Children who do not get what they deserve become the people that no society deserves, and no individual deserves to be.

- Alice Miller¹

In western culture, women who sustain breastfeeding for several years tend to be regarded as bizarre, to say the least, but the practice is not without historical precedent. Contrary to the elite practice of using wet nurses, and the pronouncements of male physicians throughout history on early cessation of breastfeeding - both of which can be traced back to the very root of western civilization - historically, for women in lower social ranks, breastfeeding was normal, and often maintained for years.

Apart from early medical commentators (usually concerned with elite women and who mention women from other classes only in the context of wet nursing), the feeding of infants, a matter too ordinary to be spoken about, doesn't appear much in the historical record. We therefore have no idea of the numbers of women who ignored the dictates of Galen and Soranus, but we can be sure that many did; even among the wet-nursed elite. Anthropologist Ian Wickes reported that Plotinus, the 2nd century Greek philosopher, 'at the age of eight used to run from his tutor to his nurse and clamour for the breast'.² When sustained breastfeeding is mentioned, the inference is clear: the practice was widespread. With the exception of wet nurses (who often weaned their own babies to make a living breastfeeding elite infants), women from the poorer classes routinely breastfed children for 1 - 2.5 years at least, and often for much longer. Tacitus, the 1st century Roman historian, reported that German mothers breastfed for several years.³ 'Nothing', it was stated in 1737, 'is more common in Lancashire (among the poorer sort)', 'than for them to let their children suck even for years',⁴ and in the 1820s it was noted that 8 year olds were commonly breastfed in East Lincolnshire.⁵ Even with the 20th century advent of artificial feeding in the west, the prohibitive cost meant that women in poorer families continued to breastfeed, and instances of long-term breastfeeding, especially in rural communities, are still anecdotally reported. Indeed, some of today's sustained breastfeeders, and in cases also their mothers and fathers, were themselves breastfed for several years.

Around the globe, sustained breastfeeding has and still does characterize many cultures. Researchers Huggins and Ziedrich, for example, report that among the Sioux a three to five year breastfeeding span was traditional, and also refer to a mother who turned up at school to breastfeed an eight year old in the break because he had a cold.⁶ In his survey, Wickes found breastfeeding spans such as: two to three years in Australian aborigines, three to four years in Greenlanders, five years in Hawaii and seven years among the Inuit.⁷ An anthropologist friend recently told me that, despite the ubiquity of infant formula, many Inuit children are still breastfed until this age. There are also many other modern-day hunter-gatherer tribes, and other traditional cultures in the developing world, in which children are breastfeed for up to six or so years.

As this book shows, many women in the industrialized world today practise sustained breastfeeding. These mothers are convinced that ongoing feeding provides physical and emotional health benefits for older children. There have been few physical health studies on children in the developing world breastfed beyond 3 years, and even fewer at that age. To my knowledge, there has been only one small (38 children) physical health study to date on sustained breastfeeding in an industrialized setting. No studies on psychosocial adjustment have been conducted on children breastfed beyond one year. There is, therefore no direct evidence to support (or contradict) the view of these mothers. However, there is other relevant evidence.

 
Anthropology

Anthropologist Katherine Dettwyler - who also notes that 'achievement of adult immune competence in humans occurs around six years of age' - investigated research on large mammals, including other primates, to examine weaning ages and correlate with a possible natural weaning age for humans. Based on the markers of tripling or quadrupling of birth weight, adult body size, gestation length and dental eruption, Dettwyler came up with human equivalents for a natural length of breastfeeding, ranging from a minimum of 2.3yrs up to 7 years.⁸

 
Psychology and the mother - child bond

Mothers speak about the emotional advantages children gain from sustained breastfeeding. Though not specifically to do with long-term breastfeeding, Attachment Theory,^* which was developed in the 1950s/60s by English psychiatrist John Bowlby and American psychologist Mary Ainsworth and widely hailed as the most influential theory of the twentieth century in child, personality and social relationships development, has great relevance.

Following wide-ranging cross-discipline research, Bowlby came to reject key psychoanalytic cornerstones. In opposition to the psychoanalytic view that children's emotional problems were due to fantasies generated from an internal conflict between aggressive and libidinal drives, Bowlby attributed them to actual family experiences and interactions. He also rejected the psychoanalytic view that an infant's love of its mother derives from sensuous oral gratification, in which need-satisfaction is seen as primary and attachment as secondary. Bowlby maintained that humans exist in what he termed an 'Environment of Evolutionary Adaptedness' in which an infant is born with an evolved innate predisposition for emotional involvement with its mother, with a concomitant urge to remain for protection in physical proximity to her. When the mother is properly attuned to the child, and thus able to read the child's cues, and responds appropriately and in a timely manner repeatedly over time, not only is the growth of security in the child nurtured and the child's trust and confidence in the mother's availability and commitment established, but the child also develops what Bowlby called an 'internal working model' of self and other(s), which forms the basis of the child's thoughts, feelings, memories and beliefs and upon which expectations of relationships are founded.

Bowlby recognized breastfeeding's efficacy to facilitate attachment. A breastfeeding mother's body produces the hormones prolactin, which calms and relaxes both mother and child, and oxytocin, which promotes bonding between mother and child. The breastfeeding dyad^** is thus a reciprocal, mutually reinforcing, emotional unit. Mother and child are emotionally impelled towards each other and, as each elicits response and counter-response in the other, initial impulses strengthen and bonds deepen. In lay terms, it is the founding and growth of love. For the child, it is the first relationship; with, as we shall see, ramifications for much that follows throughout life.

Mothers' comments provide a glimpse into the attachment process:

The force of attachment and the drive to protect and love their children that mothers experience can be incredibly powerful.

 
Secure attachment

Ainsworth provided empirical validation of Bowlby's theory.^*** Her findings revealed that a characteristic of a securely attached child is a willingness to leave its mother and a readiness to explore the surrounding environment, thus signalling the child's trust that the mother will be available when needed.

If mothers are right and children do have a bio-emotional need to sustain breastfeeding for several years, it follows that compliance with this innate need is likely to be reflected in the child's attachment style. There will of course be countless examples of securely attached children not breastfed long-term, or even not breastfed at all, whose parents consciously or unconsciously practised what might be termed 'breastfeeding behaviours' - eg prolonged eye-gazing and close physical contact, perhaps including skin to skin - through early childhood, but here I am dealing with the effects of sustained breastfeeding.

As seen in Chapter 2, many psychologists believe long-term breastfeeding impedes development and interpret a child's wish to continue as indicative of underlying anxiety and insecurity. From my personal experience of sustained breastfeeding and the incontestable evidence of secure attachment and healthy adjustment in many long-term breastfed children known to me, as well as from countless mothers' survey comments, this is clearly not the case.

Ainsworth also observed a time-effect: that early maternal sensitivity was associated with more harmonious mother - infant relationships later on in the baby's life; that babies whose mothers had responded in a timely manner early on, later cried less and were more likely to rely on facial expressions, gestures and vocalizations to signal their needs, and that babies held more early on also sought less contact later. Echoing Ainsworth's observations, and forming a parallel with research studies that have found correlations in relation to cognition and obesity with longer durations of breastfeeding⁹, mothers say that the close bond they have with their children is not only facilitated by breastfeeding but that the bond is reinforced and deepened when breastfeeding is sustained.

 
Infant distress

Crying in children, often regarded as normal and unavoidable, is tolerated to a great degree in many western societies, and there is great pressure on children to grow up quickly and learn self-reliance. Emphasis is laid on the training of even young babies. A glance at any bookshop will reveal a plethora of titles offering guidance on baby/toddler/child development: how to sleep-train, potty-train, wean, feed, encourage independence, and methods to show 'who's boss'. Distrust of children is palpable, with an ingrained belief that unless children are schooled and trained they will grow into uncontrollable feral monsters. There is a marked fear and horror of children being spoiled and parents are cautioned about being too responsive and indulgent toward their children.

In contrast, Ainsworth believed that 'an infant whose mother's responsiveness helps him to achieve his ends develops confidence in his own ability to control what happens to him', and, in having needs met by a sensitive and responsive mother, the child, according to Bowlby, develops 'an internal working model of self as valued and reliable'. In other words, the child not only understands that care will always be forthcoming but that she/he is worthy of care and therefore loved; which translates into: I am worth it! I am loveable! Not for nothing did Ainsworth say, 'my advice to parents is not to miss an opportunity to show affection to their babies'. It is a crucial foundation stone of good self-esteem.

Studies have shown that breastfeeding mothers tend to be more responsive to their infants than those that bottlefeed.¹⁰ Mothers also comment that sustained child-led breastfeeding - ie, helping 'the child achieve his ends' and allowing the child 'to control what happens to him' - fosters autonomy in the child, and is an ever-repeated demonstration of love and affection that both validates the child (I am worth it! I am loveable!) and nurtures the child's self-confidence (I can do it!) with such confirmation, these children venture boldly out.

 
The importance of touch

Ainsworth looked at mother - infant interaction and close bodily contact and concluded that a positive index of each also correlated with secure attachment. Research continues to corroborate the importance of touch. One recent study found that premature babies who received tactile stimulation showed greater weight gain, were more alert and required a shorter hospital stay. That researcher, Tiffany Field, has now founded the Touch Research Institute at the University of Miami School of Medicine, the first institution for the study of touch.

Breastfeeding, of course, entails the closest mother - infant bodily contact possible and also involves skin-to-skin contact (face to breast, at the least) and a breastfeeding mother will also often touch, stroke and pat her child as it feeds - positive interactions that are multiplied many times over, when breastfeeding is sustained for several years. Researchers have also noted these interactions.¹¹

 
Regulating negative emotions

According to Attachment Theory, a child cannot regulate its own emotions and only learns to do so through the experience of being regulated. A mother's effective and timely response to her child's early signals of distress, both contain and modulate the child's emotions. For example, when a child feels fear - at a barking dog, or thunder, etc - but realizes, from its mother's emotional signals that there is nothing to fear, the child will quieten. When the mother responds to the child's emotions effectively and in a timely manner, the child's reactions become more proportionate and, over time, the child gradually learns to modulate its own emotions and reactions to events and other people in its surroundings. The ability to quickly and effectively regulate a child's emotions is a significant aspect of breastfeeding. Sustained breastfeeding 'on demand' or 'on cue' - i.e. in accordance with a child's expressed wish or perceived need - has to be the epitome of maternal sensitivity and responsiveness. Not surprisingly, mothers that feed in this way say their children cry little. A study in the Netherlands on problematic crying in two-three month old infants found that breastfed children cry less than their non-breastfed peers.¹² Mothers that sustained breastfeeding with subsequent children noted the difference in those not breastfed or weaned early. One mother regulated feeds (in accordance with health professionals' instructions), weaned early and endured two incessantly crying babies. She made this observation:

It is amazing to see how contented a baby is whose needs are met… cutting out so much distressing and unnecessary crying. The baby gains immediate confidence in the world that surrounds it.

And here's corroboration from Jack Newman:

"I remember nights in the emergency department when Mothers would walk their ill, non-nursing babies or toddlers up and down the halls trying, often unsuccessfully, to console them, while the nursing Mothers were sitting quietly with their comforted (if not necessarily happy) children at the breast."¹³

It is interesting to note that Ainsworth also observed that securely attached infants cried little, whereas insecurely attached infants cried frequently, even when held by the mother, and concluded that secure attachment correlated with maternal sensitivity and prompt response to an infant's fussing or crying.

The need for emotional regulation can be all too apparent in the toddler and young-childhood years. Witness a young child in the throes of a tantrum, caught up in a whirlwind of agitation and rage that ratchets ever upward until, locked-into a storm of frustration and anger, the child, shocked and frightened by the ferocity of its own emotions, spirals up into a screaming emotional hurricane - and also see the nearby adult ineffectually trying to connect with the child who, for the time being, is beyond reach. Objectively, the trigger for a child's tantrum may not warrant such an extreme reaction but, subjectively, for the child,it does.

Such intensely negative emotional episodes generally do not occur with a long-term breastfed child. At the onset of any child-distress, the mother has a powerful resource: her breasts, filled with prolactin-laden milk. Breastfeeding restores a child's equilibrium instantly. Mothers who continue to breastfeed children through these critical early years are quickly able to neutralize a child's negative emotions, and thus thwart extreme distress. Gabrielle Palmer, author of The Politics of Breastfeeding and former lecturer at London University, whose children had been weaned by the age of two, said 'I was ignorant and being pilloried by health workers. In retrospect, I know that continuing (to breastfeed) would have helped with toddler tantrums.'¹⁴ Mothers also speak of the efficacy of breastfeeding to calm and soothe older children ruffled by external events (also see Ch 9).

A research study that looked at the association of breastfeeding with maternal bonding and the mother - infant relationship concluded that 'although breastfeeding dyads tended to show higher quality relationships at 12 months, bottle feeding dyads did not display poor quality or precarious relationships'.¹⁵ Since the stresses of the (non-breastfed) toddler and young childhood years can be a source of repeated distress for both child and mother and can add strain to the dyadic relationship, the question is begged: would a comparative study of breastfed two-four year olds reach the same conclusion?

 
Oxytocin, the hormone of pleasure and enjoyment

Regulation of negative emotional states in the child is, however, only one half of the equation. According to Bowlby, 'the infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute), in which both find satisfaction and enjoyment'. This emphasis on positive emotions has subsequently been validated and extended by technologically assisted advances in neuroscience research.

Biologist and neurobehaviourist, Sue Carter (who considers breastfeeding 'really important'¹⁶) pioneered groundbreaking research in the 1980s and revealed the operation of the hormone oxytocin (OT) in the brain. In response to pleasurable interactions, OT is produced in the hypothalamus and then released in pulses into the blood stream via the pituitary gland, and also directly to other parts of the brain and spinal cord, where it binds to OT-receptors. Carter's work also demonstrated the action of OT on parental affiliation to offspring. From extensions to that research (much emanating from Carter's laboratory), it is now known that the physiology of the infant's brain is affected for an extended period by mother - child interactions. Apart from facilitating bonding, OT has a dynamic role in the regulation of both the central nervous system and the autonomic system and plays a crucial part in the infant's brain development, and influences not only physiology but also behaviour. Most OT investigations have been on small mammals (voles, rats and mice), but non-invasive techniques on humans (analysis of urine, saliva, human milk and MRI scans) continue to bear out findings on animals. It is therefore significant that the animal research shows that OT levels can be affected by the type and quality of care giving. Research shows higher OT levels in infants that receive lots of maternal attention compared to those that receive less.

In related work, Tobias Esch, University Medicine Berlin, found that stress hormones have the capacity to cause physiological and behavioural changes,¹⁷ and other studies have shown stress hormones can affect OT-receptor binding in the central nervous system.¹⁸ Margaret Altemus and Carter examined the effects of lactation on stress responses and found that lactating women had consistently lower reactions to stressors - OT is thought to produce positive emotions by reducing fear and stress. However, though circulating OT may be present, just as glue is inactive without something to bind to, OT needs OT-receptors. Significantly, maternal behaviour can also affect the quantity and quality of OT-receptors in infants. According to Paul Zak, of the Center for Neuroeconomics Studies in California, 'we find in animal studies that if the mother neglects the baby, the number of oxytocin-receptors atrophy'.¹⁹ Research also shows that variation in OT-receptors results in variation in maternal behaviour.²⁰ The long-term implications for girl-children, mothers of the future, are clear.

In 2003, with specific reference to breastfeeding and the impact of OT on development, Carter, also shedding light on so-called 'comfort sucking', wrote:

"…the endogenous release of OT within the infant itself may be increased by suckling and tactile stimulation. For example, it has been shown in both young dogs and calves that nonnutritive suckling itself releases OT in the infant. The degree to which bioactive compounds in milk, or changes in OT or other peptides, produced by the infant itself that are secondary to suckling and/or maternal contact, affect physiology or behaviour has only recently become the subject of serious investigation. Still there is evidence that such early hormonal manipulations may affect either the mother and/or the infant, having consequences ranging from brain growth to later stress reactivity…"²¹

The breastfeeding dyad is awash with OT. Produced in both the child's and the mother's individual brains in response to initial pleasurable physical contact; then, as feeding continues, pulsatingly reinforced in the experience of mutual joy and pleasure - pictured beautifully by one mother: 'the deep nurturing that returns her all the way back to nearly her days in the womb, floating without a care in the world, nurtured perfectly and held closely with mother's love'. Enjoyment that is further maximized by the frequent, OT-triggering, stroking and patting that, as studies show, accompany breastfeeding.²²

In addition, human milk contains OT. Although, the possible effect on the infant of OT obtained via milk is yet to be researched, the effects of prolactin, a related hormone that interacts with OT, are known. To quote Carter again:

…research in rats has shown that the presence or absence in maternal milk of the related hormone, prolactin…can permanently modify endocrine function in the offspring… These findings document the capacity of hormones in milk to have long-term physiological consequences. OT and prolactin…may act as releasing factors on each other… Thus, the presence or absence of prolactin might have indirect effects on OT and vice versa.²³

The breastfed infant is thus permeated with OT, produced and released into circulation internally in response to pleasurable experience, and obtained externally in breastmilk. In breastfeeding these positive hormonal actions and responses are repeated in every feed; in sustained breastfeeding, they repeatedly occur and reoccur over many years. In the absence of scientific evidence to the contrary, it is reasonable to conclude that benefits continue, and accrue, throughout duration.