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What is uncertain and needs research?
What are the normal developmental signals characteristic of a breastfeeding
Inattention to breastfeeding has characterized much Western child development research, which takes behaviours associated with artificial feeding to be the norm. The four-month-old who squirms away from close body and eye contact during feeds is showing an aversion response that may be observed in many artificially fed babies. This behaviour may not be perceived as suboptimal by researchers who have come to accept it as normal through primarily studying bottle-fed babies. At the same time, researchers may not observe or record behaviours particularly associated with breastfeeding, such as the en face close body contact during breastfeeding, the child's patting of the mother's breast, the vocal interactions during milk feeding, the continuous nighttime contiguity, and the number of active responsive feeding episodes in 24 hours.
The breastfeeding mother's relationship with her child, seen by some researchers as a troublesome confounder that skews data, may instead be like the stray spore that spoiled Alexander Fleming's bacterial cultures-a hint at important unexplored terrain.
All new research in this area should differentiate between exclusive breastfeeding, levels of partial breastfeeding, any bottle-feeding, and exclusive artificial feeding and should include trained observation of breastfeeds. Very little of the existing literature on care adequately reflects current knowledge about lactation. Specific training in feed assessment from specialists in lactation management will permit collection of less naive observational data.
What constitutes adequate care for mothers?
Where women are deprived of power to control the experience of birth and birth management is brutally out of date, what constraints have prevented changes toward the decade-old Fortaleza recommendations [73]? How can we provide therapeutic care in different cultural settings for women whose own childhood was difficult or who are battered, so they can be empowered to breastfeed and to be responsive to their children? What variants of mother support exist and function well to help mothers throughout the first three years of infant and young child feeding? What avenues exist to lessen demands on young mothers' time and energy, while securing the investment of fathers and others in non-feeding care for babies under six months? What patterns of care and feeding are most possible for either urban or rural mothers whose work takes them away from the baby for much of the day?
What is the relationship between breastfeeding care, and violence toward women and children?
The possibility that young women at risk of abusing their children might be helped toward more favourable relationships by early support for breastfeeding has not yet been explored. Observation of parent child feeding interaction suggests that certain correlates of difficult relationships may be commoner in non-breastfeeding dyads, such as eye aversion, lack of touch, and lack of synchrony. We do not know how much of NOFTT, currently diagnosed as "breastfeeding failure" and commonly treated with bottles of formula, may arise from abuse of the mother. The possible factors of fear and insecurity arising from domestic violence, however, must be included in research that looks at any aspect of care for nutrition.
How do we help the mothers of children severely at risk?
What are the conditions in which parents have nothing left of energy or resources to invest in a child, and maternal responsiveness to dehydrated, malnourished, and ill children diminishes? Is it appropriate to intervene in such situations, and if so, how? In severely stressed Brazilian communities studied by Scheper-Hughes, because mothers are accustomed to respond to children's demands, if the baby does not ask for food it may simply wither away more or less disregarded [74].
How are families Investing resources In care for nutrition?
In cultures where breastfeeding is customary, overall nutritional outcomes can also be poor. Even in impoverished settings, better weight gain may sometimes be seen among children who received bottles of milk and survived the much higher mortality associated with that feeding. Presumably the purchased object and contents indicate strong parental investment in the child-money for artificial milks and for more frequent health care at the very least, and time to prepare the feeds. It could be illuminating to delineate better the trade-offs between different forms of parental investment in care for nutrition, and to observe how parents make these decisions in resource allocation.
How do we Increase breastfeeding durations and ensure good complementary feeding as well?
In many countries, the average duration of any breastfeeding may be between 6 and 15 months. Interventions achieving longer durations have yet to be developed, widely applied, and evaluated.
We also need to know what limitations on breastfeeding and what difficulties in the transition to other foods may affect families during the period of complementary feeding, between 6 and 24 months at least. For example, as a child grows, the family may insist that hunger for any food other than the breast should not be expressed, as in some sub-Saharan communities. The pattern of frequent breastfeeding that produced good growth at first may then be supplanted by a pattern of very brief breastfeeds, but without frequent meals. Where good manners demand quiet waiting for other foods with the other children, punishment may be used to teach the toddler not to express hunger. Where there are several children and no tradition of singling out the youngest for extra food, recommendations that toddlers be given complementary foods four or five times a day may be impossible to follow.
How does breastfeeding or not breastfeeding affect care for the baby's siblings?
Much existing literature studies the mother-baby dyed as if the existence of siblings was not the global norm. When a child is not breastfed, the family expenditure on breastmilk substitutes may be large enough to affect the dietary intake of all family members. In urban Bangladesh in January 1995, for example, a year's supply of the cheapest commercial infant formula required over 12,300 take (US$310). A family that saved the money by breastfeeding could purchase 205 kg of rice, 91 kg of red lentils, 948 eggs, and 41 packages (16.4 kg) of dried full cream milk, if they used a quarter of the savings for each item.
Illness or death of the baby may also absorb a large proportion of family disposable income. No study has quantified the nutritional deficits and illness in other children that may result when a baby is not optimally breastfed. The implications of artificial feeding for the nutritional status and health of the baby's siblings can no longer be disregarded in research.
What is the value of breastfeeding In the second year?
In order to advocate two years or more of breastfeeding, we need more complete knowledge of its nutritional, immunological, and cognitive effects on the baby and its nutritional and psychological effects on mothers and other caretakers.
Studies of breastfeeding in the second year have often not observed the 24-hour breastfeeding pattern to determine if substantial milk transfer is taking place. The caretaker's management of other feeding also requires careful observation. Existing evidence about nutritional effects of sustained breastfeeding is therefore ambiguous due to lack of such data. In Mali, where breastfeeding continued on demand for sustained periods, a study found that many children improved growth after weaning, as did a less well-controlled study in Ghana [75, 76]. However, a Burkina Faso case-control study showed that malnourished children between 12 to 36 months of age were more likely to be receiving no breastmilk than were adequately nourished children. The researchers concluded that there was no evidence for a detrimental nutritional effect of sustained breastfeeding, although they acknowledged the possibility that mothers had stopped breastfeeding because the child was sick or malnourished [77]. In rural China, positive associations have been found between nutritional status and breastfeeding between 12 and 47 months of age [78]. More carefully collected and analysed data, including observation of feeding behaviour, are needed.
What are the nutritional needs of mothers during sustained breastfeeding?
Studies of mothers and their nutritional status during two years of breastfeeding are long overdue. The nutritional circumstances under which extended breastfeeding contributes to maternal depletion are not known. In women who are not nutritionally depleted, lactation may actually improve maternal health by inhibiting menses, preventing pregnancy, increasing eventual bone density [79, 80], and preventing cancer [81, 82].
How does breastfeeding affect child development and parental responsiveness in the long term?
Mothers who have bottle-fed some babies and breastfed others report that the feeding does make a difference in their relationships with their children. Since anecdotal evidence abounds but controlled studies do not, it could be helpful to follow for some years two groups of mothers who intend to breastfeed: those who breastfeed only a few times and those who breastfeed close to the optimal pattern.
What are the effects of pacifiers (dummies)?
We do not yet know the effect of pacifiers on language development. Pacifiers are suspected of causing low breastmilk production, the shift in a baby's suckling technique often called nipple confusion, and a switch to artificial feeding. To the extent that pacifiers are used as a substitute for caretaker investment of time and attention and to make the child accept distance from parents, they may also affect care.
Successful strategies
International breastfeeding programmes have demonstrated some possibilities for bringing care for nutrition into the arena of governmental action and support.
Global advocacy
The Innocenti Declaration [1] and the World Summit for Children [83], both in 1990, produced a joint political commitment to improved breastfeeding. To some extent this made women's breastfeeding and caring activities more visible. Strategic advocacy by UNICEF and others, focusing on the Innocenti operational targets and the mid-decade goals derived from World Summit goals, has ensured that breastfeeding is now part of all national health agendas.
An international initiative
The BFHI, which includes both community and hospital support for breastfeeding and ending the supply of free or low-cost breastmilk substitutes to healthcare systems, has further focused national and international attention. A key feature of this initiative is its global nature, the first UNICEF programme that is needed as much in industrialized nations as in developing countries. Its common ground is the Joint Statement of WHO and UNICEF of 1989, "Protecting, Promoting, and Supporting Breastfeeding: The Special Role of Maternity Services" [84], defining the ten steps whose full implementation helps a hospital to earn the designation "baby-friendly." As of March 1995, more than 3,000 hospitals around the world in 86 countries have been awarded this recognition.
The BFHI provides a common framework for diverse country-level approaches to increased breastfeeding. Mothers not choosing to breastfeed also benefit from baby-friendly practices: being in skin-to-skin contact with their baby, rooming in, feeding on demand, and being protected from commercial influences that might impede their freedom of choice.
Strategies of the BFHI applied at the country level usually have included advocacy to policy makers; public communications; provision of training, technical support, and consulting; and recognition of accomplishments through hospital assessment and designation. An interesting side-effect of this global effort has been the spontaneous development of adjunct strategies nationally to improve maternity legislation, make breastfeeding easier for hospital staff to promote, improve obstetric care and strengthen Safe Motherhood programmes, or establish better home delivery care.
Community support
The majority of breastfeeding difficulties arise from practical or cultural rather than medical conditions. Community support for breastfeeding has helped women to answer their questions, to increase the exclusivity and duration of breastfeeding, and to provide integrated child health and care advisory support [85].
Empowering women through fostering community level breastfeeding support groups, step 10 of the BFHI, is perhaps the most problematic. It must be carried out at the community level, where hospitals rarely have effective outreach and existing social structures may not be suitable for mother-to-mother help.
In order to be effective, community support work may address both the immediate and the underlying causes of difficulties: for example, improving the baby's intake of breastmilk while building the parents' confidence and responsiveness and providing accurate information. The Nursing Mothers Association of Australia, the La Leche League of Guatemala, and the Breastfeeding Information Group of Kenya exemplify freestanding programmes that help women although they are unattached to particular health institutions. Access to help is ensured through telephones, regular presence at clinics, or networks of neighbourhood counsellors. Mother-to-mother communication and help are fostered in group meetings, facilitated by leaders with sound knowledge and counselling skills.
Hospitals themselves can institute breastfeeding support programmes: the Lactation Clinic of the Hospital for Sick Children, Toronto; the Casita programme of San Juan de Dios Hospital, Bogotá; or the lactation brigades of José Fabella Hospital, Manila, exemplify such services.
An intermediate hospital-community programme is represented by a peer counsellor initiative begun by a group of health professionals and community women who formed the Chicago Breastfeeding Task Force (CBTF). Young mothers of various ethnic groups and economic levels are trained by the group, and then give volunteer counselling aid, with backup supervision as necessary, to other mothers in their communities. The reading load for training is not heavy, and the pedagogical approach is based on the work of Paulo Freire [86]. The CBTF is now an ongoing programme of the large, urban Cook County Hospital, while retaining its woman controlled and community-based nature.
Community breastfeeding programmes may affect caring practices other than infant feeding. The woman empowered to breastfeed and given self confidence may turn to the same source to discuss immunizations, child illness, family relations, and child rearing generally.
Personal empowerment
Breastfeeding support that reinforces the mother's skills works in the long term to encourage breastfeeding for all the children in a family. The woman who has breastfed her first child exclusively for some months and then continued for about two years will almost certainly breastfeed her subsequent children. Studies of long-term breastfeeders in the United States have found that these mothers tend to breastfeed each successive child longer. However, when they are chronically undernourished, mothers tend to breastfeed less, as they feel their strength diminishing; psychological empowerment must be accompanied by nutritional and other support that gives women strength.
Permanent disempowerment can take place when a woman starts her first child on early breastmilk substitutes. She often comes to believe that she is incapable of breastfeeding without supplements and that the supplementary bottle is the real food. Within a few months, breastfeeds may be eliminated, even if the baby shows no nipple confusion. If the second baby is also given bottles, the mother, whose confidence in her ability to breastfeed is now severely damaged, may not breastfeed any subsequent baby exclusively unless she receives help and reassurance on a daily or weekly basis during the critical early weeks of the new relationship. Fortunately, since the reason that a mother does not produce enough milk is rarely physiological, timely and accessible support can almost always ensure comfortable and exclusive breastfeeding.
Some lessons to be learned
Motivation is not enough
Campaigns urging women to breastfeed, without creating the circumstances making breastfeeding possible, were mounted in numerous countries during the 1970s and 1980s. Training typically amounted to sessions for health workers focused entirely on the advantages of breastfeeding and the dangers of bottles. Health workers then gave mothers talks focused entirely on why they should breastfeed, without practical information on how to prevent or handle common difficulties.
Such motivational campaigns have not been notably successful in improving breastfeeding rates. They may increase parental guilt and raise anxiety levels, contributing to feelings of failure among women experiencing common difficulties without help. Mothers need counselling if breastfeeding is painful, if they doubt their milk is adequate, or if they are going back to a job. These are the real concerns that practical information and experienced counselling can resolve.
Help must be as accessible as the tin of formula
Few women have access to help with breastfeeding questions that can prevent and solve problems. Traditional doula systems have not been integrated into maternity care (doula refers to the traditional breastfeeding guidance that first-time mothers receive from older, more experienced women). Health workers also lack access to specialized information to resolve clinical problems without bottles. When a difficult breastfeeding situation arises, such as a cleft palate baby or a NOFTT child, breastmilk substitutes may be perceived as the only solution and may be far easier to obtain than skilled and sympathetic counselling. Breastmilk substitutes are effectively distributed; help for breastfeeding is not.
The manner of helping is also the message
Mothers for whom breastfeeding is not yet going easily need confidence. Intrusive or authoritarian help, giving too many rules for parents and babies who are just learning about each other, will undermine the parents' sense of competence. The need for sensitivity to mothers whose children are failing to thrive or need nutritional rehabilitation is aptly summarized by J.-G. Pelletier. The same words could apply to all humane interventions in support of improved care for nutrition:
Therapy, then ... requires that caregivers be extremely accessible, acutely receptive, able to help the relationship along without replacing the mother in her role ... they should guide both parties toward a satisfying contact, and restore both the child's trust in his or her mother and the mother's self-confidence. There is no such thing as a bad mother: there are only inadequate mother-child relationships [23].
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