Extended Breastfeeding

Recently, the topic of extended breastfeeding, or breastfeeding past infancy, has come up among my friends and acquaintances. 

Many pediatricians tell mothers that there is no benefit to breastfeeding after 6 months. They say breast milk is no longer nutritious after 6 months, or provides no immunological benefits, or that a nursing toddler will be socially mal-adjusted.

In the most recent case occurrence, for me, it was a husband telling his wife that breastfeeding their 18 month old (not even 2 years old!) would never teach him to be soothed by anything but the breast as he grows older. Also, daddy didn't feel like sharing mommy's breasts anymore and he wanted them back. Yes, this really happens.

A typical response to a mother who is nursing her toddler is "eww gross" and "if he/she is old enough to ask for it, he/she is too old to nurse."  If you have the urge to say or think this, I encourage you to continue reading. 

Below, I am going to provide what I know and have found to support extended breastfeeding, especially of toddlers.

Photo via tendresses lactees

The information comes from Breastfeed a Toddler - Why on Earth? by Dr. Jack Newman, Nursing After the First Year from Kellymom.com (which lists a great deal of references), and Anthropologist Katherine Dettwyler's A Natural Age of Weaning.

Now that more and more women are breastfeeding their babies, more and more are also finding that they enjoy breastfeeding enough to want to continue longer than the usual few months they initially thought they would. UNICEF has long encouraged breastfeeding for two years and longer, and the American Academy of Pediatrics is now on record as encouraging mothers to breastfeed at least one year and then for as long after as the mother and baby desire. Even the Canadian Paediatric Society, in its latest feeding statement acknowledges that women may want to breastfeed for two years or longer and Health Canada has put out a statement similar to UNICEF’s. 

Breastfeeding to 3 and 4 years of age has been common in much of the world until recently in human history, and it is still common in many societies for toddlers to breastfeed. (Newman)

A survey of 64 "traditional" studies done prior to the 1940s showed a median duration of breastfeeding of about 2.8 years, but with some societies breastfeeding for much shorter, and some for much longer. It is meaningless, statistically, to speak of an average age of weaning worldwide, as so many children never nurse at all, or their mothers give up in the first few days, or at six weeks when they go back to work. It is true that there are still many societies in the world where children are routinely breastfed until the age of four or five years or older, and even in the United States, some children are nursed for this long and longer. In societies where children are allowed to nurse "as long as they want" they usually self-wean, with no arguments or emotional trauma, between 3 and 4 years of age. (Dettwyler)

Breastfeeding your child past infancy is NORMAL (kellymom):

• The American Academy of Pediatrics recommends that "Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child... Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother... There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer." (AAP 2005)

• The American Academy of Family Physicians recommends that breastfeeding continue throughout the first year of life and that "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." They also note that "If the child is younger than two years of age, the child is at increased risk of illness if weaned." (AAFP 2008)

• A US Surgeon General has stated that it is a lucky baby who continues to nurse until age two. (Novello 1990)

• The World Health Organization emphasizes the importance of nursing up to two years of age or beyond (WHO 1993, WHO 2002).

• Scientific research by Katherine A. Dettwyler, PhD shows that 2.5 to 7.0 years of nursing is what our children have been designed to expect (Dettwyler 1995).

Anthropologist Kathy Dettwyler compared primate biology and behavior, particularly gorillas and chimpanzees (who share 98% of our genes) with human biology and behavior to try to come up with what a "natural" weaning age, outside of cultural rules, might be. 

She writes:

• It has been common for pediatricians to claim that length of gestation is approximately equal to length of nursing in many species, suggesting a weaning age of 9 months for humans. However, this relationship turns out to be affected by how large the adult animals are -- the larger the adults, the longer the length of breastfeeding relative to gestation. For chimpanzees and gorillas, the two primates closest in size to humans and also the most closely genetically related, the relationship is 6 to 1. That is to say, they nurse their offspring for SIX times the length of gestation (actually 6.1 for chimps and 6.4 for gorillas, with humans mid-way in size between these two). In humans, that would be: 4.5 years of nursing (six times the 9 months of gestation).

• It has been common for pediatricians to claim that most mammals wean their offspring when they have tripled their birth weight, suggesting a weaning age of 1 year in humans. Again though, this is affected by body weight, with larger mammals nursing their offspring until they have quadrupled their birth weight. In humans, quadrupling of birth weight occurs between 2.5 and 3.5 years, usually.

• In a group of 21 species of non-human primates (monkeys and apes) studied by Holly Smith, she found that the offspring were weaned at the same time they were getting their first permanent molars. In humans, that would be: 5.5-6.0 years. 

Her conclusion: the natural age of weaning for humans would be somewhere between 2.5 to 7 years.

Why should breastfeeding continue past six months?

Because mothers and babies often enjoy breastfeeding a lot. Why stop an enjoyable relationship? And continued breastfeeding is good for the health and welfare of both the mother and child.

(More on why mothers nurse their children into toddlerhood)

 

But it is said that breastmilk has no value after six months.

Perhaps this is said, but it is patently wrong. That anyone (including paediatricians) can say such a thing only shows how ill-informed so many people in our society are about breastfeeding. Breastmilk is, after all, milk. Even after six months, it still contains protein, fat, and other nutritionally important and appropriate elements which babies and children need. (Newman)

Breastfeeding children benefit NUTRITIONALLY (Kellymom):

• Although there has been little research done on children who breastfeed beyond the age of two, the available information indicates that breastfeeding continues to be a valuable source of nutrition and disease protection for as long as breastfeeding continues.

• "Human milk expressed by mothers who have been lactating for >1 year has significantly increased fat and energy contents, compared with milk expressed by women who have been lactating for shorter periods. During prolonged lactation, the fat energy contribution of breast milk to the infant diet might be significant."
  -- Mandel 2005

• "Breast milk continues to provide substantial amounts of key nutrients well beyond the first year of life, especially protein, fat, and most vitamins."
  -- Dewey 2001

• In the second year (12-23 months), 448 mL of breastmilk provides:
  • 29% of energy requirements
  • 43% of protein requirements
  • 36% of calcium requirements
  • 75% of vitamin A requirements
  • 76% of folate requirements
  • 94% of vitamin B₁₂ requirements
  • 60% of vitamin C requirements
  -- Dewey 2001

• Studies done in rural Bangladesh have shown that breastmilk continues to be an important source of vitamin A in the second and third year of life.
  -- Persson 1998

• It's not uncommon for weaning to be recommended for toddlers who are eating few solids. However, this recommendation is not supported by research. According to Sally Kneidel in "Nursing Beyond One Year" (New Beginnings, Vol. 6 No. 4, July-August 1990, pp. 99-103.):
  Some doctors may feel that nursing will interfere with a child's appetite for other foods. Yet there has been no documentation that nursing children are more likely than weaned children to refuse supplementary foods. In fact, most researchers in Third World countries, where a malnourished toddler's appetite may be of critical importance, recommend continued nursing for even the severely malnourished (Briend et al, 1988; Rhode, 1988; Shattock and Stephens, 1975; Whitehead, 1985). Most suggest helping the malnourished older nursing child not by weaning but by supplementing the mother's diet to improve the nutritional quality of her milk (Ahn and MacLean. 1980; Jelliffe and Jelliffe, 1978) and by offering the child more varied and more palatable foods to improve his or her appetite (Rohde, 1988; Tangermann, 1988; Underwood, 1985).

Breastmilk still contains immunologic factors that help protect the child even if he is 2 or older. In fact, some immune factors in breastmilk that protect the baby against infection are present in greater amounts in the second year of life than in the first. This is, of course as it should be, since children older than a year are generally exposed to more infections than young babies. Breastmilk still contains special growth factors that help the immune system to mature, and which help the brain, gut, and other organs to develop and mature.

It has been well shown that children in daycare who are still breastfeeding have far fewer and less severe infections than the children who are not breastfeeding. The mother thus loses less work time if she continues breastfeeding her baby once she is back at her paid work. (Newman)

I have heard that the immunologic factors in breastmilk prevent the baby from developing his own immunity if I breastfeed past six months.

This is untrue; in fact, this is absurd. It is unbelievable how so many people in our society twist around the advantages of breastfeeding and turn them into disadvantages. We give babies immunizations so that they are able to defend themselves against the real infection. Breastmilk also helps the baby to fight off infections. When the baby fights off these infections, he becomes immune. Naturally.(Newman)

Breastfeeding children are SICK LESS OFTEN (Kellymom):

• The American Academy of Family Physicians notes that children weaned before two years of age are at increased risk of illness (AAFP 2001).

• Nursing toddlers between the ages of 16 and 30 months have been found to have fewer illnesses and illnesses of shorter duration than their non-nursing peers (Gulick 1986).

• "Antibodies are abundant in human milk throughout lactation" (Nutrition During Lactation 1991; p. 134). In fact, some of the immune factors in breastmilk increase in concentration during the second year and also during the weaning process. (Goldman 1983, Goldman & Goldblum 1983, Institute of Medicine 1991).

• Per the World Health Organization, "a modest increase in breastfeeding rates could prevent up to 10% of all deaths of children under five: Breastfeeding plays an essential and sometimes underestimated role in the treatment and prevention of childhood illness." [emphasis added]

Breastfeeding children have FEWER ALLERGIES (Kellymom):

• Many studies have shown that one of the best ways to prevent allergies and asthma is to breastfeed exclusively for at least 6 months and continue breastfeeding long-term after that point.
  
  Breastfeeding can be helpful for preventing allergy by:
  1. reducing exposure to potential allergens (the later baby is exposed, the less likely that there will be an allergic reaction),
  2. speeding maturation of the protective intestinal barrier in baby's gut,
  3. coating the gut and providing a barrier to potentially allergenic molecules,
  4. providing anti-inflammatory properties that reduce the risk of infections (which can act as allergy triggers).

It is interesting that formula company marketing pushes the use of formula (a very poor copy of breastmilk) for a year, yet implies that breastmilk (which formula tries unsuccessfully to copy) is only worthwhile for 6 months or even less (“the best nutrition for newborns”). Too many health professionals have taken up the refrain. (Newman)

But I want my baby to become independent

And breastfeeding makes the toddler dependent? Don’t believe it. The child who breastfeeds until he weans himself (usually from 2 to 4 years), is usually more independent, and, perhaps, more importantly, more secure in his independence. He has received comfort and security from the breast, until he is ready to make the step himself to stop. And when a child makes that step himself, he knows he has achieved something, he knows he has moved ahead. It is a milestone in his life of which he is proud.

Often we push children to become ‘independent” too quickly. To sleep alone too soon, to wean from the breast too soon, to do without their parents too soon, to do everything too soon. Don’t push and the child will become independent soon enough. What’s the rush? Soon they will be leaving home. You want them to leave home at 14? If a need is met, it goes away. If a need is unmet (such as the need to breastfeed and be close to his mother), it remains a need well into childhood and even the teenage years.

Breastfeeding children are WELL ADJUSTED SOCIALLY (kellymom):

• According to Sally Kneidel in "Nursing Beyond One Year" (New Beginnings, Vol. 6 No. 4, July-August 1990, pp. 99-103.):
  
  "Research reports on the psychological aspects of nursing are scarce. One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers' and teachers' ratings of social adjustment in six- to eight-year-old children (Ferguson et al, 1987). In the words of the researchers, 'There are statistically significant tendencies for conduct disorder scores to decline with increasing duration of breastfeeding.'"

• According to Elizabeth N. Baldwin, Esq. in "Extended Breastfeeding and the Law":
  "Breastfeeding is a warm and loving way to meet the needs of toddlers and young children. It not only perks them up and energizes them; it also soothes the frustrations, bumps and bruises, and daily stresses of early childhood. In addition, nursing past infancy helps little ones make a gradual transition to childhood."

• Baldwin continues: "Meeting a child's dependency needs is the key to helping that child achieve independence. And children outgrow these needs according to their own unique timetable." Children who achieve independence at their own pace are more secure in that independence then children forced into independence prematurely.

Possibly the most important aspect of breastfeeding a toddler is not the nutritional or immunologic benefits, important as they are. I believe the most important aspect of breastfeeding a toddler is the special relationship between child and his mother. Breastfeeding is a life-affirming act of love that repeats itself every time the child goes to the breast. This continues when the baby becomes a toddler. Anyone without prejudices, who has ever observed an older baby or toddler breastfeeding can testify that there is something special, something far beyond food, going on. A toddler will sometimes spontaneously, for no obvious reason, break into laughter while he is breastfeeding. His delight in the breast goes far beyond a source of food. And if the mother allows herself, breastfeeding becomes a source of delight for her as well, far beyond the pleasure of providing food. Of course, it’s not always great, but what is? And when it is, it makes it all so worthwhile.

And if the child does become ill or gets hurt (and they do as they meet other children and become more daring), what easier way to comfort the child than breastfeeding? I remember nights in the emergency department when mothers would walk their ill, non-breastfeeding babies or toddlers up and down the halls trying, often unsuccessfully, to console them, while the breastfeeding mothers were sitting quietly with their comforted, if not necessarily happy, babies at the breast. The mother comforts the sick child with breastfeeding and the child comforts the mother by breastfeeding. (Newman)

MOTHERS also benefit from breastfeeding past infancy (kellymom):

• Extended nursing delays the return of fertility in some women by suppressing ovulation.

• Breastfeeding reduces the risk of breast cancer. Studies have found a significant inverse association between duration of lactation and breast cancer risk.

• Breastfeeding reduces the risk of ovarian cancer.

• Breastfeeding reduces the risk of uterine cancer.

• Breastfeeding reduces the risk of endometrial cancer.

• Breastfeeding protects against osteoporosis. During lactation a mother may experience decreases of bone mineral. A nursing mom's bone mineral density may be reduced in the whole body by 1 to 2 percent while she is still nursing. This is gained back, and bone mineral density may actually increase, when the baby is weaned from the breast. This is not dependent on additional calcium supplementation in the mother's diet. 

• Breastfeeding reduces the risk of rheumatoid arthritis.

• Breastfeeding has been shown to decrease insulin requirements in diabetic women.

• Breastfeeding moms tend to lose weight easier.