I overheard a conversation at the library the other day between two mothers with young children. Asked one, "Are you still nursing Ryan?" The other responded, "No, his doctor told me to wean him at twelve months so I did, although it nearly broke my heart."

I recalled getting the same advice from my pediatrician when my first- born reached twelve months. When I pressed for a reason, the answer I got was "So she can learn to be independent." I was able to ignore the advice only because my best friend was still nursing her two-year-old with tenderness and affection and apparently no ill effects. Yet not everyone has an alternative role model when they are told that it's time to wean. It saddens me to see so many give up nursing before mother and baby are ready for weaning, because of advice given arbitrarily.

Why do so many doctors recommend weaning at one year? Recently a woman wrote to the question-and-answer column of a popular magazine to ask, "When should I wean my baby?" The answer, from a pediatrician, reflects a common misconception. The doctor replied, "Wean at one year, because the baby can take cow's milk then." But babies breastfeed for more than just nutrition, and mothers don't just nurse their babies out of obligation, but because they find it deeply fulfilling.

For many mothers, the question is not, "How long must I nurse for the health of my baby," but rather, "Is there any age at which continued nursing can be harmful in any way?" If there is not, then why can't the decision be left to the mother? Is there any evidence to support weaning at one year?

What Research Shows. Research shows that babies may benefit from nursing beyond one year. One benefit is nutrition. Research has shown that second-year milk is very similar to the first-year milk nutritionally (Victora, 1984). Even after two years or more it continues to be a valuable source of protein, fat, calcium, and vitamins (Jelliffe and Jelliffe, 1978).

A second benefit is immunity to disease. The immunities in breast milk have been shown to increase in concentration as the baby gets older and nurses less, so older babies still receive lots of immune factors (Goldman et al, 1983). A study from Bangladesh provides a dramatic demonstration of the effect these immunities can have. In this deprived environment, it was found that weaning children eighteen to thirty-six months old doubled their risk of death (Briend et al, 1988). This effect was attributed mostly to breast milk's immune factors, although nutrition was probably important as well. Of course in developed countries weaning is not a matter or life and death, but continued breastfeeding may mean fewer trips to the doctor's office.

A third health benefit is avoidance of allergies. It is well documented that the later that cow's milk and other common allergens are introduced into the diet of a baby, the less likelihood there is of allergic reactions (Savilahti, 1987).

Psychological Considerations. Any mother who has nursed an older baby knows the tenderness and feelings of closeness generated by nursing a little one who is old enough to talk about it. We don't need medical journals to tell us it's rewarding for mother and baby. But has anything been documented and published on these benefits?

One paper written by a female psychiatrist (Waletzky, 1979) recommends natural weaning. She refers to early forced weanings as emotionally traumatic for the baby and states that most weaning recommendations given by pediatricians are "based on personal feelings and prejudices and not medical documentation." In her words: "Suddenly and prematurely taking from a baby the most emotionally satisfying experience he his ever known could . . . lead to significant immediate and long-term distress.... Such an approach considers breastfeeding only as a source of milk and fails to understand its significance as a means of comfort, pleasure, and communication for both mother and baby." Well said! Yet Waletzky's paper is based on her impressions from her psychiatric practice, not on research.

Research reports on the psychological aspects of nursing are scarce. One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers' and teachers' ratings of social adjustment in six- to eight-year-old children (Ferguson et al, 1987). In the words of the researchers, "There are statistically significant tendencies for conduct disorder scores to decline with increasing duration of breastfeeding." The authors were cautious in their interpretation of the results, saying that they did not control for differences in mother-child interaction between breastfeeders and bottlefeeders, which could account for the differences they saw in later social adjustment. But it makes no real difference whether the improvement in later child behavior is due to breastfeeding per se, or the maternal behaviors that are typical of women who are open to nursing their babies for a year or more. The outcome is what matters; the children who nursed the longest were perceived later to be those with the best social adjustment. The link between duration of breastfeeding and social adjustment was stronger and more consistent when the children's behavior was rated by mothers rather than by teachers (although for both rating groups the association was significant), suggesting that mothers who breastfeed for longer periods may tend to view their children in a more positive light than mothers who do not.

I think most of us would agree that breastfeeding helps us to react to our children in a more positive way. It helps us to feel close and loving, which can be especially helpful in weathering the irrational demands and emotional upheavals of toddlers. No matter how tense I feel when I sit down to nurse my youngest child, almost invariably we both get up feeling relaxed and cheerful.

Cultural Attitudes. Do all doctors base their advice about weaning on the results of medical research? Apparently not, because there is no indication that nursing beyond one year has any negative effects, and there is ample evidence of its benefits. Then what is the basis of the often-heard "Wean at one year"?

There are probably several factors involved. One may be simply cultural expectations and, as Dr. Waletzky put it, "personal prejudice." Doctors are subject to trends in cultural thinking like everyone else. And the trend in parenting these days seems to be toward expecting precocious development and early independence in children. An emphasis on early weaning seems to fit in with the overall trend toward encouraging early independence. Ironically, early forced weaning may actually hinder emotional development and increase dependency needs, in the opinion of Dr. Waletzky and many others.

Another influence on attitudes toward weaning may be the hurried pace of our society. Unrestricted nursing is not thought to be compatible with modern lifestyles. Many articles on weaning include an implicit assumption that mothers want to quit breastfeeding as soon as they can without compromising their babies' nutrition.

Another factor may be that doctors, again like others, are subject to prejudices based on our culture's fascination with the breast as a sexual stimulus. A child who is old enough to talk may be considered too old to find physical comfort at his mother's breast.

The bottom line may be simply that it isn't common in our culture for women to nurse beyond one year, so most people assume that a mother will want to wean a baby who is more than one year old.

Medical Misconceptions. Some doctors may feel that nursing will in terfere with a child's appetite for other foods. Yet there has been no documentation that nursing children are more likely than weaned children to refuse supplementary foods. In fact, most researchers in Third World countries, where a malnourished toddler's appetite may be of critical importance, recommend continued nursing for even the severely malnourished (Briend et al, 1988; Rhode, 1988; Shattock and Stephens, 1975; Whitehead, 1985). Most suggest helping the malnourished older nursing child not by weaning but by supplementing the mother's diet to improve the nutritional quality of her milk (Ahn and MacLean. 1980; Jelliffe and Jelliffe, 1978) and by offering the child more varied and more palatable foods to improve his or her appetite (Rohde, 1988; Tangermann, 1988; Underwood, 1985).

How to Talk to Your Doctor. Because some doctors may feel that mothers regard nursing as a nuisance rather than as a pleasure, it is especially important for a mother to tell the doctor that she wants to continue breastfeeding. The doctor may assume that the mother's only considerations are the baby's nutrition and her own convenience if she doesn't explicitly state otherwise.

Confidently expressing your point of view is probably the best way to influence your doctor positively. For example, you might say, "Meg and I are really enjoying our nursing relationship. It seems to be good for her. She's a happy baby, and she's growing so well." Compare this to a less confident approach: "I'm not sure I should wean Meg yet. Nursing doesn't seem to be doing her any harm really. Do you think it's okay to continue?" Which approach is more likely to elicit a positive reply about continued nursing?

Not all doctors recommend weaning at one year. Those who do may learn something from mothers who communicate their enthusiasm for natural weaning. Many of us keep quiet about breastfeeding at the doctor's office to avoid unwanted advice, but if we were more vocal about our enjoyment of nursing older babies, perhaps we could change some attitudes in the medical community. It takes confidence and assertiveness to speak up, but knowing that research supports natural weaning helped me feel more confident that it is medically and emotionally sound.

REFERENCES

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