The Benefits and Risks of Extended Breastfeeding for Mother and Child

Julie Shimko
&
Laura Zimmerman
CFS 453, Spring 2016
Due date: May 9, 2016
Professor Wanda Siu-Chan

Abstract
The benefits and drawbacks of breastfeeding an infant up to one year of age are well
documented; however, there are still questions surrounding the nutritional necessity, benefits and
risks of extended breastfeeding, which is breastfeeding a child into toddlerhood. This paper
identifies the benefits and risks of extended breastfeeding for both toddler and mother, as well as
identifies cultural barriers and norms associated with extended breastfeeding in developed
countries. Unfortunately, firm and reliable evidence for clinical recommendations is lacking and
further research on the health benefits and risks is still needed to determine the exact age at
which breastfeeding is no longer nutritionally relevant. At this time, the importance of a woman's
personal choice remains the ultimate deciding factor to extend breastfeeding beyond a year, until
further evidence is produced.

Breastfeeding a child is critical for health and development, and the benefits of doing so
up to one year of age for both mother and child are well documented. The Lancet Breastfeeding

Series was released in January 2016, and included 28 systematic reviews and 22 meta-analyses.
Belinda Luscombe, author of Why Do We Have the Breastfeeding Wars? Two Words: Maternity
Leave, (2016) summarizes the data:
Universal breast feeding of every child until the age of 1 would lead to preventing the
deaths of 823,000 kids under 5 years old, $300 billion in US healthcare saving, fewer
infections, increased intelligence, probable protection against obesity and diabetes for
kids. For mothers evidence has shown protection against breast cancer, possible
protection against ovarian cancer and type 2 diabetes.
Though the benefits of breastfeeding up to 1 year are clear, the benefits and risks of nursing a
child into toddlerhood are still up for debate. This is often referred to as extended breastfeeding,
and has proven to be a controversial issue. According to the World Health Organization (WHO),
Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding
along with appropriate complementary foods up to two years of age or beyond (Exclusive
Breastfeeding, n.d.). However, the recommendations in the United States are more confined.
The position of the Academy of Nutrition and Dietetics supports exclusive breastfeeding for the
first 6 months of life and breastfeeding with complementary foods from 6 months to 12 months
of age (Lessen & Kavanagh, 2015). There are still many questions surrounding the nutritional
benefits, necessity, and risks of breastfeeding a child over the age of one, for both mother and
child; therefore, this paper will serve to conduct an analysis of the nutrition and health factors for
mothers and toddlers who have already been introduced to solid foods.
Advocates for extended breastfeeding emphasize the source of comfort and security for
toddlers, though they also claim there is strong evidence supporting health benefits during and
beyond one year. For example, Breastfeeding Review cited a study conducted by Goldman and

Goldblum (1983), touting the immunologic components of breastmilk, indicating, secretory

immunoglobulin (sIgA), lactoferrin and lysozyme are maintained into the second year of
lactation and are still providing protection to the infant (Mortensen & Tawia, 2013). These
three proteins help the immune system in several ways. SIgA builds resistance against proteolytic
activity (protein breakdown) in the gastrointestinal tract, prevents the adherence of bacteria to
mucosal surfaces, and neutralizes toxins from microorganisms (Ella et al., 2010). Lactoferrin
also works at mucosal sites where it demonstrates antimicrobial activity by preventing microbial
growth, and it also initiates anti-inflammatory responses by competing with bacteria for ferric
iron (Ella et al., 2010). Finally, lysozyme is a protein that lyses bacteria and works alongside
lactoferrin and sIgA in antibacterial functions (Ella et al., 2010).
Another health benefit for toddlers to continue breastfeeding is the fat content in breast
milk continues to increase as the infant grows into toddlerhood. Evidence suggests human milk
continues to evolve and conform to the energy needs of the child. As the child requires more
energy as growing from an infant to a toddler, the content of the mother's milk continues to
become more nutrient dense. A study conducted by Lubetzky et al. found mothers who lactated
longer than one year had higher C12 and C14 fatty acid (FA) percentages in their milk than
women who lactated for 2-6 months (Lubetzky et al., 2012). The American Society for
Nutritional Sciences identifies C12 and C14 as saturated fatty acids (Uauy, 2003). The American
Academy of Pediatrics Committee on Nutrition recommends fat and cholesterol not be restricted
in children younger than two years and children older than two should obtain 30% of calories
from from fat (1992). Further evidence has found high cholesterol feeding in early life, such as
found in C12 and C14 fatty acids, may regulate cholesterol and lipoprotein metabolism in later

life (Uauy, 2003). During extended or prolonged lactation, the fat energy contribution of
breastmilk significantly contributes fatty acid to a toddler's diet (Mandel et al, 2015).
Breastfeeding in the 21st Century, published in The Lancet, states the only negative
health implication found in the meta-analysis was an increase in tooth decay for toddlers
(Victoria et al, 2016). While tooth decay is something to be aware of, the authors of the metaanalysis did not find this to be so detrimental that extended breastfeeding should be discontinued.
The recommendation is improved dental hygiene should be established.
In addition to the child, it is also important to evaluate the benefits and risks of extended
breastfeeding for the mother. Recent studies are showing the decision to breastfeed not only has
positive long-term effects for the child, but also for the mother. According to an article
published by the Mayo Clinic, extended breastfeeding has been shown to reduce the risk of
breast cancer, ovarian cancer, and type 2 diabetes (Extended Breastfeeding, n.d.). There is a
robust amount of evidence which supports the reduced risk of breast and ovarian cancer in
women who breastfeed. According to Victora et al., Each 12-month increase in lifetime
breastfeeding was associated with a reduction of 4.3% in incidence of invasive breast cancer
(Breastfeeding in the 21st Century, 2016). Victora et al. also found a 30% reduction in ovarian
cancer as a result of longer periods of breastfeeding in a meta-analysis of 41 different studies.
Alison Stuebe, author of The Risks of Not Breastfeeding for Mother and Infants,
suggests a strong correlation between lactation and maternal metabolism. Stuebes analysis
concludes breastfeeding has a positive impact on blood glucose levels, blood pressure, as well as
lipid metabolism, and the impact may persist after weaning (p. 226). Stuebe reports in a study
conducted by Dewey and associates, women who continued to breastfeed more than one year
lost 4.4 more pounds than women who weaned at 3 months (p. 227). When comparing women

who have never breastfed and those who have breastfed past the age of 1, the metabolic benefits
of breastfeeding appear to continue years after breastfeeding ceases. Stuebe notes, In the
Nurses Health Studies, the risk of type 2 diabetes in the 15 years since their last birth was 1.7fold higher among parous women who never breastfed compared with those who breastfed for a
lifetime total of 2 years or more (p. 227). Breastfeeding is also argued to have a positive effect on
Body Mass Index (BMI). Victora et al. noted an analysis of 740,000 British women with longterm follow-up showed their mean BMI was at least 1% lower for every 6 months a woman
breastfed (Breastfeeding in the 21st Century, 2016).
While there are several health benefits of extended breastfeeding for the mother, there are
also increased health risks, particularly osteoporosis. Recent studies suggest breastfeeding affects
a mothers bones, and women often lose 3-5 percent of the bone mass during breastfeeding
(Pregnancy, Breastfeeding, and Bone Health, 2015). Also, due to low estrogen, a hormone
which helps to protect bones, women may also lose bone mass during breastfeeding. The 2013
study Prolonged Breastfeeding is an Independent Risk Factor for Postmenopausal
Osteoporosis concluded extended breastfeeding a child over the age of one is the highest risk
factor for osteoporosis, independent of first breast-feeding age (Okyay, et al.). In order to help
reduce the risk of osteoporosis and to maintain bone health, it is recommended women take a
calcium supplement before, during, and after pregnancy, as well as eat calcium rich foods
(Pregnancy, Breastfeeding, and Bone Health, 2015).
In addition to osteoporosis, extended breastfeeding also causes women to have low levels
of estrogen. While low levels of estrogen do not pose a health risk, it can cause uncomfortable
side effects. Low levels of estrogen reduces fertility, and can cause symptoms of menopause,
such as night sweats, low libido, reduced fertility, as well as atrophic vaginitis, which is the

inflammation of the vulvar tissue. In her article, 3 Ways Breastfeeding Affects Your Estrogen
Levels, Jennifer Lincoln writes, Prolactin remains high in women who continue to breastfeed
regularly, and this suppresses ovulation. Because of this, the normal estrogen levels are
decreased (n.d.). Another uncomfortable side effect is atrophic vaginitis. According to
Bachmann et al., it can cause the following genital symptoms: Dryness, burning loss of vaginal
secretions, vulvar pruritus, feeling of pressure, and yellow discharge. Additionally, atrophic
vaginitis can also cause urinary tract infections, as well as discomfort while urinating
(Diagnosis and Treatment of Atrophic Vaginitis, 2000).
According to the Centers for Disease Control, in the United States, 25.5% of children are
breastfed at 12 months and 9% at 18 months, and the cause for weaning after 12 months is multidimensional (2014 Breastfeeding Report Card, 2014). In the United States, breastfeeding after
12 months is often portrayed as taboo. For example, on May 21, 2012, Time Magazine published
Are You Mom Enough?, an article about attachment parenting. The cover of the magazine is a
photo of a 26-year old mother, breastfeeding her 3-year old son, which caused much controversy
and received a plethora of media attention. In a blog post titled Breastfeeding on Demand: A
Cross Cultural Perspective, Gwen Dewar, Ph.D., points out breastfeeding is seen as risque in
Western culture because the breast is often sexualized. She writes, In most cultures, breasts are
viewed in terms of their primary function: organs for expressing milk (2014).
Additional cultural barriers to breastfeeding include the lack of education about the
importance of breastmilk to both baby and mother; the continual marketing of baby formula;
pain management; the lack of social support of breastfeeding in public; and also the assumption
once children are able to eat solid foods, mothers do not need to continue breastfeeding. In an
article titled Breastfeeding: Achieving the New Normal, published in The Lancet, it is argued

breastfeeding is one of the few health-positive behaviors more common in poor countries than
rich ones (2016, p. 404).
Identifying and understanding the benefits and risks for extended breastfeeding as well as
grasping the cultural norms in developed countries is helpful to understand what motivates a
mother to decide to extended breastfeeding into the toddler years. Some women value and truly
believe in the importance of extended breastfeeding, while others are offended by the idea. Either
way, the importance lies in allowing for a mother to choose. Unfortunately, firm and reliable
evidence for a clinical recommendation appears to be lacking. Further research on the health
benefits and risks is still needed; however, current research suggest the benefits for extended
breastfeeding outweigh the cons for both mother and child.

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