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Breastfeeding is the feeding of an infant or young child with milk from a woman's breasts. Babies have a sucking reflex that enables them to suck and swallow milk.
Experimental evidence suggests that, with few exceptions, human breast milk is the best source of nourishment for human infants.[1] Experts still disagree about how long breastfeeding should continue to gain the most benefit, and how much extra risk is involved in using breast milk substitutes.[2][3][4]
An infant may be breastfed by its own mother or by another lactating female, a wet nurse. Breast milk may be expressed and fed to a baby through a bottle, and pasteurized donor human milk may also be used. Breast milk substitutes are available for mothers or families who cannot or prefer not to breastfeed their children. While there are conflicting studies about the relative value of breast milk substitutes, the use of commercial infant formulas is acknowledged to be inferior to breastfeeding for both full term and premature infants. [5] In many countries, artificial feeding is associated with a greater mortality from diarrhoea in infants[6] but where there is clean water, many consider artificial feeding to be acceptable.[3]
Governmental strategies and international initiatives promote breastfeeding as the best method of feeding infants in their first year and beyond. The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) also promote breastfeeding.[7][8]
The production, secretion and ejection of milk is called lactation.
From the third month of pregnancy (the second and third trimesters), a woman's body produces hormones that stimulate the growth of the milk duct system in the breasts:
By the fifth or sixth month of pregnancy, the breasts are ready to produce milk. It is also possible to induce lactation.
During the latter part of pregnancy, the woman's breasts enter into the Lactogenesis I stage. This is when the breasts make colostrum, a thick, sometimes yellowish fluid. At this stage, high levels of progesterone inhibit most milk production. It is not a medical concern if a pregnant woman leaks any colostrum before her baby's birth, nor is it an indication of future milk production.
At birth, the delivery of the placenta results in a sudden drop in progesterone, estrogen, and HPL levels while prolactin levels remain high. This abrupt withdrawal of progesterone in the presence of high prolactin levels stimulates the copious milk production of Lactogenesis II.
When the breast is stimulated, prolactin levels in the blood rise, peak in about 45 minutes, and return to the pre-breastfeeding state about three hours later. The release of prolactin triggers the cells in the alveoli to make milk. Prolactin also transfers to the breast milk. Some research indicates that prolactin in milk is higher at times of higher milk production, and lower when breasts are fuller, and that the highest levels tend to occur between 2 a.m. and 6 a.m.[10]
Other hormones—notably insulin, thyroxine, and cortisol—are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II begins about 30–40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50–73 hours (2–3 days) after birth.
Colostrum is the first milk a breastfed baby receives. It contains higher amounts of white blood cells and antibodies than mature milk, and is especially high in immunoglobulin A (IgA), which coats the lining of the baby's immature intestines, and helps to prevent germs from invading the baby's system. Secretory IgA also helps prevent food allergies.[11] Over the first two weeks after the birth, colostrum production slowly gives way to mature breast milk.[9]
The hormonal endocrine control system drives milk production during pregnancy and the first few days after the birth. When the milk supply is more firmly established, autocrine (or local) control system begins. This stage is called Lactogenesis III
During this stage, the more that milk is removed from the breast, the more the breast will produce milk.[12][13] Research also suggests that draining the breasts more fully also increases the rate of milk production.[14] Thus the milk supply is strongly influenced by how often the baby feeds and how well it is able to transfer milk from the breast. Low supply can often be traced to:
Breastfeeding at least once every two to three hours helps to keep up the milk supply. For most women, a target of eight breastfeeding or pumping sessions every 24 hours keeps their milk supply high both during the early months of lactation, and especially past the fourth month.[8] It is not at all uncommon for newborn babies to feed far more often than this: 10 to 12 breastfeeding sessions every 24 hours is common, and some may even feed 18 times a day.[15] Feeding a baby on demand (sometimes referred to as "on cue"), which may mean breastfeeding many times more than the recommended minimum, is the best way to maintain milk production and ensure the baby's needs for milk and comfort are being satisfied.[7] However, it may be important to recognize whether a baby is truly hungry, as breastfeeding too frequently may mean the child receives a disproportunately high amount of foremilk, and not enough hindmilk, potentially creating problems.[16]
The release of the hormone oxytocin leads to the milk ejection or let-down reflex. Oxytocin stimulates the muscles surrounding the breast to squeeze out the milk. Breastfeeding mothers describe the sensation differently. Some feel a slight tingling, others feel immense amounts of pressure or slight pain/discomfort, and still others do not feel anything different.
The let-down reflex is not always consistent, especially at first. The thought of breastfeeding or the sound of any baby can stimulate this reflex, causing unwanted leakage, or both breasts may give out milk when an infant is feeding from one breast. However, this and other problems often settle after two weeks of feeding. If the mother is in a stressed or anxious state of mind this can cause difficulties with breastfeeding.
A poor milk ejection reflex can be due to sore or cracked nipples, separation from the infant, a history of breast surgery, or tissue damage from prior breast trauma. If a mother has trouble breastfeeding, different methods of assisting the milk ejection reflex may help. These include feeding in a familiar and comfortable location, massage of the breast or back, or warming the breast with a cloth or shower.
The surge of oxytocin that triggers the milk ejection reflex also causes the uterus to contract. During breastfeeding, mothers may feel these contractions as afterpains. These may range from period-like cramps to strong labour-like contractions and can be more severe with second and subsequent babies.[17]
Women who have never been pregnant are sometimes able to induce enough lactation to breastfeed. This is called "induced lactation". A woman who has breastfed before and re-starts is said to "relactate". If the nipples are consistently stimulated by a breast pump or actual suckling, the breasts will eventually begin to produce enough milk to begin feeding a baby. Once established, lactation adjusts to demand. This is how some adoptive mothers, usually beginning with a supplemental nursing system or some other form of supplementation, can breastfeed.[18] There is thought to be little or no difference in milk composition whether lactation is induced or a result of pregnancy. Rare accounts of male lactation (as distinct from galactorrhea) exist in the medical literature.
Some drugs, primarily atypical antipsychotics such as Risperdal, may cause lactation in both women and men. Also, some couples may use lactation for sexual purposes.
The exact properties of breast milk are not entirely understood, but the nutrient content of mature milk is relatively stable. Its ingredients come from the mother's food supply and the nutrients in her bloodstream at the time of feeding. If that is not enough, nutrients come from the mother's bodily stores. Some studies estimate that a woman who breastfeeds her infant exclusively uses 500–600 more calories a day just producing milk for her offspring.[19] The exact composition of breast milk varies from day to day, and even hour to hour, depending on both the manner in which the baby nurses and the mother's food consumption and environment, so the ratio of water to fat fluctuates.
Foremilk, the milk released at the beginning of a feed, is watery, low in fat and high in carbohydrates; hindmilk, which is increasingly released as the feed progresses is creamier. There is no sharp distinction between foremilk and hindmilk, the change is very gradual. Research from Peter Hartmann's group tells us that fat content of the milk is primarily determined by the emptiness of the breast—the less milk in the breast, the higher the fat content. The breast can never be truly "emptied" since milk production is continuous.
Breastfeeding benefits both mother and child physically and psychologically. Nutrients and antibodies are passed to the baby while hormones are released into the mother's body.[20] The bond between baby and mother can also be strengthened during breastfeeding.[21]
The health benefits of breastfeeding are well documented. According to the American Academy of Pediatrics, —American Academy of Pediatrics policy statement[8]
Breast-fed babies have a lower risk of sudden infant death syndrome (SIDS) and other diseases. Suckling at the breast encourages the proper development of the infant's teeth and speech organs. Suckling also helps prevent obstructive sleep apnea. Also, breast milk is at the right temperature and is immediately available from the breast.
Breastfeeding is associated with lower risk of the following diseases:
Breast milk has several anti-infective factors. These include the anti-malarial factor para-amino benzoic acid (PABA),[31] the anti-amoebic factor BSSL,[32], lactoferrin, the second most common protein in human milk, that binds to iron and inhibits the growth of intestinal bacteria like E. coli and Salmonella, [33][34] and IgA which protects breastfeeding infants from microbial infection.[35]
Breast milk contains the right amount of the amino acids cystine, methionine and taurine that are essential for neuronal (brain and nerve) development. [36] A New Zealand study tracking over 1000 children for 8 to 18 years found small but measurable increases in cognitive ability and education achievement. This remained even after adjusting for other factors (such as maternal education level).[37]
One study suggests that in resource-poor settings where safe infant formula is unavailable, exclusive breastfeeding (as compared with "mixed" feeding where breastfeeding is combined with formula, solids or animal milk) may reduce the risk of HIV transmission from mother to child in infants less than 6 months old.[38]
Unlike human milk, the predominant protein in cow's milk is beta-lactoglobulin, an important factor in cow milk allergies. [39]
Breastfeeding benefits the mother. It releases hormones such as oxytocin and prolactin that have been found to relax the mother and make her feel more nurturing toward her baby.[40] Breastfeeding within a short time after giving birth increases levels of systemic oxytocin. This makes the uterus contract more quickly and decreases maternal bleeding.[41]
As the fat accumulated during pregnancy is used in milk production, prolonged breastfeeding can help mothers to return to their previous weight.[42][43] Frequent and exclusive breastfeeding can cause lactational amenorrhea, a delay in the return of menstruation and therefore fertility. Sometimes this is deliberately used as a birth control method. However, it is unreliable. Many mothers have become pregnant again while still exclusively breastfeeding. Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point during the pregnancy.[44]
Breastfeeding mothers have less risk of many diseases including breast cancer,[8][21] ovarian cancer,[8][21] decreased insulin requirements in diabetic mothers,[45] stabilizing maternal endometriosis,[8] less risk of post-partum hemorrhage,[41] less risk of endometrial cancer,[46][47], less risk of osteoporosis[8][21] and beneficial effects on insulin levels of mothers with polycystic ovary syndrome.[48]
Mothers who breastfeed longer than eight months have better bone re-mineralisation.[49]
On the other hand, some women have thrush or staph infections of the nipple from breastfeeding.[50]
The hormones released during breastfeeding strengthen the mother's nurturing feelings towards the child. Strengthening the maternal bond is very important as up to 80% of mothers suffer from some form of postnatal depression, though most cases are very mild. The woman's partner and other caregivers can support her in a variety of ways and this support is an important factor in successful breastfeeding. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[51]
Breastfeeding can have an impact on the personal relationship between a mother's partner and the child. While some partners may feel left out when the mother is feeding the baby, others see it as an opportunity for strengthening family bonds. Looking after a new baby and breastfeeding take time. This can add pressure to the partner and the family, because the partner has to care for the mother as well as performing tasks she would otherwise do. However, as partners are often very willing to give this support, this pressure can help to strengthen family bonds.[52]
If the mother is away, an alternative caregiver may be able to use expressed breast milk (EBM) to feed the baby. The various breast pumps available for sale and rent, make it possible for working mothers to breastfeed their babies for as long as they want. However, the mother must produce and store enough milk to feed the child for the time she is away and this may not always be practical. Also, the other caregiver must be comfortable in handling breast milk. These two factors may prompt the mother - perhaps against her wishes - to switch to artificial feeding, either temporarily or permanently.
While breastfeeding difficulties are not uncommon, putting the baby to the breast as soon as possible after birth helps to reduce them greatly. The AAP breastfeeding policy says: Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.[8] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained nurses and hospital staff, and lactation consultants.[54]
Several factors can interfere with successful breastfeeding:
Premature infants unable to take enough calories by mouth may need enteral or gavage feeding - inserting a feeding tube into the stomach to provide enough breast milk or a substitute. This is often done together with Kangaroo care (prolonged skin-to-skin contact with the mother) which makes later breastfeeding easier. For some suckling difficulties, such as may happen with cleft lip/palate, the baby can be fed with a Haberman Feeder.
Pain often interferes with successful breastfeeding. It is cited as the second most common cause for the abandonment of exclusive breastfeeding after perceived low milk supply.[63]
Engorgement is the sense of breast fullness experienced by most women within 36 hours of delivery. Normally, this is a painless sensation of "heaviness". Breastfeeding on demand is the primary way of preventing painful engorgement.
When the breast overfills with milk it becomes painful. Engorgement comes from not getting enough milk from the breast. It happens about 3 to 7 days after delivery and occurs more often in first time mothers. The increased blood supply, the accumulated milk and the swelling all contribute to the painful engorgement.[64] Engorgement may affect the areola, the periphery of the breast or the entire breast, and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola/nipple. This makes it harder for the baby to latch on properly for feeding. Latching may occur over only part of the areola. This can irritate the nipple more, and may lead to ineffective drainage of breast milk and more pain. Engorgement may begin as a result of several factors such as nipple pain, improper feeding technique, infrequent feeding or infant-mother separation.
To prevent or treat engorgement, remove the milk from the breast, by breastfeeding, expressing or pumping. Gentle massage can help start the milk flow and so reduce the pressure. The reduced pressure softens the areola, perhaps even allowing the infant to feed. Warm water or warm compresses and expressing some milk before feeding can also help make breastfeeding more effective. Some researchers have suggested that after breastfeeding, mothers should pump and/or apply cold compresses to reduce swelling pain and vascularity even more. One published study suggested the use of "chilled cabbage leaves" applied to the breasts. Attempts to reproduce this technique met with mixed results.[65] Non-steroidal anti-inflammatory drugs or paracetamol (acetominophen) may relieve the pain.
Sore nipples are probably the most common complaint after the birth. They are generally reported by the second day after delivery but improve within 5 days.[66] Pain beyond the first week, severe pain, cracking, fissures or localized swelling is not normal. The mother should see a doctor for further evaluation. Sore nipples, a common cause of pain, often come from the baby not latching on properly. Factors include too much pressure on the nipple when not enough of the areola is latched onto and an improper release of suction at the end of the feeding. Improper use of breast pumps or topical remedies can also contribute. [67] Nipple pain can also be a sign of infection.[50]
Symptoms of candidiasis of the breast include pain, itching, burning and redness, or a shiny or white patchy appearance. The baby could have a white tongue that does not wipe clean. Candidiasis is common and may be associated with infant thrush. Both mother and baby must be treated to get rid of this infection; first-line therapies include nystatin, ketaconacole or miconazole applied to the nipple and given by mouth to the baby. Strict cleaning of clothing and breast pumps is also required to eradicate the infection.[68]
Milk stasis is when a milk duct is blocked and cannot drain properly. This may affect only a part of the breast and is not associated with any infection. It can be treated by varying the baby's feeding position and applying heat before feeding. If it happens more than once, further evaluation is needed.
This is a bacterial infection of the breast, and results in the classic signs of infection - pain (dolor), redness (rubor), swelling (turgor), and warmth (calor). Most often it occurs 2–3 weeks after delivery but can occur at any time.[69] Typical causal organisms include Staphylococcus sp., Streptococcus sp. and E. coli. Prompt treatment can prevent complications like abscess formation. Antibiotics, continued breastfeeding, and plenty of rest are the treatments of choice. Severe cases may require intravenous antibiotics.[70]
For the vast majority of mothers, breastfeeding is best for both them and their babies as medical contraindications to breastfeeding are rare. However there has been identified some situations where breastfeeding is not the best choice.
Infants with classic galactosemia cannot digest lactose and therefore cannot benefit from breast milk.[71] Breastfeeding might harm the baby also if the mother has untreated pulmonary tuberculosis (see paragraph below); is taking certain medications that suppress the immune system;[71] uses potentially harmful substances such as cocaine, heroin, and amphetamines;[8] has had unusually excessive exposure to heavy metals such as mercury;[72] or has HIV.[73][71] However, research published in the Lancet[74][75] has highlighted a lower risk of HIV transmission with exclusive breastfeeding by HIV positive mothers (4 percent risk), compared to mixed feeding (10-40 percent risk). This research is of particular importance in developing countries where infant formula is not widely available or safe to prepare.
The vast majority of medicines are compatible with breastfeeding, but there are some that might be passed onto the child through the milk. [76]
Caffeine, tobacco, and alcohol might be noticeably harmful to the baby, if consumed enough. (See Health, diet and substance abuse section.)
The baby's risk from something unsafe in breast milk depends on how much of that substance the baby gets. The level of risk depends on the concentration of the substance in the breast milk and how much milk the infant consumes. Finally, that risk is weighed against the risks of using a substitute for breast milk.
It is not safe for mothers with active, untreated tuberculosis to breastfeed until they are no longer contagious. [8] According to the American Academy of Pediatrics 2006 Redbook:
In areas where BCG vaccination is the standard of care, the WHO provides treatment recommendations and advises mothers to continue breastfeeding.[77] TB may be congenitally acquired, or perinatally acquired through airborne droplet spread.[78]
An exclusively breastfed baby depends on breast milk completely so it is important for the mother to maintain a healthy lifestyle, and especially a good diet.[79] Consumption of 1,500–1,800 calories per day could coincide with a weight loss of 0.45kg (one pound) per week.[80] While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of vitamins A, D, B<sub>6</sub> and B<sub>12</sub>.[81] She may also have a lower supply than well-fed mothers.
There are no foods that are absolutely contraindicated during breastfeeding, but a baby may show sensitivity to particular foods that the mother eats.
Breastfeeding mothers must use caution if they smoke and therefore consume nicotine. Heavy use of cigarettes by the mother (more than 20 per day) has been shown to reduce the mother's milk supply and cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfed infants. Research is ongoing to find out if the benefits of breastfeeding outweigh the potential harm of nicotine in breast milk. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment.[82] Breastfeeding mothers who smoke are counseled not to do so during or immediately before feeding their child, and are encouraged to seek advice to help them reduce their nicotine intake or quit.[83]
Heavy alcohol consumption harms the infant, causing problems with the development of motor skills and decreasing the speed of weight gain. There is no consensus on how much alcohol may be consumed safely, but it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother.[84] Considering the known dangers of alcohol exposure to the developing fetus, those mothers wishing to err on the side of caution should restrict or eliminate their alcoholic intake.[85]
If the mother consumes too much caffeine, it can cause irritability, sleeplessness, nervousness and increased feeding in the breastfed infant. Moderate use (one to two cups per day) usually produces no effect. Breastfeeding mothers are advised to restrict or avoid caffeine if her baby reacts negatively to it. Cigarette smoking is thought to increase the effects of caffeine in the baby.[86]
Cannabis is listed by the American Association of Pediatrics as a compound that transfers into human breast milk. Research demonstrated that certain compounds in marijuana have a very long half-life.[87]
Breastfed infants generally gain weight according to the following guidelines:
0–4 months: 170 grams per week<sup>†</sup> 4–6 months: 113–142 grams per week 6–12 months: 57–113 grams per week
<small><sup>†</sup> It is acceptable for some babies to gain 113–142 grams (4–5 ounces) per week. This average is taken from the lowest weight, not the birth weight.</small>
The average breastfed baby doubles birth weight in 5–6 months. By one year, the typical breastfed baby will weigh about 2½ times birth weight. At one year, breastfed babies tend to be leaner than bottle fed babies.[88] By two years, differences in weight gain and growth between breastfed and formula-fed babies are no longer evident.[9]
There are many books and videos for new mothers to advise them about breastfeeding. Advice and support can also be be obtained from a lactation consultant in hospitals or private practice, or from volunteer organizations of breastfeeding mothers such as the La Leche League.
Babies usually show they are hungry by crying, moaning or fussing. When babies' cheeks are stroked, the rooting instinct makes them move their face towards the stroking and open their mouth. Breastfeeding makes mothers thirsty, especially at first, when both mother and baby are inexperienced and when feeding sessions can last for up to an hour. Having water readily available helps mothers maintain proper hydration.
When the baby's cheek is stroked with the nipple, the baby will open its mouth and turn towards it. So that the baby will latch on well, the nipple should be pushed into its mouth so that the baby has a mouthful of nipple and areola. The nipple should be at the back of the baby's throat. Inverted or flat nipples can be massaged so that the baby will have more to latch onto. Many women wear nursing brassieres for easier access to the breast.
Pain in the nipple or breast is linked to incorrect breastfeeding techniques. Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns. A 2006 study found that inadequate parental education, incorrect breastfeeding techniques, or both were associated with higher rates of preventable hospital admissions in newborns.[89]
The baby may pull away from the nipple after a few minutes or after a much longer period of time. Sometimes the baby will re-latch on the same breast or mother may offer the other breast.
The length of feeds varies a lot. Regardless of the time taken, the breastfeeding woman should be comfortable.
While most women breastfeed their child in the cradling position, there are many ways to hold the feeding baby. It depends on the mother and child's comfort and the feeding preference of the baby. Some babies prefer one breast to the other.
When tandem breastfeeding, the mother is unable to move the baby from one breast to another and comfort can be more of an issue. As tandem breastfeeding brings extra strain to the arms, especially as the babies grow, many mothers of twins recommend the use of more supporting pillows. Favoured positions include:
Exclusive breastfeeding is when an infant receives no other food or drink, or even water, besides breast milk (whether expressed or through breastfeeding).[7]
International guidelines recommend that all infants be breastfed exclusively for the first six months of life. While each country has its own policy regarding infant feeding, it is generally accepted that newborns should be exclusively breastfed for around 6 months, and that breastfeeding should continue with the addition of appropriate foods, for two years or more. The practice of exclusive breastfeeding has dramatically reduced infant mortality in developing countries due to a reduction in diarrhea and infectious diseases.
Exclusively breastfed infants feed, anywhere from 6 to 14 times a day. Their requirements vary greatly. Newborns consume from 30 to 90 ml (1 to 3 US fluid ounces). After the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, and as it grows the amount will increase. It is important to recognise the baby's hunger signs and it is advised that the baby should dictate the number, frequency, and length of each feed, based on the assumption that it knows how much milk it needs. The supply of milk in the breast is determined by the frequency and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it larger; they should, however, go by the demands of the baby rather than what they feel is necessary.
It can be hard to accurately measure the amount of food a breastfed baby consumes, but babies normally feed to meet their own requirements.[90] Babies that fail to eat enough may exhibit symptoms of failure to thrive. If necessary, it is possible to estimate output from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours) suggests an acceptable amount of input for newborns older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools. Babies can also be weighed before and after feeds.
When direct breastfeeding is not possible a baby can still be fed breast milk. By expressing (artificially removing and storing) her milk, a mother can enable her child to be fed with her milk while she is away. With manual massage or the use of a breast pump a woman can express her milk and keep it in freezer storage bags, a supplemental nursing system, or a bottle ready for use. This container may be kept at room temperature for up to seven hours, refrigerated for up to eight days or frozen for up to four months. Research suggests that antioxidant activity in expressed breast milk decreases over time but it still remains in higher levels than in infant formula.[91]
Expressing breast milk can keep up a mother's milk supply when she and her child are apart for long. If a sick baby is unable to feed, expressed milk can be fed through a nasogastric tube.
Expressed milk can also be used when a mother is having trouble breastfeeding, such as when a newborn causes grazing and bruising. When an older baby grows teeth and bites the nipple, the mother's reaction - a jump and a cry of pain - is usually enough to discourage the child from biting again.
It is generally advised to delay using a bottle in feeding expressed breast milk until the baby is about 4-6 weeks old and is good at sucking directly from the breast.[92] This is to avoid nipple confusion and nursing strike, when the baby prefers to suck from bottle, which takes less effort, and so loses its desire to suck from the breast. If feeding expressed breast milk (EBM) must be done before 4-6 weeks of age, it is recommended that it be given by other means such as feeding spoons or feeding cups. Also, EBM should be given by someone other than the breastfeeding mother (or wet nurse), so that the baby can learn to associate direct feeding with the mother (or wet nurse) and associate bottle with other people.
Some women donate their expressed breast milk (EBM) to others, either directly or through a milk bank. Though some dislike the idea of feeding their own child with another woman's milk, others appreciate being able to give their baby the benefits of breast milk. Feeding expressed breast milk—either from donors or the baby's own mother—is the feeding method of choice for premature babies.[93]
Predominant or mixed breastfeeding means feeding breast milk along with infant formula, baby food and even water, depending on the age of the child. Babies feed differently with artificial teats than from a breast. When feeding from the breast, the tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a bottle, an infant will suck harder and the milk may come in more rapidly. Therefore, mixing breastfeeding and bottle-feeding (or using a pacifier) before the baby is used to feeding from its mother can induce the infant to prefer the bottle to the breast. Orthodontic teats, which are generally slightly longer, are closer to the nipple. Some mothers supplement feed with a small syringe or flexible cup to reduce the risk of artificial nipple preference.
Feeding two infants simultaneously is called tandem breastfeeding (Sidenote: Feeding a child while being pregnant with another can also be considered a tandem breastfeeding condition for the nursing mother, as she also provides the nutrition for two[94]). The most common need for tandem breastfeeding is after the birth of twins where both babies are fed at the same time. The appetite and feeding habits of each baby may not be the same, which could mean feeding each according to their own individual needs, while also trying to get them to breastfeed together to minimize time spent breastfeeding.
In cases of multiple births with three or more children, it can be extremely difficult for the mother to organise feeding around the appetites of all the babies. While breasts can produce large quantities of milk, according to the demand placed upon them,[95] it is common for women to use alternatives, although many mothers have been able to breastfeed their infants successfully without them.
Tandem breastfeeding may also occur when a woman has a baby while breastfeeding an older child. During the late stages of pregnancy the milk will change to colostrum, and some older nurslings will continue to feed even with this change, while others may wean due to the change in taste or drop in supply.
Although some may find it controversial, some women breastfeed their children for as many as 3 to (rarely) 7 years from birth. This is called extended breastfeeding. Supporters of extended breastfeeding believe that all the benefits of human milk, nutritional, immunological and emotional, continue for as long as a child nurses. Often the older child will nurse infrequently or sporadically as a way of bonding with the mother. Detractors may believe that prolonging breastfeeding for several years can result in the child developing emotional or psycho-sexual problems,[96] however there is no solid evidence to support these beliefs.
H.L. Hunt, the Texas oil man, was nursed by his mother until he was seven years old (1896). Hunt was something of a prodigy and his mother rewarded him by allowing him to continue nursing at her breast long past the customary weaning age. He finally stopped this practice when his father found him suckling his mother while she was standing in their kitchen kneading dough. As an adult, H.L. Hunt wrote about this without embarrassment. [97]
It is sometimes common for more than one woman to feed a child, such as in developing nations within Africa. This shared breastfeeding has been highlighted as a source of HIV infection in infants.[98]
See also: wet nurse
Weaning is the process of gradually introducing the infant to what will be its adult diet and withdrawing the supply of milk. The infant is considered to be fully weaned once it no longer receives any breast milk and begins to rely on solid foods for all its nutrition. Most mammals cease the production of the enzyme lactase at the end of weaning, becoming lactose intolerant. Many humans have a mutation that allows the production of lactase throughout life and can drink milk well beyond the age of weaning.[99] This milk comes from dairy animals, usually cows or goats.
In the past, bromocriptine was sometimes used to reduce the engorgement experienced by many women during weaning. However, it was discovered that when used for this purpose, this medication posed serious health risks to women, such as stroke, and the U.S. FDA withdrew this indication for the drug.[100]
Prior to the last few hundred years or so, alternatives to breastfeeding were rare. Attempts were made in 15th century Europe to introduce cow or goat's milk, but were not very positive. The next resurgence came in the 18th century when flour or cereal mixed with broth were introduced as substitutes, but this also did not have a favorable outcome. True commercial infant formulas did not appear on the market until the mid-1800s, and it was post-WWII that their use became widespread. As the risks of increased illness, death and other negative consequences with the use of breast milk alternatives became well-established in medical literature, breastfeeding rates have increased in recent times in countries that have enacted measures to protect the rights of infants and mothers to breastfeed.
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