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Helen C. Armstrong
Breastfeeding, which unites food, health, and care, enhances the child's abilities to elicit good care through superior attachment, rhythmic synchrony, and vision and brain development. Parental responsiveness is increased by bonding, child spacing, and time with the baby Breastfeeding and other forms of care for nutrition share the aspects of interaction, cultural mediation, erosion of traditions, endemic misinformation, small-scale decision-making, and vulnerability to institutional mismanagement. Breastfeeding differs in requiring continuity of the caretaker and in facing social and profit-motivated opposition. Research is needed on adequate care for siblings, effective help for high-risk infants, improved duration, and nutrition of both mother and child in the second year of breastfeeding Despite effective strategies, such as the baby-friendly hospital initiative and community support groups, the challenge remains to move from motivating women to ensuring access to practical and confidence-building support.
Breast feeding, which unites food security, health protection, and care, represents the strongest possible foundation for nutrition. A global consensus has evolved in recent years defining optimal feeding of infants and young children: exclusive breastfeeding from birth to about six months, followed by introduction of complementary foods drawn from the local diet at about six months. Breastfeeding should be sustained well into or beyond the second year of life, with increasing amounts of complementary foods [1-3].
Initiation, exclusivity, and duration of breastfeeding
Dramatic differences between these recommendations and current practices are found. Not all families breastfeed, many give needless early supplementation, and in only a very few countries do mean breastfeeding durations exceed 18 months.
Average figures for ever breastfed, i.e., initiation rates, drawn from the World Fertility Survey (WFS) and Demographic and Health Surveys (DHS) in developing countries, approximated 92% between 1977 and 1989 . More recent DHS figures for breastfeeding initiation are 290% in a range of countries in Africa, Asia, and Latin America . Lower initiation rates are found among less comprehensive data from Jordan (66%), Israel (84%) , the Netherlands (66%) , Luxembourg (64%), the United Kingdom (63%), Croatia (59%), the United States (56%), France (55%), and Ireland (30%)  (sources for percentages not otherwise referenced are from the database maintained by WHO/NUT, Geneva). In a few parts of the industrialized world, breastfeeding initiation is higher, as in Copenhagen in 1987-1988 (99.5%) . However, just as figures for admissions to preschools do not indicate overall national educational levels, initiation rates are not sufficient measures of a country's infant feeding patterns.
Although new WHO indicators for exclusive breastfeeding from 0 to 3 months  are not yet widely used, available figures show few babies are exclusively breastfed to 3 months . In Denmark, 4% of babies are breastfed exclusively to 4 months . DHS data from 1990 to 1993 indicate supplementation from about 2 weeks of age in many countries. DHS data show exclusive breastfeeding exceeding a median of 6 weeks only in Indonesia, Cameroon, Egypt, and Morocco . In general, families are giving something else besides breastmilk at about 2 to 9 weeks.
The duration of breastfeeding may be high even where early supplementation prevails. In the countries covered by 1977-1989 WFS and DHS studies, the age at which 50% of mothers said their babies were no longer breastfeeding ranged from 1.5 months in Costa Rica to over 24 months in Benin, Burundi, Mauritania, Indonesia, and Nepal. On average, children in the countries surveyed were taken off the breast at around 16 to 18 months of age in Asia and Africa, and around 9 to 10 months of age in Latin America and the Caribbean .
Although many DHS surveys indicate that rural children breastfeed some months longer than urban children, there are exceptions. The 1989 Kenya DHS showed Nairobi women breastfeeding as long as rural women , due to active breastfeeding promotion and support available in city clinics . Rural women in Iran breastfeed less and for shorter durations than urban women. Eighty per cent of rural children over 3 months of age are partially or wholly bottle-fed, and 75% are off the breast by 1 year of age .
Children who are classified as "breastfeeding," a category that includes "any breastfeeding" or "partial breastfeeding," consist of all children who take any milk at all from the breast, from those who are exclusively breastfed to those who have a token 60 second feed once a day. Longer duration of breastfeeding might indicate a cultural and economic environment more supportive of families and good caring practices. Nevertheless, the nutritional, immunological, child-spacing, and care significance of breastfeeding rates cannot be judged without more differentiated and specific data.
Underlying and basic determinants
The UNICEF conceptual framework for nutrition (fig. 1)  highlights some of the levels at which breastfeeding may be either supported or interfered with. When she gives birth, every woman has the potential resource of breastmilk for two years or more. This ample food resource is perfectly targeted, already distributed to households with the need, and should be controlled by the mother and baby.
Basic determinants that may deprive women of this resource include absence of family and social support; traditions of giving low household food priority to women; and young women's lack of status and power, allowing others to decide what they should do with their time and energy; and how babies are fed. Among additional factors are women's vulnerability to social pressures and to violence, their selection as targets for commercial messages, and the disproportionate demands made upon women to achieve family survival.
Cultural beliefs and practices, modern myths and misinformation, and, again, commercial influences affect perceptions at the level of education. Withholding of information, a deliberate practice of keeping women ignorant under the pretext of preventing them from feeling guilty, is another aspect of inadequate, disempowering education.
Mismanagement can arise from various underlying determinants associated with health services, including professionals without up-to-date knowledge and skills, poor maternity care practices, inaccessible or inattentive health care, and commercial influences on medical thinking and practices.
Immediate determinants of poor breastfeeding outcomes include new or traditional mismanagement of lactation, such as early supplementation, poor positioning and ineffective suckling, infrequent or abbreviated feedings, omission of night feedings, use of feeding bottles and pacifiers, and inadequate treatment of breast problems. Improvement of breastfeeding management must be the focus of reeducation for health workers and mothers, as in WHO/UNICEF training materials [17, 18]. But improvement of the condition of women at basic and underlying levels is fundamental to restoring every woman's right to make free and full use of her breastfeeding resource.
Care for women who work
All women work; work itself does not prevent breastfeeding. In Botswana, for example, breastfeeding duration is 18 months for employed women and only 2 months longer for those at home . However, when women are overworked in paid or unpaid tasks, they may be too busy to breastfeed frequently or to be attentive to other aspects of care. Long separations from their children exacerbate the difficulties. The number of dependents in a family and the close spacing of children contribute to overwork, along with seasonal demands of food production, fetching of fuel and water, distance from markets and health care, and sole responsibility for a household. Economic and ideological structures, including gendered allocation of tasks, may make optimal care for children of any age unlikely.
Although maternity legislation provides some degree of protective entitlement in most countries, women with lower social status, such as domestics, plantation workers, daily labourers, small traders, and piecework craftswomen, generally have little or no maternity leave . Yet women who work at home or in unregulated jobs do not necessarily find more time for infant feeding than those in salaried work. Breastfeeding breaks and workplace child care remain exceptions to the usual pattern, which is one of distance between mother and baby. Many official measures do not cover the most vulnerable and the poorest of working women. Their only maternity protection may come from traditional postpartum customs, for example, the 40 days of rest to which all new mothers are entitled in some Islamic cultures.
FIG. 1. UNICEF conceptual framework for nutrition
Care for women in the family
The household composition of extended unilocal families provides a sharing of child care and of household tasks that is widely assumed to simplify child rearing and breastfeeding. Looking after older relatives may increase the mother's workload, however, while she herself may receive little care and a minimal share of family food. In discussion, a group of Indian paediatricians expressed ambivalence about the role of grandparents. Their care for the family is generally valued, yet they may decide to add top feeds-needless supplementary bottles of formula- for their breastfed grandchild. By doing this they may replay their own parenting behaviour, express mistrust of the child's mother, or exert control through infant feeding.
Shrinking of the family to nuclear size increases care burdens but may give parents greater autonomy. In these families, the odds that mothers will breastfeed increase with male partner support (odds ratio in one study=32.8.) . However, educating men about how to support breastfeeding and give care to their infants in ways other than feeding them is not yet widespread. A leaflet from Kenya, "Please help your wife to breastfeed," represents valuable re-education of men in care for women and babies .
When there is only one parent, the stresses of earning a living and carrying out all responsibilities for the children intensify the parent's difficulties. Although other household compositions are not guarantees of good care for women and children, in every socio-economic setting and culture, single parent families are at higher risk.
Social isolation of parents also increases risks to children, whether caused by recent rural to urban migration, distance from family and clan members, ostracization (of unmarried mothers), or characteristics such as youth, ethnicity, or language that put them out of communication with neighbours. Isolation can also be severe in industrialized nations, where expectations of autonomy may isolate the new mother and baby amid her household appliances.
Urbanization or modernization, general rubrics for complex social changes, may entail both positive and negative conditions for breastfeeding. Telephones, bookshops, libraries, community groups, and accessible health services may provide information and counselling; water, fuel, public transport, and food availability may lessen workloads. Yet overwork, isolation from family and friends, insecurity, struggles to gain access to cash income, and the pervasive presence of breastmilk substitutes may counteract breastfeeding. Like household composition, urbanization is an ambiguous factor in breastfeeding and nutrition care.
Jean-Gérard Pelletier urges appreciation of the multidisciplinary nature of malnutrition, including disturbance of dietary intake, the mother-child relationship, and the cultural reference system . Violence against women can be recognized among such disturbances. Instability and conflict were included in a multiple-risk factor model for adverse childhood outcomes, including failure to thrive and third degree malnutrition . However, this vital factor is frequently disregarded. Domestic violence has not yet become a customary line of enquiry in history taking when a child's growth fails.
In violent and impoverished surroundings, although the mother may offer the breast, the baby may progressively deteriorate . Current studies of non-organic failure to thrive (NOFTT) in US children suggest that victims of abuse are significantly more likely to have children who fail to thrive. Eighty per cent of the mothers of 59 NOFTT children in Denver with a mean age of 13 months had been victims of physical or sexual abuse as either children or adults. "Mothers of NOFTT children very often have a legacy of abuse in their lives that is deep and intergenerational" .
Colombia is among the few developing countries undertaking surveys of violence against women. DHS figures in 1990 for more than 5,000 ever-married women showed 66% had been quarreled with, verbally abused, beaten, or raped, with those separated from their partners at highest risk of violence . In the absence of survey data from other countries, we cannot assume that domestic violence is a negligible factor in the lives of their mothers and children.
Effects of breastfeeding on the caring relationship
The breastfeeding relationship may itself be a factor in developing other caring behaviours, affecting the child's ability to elicit care, the parent's capacity to give it, and the synchrony of their responses to each other. A vigorous child appears to stimulate better parenting.
High-quality feeding interactions during the first years of life tend to be positively linked to the child's subsequent cognitive and linguistic competence and to more secure attachments to major caregivers .
Sick, malnourished, or brain-impaired babies as well as those infants expected to fail will elicit less effective social interaction.... Quiet, undemanding malnourished infants do not elicit necessary mothering from already overstressed parents .
Infant care-eliciting capacities enhanced by breastfeeding
Scent and recognition
The breastfed baby is able to recognize and respond to the mother from birth, using olfactory signals [30, 31].
Although the early postpartum hours and days are not the only period during which parent-child bonding can occur, they have long been recognized as a particularly sensitive time for parental learning . This learning may be facilitated by repeated skin contact, an interaction which is of necessity built into breastfeeding. Current emphasis on skin-to-skin contact in the first minutes of life is based on a growing literature that suggests easier and perhaps longer breastfeeding, possibly associated with long-term differences in the quality of parent-child relationships [33, 34].
Kangaroo Care, which gives both mothers and fathers hours or weeks of whole-body skin contact with premature newborns, seems to overcome the estrangement necessitated by special care [35, 36]. In Colombia, Zimbabwe, and other countries, low birth-weight babies receive 24-hour skin-to-skin care from family members [37, 38]. It can be hypothesized that wherever visual and vocal interaction with babies is not frequent, sustained touching through breastfeeding and close-contact carrying may be an essential channel for eliciting parental care.
When breastfeeding babies sleep with their mothers, their breathing and sleep-arousal cycles become synchronized . This responsiveness facilitates continued night breastfeeding not disruptive of the mother's sleep cycle.
Visual contact is a key element in baby-parent interaction in many societies, evoking positive parental attention. Newborns have a relatively fixed focal length and see best at about a 12-inch distance, approximately the distance from the breast to the mother's eyes in the en face position . Furthermore, infants fed breastmilk score better than formula-fed children on visual tests through the age of three years [41-44].
Attachment and emotional affect
The repeated day and night contact with the mother inherent in breastfeeding ensures continuity during the first year, a stage characterized as the time when a person develops trust. Conversely, patterns of multiple care may depress the infant's ability to trust parents and hence to elicit their care. In nuclear family societies, it is postulated that certain personality disorders may arise from multiple early caretakers:
Confronted with a situation in which the formation of attachments repeatedly leads to the trauma of having the bond abruptly broken, the child makes a highly adaptive adjustment of resisting any further deep relationships .
Substitute arrangements for the nurturing of infants inevitably involve shared, discontinuous and changing caretakers, an obvious disruption in the attachment process.... [Multiple separations] impair the later capacities for trust, empathy, and affection. It is time for us to become more concerned about the frequent separations and changes of caregivers in the lives of infants and toddlers .
Four premature infants who had no interested, consistent caretaker in their lives ... developed a reactive attachment disorder of infancy characterised by behavioural problems and/or failing physical states .
Recent studies suggest that long-term intelligence or cognitive scores increase with the mother's choice to breastfeed and with duration of breastfeeding . Breastfeeding may be particularly important in neurological development when some impairment is present at birth .
Breastfeeding is often accompanied by interchanges between mother and child-humming noises, murmurs, the mother talking to the child, and the child playing with the mother's mouth. In boys, later language development is positively affected by breast feeding; the effect on girls is negligible . In those cultures where early verbalization is valued, language ability may encourage caretaker attentiveness.
Parental caregiving capacities enhanced by breastfeeding
An environment that favours breastfeeding may also favour the early bonding now seen as a foundation for the development of parental caring behaviours [53, 54]. Skin-to-skin contact from the first half hour of life is recommended by the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) for all babies whether or not they are breastfed. Human adaptive capacity allows parents without this early contact to establish strong and permanent emotional ties with their children , but specific support for close touching and caregiving may be needed where cultural or medical inhibitions exist. In an intensive care unit, for example, parents treated as extraneous may withdraw from their infants .
The contraceptive effects of breastfeeding both protect maternal health and reduce the mother's workload, allowing the youngest child a longer dependency. It has been hypothesized that the shorter birth interval and larger families associated with recently adopted bottle-feeding in Yucatan result in less maternal and perhaps less overall family attention to infants .
In an industrialized culture, mothers busy with other tasks remark that breastfeeding ensures that they take time to enjoy their babies [56, 57]. Workplace day care for infants, if combined with the breastfeeding breaks mandated by International Labor Organization conventions, permits repeated daytime attention to children from mothers who are in paid employment [58, 59]. No equivalent contact is yet mandated for mothers who have stopped breastfeeding.
Objective scoring of videotaped interactions indicated that breastfeeding mothers in the United States were more closely attuned to their infants than those who bottle-fed . Mother-child breastfeeding relationships, even in the first days, can resemble play in being reciprocal, enjoyable, and totally absorbing to both baby and mother. Play interaction develops from secure attachment in infancy and signals the mother's ability to respond to her child's cues. Responsiveness, in turn, is higher in mothers who do not maltreat their children. Neglectful mothers were significantly less responsive to children than mothers with adequate rearing practices after statistically controlling for education .
Effects on parents when others give the care
These effects have yet to be studied, even in the many settings where household servants or informal care by neighbours are common. In cultures where parents do almost all of the child care, other forms of intimate contact may replace breastfeeding as channels for the growth of a mother's caregiving capacities. However, especially where maids do most of the baby care, breastfeeding may be the child's best assurance of contact with the mother. Once off the breast, the baby's strongest attachment may be to the maid, with the mother taking a more supervisory than intimate role. If the maid leaves, the baby may display a grieving anorexia while rejecting the mother. In the absence of studies in this area, sustained breastfeeding, with alternative care by permanent members of the baby's family, could be presumed to present fewer potential risks to the child's emotional and physical development and to the mother's relationship to the child.
What can breastfeeding teach us about care?
Neither breastfeeding nor care can be summed up by looking at only the child or the parent; both are processes of responsive interaction. Although a mother produces milk, both the amount and, to some extent, the composition are responsive to the baby's needs as expressed by suckling . The "calibrating phase" of the breastfeeding relationship, the early months during which the breasts and the baby get into harmony, has its equivalent in the early development of parent-child synchrony and responsiveness. The well-being of parents is fundamental to both processes.
Security in the family promotes both breastfeeding and other forms of good care. If mothers are subjected to verbal attack or physical abuse, if quarrels ricochet through the household, or if children live in fear, care for nutrition will be endangered. Symptoms that present as breastfeeding problems may in fact signal domestic violence. In the case of more generalized insecurity, as in emergencies or war, it may be essential to provide a micro-climate of woman-to-woman support to maintain both breastfeeding and other care. Replacing breastfeeding by formula in crisis settings or in conditions of domestic violence will exacerbate a woman's problems in keeping her family going.
Both breastfeeding and care are strongly mediated by culture, which prescribes normative practices such as sleeping with babies or putting them alone in another room. Parents' own capacities and characteristics also contribute to care, making parent-child relationships unique even within an established cultural framework. Breastfeeding and care grow out of the intersection of parental personality and social environment. If there is no such intersection, as when parents are socially isolated, both breastfeeding and care may be impaired.
Traditional patterns of both breastfeeding and other care for nutrition are subject to erosion. Wet nursing by grandmothers, a very valuable custom, rarely receives reinforcement from breastfeeding programmes and hence is being lost. Patterns of breastfeeding and nutritional care shift with demographic and economic changes. These shifts may be nutritionally damaging when commercial advantage can be gained by replacing old eating patterns and foods with new products of higher cost and lower value.
Both breastfeeding and care are very time consuming. One cannot hurry a baby through a feed without depriving him or her of the fat-rich hind milk that fuels growth. A toddler slowly eating spoonfuls of complementary food cannot be rushed, and may require active feeding whenever appetite falters.
Both breastfeeding and care for nutrition require investment of time, energy, attention, and emotion. They cannot be done well by a caretaker whose own health, psychological state, or workload prevents her from being attentive to the children. Such conditions may affect very markedly the quality of interpersonal relations within the household.
However, because almost all of the work of breastfeeding and other child-feeding is done by women- mothers, female relatives, and maids-this investment of time and effort has been invisible to mainline economic analyses. Recent attempts have been made to calculate an economic value for breastfeeding [63, 64]. However, breastfeeding and care behaviours are not easily quantified and hence are undervalued. Both may deteriorate a great deal before social data collection records the negative trends.
Key decisions and behaviours are small-scale, taking place in the family. Large-scale policies by themselves cannot achieve more frequent breastfeeding or better care for nutrition. Vital daily decisions- what to eat, how to cook it, how much time to spend on feeding children, what to do with the child who lacks appetite-are cumulatively the significant decisions. Persuasion, education, and help must reach the caretakers in the household.
Entrenched caring patterns are not amenable to a quick fix. Child-feeding is entwined with multiple attitudes and practices. As both policy makers and parents have a strong investment in justifying and perpetuating whatever they themselves did, there may be no rapid solution to problematic feeding behaviours.
Appropriate feeding, from the breast or otherwise, changes with child development, approximately every six months. The frequency of feeding, how long it takes, and what is given all require adaptation to the child's growth and self-feeding skills. Caretakers may need help in recognizing and responding to the shifting needs of their children, and in teaching them new skills and tastes as their diets expand.
A pattern is set with the first child. Suboptimal breastfeeding of the first child will tend to be repeated with subsequent children. Patterns are familial . Primiparae, usually teenage mothers, are therefore the prime target for education and support.
Extra care can compensate in part for a suboptimal diet. For some children, artificial infant feeding does not create major immediate problems where caring conditions are close to ideal. However, its long-term effects on chronic disease in later life or other lasting effects are still not fully known .
Endemic misinformation, the popular mythology about breastfeeding that distorts its practice and creates numerous problems for families, may have its equivalent in widely held misconceptions about other care-for-nutrition practices. In parts of West Africa, for example, a belief that all children will eat as much as they need prevents caretakers from urging anorexic toddlers to eat .
Both care and breastfeeding are vulnerable to institutional health-care practices. Both may terminate with hospital admission of a child without the mother or father. Risks of hospitalization without a parent include, besides a premature cessation of breastfeeding, emotional trauma, estrangement from parents, inadequate understanding by families on how to feed the child well when back at home, and consequent repeated infections or malnutrition. The BFHI has generated widespread interest not only in transformed maternity services, but in improving paediatric in-patient care to allow parents continuous contact and responsibility for their child's feeding.
A tendency to blame the mother for malnutrition or for so-called breastfeeding failure can be found at all levels, from the overworked clinic nurse to the global communications system. However, in the absence of evidence to the contrary, we might well assume that every mother does her best for her children in her situation at the time, and with her knowledge at the time. As breastfeeding is sensitive to disruption, breastfeeding indicators may serve as the canary in a coal mine, giving an early warning of other stresses. Difficulties in infant feeding may indicate not that women are careless, but that they are prevented from providing their children good care and nutrition by underlying and basic determinants beyond their control.
Differences between breastfeeding and other care for nutrition
The child controls breastfeeding. A baby cannot be forced to accept the breast or to go on suckling more than she or he wishes. From the first day, if fed on demand, the breastfed infant controls time, length, and total milk intake during the feed [62, 68]. The intake and proportion of fat during a single breastfeeding correlate with the time since the last feeding . The child's suckling, if unimpeded from birth, can increase milk production as the child grows up to the age of 6 to 10 months. In contrast, bottle feeds and other foods are controlled by the caretaker, are usually less freely available, do not provide automatic increases in volume or adaptations in composition, and require a more intrusive style of feeding.
Breastfeeding ensures some degree of continuity of primary caretaker. Multiple breastfeeders for a single child are very rare, although they can exist, as with the 15 different women in a Jordanian village who breastfed a boy whose mother died in his infancy .
Institutional initiatives vary in feasibility. With breastfeeding, it has been possible to go to scale by establishing national policies to protect breastfeeding from commercial pressures, and to work through the maternity care institutions toward higher initiation rates. Other feeding is not so amenable to protection from adverse influences, nor are there institutions through which to affect household-level feeding behaviours.
In most cultures, there is social opposition to breastfeeding past a generally accepted age of the child. To breastfeed past this point may be seen as an indication of poor parenting. Giving other food to one's children may be hedged with cultural restrictions but is nowhere categorically condemned.
Breastfeeding is not the only traditional feeding practice being undermined by commercial forces. However, the profit-motivated competition with breastfeeding is global and pervasive. The issues are clearly delineated, and strategies to regulate this competition have already been articulated by the World Health Assembly and other agencies [1-3, 71, 72].
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