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.
Breastfeeding until at least 2 years old is recommended by the World Health Organization because of the benefits for both child and mother. This includes developed countries such as the UK. Although there are estimates that less than 1% of UK children are still breastfed by their first birthday, the exact figure is unknown. For those families who do continue to breastfeed, it has a significant value that goes beyond nutritional or health benefits. Children allowed to continue breastfeeding will typically self-wean between the ages of 2 and 7 (natural term). A breastfed child eats normal solid foods alongside breastmilk, and they do not require any other mammalian milk (e.g. cow’s milk). There is no evidence of harm to children or mothers who breastfeed to natural term.
Breastfeeding beyond infancy is biologically normal: it should be celebrated and encouraged in mothers 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 breastfeeding. Few GPs receive high quality lactation education, and thus may be inadequately informed to support families achieve longer term breastfeeding. This guide summarises the evidence available and how GPs can help.
Effects on maternal and child health
Most GPs are aware of the vast array of benefits of breastfeeding babies (1), but may mistakenly believe that these benefits are time-limited. Breastmilk remains rich in vitamins, minerals and fats through toddlerhood and beyond (2,3), and immune components unique to human milk actually increase as the child ages (4). Children who are breastfed beyond 1 year have a reduced risk of acute otitis media (5), type 2 diabetes (6) and obesity (7). Breastfeeding beyond infancy may have psychological benefits for the child (8) and is an important source of comfort for young children. Many mothers find breastfeeding an invaluable parenting tool, by soothing a tired, injured or frustrated toddler and helping to promote sleep. Continued breastfeeding can prevent dehydration and malnourishment in unwell or hospitalised children, and 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 breastmilk (9). Breastmilk is particularly important for children with cow’s milk protein allergy, as ready-made soya, oat, coconut or other milk substitutes are unsuitable under 2 years of age (10). There are also numerous benefits for mothers, but it should be noted that few (if any) mothers continue to breastfeed beyond 12 months solely for their own benefit. Benefits include a reduction in the risk of breast cancer (11), endometrial cancer (12) ovarian cancer (13), cardiovascular disease (14) and type 2 diabetes (15). Indeed, the UK government estimates savings of over £31 million for each annual cohort of new mothers through reduction of maternal breast cancer, if more women breastfed and did so for longer (16). There is no evidence in the literature of harm to either mother or child from natural term breastfeeding, including tooth decay (17). Production of toddler ‘follow-on milks’, which in ordinary circumstances are not proven to be necessary (18), undermine the International Code of Marketing of Breast-milk Substitutes and contribute to environmental impact (19).
Considerations for GPs
Breastfeeding is not always easy, and families who have reached 12 months may have overcome many challenges (27). Whilst many mothers report they receive good breastfeeding support in the early months, this reduces as their baby gets older (28). Lactation-specific education is scarce in UK medical schools and postgraduate training programmes, leaving many GPs ill-prepared to support natural term breastfeeding. Unsolicited advice to wean, unsupportive personal opinions or inaccurate information are all unhelpful to families who trust their GP, and may damage the doctor-patient relationship (29). US research has shown that even a very brief educational programme can improve doctors’ attitude and knowledge towards breastfeeding beyond infancy (30). A doctor’s personal experience of breastfeeding can affect their breastfeeding advocacy (31). Therefore, GPs who have had a negative personal experience of breastfeeding should ensure that any advice they give is evidence-based rather than anecdotal. Mothers who fear ridicule may choose to hide the fact that they breastfeed (32). But breastfeeding in public in the UK is protected by law, and there is no upper age limit to this (33). Mothers returning to work can successfully continue breastfeeding with appropriate support, and there is no need to wean unless she or the child wish to (34).
Nursing aversion (intense unpleasant emotions experienced whilst breastfeeding) may affect mothers, particularly of older children (35). Some mothers persevere for the benefit of their child; others may wish to wean. In either case, mothers benefit from their GP asking them about their wishes and then providing appropriate signposting to achieve this. Weaning from the breast may be mother-led or child-led (or a combination): natural child-led weaning is a gradual and gentle process and all children will eventually wean (36). Families should avoid abrupt weaning due to the risk of breast engorgement, mastitis and emotional distress for both mother and child. Some mothers fall pregnant whilst breastfeeding, and may continue to breastfeed 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 (37).
Mothers seeking breastfeeding support can contact the National Breastfeeding Helpline on 0300 100 0212, or can seek face to face support from Peer/Mother Supporters, Breastfeeding Counsellors or International Board Certified Lactation Consultants. IBCLCs are recognised as the gold standard in breastfeeding support and are available throughout the UK (38). GPs who wish to learn more about breastfeeding can do so via Unicef’s e-learning package (39) or RCGP’s e-learning course (40), which is free to College members. The ABM also offers their Breastfeeding Support Training Foundation Module (41), an online course suitable for healthcare professionals. Finally an online book for doctors has recently been published and is free to access (42).
In summary, GPs have an important role to play in helping to normalise and support breastfeeding beyond infancy. Breastfeeding mothers have a right to ongoing high standards of evidence-based healthcare for as long as they choose to continue. Breastfeeding beyond infancy benefits mothers, children and the NHS and thus should be actively supported by all GPs.
Dr Naomi Dow (GP) firstname.lastname@example.org
Emma Pickett (International Board Certified Lactation Consultant, Chair of Association of Breastfeeding Mothers)
Dr Vicky Thomas (Consultant Paediatrician with special interest in growth and nutrition)
Whilst we have used the terms ‘mother’, ‘woman’ and ‘breastfeeding’, we recognise that not all families use this terminology. We encourage GPs to use the terminology preferred by each parent or family.