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This guide, written by a GP, a Paediatrician and a lactation consultant, summarises the evidence available on breastfeeding beyond infancy and how GPs can support families in their care.
Key Messages
Breastfeeding until at least 2 years old is recommended by the World Health Organization because of the benefits for both child and mothers/lactating parents. This includes industrialised countries such as the UK. For families who continue to breastfeed beyond infancy, it has a significant value that goes beyond nutritional or health benefits. Children allowed to continue feeding will typically self-wean between the ages of 2 and 7 (natural term). A breastfed child eats normal solid foods alongside human milk, and they do not require any other mammalian milk (e.g. cow’s milk). There is no evidence of harm to children or parents who breastfeed to natural term.
Feeding beyond infancy is biologically normal: it should be celebrated and encouraged in mothers and parents who wish to do so. It has health, economic and environmental benefits for the individuals involved as well as wider society; yet British culture is not generally supportive of natural term feeding. Few HCPs receive high quality lactation education, and thus may be inadequately informed to support families achieve
longer term feeding. This guide summarises the evidence available and how HCPs can help.
Effects on parental and child health
Most HCPs are aware of the vast array of benefits of breastfeeding babies (1), but may mistakenly believe that these benefits are time-limited. Human milk remains rich in vitamins, minerals and fats through toddlerhood and beyond (2,3), and unique immune components actually increase as the child ages (4). Children who receive human milk beyond 1 year have a reduced risk of acute otitis media (5), type 2 diabetes (6) and obesity (7). Nursing beyond infancy may have psychological benefits for the child (8) and is an important source of comfort for young children. Many mothers and parents find it an invaluable nurturing tool, by soothing a tired, injured or frustrated toddler and helping to promote sleep. Continued milk feeding can prevent dehydration and malnourishment in unwell or hospitalised children, and it is an ideal source of nutrition for ‘fussy eaters’; parental attempts to increase solid foods in these situations can lead to displacement of nutrient-rich human milk (9). Children with cow’s milk protein allergy may drink ready-made almond, oat, coconut or other milk substitutes once they reach 12 months (10), however plant-based milks have limitations in their micro and macro nutrients, and thus human milk is the preferred option whenever possible (11). . There are also numerous health benefits for parents, but it should be noted that few (if any) continue to breastfeed beyond 12 months solely for their own benefit. Benefits include a reduction in the risk of breast cancer (12), endometrial cancer (13) ovarian cancer (14), cardiovascular disease (15) and type 2 diabetes (16). Indeed, the UK government estimates savings of over £31million for each annual cohort of new mothers through reduction of breast cancer, if more breastfed and did so for longer (17). There is no conclusive evidence in the literature of harm to either parent or child from natural term feeding, including tooth decay (18). Production of toddler ‘follow-on milks’, which in ordinary circumstances are not proven to be necessary (19), undermine the International Code of Marketing of Breast-milk Substitutes and contribute to environmental impact (20).
Considerations for HCPs
· Nursing beyond infancy is not rare in the UK, although does vary significantly according to geographical area. At the 13-15 month review, 21% of toddlers across Scotland were receiving human milk (21).
· Parents who breastfeed or chestfeed any age of child(ren) do not require any specific dietary adjustment or supplement apart from 10mcg Vitamin D daily (22).
· It is very rarely necessary for a parent to stop feeding in order to take medication (23). Many will opt to delay treatment if a lactation-compatible medication is not prioritised. The BNF alone is an inadequate reference for safety in lactation, and prescribers should check additional sources for more comprehensive information (24): we recommend UK Drugs In Lactation Advisory Service (NHS service) or The Breastfeeding Network.
· Lactational Amenorrhoea Method of contraception is only suitable for use if the baby is under 6 months and has several strict criteria, as detailed by FSRH (25). Beyond 6 weeks of age, all hormonal forms of contraception (including COCP) are categorised as UKMEC 1 or 2 (26), however this is a complex area. Breastfeeding professionals frequently see mothers and lactating parents reporting a decrease in milk supply with all types of hormonal contraception, and HCPs should be prepared to counsel parents fully, including a discussion of the risks (27).
· Parents breastfeeding a baby or child of any age may develop sore nipples, engorgement or mastitis and should be supported appropriately – see Physician Guide to Breastfeeding for detailed information (28).
Supporting for Mothers and Parents
Breastfeeding and chestfeeding is not always easy, and families who have reached 12 months may have overcome many challenges (29). Whilst many parents report they receive good support in the early months, this reduces as their baby gets older (30). Lactation-specific education is scarce in UK undergraduate and postgraduate healthcare curricula, leaving many HCPs ill-prepared to support natural term feeding. Unsolicited advice to wean, unsupportive personal opinions or inaccurate information are all unhelpful to families who trust their HCP, and may damage the trusting/caring relationship (31). US research has shown that even a very brief educational programme can improve doctors’ attitude and knowledge towards lactation beyond infancy (32). A doctor’s personal experience of feeding their own child can affect their professional lactation advocacy (33). It is essential for all HCPs to ensure that any advice they give is evidence-based rather than anecdotal. Families who fear ridicule may choose to hide the fact that they breastfeed (34). But the Equality Act (2010) states that it is against the law to discriminate against a breastfeeding woman,(35), and there is additional legal protection for breastfeeding children up to 2 years of age in public in Scotland (36). Parents returning to work can successfully continue feeding with appropriate support, and there is no need to wean unless they or the child wish to (37).
Nursing aversion (intense unpleasant emotions experienced whilst feeding) may affect mothers and parents, particularly of older children (38). Some may persevere for the benefit of their child; others may wish to wean. In either case, parents benefit from their HCP asking them about their wishes and then providing appropriate signposting to achieve this. Weaning may be parent-led or child-led (or a combination): natural child-led weaning is a gradual and gentle process and all children will eventually wean (39). Families should ideally avoid abrupt weaning due to the risk of breast engorgement, mastitis and emotional distress for both parent and child, although there may be some rare circumstances in which this is necessary, for example if the lactating parent needs to start chemotherapy. Some parents fall pregnant whilst lactating, and may continue to feed their older child throughout their pregnancy and once their baby is born (tandem nursing). There is no evidence that breastfeeding during a normal pregnancy causes miscarriage or premature labour (40).
Mothers and parents seeking lactation support can contact the National Breastfeeding Helpline on 0300 100 0212, or can seek face to face support from Peer Supporters, Breastfeeding Counsellors or International Board Certified Lactation Consultants. IBCLCs are recognised as the gold standard in lactation support and are available throughout the UK (41). Doctors who wish to learn more about breastfeeding can do so via The Breastfeeding Network’s ‘Breastfeeding for Physicians’ course (42). UNICEF offer a range of e-learning training packages (43), and the Association of Breastfeeding Mothers also offers their Breastfeeding Support Training Foundation Module (44), an online course suitable for healthcare professionals.
Conclusions
In summary, HCPs have an important role to play in helping to normalise and support human milk feeding beyond infancy. Lactating parents have a right to ongoing high standards of evidence-based healthcare for as long as they choose to continue. Breastfeeding and chestfeeding beyond infancy benefits parents, children and the NHS and thus should be actively supported by all HCPs.
Dr Naomi Dow (GP and IBCLC) naomi.dow@nhs.scot
Emma Pickett (Breastfeeding Counsellor, International Board Certified Lactation Consultant)
Dr Vicky Thomas (Consultant Paediatrician with special interest in growth and nutrition)
We have aimed to use inclusive language in this article. We encourage HCPs to use the terminology preferred by each parent or family.
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