Breastfeeding in a New Era

Colostrum

There are many culturally defined mysteries and taboos about colostrum, which go back to the dawn of civilization. ⁶ , ⁷ , ⁸ , ¹⁹ , ²⁰ We now know of the added benefits of receiving colostrum in the first days of life because it is rich in secretory immunoglobulin A (IgA), lactoferrin, leukocytes, and epidermal growth factor. Most ancient peoples let several days pass before putting the baby to the breast, with exact times and rituals varying from group to group. Other liquids were provided in the form of herbal teas; some were pharmacologically potent, and others had no nutritional or pharmacologic worth. Culture also influenced breastfeeding. ²¹

Wet Nurses

From ad 1500 to 1700, wealthy English women did not nurse their infants, according to Fildes, ⁸ 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. ¹¹ 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. ⁷ 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 deemed not breastfeeding a child to be crueler than ostriches hiding their eggs in the earth and said that a woman would have to be hardened against her young ones as though they were not hers, a reference to Job 39:13–16. 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 18th century in England, the trend of wet nursing and artificial feeding changed, partially because medical writers drew attention to health and well-being of breastfed infants and because mothers were influenced to breastfeed their young. ⁸

In 18th-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. ²³ 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 ( Fig. 1.2 ). 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. ²⁰ 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. ²⁴

A more extensive historical review by Apple would reveal other examples of social problems in achieving adequate care of infants. ⁹ 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. Breastfeeding was more common and of longer duration in stable eras and rarer in periods of “social dazzle” and lowered moral standards. Urban mothers have had greater access to alternatives (wet nurses, milk agencies, and artificial infant feedings), and rural women have had to continue to breastfeed in greater numbers. ⁷ , ⁹ , ²⁵

“Feeding by the Book”

In the 1920s, women were encouraged to raise their infants scientifically. “Raising by the book” was commonplace. L. Emmett Holt, MD, a renowned pediatrician, published his book The Care and Feeding of Children , which, although it recommended breastfeeding, interfered with “on-demand” feeding by recommending regimentation in feeding. There were 75 printings of this popular book from 1894 to the 1940s. ¹² The US government published Infant Care in 1914 because of the high rates of infant death in the United States at that time. It was referred to as the “good book,” which was the bible of child-rearing read by women from all walks of life. ²⁶ It was republished in 1935 by the Child’s Bureau of the US Department of Labor and again multiple times up through 1989, the year of the final edition. ²⁷ The 1935 edition emphasized breastfeeding over artificial milk mixtures and recommended that when mothers could not provide breast milk to their infants of less than 6 months of age, then employing a wet nurse or obtaining breast milk from a “breast-milk agency” or from friends or relatives was preferred. For the introduction of solid foods, the 1935 text recommended cod liver oil, egg yolk, stewed fruits, and potatoes. 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.” ⁹ Apple detailed the transition from breastfeeding to raising children scientifically, by the book, and precisely as the doctor prescribes. ⁹

Around the same time, the end of the 19th century and beginning of the 20th century, there were dramatic disparities in infant mortality between breastfed and artificially fed (modified animal milk) infants. This was evident in reports covering 50,000 infants, where mortality in artificially fed infants was 3 to 10 times higher than in breastfed infants in Chicago, Minnesota, other US sites, and Britain. ¹⁷ , ²⁸ , ²⁹ In the rest of the world, especially nonindustrialized countries, the higher mortality was associated with early weaning (<6 months of age). ³⁰

Artificial Infant Feedings

Germ theory and the process of pasteurization began to influence the preparation of artificial infant feedings. In affluent homes, home sterilizers appeared in the 1890s. Parallel to this, animal milks were being further modified (sugar-added evaporated milk, unsweetened milk in a can or condensed milk) and produced commercially. In 1855, A. V. Meig made public what was recognized as the first accurate analysis of human and cow’s milk. He worked out a “formula” for a liquid infant food based on animal milk, adjusting the calories, protein, and carbohydrate content. ³¹ In 1865, a German chemist, Justus von Liebig, also created an infant food made of cow’s milk, wheat and malt flours, and potassium bicarbonate. ³² By 1883, many other infant formulas and food products were available commercially, including 27 patented brands. ³³ In the late 1800s, bottles and nipples were also improving—they were easier to clean and use, with glass bottles and rubber nipples. ⁶ , ⁷ Sterilization of these implements and the increasing use of refrigeration made the storage of artificial milk easier and more hygienic but did not improve the quality of their nutritional content. ³²

Decline of Breastfeeding

In 1922 Woodbury estimated that in the United States, breastfeeding was continuing at 12 months of age for 85% to 90% of children. ²⁹ From that point, breastfeeding declined in the United States. Reports for 1965 described breastfeeding initiation rates down to 38% and breastfeeding out to 3 months of age down to 12%. ³⁴ , ³⁵ It seemed to reach a low in the 1970s; only 24% of women reportedly breastfed at least once before discharge from the hospital. ³⁶ Presumably, this decline was due to many factors, some of which have been suggested as “raising children by the book”; the perceived science of pasteurized formulas as “safe substitutes” for breast milk; and the rise of formula companies and marketing of formula to physicians, making the formulas of economic importance to their medical practice. ¹² Apple and Parfitt separately describe social and political factors contributing to the decline: the women’s movement emancipating women through bottle-feeding formula, not breastfeeding; a general social approval of bottle-feeding, with the modern household of the 1950s being portrayed and characterized by a bottle-fed infant; pediatrician-recommended “regulated feeding patterns” interfering with “as-needed” or “on-demand” breastfeeding; and the overarching influence of formula companies, even including publications like The Motherbook , repeatedly printed by Nestle Milk Product, Inc. ³⁷

Variability in Breastfeeding Rates

How and why, with this increase in breastfeeding rates, did significant differences in breastfeeding rates arise in different groups? In the United States and worldwide, there arose dramatic disparity between black and white infants, urban and rural communities, and low- and middle-income countries versus high-income countries. US data from 2002 to 2014 reveal a 17-percentage-point gap in breastfeeding initiation between black and white infants. ⁴² Anstey et al. reported that by 2013, the exclusive breastfeeding (EBF) rate at 6 months of age was 8.5% lower, and the 12-month breastfeeding duration rate was 13.7% lower, for black infants compared with white infants. ⁴³ There are many theories and discussions as to why this is occurring and possible solutions. ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ There are numerous organizations and events that have led to improving breastfeeding rates worldwide and addressing disparities in breastfeeding ( Table 1.1 ).