Monday, November 15, 2010

Biocultural Approach to Breastfeeding

A Biocultural Approach to Breastfeeding

By Judithe A. Thompson
Gallipolis OH USA
From: NEW BEGINNINGS, Vol. 13 No. 6, November-December 1996, pp. 164-167

The biocultural model is useful for understanding breastfeeding and helping mothers to breastfeed. This model comes from anthropology, the social science which studies the relationship between biology and culture. Culture is defined by anthropologists as a people's way of life. Anthropologists consider humans to be biological organisms who constantly adapt to and modify their environment through culture.

For years, anthropologists have been collecting data on breastfeeding, but their findings have been largely ignored. Medical researchers studied every milk-producing mammal except for Homo sapiens. Anthropologists amassed enormous amounts of information about breastfeeding in human societies where the vast majority of women still breastfed, but until recently the opinion of the medical profession and of the general public about that data could be summarized as: "They are savages! What can we possibly learn from them?"

Timeless and Trustworthy

Anthropologists maintain that a process which has nourished human children since the earliest known humans must work and have advantages for mothers, infants, and the whole species. Such a process deserves respect. Successful lactation has usually meant survival for mammalian infants and an opportunity for them to grow and reproduce.

From the understanding of natural selection and adaptation has come a new area of study called evolutionary medicine (Nesse and Williams 1994). This new way of understanding health and illness, normality and abnormality, does not ask "What is wrong with this body?" but rather "What is it about being human that makes our bodies work the way they do?" A biocultural approach provides a powerful argument for why we nurse our babies, why our babies behave the way they do, and why mothers, babies, and fathers respond in certain ways to one another.

A biocultural approach is not a "back to nature" approach, it is the realization that culture and biology interact. Culture is what makes us human. Therefore, it is difficult to say what is "natural" for humans; culture plays so large a role in the decisions we make. For example, many mothers wonder how long they should nurse their babies and what the natural, or normal, age to wean is. An anthropologist would say that the timing of weaning is culturally defined and varies from one culture to another, ranging from birth (no breastfeeding) to approximately seven years. Sometimes there is also a gender difference; in some cultures boys are allowed to wean at a later age than girls. A similar question arises over the issue of tandem nursing. Bioculturally speaking, tandem nursing is uncommon. Instances of tandem nursing are extremely rare in the ethnographic literature.

Biocultural Support for Extended Nursing

Human milk is low in fat and protein. It is relatively high in carbohydrates, especially lactose. Lactose is the sugar that feeds our large brains. This explains why human milk has nearly twice as much lactose as cows' milk--cows are not expected to learn algebra! Like other primates, our infants are born relatively undeveloped, nurse frequently, and grow slowly (Stuart-Macadam and Dettwyler 1995). Primates nurse for a significant portion of their lives, partially because they have such long periods of infancy. In Breastfeeding: Biocultural Perspectives, Katherine Dettwyler says:

If humans weaned their offspring according to the primate pattern, without regard to beliefs and customs, most children would be weaned somewhere between 2.5 and 7 years of age....Age at quadrupling of birth weight, and six times the length at gestation, would be more accurate "rules of thumb" to use based on studies of large-bodied nonhuman primates....Sharply curtailing the duration of breastfeeding below what the human child has evolved to expect, has significant deleterious health consequences for modern humans.

Of course, humans do very little without regard to belief systems and customs. But this type of comparative study is helpful in countering the argument that children who nurse for an extended period of time are abnormal or that the mothers who continue to nurse them are encouraging dependency or are nursing for their own selfish reasons.

Cultural behavior can also be spectacularly non-adaptive. In 18th-century northern Europe, it was considered low-class to feed babies at the breast or even to feed them milk. Mozart considered it proper that his babies would be raised as he was--on sugar water. Four of his six children died in the first three years of life primarily because as infants they were fed mainly sugar water. The terrible health that took Mozart's life at a tragically young age may have been related in part to his "proper" Austrian diet as an infant.

Infant-Parent Co-Sleeping

Infant-parent co-sleeping is another issue where biological data clarifies a cultural pattern (Stuart-Macadam and Dettwyler 1995). Human infants are so immature and need to feed so frequently that it should surprise no one that most human infants, in most places and at most times, have slept with their mothers and often, with both parents. This was still the pattern in the United States until about 75-100 years ago when parents began to be warned about the dangers of sleeping with their babies. Popular infant care books warned about the danger of sexually stimulating the infant by putting him in bed with the mother. Some experts warned that sleeping with infants predisposed them to homosexuality.

The possibility of "overlaying," or inadvertently smothering the baby, was spoken of in very serious tones. Ironically, most of the parents who read these books had slept with their parents! The good sense of generations of families to ignore many of these reports has been supported by the work of anthropologist James McKenna. In a carefully planned and executed study, he observed mother-infant pairs sleeping in a laboratory environment. The laboratory environment, of course, is certainly not a normal way to sleep, but the ethical and logistical problems of observing mother-infant co-sleeping in the home makes the laboratory situation acceptable. The study was a controlled one which observed each mother-infant pair while both co-sleeping and sleeping separately. Along with other related studies, the research indicates:

In situations where mothers breastfeed, do not smoke, and keep their infants next to them for nocturnal sleep, SIDS death rates appear to be extremely low (Stuart-Macadam and Dettwyler 1995).

Co-Sleeping and SIDS

No one suggests that breastfeeding and/or sleeping with infants will entirely eliminate the complex causes of Sudden Infant Death Syndrome (SIDS), but research suggests that they are an important part of SIDS prevention. Because of their immature nervous systems, infants do "forget" to breathe at times. This may be related to death from SIDS. However, breastfed infants wake to nurse frequently, which probably keeps them from sleeping too long and too deeply to experience breathing problems.

Also, they have a tendency to imitate the breathing of nearby adults, which can keep them breathing. If they stop breathing for an instant the difference in breathing patterns may cause the mother or father to shift or move, which in turn may stimulate the baby to take a breath. Infants face their mother much of the time when they sleep with her and the exhaled carbon dioxide from her breath also may stimulate the baby to breathe.

There are some other hypothesized benefits of co-sleeping. If some women do vary in milk production capability (which seems likely), extending the part of the day when baby can breastfeed would increase the baby's intake. The same may apply to the intake of immune factors, since production of these probably also varies from woman to woman.

Culture-Induced Colic?

Infants sleep, but they also cry; some cry a great deal. Ronald Barr, a pediatrician at McGill University in Montreal, Quebec, Canada, has studied infant crying patterns. He discovered that infants with supposed colic do not cry more often or at particular times of the day; they just cry longer each time.

His suggestion is that such crying is normal but may be prolonged by modern practices such as longer intervals between feedings. Dr. Barr compared the results of a study done of the !Kung of South Africa with the typical ways in which American and European infants are handled and fed. The !Kung carry their babies with them constantly and feed the babies whenever they cry. Babies may be fed three or four times an hour for a minute or two at each feeding (Konner and Worthman 1980). In the United States, the average number of feedings in a day is seven and the average length of time between feedings is three hours. So Barr asked American mothers to carry their babies at least three hours a day. These mothers reported that their babies cried only half as long as babies whose mothers did not carry them for the extra three hours (Barr 1989).

Insufficient Milk Syndrome

Any mention of crying in breastfed infants brings us to an issue that has appeared recently (and sensationally) in the popular press: insufficient milk. A common reason for discontinuing breastfeeding in the US is, "I don't have enough milk." While there are instances of a genuine inability to produce enough milk, it often turns out that the one who is concerned about the breastfeeding is not the mother, but a relative or friend who argues "If that baby was getting enough to eat he wouldn't be doing all that crying."

What about insufficient milk supply? The issue has appeared in the anthropological literature for some time. In 1980, Gussler and Briesemeister published an article arguing that the feeding patterns dictated by life in urban, industrial societies--infrequent feedings, lasting for long periods of time--actually caused women to produce less milk. In response, Greiner, Van Esterik, and Latham (1981) argued several hypotheses to account for the insufficient milk syndrome. These focused on the introduction of artificial feeding and, therefore, less nipple stimulation, as the real cause of insufficient milk:

When women or health workers in close geographical proximity share the belief that insufficient milk is a common phenomena, they may become acutely watchful for signs of it. Thus they may interpret normal physiological events in the mother (e.g., cessation of milk dripping from the breasts) or non-hunger-related crying as signs of insufficient milk. Milk company promotional activities may have initiated or furthered the belief that insufficient milk is common and in other ways undermined mothers' confidence in their milk supply.

In short, breastfeeding occurs above the eyebrows as much as or more than it occurs in the mammary glands. The word "insufficient" is like the word "inadequate"--once it has been directed at a mother it can never be retracted, and her confidence in her body's ability to nurture and nourish at the breast often plummets.

Are there biological reasons for low milk supply? There could be, simply because biological diversity is such an important factor in all of life. Breasts and nipples come in all different shapes and sizes, which is one reason for concern when nipples and breasts are vigorously "assessed" before the baby is even born. Babies have different shaped mouths, different sucking patterns, and different levels of physical strength. What looks to the analyst like small size or odd shape may be perfect for a given baby. Even when a newborn and his mother struggle a bit with breastfeeding at the beginning, it is important to remember that babies grow. Facial structure changes. Muscle strength develops. Never underestimate the power of a mother and baby to find a position that works well for them. McKenna and Mosko (1993) discovered just this when they watched co-sleeping infants positioning and repositioning themselves with respect to their mothers, mostly to achieve a position to make nursing easier. A variety of studies have shown that infants can regulate their intake volume and the amount of fat in their feedings. There is evidence of infant-led variation in the degree of breast emptying, the length of feedings, and the interval between feedings (Stuart-Macadam and Dettwyler 1995). If a mother and infant are encouraged to find a pattern that suits them, they are less likely to experience any problems with milk supply.

Which Side First?

Women in traditional societies tend not to nurse in the same way as women in modern industrial societies in another respect: They pay very little attention to which breast baby nursed from at the last feeding. When baby cries he is picked up and nursed briefly on whichever side is convenient (Stuart-Macadam and Dettwyler 1995). It is interesting to note that in most women the right breast is smaller and most humans are right-handed. Size of breast does not predict quantity of milk produced, but there are often asymmetries in breast milk output, even if there is no obvious bias in breast use. The Koran tells women to start every feeding on the right breast; this probably has more to do with ideas of ritual purity than concern with asymmetrical supply, but it is certainly one way to deal with variation in milk supply. Newborns often go through a phase of preferring one breast over the other, often the left, but this usually passes. Of course, it is a very poor idea for a mother to nurse exclusively at every feeding on the same breast. Milk supply is very likely to be affected. Women are worried that they will look "lopsided" if they nurse twice in a row on the same breast, but it is rare for a woman's breasts to be the same size and shape. Most of us are unaware of this until we breastfeed, when we begin to look at our breasts in a different way and at a different angle.

Weighing the Evidence

Flexibility is the secret to successful breastfeeding. Many people are uncomfortable with flexible patterns that permit the mother and infant to find workable solutions to breastfeeding challenges. But breastfeeding is an art, not a science; there are few things that work for all mothers and all babies everywhere all the time (Stuart-Macadam and Dettwyler 1995).

Conversely, excessive rigidity often makes breastfeeding impossible. At various times and places throughout history, there was a tremendous emphasis on rigid practices in breastfeeding. Babies were weighed before and after each feeding to regulate the amount of milk consumed by the infant. Inaccurate weighing procedures were common. Not surprisingly, few women reported feeling a let-down and breastfeeding rates fell dramatically. This is not to suggest that babies should not be weighed and measured. Babies need to be weighed and measured occasionally to document growth. However, standards of growth are sometimes too doctrinaire and do not take population and individual differences into account.

Nature or Culture?

An emphasis on the biocultural along with examples from cross cultural studies may lead some to think that there is one perfect "natural" way to nurse a baby or raise a child. It is tempting for nursing mothers living in a society which is not very supportive of breastfeeding to fantasize about some perfect society where all babies are born into a warm and supportive environment, where breastfeeding is the only way to feed a baby, and weaning is never mentioned. Such a society does not exist. We live in an imperfect universe and our societies reflect that reality.

Cultures are more alike than anyone can imagine--and more different than a person can possibly believe. Birth may occur in a beautiful, comfortable environment, but in many cultures colostrum is considered unfit for babies and the mother may be forbidden to nurse until the colostrum begins to change to milk. Children may nurse until age three, but among the Dinka, the child then is taken to live with his grandparents in another village for a period of time. He or she may nurse until age six in some places, but among the Palau, the child then is abruptly forbidden to nurse and his cries and entreaties are ignored. A baby may be biologically programmed to sleep with his parents, but his culture may have a rule that says that on the day the new baby is born he must begin to sleep by himself. Early solids may be discouraged, but in many African cultures, certain protein-rich foods are not considered appropriate for toddlers, which is the beginning of a struggle with protein-deficiency diseases that some do not survive. Concepts like attachment parenting and natural weaning are beautiful concepts to many mothers, but to an anthropologist, they are cultural, not biological, in nature.

In every culture there is much to admire and emulate and much that others would reject. One of the benefits of life in a large, heterogeneous society is a diversity of customs and belief systems which provides parents with a range of child rearing choices. It's up to them to decide what best meets the needs of their family.


Barr, R.G., M.S. Kramer et al. Feeding and temperament as determinants of early infant crying/fussing behavior. Pediatrics 1989; 84:514-521.
Greiner T., R Van Esterik, and M. C. Latham. The insufficient milk syndrome: an alternative explanation. Medical Anthropology 1981; 5:233-247.
Gussler, J. D. and L. H. Briesemeister. The insufficient milk syndrome: a biocultural explanation. Medical Anthropology 1980; 4:145-174.
Hellman, C. G. Culture, Health and Illness. Butterworth-Heinemann Ltd. Oxford. 1994.
Konner, M. and C. Worthman. Nursing frequency, gonadal function, and birth spacing among !Kung hunter-gatherers. Science 1980; 207:788-791.
McKenna, J. J. An anthropological perspective on the sudden infant death syndrome (SIDS): the role of parental breathing cues and speech breathing adaptations. Medical Anthropology 1986; 10 (1):9-53.
McKenna, J. J. and Mosko, S. Evolution and infant sleep: an experimental study of infant-parent co-sleeping and its implications for SIDS. Acta Paediatrica Supplement 1993; 389:31-36.
Nesse, Randolph M, and Williams, George C. Why We Get Sick Random House, New York, 1994.
Scheper-Hughes, N. Virgin mothers: the impact of Irish Jansenism on childbearing and infant tending in Western Ireland. Anthropology of Human Birth. Margarita Artschwager Kay, ed. F. A. Davis Co., Philadelphia, 1982.
Stuart-Macadam, P. and K. A. Dettwyler, eds. Breastfeeding: Biocultural Perspectives. Aldine De Gruyter, New York, 1995.

About the Author: Judithe Thompson teaches Anthropology and Political Science at the University of Rio Grande, Rio Grande, Ohio, where she is also Co-Director of the Honors Program. Judithe and her husband (and fellow anthropologist) Barry are the parents of Alta, 20, and Chrys, 18. She is Area Professional Liaison for Ohio/West Virginia and has been an LLL Leader since 1981.

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