Historical Perspective
Man is one of 4237 species of mammals. All breastfeed their young. For thousands of years man has relied on human breastmilk to ensure it's survival as a species. When alternatives were tried, the infants almost always died. Despite this, every generation has tried to provide an alternative when a mother could not, or would not, breastfeed her infant. For centuries breastfeeding and nutrition were the purview of mothers and wet nurses. In the early 1800's, however, "men of sense" decided they knew better:

It is with great pleasure that I see at last the Preservation of Children become the Care of men of Sense. In my opinion this business has been too long finally left to the management of women, who cannot be supposed to have a proper knowledge to fit them for the Task.

Cadogan, Essay (for Nurses), London Foundling Hospital, 1756

Society fell in love with numbers and scientific measurement - we could do better than nature. Add to that the changing role of women - too delicate and refined to be simply "cows", and a major change in infant feeding was underway.

[Breastfeeding may have been natural once], but we don't live in that time now, and we must adapt our doings to the age in which we were born.......Let no mother condemn herself to be a common or ordinary cow unless she has a real desire to nurse..... Women have not the stamina they once possessed."

Mrs. Panton, Circa 1860

As Dr. Lewis Barness noted in his brief history of infant nutrition at the 1991 AAP meeting, Pediatrics developed as a specialty in large part by concocting or prescribing infant feedings. Around this time mothers could buy patent products without ever seeing a doctor. This was undesirable medically and financially:

"it would seem hardly necessary to suggest that the proper authority for establishing rules for substitute feedings should emanate from the medical profession and not from nonmedical capitalists. Yet when we study the history of substitute feeding.....the part which the family physician plays, in comparison with numberless patent and proprietary foods administered by the nurses, it is a humiliating one.....which should no longer be tolerated."

"[Infant feeding could be] the portal of entrance to a large practice."

Dr. Rotch, 1893

Improved communications, especially printing, enabled intensive commercial promotion of artificial milks. Financial support of hospitals and physicians by manufacturers also hastened the decline in breastfeeding. With World War I and World War II the percentage of breastfeeding mothers declined even faster. We exported our "modern", "better" mode of feeding to the world as a way to prevent world hunger. The size of the potential world market for infant foods did not go unnoticed by the manufacturers of artifical milks either!

Ross Laboratories Mother’s Survey
The incidence of breastfeeding at hospital discharge and later declined steadily to reach a nadir in 1972. After that time there was a rebirth of breastfeeding, which most of us feel was largely due to the efforts of a small, but vocal group of women at that time considered fanatics, La Leche League International. Slowly but surely others took up the banner as well, such that by 1982 approximately 62 % were breastfeeding in the hospital and 27 % at six months

By 1970 the World Health Organization and UNICEF were becoming extremely concerned about the decline in breastfeeding. The outcry regarding marketing of artificial milks to third world countries provoked a response in the food industries which was totally inadequate. By 1977 a boycott of the largest producer of artificial milks for the majority of the world (Nestle') was enacted.

By 1978 the United States was also becoming involved and concerned. Artificial milk errors, the most widely publicized being the 1979 lack of chloride in infant formula, prompted the U.S. Infant Formula Act of 1980. This legislation, however, had no teeth, as regulations were a long time in coming and greatly influenced by the artificial milk manufacturers themselves.

In 1981 The WHO Code called on governments to halt the advertising of breastmilk substitutes, bottles and teats to the public. The WHO adopted the code as a recommendation.

The vote was 118 to 1 with 3 abstentions (Korea, Japan and Argentina). The 1 anti vote was, ironically, the United States. The public reaction in the United States was outrage. But, because the American Medical Association and the American Academy of Pediatrics did not come out in favor of strong regulation of infant formula activities, the storm died down. It was not until 1982 that the FDA had significant quality control regulations in place.

After the resurgence 1970 to 1982, breastfeeding experienced a slight decline. There continue to be many barriers to breastfeeding including societal attitudes, advertising, marketing, hospital practices and even maternity leave policies. Most of them can be distilled into 4 areas.

First, the promotion of breastfeeding without practical help and knowledge which led to many frustrated, unsuccessful breastfeeding attempts with subsequent backlash.

Second, a much shorter hospital stay which does not provide adequate time for mother's milk to come in or for appropriate education and support. In Australia in 1993, a country which is known for its support of breastfeeding, the average hospital stay for vaginal delivery was still 5 to 7 days, and for C-section, 7 to 10 days. Australia also has the foresight to send home health vistors once the mother is discharged to offer further assistance and support.

Third, the continued increase of women in the workplace, many times by necessity and not by choice, has influenced the incidence and duration of breastfeeding. A nonsupportive work environment makes breastfeeding difficult at best.

Finally, the decline of breastfeeding has been assisted by the ambivalence of some health care professionals. This ambivalence is based on the lack of familiarity with current breastfeeding research, reliance on formula company nutritional information, and the very "well meaning" issue of not wanting to push breastfeeding because it might make the Mom who chooses artificial feeding feel guilty.

I think Ruth Lawrence in her book Breastfeeding: A Guide for the Medical Profession, addresses the issue of guilt very well.

"The medical profession has been hesitant to take anything but a neutral position in such discussions for fear of pressuring the mother. The evidence is stronger than ever that there are distinct advantages to the infant and mother in breastfeeding. Parents have the right to hear the data. They can make their own choice. Fear of instilling guilt is a poor reason to deprive a mother of an informed choice."

Do we worry about guilt when we urge our patients to stop smoking, lose weight, stay away from illicit drugs, exercise, change habits or lifestyles? Infant feeding is a health issue, just like these. Why then should we be so concerned with guilt around breastfeeding?

To our credit, we have corrected some of our mistakes, and breastfeeding incidence is beginning to rise again. Breastfeeding duration remains a major problem.

Current Efforts
The WHO/UNICEF continues its efforts by promoting the "10 Steps" and the Baby Friendly Hospital Initiative (BFHI), first put forward in the 1989 publication "Protecting, promoting and Supporting Breastfeeding: The Special Role of Maternity Services". The Innocenti Declaration, promoting breastfeeding, was signed in 1990 by representatives of 40 governments, including the United States.

On May 9, 1994 the 47th World Health Assembly reconfirmed the WHO Code, and this time the United States agreed to it. Former President Carter was among the many individuals and organizations lobbying for it.

The United States Government has set breastfeeding goals of 75% breastfeeding at hospital discharge and 50% at 6 months through its DHHS Healthy Children 2000 program. The WIC (Women, Infants, Children) supplemental nutrition program, a long time a sabateur of breastfeeding, is now a strong promoter, offering breastfeeding food supplements, education, and consultation.

The American Academy of Pediatrics (AAP) has established a network of breastfeeding coordinators under its Breastfeeding Initiative and put together an Expert Work Group on Breastfeeding to revise all AAP policies, publications, statements and educational materials relating to breastfeeding and infant nutrition. Workshops and lectures on various breastfeeding topics are now widely available. A new organization, The Academy of Breastfeeding Medicine, has been formed to promote breastfeeding by physician education, networking, and research.

Other organizations: medical, nursing, dietary, community, children's rights, etc., have issued position statements and worked to support breastfeeding. Among the most effective are the community breastfeeding coalitions, like our San Diego County Breastfeeding Coalition.

The Costs of NOT Breastfeeding
As health professionals we have been promoting the benefits of breastfeeding to mother, child, family and society, namely:

1. Species specificity
2. Balanced, changing nutrients and enzymes
3. Life-protecting immunological substances
4. Protection and warmth of frequent physical contact
5. Emotional and social development of nursing dyad cooperation
6. Enhanced maternal sensitivity to own and infant's needs
7. Minimizes postpartum bleeding
8. Conservation of maternal iron, protein, and other nutrients by lactational
9. amenorrhea
10. Optimal child spacing due to lactational infertility
11. Optimal use of personal, family and societal resources.

We should also define the costs involved in not breastfeeding. There are the obvious direct costs of buying artificial milks in various forms. Included in this cost to consumers is advertising. Assuming an average formula intake for the first year of life of 300 quarts, or 26 ounces per day, the savings afforded with breastfeeding is readily apparent. Many families in the United Statess, let alone Third World countries, cannot afford these prices.

COSTS OF INFANT FEEDING, 1990 / 1993

Given over 4 million live births in the United States in 1990, and infant mortality of approximately 38,000, that leaves us over 4.14 million infants in the United States to feed. If every woman breastfed for only 1 month, we could save over 450 million dollars.

Of course the costs of artificial feeding extend further than the cost of the formula itself. Among the indirect costs are the hazards of the artificial milks, with essential factors left out, excessive amounts of certain factors, contamination, and improper preparation, all causing adverse effects on infant health. There have been over 19 factory recalls since 1982; 7 have been Class I (life-threatening).

Another indirect cost, the immediate infant and child health consequences, is becoming more and more apparent. Artificially fed infants have more, and more serious, respiratory infections, otitis media, gastrointestinal illness, sepsis, alllergies, urinary tract infections, meningitis, immune system disorders, and even some types of cancers. The health care dollars expended for these unnecessary illnesses are enormous.

The long term health consequences of early dietary choices are just beginning to be recognized.

Nutritional programming, the concept that poor nutrition during periods of rapid growth in early life may permanently change the structure and physiology of a range of organs and tissues, is proving as true for man as for other animal species. Infants challenged with breastmilk cholesterol may prove to have less heart disease and stroke in later life. Decosahexanoic acid (DHA), available only in breastmilk, may permanently enhance brain and retinal development.

Conclusion

"Breastfeeding promotion lags 30 years behind smoking cessation. Population-based and cost-effectiveness studies of breastfeeding, upon which policy changes rely, are only beginning to appear."

Frederickson, 1993

In the not too distant future I see tax credits and health insurance discounts for breastfeeding families. Breastfeeding will be the norm and laws to permit women to breastfeed openly in public will not be necessary.

In summary, if you had a wonder drug that was safe, effective, readily accessible, engineered for individual needs, environmentally friendly, painless, had immediate onset, offered long term protection, was free, and had, as a side effect, weight loss for the provider, would you use it? We have that drug: BREASTMILK!

Bibliography

Cunningham AS, Jelliffe DB, Jelliffe EFP: Breastfeeding and health in the 1980's: a global epidemiologic review, J Pediatr 118:659, 1991.

Fredrickson DD: Breastfeeding research priorities, opportunities, and study criteria: what we learn from the smoking trail [editorial], J Hum Lact 9(3):147, 1993

Lawrence RA: Breastfeeding: A Guide for the medical Profession, 4th Ed, CV Mosby Co, St Louis, MO, 1994

Lucas A: Role of nutritional programming in determining adult morbidity, Arch Dis Child 71(4):288, 1994

Minchin M, Breastfeeding Matters, Alma Publications, Alfredton, Victoria, Australia, 1985

Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement, World Health Organization, 1211 Geneva 227, Switzerland, 1989

Dr. Wight is a board-certified Pediatrician, Neonatologist and Lactation Consultant at Sharp Mary Birch Hospital for Women and Children's Hospital and Health Center, San Diego, and Assistant Clinical Professor of Pediatrics at the University of California, San Diego. She is the Breastfeeding Coordinator for Chapter 3, District IX of the AAP, and a founding member and committee chair of the San Diego County Breastfeeding Coalition. She is a member of the California State Breastfeeding Promotion Committee for the Department of Health Services.