Breast-Feeding Beyond Babyhood
When the American Academy of Pediatrics urged in December 1997 that all babies be breast-fed for at least the first year of life, a 29-year-old mother in Champaign, Ill., cheered: The woman’s son, then 2 1/2, was still nursing at least once a day, and seemed a rosy-cheeked testimonial to the health benefits of breast milk. He recovered quickly from stomach flus and colds, and seemed bright, happy and well-adjusted. The little boy was hitting developmental milestones and climbing the growth chart right on track.
But in July, the applause suddenly stopped. The woman’s son, by then 5 years old, was removed from her home after caseworkers responded to a baby-sitter’s complaint. Judge Ann Einhorn approved the separation, declaring that the woman’s continued breast-feeding had created a situation with “enormous potential harm to this child.” To protect the boy, the judge has ordered the woman’s name withheld and has barred her from speaking to the media.
The incidence of breast-feeding in the United States is on the rise and, with a welter of new studies, the medical case for breast-feeding infants is growing stronger. But against this backdrop, the Champaign case has sparked a debate among parents, child welfare officers and health professionals: How much breast milk is enough? And can you get--or give--too much of a good thing?
In a country where fewer than 16% of babies are still being breast-fed on their first birthday, the question applies to a small group of children. And answering it is more than a case of consulting the medical literature on prolonged breast-feeding, which is, in any event, scant. For the subject of breast-feeding--and particularly the breast-feeding of older children--stirs up a complicated stew of politics, psychology and cultural belief.
Is breast-feeding beyond babyhood about sex--a charge that propelled the Champaign case into the courtroom in the first case? Does it foster a child’s independence or smother it? Is there any nutritional or health benefit to nursing beyond infancy, or is the child who continues to feed at his mother’s breast--usually no more than once a day--merely satisfying an impulse for comfort or sucking? And what exactly are the motives of the rare woman who bucks the American norm of early weaning?
Like almost all matters of child rearing--from a shared family bed to toilet training to spanking--such questions touch raw nerves and spark fervent debate at dinner parties and professional conferences. And like these practices, breast-feeding has gone in and out of vogue--responsive more to cultural and sometimes economic shifts than to clear scientific evidence. In the last century, the development and mass marketing of baby formula in the 1920s, the ebb and tide of mothers into the workplace, and even the counter-culture “earth mother” movement of the 1970s were key factors in driving nursing rates up and down.
After reaching a low point in 1971, the incidence of nursing among the mothers of newborns has reached roughly 64%, with less than three in 10 continuing to nurse at the six-month mark, and just 16% still nursing or planning to nurse at one year.
In the recent history of breast-feeding in America, that represents a spike. And in this case, the shift has had strong medical impetus. It has come at a time when two key organizations--the 55,000-member American Academy of Pediatrics and the United Nations’ World Health Organization--have adopted sweeping new guidelines intended to promote longer-term breast-feeding. In 1991, the WHO urged that all children be breast-fed until they are 2. And in 1997, the AAP, in its first-ever statement on breast-feeding, recommended that almost all babies be breast-fed “for at least 12 months, and thereafter for as long as mutually desired.”
After several decades of research, health specialists now can cite strong research evidence of breast-feeding’s positive effects in the first year. But for a host of reasons, breast-feeding beyond that milestone is territory virtually uncharted by the scientific establishment.
If Some Is Good, Is More Better?
In a small number of well-regarded studies, some researchers see growing evidence of a “dose effect” for breast-feeding. Essentially, the studies suggest that if some breast milk is good for baby’s health, then more breast milk--or breast milk given over a longer period of time--is even better.
How much continued breast-feeding will improve a child’s health, and for how long, are not precisely understood, researchers acknowledge. But one thing is clear: The more-is-better school of thought is putting the lie to the widely held belief that breast-feeding works all of its magic in the first six months of life.
“There may be a tapering-off effect” of breast milk’s benefits as a child grows older, says Dr. Lawrence Gartner, who chairs the American Academy of Pediatrics’ executive committee on breast-feeding and who oversaw the drafting of the 1997 recommendation. “But there are probably other changes in breast milk that we don’t yet understand--changes which help the older child adapt to a different environment. It’s a dynamic situation.”
Dr. Armond Goldman, an immunologist at the University of Texas, conducted research in the 1980s showing that in her second year of lactation, a mother’s milk continued to contain elements that helped bolster and build a baby’s immune system, roughly in the same concentration as her first-year milk. That, cautions Goldman, does not prove there are benefits to that milk. “But it would be rather wasteful for it to be secreted if it was not doing anything,” he says. And nature, he adds, abhors waste.
Beyond that, a number of studies conducted through the 1990s established that, contrary to widespread belief, 12 months of breast-feeding seems to protect a child better than six months of breast-feeding from diseases ranging from childhood diabetes and Crohn’s disease to leukemia and food allergies.
“No one wants to feel guilty about it, so you hate to drone on,” Goldman says. “But there are statistically significant improvements if you go on for a year.”
Emerging signs of breast milk’s dose effect aren’t confined to a child’s physical health. A 1998 study that evaluated the cognitive skills and academic achievement of New Zealanders between the ages of 8 and 18 found that the longer the children were breast-fed in their first year of life, the higher they scored.
The dose effect inference, however, leaves plenty of room for debate and discomfort among scientists, not to mention physicians and the parents who must shoulder the burden of nursing. But most scientists argue that another inference, which springs from evolutionary biology, strengthens their comfort level with the logical conclusion that dose effects suggest: Stripped of the trappings of industrialization, humans and their primate relatives will breast-feed for several years. And if nature has provided for that to happen, they surmise, the practice must be serving some useful purpose.
Katherine Dettwyler, an anthropologist at Texas A&M; University, notes that among nonindustrialized cultures in which breast-feeding is widespread, children are most commonly weaned between 3 and 5 years of age. Before the invention of infant formula in the 1920s, the practice of nursing well into the second and third years was commonplace in the United States as well.
The breast-feeding patterns of primates also provide clues as to what nature intended, says Dettwyler. Among humans’ distant relatives, Dettwyler found that the weaning of offspring is very consistent: It is a function of the length of a species’ gestation and the eruption of the baby’s molars. Applying the same formula to human children, she adds, would suggest that the natural age for weaning in our species would be somewhere between 2 1/2 and 7 years old.
Mothers like the one at the center of the Champaign court case “are outliers culturally but not biologically,” says Dettwyler. But, adds the AAP’s Dr. Lawrence Gartner, “we live in a society that is not in tune with biologic reality.” We are a culture that sees the breast as a sexual organ, says Gartner, “not a breast-feeding culture.”
In courtrooms all over the country, that bias is on regular display, say legal experts. Elizabeth Baldwin, a Florida attorney who works with La Leche League of America, says she encounters legal complaints about long-term breast-feeders frequently. A few, like the Champaign, Ill., case, involve child welfare agencies investigating charges of abuse. More often, however, such complaints arise in divorce and custody proceedings, where a man points to his wife’s decision to breast-feed long-term in an effort to cast doubt on her fitness as a mother.
Cultural Norms Matter, Some Experts Warn
“It’s not hard to do that because lawyers and judges are reflections of our society as a whole, and they don’t understand” how a mother could decide to allow a child to wean himself on his own schedule, says Baldwin.
But whatever nature may have intended, cultural norms do matter, caution some experts. And when a mother departs from a powerful one like the one that dictates early weaning, it can be a warning sign of other problems, says Harvard University pediatrician T. Berry Brazelton, co-author of “A Child’s Irreducible Needs.”
“If I were seeing that child in a clinical setting, I would be looking for separation and autonomy issues,” says Brazelton. “I would think of it as [the mother’s] issue. But I would want to make sure that her issue wasn’t making it difficult for the little boy. And you’d have to look beyond the nursing to find that out.”
In the Champaign case, Judge Einhorn ultimately rejected charges that long-term breast-feeding amounted to sexual abuse, and has, seven months after his initial removal, allowed the child’s return to his mother. But in her rulings, Einhorn appeared to accept the suggestion that the mother had problems granting her child’s growing need for independence. She has ordered parenting courses and counseling as a condition of the child’s return.
For the woman who allows her child to wean at his own pace, such messages can be a source of particular conflict. American society prizes the individual’s self-reliance, and babies are not immune to the rigors that early independence demands. Unlike most of the world, for instance, most Americans choose to put even the youngest infants to sleep in a separate bed. In that cultural context, a mother who continues to breast-feed an older child raises suspicions that she finds it difficult to break the bond of babyhood.
But Nadja Flanagan, a South Pasadena mother of four (with a fifth about to be born), sees the decision as empowering. She nursed each of her first four children, including three through a subsequent pregnancy, until they were at least 3. Flanagan clearly believes that long-term nursing has health benefits. Her oldest, now 12, had her first ear infection at age 4, and Flanagan thinks it’s the only one the family has had.
Flanagan also believes that she has boosted her children’s confidence and self-control by letting them have some control over where, when and how they seek comfort and nourishment.
“They are comfortable in their own skin, comfortable with themselves. I wanted to feed them that security because I see it as a need that won’t go away even if it’s not fed,” says Flanagan.
“They’re not independent because they have to be but because they’re empowered to be, ready to be,” she says. “Forced independence may work in the short term, but in the long run it’s not lasting.”
La Leche League, the venerable organization that champions breast-feeding, sees signs of change in Americans’ discomfort with the practice. In 1999, Congress passed a law protecting the rights of mothers to nurse publicly on federal property--the first in a welter of pending legislation that would promote breast-feeding. And pressed by the AAP, physicians who long hesitated to push the issue are more actively encouraging the practice.
As a breast-feeding researcher and pediatrician at the Venice Family Clinic, UCLA professor Wendelin Slusser straddles the two worlds of science and clinical practice. While she finds evidence of breast milk’s dose effect compelling, she says there are plenty of other good reasons to promote longer-term breast-feeding. In a baby’s second year of life, for instance, breast milk can provide as much as 25% of a child’s caloric intake and 90% of her daily need for vitamin C, in addition to an ongoing dose of immunological protection. “Breast milk is still good food. And it’s a real safety net” for babies and their families, she says.
While her clinical experience doesn’t count as research, Slusser says she perceives “a bright little twinkle” in the children she treats who are breast-fed for long periods. And she almost never, she adds with a laugh, sees them because they’re sick.
And if it provides comfort and support to an older child exploring his world? “What’s wrong with that?” Slusser asks. “That’s one of the roles of a parent.”
But finding the endpoint of a good thing is one of medical research’s most difficult challenges, says Goldman of the University of Texas. And in industrialized societies, nursing beyond the first year of life has become enough of a rarity that, even if scientists like Goldman could command the research funds to conduct them, they fear they would have problems gathering sufficient populations and designing reliable studies to explore its effects.
Which is not to say that long-term breast-feeders do not exist in the United States. In a bid to study the practice of long-term breast-feeding, anthropologist Dettwyler set out to find American women who have nursed beyond their child’s third birthday. On a first pass, she found 1,280 potential research subjects, and she continues to hear from women who step forward when they learn of her work.
“I call them my closet breast-feeders,” says Dr. Slusser.
In the final analysis, many say that while useful, much of the medical research on breast-feeding currently underway approaches the question from the wrong direction. Given that primates and humans living in nonindustrial circumstances all nurse for several years, says Dr. Gartner, researchers should be asking, what are the ill effects of early weaning as it is practiced in the United States?
“The question is, are you doing any harm?” asks Gartner. Until you answer it, he says, “there truly is no basis for any upper limit,” says Gartner.
