When do breastfed children wean?
There are two ways infants stop breastfeeding: mother-led (planned) weaning and child-led (natural) weaning. Very rarely emergency (abrupt) weaning is necessary due to maternal death or significant illness which necessitates the use of the very few drugs which are contraindicated in breastfeeding. Weaning occurs once breastfeeding has been established and maintained for a period of time. Suppression is the process used when a mother chooses not to establish breastfeeding in the post-natal period. In the UK and other parts of the world, and in some scientific publications, weaning is also (confusingly!) used to describe the stage of introducing solids. In this article we are looking at the natural end of breastfeeding.
Throughout human history, child-led weaning has been practiced. In many traditional societies, this is still the approach. Sometimes mothers might nudge the child towards the end but weaning is considered to be a gradual reduction in seeking the breast which occurs over the early years of life. Rarely would weaning occur before the third or fourth year.
Western society has had some different approaches, most notably since the individual revolution began in the mid 18th century.
Family life changed dramatically for the working people in Europe, Britain and the United States, with young people and families moving away from farming villages into towns and cities, living in cramped housing and away from extended families. As women began working outside the home to support their family, babies spent long periods away from the breast, being fed unsuitable alternatives while cared for by the very old and the very young: the only family members not working in the mines, mills and factories. Less breastfeeding meant a quicker return to fertility. More babies meant more mouths to feed and more people living together in poor conditions. Infant mortality increased and traditional ways of caring for infants were lost to generations.
For the growing middle class, who owned the smaller businesses and ran the larger ones for the upper class, children represented growth and growth meant wealth. A large family of sons meant opportunities to expand, while daughters created opportunities to marry into families of higher social standing. Breastfeeding inconveniently suppressed fertility and reduced the number of potential children a woman could bear. Better to outsource lactation to wet-nurses and concieve the next child as swiftly as possible.
The upper class, aristocratic families living on the proceeds of inherited wealth, would also employ wet-nurses, however their goal was returning to the important social engagements which were crucial for any wife and mother looking to future marriages of welcome sons and slightly-less welcome daughters (who required significant dowries to marry into families of equal or better rank.)
In the early 20th century, the influence of formula feeding, introduced in the late 19th century, led to the decline of wet nursing. The business of feeding babies boomed as patent baby foods were marketed as safer and more nourishing than mother’s milk or dubious family foods. Purees and cereals were increasingly marketed for younger and younger babies - even, a one point, for babies not yet discharged from hospital! With a primary goal of selling as much product as possible, breastfeeding was undermined and when mothers did persevere, they were strictly admonished to wean from the breast completely by nine months: "nine months in, nine months out" was a meaningless recommendation without any scientific evidence.
By the 1970s, so prevalent was the marketing of infant formula and commercial baby foods, global action was required to protect parents from aggressive promotion. The 27th World Health Assembly in 1974 noted the general decline in breastfeeding related to different factors including the production of manufactured breast-milk substitutes and urged Member countries to review sales promotion activities on baby foods and to introduce appropriate remedial measures, including advertisement codes and legislation where necessary. In 1980, the World Health Organization and UNICEF declared "There should be an international code of marketing of infant formula and other products used as breast-milk substitutes". A year later, the new code was adopted.
WHO and UNICEF recommend that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first 6 months of life – meaning no other foods or liquids are provided, including water.
Infants should be breastfed on demand – that is as often as the child wants, day and night. No bottles, teats or pacifiers should be used.
From the age of 6 months, children should begin eating safe and adequate complementary foods while continuing to breastfeed for up to two years of age and beyond.
Unfortunately, the wording is often misinterpreted by parents and health professionals as meaning breastfeeding is not important beyond six months, when in fact the guidelines clearly state breastfeeding should continue for two years and beyond. The Australian Dietary Guidelines for Infants and Children further add confusion by recommending: “Continue breastfeeding while introducing appropriate solid foods until 12 months of age and beyond, for as long as the mother and child desire.”
The Australian guidelines imply breastfeeding in the second year is optional, while the Global guidelines clearly define breastfeeding as just as important for infants aged 12-24 months.
While the World Health Organization (WHO) recommends that women breastfeed their infants to 2 years and beyond, and despite the recognized benefits for infants and mothers, few Australian women contemplate breastfeeding to this age. For this reason, breastfeeding recommendations issued by relevant authorities in Australia and other high income countries such as the USA have modified the WHO guidelines and recommend a culturally more attainable goal that women breastfeed to 12 months and beyond. Even so, relatively few women in most high income countries achieve this recommendation, where on average the prevalence is lower than 20%. In Australia, the most recent data on breastfeeding practices come from the 2014–15 National Health Survey which reported that 27.5% of children aged 13−24 months were breastfed at 12 months.
Scott J, Ahwong E, Devenish G, Ha D, Do L. Determinants of Continued Breastfeeding at 12 and 24 Months: Results of an Australian Cohort Study. Int J Environ Res Public Health. 2019 Oct 18;16(20):3980. doi: 10.3390/ijerph16203980. PMID: 31635280; PMCID: PMC6843256.
It is worth noting here the Canadian guidelines recommend two years and beyond.
Breast milk is the best food for newborn babies. The Public Health Agency of Canada, Health Canada and the World Health Organization recommend: breast milk only for feeding your baby from birth to 6 months. continuing to breastfeed for up to 2 years or more after introducing solid foods.
https://www.canada.ca/en/public-health/services/health-promotion/childhood-adolescence/stages-childhood/infancy-birth-two-years/breastfeeding-infant-nutrition.html
This study found that just under one-third of Australian women breastfed to 12 months as recommended in the Australian Infant Feeding Guidelines and fewer than 1 in 10 breastfed to 24 months as recommended by the World Health Organization. While there are benefits to be gained from breastfeeding of any duration, the majority of Australian infants and their mothers are missing out on the additional benefits of continued breastfeeding. The majority of factors associated with the practice of continued breastfeeding are potentially modifiable and could be used to identify those women who might benefit from additional breastfeeding support from health professionals in the hospital, their family and partners at home, and from employers in the workplace.
Scott J, Ahwong E, Devenish G, Ha D, Do L. Determinants of Continued Breastfeeding at 12 and 24 Months: Results of an Australian Cohort Study. Int J Environ Res Public Health. 2019 Oct 18;16(20):3980. doi: 10.3390/ijerph16203980. PMID: 31635280; PMCID: PMC6843256.
The “world-wide average”
Ruth A. Lawerence published the first edition of her book Breastfeeding: A Guide for the Medical Profession in 1980. In the 1994 edition she stated:
“The average time of complete cessation [of breastfeeding] worldwide is 4.2 years.”
In her 2009 article, A Worldwide Average Age Of Weaning? American anthropologist and advocate of breastfeeding Katherine A. Dettwyler explained why this has proved problematic:
In order for 4.2 years to be the "true" average, there would have to be many many societies that nursed their children for an average of more than 4.2 years, in order to offset the many societies that nursed their children for an average of less than 4.2 years ‑‑ to balance out and come up with an average of 4.2. The ethnographic literature provides no documentation for any society where the average age of weaning is as long as five or six years, which would be necessary to balance out the many societies with averages less than four years. In the ethnographic literature there are many references to societies where individual children may be nursed that long, and even up to the age of 12 or 15 years, but the average in those societies is still between two and four years. There are also ethnographic references to cultures (or sub-cultures, in the United States) where children are allowed to nurse as long as they like, and individual children may nurse for 8‑10 years, but again, the vast majority of children in child-led weaning situations stop breastfeeding voluntarily between three and four years of age, so the average for those societies continues to be less than 4.2 years.
One notable breastfed toddler in the US grew up to be one of that countries greatest basketball players. His mother puts his success down to him breastfeeding for three years.
In her book Breastfeeding: Biocultural Perspectives (1995), Dettwyler considers what we can learn from our closest non-human comparative populations, our primate cousins:
My research has looked at the various "life-history" variables (such as length of gestation, birth weight, growth rate, age at sexual maturity, age at eruption of teeth, life span, etc.) in non-human primates and then looked at how these variables correlate with age at weaning in these animals. These are our closest relatives in the animal kingdom, especially gorillas and chimpanzees, who share more than 98% of their genes with humans. I came up with a number of predictions for when humans would "naturally" wean their children if they didn't have a lot of cultural rules about it.
The minimum predicted age for a natural age of weaning in humans is 2.5 years, with a maximum of 7.0 years.
Given there are demonstrated reasons for, and evidence supporting practice of, breastfeeding into at least the third year of life as typical human practice, why are the rates of reaching the global recommended minimum of two years so low?
The reality is, the primary support and focus on breastfeeding is that it be initiated at all and when it is, to minimise the exposure of those breastfed babies to infant formula and solid foods for the optimal period. The exclusive part of the recommendation , the first six months, is a struggle for many to reach. The reasons are two-fold:
The use of breastmilk substitutes to supplement breastfed babies
The premature introduction of solids which are often suggested as ‘suitable’ from 4 months and recommended from 4-6 months
Some parents are shocked to learn their baby is considered not to be exclusively breastfed, due the top-ups of formula given for a day or two in hospital or the fact their baby started solids before six months by the calendar. The problem here is the way data is gathered, the definitions used and the irregularity of how those definitions are applied. Terms like “ever breastfed” lump together the baby reluctantly put to the breast just once and the baby breastfed for two years in some studies, whereas the qualification of “exclusively breastfed” at six months will exclude both the baby who was supplemented with formula from Day one and the baby who started solids at 5 months and four days. Babies who are exclusively fed expressed breastmilk from birth are considered equal to babies who have received every drop of milk directly from the breast: the act of breastfeeding and the act of providing breastmilk are not separated in the name of research. And in a world of informal breastmilk sharing and the slow but upward trend to reestablishing breastmilk banks - we need data on babies who have received donated breastmilk compared to those who are supplemented with infant formula.
Who weans when?
Different cultures around the world have long-held beliefs around breastfeeding.
Muslim families closely following the Quran will breastfeed their child for at least two years and - depending on which guidance the family chooses to follow - as long as seven years. However, Muslim women living modern Westernised lifestyles face many of the same barriers to breastfeeding and most wean well before this age.
According to Jewish traditions, weaning could take place anywhere between 18 months and 5 years of age. However, once again, modern life is very different to Biblical times and Jewish mothers may not reach such expectations.
Mongolian mothers traditionally breastfeed their infants beyond the first year, with a 2005 study by UNICEF showing 82 percent of children in Mongolia continued to breastfeed at 12 to 15 months, and 65 percent were still doing so at 20 to 23 months. Anecdotally, adults will boast of how many years they were breastfed and it is said the best wrestlers fed at the breast for at least six years!
The average age of weaning in Bangladesh is 33 months (2 years and 9 months). And that is not a minority practice: 95 percent of one-year-olds are still being breastfed, as are 91 percent of two-year-olds.
Traditionally, an Inuit child would usually be weaned when the mother became pregnant with her next child. On average this was 3 years but it was not uncommon to have children as old as five years still being breastfed.
In many traditional cultures around the world, breastfeeding one child ends with the conception of the next. The right of the infant to breastmilk is so highly valued in some societies that any risk of pregnancy is prevented by taboo around having intercourse with a woman who is breastfeeding. One example is the Tarok in Plateau State of Nigeria. Women are expected to breastfeed their babies without reservation for a minimum of one to two years as breast milk is generally believed to be nourishing and essential to child survival. However, it is forbidden for men to have sex with a breastfeeding woman. The man, however, can freely have intercourse with his other - non-lactating - wives. Managed carefully, he can have many children, each breastfed as long as expected.
What we know about continued breastfeeding today
Data on breastfeeding rates beyond the first year have not always been collected, making it hard to track trends over time. This is changing, with studies increasingly asking parents directly about breastfeeding at one year (12-15 months) and two years (20-23 months). Global data is broken down into World Health Organization Regions.
In this study published in 2021, continued breastfeeding rates globally at one year were 83.1% and two years were 56.2
By Region, the rates at one year and two years were:
African 87.2% and 50.7 %
Americas 70.4% and 40.6%
Eastern Mediterranean 72.2% and 38.7%
European 66% and 34.8%
South-East Asia/Western Pacific 84.8% and 69.3%
However, if we were to look at this broken down further by country, the differences in breastfeeding culture and support for breastfeeding families becomes very evident: after all, every woman and baby born without underlying physical barriers to breastfeeding should have a level playing field - which they clearly do not. Proactive measures at government and community level have seen breastfeeding rates steadily increase in Brazil, while mothers in the US continue to have some of the lowest rates in the world. But it is the UK where we see the very poorest statistics of all:
Only 1 in 200 UK women do any breastfeeding after a year . That’s 0.5%
Conclusion
Breastfeeding is a relationship. A child knows nothing of weaning and mother-led weaning can come as a great shock. To a woman there is a time before breastfeeding, a time of breastfeeding and a time after breastfeeding. She has an awareness her child cannot comprehend. Wherever possible, the ideal is a child continue to breastfeed until they don’t. Weaning isn’t an event but a transition and when occurring naturally, is both an end to infancy and the beginning of childhood. The only other person who has any say in the length of breastfeeding is the mother. But modern society has introduced new barriers to natural-term breastfeeding. Advanced Matenal Age (previously called Geriatric Pregnancy!) refers to women aged 35 and beyond, yet the average age of first time mothers in Australia is now 32. As many as 1 in 6 births are facilitated by Assisted Reproductive Technology. In 2020 the average birth rate in Australia was the lowest ever recorded, just 1.59 per woman.
Woman are under pressure to have their one or two babies (three is now considered a large family), with minimal disruption of their career, in the shortening window of opportunity of fertility. Breastfeeding a first child to natural term can become a choice between delaying conception of the second or the non-guaranteed progress into breastfeeding during pregnancy and possibly tandem feeding. Many assisted reproduction facilitators require weaning before treatments can commence, despite evidence this is not always necessary. Those parents who have set a personal goal of meeting the World Health Organization’s recommended two years and beyond can be conflicted between prematurely weaning the baby they have so they can potentially conceive the baby they might have within the time left to them. Options available at 30, 35 or 40 can look very different.
