Weaning the Breastfed 4-Year-Old

Authors: 

HEATHER CLAWGES, MD, IBCLC and LINDA S. NIELD, MD—Series Editor

Dr Clawges is assistant professor of pediatrics at West Virginia University School of Medicine in Morgantown. Dr Clawges is also an international board certified lactation consultant. Dr Nield is associate professor of pediatrics at the same institution.

A MOTHER ASKS:
My 4-year-old daughter is still attached to breastfeeding once a day. Is this abnormal or harmful to her development? How should I go about weaning her completely?

THE PARENT COACH ADVISES:
Breastfeeding a 4-year-old is uncommon today but certainly not abnormal. Extended breastfeeding, defined as continued nursing beyond 1 year of age, has not been shown to cause the child psychological or developmental harm.1 Yet, there is a social stigma associated with prolonged breastfeeding that stems from the negative attitudes and ignorance of others,2 even of some pediatricians. A survey within the last decade indicated that only 37% of 1602 pediatricians recommended breastfeeding to a year.3 When counseling a nursing mother, it is important to reassure her that breastfeeding longer than “normal” (longer than the typical duration by today’s standards) causes no harm and may even convey added health benefits. At the same time, it is important to support the mother’s weaning efforts and provide concrete ways on how to effectively wean the child.

How long is too long for nursing? According to CDC data from 2003, 5.7% of breastfeeding mothers in the United Sates were still nursing at 18 months.4 A study of 179 women who practiced extended breastfeeding estimated that the average age of their children at weaning was 2.3 years.5 Historically, extended breastfeeding was common. Wet nursing contracts from Babylonia, dating back as far as 1000 bc, provide guidelines for nursing until 2 years of age.6 Both the Talmud and Koran specify breastfeeding duration of 2 years.6 It was not until the late 1800s and early 1900s, when artificial formula was introduced, that breastfeeding durations shortened.6 Some anthropological data, extrapolated from studies of nonhuman primates, suggest that the natural age of human weaning is a minimum of 2.5 years and a maximum of 7.0 years.7 The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months, then with complementary foods until 1 year, and thereafter as long as mutually desired by mother and baby.1

Health benefits of extended breastfeeding. Breastfeeding up to 6 months has been shown to decrease the incidence or severity of numerous illnesses in the infant, including bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, diabetes, lymphoma, leukemia, obesity, hypercholesterolemia, and asthma.1 Immunological factors and nutrients remain stable in breast milk throughout lactation regardless of the age of the child.

Although most of the evidence on the health benefits of breastfeeding comes from studies that evaluated nursing infants only in the first year of life, some studies have examined the health benefits of extended breastfeeding. These studies show prolonged protection against infection with Haemophilus influenzae and otitis media and increased protection against leukemia and lymphoma.6 Cognitive benefits may also increase with increasing duration of breastfeeding.6 Numerous studies validate the positive bonding experience associated with extended nursing.8 Mothers who practice
extended nursing realize many benefits, including the positive effect on the child’s emotional well-being, better physical health of the child, the child’s increased sense of security when separated from parents, and the development of a close mother-child bond.2

How to wean the breastfed child. Weaning can be divided into 4 categories9:
Abrupt weaning is a sudden end to breastfeeding and often the result of maternal or child illness. This type of weaning is most difficult because the child has no time to transition. The mother is unable to gradually reduce supply and may become engorged. Engorgement of the breasts induced by milk oversupply or stasis may lead to mastitis.
Planned or gradual weaning is usually driven by the mother. She eliminates one feed, often the child’s least favorite, every couple of days to weeks. The breastfeeding session is typically replaced by alternative nutrition and comforting. When weaning is gradual, the child transitions well and the mother has no engorgement or rapid hormonal changes.
Partial weaning is gradual elimination of most feeding sessions except for 1 or 2 daily. The child is able to nurse at a favorite time of day, usually morning or evening, and this predictable schedule provides more maternal freedom.
Natural weaning allows the child to determine the length of breastfeeding. Ideally, breastfeeding ends when the child outgrows the need.

La Leche League recommends natural weaning for several reasons: it is an easy transition, mothers feel more positive, and the child feels a sense of control.9

Tips for weaning the resistant child. Completely weaning the partially weaned 4-year-old may be accompanied by some resistance from the child. To overcome this, the mother must set limits to breastfeeding and diligently replace the daily nursing episode with another enjoyable or comforting activity (such as rocking, reading a book, or playing a game). Consistency is a must! Weaning is most likely to be prompt and pleasant when the mother is consistent in replacing every nursing episode with another activity. Positive reinforcement of the child’s participation in the substituted activity should be encouraged. Because weaning ends a unique physically intimate mother-child experience, assure the mother that it is typical to experience some transient sense of sadness and that this may occur regardless of how and when weaning is accomplished.


 

REFERENCES:

1. American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.

2. Reamer SB, Sugarman M. Breastfeeding beyond six months: mother’ perceptions of the positive and negative consequences. J Trop Pediatr. 1987;33:93-97.

3. Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians’ practices and attitudes regarding breastfeeding promotion. Pediatrics. 1999;103:E35.

4. Centers for Disease Control and Prevention. US National Breastfeeding Rates, 2003. National Immunization Survey. Available at: http://www.cdc.gov/breastfeeding/data/NIS_data/2003/age.htm. Accessed April 29, 2011.

5. Sugarman M, Kendall-Tackett KA. Weaning ages in a sample of American women who practice extended breastfeeding. Clin Pediatr (Phila). 1995;34:642-647.

6. Piovanetti Y. Breastfeeding beyond 12 months. An historical perspective. Pediatr Clin North Am. 2001;48:199-206.

7. Dettwyler K. A time to wean: the hominid blueprint for the natural age of weaning in modern human populations. In: Stuart-Macadam P, Dettwyler K, eds. Breastfeeding: Biocultural Perspectives. Hawthorne, NY: Aldine De Gruyter; 1995:39-73.

8. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 5th ed. Pennsylvania: Elsevier Mosby; 2005:372.

9. Bengson D. How Weaning Happens. Schaumburg, Ill: La Leche League International; 2000:2-14.

Comments


Clearly the term "extended breastfeeding" to indicate periods of time half the recommendations of both the WHO and NIH only perpetuates the stigmatisation here.  If the reason for the qualifier has nothing to do with biological, psychological, or other scientific properties (as the article then goes on itself to argue) and is entirely due to social barriers due to modern stigmatisation, then it may be best to drop the qualifier.


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