Full-term Breastfeeding

AIMS Journal, 2013, Vol 25 No 3

Katherine Dettwyler discusses how biological norms are overwritten by culture

I have spent my career as a biocultural anthropologist researching, pondering, observing, and writing about breastfeeding and weaning.

My experiences have included:

• conducting research for almost three years in Mali, West Africa – a country where everyone breastfeeds, whenever and wherever they wish, and no one thinks of breasts as being sexual;
• conducting research on what would be a 'natural age of weaning' for humans as a species, using the term 'weaning' to mean the very end of any breastfeeding;
• conducting research on women in the US who breastfeed for three years or longer;
• providing scientific backup for mothers to use in court cases where they are either being accused of sexual abuse for breastfeeding their older children, or are struggling to maintain their milk supply and breastfeeding relationship in the face of shared custody or extended visitation orders;
• breastfeeding my own three children, the longest for five and a half years, in the US and watching my daughter Miranda breastfeed my grandchildren.

Over this stretch of time – more than 30 years already – I have seen a number of changes in how breastfeeding is perceived, how it is supported (or not) by society, and how it is practised. Breastfeeding research has taught us so much over the past three decades. We know that breastfeeding is essential to the normal development of a child's gut, immune system, eyes, and brain. We know that breastmilk is full of factors that help protect a child from illness and help her recover if she does get sick. We know that formula-fed children have higher rates of death in childhood, higher rates of many diseases throughout life, and lower IQs than their comparable breastfed counterparts. We know that mothers who breastfeed gain from the experience, in terms of their own health (including lower rates of reproductive cancers and better bone density) but perhaps, most importantly, in the strong bond they develop with their child through the presence of high levels of the mothering hormones prolactin and, especially, oxytocin in their bloodstream.

My own work on what I call 'a natural age of weaning' is based on comparing life-history variables in the nonhuman primates (our closest relatives in the animal kingdom) and exploring the relationship between such variables and the typical age of weaning for the species. The life-history variables include length of pregnancy, rates of growth in childhood, dental eruption patterns, age at sexual maturity, weight of adult females, and others. Taken together, these data suggest that for human children – who have relatively huge brains, grow very slowly, and end up as large-bodied adults – the natural length of breastfeeding is between two and a half and seven years (adding solids at around six months of age).

But what are we, as healthcare providers and/or as parents, to make of these research findings? Must everyone breastfeed for two and a half years? For seven years? What does it mean to say that two and a half to seven years is normal or typical for our species? If I only breastfed my child for one year, or only for six months, does that make me a bad mother? If I want to let my child self-wean and they're still going strong at four years, what do I tell my disapproving family members, friends, neighbours, and even random strangers who question my motives? How do I balance my child's need to continue feeding with my ex-partner's desire to have long visitations, including overnights?

I'd like to make several points. First, I think any breastfeeding is better than no breastfeeding. If, for whatever reason(s), a mother breastfeeds for six months, or six weeks, or six days, that's still wonderful. It's not a competition to see who can feed the longest, or who can persist through the most difficult obstacles and setbacks. I nursed one of my children for only four months due to serious complications on both my part and his. I breastfed the other two much, much longer. We need to educate healthcare professionals and mothers about the importance of breastfeeding, but we also need to work to provide all mothers with the information and support they need to be able to breastfeed as long as they wish. That means better prenatal care, more humane childbirth experiences, skin-to-skin immediately after birth with no separation, well-trained lactation consultants to help in the first days if needed, and sufficient maternity leave. It also means making sure that mothers know that they need to breastfeed early and often (several times an hour in the first weeks and months), around the clock, and let their babies just 'hang out at the breast' even when they are not actively breastfeeding. Breastfeeding is about way more than just getting food into the baby.

Second, we need to remember that breastfeeding is a relationship between two people, both of whose needs and preferences should be considered. Not all mothers will want to, or be available to, breastfeed for several years. A mother may have postponed childbearing and want to fit in another child before she gets too close to menopause, and whilst it is not necessary to cease breastfeeding for another pregnancy, some women find that their fertility does not return until their baby is weaned. A mother may want to return to a job that involves extensive travel or a significant time commitment. In addition, not all children will want to breastfeed for several years. Some children will be happy to feed for 4- 5-6-7 years, while others seem to lose interest on their own before the age of three. We must find a way to balance the offer of information and support to continue breastfeeding with the needs of a particular mother-child pair to stop for any number of reasons, and not put mothers on the spot to justify their decisions.

Third, we need to understand that when a mother is breastfeeding an older child, she is behaving in a manner that is perfectly normal for a member of our species. Breastfeeding a 4-5-6-7 year old is quite different from breastfeeding a newborn or young infant. The child may breastfeed first thing in the morning and last thing before naps and bedtime. The child may breastfeed more when they are cutting teeth, or when they are stressed, sick, injured, or frightened. They may breastfeed only once every few days for the last months of their breastfeeding experience. No matter how old the child, mother's milk provides her child's diet with an excellent source of protein, carbohydrates, and fats. The milk doesn't suddenly lose its nutritional value when the child reaches a specific age! No matter how old the child, mother's milk provides immune factors that help build and augment the child's own developing immune system. No matter how old the child, the act of being held in her mother's warm loving arms, hearing her heartbeat and her voice, smelling her familiar smell, and the very act of suckling itself help to relieve stress and pain, lower the child's blood pressure and heart rate, and provide immense emotional comfort. Additionally, the act of breastfeeding provides a boost of oxytocin to the mother, helping her remain calm and loving in the face of whatever challenges life is throwing at her that day.

Fourth, we need to understand that 'full-term breastfeeding' (or 'extended breastfeeding', or 'biological breastfeeding', or whateveryou want to call it) does not involve sexual feelings on the part of either mother or child – it is not sexual in any way, shape, or form. It is only in a few cultures around the world – regrettably mostly Western ones – that breasts are viewed as sexual objects and manipulated during sexual activity. The standard Western obsession with breasts as sex objects is actually quite strange – it is not found in any other mammals, and not found in the majority of the world's cultures. A child will not 'suddenly realise' that he is having sex with his mother, as some critics have suggested. A mother does not breastfeed a five year old for sexual pleasure – far from it. There is no evidence to suggest that breastfeeding a child, even for seven years or longer, is in any way harmful to the child – not emotionally, not nutritionally, not physically.

Expert recommendations on how long children should breastfeed include the following:

• Exclusive breastfeeding (nothing other than breastmilk) for the first six months, then slowly adding appropriate solid foods.¹
• Continued breastfeeding for a minimum of one year² or a minimum of two years.³
• Continued breastfeeding beyond one to two years for as long as mother and child wish.⁴

Fifth, we need to understand that there is no need for a child to give up breastfeeding before she is ready in order to facilitate a deep bond with a parent who is no longer living full-time with the mother and child. These two options are often juxtaposed as though it must be either/or, when in reality, it is quite possible for the breastfeeding relationship to be protected while still allowing the other parent to have plenty of time with the child. Both relationships are important. It may require flexibility and compromise, and working together for the benefit of the child, but it can be done.

Ideally, the non-breastfeeding parent would have several opportunities to spend time with the child each and every day. When the child is younger, these should not be for too long a time at a stretch, so that the child is not upset and so that the mother doesn't have to pump, or the other parent provide formula. As the child gets older and is eating solids, these visits might extend to several hours' duration. Still, when the child expresses a desire to be with his mother to breastfeed to sleep for a nap, or because he has fallen and scraped his knee, or whatever, he should be returned to his mother. Most children will continue to breastfeed to sleep and breastfeed several times during the night until they have finished cutting their baby teeth around two years. Overnight visits should be based on the child's needs, their temperament, and their patterns of breastfeeding. Most of the night, the child will be asleep, so it isn't as though anyone is really missing out if overnight visits are postponed until the child is three or four years of age or older. As long as the child continues to breastfeed, both parents should avoid planning excursions that would separate mother and child for more than a couple of days, even if the child is four or five or six years of age. A strong bond with the nonbreastfeeding parent is very important for a child throughout their life, but there is no reason why it need require that the mother and child stop breastfeeding.

Kathy Dettwyler

References

1. Royal College of Paediatrics & Child Health (2011) Position Statement - Breastfeeding. www.rcpch.ac.uk/system/files/protected/ page/RCPCH%20breastfeeding%20PS%20FINAL.pdf
2. American Academy of Pediatrics (2012 ) Policy Statement – Breastfeeding and the Use of Human Milk. pediatrics.aappublications.org/content/129/3/e827.full#content-block
3. World Health Organization (2013) Infant and Young Child Feeding Fact Sheet. www.who.int/mediacentre/factsheets/fs342/en/index.html
4. Centers for Disease Control and Prevention(2013) Breastfeeding FAQs. www.cdc.gov/breastfeeding/faq/