The History of Breastfeeding

The world scientific literature, predominantly from countries other than the United States, includes many tributes to human milk. Early writings on infant care in the 1800s and early 1900s pointed out the hazards of serious infection in bottle-fed infants. Mortality charts were clear on the difference in mortality risk between breastfed and bottle-fed infants. Only in recent years have the reasons for this phenomenon been identified in terms comparable with those used to define other antiinfectious properties. The identification of specific immunoglobulins and determination of the specific influence of the pH and flora in the intestine of the breastfed infant are examples. It became clear that the infant receives systemic protection transplacentally and local intestinal tract protection orally via the colostrum and mature milk. The intestinal tract environment of a breastfed infant continues to afford protection against infection by influencing the bacterial flora until the infant is weaned. Breastfed infants also have fewer respiratory infections, occurrences of otitis media, gastrointestinal infections, and other illnesses. The immunologic protection afforded by specific antibodies such as respiratory syncytial virus and rotavirus also protects the infant from illness.

Refinement in the biochemistry of nutrition has afforded an opportunity to restudy the constituents of human milk. Attention to brain growth and neurologic development emphasizes the unique constituents of human milk that enhance the growth and development of the exclusively breastfed infant. Because the human brain doubles in size in the first year of life, the nutrients provided for brain growth are critical (see Chapter 7 ). A closer look at the amino acids in human milk has demonstrated clearly that the array is physiologically suited for the human newborn. Forced by legislation in the 1970s that mandated mass newborn screening for phenylalanine in all hospitals, physicians were faced with the problem of the newborn that had high phenylalanine or tyrosine levels. It became apparent that many traditional formulas provided an overload of these amino acids, which some infants were unable to tolerate even though they did not have phenylketonuria.

The mysteries and taboos about colostrum go back to the dawn of civilization. Most ancient peoples let several days pass before putting the baby to the breast, with exact times and rituals varying from tribe to tribe. Other liquids were provided in the form of herbal teas; some were pharmacologically potent, and others had no nutritional or pharmacologic worth. Breastfeeding positions varied as well. In most cultures, mothers held their infants while seated; however, Armenian and some Asian women would lean over the supine baby, resting on a bar that ran above the cradle for support ( Figure 1-3 ). The infants were not lifted for the purpose of burping. Many groups carried infants on their backs and swung them into position frequently for feedings, a method that continues today. These infants are also not burped but remain semierect in the swaddling on the mother’s back. The ritual of burping is actually a product of necessity in bottle-feeding because air is so easily swallowed.

Armenian woman suckling her child.

(Redrawn from Wickes IG: A history of infant feeding, Arch Dis Child 28:151, 1953.)

Although modern women may be selectively chastised for abandoning breastfeeding because of the ready availability of prepared formulas, paraphernalia of bottles and rubber nipples, and ease of sterilization, this is not a new issue. Meticulous combing of civilized history reveals that almost every generation had to provide alternatives when the mother could not or would not nurse her infant.

Hammurabi’s Code from about 1800 bc contained regulations on the practice of wet nursing, that is, nursing another woman’s infant, often for hire. Throughout Europe, spouted feeding cups have been found in the graves of infants dating from about 2000 bc .

Although ancient Egyptian feeding flasks are almost unknown, specimens of Greek origin are fairly common in infant burials. Paralleling the information about ancient feeding techniques is the problem of abandoned infants. Well-known biblical stories report such events, as do accounts from Rome during the time of the early popes. In fact, so many infants were abandoned that foundling homes were started. French foundling homes in the 1700s were staffed by wet nurses who were carefully selected and their lives and activities controlled to ensure adequate nourishment for the foundlings.

In Spartan times a woman, even if she was the wife of a king, was required to nurse her eldest son; plebeians were to nurse all their children. Plutarch, an ancient scribe, reported that a second son of King Themistes inherited the kingdom of Sparta only because he was nursed with his mother’s milk. The eldest son had been nursed by a stranger and therefore was rejected.

No known written works describe infant feeding from ancient times to the Renaissance. In 1472, the first pediatric incunabulum, written by Paul Bagellardus, was printed in Padua, Italy. It described the characteristics of a good wet nurse and provided counseling about hiccups, diarrhea, and vomiting. Thomas Moffat (1584) wrote of the medicinal and therapeutic use of human milk for men and women of “riper years, fallen by age or by sickness into compositions.” His writings referred to the milk of the ass as being the best substitute for human milk at any age when nourishment was an issue. The milk of an ass is low in solids compared with that of most species, low in fat and protein, and high in lactose.

From ad 1500 to 1700, wealthy English women did not nurse their infants, according to Fildes, who laboriously and meticulously reviewed infant feeding history in Great Britain. Although breastfeeding was well recognized as a means of delaying another pregnancy, these women preferred to bear anywhere from 12 to 20 babies than to breastfeed them. They had a notion that breastfeeding spoiled their figures and made them old before their time. Husbands had much to say about how the infants were fed. Wet nurses were replaced by feeding cereal or bread gruel from a spoon. The death rate in foundling homes from this practice approached 100%.

The Dowager Countess of Lincoln wrote on “the duty of nursing, due by mothers to their children” in 1662. She had borne 18 children, all fed by wet nurses; only one survived. When her son’s wife bore a child and nursed it, the countess saw the error of her ways. She cited the biblical example of Eve, who breastfed Cain, Abel, and Seth. She also noted that Job 39:16 states that to withhold a full breast is to be more savage than dragons and more cruel than ostriches to their little ones. The noblewoman concluded her appeal to women to avoid her mistakes: “Be not so unnatural as to thrust away your own children; be not so hardy as to venture a tender babe to a less tender breast; be not accessory to that disorder of causing a poorer woman to banish her own infant for the entertaining of a richer woman’s child, as it were bidding her to unlove her own to love yours.”

Toward the end of the eighteenth century in England, the trend of wet nursing and artificial feeding changed, partially because medical writers drew attention to health and well-being and mothers made more decisions about feeding their young.

In eighteenth-century France, both before and during the revolution that swept Louis XVI from the throne and brought Napoleon to power, infant feeding included maternal nursing, wet nursing, artificial feeding with the milk of animals, and feeding of pap and panada. Panada is from the French panade , meaning bread, and means a food consisting of bread, water or other liquid, and seasoning and boiled to the consistency of pulp ( Figure 1-4 ). The majority of infants born to wealthy and middle-income women, especially in Paris, were placed with wet nurses. In 1718, Dionis wrote, “Today not only ladies of nobility, but yet the rich and the wives of the least of the artisans have lost the custom of nursing their infants.” As early as 1705, laws controlling wet nursing required wet nurses to register, forbade them to nurse more than two infants in addition to their own, and stipulated that a crib should be available for each infant, to prevent the nurse from taking a baby to bed and chancing suffocation. On the birth of the Prince of Wales (later George IV) in 1762, it was officially announced: wet nurse, Mrs. Scott; dry nurse, Mrs. Chapman; rockers, Jane Simpson and Catherine Johnson.

Pewter pap spoon, circa ad 1800. Thin pap, a mixture of bread and water, was placed in bowl. Tip of bowl was placed in child’s mouth. Flow could be controlled by placing finger over open end of hollow handle. If contents were not taken as rapidly as desired, one could blow down on handle.

A more extensive historical review would reveal other examples of social problems in achieving adequate care of infants. Long before our modern society, some women failed to accept their biologic role as nursing mothers, and society failed to provide adequate support for nursing mothers ( Figure 1-5 ). *

* The National Convention of France of 1793 passed laws to provide relief for infants of indigent families. The provisions are quite similar to those in our present-day welfare programs.

Arnold Steam Sterilizer advertisement.

(From N Y Med J June 22, 1895.)

In the 1920s, women were encouraged to raise their infants scientifically. “Raising by the book” was commonplace. The U.S. government published Infant Care , referred to as the “good book,” which was the bible of child rearing read by women from all walks of life. It emphasized cod liver oil, orange juice, and artificial feeding. A quote from Parents magazine in 1938 reflects the attitude of women’s magazines in general, undermining even the staunchest breastfeeders: “You hope to nurse him, but there are an alarming number of young mothers today who are unable to breastfeed their babies and you may be one of them.” Apple detailed the transition from breastfeeding to raising children scientifically, by the book, and precisely as the doctor prescribes.

There are encouraging trends, however. The acceptance or rejection of breastfeeding is being influenced in the Western world to a greater degree by the knowledge of the benefits of human milk and breastfeeding. Cultural rejection, negative attitudes, and lack of support from health professionals are being replaced by well-educated women’s interest in child rearing and preparation for childbirth. This has created a system that encourages a prospective mother to consider the options for herself and her infant. The attitude in the Western world toward the female breast as a sex object to the exclusion of its ability to nurture has influenced young mothers in particular not to breastfeed. The emancipation of women, which began in the 1920s, was symbolized by short hair, short skirts, contraceptives, cigarettes, and bottle-feeding. In the second half of the twentieth century, women sought to be well informed, and many wanted the right to choose how they fed their infants.

The first action began in the 1940s when Edith Jackson, MD, of Yale University School of Medicine and the Grace-New Haven Hospital was awarded a federal grant to establish the First Rooming-In Unit in the United States. This project included the first program to prepare women for childbirth modeled after the British obstetrician Grantly Dick-Read’s Child Birth Without Fear . This was developed with the Department of Obstetrics to reduce maternal medication during birth and keep mother and baby alert and together. Of course, it included breastfeeding. Trainees from this program in Pediatrics and Obstetrics spread across the country starting programs elsewhere. Mothers chimed in when La Leche League was organized in the late 1950s. Professional organizations such as the AAP, American College of Obstetrics and Gynecology (ACOG), and American Academy of Family Practice (AAFP) were slow to speak out as they wrestled with the grip the formula companies had on medical education.

The great success of the mother-to-mother program of the La Leche League and other women’s support groups in helping women breastfeed or, as with International Childbirth Education Association (ICEA), in helping women plan and participate in childbirth, is an example of the power of social relationships. Raphael described the doula as a “friend from across the street” who came by at the birth of a new baby to support the mother. She would “mother the mother.” The doula is now known as a key person for lactation support, especially in the first critical days and weeks after delivery.

Bryant explored the social networks in her study of the impact of kin, friend, and neighbor networks on infant-feeding practices in Cuban, Puerto Rican, and Anglo families in Florida. She found that these networks strongly influenced decisions about breastfeeding, bottle-feeding, use of supplements, and introduction of solid foods. Network members’ advice and encouragement contributed to a successful lactation experience. The impact of the health care professional is inversely proportional to the distance of the mother from her network. The health care worker must work within the cultural norms for the network. For individuals isolated from their cultural roots, the health care system may have to provide more support and encouragement to ensure lactation success and adherence to health care guidelines.

The trend in infant feeding among mothers who participated in the Women, Infants, and Children (WIC) program in the late 1970s and early 1980s was analyzed separately by Martinez and Stahl ^, from the data collected by questionnaires mailed quarterly as part of the Ross Laboratories Mothers Survey. The responses represented 4.8% of the total births in the United States in 1977 and 14.1% of the total births in the United States in 1980. WIC participants in 1977, including those who supplemented with formula or cow milk, were breastfeeding in the hospital in 33.6% of cases. A steady and significant increase occurred in the frequency of breastfeeding; it rose to 40.4% in 1980 ( p < 0.5). WIC data continue to be collected, and the trends have paralleled other groups.

The Food and Consumer Service (FCS) of the U.S. Department of Agriculture (USDA) entered into a cooperative agreement with Best Start, a not-for-profit social marketing organization that promoted breastfeeding to develop a WIC breastfeeding promotion project that was national in scope and implemented at the state level. The project consisted of six components: social marketing research, a media campaign, a staff support kit, a breastfeeding resource guide, a training conference, and continuing education and technical assistance. With an annual $8 million budget for WIC, the project’s goals are to increase the initiation and duration of breastfeeding among clients of WIC and to expand public acceptance and support of breastfeeding. Breastfeeding women are favored in the WIC priority system when benefits are limited; they can continue in the program for a year, but those who do not breastfeed are limited to 6 months. All pregnant participants of WIC are encouraged to breastfeed.

Montgomery and Splett reported the economic benefits of breastfeeding infants for mothers enrolled in WIC. Comparing the costs of the WIC program and Medicaid for food and health care in Colorado, administrative and health care costs for a formula-fed infant minus the rebate for the first 180 days of life were $273 higher than those for the breastfed infant. These calculations did not include the pharmacy costs for illness. When these figures were translated to large WIC programs in high-cost areas (e.g., New York City, Los Angeles) and multiplied by millions of WIC participants, the savings from breastfeeding were substantial ( Table 1-2 ). If the goal of 75% breastfeeding women by the year 2010 had been realized among WIC recipients, the cost savings could have been at least $4 million a month for the WIC program. Since 2000, WIC programs have energetically promoted breastfeeding, but the street value of the package for bottle-feeders has been popular. A new WIC package has been developed and slowly supported through the system. It increased the food allowance for lactating women. Progress continues slowly.

The WIC program, through the extensive actions of the directors and staff, has increased the numbers of WIC mothers choosing to breastfeed. Many programs have hired and trained peer support mothers with breastfeeding experience to help other clients.

Frequency of Breastfeeding

Data collected in the 1970s in the Ross Laboratories Mothers Survey MR77-48, which included 10,000 mothers, revealed a general trend toward breastfeeding. In 1975, 33% of the mothers started out breastfeeding, and 15% were still breastfeeding at 5 to 6 months. In 1977, 43% of the mothers left the hospital breastfeeding, and 20% were still breastfeeding at 5 to 6 months. Other studies have shown a regional variation, with a higher percentage of mothers breastfeeding on the West Coast than in the East.

A continuation of the study of milk-feeding patterns in 1981 in the United States by Martinez and Dodd showed a sustained trend toward breastfeeding in 55% of the 51,537 new mothers contacted by mail. Although mothers who breastfeed continue to be more highly educated and have a higher income, the greatest increase in breastfeeding occurred among women with less education. From 1971 to 1981, breastfeeding in the hospital more than doubled (from 24.7% to 57.6%), with an average rate of gain of 8.8%. For infants 2 months old, breastfeeding more than tripled (from 13.9% to 44.2%) in this 10-year period ( Table 1-3 ).

The National Natality Surveys (NNS) conducted by the CDC in 1969 and 1980 included questions for married women about infant-feeding practices after birth. ^, Questionnaires were mailed at 3 and 6 months postpartum. In 1969, 19% of white women and 9% of black women were exclusively breastfeeding. The highest rate was among white women up to 34 years old, with three to six children. In 1980, 51% of white women and 25% of black women were exclusively breastfeeding, and they were more highly educated and primiparous.

The Ross surveys continue, and 725,000 surveys are mailed annually. The results have documented the persistent decline in the number of women initially breastfeeding, from a high in 1982 of 61.9% to an apparent low in 1991 of 51%, with the decline finally involving all categories of women, including those with higher socioeconomic status and higher education.

The Mothers Survey included 1.4 million questionnaires mailed in 2001, and this time two categories of questions were asked: any amount of breastfeeding and exclusive breastfeeding. Record high levels of any breastfeeding were reported: 69.5% initiation rate and 32.5% at 6 months postpartum with increases across all sociodemographic groups. The greatest increases were among young mothers (older than 20 years of age), the less educated, primiparous mothers, and those employed at the time of the survey. Mothers who practiced exclusive breastfeeding at hospital discharge (46.2%) and at 6 months (17.2%) were older and better educated.

The CDC took an active role in gathering breastfeeding data in 1988 and gradually established a system for monitoring progress. The Breastfeeding Report Card was established, and the CDC’s Maternity Practices in Infant Nutrition and Care (MPINC) survey assesses and scores how well maternity care practices at hospitals and birth centers support breastfeeding on a scale of 0 to 100—the higher the score, the better the practices. The national average from 2009 to 2011 increased from 65 to 70. The number of babies born in Baby Friendly Hospitals increased from less than 2% in 2008 to 6% in 2012.

Ethnic Factors

The Pediatric Nutrition Surveillance System (PedNSS) is a child-based public health surveillance system that monitors the nutritional status of low-income children in federally funded maternal and child health programs. The process begins in the clinic, it aggregates at the state level, and the data are submitted to the CDC for analysis. In 2001, 39 states, the District of Columbia, Puerto Rico, American Samoa, and six tribal governments participated, representing 5 million children from birth to 5 years of age; 37% of findings were from children younger than 1 year old from the six major ethnic groups.

In 2001, PedNSS reported 50.9% of children were ever breastfed, 20.8% were breastfed for at least 6 months, and 13.6% were breastfed for at least 12 months ( Figure 1-6 ). Breastfeeding rates improved 45% from the 1992 rate of 34.9% across all racial and ethnic groups. The CDC has continued to monitor breastfeeding rates and issued a breastfeeding report card in 2007; 73.8% of infants born in 2004 were ever breastfed, and only 41.5% were still breastfeeding at 6 months and 20.9% at 12 months. Exclusive breastfeeding was 30.5% at 3 months and 11.3% at 6 months. Tables 1-4 and 1-5 show the states that have met the 2010 breastfeeding objectives.

Percentage of infants who were ever breastfed by birth cohort and race-ethnicity: United States, 1993 to 2006.

(From McDowell MM, Wang CY, Kennedy-Stephenson J: Breastfeeding in the United States: findings from the National Health and Nutrition Examination Surveys, 1999-2006, NCHS Data Brief April(5):1–8, 2008.)

Table 1-5

Impact of Baby-Friendly Facilities, Lactation Support, and State Legislation

State	Percentage of Live Births Occurring at Facilities Designated as Baby Friendly (BFHI)	Number of IBCLCs per 1000 Live Births, 2007	Number of La Leche League Groups per 1000 Live Births	Number of State Health Dept. FTEs Dedicated to Breastfeeding	State Legislation about Breastfeeding in Public Places	State Legislation about Lactation and Employment	Presence of an Active Statewide Breastfeeding Coalition	Presence of Statewide Breastfeeding Coalition Web Site
Process indicators
U.S. National	3.31	2.12	0.35	80.66	46	15	42	33
Alabama	0	1.90	0.23	2.00	Yes	No	Yes	Yes
Alaska	0	5.83	0.96	0.25	Yes	No	Yes	Yes
Arizona	0	1.31	0.25	1.50	Yes	No	Yes	Yes
Arkansas	0	1.68	0.23	3.50	Yes	No	Yes	Yes
California	3.28	1.66	0.21	8.50	Yes	Yes	Yes	Yes
Colorado	2.13	2.00	0.45	0.88	Yes	No	Yes	Yes
Connecticut	12.44	3.76	0.67	1.00	Yes	Yes	Yes	Yes
Delaware	0	2.92	0.25	2.00	Yes	No	Yes	Yes
District of Columbia	0	1.14	0.09	1.00	No	No	Yes	Yes
Florida	1.80	1.56	0.24	1.00	Yes	No	No	No
Georgia	0	1.73	0.20	2.00	Yes	Yes	Yes	Yes
Hawaii	10.46	2.51	0.22	0.50	Yes	Yes	Yes	Yes
Idaho	6.10	1.95	0.43	1.00	No	No	No	No
Illinois	1.49	2.04	0.34	2.00	Yes	Yes	Yes	No
Indiana	2.39	2.44	0.32	1.75	Yes	No	Yes	Yes
Iowa	0	2.01	0.33	0.50	Yes	No	Yes	No
Kansas	0	2.23	0.60	1.00	Yes	No	No	No
Kentucky	5.69	1.95	0.30	2.50	Yes	No	Yes	No
Louisiana	0	1.41	0.23	2.00	Yes	No	Yes	No
Maine	17.37	5.31	0.71	1.00	Yes	No	Yes	No
Maryland	0	3.08	0.35	1.05	Yes	No	Yes	Yes
Massachusetts	2.83	4.45	0.61	1.33	No	No	Yes	Yes
Michigan	0	1.96	0.49	2.00	Yes	No	Yes	Yes
Minnesota	0	2.54	0.49	1.00	Yes	Yes	Yes	No
Mississippi	0	1.39	0.21	2.00	Yes	No	Yes	Yes
Missouri	0	1.92	0.50	1.00	Yes	No	No	No
Montana	0.34	1.98	0.60	1.00	Yes	No	Yes	Yes
Nebraska	13.54	1.61	0.76	0.50	No	No	No	No
Nevada	0	0.91	0.21	2.00	Yes	No	Yes	Yes
New Hampshire	5.73	5.68	0.49	1.00	Yes	No	Yes	Yes
New Jersey	0	2.16	0.40	2.00	Yes	No	Yes	Yes
New Mexico	0	2.01	0.38	1.00	Yes	Yes	Yes	Yes
New York	1.01	2.18	0.31	2.50	Yes	Yes	Yes	No
North Carolina	0	2.82	0.45	2.00	Yes	No	Yes	Yes
North Dakota	0	1.43	0.36	1.00	No	No	Yes	Yes
Ohio	2.36	2.71	0.43	1.00	Yes	No	No	No
Oklahoma	0	1.70	0.33	2.00	Yes	Yes	Yes	No
Oregon	6.37	4.48	0.37	1.20	Yes	Yes	Yes	Yes
Pennsylvania	0.21	2.26	0.32	2.00	Yes	No	Yes	Yes
Rhode Island	9.69	3.86	0.32	1.00	Yes	Yes	Yes	Yes
South Carolina	0	1.56	0.28	1.00	Yes	No	Yes	Yes
South Dakota	0	2.01	0.09	1.00	Yes	No	Yes	Yes
Tennessee	0.46	1.84	0.20	1.00	Yes	Yes	Yes	No
Texas	0	1.28	0.18	5.00	Yes	Yes	Yes	Yes
Utah	0	1.20	0.21	1.20	Yes	No	Yes	Yes
Vermont	3.77	8.96	1.54	1.00	Yes	No	Yes	Yes
Virginia	0	2.96	0.52	1.00	Yes	Yes	Yes	Yes
Washington	8.97	4.15	0.59	1.00	Yes	Yes	Yes	Yes
West Virginia	0	2.54	0.05	1.00	Yes	No	No	No
Wisconsin	9.10	2.58	0.55	1.00	Yes	No	No	No
Wyoming	0	2.07	0.69	2.00	Yes	No	No	No

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