Infant Feeding History revised

Chapter 14 of Breastfeeding and Breast Milk: from Biochemistry to Impact.

What follows is the Content (but not the lovely formatting) of the entire chapter and references, pp. 219-239, as from my galley proofs of the above-titled book, published by Georg Thieme Verlag, Stuttgart in September 2018. Reproduced here with the consent of the publisher, whose book sets it out much more attractively, and is available as both as e-book and very reasonably proved hardback. ISBN 978-3-13-220401-0 Which I strongly recommend you add to your library and students’ reading lists!

The feminist perspective of this history is influenced by four decades of wide-ranging reading and clinical work with breastfeeding families; it is strongly critical of much that is quietly accepted in other versions of the history of infant feeding, that largest uncontrolled and unexamined in vivo experiment on human infants, to paraphrase Professor Lars Hambraeus in the 1970s. 

14.1 Overview and Introduction

Mammalian lactation assures a reliable supply of quality food for the young, and was critical to evolutionary success. From some 13 million years ago until recorded time, evolving humans, like their primate cousins, breastfed their babies for anything from 2–7 years. Lactation is a robust, resilient and reliable survival mechanism [1]. Milk is both highly species-specific and responsive to both the environment and the needs of the young. Thus their own mother’s milk fed from her breasts, supplemented if necessary by surrogate breastfeeding, should have been, and generally was, the automatic universal birth right of children throughout history [1], [2]. Without it, in any context, infant mortality rates rise.

But thanks to pressures rooted in the social and cultural status of women, many babies throughout recorded history have never received that birth right. Commercially organised surrogate feeding and the use of foods other than women’s milk have been recorded in many cultures. 19th century industrialisation and the growing authority of medical professionals early in the 20th century re- sulted in substantial shifts away from breastfeeding towards commercial products: thanks to well- targeted hospital-based marketing by the infant food industry, by 1960 fewer than 20% of infants in some countries received any breast milk. In some nations summarised as WEIRD (western, educated, industrialised, rich, and democratic), virtually all infants were exposed to bovine formula products perinatally. The use of these animal and vegetable “soups” and mixtures has become the dominant mode of feeding in such nations, resulting in new epidemics of disease, much of it also affecting succeeding generations. Impacts on the economy, the environment, and population growth remained largely unrecognised, although substantial [3].

Marketing by association with health professionals established an unjustified belief in the complete safety and efficacy of infant formula feeding [4]. The change to formula feeding as the norm was led by advantaged western women who trusted doctors and hospitals to know what was best for their babies. By the 1970s that same demographic would lead the drive back to mother-feeding, but in cultural contexts that increasingly required physical separation of mother and child for long periods in each day [5]. In such contexts, simply promoting breastfeeding as best is ineffective in raising breastfeeding rates and duration. The effective solutions to low breastfeeding rates have been structural changes to enable breastfeed- ing, such as adequate maternity leave, implemented in states such as Finland that bear the costs of increased illness due to artificial feeding and care outside the home [4]. The alternative, more commonly practised, has been the provision of equipment to enable women to express their milk for others to feed their baby. The increased work and cost of this latter strategy, an impossible task for many women, is only now being realised as an unfair burden on mothers and an overlooked societal responsibility (see Chapters 8 and 9). However, breast milk expression has legitimised the feeding bottle and teat as a way of providing breast milk, undermining awareness of the impacts of the feeding method itself.

So industrial innovation has provided solutions that separate the breast from feeding, mother from infant, creating new norms and expectations around breastfeeding that are a long way from what the World Health Organization recommends as ideal: exclusive breastfeeding until around 6 months, and continued breastfeeding into the second year and beyond. Yet in the 21st century, exclusive breastfeeding’s critical role in the development of the microbiome and lifelong health, in the prevention of vertically-communicated inflammatory disease such as obesity and cardiovascular disease, is being revealed by research. Both the positive biological effects of breastfeeding and the negative effects of early infant formula exposure are creating pressure in this century to see all human infants receiving only women’s milk, and new strategies are already emerging as advantaged parents seek to use the new media to ensure that their babies get the best possible start in life. Milk sharing by women is increasing, as are the numbers of milk banks (see Chapters 10 and 14). Here, breast pumps and feeding bottles play a valuable role in allowing children whose mothers cannot provide enough milk (or any) to receive species-specific women’s milk, albeit not from a living breast.

This chapter can only be a generalised outline sketch of a vast topic, which cannot do justice to many national and regional variations and their consequences. Readers wanting a more complete or in-depth discussion should read the works of Valerie Fildes [3], [6], Rima Apple [7], Jacqueline Wolf [1], [8], Christina Hardyment [9], PhilippaMein-Smith [10], Florence Williams [11], and Maureen Minchin [4] and their sources. Additionally, fascinating work by Sarah Blaffer-Hrdy [12] and Wenda Trevathan [13] puts recorded history into its evolutionary and biological context. Tables in the following roughly chronological sections list only a few of the notable people and events.

14.1.1 Infant feeding in antiquity

  • 3500 BC: Egyptian papyri praised breast milk’s healing powers and described ways of stimulat ing milk flow [13].
  • 2000 BC: Clay feeding vessels, oblong with a nipple-shaped spout, date from 2000 BC onwards in graves of newborn infants. Casein residues show that animal milk was used, possibly explaining the death of the child [14].
  • 1550 BC: The earliest medical encyclopaedia,The Papyrus Ebers from Egypt, mentions lactation failure [15]. Surrogate nursing was accepted as the natural alternative to starvation for such infants; it could become adoptive nursing.
  • 950 BC–625 BC: Greek women of higher social status frequently employed wet nurses. Greek Paulus Aegina recommended that a wet nurse should be between 25 and 35 years old, with well-developed breasts and chest and should have recently given birth to a male child. (Others contested this latter point.) She should avoid salty and spicy foods and sexual activity, and she should regularly exercise her arms and shoulders, by grinding or working at a loom [14].
  • 400 BC–200 BC: Ayurvedic texts reported that children should be fully breastfeed for at least six months, until the eruption of teeth. Illustrations described the importance and value of breast milk and breastfeeding.
  • Byzantines fed newborns with honey during the first 4 days of life. Aetius (2nd century BC) and Oribasius (320–403 BC Greece), considered colostrum to be unsuitable for newborns, therefore breastfeeding was ideally started between the 3rd and 5th day of life.
  • Aristotle (384–322 BC) shared this prejudice, though he considered maternal breastfeeding a duty, and was aware of its contraceptive value [16].
  • 300 BC–400 AD: At the height of the Roman Empire, written contracts obliged wet nurses to feed abandoned infants, as a cheap source of slaves [6].
  • approx. 100 AD–400 AD: Medical authors such as Soranus of Ephesus, Galen of Pergamon, and Oribasius (Greek physician for Emperor Julian) wrote about breastfeeding and wet nursing, including qualifications for a wet nurse [14]. Soranus recorded a milk quality test: When a drop of breast milk is placed on a nail and the finger moved, the milk should be thick enough to not run across the surface of the nail. When the finger was turned downwards, the milk should be watery enough to not adhere to the nail [14].
  • Soranus also wrongly saw colostrum as indigestible, and so advised mothers not to breastfeed in the first two days after birth, a widespread prejudice that has done great harm. Colostrum was considered harmful, possibly because of its laxative qualities, and mothers gave babies cows’ milk, water and honey [17], [18].
  • 609–632 AD: The Koran evolved over this period; it includes a great deal about breastfeeding and the right of the child to be breastfed for two years, and endorses some foster-nursing as establishing kinship.

14.2 The Middle Ages and Renaissance

As is still usual in many cultures, an infant’s mother was ordinarily the primary caregiver and infants were cared for within families, with older children and female relatives assisting with care [2]. The Church encouraged mothers to breastfeed, valuing breast milk as the food that grew the infant Jesus, and breastfeeding was seen as an expression of charity. Images of Mary lactating (Maria lactans) were objects of devotion in western churches; a mother breastfeeding her own child was an act of virtue [19]. Society viewed childhood as a time of risk and vulnerability, and there were many concerns about the use of wet nurses. Breastmilk was thought to transmit both physical and psychological characteristics. This belief resulted in protests against the hiring of women for wet nursing, and concern about their moral character [17]. But as in any place with a high child mortality rate from infectious disease, the emphasis was on producing large families. Fertility was prized. It was not uncommon for women to bear 10–20 children, few of whom would survive to adulthood. The contraceptive effects of lactation were known; for many husbands, the role of wives was to produce children that others could suckle and raise past the danger period of early infancy.

Feeding devices were made from wood, ceramics, and animal horns. A perforated cow’s horn may have been the most common type of feeding bottle during the Middle Ages [15]. All resulted in infant deaths from infection, as did many later types. Open boats and feeders were (and are) more readily cleaned than spouted pots and bottles.

14.2.1 Infant feeding in the Renaissance

  • 1472: In Padua, Italy, Paolo Bagellardus published De infantium aegritudinibus et remediis, an early paediatric text describing the characteristics of a good wet nurse, and offering advice about gut disorders.
  • 1545: Thomas Phayer described in the first English textbook, The Boke of Chyldren, the criteria for choosing a wet nurse, the nail test and remedies for increasing milk supply. He also believed that the milk of a nurse influenced temperament and morals, in addition to diseases [14].
  • 1565: The first French paediatric text, Cinq Livres de la Manière de Nourrir et Gouverner les Enfants des Leur Naissance by Simon de Vallambert, recommended the use of cow’s or goat’s milk after the third month of life. He was also the first to mention the possibility of transmission of syphilis from the nurse to the infant [14].
  • 1577: De Arte Medica Infantium, written by Omnibonus Ferrarius, stated that the mother is the best option for infant feeding, with the wet nurse second best if the mother could not breastfeed, and that babies might prefer the nurse over their mother. His book contains an image of an early suction breast pump: a receptacle with an opening for the nipple and a long spout reaching up to the mother’s mouth [14].
  • Jacques Guillemeau (1550–1630) stated four objections to wet nursing: the child — often taken as an infant and returned as a toddler — could be exchanged for another child; the love between mother and child might be affected; the child might adopt an undesirable trait from the nurse; or they might pick up transmissible diseases [20].
  • 1584: Thomas Muffett’s book, De jure et praestantia chemicorum medicamentorum, recommended the use of breast milk for the sick elderly, and saw donkey milk as the best nutritional substitute at any age.
  • 16th century: Tintoretto and Rubens both depicted the vigorous milk ejection reflex that in classical mythology produced the Milky Way galaxy.

14.3 17th to 18th Century

In Europe, most women breastfed, many not exclusively from birth. In some regions (generally in colder climates where animal milks were available), artificial feeding or hand-rearing, also referred to as dry nursing, was becoming normative, as deaths during infancy and childhood were accepted. Those who survived might well have been the initially breastfed with the strongest immune systems.

Wet nursing was still accepted. Wealthy families might employ more than one wet nurse. For un- married or poor mothers, wet nursing in an upper-class home was sometimes one of the few possible ways of earning a relatively comfortable living, sometimes at the expense of their own child’s health or life. The importance of wet-nurses to the survival of children gave them greater social status than other servants, and children could become very attached to the nurse, who might live with the family for some years. In England, royal physicians mandated dry nursing for infant Prince of Wales in 1688. Starved and dying after 7 weeks of hand-rearing, his life was saved by a wet nurse. That royal physicians preferred hand rearing to breastfeeding by some lower class woman might have influenced the recorded rise in infant mortality in the last decades of the 17th century [6]. From around 1500–1700 very few wealthy English women had breastfed, but this would change to- wards the end of the 18th century.

However, most families could not afford a resident nurse. Many more children were farmed out to wet nurses in their own homes, often in villages at some distance from the child’s family. Infant mortality was high in such cases, as living conditions were poorer and children not always breastfed or well-cared for, and they were kept quiet with opiates and alcohol. Foundlings and un-wanted children were almost never wet nursed but hand reared, and almost all died. High mortality rates eventually caused some governments to regulate wet nursing [3], [16], [21]. The promotion of maternal breastfeeding was associated with a decline in infant mortality during the second half of the 18th century.

By the end of the 18th century in Europe, four modes of feeding were in use: maternal breast- feeding, wet nursing, hand feeding with animal milks, and with pap and/or panada (soft mushy mixtures of bread or flour with milk or water or egg, some cooked in broth) [16]. The use of soft starchy foods based on local staples has been common in many parts of the world, and contributes to higher mortality wherever it is practised. Nicolas Brouzet, physician to Louis XV, in An Essay on the Medicinal Education of Children, posed three questions: Should infants be nourished with milk? Should that milk be human? Should that milk be the mother’s milk? In some regions infants were rarely breastfed; raw fish and cream were fed by advantaged Icelandic families. Other foods given included animal milks, raw meat juice, and eggs. That some children survived is a tribute to human omnivore adaptability, not proof of dietary suitability — just as survival and growth on infant formula is not proof of its perfection, least of all where antibiotics are available to treat infection. Artificial feeding had become an accepted alternative to breastfeeding, reducing the duration of breastfeeding from approximately 18 months in the early 16th century to around 7 months in the late 18th century [6].

14.3.1 Infant feeding in the 17th and 18th century

  • 1662: The influential Dowager Countess of Lincoln wrote on the duty of nursing, by mothers to their children, after birthing 18 children, 17 of whom died, and then seeing her son’s child mother-fed and healthy.
  • 1668: Francois Mauriceau in The Accomplisht Midwife advised giving only breast milk for at least 2–3 months and warned against early introduction of paps; he noted that the first day’s milk had a laxative effect and suggested — after the first day — expressing milk into the baby’s mouth if need be, and then feeding little and often day and night, whenever the baby wanted to.
  • 1676: Nicholas Culpepper’s A Directory for Midwives contained advice undersupply and over-supply as well as a recipe for pap: barley bread steeped in water and boiled in milk, basically the same as the first infant formulas of the 19th century.
  • 1712–1778: Jean Jacques Rousseau’s writings highlighted the significant decline of infant mortality associated with maternal breastfeeding; the influence of his philosophy led to growing popularity of natural feeding [6].
  • 1748: William Cadogan published An Essay upon Nursing and the Management of Children, from their Birth to Three Years of Age [22] based on his experience as a father and as physician at the London Foundling Hospital. His advice promoted breastfeeding – he urged early feeding of colostrum – but also undermined it by limiting the number of feeds to four per day.
  • 1760: In his Treatise of Physical Upbringing of Children, Jean Charles Des-Essartz compared the composition of human milk to that of the cow, sheep, ass, mare, and goat, justifying human milk as the best infant food [23].
  • 18th century: The disastrous experience of hand feeding in anglophone foundling hospitals testified to the importance of women’s milk. The worst record was Dublin (founded 1702) where 99.6% of all children under one died, none were wet nursed. The hospital closed in 1829.

14.4 The 19th Century

The 19th century was an era of rapid technological change, urbanisation and population growth and mobility. Lost agricultural jobs were replaced by factory work as people moved to urban areas. Mothers, some sole breadwinners, had to work away from home for long hours, making frequent breastfeeding impossible and artificial substitutes unavoidable [16]. Poverty and poor maternal nutrition were associated with high infant mortality, notably less in communities where breastfeeding was normal. Women often ate last and least in poor families, as many still do in patriarchal societies. Despite the ongoing development of sanitation and urban water supplies, the high infant mortality rate remained static for the major part of the 19th century, or even increased in the second half in England along with artificial feeding. It is generally accepted that this rise was due to the high incidence of gastroenteritis [24]. Foods other than liquids and paps were not generally introduced early to infants in poor households: where food was scarce, breastfeeding was seen as a way to economise and the continuation of breastfeeding into the second year of life could be a sign of poverty.

14.4.1 Infant feeding in the 19th century

  • 1835: William Newton invented and patented evaporated milk [15].
  • 1838 onwards: Chemists such as Justus Von Liebig and Arthur V Meigs pioneered chemical analysis of milks, and this unreliable information would be used to create “Milchsuppe” or “Kindersuppe” claimed to be perfect or virtually identical to mother’s milk [15].
  • 1845: Teats for feeding developed as technology improved. In 1845, the first India rubber nipple was introduced [19] replacing leather and cloth and cork devices. With different chemical composition and treatment, latex teats would remain the norm until the development of silicone teats a century later. Latex allergy was not immediately recognised as a problem.
  • 1851: The glass feeding bottle began to evolve. French feeding bottles created in 1851 contained a cork teat and ivory pins at air inlets to regulate the flow [15]. A simpler, open-ended, boat-shaped bottle was developed in England in 1896, became popular, and was sold well into the 1950s [25]. Other bottles contained a glass tube connected to a long rubber tube with a teat on the end, to enable the baby to self-feed. These “murder bottles” were outlawed in France [4] in 1912, but variants are still sold today.
  • 1853: Texan Gale Borden added sugar (a preservative) to milk, and sold cans of Eagle Brand Condensed Milk, soon a popular infant food [15]. Epidemics of scurvy, rickets, convulsions, malnutrition and anaemia would result from its deficiencies, although the causes would not be identified or remedied for decades, and so did not affect the growing popularity of artificial feeding.
  • 1860s onwards: Louis Pasteur (1822–1895) and Robert Koch (1843–1910) drew attention to the danger of microorganisms in milk, so that sterilized undiluted cow’s milk was seen by some as best when breast milk was not available.
  • from 1865: Von Liebig patented and marketed artificial infant food in granule form to be dissolved in hot water, then (often unhygienic) milk added. Liebig’s recipe for milk soup — consisting of cow’s milk, wheat and malt flour, and potassium bicarbonate — quickly became the then state-of-the-art infant food [23] thanks to advertising in contemporary media, along with medical and popular credulity and ignorance about breast milk. Modern epidemics of hyper-sensitivity to milk and wheat would develop over generations.
  • 1866: William Newton advanced the production of dehydrated milk using vacuum extraction processes. The unsterile outcome was pack- aged and sold in “tin boxes” [16]. In parallel with the evolution of dried milk, numerous infant foods were developed and sold as mod- ern and safe.
  • By 1883, there were at least 27 patented brands of commercial infant food [26]. All were cereal and/or milk bases with added car- bohydrates such as sugars, starches, and dex- trins; some contained egg. Brands included Nestlé’s Food, Horlick’s Malted Milk, Hill’s Malted Biscuit Powder, Mellin’s Food, Eskay’s Food, Imperial Granum, and Robinson’s Patent Barley.
  • In an era when fat babies were prized, the foods were fattening, but seriously deficient. Then as now, weight gain was the main criterion for assessing dietary adequacy, and suspicion – and so detection – of other or more subtle negative effects was (and in places is)almost non-existent.
  • 1868: Henri Nestlé started selling his infant food: baked rusks crumbled into sweetened condensed milk then dried into brown granules – in Switzerland, Germany, France, and England and from 1873 in the USA [8]. This food did not require milk to be added after dissolving the granules in hot water, and so rapidly gained market share.
  • 1885: John B. Meyenberg developed an unsweetened evaporated milk. Highly recommended by paediatricians, this was a popular choice for home formula-making in the USA until the 1940s or later [8].
  • 1894: First edition of L Emmett Holt’s The Care and Feeding of Children: A Catechism for the Use of Mothers and Children’s Nurses. Watson’s Psychological Care of Infant and Child (1928) and then Spock’s Baby and Child Care (1946 onwards) succeeded this manual as American norms [9]. In different ways, all undermined breastfeeding in practice while supporting it in theory.
  • 1892: Pierre Budin (physician at the famous Charité and later Maternité hospital in Paris, which had extensive wet-nurse experience) founded the first infant feeding and welfare clinic, the Consultation des Nourissons, where breastfeeding was encouraged — and sterilized bovine milk was provided in sealed bottles, for single use [16]. His book, Le Nourrison, would be a classic, and was translated into English in 1907. It contains detailed infant growth charts of breastfed, wet nursed and hand-fed infants.

14.5 The 20th Century

Development of the feeding bottle and the availability of cleaner animal milks reduced the market for wet nurses, and increased both the workload of mothers and infant morbidity and mortality. By 1900, wet nursing was becoming less common, although it would persist into the mid-20th century in some hospitals which recognised its value for preterm infants. Milk banking would develop where human milk was recognised as life-saving. Wherever human milk was not used, an epidemic of necrotising enterocolitis (NEC) affected up to 7% of all preterm infants by the 1970s–80s, and some term infants. (By comparison, in some European hospitals using only human milk, the NEC rate was.05%, with NEC arising only from causes such as asphyxia or transfusions [27].) The accepted mortality rate for NEC is 20–25%; in 1990 Lucas estimated NEC caused 500 extra cases and 100 unnecessary deaths per year in the UK alone.

Early 20th century concern about high infant mortality rates in western countries brought structural action for change. The child welfare movement arose from many concerns, not least the appalling health of male army recruits for the many wars of the late 19th and early 20th century [29]. Emphasis was placed on cleanliness and the improvement in the quality of milk supplies, such as providing better care for dairy cattle and forming infant milk clinics to disburse clean milk to the public [15]. A steady reduction in infant mortality from record levels began during this period, as sanitation brought cleaner water supplies. Welfare clinics were set up to educate mothers about the great value of breastfeeding and the safer use of dried milks. Ignorance about normal lactation meant that the advice given often caused lactation failure [4], [30].

The control of infant feeding was instrumental in the creation and success of the profession of paediatrics [8]. Doctors knew little about breastfeeding problems, although they still urged women to breastfeed and were considered experts – though their advice undermined breastfeeding. Artificial feeding could require frequent return visits, impractical for all but advantaged women. Many new infant formulas were developed by, or with the help of, noted US paediatricians [31], [32]. This close relationship, together with the status of doctors at the time, helped convince many that modern scientific formulas were preferable to, or at least more reliable than, women’s milk.

Hospital birthing allowed ignorant management of normal processes to become the norm, sabotag- ing the initiation of lactation and modelling the use and normality of commercial products. Data from the National Fertility Study (USA) show that the percentage of initially breastfed infants declined steadily from the 1930s estimate of 40–70%, to just 20–50% in 1946–1950 [16]. By 1960 more than 80% of those being bottle-fed were drinking evaporated milk mixtures; by 1970 this would decline to just 5% as brand name formulas were used by hospitals and so mass marketed to birthing women. One industry source stated that loyalty to the hospital brand was 93% [4]. By the 1970s exposure to infant formula was almost universal in major hospitals, and the duration of breastfeeding shortened as mothers weaned on to formula as safe and equivalent to breast milk.

Such mothers were known to continue to use formula for longer than mothers who began to formula feed from birth, who typically moved on to cows milk and other foods from three months onwards. The use of infant formula for the first full year of life, not merely the first three or six months, began to be normalised in the 1980s, and so-called Stage 2 or Follow-on milks (post 3 or 6 months) were developed. These were condemned by the World Health Assembly in 1986 as unnecessary, and by some paediatric authorities as less suitable than a first infant formula for the first 12 months. In the 1990s, formula feeding was extended again, into the second year of life, with the development of so-called Toddler milks or Stage 3 milks. This was probably inevitable, but has been interpreted as an attempt to evade the controls on infant formula marketing required by the International Code of Marketing of Breast-milk Substitutes endorsed by the World Health Assembly (WHA) in 1981. The World Health Organization’s (WHO) concern about appropriate complementary feeding increased as problems emerged [33].

Early in the 20th century no such “weaning foods” were generally introduced to fully breastfed children under 6 months, even 9 months. The development of the canned food industry and its mass marketing [34] led to rapid changes in some countries and to unexpected epidemics of disease.

14.5.1 Infant feeding in the 20th century

  • Early 20th century: Roller drying made larger scale production of cheaper powdered milk possible. Better transport, ice boxes and later refrigerators began to reduce microbial growth rates in milk. (No powdered milk could (or can) be sterile.)
  • Local government agencies in western countries began to purchase and supply dried milk products labelled as suitable for infant feeding to poor families, sometimes as much to subsidise agriculture as to support child health.
  • Early infant formulas caused children to develop deficiency diseases. Orange juice was prescribed to prevent scurvy from around the 1920s, and cod liver oil drops to prevent rickets from the 1930s; vitamin C was added to increase iron bioavailability and by the late 1950s a form of iron was found for use in for- mula to prevent anaemias. A wide range of iron was added to formulas, from 1–12 mg/L. Deficiency is damaging, while iron overload promotes gut dysbiosis, and has been associated with IQ loss of up to 12 points (discussed in Milk Matters [82]).
  • 1909–1910: In 1909 the first milk bank — and also the first blood bank — was established in Vienna, Austria. In 1910, two more milk banks were established: one in Boston, Massachusetts, and one in Germany. Breast milk bank centres were set up where breast milk from several women was pooled and pasteurized before distribution. The first ones to open were in Boston in 1910 and in London at Queen Charlotte’s Hospital and after that, several more were established all over Europe [16]. Interest in milk banking grew as premature infants of earlier gestational age and infants with more complex illnesses survived owning to advances in health care and human milk feeding [35].
  • 1919: The International Labour Organization (ILO) proclaimed, in its “Maternity Protection Convention” [36], the right of mothers to take breastfeeding breaks during working hours. Few countries would implement this right for decades to come. Italy was the first country to do so, through the Regio Decreto [37].
  • 1920–1950: Physicians and consumers in America came to regard the use of formula as a well-known, popular, and safe substitute for breast milk [26].
  • The US government published Infant Care as a free guide to parents; it ‘emphasized cod liver oil, orange juice and artificial feeding’ [38].
  • In British countries, the institutionalised work of Sir Frederick Truby King (1858–1938) would continue to promote, but undermine, breastfeeding well into the 1960s and beyond by its unscientific emphasis on scheduled feeds and regularity [9], [10].
  • 1929: The American Medical Association (AMA) formed the Committee on Foods to approve the safety and quality of formula, forcing infant food manufacturers to seek their ‘‘Seal of Acceptance’’ [15]. To be given that Seal, companies were required to remove all preparation instructions from the can. This was to ensure that bottle feeding parents regularly consulted doctors, on the grounds that their children were at greater risk of illness. Those who could not afford to see doctors were put at greater risk. In other countries, governments were passive on-lookers as formula companies regularly provided free “educational” literature to parents and advertised their consumer help services, by- passing doctors to educate and recruit parents.
  • 1932: US manufacturers wanting AMA approval were to advertise directly only to physicians [15]. Cost-effective mass marketing to professionals and via hospital contracts expanded, along with paid advertising in journals and sponsorship of conferences and associations. Hospital exclusivity contracts could be worth millions of dollars, and determined what brand mothers were exposed to [1], [7].
  • 1939: Cicely Williams’s Milk and Murder speech in Singapore testified that artificial feeding was killing children. During the war that followed, in her prison camp all eleven birthing mothers breastfed, and all babies survived until liberation. Lactation is protective for mothers as well as infants [1], [41].
  • 1941: The Food and Drug Act required infant food labels to declare only moisture, energy, protein, fat, carbohydrates, fibre, calcium, phosphorus, iron and vitamins A, B1, C and D. This unpoliced declaration added to the population’s perception that formula feeding was as safe and beneficial as breastfeeding [16]. There was little awareness of the many deficiencies of these formulas.
  • In America by 1950, artificial feeding was the cultural norm. Lip service was still paid to the idea that breastfeeding was best for baby, but it was seen as incompatible with modernity, and embarrassing, since breasts were sexual objects [41], [42].
  • Other countries affected by the Second World War lagged behind in acceptance, but soon followed America’s lead. Marketing and availability of artificial food increased globally in the post-war period, and played a significant role in the dramatic decrease of breastfeeding rates in developing countries, as well as increases in infant and maternal mortality and morbidity.
  • Industry literature blamed negative outcomes on poverty and lack of clean water, or mater nal carelessness in preparation. Regrettably, many breastfeeding advocates have accepted this rationale uncritically, although milk powders cannot be sterile.
  • 1950-1970s: Dr Mavis Gunther made original observations on human lactation and interested animal physiologists in studying lactation. Her work and eventual book, Infant Feeding (1970) was extremely influential and helped reduce the excessive sodium levels involved in annual summer epidemics of hypernatremia.
  • New high-dose hormonal contraceptives led both to advice not to breastfeed, and to difficulties sustaining lactation.
  • Research demonstrated that responsive feeding on request and rooming in facilitated the establishment of lactation, requiring hospitals to rethink controlling policies such as four-hourly feeds [4]. Most did not.
  • 1952–1954: Discovery of formula problems continued: Processing temperature destroyed B vitamins leading to permanent neurological damage. In 1981 one victim appeared on TV and a confidential settlement followed [4].
  • 1956: La Leche League was founded to give information and encouragement to all mothers wanting to breastfeed their babies [43]. Similar groups followed, such as the Nursing Mothers’ Association of Australia in 1964 [44]. Increasing awareness of environmental issues would lead many to a “Back to Nature” mentality that favoured breastfeeding, as concern about nuclear testing arose and radioactive compounds were found in cows milk and breast milk, tested as measures of human exposure to radioactivity.
  • Pioneering work on negative pressure breast- pumps by Einer Egnell [35]. Rapid develop- ment and uptake would follow.
  • 1959: More bioavailable forms of iron were introduced into formulas, reducing cases of anaemia in formula-fed children. Megaloblastic anaemia caused by the lack of Vitamin C in formula had earlier been identified after Ross Laboratories, makers of Similac, convened a conference on the subject in 1950. At the same time, formulas with too little iron continued in use, as the permitted range of formula iron was and remains very wide.
  • 1970s: Awareness of the excessive sodium content of infant formula led to product re-formulations, to reduce potential kidney damage and the constant epidemics of hypernatremia in hot weather.
  • Concern about lead solder in cans contaminating infant formula (up to 50 mcg/100 mL) was heightened by the realisation of the (still ongoing) high levels of lead in some municipal water supplies in the USA. Industry was given 10 years to phase out lead solder, possible because of new canning technology. FDA set tolerable limits of 30 ppb in municipal water supplies. Lead is an ongoing problem [45].
  • Whey-dominant formulas containing tropical oils such as palm and coconut began to challenge older casein-dominant formulas containing both oils and bovine fats (milk fat and oleo/destearinated lard). US companies led this change; milk fat was still used in other dairying nations for some time. Marketing falsely claimed that all-vegetable oils would decrease cardiovascular disease. Some older original formulas were later re-purposed as follow-on formulas.
  • The supplemental use of fish liver oil drops declined after cases of harm from the over-load of fat-soluble vitamin drops, so that for the first time in human history healthy infants would lack important long chain fats needed for optimal brain and immune development. These would later be added to expensive “gold” formulas (USA 2003, other countries in the 1990s).
  • Lack of iodine in early soy formulas caused cases of goitre. Concerns about thyroid issues persist in relation to soy, especially given the wide range of iodine found in water supplies used to make formula. (In Denmark in the 1990s, the variance was a hundredfold.) Arsenic and other minerals in water supplies used in infant feeding are ongoing concerns. Concerns were first raised about levels of manganese in soy infant formulas in the 1970s.
  • 1974: UK Oppe Report, Present Day Practice in Infant Feeding, was the first of an invaluable series of five-yearly reports between 1975 and 2010, regrettably the victim of ill-advised conservative government cost-cutting in 2014. No similar series exists anywhere else.
  •  1978: Derrick and Patrice Jelliffe’s encyclopaedic Human Milk in the Modern World [46] was published by Oxford University Press, summarising what was then known. This was a true milestone in awareness of the value of human milk, but not widely read.
  • 1970s:– In the 1970s, religious, medical, and development groups campaigned vigorously to end “commerciogenic malnutrition” as Professor Derrick Jelliffe labelled the problem in 1968. The US Kennedy hearings (1978) called on WHO to convene a meeting, with all stakeholders present. This took place in Geneva in October 1979. NGO representatives at the meeting formed the International Baby Food Action Network (IBFAN), which then campaigned for a strong and effective marketing code for all foods that act as ersatz substitutes for breast milk.
  • Reproductive biologists such as Roger Short researched lactation; the Lactational Amennorrhea Method was developed as global contraception. Promotion of breastfeeding is seen as critical by major groups such as Family Health International, and UN bodies.
  • 1978–1979: The first institution to offer courses in clinical lactation, The Lactation Institute, was created by Chele Marmet and Ellen Shell in Encino, California.
  • 1980: Global infant formula sales were US $2billion. A quarter was US sales, as the US Department of Agriculture’s Women Infants and Children (WIC) programme paid full retail price for formula to be given free to poor families, discouraging breastfeeding.Unlike the rest of the world, most 1980s US formula sales were of sterile liquid ready to feed or concentrates, reducing formula’s negative health impacts [47].
  • After yet another recall of defective infant formula, publicised by parents of damaged children, the American Academy of Pediatrics (AAP) recommended 4–6 months for the introduction of solid foods to all infants, despite clear awareness of the Committee Chair that this was early, and possibly disadvantageous, for breastfeeding infants [33]. Four months was stated as being a compromise to protect formula fed infants from possible nutrient deficiencies after their in utero body stores were exhausted [4].
  • US Congress passed the Infant Formula Act, which attempted to regulate the required content of formulas for sale in the US, mandating the USFDA to develop new standards and enforce them. It was years before any regulations were finalised [33].
  • The United Nations International Children’s Fund (UNICEF) Director James P Grant called for a Child survival Revolution and subsequently stated that a million children die every year because they are not breastfed. UNICEF makes breastfeeding a key intervention in its global GOBI-FFF programme. (G for growth monitoring, O for oral rehydration therapy, B for breastfeeding and I for immuni- sation against the six basic childhood dis- eases: tuberculosis, polio, diphtheria, tetanus, whooping cough, and measles. The FFF were food supplement, family planning and female education.)
  • 1980s onwards: Allergy had become common-place in the United States by the 1960s, and by the 1980s parent support groups in Australia, NZ, the UK and Canada were advocating action about the rising incidence of food allergy and intolerance. Breastfeeding mothers made connections between the hospital use of infant formula and the emergence after 10–21 days of infant gut distress. Their concerns were often dismissed, but prompted growing research into food hypersensitivity, an emerging epidemic. Professor John Gerrard [48] wrote an influential small book on food allergy among Canadian children, and Minchin published Food for Thought: a parent’s guide to food intolerance [49], summarising Australian breastfeeding mothers’ experiences, recognising the intergenerational impacts for which epigenetics and genomics would later provide explanatory mechanisms [49].
  • 1981: In 1981, the WHA adopted The International Code of Marketing of Breastmilk Substitutes as a recommendation to governments. WHA has since adopted further relevant Resolutions. The IBFAN reports regularly on the implementation of the Code [50]. Most countries and companies have taken little or no effective action to implement the Code, so it has made little difference to industry market expansion.
  • The Codex Alimentarius Commission specified basic minimum standards of infant formula globally. This would be revised and updated periodically; some countries created more rigorous standards.
  • 1985: Addressing the need to improve health worker knowledge of infant feeding, La Leche League International (LLLI) funded the creation of the International Board of Lactation Consultant Examiners® (IBLCE®) [51]. A professional NGO, the International Lactation Consultant Association (ILCA), was soon launched. Lawrence’s Breastfeeding: a guide for the medical profession [38], and Minchin’s Breastfeeding Matters: What we Need to Know about Infant Feeding [4] argue strongly for better clinical practice by health professionals. Both see breastfeeding failure as the almost inevitable result of poor health professional care and socio-cultural pressures.
  • The Human Milk Banking Association of North America (HMBANA) was founded with the goal of standardizing US donor milk bank- ing operations [35]. Similar organisations ex- ist in the UK (UKAMB) and Europe (EMBA) and expand worldwide. By 2016 Brazil leads the world in structural support for, and the number of, milk banks, while Norway contin- ues its since-1920s unbroken tradition of us- ing fresh donor milk.
  • 1988: Formal creation of the multidisciplinary scientific International Society for Research on Human Milk and Lactation (ISRHML)
  • 1980s onwards: Just as global agencies begin to advocate breastfeeding as a key intervention, Ziegler et al. in Australia reported a single case of post-natally-acquired HIV [52]. This was assumed to be due to breastfeeding, publicised widely (including via free videos from the infant formula industry), and led to blanket bans on breastfeeding by HIV + women living in the USA and Europe, and the closure of many milk banks. No research was done on likely outcomes prior to this ban, although the replacement of breast milk in NICUs increased rates of NEC and sepsis [28]. The ban created enormous prejudice about breast milk, and reinforced myths about infant formula safety; it persisted even after studies in the 1990s began to show higher death rates of children given “replacement” feeding by charities and NGOs. But no change in global policy occurred until after the Botswana government called in the CDC in December 2005 to investigate the very high mortality rate in HIV-exposed formula-fed babies following flooding in Mozambique and Botswana (see Chapter 16).
  • Research in Scotland [53] and Brazil [54] proved formula feeding per se causes gastroenteritis, regardless of socio-economic status.
  • 1989: Joint WHO/UNICEF Statement, Protecting Promoting and Supporting Breastfeeding: the special role of the maternity services. This contained the Ten Steps to Successful Breastfeeding that form the basis of the global Baby-Friendly Hospital Initiative (see below).
  • 1989: The UN General Assembly adopted The Convention on the Rights of the Child.
  • 1990: WHO and UNICEF and representatives of 32 national governments and organisations drafted and signed the Innocenti Declaration, calling for structural changes to improve declining breastfeeding uptake and duration.
  • WHO stated that the optimal way to feed an infant is exclusive breastfeeding up to 4–6 months, with continued breastfeeding along with appropriate complementary foods for up to 2 years and beyond [55].
  • 1991–1992: WHO and UNICEF develop and launch the Baby-Friendly Hospital Initiative (BFHI) [56]. The first pilot assessments take place in February 1992 in 12 countries.
  • 1991: Formation of the World Alliance for Breastfeeding Action (WABA). WABA envisioned a global breastfeeding strategy.
  • 1991:WHO created the Global Databank on Infant and Young Child Feeding. Few studies past or present ever control for hospital exposure of breastfed infants to infant formula (assumed to be of no significance despite 1970s studies showing long-term effects on gut flora); few define exclusive breastfeeding accurately.
  • 1991: WHO published Infant Feeding: the Physiological Basis. Translated into 13 languages, this slight book (now in need of updating) was a ground-breaking forerunner of later WHO infant feeding resources still online.
  • 1992: WABA established World Breastfeeding Week, endorsed by UNICEF, WHO, FAO and the International Pediatric Association (IPA).
  • 1995: Creation of the Academy of Breastfeeding Medicine (ABM), a global physician-only or ganisation attempting to remedy medical ignorance about infant feeding.
  • 1995: Pope John Paul II spoke publicly in support of breastfeeding, hosting an important Vatican conference on the topic of Breastfeeding, science and society [57].
  • 1990s: UK RCTs demonstrated conclusively that infant formula increased the rates of NEC [58], and decreased average IQ scores [59]. Prior maternal choice of infant feeding made no difference to cognitive outcomes; actual breastfeeding duration did [28], [59]. Preterm infant formulas develop which, by comparison with the sole use of older formulas, result in better IQ scores. However, little notice was taken of the fact that giving even a little breast milk to the infants fed term formulas had obliterated the outcome difference, while breastfeeding at hospital discharge was associated with higher IQ. (average 12point) Preterm formula rapidly replaced both breastmilk and term formula use in neonatal units, and NEC continued at 6–7% in some units.
  • Unsterile formula powders now become the dominant US product, after competitive tendering reduced what WIC pays for formula, and so increased formula costs at retail. From around 1960 end-sterilised liquid concentrates and ready to feed products had dominated the US market after evaporated milk products were abandoned. For cost reasons this had never been the case in other Anglophone countries.
  • Some formula companies add 5 nucleotides to infant formula. Marketing suggests this aligns formula more closely with breast milk and supports better immune function. Nucleotides are later judged unnecessary [4] but justify price increases.
  • Companies other than in the USA add micro-encapsulated DHA and ARA produced in the US on an industrial scale using genetically modified marine algae and soil fungi. The encapsulating proteins in formula for milk-allergic infants trigger reactions; traces of neuro-toxic hexane used to extract oils from biomass cause concern.
  • Debate continued from the 1970s about levels of selenium fortification needed for infant formula. The UK specified a minimum of 1mcg/L and maximum of 9mcg/L in its 2007 Infant Formula and Follow On Formula Regulations. The FDA considered the issue in 2013, accepting industry’s levels of added selenium [4].

14.6 21st Century

Evolutionary medicine and medical anthropology has established the normalcy of human infant feeding patterns, and the physical and psychological harms done by deviations from highly evolved norms [12]. New research in microbiology, genomics and epigenetics make it clear that mother’s milk remains the best food for any baby for the first 6 months of life, and advantages the breastfeeding mother as well. Increasing evidence emerges that breastfeeding needs to be exclusive from birth to create the normal microbiome that is the basis for good health through life.

Further changes in infant formula composition attempt to mimic breast milk effects on the infant gut microbiome, by adding new ingredients such as probiotics (bacteria) and prebiotics (largely indigestible carbohydrate food for those bacteria). Press releases and marketing succeed in persuading many people that infant formula has now “closed the gap” with breast milk. An articulate minority of advantaged western women make such claims via electronic media, and start protesting against any truth-telling about infant formula risks or harms by public health advocates [33].

Research has by now established that lack of breast milk and the presence of infant formula increases the risk of many serious diseases in the infant, such as acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, obesity, type 1 and 2 diabetes, childhood leukaemia, sudden infant death syndrome (SIDS) and NEC [60], [61],[62]. Early biological differences between children who are breastfed and those who are not are documented, such as differences in organ size and structure (enlarged kidneys, smaller thymus, different heart structure in preterms), brain white matter development, DNA damage and chromosomal breaks, differences in reproductive tissue growth evident by ultrasound at 4 months of age, different trajectories of body growth and patterns of adipose tissue deposition (all referenced and discussed in Milk Matters [33]). The accepted concept of programming makes it clear that such children are likely to grow on different developmental trajectories. And the rapid growth of allergy and other inflammatory disease epidemics since the 1970s means that parental reports of infant food intolerances are now being taken seriously. Allergy practices are expanding, but struggling to cope with the need for their services, where parents can afford to consult doctors under national health schemes.

Economic research proves that artificial feeding results in greater short- and long-term national health expenditures, and loss of productivity [63]. Not breastfeeding also adversely affects women’s health. The loss of lactational amenorrhea and normal postpartum hormonal levels exposes women to greater risk of postpartum infection and anaemia, as well as higher rates of stress and reproductive cancers, diabetes and osteoporosis.

World health authorities and national economists [64] have started to recognise the enormous impact of breastfeeding on individual and population health. Despite the strong efforts by different non-governmental organisations to raise breastfeeding to international and national health agendas, the pace is slow, and hampered by vociferous opposition and “pushback” from advantaged western women with media access, who believe that infant formula is harmful only when misused, and is a safe breast milk equivalent, so that breastfeeding advocates are not genuine public health advocates, but are shaming women who choose not to breastfeed. How much of this “pushback” is due to culpable ignorance, and how much is astroturfing by vested interests remains unresearched. Formula industry presence online is substantial, with special offers and mother’s clubs and many forms of marketing and recruitment [65].

Meanwhile, human milk and breastfeeding research remain under-explored, but growing, fields with high potential for impact on long-term health. However, much of this research is funded by the infant formula industry with a view to identifying even more possible new additives that can be industrially produced and then marketed as acting in formula as they do in breast milk. To date, this has proved impossible, as breast milk is a complex living tissue in which multiple ingredients interact to produce positive effects, and no industrially-produced heat-treated and/or dehydrated product can replicate the action of its complex biological structure and microbiome.

14.6.1 Infant feeding in the 21st century

  • 2000+: Despite the evidence base for responsive infant care, self-styled experts and “baby whisperers” promote regimented care akin to that of Truby King and earlier authors.
  • 2000:the International Labour Organisation (ILO) adopts Maternity Protection Convention 183 and Recommendation 191 [66]
  • UK government funds publication of a structured review of factors promoting or inhibiting breastfeeding, entitled Enabling women to breastfeed [67].
  • 2001: WHA adopts Resolution 54.2 calling for strengthened BF promotion: recommends exclusive breastfeeding for 6 months, to be continued with appropriate foods, for two or more years.
  • 2002: WHA adopts the Global Strategy on Infant and Young Child Feeding WHA 5525 [68]
  • The United Nations Millennium Campaign started to support the eight Millennium Development Goals (MDGs) — which range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education started. It mentions interventions to improve maternal nutrition, especially before, during and immediately after pregnancy; early and exclusive breastfeeding; and timely introduction of safe, appropriate and high- quality complementary food for infants, accompanied by appropriate micronutrient interventions [69].
  • 2002–2003: US Office of Women’s Health and the US Breastfeeding Coalition (formed in 2000) created a professional risk-based advertising campaign with the National Advertising Council: Babies Are Born to be Breastfed [70]. The Campaign was undermined and reduced in effectiveness by industry lobbying of government, with TV spots withdrawn at the insistence of the DHHS [38].
  • 2000 onwards: Industry increased its online presence, stating support of breastfeeding but in fact defending the normalcy and safety of artificial feeding and perhaps inadvertently encouraging increasing “pushback” against the public promotion of breastfeeding. Creation of “the Mommy wars” encouraged bullying of breast- feeding advocates. The Internet emerged as a major promotional vehicle for infant formula as global sales increase dramatically [41].
  • 2003: DHA and ARA finally added to US infant formulas. These “Gold” brands then rapidly became the de facto standard for US infant formulas after a Bush administration decision in 2004 not to allow WIC programmes to specify the infant formulas on which companies would base their WIC tenders [47]. Repeated Cochrane Collaboration reviews show no benefit to these supplements [71].
  • Following infant deaths over previous decades in Israel, France and the United States from Cronobacter infections (formerly E. Sakazaa- kii), the WHO website stated that powdered infant formula was not a sterile product and recommended mixing with water at no less than 70 °C. Other pathogens documented in formula include Salmonellas, Klebsiella, Bacillus cereus, and Citrobacter, along with moulds. Controversy continued about how to make up infant formula, as heat will kill newly-added bacteria (probiotics) and possibly affect nutrients. Given that infant formula products vary, the effects may be different for each brand or even batch.
  • 2005: Publication of a major ground-breaking scientific paper on ultrasound investigation of lactating breast anatomy by Hartmann Group researchers at The University of Western Australia [72]. Other evidence-based studies followed in this centre, which had previously developed accurate ways of measuring breast volume and infant intake.
  • 2006: WHO Child Growth Standards published: the first normative growth tables based on breastfed rather than formula or mixed-fed children.
  • 2007: Codex Committee finalised revised standard for infant formula; the European Commission set the requirements for the composition and labelling of infant and follow-on formula milks in Europe.
  • 2007/2012: Researchers from the Hartmann Group discovered the presence of stem cells in human milk [71] and revealed their embryonic stem cell (ECS)-like properties [74], [75].
  • 2007: A Witness Seminar on the Resurgence of Breastfeeding was held by the Wellcome Trust Centre for the History of Medicine at UCL, Lon- don, on 24 April 2007. The transcript is available online [76].
  • 2008: WHO published Indicators for Monitoring Infant and Young Child Feeding practices.
  • Publication of a ground-breaking systematic review of the cleaning and sterilising of infant feeding equipment [70].
  • 2009: Major campaign funded by the Gates Foundation is said to have tripled the rate of exclusive breastfeeding in Vietnam.
  • HIV 1997–2009: Except where artificial feeding was acceptable, feasible, affordable, sustainable and safe (AFASS), WHO advised exclusive breastfeeding for 6 months and abrupt weaning (called “early cessation”) for HIV + women [78]. This policy, promoting replacement feeding by HIV + mothers, was reversed in November 2009 after researchers attending a consultation in Geneva threaten to publicise the excess deaths from formula feeding.
  • 2010: WHO advised anti-retroviral therapy (ART) on diagnosis and continued for life for HIV + women, with exclusive breastfeeding for 6 months and continued breastfeeding for up to 24 months, as studies showed greater harm when breastfeeding ends at 6 months, and infection via breastfeeding is extremely rare [79].
  • Eats on Feets Facebook page created to organise responsible community breast milk sharing, as advantaged women realised that this was the way forward for those mothers unable to fully breastfeed.
  • 2011: Creation of global network for milk sharing: Human Milk 4 Human Babies (HM4HB).
  • 2010 onwards: Some allergists and nutritionists overlooked the harm to infants (more infections) and mothers (e.g., more cases of reproductive cancers, CVD, increased cost and workload) and challenged the WHO advice for 6 months exclusive breastfeeding. This seemed to arise from research indicating that tolerance was more likely to develop if foods were introduced before 11 months and while mothers are still breastfeeding, together with an assumption that breastfeeding ended at 6 months — which in WEIRD (western educated industrialised rich and democratic) nations it often did. This could change given the importance of normal breastfeeding duration.
  • Creation of First Steps Nutrition Trust, the first independent website to provide evidence- based detailed and accurate information about current infant formulas. Many valuable resources are free online at http://www.first-
  • 2013: Family Larsson-Rosenquist Foundation (FLRF) was set up under Swiss law, the only foundation created to promote and support scientific research of human milk and breastfeeding [80].
  • 2014: Professor Allan Walker and others concerned with immune development and the microbiome wrote of ‘the necessity of breastfeeding as the first food for infants’ [81]. Walker and other scientists participating in Nestle Nutrition Institute Workshop 88 (September 2016) agreed on the importance of exclusive breastfeeding (EBF) in the first days of life; one comments that an intergenerational databank of First Nations families had unexpectedly revealed that among the offspring of women with gestational diabetes, no child who was EBF for just 2 days (the extent of data collection) developed diabetes in adolescence, as is common.
  • 2015: The extensive and updated review, Breastfeeding and Maternal Health Outcomes: a systematic review and meta-analysis, outlined the risks of not breastfeeding for women [63].
  • Pope Francis invited mothers to breastfeed in the Sistine Chapel, spoke in support of breastfeeding [82].
  • United Nations Sustainable Development Goals [83] to end poverty, protect the planet, and ensure prosperity for all were adopted. Breastfeeding is a necessary factor in most if not all the goals, though not highlighted.
  • Milk Matters: Infant Feeding and Immune Disorder proposed the Milk hypothesis: that the interlinked inflammatory epidemics of immune disorder, obesity, diabetes and cardiovascular disease all have their origins in formula-related distortions of normal postpartum processes. Epigenetics indicate that these effects are heritable and may compound through succeeding generations. The book brings together current evidence for infant formula’s separate detrimental effects on biological development as well as the effects of the absence of breastfeeding and women’s milk, chronicling the evolution of infant feeding as a series of ongoing uncontrolled, and almost entirely unexamined, experiments [82].
  • 2016: Joint statement by the UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child affirmed breastfeeding as a human rights issue for mother and child alike and called for government action to enable breastfeeding [84].
  • Consensus statement from the CFAR Summit on Food Allergy held in May 2016 at the Royal Children’s Hospital in Melbourne, Australia offered hope of resolving disagreement between allergists and WHO on the age for introduction of other foods to breastfed children [85].
  • Major American collaborative review, Suboptimal Breastfeeding in the United States: Maternal and paediatric health outcomes and costs, estimated excess 3,340 needless premature maternal deaths and 721 excess paediatric deaths, along with billions in healthcare costs [64].
  • Ongoing efforts to improve infant formula included adding back some bovine milk fat products and complex sugars, because many (different and interactive) types exist naturally in breast milk!
  • Increasing awareness of the multiple structural issues inhibiting successful breastfeeding in high-income countries [42].
  • Infant formula sales ($2 billion in 1980) exceeded $45 billion and were projected to reach $70 billion by 2019. China became the world’s largest market for infant formula; demand estimated to reach $30 billion by 2017 [41].
  • Type 1 diabetes increased dramatically in China, especially in children, the fastest increase in under 5s.

14.7 Current Overview and Conclusion

Rates of exclusive breastfeeding in hospitals worldwide are still not being well monitored, and infant formula use for newborns is still prevalent. Definitions of “exclusive breastfeeding” still ignore in-hospital exposures. Health authorities are clearly not being effective in countering industry presence and marketing strategies. Many are co-opted partners in promoting artificial feeding, because they refuse to provide the information about infant formula risks and harms that parents need to make any truly informed choice. In a rationale unique to this one major public health message, refusal to publicise known harms is publicly justified by the desire not to create anxiety or guilt among parents already feeding artificially.

In WEIRD nations (western, educated, industrialised, rich and democratic) in the 21st century, it is now largely advantaged women who breastfeed and/or are able to pump their milk to feed their babies, together with – in some areas – women too poor to have any choice but to breastfeed. Proportionally, it is less advantaged women with some disposable income who are now feeding artificial substitutes for breast milk to their children. Breastfeeding support is increasingly seen by researchers as an important strategy to reduce social inequality. So too is generous maternity leave [42], [49].

In emerging economies, advantaged women are now repeating the mistakes their advantaged sisters made a century ago in the 1920s, wasting money on buying dehydrated substitutes for a priceless living liquid that provides daily free stem cell transplants. And the elite’s example will lead disadvantaged women in those communities to buy the unaffordable status symbols of imported infant formula [39], wanting “the best” for their babies. In fact, such families are risking their child’s life and pushing the whole family further into poverty, closing off avenues of escape from poverty via the education of gifted children. Artificial feeding is closing the poverty trap on the bodies of some children, tightening it for many of those exposed too early to an expensive industrial product valuable as a supplement or replacement only when breast milk is unavailable.

In desperately poor communities exposed to global media, breastfeeding women are watching. With billions of dollars being spent on marketing, and with western governments supporting the expanded production and global export of infant formula, it will not be long before the cycle of artificial feeding’s dysnutrition and dysbiois and immune disorder grows even in the poorest communities. Naïve parents believe that there are regulations that would not let companies sell products that harm their children: ‘they wouldn’t let them say those things if they weren’t true’; ‘they wouldn’t let them sell formula if it would harm my child’. A recent book by Professor George Kent illustrates the extent to which governments have themselves become formula-pushers, and are failing to regulate infant formula, or to protect and enable breastfeeding adequately. Few parents understand that industry self-regulation is the reality, and that routine independent assays of infant formula products do not occur in most countries.

Infant formula became the dominant norm in WEIRD countries because of many decades of sustained taxpayer-funded structural support for the industry, and for parents wanting or needing to formula feed. One senior scientist stated in 1984 that the FDA ‘needs to reassure parents that American formula is safe because American society depends on bottle feeding’ [4]. Promoting breast-feeding as the mother’s responsibility while buying or exporting or subsidising millions of cans of infant formula is divisive and hypocritical. Not informing the community of the risks and harms of infant formula feeding is negligence at best. It may well be judged as criminal liability once class action lawyers investigate the possibilities that Professor Peter Hartmann foresaw when he said that ‘Infant formula is the tobacco of the 21st century’.

A formula slogan, once found on every can of Cow and Gate infant formula, was this:

What we feed them now matters forever.

It does. So what we feed babies needs to be women’s milk.

Enabling breastfeeding and providing womens milk for those who cannot breastfeed, are both possible, once they are seen as necessary for nor- mal human health and development.

Science makes clear that they are.

Societies need to invest significant funds (on the scale of industry subsidies for formula ingredients and products) in enabling, as well as promoting and protecting, breastfeeding. Establishing breastfeeding as the community norm worldwide will save much more than it costs.

Key Points

  • Lactation is a robust, resilient, and reliable survival mechanism, and was critical to mammalian evolutionary success. With the development of bovine derived products many infants are missing out on this valuable resource
  • Industrialisation and pressures from modern society has resulted in shifts away from breastfeeding towards readily available commercial products
  • With the increased understanding of the health benefits to both baby and mother, the focus is shifting back to breastfeeding
  • Ensuring mothers and families can make an informed choice is essential in ensuring a refocus on breastfeeding and the use of human milk


Maureen Minchin, BA, MA, is an historian and educator who has worked globally to educate health professionals since the publication of her books, Food for Thought and Breastfeeding Matters, in the 1980s. A founding member of the lactation consultant profession, she was involved in the creation of the WHO/UNICEF Baby Friendly Initiative, has acted as consultant to the World Health Organization, and is on the Editorial Board of the International Breastfeeding Journal. Her most recent book is Milk Matters, Infant Feeding & Immune Disorders.


  1. Wolf JH. What Feminists can do for Breastfeeding and what Breastfeeding can do for Feminists. Signs J Women Culture Soc 2006; 31(2): 397–424
  2. Ploss HH, Bartels M, Bartels P. Woman: an Historical, Gynaecological, and Anthropological Compendium. WM Heinemann Books. 1935; 3 vols
  3. 3. Fildes V. Wet Nursing: A History from Antiquity to the Present. Blackwell; 1984
  4. Minchin MK. Breastfeeding Matters: What we Need to Know about Infant Feeding. Alma Publications; 4th revised edition. 1998. Available at:  Accessed March 2017
  5. Shortall J. Work in the only industrialized country without paid maternity leave. Available at: Accessed March 2017
  6.  Fildes V. Breasts Bottles and Babies. Edinburgh: University Press; 1986
  7. Apple, Rima DA. Mothers and Medicine: A Social History of Infant Feeding. 1890–1950. Wisconsin Publications in the History of Science and Medicine; 1987
  8.  Wolf JH. Don’t Kill your Baby: Public Health and the Decline of Breastfeeding in the 19th and 20th Centu- ries. Ohio State University; 2001
  9. Hardyment C. Dream Babies: Childcare from Locke to Spock. Jonathan Cape; 1983
  10. Mein-Smith P. Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia 1880– 1950. Macmillan Press; 1997
  11. Williams F. Breasts. A Natural and Unnatural History. WW Norton; 2012
  12. Blaffer Hrdy, S. Mothers and Others. The Evolutionary Origins of Mutual Understanding. Belknap Press of Harvard University Press. 2009; Mother Nature. Natural selection and the female of the species. Chatto & Windus; 1999
  13. Trevathan W. Ancient Bodies, Modern Lives. How Evolution has Shaped Women’s Health. Oxford University Press; 2010
  14. Wickes IG. A History of Infant Feeding. Part I. Primitive peoples: Ancient works; Renaissance writers. Arch Dis Child 1953; 28(138): 151–158
  15. Stevens EE, Patrick TE, Pickler R. A History of Infant Feeding. J Perinat Educ 2009; 18(2): 32–39
  16. Papastavrou M, Genitsaridi SM, Komodiki E et al. Breastfeeding in the Course of History. J Pediatr Neo- natal Care 2015; 2(6): 00096
  17. Gatrad AR, Ray M, Sheikh A. Hindu Birth Customs.Arch Dis Child 2004; 89(12): 1094–1097
  18. Hinde K. Colostrum through a Cultural Lens. Splash! Milk science update February 2017. Available at: Accessed March 2017
  19. Osborn ML. The Rent Breasts: A Brief History of Wet Nursing. Midwife Health Visit Community Nurse 1979; 15(8): 302–306; Part II. Midwife, Health Visitor Community Nurse 1979; 15(9): 347–348
  20. Wickes IG. A History of Infant Feeding. Part II: seventeenth and eighteenth centuries. Arch Dis Child 1953b; 28(139): 232–240
  21. Sussman GD. Selling Mothers’ Milk. The Wet-Nursing Business in France 1715–1914. University of Illinois Press; 1982
  22. Cadogan W. An Essay upon Nursing and the Management of Children. Published by order of the general committee for transacting the affairs of the said hospital. London. Available at: books?id=Ay5cAAAAQAAJ&printsec=frontcover&sour- ce=gbs_ge_summary_r&cad=0#v=onepage&q&f=- false. Accessed March 2017
  23. Radbill, S. Infant feeding Through the Ages. Clinical Pediatrics 1981; 20(10): 613–621
  24. Wickes IG. A History of Infant Feeding. Part III: Eighteenth and nineteenth century writers. Arch Dis Child 1953c; 28(140): 332–340
  25. Wickes IG. A History of Infant Feeding. Part IV: Nineteenth century continued. Arch Dis Child 1953d; 28: 416–422
  26. Fomon S. Infant Feeding in the 20th Century: Formula and Beikost. J Nutr 2001; 131(2): 409S–420S
  27. Akre J (ed). Infant Feeding: The Physiological Basis. World Health Organization. 1990. Available at: Accessed March 2017
  28. Lucas A, Cole TJ, Morley R et al. Factors Associated with Maternal Choice to Provide Breast Milk for Low Birthweight Infants. Arch Dis Child 1988; 63(1): 48– 52
  29. Dwork D. War Is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England 1898–1918. London: Tavistock Publication; 1987
  30. Nathoo T, Ostry A. The One Best Way? Breastfeeding History, Policy and Politics in Canada. Wilfrid Laurier University Press; 2009
  31. Apple R. Mothers and Medicine. A Social History of Infant Feeding 1980–1950. University of Wisconsin Press; 1987; Perfect Motherhood. Science and childrearing in America. Rutgers University Press; 2006; ‘To be used only under the direction of a physician’: commercial infant feeding and medical practice, 1870–1940. Bull Hist Med 1980; 54(3): 402–417
  32. Cone TE. History of American Pediatrics. Little Brown & Co; 1979: 134–135
  33. Minchin MK. Milk Matters: infant feeding and immune disorder. Australia: Milk Matters Pty Ltd; 2015
  34. Golden J. A Social History of Wet Nursing in America. Cambridge University Press; 1996
  35. Wambach K, Riordan J. Breastfeeding and Human Lactation. 5th Edition. Burlington: Jones & Bartlett Learn- ing; 2016: 527
  36. International Labour Organization. NORMLEX Information System on International Labour Standards. C003 – Maternity Protection Convention. 1919 (No. 3). Convention concerning the Employment of Women before and after Childbirth (Entry into force: 13 Jun 1921)
  37. Capo del Governo, primo ministro segretario di Stato, ministro delle corporazioni e dell’interno, Mussolini, ministro di grazia e giustizia, De Francisci, ministro delle finanze, Jung. “Conversione in legge del r.d.l. 22 marzo 1934, n. 654, sulla tutela della maternità delle lavoratrici” 01.05.1934–09.05.1934. (1309): 961– 1001 cc. (41 cc.)
  38. Lawrence RA, Lawrence R. Breastfeeding A Guide for the Medical Profession. 8th revised edition. Elsevier; 20
  39. Barennes H, Empis G, Quang TD et al. Breast-Milk Substitutes: A New Old-Threat for Breastfeeding Policy in Developing Countries. A Case Study in a Traditionally High Breastfeeding Country. PLoS One 2012; 7(2): e30634
  40. Greer FR, Apple RD. Physicians, Formula Companies, and Advertising. A Historical Perspective. Am J Dis Child 1991; 145(3): 282–286
  41. Grayson J. Unlatched. The Evolution of Breastfeeding and the Making of a Controversy. Harper Collins; 2016
  42. Brown A. Breastfeeding Uncovered. Who Really Decides How We Feed our Babies? Pinter and Martin; 2016
  43. La Leche League. Available at: https://www.laleche. Accessed March 2018
  44. Brodribb W. Breastfeeding Management in Australia. ABA 1990. 4th edition; 2012
  45. World Health Organization 2011. Lead in Drinking Water. Available at: tion_health/dwq/chemicals/lead.pdf. Accessed March 2018
  46. Jelliffe DB, Jelliffe EFP. Human Milk in the Modern World. Oxford University Press; 1978
  47. Kent G. Regulating Infant Formula. Hale Publishing 2010; Governments Pushing Formula (working title).Pinter and Martin; 2017
  48. Gerrard JG. Food Allergy: New Perspectives. Illinois: Thomas; 1980
  49. Minchin MK. Food for Thought: a parent’s guide to food intolerance. 4th edition. Alma Publications; 1992
  50. International Baby Food Action Network. 1979/1981. International Code of Marketing of Breastmilk Substi- tutes. Available at: Accessed March 2018
  51. International Board of Lactation Consultant Examiners. History. Available at: Accessed March 2018
  52. Ziegler JB, Cooper DA, Johnson RO et al. Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet 1985; 1(8434): 896–898
  53. Howie PW, Forsyth JS, Ogston SA et al. Protective Effect of Breastfeeding against Infection. BMJ 1990; 300: 11–16
  54. Victora CG, Horta BL, Loret de Mola C et al. Association Between Breastfeeding and Intelligence, Educa- tional Attainment, and Income at 30 Years of Age: A Prospective Birth Cohort Study from Brazil. Lancet 2015; 3(4): e199–e205. See also the Lancet series on breastfeeding
  55. World Health Organization. Innocenti Declaration. 1990. Available at: Accessed March 2018
  56. World Health Organization. Baby-Friendly Hospital Initiative. 1991. Available at: Accessed March 2018
  57. Pope John Paul II. Solemn Papal Audience: Breastfeeding Science and Society. Food Nutr Bull 1996; 17: 289
  58. Lucas A, Cole TJ. Breast Milk and Neonatal Necrotising Enterocolitis. Lancet 1990; 336(8730): 1519–1523
  59. Lucas A, Morley R, Cole TJ, et al. Breast Milk and Subsequent Intelligence Quotient in Children Born Pre- term. Lancet 1992: 339(8788): 261–264
  60. Bahl R, Frost C, Kirkwood BR et al. Infant Feeding Patterns and Risks of Death and Hospitalization in the First Half of Infancy: multicentre cohort study. Bull World Health Org 2005; 83(6): 418–426
  61. Good M, Sodhi CP, Egan CE et al. Breast Milk Protects against the Development of Necrotizing Enterocolitis through Inhibition of Toll-like Receptor 4 in the Intestinal Epithelium via Activation of the Epidermal Growth Factor Receptor. Mucosal Immunol 2015; 8 (5): 1166–1179
  62. Meinzen-Derr J, Poindexter B, Wrage L et al. Role of Human Milk in Extremely Low Birth-Weight Infants’ Risk of Necrotizing Enterocolitis or Death. J Perinatol 2009; 29(1): 57–62
  63. Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and Maternal Health Outcomes: A Systematic Review and Meta-analysis. Acta Paediatr 2015; 104(467): 96– 113
  64. Bartick MC, Schwarz EB, Green BD et al. Suboptimal Breastfeeding in the United States: Maternal and Pe- diatric Health Outcomes and Costs. Matern Child Nutr 2017; 13(1). doi: 10.1111/mcn.1236
  65. Jameson N. The Sisterhood of Marketing. Available at: Accessed March 2018
  66. International Labour Organization 2000: Maternity Protection Convention (No. 183). Convention concerning the revision of the Maternity Protection Convention (Revised), 1952 (Entry into force: 07 Feb 2002), Adoption: Geneva, 88th ILC session (15 Jun 2000)
  67. Renfrew MJ, Woolridge MW, McGill HR. Enabling Women to Breastfeed. A review of practices which promote or inhibit breastfeeding – with evidence-based guidance for practice. London: The Stationery Office; 2000
  68. World Health Organization. Global Strategy for Infant and Young Child Feeding. Geneva, Switzerland: World Health Organization. 2003
  69. United Nations. Millennium Development Goals Acceleration and Beyond 2015. Available at: http://www. Accessed March 2018
  70. Institute of Medicine. Updating the USDA National Breastfeeding Campaign. National Academy of Scien- ces; 2011
  71. Cochrane Reviews. Available at:  Accessed March 2018
  72. Ramsay D, Kent J, Hartmann R et al. Anatomy of the Lactating Human Breast Redefined with Ultrasound Imaging. J Anat 2005; 206(6): 525–534
  73. Fan Y, Chong YS, Choolani MA et al. Unravelling the Mystery of Stem/Progenitor Cells in Human Breast Milk. PloS One 2010: 5(12): e14421
  74. Hassiotou F, Beltran A, Chetwynd E et al. Breastmilk Is a Novel Source of Stem Cells with Multilineage Differentiation Potential. Stem Cells 2012; 30(10): 2164– 2174
  75. Witkowska-Zimny M, Kaminska-El-Hassan E. Cells of human breast milk. Cell Mol Biol Lett 2017; 22: 11. Available at: 28717367
  76. Crowther SM, Reynolds LA, Tansey EM (eds). The Resurgence of Breastfeeding 1975–2000. Wellcome Witnesses to the 20th Century Series. 2009; vol 35. University College London: Wellcome Trust Centre for the History of Medicine. 2009
  77. Renfrew MJ, McLoughlan M, McFadden A. Cleaning and Sterilisation of Infant Feeding Equipment: A Sys- tematic Review. Public Health Nutrition 2008; 11(11): 1188–1199
  78. World Health Organization. Guidelines on HIV and Infant Feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. 2010. Available at: 9789241599535/en/  Accessed March 2018; updated: WHO-UNICEF. Guideline: Updates on HIV and Infant Feeding. 2016. Available at: bitstream/10665/246260/1/9789241549707-eng. pdf. Accessed March 2018
  79. World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach – Second edition. 2016. Avail- able at:  Accessed March 2018
  80. Family Larsson-Rosenquist Foundation. 2013. Available at: Accessed March 2018
  81. Jain N, Walker WA. Diet and Host-Microbial Crosstalk in Postnatal Intestinal Immune Homeostasis. Nat Rev Gastroenterol Hepatol 2015; 12(1): 14–25
  82. Pope Francis encourages Breastfeeding: Available at: 07/576319476/pope-francis-once-again-encourages-mothers-to-breastfeed-in-the-sistine-chapel/ Ac- cessed March 2018
  83. United Nations. Sustainable Development Goals. Available at: Accessed March 2018
  84. Office of the United Nations High Commissioner for Human Rights. Joint statement by the UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child in support of increased efforts to promote, support and protect breast-feeding. Available at:  Accessed March 2018
  85. Murdoch Children’s Research Institute. Available at: Accessed March 2018