Breastfeeding Beyond a

Year: Why Is the AAFP

Stretching the Truth
About the Benefits?
Posted on October 27, 2011
The benefits of breastfeeding to a young infant’s health are well-
documented (though sometimes debated), and the American
Academy of Pediatrics (AAP) recommends that babies be breastfed
for the first year of life if possible. Are there any health benefits to
the child for breastfeeding beyond a year? I am curious about this
as my daughter approaches her first birthday.

Photo credit: Santiago Fernánde. via Wikimedia Commons

I shouldn’t have been surprised to find that there have been
very few studies of extended breastfeeding (> 1 year)
conducted in the developed world. Breastfeeding research is
notoriously hard to do, and good research on extended
breastfeeding is nearly impossible. As a population, women in
the developed world who breastfeed their babies are already
likely to be different from mothers who choose not to
breastfeed, setting their babies up for different outcomes well
before their boobs even hit the baby’s lips. (This is of course
a very broad generalization, and I recognize there are
exceptions.) These differences are likely even greater in
women who choose to breastfeed beyond a year. Only 24%
breastfeed to one year in the U.S. [1], and we don’t know how
many continue beyond that. These mothers are more likely
to be well-educated, white, older, richer, buying organic food,
fretting about BPA exposure, and the list goes on. Sure, we
can use statistics to try to account for these confounding
variables, but these methods require (A) that you’ve identified
the most important variables, and (B) that you have study
participants that represent a spectrum along that variable.
This research is hard to do.
It is also important to point out that breastfeeding research
conducted in developing countries does not tell us anything
about outcomes in the U.S. and other developed countries.
There is real evidence that extended breastfeeding benefits children
in the developing world, where young children are challenged by
malnutrition and greater exposure to infectious diseases, which is
why the World Health Organization recommends breastfeeding for
two years. My child has access to balanced nutrition and clean
water, so whether she nurses beyond a year is less likely to affect
her health.
These caveats aside, is there any research to support extended
breastfeeding for the sake of my child’s health?
The AAP policy statement on breastfeeding doesn’t discuss
breastfeeding beyond a year so didn’t provide any leads. Next, I
checked the policy of the American Academy of Family
Physicians (AAFP). On nursing beyond infancy, the AAFP
position paper states,
“As recommended by the WHO, breastfeeding should ideally
continue beyond infancy… It has been estimated that a natural
weaning age for humans is between two and seven years [2].
Family physicians should be knowledgeable regarding the ongoing
benefits to the child of extended breastfeeding, including continued
immune protection [3], better social adjustment [4], and having a
sustainable food source in times of emergency.” And on weaning a
child due to a subsequent pregnancy, they state: “If the child is
younger than two years, the child is at increased risk of illness if
weaned [no citation].”
Let’s look at the research cited by the AAFP:

Should I wean my child at the “natural age”?

Katherine Dettwyler is an anthropologist at the University of
Delaware. The reference of her work in the AAFP statement is for
a book chapter that she wrote [2], but you can also read a summary
of her research on her personal webpage. Dettwyler reviewed
research on weaning in non-human primates and extrapolated from
those observations to determine that the “natural” age of weaning of
humans should be 2.5-7 years.
While I appreciate this anthropological perspective, I think it is
inappropriate for the AAFP to make recommendations to humans
based on what monkeys do. The monkeys do what they do because
it probably does benefit their offspring, but this is not evidence that
extended breastfeeding will benefit my child. And early human
societies probably did breastfeed their children beyond a year.
Let’s say that you were a mother raising a baby in a hunter-gatherer
society. In your world, you don’t have a safe way to store food, so
you have periods of relative feast and relative famine. Your food
supply on a given day depends on the success of the most recent
hunt and the seasonal availability of wild plant foods. Babies and
toddlers don’t cope well with intermittent food supply. They need
to eat often to support their rapid rate of growth and
development. Of course you would breastfeed as long as possible
so that you could provide your child with a reliable source of
nutrients. This would allow you, the mother, to store calories and
nutrients when food was abundant and later mobilize them to breast
milk so that your child could continue to eat even when food was
scarce. This is a brilliant evolutionary advantage of mammalian
lactation, but it doesn’t really apply in today’s developed societies,
where most children have ready access to more than enough
calories and nutrients.
Does extended breastfeeding give my child immune protection?
The AAFP cites a 1983 study [3], which shows that concentrations
of IgA, lactoferrin, and lysozyme are similar between 12 and 24
months of lactation. However, this was a tiny cross-sectional study,
involving just 15 milk samples. And though it tells us is that breast
milk still has immunological proteins in the second year of
breastfeeding – we don’t know if breastfed toddlers are actually less
likely to get sick.
Will my child have better social adjustment if I breastfeed
longer?
To support their statement that extended breastfeeding leads to
better social adjustment, the AAFP cites a prospective study of
1024 New Zealand kids enrolled at birth and studied for 8 years
[4]. The study looked at correlations between duration of
breastfeeding and conduct disorders, which were assessed by both
the children’s teachers and their mothers. Once the data were
adjusted for confounding variables such as family income or
disruptions such as divorce, there was a small but significant
correlation between longer breastfeeding and better conduct
scores, as assessed by the mothers. In other words, the mothers that
breastfed their children longer thought a bit more highly of their
children, but mothers can be sort of biased, don’t you think? There
was little relationship between breastfeeding and the teachers’
scores. The authors conclude, “Certainly, the results provide no
support for the view that prolonged breastfeeding makes a major
impact on subsequent social adjustment.” I agree – there are lots of
ways to influence your child’s behavior in elementary school, but
based on this study, breastfeeding is unlikely to help much.
Is breast milk a good food source in times of emergency?
Yes! I’m comfortable saying this even without any science to back
it up. If we are ever victims of an earthquake or some other natural
disaster, I can imagine it would be very useful to be lactating so that
I know I have a ready-made clean source of food and water for my
child. However, I probably won’t make my decision based on this
unlikely event.

Is my child at increased risk for illness if weaned before 2

years?
Although the AAFP makes this statement, they don’t provide any
research to back it up. I looked through countless other studies as
well, and I couldn’t find anything to support this statement. So as
far as we know, your child will be just fine if you wean before 2
years.

Needless to say, I’m disappointed in the AAFP. I whole-heartedly

respect the mission of promoting breastfeeding and believe
mothers should be supported if they want to continue
breastfeeding beyond a year, but you shouldn’t have to stretch
the truth about scientific studies to do so. Most women would
read the AAFP’s policy statement and conclude that there is
scientific evidence that their kids will be healthier and better-
behaved if they breastfeed to two years. Women deserve to have
accurate information with which to make their choices. You can
tell them that they might enjoy breastfeeding their toddler and there
is no rush to wean. You can even say that there maybe health
benefits, but there isn’t enough research to say for sure. Just don’t
cite scientific evidence where there is none. Based on the research
cited by the AAFP, there is no scientific evidence that it will
compromise a child’s health to wean at a year.
I did read many more studies than these few cited by the AAFP, but
this post has already gone on too long. I’ll let you know what data I
did find and my own decision about breastfeeding beyond a year in
uncoming posts. If anyone has run across a study that looked at
breastfeeding beyond a year in the developed world, please pass it
on!

What do you think? Does the end justify the means? Is it fair
for the AAFP to stretch the scientific evidence to encourage
women to breastfeed longer?
REFERENCES

1. CDC, Breastfeeding Report Card – United States, 2011. 2011.

2. Dettwyler, K.A. A Time to Wean, in Breastfeeding: Biocultural

Perspectives, D.K. Stuart-Macadam P, Editor. 1995, Aldine De
Gruyter: New York, NY. p. 39-73.
3. Goldman, A.S., R.M. Goldblum, and C. Garza. Immunologic
components in human milk during the second year of
lactation. Acta Paediatr Scand. 72(3): p. 461-2. 1983.
4. Fergusson, D.M., L.J. Horwood, and F.T. Shannon.
Breastfeeding and subsequent social adjustment in six- to eight-
year-old children. J Child Psychol Psychiatry. 28(3): p. 379-86.
1987.
past age two years lead to better future health
of the Baby and the mother
up Although exclusive breast feeding for 6 months is recommended , Apart
4
vote d from reduction of Obesity, I would like to know what health benefits does
own
extended breastfeeding duration (2yr and beyond) as recommended by
vote WHO provide to both the mother and the baby? I would also like to know some
favorite

personal experiences of parents who have done this.

2 health breastfeeding

shareimprove this question edited Jul 15 '13 at 11:42 asked Ju

Chrys parentin
6,6191935 543318

According to this exceptional overview of the evidence, there is a possibility that there are benefits
1 year, but no conclusive evidence at all. – justkt Jul 15 '13 at 13:40

"Reduction of obesity" is a misleading way of phrasing it, as it is a collection of a number of other fa

1 chance of obesity. Breast feeding is the baseline. – Dave Clarke Jul 16 '13 at 17:03

add a comment

2 Answers
activeoldestvotes

up An important thing which most analyses of breastfeeding studies that I have

6
vote d read note is that women who breastfeed tend to have higher IQs and incomes
own
than women who don't, at least in first world countries. Because of the changes
vote in lifestyle factors which result, it is nearly impossible to sort out what impacts
on women and children are from breastfeeding and what are from better access
to quality foods, better access to educational resources, and so on. This is even
more true of women who breastfeed for an extended period of time.

From the World Health Organization comes a paper on the long-term effects of
breastfeeding - in general, with some studies only going to 3 months - dated
2013. The Skeptical OB has a summary. In the case of most health benefits that
are commonly claimed to be associated with breastfeeding and even more with
extended breastfeeding the WHO determined that confounding variables such as
maternal intelligence, education, and income could not be ruled out. These
benefits included a slight reduction in obesity, a tiny increase in IQ, and a small
decrease in blood pressure. The conclusion is:
Total cholesterol. There was no effect in the overall meta-analyses. In the 2007
review, there was a significant effect among adults, which is no longer present
in the updated analyses. The UK trial of preterm infants showed a small
protective effect (3), while the Belarus trial did not report on this outcome. We
conclude that breastfeeding does not seem to protect against total
cholesterol levels.
Blood pressure. The pooled estimate from the high-quality studies indicates a
small reduction of less than 1 mmHg in systolic pressure among breastfed
subjects, and no significant protection in terms of diastolic pressure. Residual
confounding may be an important problem. The Belarus and UK preterm trials
found no effect of breastfeeding (2,4). We conclude that the protective effect
of breastfeeding, if any, is too small to be of public health significance.
Diabetes. There was substantial protection in the pooled analyses, with a 34%
reduction, but few studies are available and their results were considerably
heterogeneous. Only two high-quality studies were identified, with conflicting
results (one showing an increase and another a reduction among breastfed
subjects). The randomized trials did not present any results on these
outcomes.Our conclusion is that further studies are needed on this outcome.
Overweight-obesity. In the pooled analyses of all studies, breastfeeding was
associated with a 24% reduction in overweight and/or obesity, but the reduction
was only 12% in the high-quality studies. Residual confounding may be still
affecting these results, because protection is not evident in studies from low and
middle-income countries where the social patterning of breastfeeding is not
clear cut. The Belarus trial did not find an association (4). We conclude that
breastfeeding may provide some protection against overweight or obesity,
but residual confounding cannot be ruled out.
Intelligence tests. Breastfeeding was associated with an increase in 3.5 points in
normalized test scores in the pooled analyses of all studies, and 2.2 points when
only the high-quality studies are included. The two randomized trials also found
significant effects (1,5). We conclude that there is strong evidence of a
causal effect of breastfeeding on IQ, although the magnitude of this effect
seems to be modest.
The most recent Harvard study referenced in the other answer also has serious
flaws as reported by the Skeptical OB. As with other breastfeeding studies, the
 major flaw is that this study did not take out the confounding variables.
After doing some research I have found two studies which attempted to separate
out socio-economic status and educational status in the mother from
breastfeeding status. Unfortunately neither measured breastfeeding duration
over 2 years and both are based on the same group of children. The studies
looked at a less than six month duration and a 12-18 month duration of
breastfeeding. Both studies [1] and [2] did show the minor IQ bump, as
mentioned above in the quote from the WHO paper.
I am not convinced that all the benefits of breastmilk have been discovered yet,
as it seems that something that is newly discovered and amazing about
breastmilk is being discovered every year. However so far the scientific
evidence does not support a significant public health benefit over the long term
to extended breastfeeding.

The initial challenges to breastfeeding tend to be in the early months - getting

the milk supply established, getting past cluster feeding and growth spurts,
dealing with pain for the mother, the transition to going back to work, and so
on. In my opinion overstating the small benefits of breastfeeding in general and
extended breastfeeding in particular will not help families who desire to
breastfeed be any more motivated to overcome these challenges.

No matter what the studies say, for some families there will be benefits to
breastfeeding up to and past age two. There are all sorts of intangibles, many
mentioned here that are backed up by experience, not science. Breastfeeding
provides cuddle time with notoriously on-the-go toddlers. It may help with
hydration during illness. It can be a tool for calm in the emotionally stormy
times of toddlerhood. If extended breastfeeding is working, that's great. There's
no need to exagerate the health benefits to defend it.
shareimprove this answer edited Jul 16 '13 at 21:52 answere

justkt
4,206192

add a comment

up Breastfeeding up to two years of age or beyond is based on the fact that breast
1
vote d milk is a key organic source of DHA (Omega fatty acids), vitamin A, calcium
own and proteins and provides protection against infectious agents.
vote In 2008 the American Academy of Family Physicians said this in their position
paper:
It has been estimated that a natural weaning age for humans is between two and
seven years. Family physicians should be knowledgeable regarding the ongoing
benefits to the child of extended breastfeeding, including continued immune
protection, better social adjustment and having a sustainable food source in
times of emergency. The longer women breastfeed, the greater the decrease in
their risk of breast cancer. There is no evidence that extended breastfeeding is
harmful to mother or child.
Many scientific studies prove the point that longer breastfeeding enhances the
neurodevelopment of infants and their intellectual and scholastic ability in later
life. from one of these studies increase in the IQ by breastfeeding is
directly related to the duration of breastfeeding. These benefits are strongest
for the infants of low birth weight on breastmilk feeding. It is found that Poor
who are more likely to enter into child malnutrition are more likely to benefit
from enhanced optimal breastfeeding practices.
longer breastfeeding promotes suppression of following Diseases and benefits
to the infant :
 Enhanced stereoscopic vision

 Neuromotor development
 Lower chances of obesity in Adult life
 Increase in height
 suppression of gastrointestinal and respiratory infectious morbidity
 suppression of atopic eczema
 suppression of asthma
Benefits for the Mother:
 Weight loss
 lower chances of breast cancer

 lower chances of premenopausal ovarian cancer

 suppression of hypertension
 suppression of type 2 diabetes
 suppression of myocardial infarction (heart attack).
WHO recommends that breastfeeding should continue for two years or
more without accurately establishing a maximum duration for
breastfeeding.In addition, there is insufficient evidence on the advantages
and disadvantages of continuing breastfeeding after two years.
It is unfortunate that about many mothers are unable to breast feed even upto 1
year. This may be because We’ve sexualized the breast so much that people
have forgotten breasts are for breast-feeding. There is A Harvard Study which
looks at both health AND cost outcomes for U.S. mothers if they were to
breastfeed for 1 year.The study found that if 90% of mothers breastfed, U.S.
women would significantly lower their risk of heart attack, breast cancer, and
hypertension. On a macro level, further investment in lactation support for
moms could prevent $17.4 billion in maternal health costs.
Many mothers have shared positive Experiences of extended breastfeeding in
this article.
Breastfeeding rates in Australia
The World Health Organization recommends exclusive* breastfeeding for babies to 6 months of
age, and thereafter for breastfeeding to continue alongside suitable complementary foods for up
to 2 years and beyond.1
The National Health and Medical Research Council recommends exclusive breastfeeding for
around 6 months and then for breastfeeding to continue alongside complementary food until 12
months of age and beyond, for as long as the mother and child desire.2
Australian breastfeeding statistics indicate we are falling well short of the above
recommendations. Statistics from the 2010 Australian National Infant Feeding Survey3results
indicate that 96% of mothers initiate breastfeeding. Thereafter, exclusive breastfeeding rates drop
off. Less than half (39%) of babies are still being exclusively breastfed to 3 months (less than 4
months) and less than one quarter (15%) to 5 months (less than 6 months).
Thereafter, statistics fromThe 2006-2007 Longitudinal Study of Australian Children 4study show
that at 12 months, 28% of children were still being breastfed; at 18 months, 9% of children; and
at 24 months, 5% were still being breastfed.
*Exclusive breastfeeding means that the baby receives only breastmilk. No other liquids or solids
are given – not even water – with the exception of an oral rehydration solution, or drops/syrups of
vitamins, minerals or medicines.5
References
1. World Health Organization statement 2011, Exclusive breastfeeding for six months best for
babies everywhere, Geneva: World Health Organization.
URL: www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/index.html A
ccessed 30/7/13
2. National Health and Medical Research Council 2012, Infant Feeding Guidelines,Canberra:
National Health and Medical Research Council URL:www.eatforhealth.gov.au Accessed 30/7/13
3. Australian Institute of Health and Welfare 2011, 2010 Australian National Infant Feeding
Survey: Indicator Results. Canberra: AIHW. URL:http://www.aihw.gov.au/publication-
detail/?id=10737420927 Accessed 30/7/13
4. Australian Institute of Family Studies (AIFS) 2008, Growing Up In Australia: The
Longitudinal Study of Australian Children, Annual Report 2006-07;
URL:www.aifs.gov.au/growingup/pubs/ar/ar200607/breastfeeding (accessed 30/7/13).
5. World Health Organization 2012, Breastfeeding – exclusive breastfeeding, Geneva: World
Health Organization. URL:www.who.int/elena/titles/exclusive_breastfeeding/en/ Accessed
30/7/13
 EDT
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(Reuters Health) - Breastfeeding is credited with a long list of benefits, but
one downside of extended and intensive breastfeeding may be a higher risk
of cavities in baby's first teeth, according to a new study.

The more frequently a mother breastfed her child beyond the age of 24
months during the day, the greater the child's risk of severe early tooth
decay, researchers found.

"The No. 1 priority for the breastfeeding mother is to make sure that her
child is getting optimal nutrition," lead author Benjamin Chaffee of the
University of California, San Francisco told Reuters Health.

Chaffee completed the study as a doctoral student at the University of

California at Berkeley.

He and his team looked at a possible link between longer-term

breastfeeding and the risk of tooth decay and cavities in a survey of 458
babies in low-income families in the city of Porto Alegre, Brazil.

Because the study lasted more than one year, most babies were eating
various kinds of solid food and liquids in addition to breast milk.

The World Health Organization (WHO) recommends that babies are fed
breast milk exclusively for the first six months of their lives, with solid
foods added to the diet at that point. However, the WHO also recommends
continued breastfeeding up to age two and beyond, the authors note.

For the study, the researchers checked in on babies when they were about
6, 12 and 38 months old. At six months, the study team gathered data on
the number of breast milk bottles the baby drank the day before and any
other liquids, like juice.

At the 12-month mark, parents reported whether they fed their babies any
of 29 specific foods, including fruits, vegetables, beans, organ meat, candy
chips, chocolate milk, cookies, honey, soft drinks or sweet biscuits.

Two trained dentists examined all of the babies at each of the visits.

Nearly half of the children had consumed a prepared infant formula drink
by age 6 months, the researchers write in the Annals of Epidemiology, but
very few still drank formula by age 1.

The researchers found that about 40 percent of children breastfed between

ages 6 and 24 months had some tooth decay by the end of the study. For
babies breastfed for longer than two years and frequently, that number rose
to 48 percent.

"Our study does not suggest that breastfeeding causes caries," Chaffee said.

It is possible that breast milk in conjunction with excess refined sugar in

modern foods may be contributing to the greater tooth decay seen in babies
breastfed the longest and most often, the authors speculate in their report.

More research is needed to determine what's going on, but the findings are
in keeping with professional dental guidelines that suggest avoiding on-
demand breastfeeding after tooth eruption, they write.
"There are two aspects of breastfeeding - the actual human milk, which has
some, but very little, ability to promote tooth decay," said William Bowen,
professor emeritus in the Center for Oral Biology at the University of
Rochester Medical Center in New York.

"The second is the physical aspect of breastfeeding, or even bottle-feeding,

and that's where the problem arrives," he said.

Bowen was not involved in the new study.

When a baby sucks on a mother's breast or from a bottle, the baby's teeth
are sealed off from saliva in the mouth. This physical barrier prevents the
saliva from breaking down bacteria, and increases the chances of tooth
decay, Bowen said.

Even though participants in the study came from poor backgrounds, "bad
habits can form at any socioeconomic level," Bowen told Reuters Health.

About 16 percent of babies in the U.S. were still exclusively breastfed at age
6 months last year, according to the National Center for Chronic Disease
Prevention and Health Promotion.

The good news, Bowen said, is that it's very easy to clean an infant's teeth.

A simple wipe in the mouth with a water-dampened cloth or Q-tip can

effectively remove food before the baby's first teeth, he said, adding: "It's
important to get the excess food out of the mouth."

One not-so-good habit is allowing infants to stay on a mother's nipple

throughout the night, Bowen said. This usually means very little saliva
circulates in the baby's mouth, which can increase the risk of decay.
The primary caregiver of the baby should also maintain good dental health
because the bacteria that cause tooth decay in a baby usually come from the
primary caregiver, Bowen explained.

The American Academy of Pediatric Dentistry recommends that parents

take their child to its first dental visit when the first tooth appears, or no
later than its first birthday.

"Finding the right age to wean a baby off breast milk can be a decision
made with the support of a pediatrician," Chaffee said, adding that dental
health is one consideration that could play a role.

Brushing teeth might help, Chaffee said, The study researchers collected
data on tooth brushing habits, but did not investigate a specific link
between cleaning teeth after the last feeding and caries.

"But anything that removes carbohydrates and sugars from the oral cavity
should help prevent too decay," Chaffee said.

SOURCE: bit.ly/1eSbAB9 Annals of Epidemiology, online February 19,

2014.