Breastfeeding: A look back at good, better, and best

By Dr. Margaret Boland

A position statement on breastfeeding published in 1978 to mark the International Year of the Child in 1979, was a joint effort of the nutrition committees of both the Canadian Paediatric Society and the American Academy of Pediatrics. One of the features of the article that immediately struck me was that all the authors were men. And while I can’t be sure, I would hazard a guess that they were also all White men. The statement sketches what was known about the contents of breast milk nutritionally and immunologically, and then discusses the decline of and ways to increase breastfeeding. The authors were giving important advice.

“Nursing personnel with personal experience in breast-feeding can be extremely helpful,” they write. The majority of doctors at the time, even paediatricians, were men and the vast majority of nurses were women. There was definitely recognition that “breast was best”, although the scientific basis for the recommendation was still limited.

The historical context for this statement is interesting to recall. Breastfeeding had been declining through the middle of the 20th century. Anecdotally, I remember watching my own mother in the 1950s mixing canned evaporated milk with boiled water and a little corn syrup to dilute the protein. She put it into sterilized glass baby bottles for my infant brother, about 6 bottles for the day. Of course, infant formula was available as a more expensive choice, but not in our house. My mother, a nurse who had some midwife training, described binding women’s breasts after delivery by wrapping sheeting around their torso and pinning in place to inhibit production of breast milk.

The infant formula and artificial infant feeding industry was established as the modern, progressive way to feed infants. This led to the decline of breastfeeding and the loss of generational knowledge of the skill to breastfeed, often passed from mother to daughter. As a profit-generating industry, the formula companies also funded much of the nutrition research. Research on formula feeding, used by the industry to enhance its product, of course made formula more like breast milk!

One paragraph in particular stood out as a reflection of another time: “With the profound social transformations which have taken place in the Western world, breast-feeding is frequently considered incompatible with modern life-styles or with work outside the home...”

By the 1970s, with the rise of the women’s movement, domestic interest in breastfeeding increased, but mainly among better educated women. The WHO and health professions also recognized the hazards of formula feeding for developing countries. Women themselves took on the practice of breastfeeding with the establishment of the La Leche League International and other lay organizations. By the time I had my own children in the early 80s I had no doubt I was going to breastfeed, but there were very few resources to teach the skill. My mother had not breastfed us and my medical training made no mention of the “ways and means”. Interestingly, the article reminded me that with formula feeding “solids” were introduced to the infant at an earlier time, and I do remember being taught in medical school that solids could start to be introduced at about 3 weeks of age. My own experience of breastfeeding was trial and error, reading and re-reading a dog-eared copy of The Womanly Art of Breastfeeding, first published by La Leche League International in 1956 and now in its 8th edition. I breastfed two infants during my fellowship, surviving cracked bleeding nipples, mild mastitis, leaking, and painful engorgement.  

The 1978 statement had much good advice to promote breastfeeding, which remains a long uphill struggle. The limits of breastfeeding are found in one sentence that reads: “….a marketing survey completed in 1973 by Ross Laboratories in Canada [found that] 35% of infants were breast-fed during the first week of life; by….6 months, only …..6% ….still breast-fed”.

Recognizing the negative role of the formula industry on breastfeeding, the WHO in 1981 published the International Code of Marketing of Breast-milk Substitutes, a voluntary code to limit misuse of artificial infant feeding and limit industry’s undermining of breastfeeding, especially, but not solely, in developing countries. The WHO now recommends exclusive breastfeeding for 6 months, introducing age-appropriate and safe complementary foods at 6 months, and continuing breastfeeding for up to 2 years or beyond. The best feeding option globally is initiation of breastfeeding within the first hour of life.

The Baby-Friendly™ Hospital Initiative (BFHI)—launched in 1991 by WHO/UNICEF—works around the world through bodies like the Breastfeeding Committee for Canada to ensure that all maternity units become centres of breastfeeding support and that all mothers receive the support they need to successfully breastfeed. Canada has well over 50 BFHI-accredited hospitals, birthing centres and health units, but this is still not the majority. From 2020 data, in Canada, 91% of all mothers initiate breastfeeding, but 40% to 50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women (1).

We are well over 40 years on from this CPS statement. As we weather our current health problems, it is nice to know that the Public Health Agency of Canada, the WHO, and the Canadian Paediatric Society all recommend that mothers/birth parents with suspected or confirmed COVID-19 continue to breastfeed. Breastfeeding provides increased food security and contributes to emergency preparedness. Breastfeeding also provides immuno-protection that plays a unique role during the COVID-19 pandemic. Human milk is important for all babies, especially for preterm or unwell infants in the NICU (2).

We have learned a lot about breastfeeding and its advantages since 1978 and are doing much better with the practice. The authors would approve.

Dr. Margaret Boland, associate professor of paediatrics at the University of Ottawa, provided nutrition care to children at CHEO for more than a quarter century. She chaired the CPS Nutrition Committee (as it then was) and was an editorial board member for the 2008 edition of the CPS book Well Beings: A Guide to Health in Child Care.   

References

1. Statistics Canada. Health characteristics, two-year period estimates. Table 13-10-0113-01, release date 1022-04-19: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310011301 (Accessed April 26, 2022).
2. Breastfeeding Committee for Canada. Key messages: Infant Feeding and COVID-19 (posted May 2020, updated January 2021): https://breastfeedingcanada.ca/wp-content/uploads/2021/01/BCC-Covid-19-and-Infant-Feeding-Key-Messages-Jan-6-2021-clean-copy.pdf (Accessed April 26, 2022)

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