ON AIR
Breastfeeding older children
Breastfeeding research about feeding older children
Is it of benefit to children, or just a way for mothers to continue to feel needed?
Ann Sinnott wrote a book on the subject (Breastfeeding Older Children, Free Association Books, 2009), which has the largest survey on the subject, covering more than 2000 mothers and 4000 children, from 48 different countries from all continents. Her research has concluded, like many other organisations looking into the subject that is for the benefit of the child, not the mother.
Toddlers breastfeed for many of the same reasons infants breastfeed: for nutrition, comfort, security, for a way to calm down and for reassurance. Mothers breastfeed their toddlers for many of the same reasons they breastfeed their infants: they recognise their children’s needs, they enjoy the closeness, they want to offer comfort, and they understand the health benefits.
Click the titles listed below to read the details on each subject or just read the full article.
Extended Breastfeeding Facts, Benefits and Research
Although most will now see visions of Little Britain’s David Walliams saying “not bitty later, bitty now” upon hearing the words “Breastfeeding Older Children” - the truth is, the numbers of mothers who partake in extended breastfeeding, or sustained breastfeeding, are on the rise. However western culture views breasts as sexual objects. In actual fact, the worldwide average age of weaning is 4.2 years.
Extended Breastfeeding is seen as feeding a child over the age of one, although in Western countries, this is could also be seen as over the age of 6 months. This is against World Health Organistation (WHO) recommendations that “All mothers should have access to skilled support to initiate and sustain exclusive breastfeeding for 6 months and ensure the timely introduction of adequate and safe complementary foods with continued breastfeeding up to two years or beyond.” - Global Stratergy for Infant and Young Child Feeding.
There is a common myth, that after 6 months, and definitely after a year, that breastmilk has no value to a child. But it is known that breastmilk will continue to have valuable vitamins, calcium and antibodies for as long as it is produced. The immune factors of breastmilk are actually in greater amounts in the second year of life, compared to the first year. Breastmilk also contains special growth factors, helping to develop not only a strong and healthy immune system, but help the brain, gut and other organs to develop and mature. This myth is usually told by mothers who either did not breastfeed, or gave up breastfeeding their children at an earlier age. Is this guilt or envy, some experts say that it is both. It also shows how ill-informed our culture has become. The Director General of the Health Department in Pakistan claims that 22 percent of infant deaths could be prevented if the mothers had breastfed for at least the first six months of the baby’s life, even more if they breastfed longer.
The Breastfeeding Magazine (www.breastfeeding-magazine.com) lists the following extended breastfeeding facts about Extended Breastfeeding:
• Cancer risk decreases the longer a mother breast feeds.
• After 6 months breast feeding is usually a pleasure - Mothers and babies are comfortable and are in sync. Why give up before then?
• Studies have shown that kids who are breastfed grow up to be more secure and self reliant than their bottle-fed peers.
The Breastfeeding Magazine also lists the following benefits to both child and mother:
• Toddlers get energy, protein, calcium, essential fatty acids, vitamins A, B12 and C from breast milk. They also get 76% of their folate requirements from nursing.
• Breastfeeding beyond the age of one protects the toddler from illness. Studies are showing that toddlers who nurse between the ages of 16 and 30 months have fewer illnesses, and those they do get it ill, it lasts a shorter period of time.
• When a child develops an illness like diarrhea or fever, the appetite usually decreases. Children in these circumstances are still willing to nurse, preventing dehydration and providing nutrition during the course of the illness.
• The World Health Organization states that “a modest increase in breastfeeding rates could prevent up to 10% of all deaths of children under the age of five. Breastfeeding plays an essential and sometimes underestimated role in the treatment and prevention of childhood illness.”
• Toddlers who nurse develop fewer allergies and cases of asthma.
• Nursing toddlers do better in school later. Breastfeeding builds the brain.
• Toddlers that breastfeed make better adjusted children. Their needs are met physically and emotionally through breastfeeding and the close relationship between mom and child. They develop their sense of independence, secure in who they are.
• While short-term breastfeeding offers some protection for children from leukemia, sustained breastfeeding gives them an even greater reduced risk.
• The longer a woman breastfeeds, the more protection she has from breast cancer. Studies show a distinct correlation between how many years are spent breastfeeding and increasing protection from breast cancer.
• Extended breastfeeding reduces the chances of developing ovarian cancer.
• Breastfeeding reduces the chances of developing uterine cancer.
• Breastfeeding reduces the chances of developing endometrial cancer.
• Breastfeeding reduces the chances of developing rheumatoid arthritis.
• Breastfeeding helps moms lose weight with less effort.
• Breastfeeding helps protect women from osteoporosis. While nursing, a mother may lose 1 to 2% of bone density. This loss is gained back after weaning, often to the mother’s benefit as an increased amount is added to the bones than was lost.
• Sustained breastfeeding delays fertility in many women by suppressing ovulation.
On the Australian Breastfeeding Association website, Karen Mortensen (Grad Dip (Counselling), IBCLC, NMAA Counsellor) asks the question “What does the research say about Sustained Breastfeeding?” and lists her findings:
Sustained breastfeeding provides valuable nutritional and immunological benefits (Lawrence & Lawrence 1999). Goldman and Goldblum (1983) showed that immunologic components of breastmilk are maintained into the second year of lactation and are still providing protection to the infant. The data showed that the production of IgA antibodies operates throughout lactation. Gulick found breastfeeding was inversely associated with episodes of illness in infants. He found breastfed infants had less episodes of illness as toddlers between the ages of 16 and 30 months. Human milk continues to provide valuable nutrition and immuno-protection beyond the baby’s first year. Objections to continued nursing are principally based on custom in addition to a lack of knowledge about the ongoing value of breastmilk. Lawrence states that while research documents protection and improved development for at least two years there is also a positive emotional and bonding experience with long-term nursing. “Thousands of normal healthy children are breastfed until they are three or four years old” (p 346).
Enhanced cognitive development has been shown to be positively associated with duration of breastfeeding. Rogan and Gladen (1993) tested children, some of whom were breastfed up to two years, for IQ and school grades. The results showed a dose dependent relationship between higher score and duration of breastfeeding. Horwood et al (2001) studied 214 very low-birthweight children who were assessed for cognitive ability at seven to eight years. Mothers’ retrospective recall of breastmilk feeding was cross checked with hospital records and child health record books were also used to aid maternal recall. Using the revised Wechsler Intelligence Scale the authors found a six point advantage in verbal IQ for infants who received breastmilk for eight months or more compared with those who did not receive breastmilk. They also found a clear and significant dose response relationship even after controlling for confounding factors. This study points to the growing body of evidence for the beneficial effect of breastmilk on cognitive development.
Kries (1999) in a cross-sectional study found a clear, inverse, dose-response relationship between the duration of breastfeeding and incidence of obesity and overweight. Longer breastfeeding duration was a significant protective factor, attributed to the composition of breastmilk rather than other lifestyle factors which were adjusted for. In a study of affluent United States infants, those who stopped breastfeeding before 18 months gained more weight from 12 to 24 months, but were the same in length, in comparison with the infants who breastfed for longer than 18 months (Dewey et al 1995). Whether or not this higher weight gain is an advantage is debatable in affluent populations where there is already a high number of overweight children. In a recent report, type-one diabetes was linked with higher weight gains during the first year of life (Bruining 2000). In the isolated situation where inadequate weight gain is a concern, encouraging greater consumption of good quality complementary foods is advisable rather than ceasing breastfeeding (WHO 1998).
Another study of mothers who breastfed for 12 months or more showed a more relaxed attitude to feeding their toddlers and they were less likely to exhibit high levels of control over when and what their toddlers ate and drank. The increased intake by toddlers of a variety of foods as well as the fact that these toddlers were leaner but taller was attributed to the maternal style of feeding which accompanied longer-term breastfeeding (Fisher et al 2000). The Toowoomba Children’s Nutrition Study (1999) showed that breastfed infants consumed significantly less full-cream milk, soft drink, cordial and soy drinks at 12 months of age.
The study by Marangoni et al (2000) showed that concentrations of arachidonic and docosahexaenoic as well as polyunsaturated fatty acids remain stable in breastmilk through the period of breastfeeding from one month to 12 months. Research by Kent et al 1999 also showed that while breastmilk volume declined it remained a substantial part of the toddlers diet. They also showed that milk production responds to infant demand throughout lactation. 500 ml/day of breastmilk can provide about one-third of the protein and energy, 45% of vitamin A, and almost all of the vitamin C that a child needs in the second year of life (WHO 1993).
Backstrom et al (1999) followed a group of pre-term infants and found that while mineral supplementation in the short term showed better bone mineralisation, this advantage was not sustained long term. The greater the amount of breastmilk infants received, the greater bone mineral acquisition in the long term. The periods of lactation studied went up to 12 months. (This was considered a long period of lactation by the authors.) The authors recommend a long period of breastfeeding to optimise long-term bone mineral acquisition.
Breastfeeding promotes mother-child attachment and bonding which in turn may lead to a greater sense of security for the child (Fergusson & Woodward 1999; Ainsworth 1973). The emotional benefits of breastfeeding the older child were emphasised by mothers who cite them as being the most important reasons for continuing to breastfeed. (Kendall-Tackett & Sugarman 1995; Fergusson & Woodward 1999; Hills-Bonczyk 1994). Breastfeeding is both a biological and a cultural activity that is modified by a wide variety of beliefs. Beliefs about the nature of human infancy, the relationship of mother and child, mothers’ work expectations, and ideas about personal independence and autonomy will affect the breastfeeding relationship (Dettwyler 1995). Reasons for weaning early can include a mistaken belief that a child will become too dependent and have difficulty separating from the mother. Ainsworth’s (1973) research showed that a secure attachment to the mother through breastfeeding enabled children to form attachments to others and to become more independent than a comparable group of bottle-fed infants. In Fergusson and Woodward’s (1999) study those children breastfed for a longer duration tended to perceive their mothers as more caring and less over-protective. Mothers in this study who elected to breastfeed were more likely to come from advantaged socio-economic backgrounds; however, even after adjusting for these factors, adolescent perceptions of higher maternal care were significantly associated with duration of breastfeeding.
Sustained breastfeeding also provides many benefits to the mother including lower risk of anaemia, longer periods of lactational amenorrhea, reduced risk of osteoporosis and breast cancer, promotion of postpartum weight loss and sense of personal achievement.
Research by Sinigaglia et al (1996) found that women with a median lactation of 22 months were not significantly different in bone mineral density to other matched groups who had either lactated for a shorter time or not at all. Melton et al in 1993 studied a random sample of 304 white women in the United States, showed that breastfeeding beyond eight months was associated with greater bone mineral density in later life. Reduced risk for osteoporosis has also been found in other studies with even shorter durations of breastfeeding.
Studies from China and Japan have previously shown a reduced risk for breast cancer. More recently Zheng et al (2000) showed that prolonged breastfeeding significantly reduced breast cancer risk, especially for those with a total lactation duration greater than 72 months. This duration of lactation has not been studied in Western populations leading the authors to believe that this is the reason why such a strong protective effect has not been apparent in Western studies.
Mothers find-long term breastfeeding rewarding and natural. They enjoy the close bond that develops with their child; the main difficulty was being ’strong’ in the face of negative reactions. These were the main themes that emerged from a prospective longitudinal study of 82 primiparas examining attitudes and reasons for long-term breastfeeding (Hills-Bonyczyket et al 1994).
In many countries of the world breastfeeding does continue well into childhood, two to three years and longer. For example by about two years of age a third or more of the children in sub-Saharan Africa were still breastfeeding. In five out of seven Asian countries studied, 50% or more were still being breastfed at two years; in Bolivia, Peru and Guatemala 40% of children; and in Indonesia 63% of children are still breastfed at this age (Haggerty & Rutstein 1999). In the developing nations, sustained breastfeeding is vital to a child’s health and growth (Prentice 1991). At one time extended lactation was considered a risk factor for malnutrition and growth stunting. However subsequent research has confirmed that these findings were due in part to reverse causality, as mothers continued to breastfeed a child who was sick or malnourished, while healthy strong children tended to be weaned a little earlier (Simonden & Simonden, 1998). In Peru mothers will relactate if a recently weaned child falls sick (Marquis et al 1997). Fawzi et al (1998) found that child undernutrition had no association with prolonged breastfeeding, only with poverty and illiteracy. In rural China exclusive breastfeeding for up to 12 months, combined with extended breastfeeding, resulted in good growth and nutritional status (Taren & Chen 1993; Prentice 1994). In developing countries prior to the Innocenti Declaration and the launch of the Baby Friendly Hospital Initiative, campaigns to encourage breastfeeding for two years were successful in increasing breastfeeding rates. As the focus shifted to the importance of exclusive breastfeeding in the early months, breastfeeding the older child received less attention. In developed countries also, international agencies, doctors and academics have not strongly advocated sustained breastfeeding beyond 12 months, nor do training courses for medical and nursing students pay enough attention to the management of sustained breastfeeding (Haider, WHO Report 2000). Kathryn Dewey (WHO Report, 2000) points out that while improved complementary foods along with promotion of sustained breastfeeding show good growth effects, recommendations need to be cautious about amounts of complementary foods to avoid displacement of breastmilk in the infant’s diet. This caution applies to Australia as when solids are introduced to an infants diet they often replace rather than complement breastfeeding. This may be quite deliberate with some mothers as they wish to wean their babies, while other mothers may find their infants weaning prematurely.
Anthropologist Katherine Dettwyler (1995) posed the question of what would be the natural age of weaning, if we were free from cultural beliefs. By looking at age of weaning in other large mammals, particularly primates which are closest to humans, Dettwyler estimated the natural age of weaning to be around two and a half to seven years of age. The markers for weaning in large mammals and primates include quadrupling of birthweight; attainment of one-third adult weight; adult body size; gestation length; and dental eruption. In humans, quadrupling of birthweight occurs at around 27 months for males and around 30 months for females. Dettwyler also concludes that while improved sanitation, vaccines and antibiotics can compensate for not breastfeeding to some degree, the physical, cognitive and emotional needs of the young child still exist.
To sum up, it would seem that further research into this area is desperately needed - research into the psychological, the cognitive and the physical benefits for both child and mother. The need for more openess on the subject of Extended Breastfeeding (and Breastfeeding in general) is also greatly needed in Western cultures. In the UK, many mothers are felt guilt-tripped into breastfeeding, hence why they do not continue after 6 weeks. However, there are women who do feel guilty about stopping, and this seems to be down to a lack of research, a lack of openess and possibly a lack of support.
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