Breastfeeding Myth One: Extended Breastfeeding and what WHO REALLY says

It should come as no surprise that I am an "extended breastfeeder", i.e. someone who breastfeeds her child past the age of one. It was a personal choice, one that I very rarely regret or question (because having an 18 month old shove his butt in your face while he's nursing when he's changed his position 90 degrees and you've just woken up and are kind of out of it is enough to make one question many parenting choices they've made along the way). There is this belief in the US, though, that breastfeeding past twelve months is somehow extraneous and unnecessary. Six months is great, twelve months is awesome, but past that is not really anything to worry about, except if you're looking to get that medal to put next to the one you get for having a natural childbirth. There's also a large number of people who classify extended breastfeeding as gross and label the women who do it crazy. Peek in on a discussion about EBF and you'll even find people who classify it as sexual abuse. All of this judgment, even though the World Health Organization officially recommends that children be breastfed for a minimum of 24 months:

The World Health Organization recommends that infants start breastfeeding within one hour of life, are exclusively breastfed for six months, with timely initiation of adequate, safe and properly fed complementary foods while continuing breastfeeding for up to two years of age or beyond.

And that's the topic that compelled me out of almost six months of non-blogging to address. Because the one thing women who cite that little fact hear over and over, ad nauseum, is that that recommendation is only for women in developing countries who don't have access to clean water for formula. And frankly, I'm pissed off about it. And I have a degree in History. If there's one thing History majors learn, it's that you get your facts from the source if at all possible. Luckily for everyone, the World Health Organization has a website, with like, information and stuff! Boy, this is a lot easier than the time I had to go through microfiche to see what the public reaction to Mary I burning Protestants was.

So, what does WHO say (WHO, BTW, is an organization that focuses on what is best for health, not what is normal or socially acceptable, which is why their recommendation differs from the American Academy of Pediatrics, which is more apt to take into account what is considered "normal" for the US)? Well, first there's this:

WHO recommends that infants start receiving complementary foods at six months (180 days) of age in addition to breast milk. Complementary foods should be given 2–3 times a day between 6–8 months, increasing to 3–4 times a day between 9–11 months. Between 12–23 months of age, 3–4 meals should be given. In addition, depending on the child's appetite, 1–2 nutritious snacks can be offered between meals. These foods should be adequate, meaning that they provide sufficient energy, protein and micronutrients to meet a growing child's nutritional needs. Foods should be prepared and given in a safe manner to minimize the risk of contamination. Feeding young infants requires active care and stimulation to encourage the child to eat.


And then, in case that's confusing, there's this helpful chart:

Age Texture Frequency Amount at each meal
6–8 months Start with thick porridge, well mashed foods
Continue with mashed family foods 2–3 meals per day, plus frequent breastfeeds
Depending on the child's appetite, 1–2 snacks may be offered Start with 2–3 tablespoonfuls per feed, increasing gradually to ½ of a 250 ml cup
9–11 months Finely chopped or mashed foods, and foods that baby can pick up 3–4 meals per day, plus breastfeeds
Depending on the child's appetite, 1–2 snacks may be offered ½ of a 250 ml cup/bowl
12–23 months Family foods, chopped or mashed if necessary 3–4 meals per day, plus breastfeeds
Depending on the child's appetite, 1–2 snacks may be offered ¾ to full 250 ml cup/bowl
a Note: If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day.

You can view the whole page here: http://www.who.int/features/qa/21/en/index.html

So, nothing specifying for which countries extended breastfeeding is best there. In fact, the question is quite broad and would seem to apply universally for mothers in every country. This isn't the last of the WHO's information about breastfeeding, though.

There's also this statement:

Breast milk is also an important source of energy and nutrients in children 6 to 23 months of age. It can provide one half or more of a child's energy needs between 6 and 12 months of age, and one third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy and nutrients during illness and reduces mortality among children who are malnourished.


I guess they forgot to specify that they meant only for children in developing countries. For God's sake, I live in the United States and can afford to buy healthy food and my 18 month old would be undernourished if he wasn't nursing. He eats what he eats and that's that.

I wanted to probe this a bit further, however, specifically the claim about clean water. It's well-known that formula feeding caused several hundred deaths in developing countries in the seventies due to contaminated water. And it's been estimated that 911 children's lives could be saved per year if breastfeeding rates were higher (not to mention healthcare costs). But, as most people with children have probably heard, at one year a child is able to switch from formula or breast milk (at their parents' discretion) to whole milk. So why would the WHO recommend 24 months due to concerns over formula and the cleanliness of the water it's mixed with if a child over the age of one could just drink cow or goat or even camel milk?

Luckily, the WHO has a guide to nutrition for children who are NOT breastfed from 6-23 months. Find it here: http://whqlibdoc.who.int/publications/2005/9241593431.pdf

I decided to make my work easier and just do a search for formula to see what they had to say about mixing it with unclean water. And lo and behold, right there in the introduction: However, because these guiding principles are targeted primarily at populations in
which use of commercial infant formulas after six months of age would be uncommon, the
energy requirements of breastfed infants have been used as the reference.

Huh. So, just to get the argument straight again: the WHO recommends breastfeeding for a minimum of 24 months, but that only applies to mothers in developing countries because they could have dirty water and it'd be unsafe to mix with formula, even though their own Guiding Principles for Feeding Non-Breastfed Children Ages 6-23 Months state that they're targeted at populations in which babies would not receive formula past six months (which I would assume means are also the populations with the highest risk of malnutrition and contaminated water)? Glad we cleared that one up.

So, just for the record, what ARE the benefits of breastfeeding past the age of one?

-In the second year (12-23 months), 448 mL of breastmilk provides:
29% of energy requirements
43% of protein requirements
36% of calcium requirements
75% of vitamin A requirements
76% of folate requirements
94% of vitamin B12 requirements
60% of vitamin C requirements

-The American Academy of Family Physicians notes that children weaned before two years of age are at increased risk of illness (AAFP 2001).

-"Antibodies are abundant in human milk throughout lactation" (Nutrition During Lactation 1991; p. 134). In fact, some of the immune factors in breastmilk increase in concentration during the second year and also during the weaning process. (Goldman 1983, Goldman & Goldblum 1983, Institute of Medicine 1991).

-According to Sally Kneidel in "Nursing Beyond One Year" (New Beginnings, Vol. 6 No. 4, July-August 1990, pp. 99-103.):
"Research reports on the psychological aspects of nursing are scarce. One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers' and teachers' ratings of social adjustment in six- to eight-year-old children (Ferguson et al, 1987). In the words of the researchers, 'There are statistically significant tendencies for conduct disorder scores to decline with increasing duration of breastfeeding.'"

And let's not minimize the positive health effect extended breastfeeding has on mothers:
-Breastfeeding reduces the risk of breast cancer. Studies have found a significant inverse association between duration of lactation and breast cancer risk.
-Breastfeeding reduces the risk of ovarian cancer.
-Breastfeeding reduces the risk of uterine cancer.
-Breastfeeding reduces the risk of endometrial cancer.
-Breastfeeding protects against osteoporosis. During lactation a mother may experience decreases of bone mineral. A nursing mom's bone mineral density may be reduced in the whole body by 1 to 2 percent while she is still nursing. This is gained back, and bone mineral density may actually increase, when the baby is weaned from the breast. This is not dependent on additional calcium supplementation in the mother's diet.
-Breastfeeding reduces the risk of rheumatoid arthritis.
-Breastfeeding has been shown to decrease insulin requirements in diabetic women.

(all examples are from the wonderful kellymom.com: http://www.kellymom.com/bf/bfextended/ebf-benefits.html)

Now, this post is not meant to be an order or even a recommendation. I believe above all else in a person's right to bodily autonomy, and choosing to breastfeed or not, as well as choosing when to wean, is a personal choice every woman deserves to and should make for herself. But there's too much misinformation out there, especially when it comes to who actually benefits from extended breastfeeding. And it's nice to know my acrobatic 18 month old living in the United States is getting just as many benefits from still nursing as any of his counterparts in the developing world.