Contents - Previous - Next

This is the old United Nations University website. Visit the new site at

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Where women are deprived of power to control the experience of birth and birth management is brutally out of date, what constraints have prevented changes toward the decade-old Fortaleza recommendations [73]?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].


1. WHO/UNICEF meeting on Breastfeeding in the 1990s: a global initiative. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. Florence, Italy, 1 August 1990. New York: UNICEF, 1990.

2. World Health Assembly. Infant and young child nutrition. Resolution 45.34 of the 45th World Health Assembly, Geneva, 14 May 1992. Geneva: WHO, 1992.

3. World Health Assembly. Infant and young child nutrition. Resolution 47.5 of the 47th World Health Assembly, Geneva, 9 May 1994. Geneva: WHO, 1994.

4. Trussell J. Grummer-Strawn L, Rodriguez G. Vanlandingham M. Trends and differentials in breastfeeding behaviour: evidence from the WFS and DHS. Pop Stud 1992;46:285-307.

5. Demographic and Health Surveys. Columbia, Md, USA: Macro International, 1990-1993.

6. Heldenberg D, Tenenbaum G, Weizer S. Breastfeeding habits among Jewish and Arab mothers in Hadera County, Israel. J Pediatr Gastroenterol Nutr 1993;17:86-91.

7. van den Bogaard C, van den Hoogen HJM, Huygen FJ, Van Weel C. The relationship between breast-feeding and early childhood morbidity in a general population. Family Med 1991;23:510-5.

8. Becker GE. Breastfeeding knowledge of hospital staff in rural maternity units in Ireland. J Hum Lact 1992; 8:137-42.

9. Michaelson KF, Larsen PS, Thomsen BL, Samuelson G. The Copenhagen cohort study on infant nutrition and growth: duration of breastfeeding and influencing factors. Acta Paediatr 1994;83:565-71.

10. World Health Organization. Indicators for assessing breastfeeding practices. WHO/CDD/SER/91.14. Report of an informal meeting 11-12 June 1991. Geneva: WHO, 1991.

11. UNICEF. State of the World's Children 1995. New York: UNICEF, 1994.

12. Vestermark V, Hogdall CK, Plenov G, Birch M, Toftager-Larsen K. The duration of breastfeeding. Scand J Soc Med 1991;19:105-9.

13. Demographic and Health Survey, Kenya. Columbia, Md, USA: Macro International, 1989.

14. Nakhisa S. Kenya: The Breastfeeding Information Group. In: Jelliffe DB, Jelliffe EFP, eds. Prgrammes to promote breastfeeding. Oxford: Oxford University Press, 1988:210-4.

15. Rabiee R, Geissler C. The impact of maternal workload on child nutrition in rural Iran. Food Nutr Bull 1992;14:43-8.

16. UNICEF Nutrition Section. Strategy for improved nutrition of children and women in developing countries. New York: UNICEF, 1990.

17. UNICEF, WHO. Breastfeeding management and promotion in a baby-friendly hospital: an 18-hour course for maternity staff. New York: UNICEF, 1993.

18. WHO, UNICEF. Breastfeeding counselling: a training course. Geneva: WHO, 1993.

19. Botswana Ministry of Health. Family health study 11. Gaborones: Ministry of Finance and Development Planning and Ministry of Health, 1989.

20. American Public Health Association. Legislation and policies to support maternal and child nutrition. Report no. 6. Washington: APHA, 1989.

21. Giugliani ERJ, Caiaffa WT, Vogelbut J, Witter FR, Perman JA. Effect of breastfeeding support from different sources on mothers' decisions to breastfeed. J Hum Lact 1994;10:157-61.

22. Breastfeeding Information Group. Please help your wife to breastfeed. Nairobi, Kenya: BIG, 1986.

23. Pelletier J-G. Severe malnutrition: a global approach. Children in the tropics. No. 208-9. Paris: Centre Internationale de l'Enfance, 1993.

24. Ricciuti HN, Dorman R. Interaction of multiple factors contributing to high-risk parenting. In: Hoekelman RA, ed. Minimizing high-risk parenting. Media, Pa, USA: Harwal, 1983:187-210.

25. Scheper Hughes N, ed. Child survival: anthropological perspectives on the treatment and maltreatment of children. Dordrecht, the Netherlands: D Reidel, 1987.

26. Weston JA, Colloton M, Halsey S, Covington S, Gilbert J, Sorrentino-Kelly L, Renoud S. A legacy of violence in nonorganic failure to thrive. Child Abuse and Neglect 1993;17:709-14.

27. Demographic and Health Survey, Colombia 1990. Columbia, Md, USA: Macro International, 1990.

28. Satter E. The feeding relationship. Zero to three. Bulletin of National Center for Clinical Infant Programs (Arlington, Va, USA). 1992;12(5):1-9.

29. Landers C, ed. Early child development. Summary report of an Innocenti Global Seminar 12-30 June 1989. Florence, Italy: UNICEF, 1989.

30. Varendi H, Porter RH, Winberg J. Does the newborn find the nipple by smell? Lancet 1994;344:989-90.

31. Porter RH, Makin JW, Davis LB, Christensen KM. Breast-fed infants respond to olfactory cues from their own mother and unfamiliar lactating females. Inf Behav Dev 1992;15:85-93.

32. Myers BJ. Mother-infant bonding: the status of this critical-period hypothesis. Dev Rev 1984;4:240-74.

33. Widstrom AM, Wahlberg V, Matthiesen AS, Eneroth P, Uvnas-Modberg K, Werner S, Winberg J. Short-term effects of early suckling and touch of the nipple on maternal behaviour. Early Hum Dev 1990; 21:15363.

34. Sosa R, Kennell JH, Klaus M, Urrutia SJ. The effect of early mother-infant contact on breast-feeding, infection and growth. CIBA Found Symp 1976;45:179-93.

35. Anderson GC. Current knowledge about skin-to-skin (kangaroo) care for preterm infants. J Perinatol 1991;11:21626 and Breastfeed Rev 1993;2:364-73.

36. Ludington-Hoe SM, Golant SK. Kangaroo care: the best you can do to help your preterm infant. New York: Bantam, 1993.

37. Rey ES, Martinez HG. Manejo racional del nino prematuro. In: Proceedings of the Conference I Curso de Medicina Fetal y Neonatal. Bogota, Colombia 1981: 137-51.

38. Bergman NJ, Jurisoo LA. The 'kangaroo method' for treating low birth weight babies in a developing country. Trop Doctor 1994;24:57-60.

39. McKenna JJ, Mosko S. Evolution and infant sleep: an experimental study of infant-parent co-sleeping and its implications for SIDS. Acta Paediatr 1993;Suppl 389: 31 -6.

40. Stratton P. Significance of the psychobiology of the human newborn. In: Stratton P, ed. Psychobiology of the human newborn. Chichester, UK: John Wiley, 1982:1 -16.

41. Uauy R, Hoffman DR. Essential fatty acid requirements for normal eye and brain development. Semin Prenatol 1991;15:449-55.

42. Uauy R, Birch E, Birch D, Peirano P. Visual and brain function measurements in studies of omega-3 fatty acid requirements of infants. J Pediatr 1992;120:S168-80.

43. Makrides M, Simmer K, Goggin M, Gibson RA. Erythrocytic docosahexaenoic acid correlates with the visual response of healthy, term infants. Pediatr Res 1993;34:425-7.

44. Birch E, Birch D, Hoffman D, Hale L, Everett M, Uavy R. Breastfeeding and optimal visual development. J Pediatr Ophthalmol Strabis 1993;30:33-8.

45. Barker E. The critical importance of mothering. Schaumberg, Ill, USA: La Leche League International, 1988.

46. Goodfriend MS. Treatment of attachment disorder of infancy in a neonatal intensive care unit. Pediatrics 1993;91:139-42.

47. Morrow-Tlucak M, Haude RH, Ernhart CB. Breastfeeding and cognitive development in the first two years of life. Soc Sci Med 1988;26:635-9.

48. Lucas A, Morley R. Cole TJ, Lister G, Leeson-Payne C. Breastmilk and subsequent intelligence quotient in children born preterm. Lancet 1991;339:261-4.

49. Rogan WJ, Gladen BC. Breast-feeding and cognitive development. Early Hum Dev 1993;31:181-93.

50. Pollack JI. Long-term associations with infant feeding in a clinically advantaged population of babies. Dev Med Child Neurol 1994;36:429-40.

51. Lanting CI, Fidler V, Huisman M, Touwen BC, Boersma ER. Neurological differences between 9 year-old children fed breast-milk or formula-milk as babies. Lancet 1994;344:131922.

52. Broad FE, Duganzich DM. The effects of infant feeding, birth order, occupation and socio-economic status on speech in six-year-old children. N Zeal Med J 1983;96:483-6.

53. Bowlby J. Attachment. Harmondsworth, UK: Penguin, 1971.

54. Klaus MH, Kennell JH. Maternal-infant bonding. St Louis, Mo, USA: Mosby, 1976.

55. Howrigan GA. Fertility, infant feeding and change in Yucatan. Special issue: Parental behavior in diverse societies. New Directions for Child Development 1988;40: 37 -50.

56. La Leche League. The womanly art of breastfeeding. 4th ed. Franklin Park, Ill, USA: La Leche League International, 1987.

57. Epstein K. The interactions between breastfeeding mothers and their babies during the breastfeeding session. Early Child Dev Care 1993;87:93-104.

58. International Labour Organization. Maternity Protection Conventions no. 3 (1919) and no. 103 (1952) Geneva: ILO, 1952.

59. van Esterik P. Women, work, and breastfeeding. Cornell International Nutrition Monograph series, no. 23. Ithaca, NY, USA: Cornell Program in International Nutrition, 1992.

60. Walton MD, Vallelunge LR. The role of breastfeeding in establishing early mother-infant interactions. Society for Research in Child Development conference, Kansas City, Mo, USA, 1989 (abstr).

61. Fagan J. Dore MM. Mother-child play interaction in neglecting and non-neglecting mothers. Early Child Dev Care 1993;87:59-68.

62. Woolridge MW, Baum JD. Infant appetite-control and the regulation of breast milk supply. Children's Hospital Quarterly (Bristol Institute of Child Health) 1991; 3:113-9.

63. Levine R. Huffman S. The economic value of breastfeeding. Washington, DC: Academy for Educational Development, 1990.

64. Gupta A, Rohde J. Economic value of breast-feeding in India. Economic and Political Weekly, 26 June 1993: 1390-3.

65. da Vanzo J. Starbird E, Beibowitz A. Do women's breastfeeding experiences with their first-borns affect whether they breastfeed their subsequent children? Soc Biol 1990;37:223-32.

66. Jelliffe DB, Jelliffe EFP, Cunningham AS. Breastfeeding, growth and illness: an annotated bibliography. New York: UNICEF, 1992.

67. Piwoz E. Improving feeding practices during childhood illness and convalescence: lessons learned in Africa. Washington, DC: SARA Project, Academy for Educational Development, 1994.

68. Dewey KG, Heinig J. Nommsen LA, Lonnerdal B. Maternal versus infant factors related to breast milk intake and residual milk volume: the DARLING study. Pediatrics 1990;87:829-37.

69. Matheny RJ, Birch LL, Picciano MF. Control of intake by human milk-fed infants; relationships between feeding size and interval. Dev Psychobiol 1990;23: 511-8.

70. Personal communication from the child, now an obstetrician. Irbid, Jordan, 1994.

71. WHO. International code of marketing of breast-milk substitutes. Geneva: WHO, 1981.

72. World Health Assembly. Infant and young child nutrition. Resolution 39.28 of the 39th World Health Assembly, May 1986. Geneva: WHO, 1986.

73. Fortaleza Conference on Appropriate Technology for Birth. Childbirth recommendations from WHO. Nairobi, Kenya: IBFAN Africa News, February 1986.

74. Scheper Hughes N. Death without weeping: the violence of everyday life in Brazil. Berkeley, Calif, USA: University of California Press, 1992.

75. Dettwyler KA. Breastfeeding and weaning in Mali: cultural context and hard data. Soc Sci Med 1987;24:63344.

76. Brakohiapa LA, Bille A, Quansah E, Kishi K, Yartey J, Harrison E, Armar MA, Yamamoto S. Does prolonged breastfeeding adversely affect a child's nutritional status? Lancet 1988;2:416-8.

77. Cousens S, Nacro B, Curtis V, Kanki B, Tull F, Traore E, Diallo I, Mertens T. Prolonged breast-feeding: no association with increased risk of clinical malnutrition in young children in Burkina Faso. Bull WHO 1993; 71:713-22.

78. Taren D, Chen J. A positive association between extended breast-feeding and nutritional status in rural Hubei Province, People's Republic of China. Am J Clin Nutr 1993;58:862-7.

79. Sowers M, Corton G, Shapiro B, Jannausch ML, Crutchfield M, Smith ML, Randolph JF, Hollis B. Changes in bone density with lactation. JAMA 1993;269:3130-5.

80. Cumming RG, Klineberg RJ. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women. Int J Epidemiol 1993;22:684-92.

81. Newcomb PA, Storer BE, Longnecker MP, Mittendorf R, Greenberg ER, Clapp RW, Burke KP, Willett WC, MacMahon B. Lactation and a reduced risk of pre-menopausal breast cancer. N Engl J Med 1994;330:81-7.

82. Rosenblatt KA, Thomas DM. WHO Collaborative study of neoplasia and steroid contraceptives. Lactation and the risk of epithelial ovarian cancer. Int J Epidemiol 1993;22:192-7.

83. World declaration on the survival, protection and development of children and plan of action for implementing the world declaration in the 1990s. New York: United Nations, 30 September 1990.

84. WHO, UNICEF. Protecting, promoting, and supporting breastfeeding: the special role of maternity services. Geneva: WHO, 1989.

85. Kyenkya-lsabirye M, Magalhaes R. The mothers' support group role in the health care system. Int J Gynecol Obstet 1990;31(Suppl 1):85-90.

86. Chicago Breastfeeding Task Force. The Illinois Breastfeeding Peer Counselor Manual: mothers helping mothers. Chicago: CBTF, 1994.

Contents - Previous - Next