Revised and condensed version of Greiner T. Sustained breastfeeding, complementation and care. Food and Nutrition Bulletin, 16(4):313-319, 1995. This was first presented at a UNICEF meeting to define and describe the components of “care” as one of the three underlying determinants of young child nutritional status.
The advantages of early breastfeeding for care
The younger the child, the greater the extent to which his physical as well as emotional welfare is dependent on care. Regarding feeding, however, the time and knowledge required for proper care increase to a maximum during the age period 6-18 months. Up until six months of age, breastfeeding can meet the infant’s nutritional needs and any additional time and resources spent on feeding of supplements are usually unnecessary and may be harmful. Most of the key basic knowledge required in these first months is “automatically” transferred as a part of growing up and becoming a mother in traditional cultures. As the child grows older, language capabilities and motor skills enable him better to express and independently to respond to his own hunger signals.
Breastfeeding contributes to care by fostering maternal-infant bonding, stimulation, and skin and eye contact, as well as providing high quality nutrients hygienically and countering infection. Human milk appears to contain factors that promote brain growth and development, particularly visible in infants born pre-term . Breast milk is rapidly digested. When breast milk forms all or nearly all of the infant’s food, the infant will want the breast often and this will naturally lead to frequent contact between mother and infant.
Bottle feeding levels reached their height in the West by about 1970. By that time Western culture was so bottle oriented that it was assumed that there were no differences, even psychologically, between bottle- and breastfeeding, as long as the bottle feeding mother looked at and fondled the infant. This no doubt influenced the type of research done at the time. Jelliffe and Jelliffe  illustrate this by citing a book on mother-infant attachment that does not even refer to breastfeeding . Newton and Newton  and some of the bonding research by Klaus and Kennell  began to question this assumption. Research by A.-M. Widstrm and others in Stockholm [6,7] suggests that, via the effects of oxytocin and gastro-intestinal hormones, breastfeeding appears to change the psychological profile of the mother to make her more open, flexible and more “service-oriented.”
The advantages of sustained breastfeeding for care
Breastfeeding for three years or longer is not as uncommon as most researchers assume. Among La Leche League members in the USA even during the 1970s when breastfeeding rates were at their lowest level, it was practiced but kept it secret, “in the closet” . Even in developing countries little attention is given to breastfeeding that takes place for several years. Some researchers seem unconsciously to adhere to “norms” that lead them to expect that little if any breastfeeding is taking place after a certain age (often two-three years). I have observed in both Ghana and Lesotho, children in school uniforms breastfeeding. These children, usually standing or kneeling beside mothers who were sitting, took the breast themselves from compliant mothers who otherwise went on with their business. Neither the mothers nor bystanders paid attention to these children’s breastfeeding behavior.
I have not come across much discussion of this kind of very long breastfeeding. Perhaps these children have younger siblings who are breast-fed and, if asked in a survey, their mothers might not consider the older children still to be breastfeeding. Even if they did, the investigator might not. Jelliffe  cites Oomen as writing, “In the case of the small boys at Jobakogl (Papuan village) who strolled to the women’s house at dawn to have their morning drink, it requires some twisting of the term to consider them still ‘breast-fed.'”
A major reason for practicing sustained breastfeeding in industrialized countries in the face of social disapproval has been the belief that it provides a closer bond between mother and child. These children are often said to be more secure and more independent. They continue to remember this close bond and their mothers believe that it continues in some sense, even into adolescence, easing the difficulties in the mother-child relationship during this period [8,10].
There are unquestionable nutritional and economic advantages of sustained breastfeeding . Even beyond infancy young children return to the breast for comfort when they are sick and anorexic and thereby passively receive more food than others who are sick [12, 13]. In poor countries, breast milk can play a key role in vitamin A nutrition irrespective of age . Its effects in promoting child survival seem to be more distinct than its effects in promoting child growth . For older children in very poor situations where household access to food is highly insecure, exclusive or nearly exclusive breastfeeding may in effect have a trade-off effect, providing an increased chance for survival but at the cost of a reduced growth rate. If so, this would be an exception to the usual situation in which increased growth is assumed to be a proxy for health and survival.
The duration of breastfeeding (as well as its exclusivity) does contribute to longer birth spacing. An example of the importance of this for child survival is seen in Yemen, where combined breast and bottle feeding was the norm according to the 1979 National Nutrition Survey. The 1979 World Fertility Survey estimated that only 2% of couples practiced and modern family planning method. Abstinence in this traditional Muslim setting was mandated for only the first 40 days. Thus breastfeeding practices were the major determinant of birth spacing. Mortality rates were much higher for younger infants when birth spaces were shorter, but even for children 1-4 years old: when the birth space for the subsequent child was <24 months, the 1-4 year old death rate was 141/1000 alive at that age; with a birth space of 2-3 years it was 18/1000; for 3-5 years it was 2/1000 and for longer birth spaces it was 3/1000*.
As the recent adoption of combined breast and bottle feeding has led to shorter birth spaces in Yemen, many women now are attempting to care for three or even four children under the age of five and cannot cope. Many who did breast feed longer than average said they did so to achieve longer birth spacing .
The constraints related to care
The many factors that lead to less than optimal infant feeding patterns can be divided into “ideational” (knowledge, attitudes, and beliefs) and “external” constraints. It is commonly assumed that “external” constraints are mainly responsible for the fact that exclusive breastfeeding is rare, particularly its high opportunity cost, at least in “modern” settings.
Any other kind of infant feeding requires someone to devote time specifically to (1) food preparation, (2) feeding of this food to the infant, and (3) hygienic preparation of the food and cleaning of utensils (especially time-consuming where clean running water and modern cooking and refrigeration facilities are lacking). In artificial feeding, some of these time-consuming steps are often cut down beyond what good hygiene demands. Even when women are educated and make an effort to clean the bottle properly, however, resource constraints can prove impossible to overcome .
Other efforts to save time (reduce care demands) include offering gruels to older infants either in a bottle (with the nipple cut open to allow a thicker fluid to pass through) or a “feeding cup” with a lid and a perforated spout. The reason given for adding solid foods early is often that it reduces the frequency of infant crying, allowing the mother to get on with her work. Pacifiers (“dummies”) are used for similar reasons. Much infant crying may be due to hunger or inherent sucking needs, but part is probably related to needs for care and comfort. Thus some of the “premature” supplementation seen in the early months of life throughout the world probably reflect an attempt to cope with time constraints (or lack of support for the mother).
In the economic model utilized by Greiner, et al , it is pointed out that these ways of saving time incur other costs. Bottle propping deprives the infant of body and eye contact and stimulation and may lead to increased ear infections. Older infants who carry the bottle around with them make little effort to keep it free from dirt and flies. Increased illness results in high costs for extra care. However, individuals are usually not aware of the trade-offs involved or feel they have no choice. For example, piece workers, even if they work at home, may consciously reduce breastfeeding to increase the time available for earning money .
Furthermore, although other forms of feeding require more time than breastfeeding, they do not necessarily require the mother’s time. The availability of very low-cost forms of child care probably leads to decreased breastfeeding in situations where opportunity costs for child care by the mother increase (e.g., when new demands are placed on the mother’s time or when new opportunities arise for income earning) . Then grandmothers, sisters or others take over more of the young child care and feeding responsibilities. However, potentially negative trade-offs are involved here, too, particularly when the education of young girls stops so that they can take over child care responsibilities.
The poor caring capabilities of uneducated younger siblings and housemaids is also sometimes cited by mothers and researchers as a cause of malnutrition . In a study in Sierra Leone, children who were sent away from the mother suffered from higher mortality rates only if they were young at the time , suggesting that the biological mother’s role in care is superior only at earlier ages, perhaps due in part to breastfeeding.
Breastfeeding may explain the evolution of patterns of child care based on the mother as the major care giver during the early months of life. In traditional settings it is rarely perceived as something separate from or additional to her other child care responsibilities. Breastfeeding can be and commonly is done at the same time as the hands are busy with something else. Young babies are swung around from the back to the front to breast feed. Older children take the breast on their own when it is easily available. In either case the mother may pay no attention and continue undisturbed with her work or sleep. When women do choose to take time off for breastfeeding, they sometimes describe this as a necessary rest and an advantage of breastfeeding. Breastfeeding provides women with special status and benefits in some cultures.
Brown , in a study of several subsistence cultures, found that women tend to perform tasks compatible with child care. The characteristics of these tasks include: (a) they take place in an environment not likely to pose dangers to a young child, (b) they are repetitive and can be easily interrupted, and (c) they are carried out not too far from home. However, women lose power over the nature and location of their work as needs for earning cash increase. In overcoming this problem, attention commonly focuses on the need to overcome constraints for formally employed women workers. This is an important strategy, especially for women working in the health and education sectors, since they are influential in society and could help lead the way towards change for others if enabled to care and breast feed their own infants better during the first year or so of life . Women doing paid agricultural work and employed in the informal sector also need to be enabled to breast feed as much as possible and little attention has been given to how to meet their needs.
“Ideational” factors are also important in explaining the lack of exclusive breastfeeding . In many cases, women need not only to be “enabled” through correct information (rarely available where health workers are inadequately educated regarding breastfeeding or where the infant food industry is the major source of information) and assistance dealing with health and lactation management problems that may interfere with breastfeeding, but also “empowered” through emotional and practical support from their peers, spouses, employers and others.
In traditional rural settings, approaches dealing with ideational aspects alone may be able to increase rates of exclusive breastfeeding substantially. In these settings, neither the financial nor the opportunity costs of breastfeeding are as great as those of supplemental feeding , particularly where women’s economic activities tend not to conflict much with breastfeeding. Information on the value of exclusive breastfeeding and the dangers of feeding unnecessary supplemental fluids is rarely available in appropriate or credible forms.
Like other aspects of infant and child care, breastfeeding is often considered unimportant or at least something simple that women can take care of alongside other tasks society expects them to handle. Women have been left to cope as best they can, often expected to achieve some kind of “supermother” ideal of combining productive and reproductive work with little support for either.
If the importance of exclusive breastfeeding were appreciated, and if the trade-offs for not doing it were explicitly visible to all, society would have made an effort to ensure that ideational and external constraints did not interfere with it.
In some settings the major resource available that could increase support for the breastfeeding mother would be the free time that fathers tend to have in more abundance than mothers. However, models are needed to encourage men to provide a wide range of support for women and children. Lacking in this, the main model being offered in many places now is the advertisers’ image of the father bottle feeding his baby.
The complementation process
In much of the English language technical literature, it is not always clear that authors are aware that complementation and replacement of breast milk are two separate components of the “weaning process.” For example, they are indistinguishable in the diagram in Figure 1, commonly used to illustrate “weaning.”
Thus mothers are rarely advised how to achieve complementation, that is, to avoid unintentionally replacing breast milk by providing so much additional food and fluids that breast milk production is reduced. Advice commonly a part of nutrition education, like, “feed solids to your baby x number of times starting at age y months,” does not even indicate the desirability of complementing rather than replacing breast milk. Attention almost never focuses on how much breast milk the child receives after the period of exclusive breastfeeding. It is often simply assumed that breast milk quantity gradually declines from high levels a few months after delivery to low levels a few months later, and that both of these levels are somehow biologically predetermined rather than the result of largely behavioral factors subject to educational efforts (e.g., frequency and intensity of suckling).
The components of the overall “weaning process” can best be illustrated by comparing a schematic plot of the infant’s approximate total daily nutritional requirements with the amount of these nutrients that might be provided if the mother breast-fed exclusively for the first six months and continued to breast feed fully but with adequate complementary foods for many months thereafter (Figure 2). Four of these components are sometimes individually referred to as “weaning” but often the meaning is uncertain or vague. Numbers “1” and “2” refer to the initiation of breastfeeding and the period of exclusive breastfeeding. The zone containing the number “3” illustrates complementation and the dotted plateau at “4” illustrates the desirability of continuing to breast feed at the same level even once complementation begins. The “5” is located in the area that illustrates replacement. Finally, the word “wean” has commonly used by authors to refer to the cessation of breastfeeding (number “6” on Figure 2).
When solid foods are added to the diet of “exclusively” breast-fed infants, a partial replacement of breast milk occurs , even when the mothers are “advised to maintain the same nursing pattern, not to decrease nursing frequency, and to feed solid foods after nursing” . However, it cannot be assumed that such advice is optimally effective and whether efforts to provide more effective communication and support can help women to achieve complementation without replacement needs to be tested.
Achieving conceptual clarity on this issue has been complicated by the fact that in industrialized countries (and among the urban elite in much of the developing world) many women begin reducing how much they breast feed already by six months of age or earlier. They often do not sleep with their baby, carry him on their body or provide the breast very often for “comfort” or other purposes besides feeding. For them (and the health care establishment that advises them to care for their infants this way), how to achieve complementation without replacement has never been an issue. Replacement feeding with various liquids is intentionally started in the early weeks of life.
In a controlled experiment, Cohen, et al  found that infants offered complementary foods in Honduras at four months of age consumed slightly less breast milk than those who were offered nothing extra. By six months of age there was no difference in growth rates among those who received complementary feeds and those who continued exclusive breastfeeding. Since these foods were sterile and of high nutritional quality, complementation before six months of age in a poor setting would probably have a negative effect on growth.
However, until there is widespread cultural support for exclusive breastfeeding for six months, it is likely that very few women will be able to achieve it. The question of how many women may be physically or nutritionally unable to achieve it can be studied only incompletely until these cultural barriers are removed. The net effect of delaying complementation even later than six months also needs to be studied.
Based on what we know today, the following recommendation might be more appropriate than “weaning” advice given currently: “Introduce your baby gradually to solid foods starting at about six months of age. Once he accepts them, continue breastfeeding as often as before and add solids as the baby’s appetite seems to increase. Once or twice a day is enough in the beginning, but gradually increase. The child should continue breastfeeding just as often during the second year, but offer solid foods a few times a day. Once you do start to breast feed less often, remember that you must make even greater efforts to ensure that your child eats several meals of nutritious food each day.”
Care aspects of the cessation of breastfeeding (sevrage)
Cessation of the breastfeeding relationship is seen by psychologists as a positive developmental step for the child . Where sustained breastfeeding is considered deviant behavior, sevrage may actually be a relief for the child who receives negative messages, for example, that this is something “only babies do” . Having studied data on US breastfeeding pairs in the 1970s, Reame and Sugarman  write that a toddler who is still breastfeeding “leads the weaning process, with some help from a mother who no longer offers the breast without vigorous request.” However, where no such societal biases exist, sevrage is quite different. When the child is older, the mother can discuss it with him or just let external circumstances determine when and if occasional breastfeeding continues. In many developing country settings, sevrage is usually occasioned by the next pregnancy. Breast milk from a pregnant mother may be considered harmful or breastfeeding may be thought to harm the fetus. Where intercourse is forbidden with a lactating woman, the need for its resumption will influence the duration of breastfeeding. There is anecdotal evidence that some women breast feed less in recent years in order to reduce the period of abstinence. They hope that this will reduce the risk of their partners contracting AIDS.
In many cases sevrage may be rapid, achieved by placing something bitter on the nipples or sending the child to live with a relative for some time. The psychological impact of sevrage on the infant has long been regarded as one cause of kwashiorkor  and was once considered so important that it was studied prospectively on 16 Zulu “volunteers” whose children were given dried milk powder “in at attempt to offset nutritional ill effects” . These children become extremely sad and frustrated. To soothe them, their caregivers may put them to the “dry” breast. Not infrequently, this rapidly leads to the appearance of milk, so-called relactation , even among grandmothers .
Breastfeeding appears to work best in a carefree environment where it is given little specific attention by most women except in circumstances where they perceive problems are occurring. Except in problematic situations, there is a danger that intervention will change perceptions about breastfeeding, with results that are difficult to predict. We know from long historical experience that breastfeeding is biologically extremely robust, but psychologically vulnerable. Thus breastfeeding projects should pilot promotional and supportive approaches before implementing them on large scale, especially in countries where the median length of breastfeeding is still longer than one year or so. Even in countries where the duration of breastfeeding is already short, breastfeeding programs have a responsibility to document what actions are taken and their impact.
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