Archive for April, 2011

Breastfeeding for longer than a year – myths, facts, and what the research really shows

(This post first appeared on the Good Enough Mum blog as a submission to the April 2011 Carnival of Breastfeeding.  You can read the original here.)

Extended breastfeeding is the term given, in our society, to breastfeeding a child beyond the first year.  An increasing number of women are choosing to do this, and, sadly, are more often than not incurring heated disapproval for doing so. Breastfeeding toddlers or older children is believed to make them overly dependent, mothers who do so are accused of thinking only of their own needs and not of their children (that ultimate indictment for mothers), and the practice is looked on as inappropriate and downright perverse.

Fortunately, it’s now being increasingly recognised that this position is not supported by either logic or evidence.  Not only is there not a shred of evidence that breastfeeding beyond a year is harmful, there is positive evidence to reassure us on this score – the world is full of societies in which it is considered normal and expected behaviour to continue breastfeeding for considerably longer than a year, and the children raised thusly seem to be doing perfectly well on the practice.  It is, of course, hugely beneficial for children in developing countries where food can be scarce and malnutrition rife, and it has some potential benefits even in our affluent society – it can be a valuable source of nutrition for otherwise faddy toddlers, and it slightly reduces a mother’s risk of breast cancer or rheumatoid arthritis.

I’m delighted to see it becoming more widely recognised that there is absolutely no reason why a mother should feel obliged to wean simply because an arbitrary date on the calendar is approaching.  However, there’s a twist to this; the pressure is starting to go the other way.  A small but vocal minority are pushing for breastfeeding past a year to be seen not merely as an option for women who want to do so, but as a goal for everyone to aim for.  Breastfeeding a toddler (or older child) is enthusiastically touted as having a host of physical and psychological benefits.  Lactivists are advising mothers that they should do their best to continue nursing until two years at the very least, and preferably longer (nursing until the child decides spontaneously to stop is held up as the ideal).  And the problem is that there really isn’t any decent evidence to support this attempted move towards yet another blanket parenting ‘should’.

I’m not objecting, here, to an individual woman deciding that there may be particular circumstances in her child’s case – deprived circumstances, an unusual health problem, or even just food faddiness – that might lead to her wanting to continue to breastfeed in hopes that it will be of some benefit.  Also, of course, I’m talking specifically about the situation in the developed world here, not about breastfeeding in developing countries where it is indeed likely to remain beneficial for long past infancy.  My objection is to the claims that extended breastfeeding has been shown to be of general benefit even in situations where other sources of nutrition are plentiful.  It hasn’t.  And while this kind of pro-extended-breastfeeding advocacy has been a huge comfort to plenty of women who, having struggled with the pressure from others to wean before they wish to, now feel vindicated, it’s also putting some women in the position of feeling obliged to nurse for longer than they really want to, in the belief that they’ll be somehow depriving or disadvantaging their children if they don’t.  That is not a trend I want to see.

That position, of course, is controversial enough in lactivist circles that it’ll need some defending; to break up what’s now set to be a very long post, I’m going to go for the ‘Debate With Imaginary Opponent’ format.

What do you mean, there’s no evidence that nursing past a year is beneficial?  Are you trying to claim that a fluid so packed with nutrition, antibodies, and general goodness somehow magically loses all its benefits just because a child has passed the age of one?

Of course not.  What happens is that the child gradually grows, develops and reaches the point where breast milk just doesn’t have anything much further to add.  (Just to clarify, in case anyone was forgetting how I began this post, I’m fine with children continuing to nurse after that point if they and their mothers so wish.   All I’m objecting to is the claim that they should continue to nurse, which I don’t agree with any more than the claim that they should stop.)

But there’s plenty of evidence that breasfeeding is beneficial to toddlers.  For starters, one study by Gulick (1) showed that breastfed toddlers between 16 and 30 months old get sick less often than non-breastfed toddlers and get better more quickly when they do…

No, it didn’t.

Huh?

It didn’t.  Although lactivist websites all over the Internet claim that that study shows a decreased rate of infections in breastfed toddlers between 16 and 30 months old, it actually shows nothing of the sort.  I know this because I’ve got hold of a copy of the study and read it for myself.  The toddlers being studied weren’t breastfed toddlers – they were toddlers who’d been breastfed in the past but had stopped breastfeeding before entering the study.  What the study was actually looking at was whether longer duration of breastfeeding during infancy had any benefit in terms of reducing infection rates in toddlerhood after breastfeeding cessation.  (It didn’t, in case you’re interested; at least, not in that study.)  Somehow, someone has managed to utterly and crashingly misreport what the study was into and what it showed, and lactivists across the Internet have simply repeated this misinformation without question.  It’s one of the biggest breastfeeding myths I’ve seen out there.

Well, come on – what about the other studies on the topic?  Look – Kellymom has a whole list of studies showing the immunological benefits to breastfed toddlers!

One of those is a study set in a developing country, showing benefit to children who are severely malnourished children.  As I said, breastfeeding can indeed be beneficial past infancy in such a setting, but it just isn’t valid to assume that those results will be applicable to children living in our relatively privileged Western settings.  One wasn’t even studying toddlers – it was a study of breastfeeding benefits in babies up to the age of 20 weeks, which is not toddlerhood by any remote stretch of the imagination.  The rest, as far as I can see, all just look at concentrations of antibodies in breastmilk of mothers of nursing toddlers, not at whether those antibodies are actually adding anything to the toddler’s own antibodies when it comes to fighting off infections.

Oh, come on.  Surely all those antibodies have to be doing something.

Not necessarily.  Bear in mind that a child’s own immune system also develops rapidly during the early years, and at some point it’s going to reach the stage where breast milk just doesn’t have a lot else to contribute.

That surely can’t be as early as a year, though.  I can’t believe that breastmilk doesn’t still have some benefit to children older than that.

You’re welcome to believe what you like.  It’s the claim that it’s been proved to be beneficial that I’m objecting to.

So have you any evidence that it isn’t?

In the one study I have been able to find on infection rates in breastfed vs. non-breastfed toddlers – a study in New Zealand that followed over a thousand children up to the age of two, looking at respiratory and gastrointestinal infections – breastfeeding didn’t show any benefit in toddlers, or for that matter, in older babies (2).  Of course, there are flaws in every study, and I can think of several possible reasons why this one might have underestimated results enough to miss a small but genuine benefit, but it does seem to me that, if that’s the case, we can’t be talking about that great a benefit.  And, frankly, when the one study we have on the subject shows a complete lack of any benefit, I don’t really think that the people claiming evidence of benefit are on solid ground.

But, what about the other benefits for breastfed toddlers?  Just look at the way that it helps an upset or tantrumming toddler to calm down.

I agree that that can be a wonderful convenience of breastfeeding.  However – and feel free to take this or leave it as you like, because we are temporarily stepping out of the realm of objective scientific evidence and into that of my own opinion – I do have my doubts as to whether it’s a good idea to do so.  After all, what message does it send children when we regularly and repeatedly teach them to turn to a sweet-tasting food source at times when they need comfort?  I wouldn’t use any other form of food or drink to distract my child from a tantrum, because that’s not the message I want to be giving to my children about how food should be used; it’s not encouraging healthy eating habits.  Why should I make an exception for breastfeeding?  I tried to avoid doing so, for both my children.  Just because something is the most convenient way to calm an upset child doesn’t mean it’s necessarily the best way in the long term.

But it has psychological benefits over and beyond just calming tantrums.  Breastfeeding for longer actually helps children become more independent!

No evidence for that claim.

Look, Jack Newman says so!  And Elizabeth Baldwin!

And they’re entitled to their opinion on the matter.  However, I don’t see any reason why I should automatically believe it, any more than I should automatically believe the equally unreferenced opinions of the doctors who claim that longer breastfeeding makes children more dependent.  Either way, they’re opinions, which are not the same thing as evidence.

But there is evidence!  Check out this quote on Kellymom’s site – ‘One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers’ and teachers’ ratings of social adjustment in six- to eight-year-old children’ (3).  Or are you trying to claim that that study’s being misrepresented as well?

Oh, not with the kind of spectacular degree of inaccuracy as the study by Gulick we discussed above.  However, that quote makes the results sound far more impressive than they were.  We’re not told that the differences found were very small, that they showed up in only one of the several measures of psychosocial adjustment that were tested, that adjusting for other factors eliminated practically all the difference found in the teachers’ ratings, or that the researchers themselves were pretty unimpressed by their results.  To quote from their conclusion: ‘In general the evidence above gives only very weak support for the view that breastfeeding makes a significant contribution to later social adjustment.  The research findings tend to be both inconsistent over time and between measurement sources and at best suggest a very small association between breastfeeding and subsequent social adjustment.  Further it is more than likely that even the small and inconsistent associations that have been reported could have arisen from factors which have not been controlled in the analysis.’  As evidence goes, I have to say that that doesn’t really strike me as compelling enough to justify trying to persuade women to continue breastfeeding if they don’t want to.

So what about all the other studies listed on Kellymom?  Showing that breastfed toddlers suffer from fewer allergies and have higher IQs?

I’ve checked all five of the papers she lists as supposedly backing up her claim about reduced allergies in breastfed toddlers (full text of four of them, the abstract of the other), and none of them are about toddlers.  They’re all looking at breastfeeding in infancy.  In fact, one of them (a review rather than a study) actually mentions in passing that the existing research shows ‘some suggestions’ that longer breastfeeding may be related to an increase in allergy risk.

When it came to the studies on breastfeeding and intelligence, after a while I simply gave up.  The only study I did manage to find that looked at breastfeeding over a year didn’t find any substantial difference in intelligence or school performance between children breastfed for that length of time and children who stopped shortly before that – longer duration of breastfeeding was initially associated with a slight increase in intelligence level, but then the effect leveled out.  (That one’s not available on line, but you might be interested in checking out this one by Mortensen et al that Kellymom also links to, which also studied the association between intelligence and breastfeeding duration and reached a similar conclusion – initially the increased duration of breastfeeding was associated with slight improvement on the intelligence scales, but the effect then levelled off, with children breastfed for longer than nine months having scores no better than those breastfed for 7 – 9 months.)

I checked several other studies on her list which, again, all turned out to be follow-ups on breastfed babies, not children breastfed past a year.  So, as I say, I gave up.  Checking all the studies she lists would have taken forever and I’m afraid there are limits to the amount of time and effort even I can put in to checking references from someone who’s clearly such an unreliable source of information.  (And, before anyone gets offended at me dissing Kellymom, I do actually think she’s a great source of information when it comes to dealing with breastfeeding problems; I’ve just found her to be appallingly bad at giving accurate information on any research dealing with any question in the general category of ‘Is it possible that breastfeeding in circumstance X is anything less than incredibly beneficial?’)

So, for all you know, there might be studies on her list that do show benefits of toddler breastfeeding and you just haven’t seen them?

Well, if you find any, by all means let me know.  I mean that – I’d be interested to read them and happy to spread the word about them.  But, until I actually see a decent-quality study providing good evidence that breastfeeding past a year is actively beneficial for children, I’m not going to tell women it is.  And, given how many studies are being erroneously cited as showing benefits of toddler breastfeeding when they show nothing of the sort – frankly, I think my scepticism about the existence of any studies that do show benefits is completely excusable.

Well, I don’t care!  I love breastfeeding my older child and I want to carry on whether or not you’ve found any studies proving that it’s beneficial!  We’re both enjoying it, and that’s benefit enough!

EXACTLY!  And that’s the ONLY reason you need.  You don’t need to prove that it’s in some way superior to what all the other mothers are doing.  You don’t need to score Good Motherhood points on some imaginary scale to justify your choice to others.  You just need the confidence to believe that it’s OK and that it’s what works for you.  Enjoy nursing your toddler or older child, accept that mothers who have made a different choice from you are doing just as well by their child and shouldn’t be conned into nursing for longer than they want to, and support every mother in the choice she makes on the matter, in the knowledge that, as far as we can see from the available evidence, nursing or not nursing a child of that age are equally good options to go for and thus we can happily leave this one in the realm of personal preference where it belongs.

 

References

1. Gulick E. The Effects of Breastfeeding on Toddler Health.  Pediatric Nursing 1986; 12(1): 51 – 4. 

2. Fergusson D.M., Horwood L.J., Shannon F.T., and Taylor B.  Breast-feeding, gastrointestinal and lower respiratory illness in the first two years.  Australian Paediatric Journal 1981; 17: 191 – 5.

3. Fergusson D.M., Horwood L.J., and Shannon F.T.  Breastfeeding and subsequent social adjustment in six- to eight-year-old children.  Journal of Child Psychology and Psychiatry 1987; 28(3): 378 – 86.

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April 18, 2011 at 9:40 pm 11 comments


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