Attitudes towards extended breastfeeding

Is it weird to breastfeed past the first year?

Extended breastfeeding which is breastfeeding beyond one year of age, is biologically normal, but today it makes many people uncomfortable. Both today and throughout history, mothers have breastfed their children for long periods. In large areas of the world, most babies are breastfed at one year of age and in some societies, the average age of weaning is between three and four years. In other areas, rates of extended breastfeeding are low and there may be no cultural precedent for it. As a result, friends and family may be unable to support it because they have no experience with it, health-care providers may be unhelpful, and mothers may find themselves harassed when breastfeeding in public. 

A) Describing extended breastfeeding

Painting showing interaction between mother and child while breastfeeding. Cassatt, Mary. Louise Nursing Her Child (1898). Rau pour le Tiers Monde Foundation, Zürich, Switzerland.

Extended breastfeeding refers to breastfeeding a child beyond one year of age. Extended breastfeeding is normal and benefits mothers and children and can continue for as long as mother and baby wish. 

B) Why extended breastfeeding is normal

1) Extended breastfeeding was the norm for most of our history

Throughout history, mothers have breastfed their children for long periods. Two million years ago, some of our most distant relatives breastfed for extended periods (Joannes-Boyau 2019; Tacail 2019). As long as 12,000 years ago and before the start of modern agriculture, ancient peoples weaned between one and four years of age (Tsutaya 2017). Religious texts, including the Bible, the Talmud, and the Qur’an, as well as ancient Greek and Roman medical texts encouraged extended breastfeeding (Eidelman 2006; Fulminante 2015; Hawwas 1988).

 2) Extended breastfeeding is normal for our species

Humans are born very immature and benefit from long-term breastfeeding.

The great apes are our closest genetic relatives. They breastfeed their young for many years. Orangutans have the longest recorded breastfeeding period at 6 to 8 years (Smith 2017). This suggests that extended breastfeeding is normal for humans.

3) Extended breastfeeding is the norm in many societies.

Most children in traditional hunter-gatherer societies are weaned between two and four years of age but breastfeeding beyond this age can also be practiced (Dettwyler 1995).

Around the world, many babies are breastfed at one year of age and of these, roughly half continue to breastfeed at two years of age. The rate of breastfeeding past 12 months is highest in sub-Saharan Africa and south Asia.

Breastfeeding Rates Past One Year of Age Around the World (UNICEF 2018)

Rates of extended breastfeeding can vary greatly from country to country. For example, even though they are neighbouring countries, the percent of babies breastfed at one year of age is 60% in Albania but only 6% in Greece (Bagci Bosi 2015). A 2015 review (Bagci Bosi 2015) reported national breastfeeding rates at 1 year of age in the European region ranged from 1% to 78% with the midpoint (median) being 28%.

In general, breastfeeding rates are lower in higher-income countries (Victora 2016). The United Kingdom (U.K.) has very low overall breastfeeding rates and correspondingly low rates at one year of age. One survey done in 2010 (McAndrew 2012) reported that less than 1% of babies born in the U.K. were breastfeeding at one year of age.

C) Barriers to extended breastfeeding

Even though extended breastfeeding is biologically normal and beneficial, it makes many people uncomfortable. Consider that (Dowling 2013; Jackson 2021; Madarshahian 2012):

  • There may be no cultural precedent for breastfeeding older children.
  • Breasts are heavily sexualized in the media, so anything involving the breasts is deemed sexual and inappropriate.
  • Friends and family members are unable to support mothers with practical information based on their own experiences.
  • Some cultures actively discourage mothers from breastfeeding once they are pregnant with the next baby.
  • Workplaces and employers may stigmatize mothers.

Some people are unsettled when a breastfeeding child can talk about breastfeeding and may discourage mothers from continuing to breastfeed or harass mothers who breastfeed in public (Newman 2018).

Health-care providers may not have the skills to supporting extended breastfeeding. They may also be biased against it (Baranowska 2019; Radzyminski 2015, Zhuang 2019). The older the child, the more negative the attitudes can become and may lead health-care providers to give advice that is not based on evidence (Cockerham-Colas 2012; Shaw 2018; Sigman-Grant 2016; Tchaconas 2018).

References

Bagci Bosi AT, Eriksen KG, Sobko T, et al. Breastfeeding practices and policies in WHO European Region Member States. Public Health Nutr. 2015;19(4):753-64
 
Baranowska B, Malinowska M, Stanaszek E, et al. Extended Breastfeeding in Poland: Knowledge of Health Care Providers and Attitudes on Breastfeeding Beyond Infancy. J Hum Lact. 2019 May;35(2):371-380
 
Cockerham-Colas L, Geer L, Benker K, et al. Exploring and influencing the knowledge and attitudes of health professionals towards extended breastfeeding. Breastfeed Med. 2012 Jun;7(3):143-50
 
Dettwyler K. A time to Wean: The Hominid Blueprint for the natural age of Weaning in Modern Human Populations. In: Stewart-MacAdam P, Dettwyler KA, editors. Breastfeeding: Biocultural Perspectives. New York: Aldine deGruyter; 1995
 
Dowling S, Brown A. An exploration of the experiences of mothers who breastfeed long-term: what are the issues and why does it matter? Breastfeed Med. 2013 Feb;8(1):45-52
 
Eidelman AI. The Talmud and human lactation: the cultural basis for increased frequency and duration of breastfeeding among Orthodox Jewish women. Breastfeed Med. 2006 Spring;1(1):36-40
 
Fulminante F. Infant Feeding Practices in Europe and the Mediterranean from Prehistory to the Middle Ages: A Comparison between the Historical Sources and Bioarchaeology. Childhood in the Past. 2015;8(1): 24-47
 
Hawwas AW. Breast feeding as seen by Islam. Popul Sci. 1988;8:55-8. PMID: 12315539
 
Joannes-Boyau R, Adams JW, Austin C, et al. Elemental signatures of Australopithecus africanus teeth reveal seasonal dietary stress. Nature. 2019 Jul 15

Jackson JE, Hallam JL. 'It's quite a taboo subject': an investigation of mother's experiences of breastfeeding beyond infancy and the challenges they face. Women Health. 2021

Madarshahian F, Hassanabadi M. A comparative study of breastfeeding during pregnancy: impact on maternal and newborn outcomes. J Nurs Res. 2012 Mar;20(1):74-80
 
McAndrew F, Thompson J, Fellows L, et al. Infant Feeding Survey 2010. NHS Health and Social Care Information Centre. Copyright © 2012, Health and Social Care Information Centre
 
Newman KL, Williamson IR. Why aren't you stopping now?!' Exploring accounts of white women breastfeeding beyond six months in the East of England. Appetite. 2018 Oct 1;129:228-235
 
Radzyminski S, Callister LC. Health Professionals’ Attitudes and Beliefs About Breastfeeding. The Journal of Perinatal Education. 2015;24(2):102-109
 
Shaw SC, Devgan A. Knowledge of breastfeeding practices in doctors and nurses: A questionnaire-based survey. Med J Armed Forces India. 2018 Jul;74(3):217-219
 
Sigman-Grant M, Kim Y. Breastfeeding Knowledge and Attitudes of Nevada Health Care Professionals Remain Virtually Unchanged over 10 Years. J Hum Lact. 2016 May;32(2):350-4
 
Smith TM, Austin C, Hinde K, et al. Cyclical nursing patterns in wild orangutans. Science Advances 2017;3(5)
 
Tacail T, Martin JE, Arnaud-Godet F, et al. Calcium isotopic patterns in enamel reflect different nursing behaviors among South African early hominins. Sci Adv. 2019 Aug 28;5(8):eaax3250
 
Tchaconas A, Keim SA, Heffern D, et al. Pediatric Care Providers, Family, and Friends as Sources of Breastfeeding Support Beyond Infancy. Breastfeed Med. 2018 Mar;13(2):116-122
 
Tsutaya, T. Post‐weaning diet in archaeological human populations: A meta‐analysis of carbon and nitrogen stable isotope ratios of child skeletons. Am J Phys Anthropol. 2017; 164: 546– 557
 
United Nations Children’s Fund (UNICEF). UNICEF global databases, 2018, based in MICS, DHS and other nationally representative surveys, 2013-2018. New York: United Nations Chilren’s Fund; 2018 Jul [cited 2019 Jan]
 
Victora CG, Bahl R, Barros AJ, et al; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016 Jan 30;387(10017):475-90
 
Zhuang J, Hitt R, Goldbort J, et al. Too Old to Be Breastfed? Examination of Pre-Healthcare Professionals' Beliefs About, and Emotional and Behavioral Responses toward Extended Breastfeeding. Health Commun. 2019 Mar 1:1-9