is infected with tuberculosis or HIV). Experts disagree about how long to breastfeed to gain the greatest benefit, and about the risks of using artificial formulas.[4][5][6] In both developing and developed countries, artificial feeding is associated with more deaths from diarrhoea in infants.[7]

The World Health Organization recommends a minimum of two years of breastfeeding and exclusive breastfeeding for the first six months of life. AAP recommends at least one year of breastfeeding and exclusive breastfeeding for the first six months of life. Exclusive breastfeeding for the first six months of life "provides continuing protection against diarrhea and respiratory tract infection" that is more common in babies fed formula. [4]The World Health Organization (WHO)[8] and American Academy of Pediatrics (AAP)[9] both stress the value of breastfeeding for mothers and children. While recognizing the superiority of breastfeeding, regulating authorities work to make artificial feeding safer when it is not used.[5]

## Lactation

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Main article: Lactation

The production, secretion and ejection of milk is called lactation. It is one of the defining features of being a mammal.

## Breast milk

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Main article: Breast milk

Polar bear is nursing a cub

Not all the properties of breast milk are understood, but its nutrient content is relatively stable. Breast milk is made from the nutrients in the mother's bloodstream and bodily stores. Some studies estimate that a woman who breastfeeds her infant exclusively uses 400 - 600 extra calories a day in producing milk.[10] The composition of breast milk depends on how long the baby nurses.

"Research shows that the fat and energy content of breastmilk actually increases after the first year.[8] Breastmilk adapts to a toddler's developing system, providing exactly the right amount of nutrition at exactly the right time.[9] In fact, research shows that between the ages of 12 and 24 months, 448 milliliters of a mother's milk provide these percentages of the following minimum daily requirements:

Energy 29% Folate 76% Protein 43% Vitamin B12 94% Calcium 36% Vitamin C 60 Vitamin A 75% "[5]

## Benefits for the infant

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Himba woman and child.

During breastfeeding nutrients and antibodies pass to the baby[11] and the maternal bond can also be strengthened.[12] Research has demonstrated a variety of benefits to breastfeeding an infant. [13] These include:

### Breast Cancer

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A study at the University of Wisconsin found that adult women who were breast fed in infancy may have a lower risk of developing breast cancer than their non breast-fed counterparts. [14]

### Atopy

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In children who are at risk (defined as at least one parent or sibling having atopy) atopic syndrome can be prevented or delayed through exclusive breastfeeding for four months, though these benefits may not be present after four months of age[15] though the key factor may be the age at which non-breastmilk is introduced rather than duration of breastfeeding.[16] Atopic dermatitis, the most common form of eczema, can be reduced through exclusive breastfeeding beyond 12 weeks in individuals with a family history of atopy, but when breastfeeding beyond 12 weeks is combined with other foods incidents of eczema rise irrespective of family history.[17]

### Celiac disease

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A review of the association between breastfeeding and celiac disease (CD) concluded that breast feeding while introducing gluten to the diet reduced the risk of CD. The study was unable to determine if breastfeeding merely delayed symptoms or offerred life-long protection.[18]

### Diabetes mellitus

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Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.[19] Breastfeeding also appears to protect against diabetes mellitus type 2,[20][21] at least in part due to its effects on the child's weight.[21]

### Diarrhea

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Breastfeeding protects infants against diarrhea as compared to formula-fed peers;[22] compared to formula-fed peers, death rates due to diarrhea in breastfed infants are lower irrespective of the development level of the country.[7]

### Immune health

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Breastmilk include several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections), lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria)[23][24] and immunoglobulin A protecting against microorganisms.[25]

Despite also being a factor in the transmission of HIV from mother to child, some constituents in breastmilk may be protective of infection. In particular, high levels of certain polyunsaturated fatty acids in breastmilk (including eicosadienoic, arachidonic and gamma-Linolenic acids) are associated with a reduced risk of child infection when nursed by HIV-positive mothers. Arachidonic acid and gamma-linolenic acid may also reduce viral shedding of the HIV virus in breastmilk.[26]

Breastfeeding does not appear to offer protection against allergies.[27]

### Intelligence

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Babies with a specific variant of the FADS2 gene (approximately 90% of all babies) demonstrate an IQ an average of 7 points higher if breastfed.[28]

### Necrotizing enterocolitis

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Necrotizing enterocolitis (NC), found mainly in premature births, is six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, as compared to exclusive breastfeeding. In infants born at more than 30 weeks, NC was twenty times more common in infants fed exclusively on formula.[29]

### Nutrition

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Breast milk contains the ideal ratio of the amino acids cystine, methionine, and taurine to support development of the central and peripheral nervous system. Children aged seven and eight years old who were of low birthweight who were breastfed for more than eight months demonstrated significantly higher intelligence quotient scores than comparable children breastfed for less time, suggesting breastfeeding offers long-term cognitive benefits in some populations.[30]

### Obesity

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Breastfeeding appears to reduce the risk of extreme obesity in children aged 39 to 42 months.[31] The protective effect of breastfeeding against obesity is consistent, though small, across many studies, and appears to increase with the duration of breastfeeding.[32]

### Otitis media

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Increased duration of certain types of middle ear infections (otitis media with effusion, OME) in the first two years of life is associated with a shorter period of breastfeeding, in addition to feeding while lying down and maternal cigarette smoking.[33] A reduced proportion and duration of any otitis media infection was associated with breastfeeding rather than formula feeding for the first twelve months of life.[22]

### Respiratory infections

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Breastfeeding appears to reduce symptoms of upper respiratory tract infections in premature infants up to seven months after release from hospital.[34]

### Sudden infant death syndrome

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Breastfed babies have improved arousal from sleep, which may reduce the risk of sudden infant death syndrome.[35]

### Urinary tract infection

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Breastfeeding reduced the risk of acquiring urinary tract infections in infants up to seven months post-partum. The protection was strongest immediately after birth, and was ineffective past seven months[36]

## Benefits for mothers

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Zanzibari woman breastfeeding

Breastfeeding is a cost effective way of feeding an infant, and provides the best nourishment for a child at a small nutrient cost to the mother. Frequent and exclusive breastfeeding can delay the return of fertility through lactational amenorrhea, though breastfeeding is at best an imperfect means of birth control. During breastfeeding beneficial hormones are released into the mother's body.[11] and the maternal bond can be strengthened.[12] Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point.[37]

### Breast cancer

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Breastfeeding mothers have less risk of endometrial,[38][39] breast and ovarian cancer,[9][12] and osteoporosis.[9][12] Mothers who breastfeed longer than eight months also benefit from bone re-mineralisation[40] and breastfeeding diabetic mothers require less insulin.[41] Breastfeeding helps stabilize maternal endometriosis,[9] reduces the risk of post-partum bleeding[42] and benefits the insulin levels for mothers with polycystic ovary syndrome.[43]

Some breastfeeding women have pain from candidiasisor staphylococcus infections of the nipple[44] though these can be managed with medical attention with little concern for mother and child.

### Arthritis

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Women who breast feed for longer have a smaller chance of getting rheumatoid arthritis, suggests a Malmo University study published online ahead of print in the Annals of the Rheumatic Diseases (See Women Who Breast Feed for More than a Year Halve Their Risk of Rheumatoid Arthritis). The study also found that taking oral contraceptives, which are suspected to protect against the disease because they contain hormones that are raised in pregnancy, did not have the same effect. Simply having children but not breast feeding also did not seem to be protective.

### Bonding

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The hormones released during breastfeeding strengthen the maternal bond. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[45] Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.[46]

If the mother is away, an alternative caregiver may be able to feed the baby with expressed breast milk. The various breast pumps available for sale and rent help working mothers to feed their babies breast milk for as long as they want. To be successful, the mother must produce and store enough milk to feed the child for the time she is away, and the feeding caregiver must be comfortable in handling breast milk.

### Hormone release

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Breastfeeding releases the hormones oxytocin and prolactin which relax the mother and make her feel more nurturing toward her baby.[47] Breastfeeding soon after giving birth increases the mother's oxytocin levels, making her uterus contract more quickly and reducing bleeding. Oxytocin is similar to pitocin, a synthetic hormone used to make the uterus contract.[42]

### Weight loss

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As fat accumulated during pregnancy is used to produce milk, extended breastfeeding--at least 6 months--can help mothers lose weight.[48] However, weight loss is highly variable among lactating women, and diet and exercise is a more reliable way of losing weight.[49]

## Organisational endorsements

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### World Health Organization

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“  | [the] 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. Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group.[50] | ”

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The WHO recommends two years of breastfeeding and exclusive breastfeeding for the first six months of life.

### American Academy of Pediatrics

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“  | 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.[9] | ”

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AAP recommends at least one year of breastfeeding and exclusive breastfeeding for the first six months of life.

## Breastfeeding difficulties

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Main article: Breastfeeding complications § When breastfeeding might harm the infant

Despite being a natural human activity, breastfeeding difficulties are not uncommon. Putting the baby to the breast as soon as possible after birth helps to avoid many problems. The AAP breastfeeding policy says: Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.[9] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained midwives, doctors and hospital staff, and lactation consultants.[51] There are some situations in which breastfeeding may be harmful to the infant, including infection with tuberculosis or HIV, some medications and some drugs.

## Infant weight gain

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Breastfed infants generally gain weight according to the following guidelines:

0–4 months: 170 grams per week†
4–6 months: 113–142 grams per week
6–12 months: 57–113 grams per week

† It is acceptable for some babies to gain 113–142 grams (4–5 ounces) per week. This average is taken from the lowest weight, not the birth weight.

The average breastfed baby doubles birth weight in 5–6 months. By one year, the typical breastfed baby will weigh about 2½ times birth weight. At one year, breastfed babies tend to be leaner than bottle fed babies.[52] By two years, differences in weight gain and growth between breastfed and formula-fed babies are no longer evident.[53];

## Methods and considerations

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

### Early breastfeeding

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In the half hour after birth, the baby's suckling reflex is strongest, and the baby is more alert, so it is the ideal time to start breastfeeding. [54]. Early breast-feeding is associated with fewer nighttime feeding problems [55]

### Time and place for breastfeeding

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Breastfeeding at least once every two to three hours helps to maintain milk production. For most women, eight breastfeeding or pumping sessions every 24 hours keeps their milk production high.[9] Newborn babies may feed more often than this: 10 to 12 breastfeeding sessions every 24 hours is common, and some may even feed 18 times a day.[56] Feeding a baby on demand (sometimes referred to as "on cue"), may mean breastfeeding much more than the recommended minimum. Feeding when the baby shows early signs of hunger, is the best way to maintain milk production and ensure the baby's needs for milk and comfort are being met.[8] However, it may be important to recognize whether a baby is truly hungry, as breastfeeding too frequently may mean the child receives a disproportionately high amount of foremilk, and not enough hindmilk, potentially creating problems.[57].

"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.[6]"

"Comforting and meeting sucking needs at the breast is nature's original design. Pacifiers (dummies, soothers) are literally a substitute for the mother when she can't 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.[7]"

Babies usually show they are hungry by waking up (newborns), mouthing their fists, moaning or fussing. Crying is a late indicator of hunger. When a baby's cheeks are stroked, the rooting instinct makes it move its face towards the stroking and open its mouth.

Breastfeeding can make mothers thirsty, especially at first, when both mother and baby are inexperienced and when feeding sessions can last for an hour or more (there is no time limit for breastfeeding). Having water readily available helps mothers maintain proper hydration.

Rooming-in bassinet

Most US states now have breastfeeding laws which allow a mother to breastfeed her baby anywhere she is allowed to be. In hospitals, rooming-in care is used for breastfeeding. There are breastfeeding rooms in some places, including hypermarkets.

### Latching on, feeding and positioning

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When the nipple strokes the baby's cheek the baby will open its mouth and turn towards the nipple. To help the baby latch on well, tickle the baby's top lip with the nipple, wait until the baby's mouth opens wide, then bring the baby up towards the nipple quickly, so that the baby has a mouthful of nipple and areola. The nipple should be at the back of the baby's throat, with the baby's tongue lying flat in its mouth.  Inverted or flat nipples can be massaged so that the baby will have more to latch onto. Resist the temptation to move towards the baby, as this can lead to poor attachment.

Many women wear nursing brassieres for easier access to the breast, but these are not always necessary and certainly not required. In the very early days, wearing a nursing bra can make breastfeeding complicated and uncomfortable. Wearing a bra at any time after birth will not affect how the breast changes with pregnancy and breastfeeding. Many women find that the size of their breasts change dramatically and so fitting a bra is better done after childbirth rather than before. An ill-fitting bra, whether designed for nursing or otherwise, can cause plugged ducts or mastitis.

Pain in the nipple or breast is linked to incorrect breastfeeding techniques. Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns. A 2006 study found that inadequate parental education, incorrect breastfeeding techniques, or both were associated with higher rates of preventable hospital admissions in newborns.[58]

The baby may pull away from the nipple after a few minutes or after a much longer period of time. Normal feeds at the breast can last a few sucks (newborns), from 10 to 20 minutes or even longer (on demand). Sometimes, after the finishing of a breast, the mother may offer the other breast.

The length of feeds varies a lot. Regardless of the time taken, the breastfeeding mother should be comfortable.

* Upright: The sitting position with the back straight and leaning back comfortably.
* 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
* 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 (nursing more than one child)
* 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)

While most women breastfeed their child in the cradling position, there are many ways to hold the feeding baby. It depends on the mother and child's comfort and the feeding preference of the baby. Some babies prefer one breast to the other, but the mother should offer both breasts at every nursing with her newborn.

* 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 image
* 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. This position is especially useful for feeding twins simultaneously image
* 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. As tandem breastfeeding brings extra strain to the arms, especially as the babies grow, many mothers of twins recommend the use of more supporting pillows. Favored positions include:

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

### Exclusive breastfeeding

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Exclusive breastfeeding is when an infant receives no other food or drink besides breast milk.[8] National and international guidelines recommend that all infants be breastfed exclusively for the first six months of life. It is generally accepted that newborns should be exclusively breastfed for around 6 months. 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.

Exclusively breastfed infants feed anywhere from 6 to 14 times a day. Newborns consume from 30 to 90 ml (1 to 3 US fluid ounces). After the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, but as it grows the amount will increase. It is important to recognize the baby's hunger signs. It is assumed that the baby knows how much milk it needs and it is therefore advised that the baby should dictate the number, frequency, and length of each feed. The supply of milk from the breast is determined by the number and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it larger; they should, however, go by the demands of the baby rather than what they feel is necessary.

While it can be hard to measure how much food a breastfed baby consumes, babies normally feed to meet their own requirements.[59] Babies that fail to eat enough may exhibit symptoms of failure to thrive. If necessary, it is possible to estimate feeding from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours suggests an acceptable amount of input for newborns older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools. Babies can also be weighed before and after feeds.

### Expressing breast milk

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Manual breast pump

When direct breastfeeding is not possible, a mother can express (artificially remove and store) her milk. With manual massage or using a breast pump, a woman can express her milk and keep it in freezer storage bags, a supplemental nursing system, or a bottle ready for use. Breast milk may be kept at room temperature for up to ten hours, refrigerated for up to eight days or frozen for up to four to six months. Research suggests that the antioxidant activity in expressed breast milk decreases over time but it still remains at higher levels than in infant formula.[60]

Expressing breast milk can maintain a mother's milk supply when she and her child are apart. If a sick baby is unable to feed, expressed milk can be fed through a nasogastric tube.

Expressed milk can also be used when a mother is having trouble breastfeeding, such as when a newborn causes grazing and bruising. If an older baby bites the nipple, the mother's reaction - a jump and a cry of pain - is usually enough to discourage the child from biting again. (Another possibility is responding to the bite by drawing the baby so close that his nose is covered and he cannot breathe without releasing.[61]) Babies or toddlers that are truly feeding cannot physically bite the nipple.

"Exclusively Expressing", "Exclusively pumping" and "EPing" are terms for a mother who feeds her baby exclusively on her breastmilk while not physically breastfeeding. This may arise because her baby is unable or unwilling to latch on to the breast. With good pumping habits, particularly in the first 12 weeks when the milk supply is being established, it is possible to produce enough milk to feed the baby for as long as the mother wishes. Kellymom [8] has a page of links relating to exclusive pumping.

It is generally advised to delay using a bottle to feed expressed breast milk until the baby is 4-6 weeks old and is good at sucking directly from the breast.[62] Because It takes less effort to suck from a bottle, a baby might lose its desire to suck from the breast. This is called nursing strike or nipple confusion. To avoid this when feeding expressed breast milk (EBM) before 4-6 weeks of age, it is recommended that breast milk be given by other means such as feeding spoons or feeding cups. Also, EBM should be given by someone other than the breastfeeding mother (or wet nurse), so that the baby can learn to associate direct feeding with the mother (or wet nurse) and associate bottle feeding with other people.[citation needed]

Some women donate their expressed breast milk (EBM) to others, either directly or through a milk bank. Though historically the use of wet nurses was common, some women dislike the idea of feeding their own child with another woman's milk; others appreciate being able to give their baby the benefits of breast milk. Feeding expressed breast milk--either from donors or the baby's own mother--is the feeding method of choice for premature babies.[63] The transmission of some viral diseases through breastfeeding can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.[64]

### Mixed feeding

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

Predominant or mixed breastfeeding means feeding breast milk along with infant formula, baby food and even water, depending on the age of the child. Babies feed differently with artificial teats than from a breast. When feeding from the breast, the tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a bottle, an infant will suck harder and the milk may come in more rapidly. Therefore, mixing breastfeeding and bottle-feeding (or using a pacifier) before the baby is used to feeding from its mother can induce the infant to prefer the bottle to the breast. Orthodontic teats, which are generally slightly longer, are closer to the nipple. Some mothers supplement feed with a small syringe or flexible cup to reduce the risk of artificial nipple preference.

### Tandem breastfeeding

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Feeding two children at the same time is called tandem breastfeeding The most common reason for tandem breastfeeding is the birth of twins, although women with closely spaced children can and do continue to nurse the older as well as the younger. As the appetite and feeding habits of each baby may not be the same, this could mean feeding each according to their own individual needs, and can also include breastfeeding them together, one on each breast.

In cases of triplets or more, it is a challenge for a mother to organize feeding around the appetites of all the babies. While breasts can respond to the demand and produce large quantities of milk, it is common for women to use alternatives. However, some mothers have been able to breastfeed triplets successfully [65][66] [67].

Tandem breastfeeding may also occur when a woman has a baby while breastfeeding an older child. During the late stages of pregnancy the milk will change to colostrum, and some older nurslings will continue to feed even with this change, while others may wean due to the change in taste or drop in supply. Feeding a child while being pregnant with another can also be considered a form of tandem feeding for the nursing mother, as she also provides the nutrition for two.[68]

### Extended breastfeeding

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Breastfeeding past two years is called extended breastfeeding or "sustained breastfeeding" by supporters and those outside the U.S.[69]) Supporters of extended breastfeeding believe that all the benefits of human milk, nutritional, immunological and emotional, continue for as long as a child nurses. Often the older child will nurse infrequently or sporadically as a way of bonding with the mother.[citation needed]

### Shared breastfeeding

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Main article: Wet nurse

It used to be common worldwide, and still is in developing nations such as those in Africa, for more than one woman to breastfeed a child. Shared breastfeeding is a risk factor for HIV infection in infants.[70] A woman who is engaged to breastfeed another's baby is known as a wet nurse. Islam has codified the relationship between this woman and the infants she nurses, and also between the infants when they grow up, so that milk siblings are considered as blood siblings and cannot marry. Shared breastfeeding can incur strong negative reactions in the Anglosphere[71]; American feminist activist Jennifer Baumgardner has written about her experiences in New York with this issue[72].

### Weaning

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Weaning is the process of introducing the infant to other food and reducing the supply of breast milk. The infant is fully weaned once it relies on other food for all its nutrition and it no longer receives any breast milk. Most mammals stop producing the enzyme lactase at the end of weaning, and become lactose intolerant. Many humans have a mutation that allows the production of lactase throughout life and can drink milk - usually cow or goat milk - well beyond the age of weaning.[73]

In the past, bromocriptine was sometimes used to reduce the engorgement experienced by many women during weaning. However, it was discovered that when used for this purpose, this medication posed serious health risks to women, such as stroke, and the U.S. FDA withdrew this indication for the drug in 1994.[74]

## History of breastfeeding

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Famille d’un Chef Camacan se préparant pour une Fête ("Family of a Camacan chief preparing for a Festival") by Jean-Baptiste Debret shows a woman breastfeeding a child in the background.

Main article: History of breastfeeding

Prior to the twentieth century, alternatives to breastfeeding were rare. Attempts in 15th century Europe to use cow or goat's milk were not very positive. In the 18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding, but this did not have a favorable outcome, either. True commercial infant formulas appeared on the market in the mid 19th Century but their use did not become widespread until after WWII. As the superior qualities of breast milk became better-established in medical literature, breastfeeding rates have increased and countries have enacted measures to protect the rights of infants and mothers to breastfeed.

## Sociological factors with breastfeeding

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Researchers have found several social factors that correlate with differences in initiation, frequency, and duration of breastfeeding practices of mothers. Race, ethnic differences and socioeconomic status and other factors have been shown to affect a mother’s choice whether or not to breastfeed and how long she breastfeeds her child.
Education According to Singh, Kogan, and Lee, more mothers with higher education levels correlate breastfeed, and these mothers breastfeed for longer.
Race and culture Singh et al also found that African American women are less likely than white women of similar socioeconomic status to breastfeed and Hispanic women are more likely to breastfeed. This may be evidence that breastfeeding acceptability is based on cultural acceptance, and that acceptance is related to socioeconomic status in the mother’s culture. The Center of Disease Control used information from the National Immunization Survey to determine the proportion of Caucasian and African American children that were ever breast fed. They found that 71.5% of Caucasians had breastfed their child while only 50.1% of African Americans had. At six months of age this fell to 53.9% of Caucasian mothers and 43.2% of African American mothers who were still breastfeeding.
Income Deborah L. Dee's research found that women and children who qualify for WIC, Special Supplemental Nutrition Program for Women, Infants, and Children were among those who were least likely to initiate breastfeeding. Income level can also contribute to women discontinuing breastfeeding early. More highly educated women are more likely to have access to information regarding difficulties with breastfeeding, allowing them to continue breastfeeding through difficulty rather than weaning early. Women in higher status jobs are more likely to have access to a lactation room and suffer less social stigma from having to breastfeed or express breastmilk at work. In addition, women who are unable to take an extended leave from work following the birth of their child are less likely to continue breastfeeding when they return to work.
Other factors Other factors they found to have an effect on breastfeeding are “household composition, metropolitan/non-metropolitan residence, parental education, household income or poverty status, neighborhood safety, familial support, maternal physical activity, and household smoking status.”

## Economic factors of breastfeeding

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Women who are less likely to breastfeed are more likely to incur medical bills due to the lack of protection that breast milk gives to the child. In the case of poor mothers this combined with the extra cost of artificial feeding could result in more debt, and even worse poverty. The birth of a child puts an economic strain on parents, but this is exacerbated if the baby is not breastfed. This is also linked to Michael Marmot’s theory of status syndrome, in which status level, determined by education, wealth, occupation, and social prestige, determines how healthy people are. Many programs have been created to help reduce the disparity between low income and African American mothers and other mothers in choosing to breastfeed. These programs include the WIC, WHO, the World Health Organization, UNICEF, United Nation’s Children’s Fund, and La Leche League International. They work to educate women about breastfeeding and try to alleviate some of the stresses in breastfeeding in today’s society. However, according to the latest figures, WIC’s efforts have not been successful in increasing the number of breastfed infants. If these organizations had a little more success, the disparity between the socioeconomic groups could be reduced, and result in a healthier general population. Higher breastfeeding rates will not reduce the socioeconomic disparity, but it might help to increase the health of those who are poor and disadvantaged. So, breastfeeding could help to alleviate the economic stresses and poor health of the working class and the poor.

## See also

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* Baby-friendly hospital
* Baby-led weaning
* Breast shell
* Erotic lactation
* Human milk banking in North America
* Milk line
* Nursing chair

## Footnotes

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1. ↑ Secretariat, World Health Organization (24 November 2001). Infant and Young Child Nutrition: Global strategy for infant and young child feeding (PDF). World Health Organization. WHO Executive Board 109th Session provisional agenda item 3.8 (EB109/12).
2. ↑ Picciano M (2001). "Nutrient composition of human milk". Pediatr Clin North Am. 48 (1): 53–67. doi:10.1016/S0031-3955(05)70285-6. PMID 11236733.
3. ↑ Riordan JM (1997). "The cost of not breastfeeding: a commentary". J Hum Lact. 13 (2): 93–97. doi:10.1177/089033449701300202. PMID 9233193.
4. ↑ Kramer M, Kakuma R (2002). "Optimal duration of exclusive breastfeeding". Cochrane Database Syst Rev: CD003517. doi:10.1002/14651858.CD003517. Text "i 11869667 " ignored (help)
5. ↑ 5.0 5.1 Baker R (2003). "Human milk substitutes. An American perspective". Minerva Pediatr. 55 (3): 195–207. PMID 12900706.
6. ↑ Agostoni C, Haschke F (2003). "Infant formulas. Recent developments and new issues". Minerva Pediatr. 55 (3): 181–94. PMID 12900705.
7. ↑ 7.0 7.1 Horton S, Sanghvi T, Phillips M; et al. (1996). "Breastfeeding promotion and priority setting in health". Health Policy Plan. 11 (2): 156–68. doi:10.1093/heapol/11.2.156. PMID 10158457.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
8. ↑ 8.0 8.1 8.2 8.3 "Exclusive Breastfeeding". WHO: Child and Adolescent Health and Development. Retrieved 2006-05-03.
9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Gartner LM; et al. (2005). "Breastfeeding and the use of human milk". Pediatrics. 115 (2): 496–506. doi:10.1542/peds.2004-2491. PMID 15687461.CS1 maint: Explicit use of et al. (link)
10. ↑ "Breastfeeding Guidelines". Rady Children's Hospital San Diego. Retrieved 2007-03-04.
11. ↑ 11.0 11.1 "Breastfeeding". Centers for Disease Control and Prevention. Retrieved 2007-01-23.
12. ↑ 12.0 12.1 12.2 12.3 "Benefits of Breastfeeding". U.S. Department of Health and Human Services. Retrieved 2007-01-23.
13. ↑ Ip S, Chung M, Raman G; et al. (2007). "Breastfeeding and maternal and infant health outcomes in developed countries". Evid Rep Technol Assess (Full Rep) (153): 1–186. PMID 17764214.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
14. ↑ [1]
15. ↑ Greer FR, Sicherer SH, Burks AW (2008). "Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas". Pediatrics. 121 (1): 183–91. doi:10.1542/peds.2007-3022. PMID 18166574.CS1 maint: Multiple names: authors list (link)
16. ↑ Oddy WH, Holt PG, Sly PD; et al. (1999). "Association between breast feeding and asthma in 6 year old children: findings of a prospective birth cohort study". BMJ. 319 (7213): 815–9. PMID 10496824.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
17. ↑ Pratt HF (1984). "Breastfeeding and eczema". Early Hum. Dev. 9 (3): 283–90. doi:10.1016/0378-3782(84)90039-2. PMID 6734490.
18. ↑ Akobeng AK, Ramanan AV, Buchan I, Heller RF (2006). "Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies". Arch. Dis. Child. 91 (1): 39–43. doi:10.1136/adc.2005.082016. PMID 16287899.CS1 maint: Multiple names: authors list (link)
19. ↑ Perez-Bravo F, Carrasco E, Gutierrez-Lopez MD, Martinez MT, Lopez G, de los Rios MG (1996). "Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children". J. Mol. Med. 74 (2): 105–9. doi:10.1007/BF00196786. PMID 8820406.CS1 maint: Multiple names: authors list (link)
20. ↑ Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG (2006). "Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence". Am. J. Clin. Nutr. 84 (5): 1043–54. PMID 17093156.CS1 maint: Multiple names: authors list (link)
21. ↑ 21.0 21.1 Mayer-Davis EJ, Dabelea D, Lamichhane AP; et al. (2008). "Breast-feeding and type 2 diabetes in the youth of three ethnic groups: the SEARCh for diabetes in youth case-control study". Diabetes Care. 31 (3): 470–5. doi:10.2337/dc07-1321. PMID 18071004.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
22. ↑ 22.0 22.1 Dewey KG, Heinig MJ, Nommsen-Rivers LA (1995). "Differences in morbidity between breast-fed and formula-fed infants". J. Pediatr. 126 (5 Pt 1): 696–702. PMID 7751991.CS1 maint: Multiple names: authors list (link)
23. ↑ Kunz C, Rodriguez-Palmero M, Koletzko B, Jensen R (1999). "Nutritional and biochemical properties of human milk, Part I: General aspects, proteins, and carbohydrates". Clin Perinatol. 26 (2): 307–33. PMID 10394490.CS1 maint: Multiple names: authors list (link)
24. ↑ Rodriguez-Palmero M, Koletzko B, Kunz C, Jensen R (1999). "Nutritional and biochemical properties of human milk: II. Lipids, micronutrients, and bioactive factors". Clin Perinatol. 26 (2): 335–59. PMID 10394491.CS1 maint: Multiple names: authors list (link)
25. ↑ Glass RI, Svennerholm AM, Stoll BJ; et al. (1983). "Protection against cholera in breast-fed children by antibodies in breast milk". N. Engl. J. Med. 308 (23): 1389–92. PMID 6843632.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
26. ↑ Villamor E, Koulinska IN, Furtado J; et al. (2007). "Long-chain n-6 polyunsaturated fatty acids in breast milk decrease the risk of HIV transmission through breastfeeding". Am. J. Clin. Nutr. 86 (3): 682–9. PMID 17823433.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
27. ↑ Kramer MS, Matush L, Vanilovich I; et al. (2007). "Effect of prolonged and exclusive breast feeding on risk of allergy and asthma: cluster randomised trial". BMJ. 335 (7624): 815. doi:10.1136/bmj.39304.464016.AE. PMID 17855282.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
28. ↑ Caspi A, Williams B, Kim-Cohen J; et al. (2007). "Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism". Proc. Natl. Acad. Sci. U.S.A. 104 (47): 18860–5. doi:10.1073/pnas.0704292104. PMID 17984066.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) ; lay-summary
29. ↑ Lucas A, Cole TJ (1990). "Breast milk and neonatal necrotising enterocolitis". Lancet. 336 (8730): 1519–23. doi:10.1016/0140-6736(90)93304-8. PMID 1979363.
30. ↑ Horwood LJ, Darlow BA, Mogridge N (2001). "Breast milk feeding and cognitive ability at 7-8 years". Arch. Dis. Child. Fetal Neonatal Ed. 84 (1): F23–7. doi:10.1136/fn.84.1.F23. PMID 11124919.CS1 maint: Multiple names: authors list (link)
31. ↑ Armstrong J, Reilly JJ (2002). "Breastfeeding and lowering the risk of childhood obesity". Lancet. 359 (9322): 2003–4. doi:10.1016/S0140-6736(02)08837-2. PMID 12076560.
32. ↑ Arenz S, Rückerl R, Koletzko B, von Kries R (2004). "Breast-feeding and childhood obesity--a systematic review". Int. J. Obes. Relat. Metab. Disord. 28 (10): 1247–56. doi:10.1038/sj.ijo.0802758. PMID 15314625.CS1 maint: Multiple names: authors list (link)
33. ↑ Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM (1993). "Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life". J. Pediatr. 123 (5): 702–11. PMID 8229477.CS1 maint: Multiple names: authors list (link)
34. ↑ Blaymore Bier JA, Oliver T, Ferguson A, Vohr BR (2002). "Human milk reduces outpatient upper respiratory symptoms in premature infants during their first year of life". J Perinatol. 22 (5): 354–9. doi:10.1038/sj.jp.7210742. PMID 12082468.CS1 maint: Multiple names: authors list (link)
35. ↑ Horne RS, Parslow PM, Ferens D, Watts AM, Adamson TM (2004). "Comparison of evoked arousability in breast and formula fed infants". Arch. Dis. Child. 89 (1): 22–5. PMID 14709496.CS1 maint: Multiple names: authors list (link)
36. ↑ Mårild S, Hansson S, Jodal U, Odén A, Svedberg K (2004). "Protective effect of breastfeeding against urinary tract infection". Acta Paediatr. 93 (2): 164–8. PMID 15046267.CS1 maint: Multiple names: authors list (link)
37. ↑ Feldman S (July–August 2000). "Nursing Through Pregnancy". New Beginnings. La Leche League International. 17 (4): pp. 116-118, 145. Retrieved 2007-03-15.CS1 maint: Extra text (link) CS1 maint: Date format (link)
38. ↑ Rosenblatt K, Thomas D (1995). "Prolonged lactation and endometrial cancer. WHO Collaborative Study of Neoplasia and Steroid Contraceptives". Int J Epidemiol. 24 (3): 499–503. PMID 7672888.
39. ↑ Newcomb P, Trentham-Dietz A (2000). "Breast feeding practices in relation to endometrial cancer risk, USA". Cancer Causes Control. 11 (7): 663–7. PMID 10977111.
40. ↑ Melton III L (March 1993). "Influence of breastfeeding and other reproductive factors on bone mass later in life". Osteoporosis International. London: Springer. 3 (2): 76. doi:10.1007/BF01623377. PMID 8453194. Unknown parameter `|coauthors=` ignored (help)
41. ↑ Rayburn W, Piehl E, Lewis E, Schork A, Sereika S, Zabrensky K (1985). "Changes in insulin therapy during pregnancy". Am J Perinatol. 2 (4): 271–5. PMID 3902039.CS1 maint: Multiple names: authors list (link)
42. ↑ 42.0 42.1 Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam S (1994). "Influence of breastfeeding and nipple stimulation on postpartum uterine activity". Br J Obstet Gynaecol. 101 (9): 804–5. PMID 7947531.CS1 maint: Multiple names: authors list (link)
43. ↑ Sir-Petermann T, Devoto L, Maliqueo M, Peirano P, Recabarren S, Wildt L (2001). "Resumption of ovarian function during lactational amenorrhoea in breastfeeding women with polycystic ovarian syndrome: endocrine aspects". Hum Reprod. 16 (8): 1603–10. doi:10.1093/humrep/16.8.1603. PMID 11473950.CS1 maint: Multiple names: authors list (link)
44. ↑ Amir L (1996). "Candida albicans: is it associated with nipple pain in lactating women?". Gynecol Obstet Invest. Karger. 41 (1): pp. 30-34. PMID 8821881. Unknown parameter `|coauthors=` ignored (help)CS1 maint: Extra text (link)
45. ↑ Pisacane A, Continisio GI, Aldinucci M, D'Amora S, Continisio P (2005). "A controlled trial of the father's role in breastfeeding promotion". Pediatrics. 116 (4): e494–8. doi:10.1542/peds.2005-0479. PMID 16199676.CS1 maint: Multiple names: authors list (link)
46. ↑ Van Willigen, John; John van Willigen (2002). Applied anthropology: an introduction. New York: Bergin & Garvey. ISBN 0897898338.CS1 maint: Multiple names: authors list (link)
47. ↑ Dettwyler K (1995). Breastfeeding: Biocultural Perspectives. Aldine Transaction. pp. p. 131. ISBN 978-0-202-01192-9. Unknown parameter `|coauthors=` ignored (help)CS1 maint: Extra text (link)
48. ↑ Dewey K, Heinig M, Nommsen L (1993). "Maternal weight-loss patterns during prolonged lactation". Am J Clin Nutr. 58 (2): 162–6. PMID 8338042.CS1 maint: Multiple names: authors list (link)
49. ↑ Lovelady C, Garner K, Moreno K, Williams J (2000). "The effect of weight loss in overweight, lactating women on the growth of their infants". N Engl J Med. 342 (7): 449–53. doi:10.1056/NEJM200002173420701. PMID 10675424.CS1 maint: Multiple names: authors list (link)
50. ↑ "Infant and young child nutrition: Global strategy for infant and young child feeding" (pdf). Geneva, Switzerland: World Health Organization. World Health Organization. 2001-11-24. Retrieved 2008-03-13.
51. ↑ Newman J (2000). Dr. Jack Newman's guide to breastfeeding. HarperCollins Publishers. ISBN 0006385680. Unknown parameter `|coauthors=` ignored (help)
52. ↑ "Weight gain (Growth patterns)". AskDrSears.com. Retrieved 2007-04-03.
53. ↑ Mohrbacher, Nancy (2003). The Breastfeeding Answer Book (3rd ed. (revised) ed.). La Leche League International. ISBN 0-912500-92-1. Unknown parameter `|coauthor=` ignored (help)
54. ↑ Widstrom AM, Wahlberg V, Matthiesen AS, Eneroth P, Uvnas-Moberg K, Werner S, et al. Short-term effects of early suckling and touch of the nipple on maternal behavior. Early Hum Dev 1990; 21:153-63.
55. ↑ Renfrew MJ, Lang S. Early versus delayed initiation of breastfeeding. In: The Cochrane Library [on CD-ROM]. Oxford: Update Software;1998.
56. ↑ "Infant feeding – Breast or bottle and how to breast feed". Retrieved 2007-05-26.
57. ↑ V Livingstone. The Art of Successful Breastfeeding (VHS). Vancouver, BC, Canada: New Vision Media Ltd.
58. ↑ Paul I, Lehman E, Hollenbeak C, Maisels M (2006). "Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act". Pediatrics. 118 (6): 2349–58. doi:10.1542/peds.2006-2043. PMID 17142518.CS1 maint: Multiple names: authors list (link)
59. ↑ Iwinski S (2006), "Is Weighing Baby to Measure Milk Intake a Good Idea?", LEAVEN, 42 (3): 51–3, retrieved 2007-04-08
60. ↑ Hanna N (November 2004). "Effect of storage on breast milk antioxidant activity". Arch Dis Child Fetal Neonatal Ed. BMJ Publishing Group Ltd. 89 (6): pp. F518-20. doi:10.1136/adc.2004.049247. PMID 15499145. Unknown parameter `|coauthor=` ignored (help)CS1 maint: Extra text (link)
61. ↑ [2]
62. ↑ Arlene Eisenberg (1989). What to Expect the First Year. Workman Publishing Company. ISBN 0894805770.
63. ↑ Spatz D (2006). "State of the science: use of human milk and breast-feeding for vulnerable infants". J Perinat Neonatal Nurs. 20 (1): 51–5. PMID 16508463.
64. ↑ Tully DB, Jones F, Tully MR (2001). "Donor milk: what's in it and what's not". J Hum Lact. 17 (2): 152–5. PMID 11847831.CS1 maint: Multiple names: authors list (link)
65. ↑ Grunberg R (1992). "Breastfeeding multiples: Breastfeeding triplets". New Beginnings. 9 (5): 135–6.
66. ↑ Australian Breast Feeding Association: Breastfeeding triplets, quads and higher
67. ↑ Association of Radical Midwives: Breastfeeding triplets
68. ↑ Flower H (2003). Adventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond. La Leche League International. ISBN 978-0912500973.
69. ↑ La Leche League International. "Report from the Board: Update from the LLLI Board of Directors". LLL. Retrieved 2007-08-02.
70. ↑ Alcorn K (2004-08-24). "Shared breastfeeding identified as new risk factor for HIV". Aidsmap. Retrieved 2007-04-10.
71. ↑ Guardian Unlimited: Not your mother's milk
72. ↑ Jennifer Baumgardner, Breast Friends, Babble, 2007
73. ↑ http://www.aafp.org/afp/20020501/1845.html Aapf.org
74. ↑ http://www.fda.gov/bbs/topics/ANSWERS/ANS00594.html FDA.gov

## References

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* Hausman, Bernice (2003). Mother's Milk: Breastfeeding Controversies in American Culture. New York: Routledge. ISBN 0-415-96656-6.
* Huggins, Kathleen (1999). The Nursing Mother's Companion (4th ed. ed.). Harvard Common Press. ISBN 1-55832-152-7.CS1 maint: Extra text (link)
* Mohrbacher N, Stock J (2003). The Breastfeeding Answer Book. La Leche League International, Schaumburg, Illinois. ISBN 0-912500-92-1.
* Stuart-Macadam P, Dettwyler K (1995). Breastfeeding: Biocultural Perspectives (Foundations of Human Behavior). Aldine de Gruyter. ISBN 0-202-01192-5.
* Leeson C, Kattenhorn M, Deanfield J, Lucas A (2001). "Duration of breast feeding and arterial distensibility in early adult life: population based study". BMJ. 322 (7287): 643–7. doi:10.1136/bmj.322.7287.643. PMID 11250848.CS1 maint: Multiple names: authors list (link)
* Health risks of not breastfeeding US Department of Health & Human Services

## External links

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| Wikimedia Commons has media related to Breastfeeding.

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* High Quality Breastfeeding Online Guide
* Template:DMOZ
* Human Milk Secretion: An Overview from the US National Institute of Health

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