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Parental Concerns About Extended Breastfeeding in a Toddler^*

Abbreviations: breastfeeding • extended breastfeeding

	CASE

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
Matthew, a healthy 18-month-old toddler, is seen for a health-supervision visit. The dietary history reveals that Matthew is breastfeeding and eats a variety of fruits, vegetables, cheese, yogurt, and grains. He is able to feed himself with a spoon, although he prefers to use his fingers. His height, weight, and head circumference have followed the 50th percentile, and developmental milestones are appropriate for 18 months. Matthew's mother is conflicted about continuing to breastfeed. Matthew often pulls at her shirt and puts his hand down her shirt when they are out in public. He seems to want to breastfeed when he is upset or in a new or unfamiliar situation. She is aware of some of the benefits of breastfeeding, and after checking with the American Academy of Pediatrics Web site, she discovered that extended breastfeeding is encouraged. Matthew's mother asks her pediatrician for guidance.

Parental Concerns About Extended Breastfeeding in a Toddler^,*

University of California
Children's Hospital San Diego
San Diego, California

	Dr Martin T. Stein

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
The links between nutrition, developmental maturation, behavior, and culture are found in each health-supervision visit in early childhood. Pediatricians are aware of these connections when they participate in decisions about initiating and extending breastfeeding. Following the popularity of formula feeding in the middle of the last century, breastfeeding has emerged during the past 30 years as the best nutritional source for infants. Breastfeeding of infants provides advantages in general health, growth, and development and reduces the risk for many acute and chronic diseases. Numerous studies suggest potential health benefits for mothers.¹

Approximately 60% of women in the United States breastfeed either exclusively or in combination with formula feeding at the time of hospital discharge; however, only 25% of mothers nurse at 6 months, often supplementing with formula. The highest rates of breastfeeding are observed among higher-income, college-educated women over 30 years of age living in the Mountain and Pacific regions of the United States. Several factors appear to work together to create obstacles to the continuation of breastfeeding, including maternal employment (especially without facilities in the workplace and in the absence of support for breastfeeding), lack of broad societal support, media portrayal of bottle-feeding as normative, commercial promotion of infant formula, and television and magazine advertising.¹

This case illustrates the challenges for parents and clinicians when a mother expresses ambivalence about continuing nursing beyond 18 months of age. Dr Eyla Boies is a primary care pediatrician. She is a clinician and teacher at the University of California, San Diego, where she studies the epidemiology of nursing and plans programs for physicians, nurses, and parents to promote the initiation and continuation of breastfeeding. Dr David Snyder is a developmental and behavioral pediatrician at the Valley Children's Hospital in Fresno, California. His observations in this case are a guide by an experienced clinician to general principles of child development and family dynamics when assisting a parent in the decision process.

	REFERENCE

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 

1. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1997;100 :1035 –1039[Abstract/Free Full Text]

Parental Concerns About Extended Breastfeeding in a Toddler^*

University of California
Children's Hospital San Diego
San Diego, California

	Dr Eyla G. Boies

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
Feeding issues are a frequent topic for discussion during the health-supervision visit of a toddler. Parents often express concern about a toddler who refuses to eat many foods, and they perceive an inadequate nutritional intake. In this case, however, Matthew has a balanced diet and wants to breastfeed, but at awkward moments for his mother. This scenario exemplifies the predictable contradictions in the life of an 18-month-old. Although Matthew is striving for independence in many areas of his life, he still looks to his parents, especially his mother, for security when he feels the need.

In responding to Matthew's mother, several factors should be considered to help her make an informed decision. The benefits of breastfeeding, especially beyond 1 year of life, her own feelings about extending the period of breastfeeding, and Matthew's needs in relationship to his developmental level should be considered. It is often helpful to discuss breastfeeding duration in a historical and cultural context.

Breastfeeding beyond 1 year of age is considered extended breastfeeding in the United States, and as the term "extended breastfeeding" implies, it is not the customary practice. The age of weaning, however, ranges from 2 to 4 years in many societies around the world. For example, in Guinea Bissau, West Africa, the median time for weaning is 22.6 months,¹ and mothers in India frequently breastfeed their infants until 3 or 4 years of age (Anne Seshadri, personal communication, 2002). Ancient Greeks, Hebrews, and Muslims all recommended breastfeeding of infants for 2 to 3 years as found in the writings of Aristotle, the Talmud, and the Koran.^2–4 In sharing this information with Matthew's mother, you allow her to view extended breastfeeding in a broader context.

Breastfeeding in the first year of life is protective against numerous infections and the development of allergies.⁵ There is limited but increasing evidence that breastfeeding beyond 1 year is also beneficial to the health of the child and, possibly, the mother. The duration of an episode of otitis media is shortened in children who are breastfeeding after 1 year of age.⁶ This finding is consistent with the data that concentrations of lysozyme, lactoferrin, and secretory IgA are stable and even increase in the breast milk of mothers who are breastfeeding for longer than 1 year.⁷ Preliminary studies suggest that extended breastfeeding may be protective against childhood lymphoma and leukemia.^8,9 Evidence is now accumulating that increasing duration of lifetime breastfeeding reduces the risk of premenopausal breast cancer in the mother.^10,11 Reports that some children breastfed beyond 1 year were at increased risk for malnutrition have been discredited because of poor study designs.¹² Most experts agree that, as long as a breastfeeding toddler is eating a variety of grains, vegetables, fruits, and foods or supplements that provide adequate iron and vitamin D, nutrition will be adequate and appropriate growth and development will be ensured.

An important factor in helping Matthew's mother make her decision is an understanding of her feelings about continuing to breastfeed. Often mothers in her situation are subject to criticism from friends or family members who intimate or state that Matthew is too old to breastfeed and that "he should be a big boy." Matthew's mother may feel guilty at this suggestion; however, she and Matthew may enjoy the times they breastfeed at home in a quiet place.

Matthew is breastfeeding for comfort and reassurance in unfamiliar situations. These are the same situations that are socially awkward for his mother to breastfeed. One approach to this problem is to encourage Matthew's mother to speak reassuringly to Matthew, encourage the use of a favorite blanket or stuffed animal as a comfort object, and tell him they will "nurse" or "breastfeed" at home. Toddlers of Matthew's age typically have ample receptive language skills, even if their expressive vocabulary is limited; they understand when spoken to in simple and concrete terms. Establishing routine times and places, preferably in the home, will also make it easier for Matthew to understand that he can no longer breastfeed on demand, especially when out in public places.

Matthew's mother may also wonder when and how she will ever wean him if she continues to breastfeed. A survey of 134 mothers who were attending a La Leche League conference and who had breastfed beyond 1 year indicated that they weaned gradually and described the process as child-led. The average age of weaning was 36 months in this group.¹³ In India, women often wean their 3- or 4-year-old by putting the juice of a bitter gourd or melon on their nipples. The child dislikes the taste and quickly gives up breastfeeding (Anne Seshadri, personal communication, 2002).

For many mothers and toddlers, the major advantage of extended breastfeeding may be found in their emotional well-being. A toddler is often competing for his or her mother's attention in a very busy and harried life. A mother in my practice who breastfed 2 children until 2 years of age explained that she would slow down and give her undivided attention to her child several times each day when breastfeeding. Her children knew that she always had time for those moments each day. This time was also important to the mother for relaxing and unwinding.

I would encourage Matthew's mother to continue to breastfeed at home or in quiet and private places. I would also suggest offering a comfort object such as a blanket or a stuffed animal when Matthew needs a hug and something to hold onto when it would be awkward for her to breastfeed. I would review Matthew's diet, consider prescribing a vitamin D and an iron supplement, and review good dental hygiene, including brushing the teeth before bedtime, and I would discourage breastfeeding throughout the night. Finally, I would encourage Matthew's mother to continue to breastfeed for as long as she and Matthew feel that it is right for them.

	REFERENCES

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 

1. Jakobsen M. Reason for termination of breastfeeding and length of breastfeeding. Int J Epidemiol. 1996;25 :115 –121[Abstract/Free Full Text]
2. Huggins K, Ziedrich L. The Nursing Mother's Guide to Weaning. Boston, MA: The Harvard Common Press; 1994:7 –24
3. Fildes V. Breasts, Bottles and Babies: A History of Infant Feeding. Edinburgh Scotland: Edinburgh University Press; 1986
4. Piovanetti Y. Breastfeeding beyond 12 months. An historical perspective. Pediatr Clin North Am. 2001;48 :199 –206[CrossRef][ISI][Medline]
5. Heinig J. Host defense benefits of breastfeeding for the infant. Pediatr Clin North Am. 2001;48 :105 –123[CrossRef][ISI][Medline]
6. Dewey K, Heinig J, Nommsen-Rivers L. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126 :696 –702[CrossRef][ISI][Medline]
7. Goldman A, Goldblum R. Immunologic components in human milk during the second year of lactation. Acta Paediatr Scand. 1983;72 :461 –462
8. Davis M. Review of the evidence for an association between infant feeding and childhood cancer. Int J Cancer Suppl. 1998;11 :29 –33[Medline]
9. Xiao S, Linet M, Steinbuch M, et al. Breast-feeding and risk of childhood acute leukemia. J Natl Cancer Inst. 1999;91 :1765 –1772[Abstract/Free Full Text]
10. Labbok M. Effects of breastfeeding on the mother. Pediatr Clin North Am. 2001;48 :143 –158[CrossRef][ISI][Medline]
11. Newcomb P, Storer B, Longnecker M, et al. Lactation and a reduced risk of premenopausal breast cancer. N Engl J Med. 1994;330 :81 –87[Abstract/Free Full Text]
12. Grummer-Strawn L. Does prolonged breastfeeding impair child growth? A critical review. Pediatrics. 1993;91 :766 –771[Abstract/Free Full Text]
13. Sugarman M, Kendall-Tackett K. Weaning ages in a sample of Americans who practice extended breastfeeding. Clin Pediatr (Phila). 1995;34 :642 –647

Parental Concerns About Extended Breastfeeding in a Toddler^*

Valley Children's Hospital
Fresno, California
University of California
San Francisco, California

	Dr David M. Snyder

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
Matthew's mother is seeking assistance in making a decision about weaning him. This is prompted by his desire to use the breast for comfort "when he is upset or in a new or unfamiliar situation." It may be tempting to respond to Matthew's mother glibly, either by pointing out that Matthew's behavior is perfectly normal for a nursing toddler (which is true) and that she should just get used to it, or, on the other hand, that weaning him now really won't do him any harm as long as it is done properly (which is also true). However, neither response truly addresses the question, "Should Matthew be weaned at this particular time?"

Karen Pryor, the author of my favorite book for nursing mothers, Nursing Your Baby,¹ said it well: "The time to stop nursing altogether is when either partner is really ready to quit." So, is Matthew or his mother "really ready to quit," or is the real issue his mother's feelings about Matthew's behavior?

I would begin by addressing the mother's conflicts about nursing. The case description suggests that Matthew's desire to nurse in public places when under stress is what is pushing his mother toward weaning, but is this the only reason she is thinking about weaning? If so, does she want help in stopping this particular behavior? If not, are family or friends telling her it's time to wean? Does she wonder if continued breastfeeding is somehow interfering with Matthew's development? Is his breastfeeding interfering with some other priority in her life? How does Matthew's father feel about Matthew's continued breastfeeding?

What is the other side of the mother's ambivalence? Is she concerned about Matthew's nutritional needs? Is she concerned that he needs the breast to comfort himself? Does she still really enjoy breastfeeding for the special closeness it brings to her relationship with her (presumably) increasingly independent toddler?

It may be important at this point to know what meanings—both positive and negative—breastfeeding has for Matthew's mother. These may relate to her self-concept as a nurturer, to previous experiences of success or failure with Matthew's older siblings (if any), or to her relationship with her own mother or with Matthew's father. The degree to which the pediatrician needs to probe these issues is a matter of judgment, but if the emotional intensity of the mother's questioning seems out of proportion to the explicit issues, it is a pretty good bet that there are other issues below the surface that the pediatrician better know about before prescribing a specific course of action.

Once the real issues are on the table, the pediatrician can begin providing appropriate advice. If she is really ready, Matthew's mother should be given appropriate advice regarding weaning. Many good sources of information on weaning techniques are available in print (La Leche League's The Womanly Art of Breast Feeding² or Karen Pryor's book¹ mentioned above) and on the Internet (the La Leche League³, "Breastfeeding Basics"⁴).

If she truly just wants to eliminate Matthew's troublesome desire to breastfeed for security in stressful situations, the pediatrician should address the following points:

1. Matthew's behavior is normal. For many nursing toddlers, the breast comes to serve the same function as a favorite blanket or stuffed animal in providing comfort and a sense of security. If the child already has another transitional object, the mother may find it easier to give him this when he asks to nurse in stressful situations. If he does not have a "lovey" already, the mother may be able to get him to attach to one, although this is not always successful.
   
2. If the mother is not really bothered by Matthew's behavior, she may just want reassurance that it is "okay." On the other hand, if she really does want to stop it, she should be told that it is also "okay" to set limits on his nursing. As in other instances of limit-setting, having a clear "rule" that is consistently enforced is important. A normal 18-month-old often has good enough language comprehension to understand "We don't nurse at the mall," or "We will nurse just as soon as we get back home."
   
3. If he has particular difficulties in unfamiliar environments, it may be helpful to tell him in advance about the place mother will be taking him and to assure him that it is safe and to emphasize the fun or interesting things about it. Fostering a positive expectation may decrease his anxiety. Of course, there may be some environments that are unavoidably stressful for a child, such as any place with an excessive noise level. When possible, these should just be avoided, for example, by going there only when someone else can care for the child.
   
4. In any case, the pediatrician's guidance should be tailored to Matthew's developmental issues, his temperament, his mother's emotional needs, and the social/cultural circumstances of their family.
   

	REFERENCES

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 

1. Pryor K. Nursing Your Baby. New York, NY: Pocket Books; 1991
2. La Leche League International. The Womanly Art of Breastfeeding. 4th ed. New York, NY: New American Library; 1987
3. La Leche League. Available at: www.lalecheleague.org. Accessed September 17, 2002
4. Breastfeeding Basics. Available at: www.breastfeedingbasics.com. Accessed September 17, 2002

Parental Concerns About Extended Breastfeeding in a Toddler^*

	Web Site Discussion

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
The case summary for the Challenging Case was posted on the Developmental and Behavioral Pediatrics Web site (www.dbpeds.org.list) and the Journal's Web site (www.lww.com/DBP). Comments were solicited.

	Meg Zweiback, RN, CPNP, Oakland, California

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
Although the World Health Organization recommends breastfeeding infants in developing countries for 2 years, I don't think the recommendations of the American Academy of Pediatrics are as extensive. A 1997 American Academy of Pediatrics policy statement on breastfeeding states: "It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired."¹

I think that a mother nursing a toddler should be helped to look at the advantages and disadvantages of nursing her child. Since nutritional reasons for extended nursing in developed countries are no longer prevailing, attention can be given to the mother-child relationship. Frequent nursing "on demand" may cause her to feel ambivalent about continuing nursing. I usually ask a mother to imagine any kind of nursing pattern that seems ideal to them—when, where, and how often. We work on these issues, reevaluating along the way.

	REFERENCE

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 

1. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1997;100 :1035 –1039

Parental Concerns About Extended Breastfeeding in a Toddler^,*

	Neil Stalker, MD, Peru, Indiana

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

Parental Concerns About Extended Breastfeeding in a Toddler^,*

	Dr Martin T. Stein

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

That breastfeeding into the 2nd year of life is a "natural" experience and connected to our survival as a species over time cannot be argued. I suspect that 1 major source for concern among many professionals and parents about extended breastfeeding is that it challenges our ideas about the importance of "autonomy," an important developmental task in the 2nd and 3rd year of life. However, autonomy has many facets and forms during the toddler years. For example, when a pediatrician discovers that an 18-month-old toddler is feeding himself solid foods, playing by himself, able to separate from both parents when left at childcare or when a sitter comes into the home, and beginning to settle himself to sleep at night, the initial steps to psychological autonomy are established. Extended nursing should not be seen as a hindrance to developmental progress. Reframing extended nursing in the larger context of the child's motor, social, and language maturation may assist Matthew's mother in the decision process. At the least, it is a teachable moment when a pediatrician provides a fresh understanding about a child's developmental potential.

Surveys among physicians have documented that obstacles to the continuation of breastfeeding include physician apathy and misinformation.^2,3 Even among contemporary clinicians who support breastfeeding, how many ask mothers at health-supervision visits, "Do you plan to continue nursing? How long?" and then follow up their response with something like, "That's just great that you are committed to continuing to nurse your child...go for it as long as you are comfortable nursing and your baby is enjoying the experience." Pediatricians can influence the initiation and duration of breastfeeding by conveying unambivalent, positive statements—in the examining room, in the office waiting room (with posters, pamphlets, and Web site information), and in the community.

Both Drs Boies and Snyder emphasized the importance of determining the issues or "conflicts" that Matthew's mother may have perceived as important to the continuation of nursing. It is a reminder that there is not a single response suitable to all parents. Extended nursing is a personal decision. Pediatricians can proactively encourage breastfeeding beyond 1 year while they recognize the individual needs of each mother, child, and other members of the family.

	FOOTNOTES

 
^* Originally published in J Dev Behav Pediatr. 2002;23:438–442.

	FOOTNOTES

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 
A bimonthly discussion of an upcoming Challenging Case takes place at the Developmental and Behavioral Pediatrics Web site. This Web site is sponsored by the Maternal and Child Health Bureau and the American Academy of Pediatrics section on Developmental and Behavioral Pediatrics. Henry L. Shapiro, MD, is the editor of the Web site. Martin Stein, MD, the Challenging Case editor, incorporates comments from the Web discussion into the published Challenging Case. To become part of the discussion at the Developmental and Behavioral Pediatrics home page, go to www.dbpeds.org.

	REFERENCES

TOP CASE Dr Martin T. Stein REFERENCE Dr Eyla G. Boies REFERENCES  Dr David M. Snyder REFERENCES   FOOTNOTES  Web Site Discussion Meg Zweiback, RN, CPNP,... REFERENCE    Neil Stalker, MD, Peru,... Dr Martin T. Stein REFERENCES

 

1. Stein MT, Colarusso CA, McKenna JJ, Powers NG. Cosleeping (bedsharing) among infants and toddlers. J Dev Behav Pediatr. 1997;18 :408 –412[CrossRef][ISI][Medline]
2. Freed GL, Clark SJ, Sorenson J, Lohr JA, Cefalo R, Curtis P. National assessment of physicians' breast-feeding knowledge, attitudes, training, and experience. JAMA. 1995;273 :472 –476[Abstract]
3. Williams EL, Hammer LD. Breastfeeding attitudes and knowledge of pediatricians-in-training. Am J Prev Med. 1995;11 :26 –33[ISI][Medline]

This Article Extract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Stein, M. T. Articles by Snyder, D. M. Search for Related Content PubMed Articles by Stein, M. T. Articles by Snyder, D. M. Related Collections Office Practice

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