Breastfeeding

Wet nursing and early feeding vessels

A historical review of infant feeding reports that wet nursing began as early as 2000 BC and lasted into the twentieth century, and that it was the safest and most common alternative to the mother's own milk before bottles and formula. The review cites a prescription for lactation failure in the Egyptian Papyrus Ebers, dated to about 1550 BC, and Roman written contracts for wet nurses. It describes the profession as common among wealthy families and, during the Industrial Revolution, among poor women, and states that by 1900 it had died out.

The same review reports clay vessels with nipple-shaped spouts found in infant graves from about 2000 BC, with residue showing that animal milk was used, and perforated cow's horns as common bottles in the Middle Ages. It states that in the early 1800s dirty devices and poor milk storage contributed to high infant mortality, and that one third of artificially fed infants died in their first year. These are the review's own summaries of historical accounts and are not individually verified here.

Formula, decline and promotion

According to the same review, a powdered infant food based on cow's milk, wheat and malt flour was patented by Justus von Liebig in 1865, and 27 patented infant food brands existed by 1883. Formula became a well-known and popular substitute in the 1940s and 1950s, and breastfeeding declined until the 1970s. The review adds that aggressive marketing in developing countries and a backlash in the 1970s led to a breastfeeding promotion movement in the United States.

In May 1981 the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes, following a 1980 recommendation that an international code for infant formula and other breast-milk substitutes be drawn up. WHO's publication page places the Code within WHO and UNICEF efforts to maintain and revive breastfeeding as a way to improve the health and nutrition of infants and young children. This page describes the Code only as a public-health document and does not analyze how countries apply it.

Hospital programs

WHO and UNICEF published revised implementation guidance for the Baby-friendly Hospital Initiative in 2018, described as the first revision of the Ten Steps since 1989. The guidance is aimed at governments, health managers and the leaders of maternity and newborn facilities. Its first step covers full application of the International Code and related World Health Assembly resolutions together with internal monitoring of clinical practice.

Feeding terms used in guidance and research

WHO defines exclusive breastfeeding as feeding only breast milk, and its infant and young child feeding fact sheet recommends it for the first six months of life. The Cochrane review of breastfeeding support separates exclusive breastfeeding from any breastfeeding, a category that includes partial and exclusive feeding, because trials measured the two outcomes separately. The American Academy of Pediatrics policy statement uses the term human milk and describes breastfeeding or the provision of human milk as the normative standard for infant feeding.

Complementary foods are the solid foods introduced alongside breastfeeding; WHO places their introduction from six months. Breast-milk substitutes are the products covered by the International Code, which WHO's page describes as infant formula and other products used as breast-milk substitutes.

Support roles and milk-supply products

The Cochrane review describes extra breastfeeding support as delivered by lay people or professionals, before or after birth, face to face or by telephone. Lactation consultants may hold the IBCLC credential (International Board Certified Lactation Consultant), whose requirements are set out by the IBCLC Commission. A review of milk-supply products defines galactagogues as pharmaceutical and herbal compounds used to increase lactation.

What public-health bodies recommend

WHO and UNICEF recommend that infants begin breastfeeding within one hour of birth, are fed only breast milk for the first six months, and continue breastfeeding up to two years of age or beyond, with nutritionally adequate complementary foods from six months. The AAP recommends exclusive breastfeeding for about six months and supports continued breastfeeding with complementary foods for two years or beyond, for as long as mother and child mutually desire, which it describes as consistent with WHO. This page reports these positions and does not describe how to breastfeed.

Care settings and support

WHO recommends the Ten Steps to Successful Breastfeeding as the standard of care in maternity services. Practices named on its fact sheet include skin-to-skin contact and breastfeeding support in the first hour after birth, responsive feeding, rooming-in, and avoiding additional food or drink for babies unless medically necessary. WHO has also published a guideline on counseling women to improve breastfeeding practices, which addresses how often, when, by what mode and by whom counseling should be provided.

The Cochrane review included trials of support delivered by professionals and by lay people, in 29 countries, with timing before birth, after birth or both. Peer or lay support is therefore one of the forms that has been tested in controlled studies, alongside lactation consultants and other health workers.

Related Machipedia pages

Breastfeeding is one of the practices grouped on the Parenting Approaches page. Other Machipedia pages that readers often view alongside it include Attachment Parenting, Babywearing, Infant Sleep Coaching, Kangaroo Mother Care and Doula, and, for the herbal and dietary topics below, Herbal Medicine and Nutritional Therapy. This page makes no claim about how those practices relate to breastfeeding outcomes.

Reasons given for breastfeeding

The 2016 Lancet Breastfeeding Series reported meta-analyses indicating protection against child infections and malocclusion, higher scores on intelligence tests, and probable reductions in overweight and diabetes. For women who breastfeed, it reported protection against breast cancer and improved birth spacing, and possible protection against ovarian cancer and type 2 diabetes. It did not find associations with allergic disorders, blood pressure or cholesterol, and it noted more tooth decay with longer periods of breastfeeding.

The series authors estimated that near-universal breastfeeding could prevent 823,000 annual deaths in children younger than 5 years and 20,000 annual deaths from breast cancer. These are modeled estimates from the abstract. The AAP policy statement describes breastfeeding as a public health imperative because of short- and long-term medical and neurodevelopmental advantages.

Herbal products for milk supply

Herbal products such as fenugreek are promoted to increase milk supply. A review of galactagogues presents data indicating popular demand for such products and notes that insufficient milk is a concern for women who have not had success with counseling alone. The review lists shatavari, fenugreek, silymarin, garlic and malunggay as popular herbal galactagogues tested in blinded, placebo-controlled trials.

Evidence on breastfeeding support

The 2017 Cochrane review of support for healthy breastfeeding mothers with healthy term babies included 100 trials, of which 73 trials in 29 countries contributed data. All forms of extra support together were associated with fewer mothers stopping any breastfeeding before six months (average risk ratio 0.91, 95% confidence interval 0.88 to 0.95) and fewer stopping exclusive breastfeeding at six months (0.88, 0.85 to 0.92). The authors rated this evidence as moderate quality because of very high heterogeneity.

Support from lay people and from professionals both had a positive effect on breastfeeding outcomes, but subgroup findings were not consistent enough for firm conclusions because heterogeneity remained high. The review measured breastfeeding duration and exclusivity, not health outcomes for infants or mothers.

The PROBIT trial and its follow-ups

The Promotion of Breastfeeding Intervention Trial (PROBIT) randomized 31 maternity hospitals and polyclinics in Belarus, enrolling 17,046 mother-infant pairs in 1996 and 1997. Sites received an intervention modeled on the Baby-Friendly Hospital Initiative or continued usual practice. At three months, 43.3 percent of infants at intervention sites were exclusively breastfed, against 6.4 percent at control sites, with fewer gastrointestinal infections and less atopic eczema in the first year.

A follow-up of 13,889 children at age 6.5 years assessed cognitive ability and school performance, and its authors concluded that prolonged and exclusive breastfeeding improved cognitive development. A follow-up of 13,879 children at a median age of 11.5 years found no clear difference in body mass index, body fat or overweight and obesity, and no difference in insulin-like growth factor-I; those authors concluded that population strategies to lengthen breastfeeding are unlikely to curb obesity. The trial randomized the promotion program, not individual infants.

Confounding and sibling comparisons

The PROBIT authors noted that earlier evidence came exclusively from observational studies, in which bias had raised doubts about the size of benefits in industrialized countries. Mothers who breastfeed differ from those who do not in ways that also affect child outcomes, called selection or confounding.

Colen and Ramey analyzed United States survey data on children aged 4 to 14. In standard models, breastfed children did significantly better on 10 of 11 outcomes; among siblings who were fed differently, estimates for all but one outcome dropped sharply and lost statistical significance. The authors concluded that much of the long-term benefit usually attributed to breastfeeding may reflect selection by race and socioeconomic status. This single observational study does not show that breastfeeding has no effect.

Evidence on herbal galactagogues

A review of galactagogue trials found blinded, placebo-controlled trials of five herbal products with mixed results, and concluded that high-quality trials are lacking. NCCIH states that evidence for fenugreek in breastfeeding is weak and that it is uncertain whether fenugreek helps.

Situations where breastfeeding is not recommended

The AAP states that medical contraindications to breastfeeding are rare. The US Centers for Disease Control and Prevention (CDC) says physicians should make case-by-case assessments and lists situations in which mothers should not breastfeed or feed expressed milk, including infant classic galactosemia, a rare genetic metabolic disorder, maternal HIV without sustained viral suppression, maternal HTLV-1 or HTLV-2 infection, use of illicit drugs such as opioids, PCP or cocaine, and suspected or confirmed Ebola virus disease.

CDC also lists situations in which breastfeeding should pause temporarily, among them untreated brucellosis, certain medications, diagnostic imaging with radiopharmaceuticals, and active herpes simplex with breast lesions. It notes that few medications are incompatible with breastfeeding and tells clinicians to weigh risks and benefits. Any person who is unsure whether a medicine, infection or infant condition affects breastfeeding is directed by these sources to a clinician.

Formula feeding and informed choice

WHO recommends restricting the marketing of formula and feeding bottles in line with the International Code, and the Ten Steps include avoiding additional food or drink for breastfed babies unless medically necessary. CDC separately publishes guidance for families who feed infant formula, covering how to choose, prepare, store and feed it. The sources reviewed for this page do not set out a position on how health workers should support families in choosing a feeding method, so none is stated here. Formula feeding is not discussed in this page as a failure or an error.

Care boundaries and herbal products

The sources reviewed do not describe breast problems or infant weight concerns in detail. A general care boundary applies: breast pain, fever, or worries about an infant's feeding or weight are matters for a doctor, nurse or other clinician, and lactation support does not replace medical assessment.

NCCIH reports that fenugreek can cause diarrhea, nausea and allergic reactions, which can be serious, and that large amounts may lower blood sugar. It advises against amounts above those in food during pregnancy, linking use to birth defects in animals and people, and states that little is known about amounts above food levels while breastfeeding. It advises checking with a health care provider before using fenugreek with any medicine.

Training and credentials

The IBCLC Commission lists requirements of health science education, lactation-specific education, clinical practice through one of three pathways, a code of professional conduct and an examination. Its page does not state hour totals, so they are not given here. The sources reviewed do not describe credentials of peer-support organizations or the status of the title lactation counselor.