Abstract
For millennia, the word “breastfeeding” has meant feeding an infant at his/her own mother's breast. With the recent introduction of high-efficiency breast pumps, other possibilities are now widely used, including feeding an infant his/her own mother's milk from a cup or bottle. This milk may be recently pumped or stored for a short or long time. Infants also may be fed another mother's milk. As a result, the use of the term “breastfeeding” to describe these different behaviors now inhibits clear communication among and between healthcare providers, researchers, mothers, and members of the lay public. We propose a comprehensive set of terms to describe these and related behaviors. Adoption and consistent use of these terms would facilitate communication among all interested parties on the topic of maternal lactation and infant feeding.
Keywords: : breastfeeding, breast milk, milk expression, infant feeding
Introduction
Historically, the term “breastfeeding” described a simultaneous dyadic behavior: the mother feeding her infant at her breast. This is the meaning of “breastfeeding” that is assumed, for example, in the Innocenti Declaration,1 which describes a child's right to be breastfed, and in the World Health Organization's recommendations for the duration of “exclusive breastfeeding.”2 However, the meaning of the term “breastfeeding” is no longer clear because the development of affordable high-efficiency pumps and their widespread adoption by women provide the means for women to pump and store their milk that is separate from how and when their own infant is fed. Mother's milk is no longer provided just “at the breast,” but also in substantial quantities from a bottle or cup.3 This milk may have been stored in various ways and/or transported long or short distances.4,5 Moreover, a mother may stop lactating and have enough milk stored so that her child (or another child) can be fed this milk weeks to months later. In the United States, we use the term “breastfeeding” in our health recommendations,6,7 but we measure this behavior by assessing the child's intake of breasta milk, without regard to who produced it or whether it was obtained directly at the breast or from a spoon, cup, or bottle.8 More importantly, American women and their health professionals talk about “breastfeeding” in ways that may include a variety of ways of obtaining and consuming breast milk.
In fact, the term “breastfeeding” is now so ambiguous that it is impossible to discuss contemporary breast milk feeding behaviors using this word. We have diagrammed the multiple ways “breastfeeding” is practiced previously in this journal.9 The ambiguity about the meaning of “breastfeeding” is a problem for women when they talk to one another and for health professionals when they talk to women. It is also a problem for researchers as there is now no consistent and unambiguous way to study the determinants and consequences of the range of maternal behaviors related to obtaining and producing breast milk and infant behaviors related to consuming it. In this article, we illustrate these challenges with some published and unpublished quotations from our qualitative studies. We propose a comprehensive set of terms to facilitate communication about this topic and to permit the development of clear and effective recommendations for women's behaviors and clear and effective questions for use in research.
The Current Situation
To illustrate the challenges to the meaning of the term “breastfeeding,” we use quotations obtained from several of our recently completed qualitative studies in which women and health professionals described “breastfeeding.” In these examples, both women and health professionals used the word “breastfeeding” to include the behavior of feeding expressed breast milk.
One woman said, “I just had this fear, my fear is always to not be able, is not be able to breastfeed for a year. So I wanted to hang on to it [excess frozen milk] until I was getting close to her birthday so that I knew I was ok.” (Pilar)10 Another woman described pumping at work as “breastfeeding” in this quotation:
“I worked in small office at the time so there were only about 12 of us, 12 employees and I'd had 2 coworkers before me who had been breastfeeding moms while they had been at work um, and so the stage was sort of set a little bit. Like people expected it, I used the same shade as my coworker [while pumping] so they're like “oh, the shade's up, she's breastfeeding.” (Zoe)10
Health professionals also use “breastfeeding” interchangeably with feeding expressed breast milk, as in this example from a nurse who is also a lactation consultant:
“I have a lot more moms saying, we ask them: ‘how long do you plan on breastfeeding?’ ‘Well I have to go back to work, but I plan on giving them breast milk for at least up to 6 months.’ So, you know, they are going to be pumping at work, and leaving the breast milk at home, and that's considered breastfeeding obviously, getting the breast milk.” (10RNLC)12
Given that breast milk is now being fed in bottles in addition to at the breast, terminology on this subject is also important. Women may be confused or upset by the breast versus bottle choice offered by their healthcare providers, as in this example from a woman who was exclusively pumping to be able to bottle-feed her milk to her premature infant:
“I was always really annoyed at that question about the breastfed versus bottle-fed. And I would say it every time, and every time they would ask me…and I'm thinking, ‘I told you the last time I was annoyed at this question,’ like clearly this is a sensitive matter, why don't, why don't you switch this to ‘breast milk or formula?’” (Colette)10
Finally, even feeding shared expressed breast milk was considered “breastfeeding” by one respondent: “Like my friend … was motivated [to use shared milk] ‘cause she wanted to continue breastfeeding and she wanted her baby to be exclusively breastfed’.” (Olive)10
Proposal for Preferred Language
Given these challenges to clear communication around the feeding of breast milk to infants, we make several proposals for preferred language. The rationale for these proposed changes is summarized in Table 1. These proposals were developed from a detailed consideration of the many possible ways breast milk could be transferred to infants, as well as our experience in communicating the results of our own research studies to a wider audience. A detailed set of proposed terms that can be widely applied along with definitions of each proposed term is provided in Table 2.
Table 1.
Summary of Proposed Ways to Describe the Feeding of Breast Milk and the Rationale for Each
| Proposal | Rationale |
|---|---|
| Use the term “feeding at the breast” or “at-the-breast feeding” instead of “breastfeeding” | This approach distinguishes the dyadic behavior from other ways in which infants obtain breast milk. |
| Use the term “expressed” for breast milk that is removed from the breast by hand or pump before it is fed to the infant | Breast milk that has been in contact with another vessel (or vessels) has a different composition than milk that goes directly from the breast to the infant's mouth. This distinction is required to be able to study the determinants and consequences of this behavior for both the mother and the infant. Moreover, the term “expressed” covers both milk that is hand-expressed and milk that is removed from the breast with a pump. |
| Use the term “donated” to describe breast milk that is obtained from a milk bank | Breast milk that has been obtained from a nonprofit or for-profit milk bank, which has been screened for infectious agents and has been pasteurized; donations may contain breast milk from multiple women. |
| Use “shared” to describe breast milk that is obtained without cost from a mother other than an infant's own without having been screened and processed by a milk bank | Breast milk obtained from another mother may be fed at her breast or from a bottle and, in either case, represents a significant departure from the dyadic behavior of a mother providing breast milk for her own child. |
| Use the term “purchased” to describe breast milk that is obtained from a mother other than the infant's own in exchange for money or services and that has not been screened or processed by a milk bank | Obtaining milk from another mother represents a significant departure from the dyadic behavior of a mother providing breast milk for her own child. |
Table 2.
Proposed Terms for Description of Behaviors Related to Breast Milk Production and Its Consumption by the Recipient Infant
| Term | Perspective | Definition |
|---|---|---|
| Foods | ||
| Breast milk | Milk produced by human mammary glands | |
| Expressed breast milk | Milk expressed by hand or pump (manual or electric); such milk is, by necessity, placed in a receiving vessel and may be transferred to another vessel or stored before being fed to the recipient infant | |
| Behaviors | ||
| Main/general/primary behaviors | ||
| Feeding at the breast OR at-the-breast feeding | Both mother and infant | The dyadic behavior in which the infant obtains breast milk at his/her own mother's breast |
| Breast milk expression | Mother | The act of expressing breast milk either by hand or pump |
| Feeding expressed breast milk OR expressed breast milk feeding | Infant | Feeding breast milk that was expressed by hand or pump to the infant by spoon, sippy cup, or feeding bottle, with or without added infant formula or solid foods |
| Milk sharing behaviors | ||
| At the breast milk sharing or wet nursing | Mother | Feeding an infant other than one's own at the breast |
| Expressed breast milk sharing | Mother | Providing fresh or frozen expressed breast milk to another mother to feed to her child |
| Expressed breast milk donating | Mother | Providing expressed breast milk to a milk bank |
| Shared expressed breast milk feeding | Infant | Feeding an infant the expressed breast milk of a mother other than his/her own, purchased or obtained freely |
| Donated expressed breast milk feeding | Infant | Feeding an infant the expressed breast milk of a mother other than his/her own, obtained through a donor milk bank |
| Measurement of behaviors | ||
| Duration of feeding at the breast OR at-the-breast feeding | Both mother and infant | Period during which the infant receives any/all of his/her breast milk at the breast of his/her own mother or another mother |
| Duration of breast milk production (lactation) | Mother | Period during which a woman is producing milk regardless of whether it is removed by the infant or by expression by hand or pump |
| Duration of breast milk expression | Mother | Period during which a woman expresses her milk by hand or with a pump |
| Duration of exclusive breast milk feeding of own mother's milk AND | Infant | Period during which the infant receives only breast milk to the exclusion of other beverages or solid foods |
| Duration of exclusive breast milk feeding, including another mother's milk | ||
| Duration of breast milk feeding of own mother's milk AND | Infant | Period during which the infant receives breast milk, either from his/her own mother or another woman, regardless of other foods or beverages fed in addition |
| Duration of breast milk feeding, including another mother's milk | ||
| Proportion of expressed breast milk feeds | Infant | Proportion of expressed breast milk feeds among all breast milk feeds (regardless of the source of expressed breast milk) during a specified period |
| Duration of shared breast milk feeding | Infant | Period during which the infant receives milk from woman other than his/her own that has not been processed through a milk bank |
| Duration of donor breast milk feeding | Infant | Period during which the infant receives donated breast milk from a milk bank |
| Proportion of own mother's milk feeds | Infant | Proportion of feeds of infant's own mother's milk among all breast milk feeds during a specified period |
| Proportion of shared breast milk feeds AND | Infant | Proportion of shared or donor breast milk feeds among all breast milk feeds during a specified period |
| Proportion of donor milk feeds | ||
With these changes in how we describe breast milk feeding, it is now clearer that they describe separate behaviors by mothers and their infants. It is also clear that, as illustrated in Table 3, the questions included in the National Immunization Survey8 to provide national breastfeeding statistics cover a wide range of behaviors, some of which may not have the same implications for the health of the mother or infant as at-the-breast feeding.
Table 3.
National Breastfeeding Recommendations, the Questions Used to Monitor Progress Toward Meeting Targets, and the Potential Interpretations of These Questions
| Current recommendation | National Breastfeeding Report Card language11 | NIS question8 | Potential interpretations of the NIS question(s) |
|---|---|---|---|
| Initiate breastfeeding | “Ever breastfed” | Was (child) ever breastfed or fed breast milk? | Did your child ever, at any age, consume: |
| • Breast milk from his/her own mother's breast? | |||
| • His/her own mother's expressed breast milk from a tube, spoon, cup, or bottle, without ever having to consume breast milk from the breast? | |||
| • Breast milk at another mother's breast? | |||
| • Another mother's untested and unpasteurized expressed breast milk from a tube, spoon, cup, or bottle, without ever having to consume breast milk from the breast? | |||
| • Another mother's tested and pasteurized breast milk from a tube, spoon, cup, or bottle, without ever having to consume breast milk from the breast (breast milk from a milk bank)? | |||
| Breastfeed exclusively until the infant is 6 months old | “Exclusive breastfeeding at 6 months” | How old was (child's name) when (child's name) completely stopped breastfeeding or being fed breast milk? | When was the very last time your infant consumed: |
| And | • His/her own mother's breast milk—either at the breast or expressed breast milk—regardless of whether the infant's own mother is still producing breast milk (lactating)? | ||
| How old was (child's name) when (he/she) was first fed formula? | • Another mother's breast milk—either at the breast or expressed breast milk—regardless of whether the infant's own mother is still producing breast milk (lactating)? | ||
| And | AND | ||
| When was the first time your infant consumed: | |||
| This next question is about the first thing that (child) was given other than breast milk or formula. Please include juice, cow's milk, sugar water, baby food, or anything else that (child) may have been given, even water. How old was (child's name) when (he/she) was first fed anything other than breast milk or formula? | • Any liquid or solid other than breast milk? | ||
| Breastfeed in combination with complementary foods until the infant is at least 12 months olda | “Breastfeeding at 12 months” | How old was (child's name) when (child's name) completely stopped breastfeeding or being fed breast milk? | When was the very last time your infant consumed: |
| • His/her own mother's breast milk—either at the breast or expressed breast milk—regardless of whether the infant's own mother is still producing breast milk (lactating)? | |||
| • Another mother's breast milk—either at the breast or expressed breast milk—regardless of whether the infant's own mother is still producing breast milk (lactating)? |
Discussion
Our recent research10,12–15 revealed many instances in which health professionals, researchers, and the women they serve and study were not using a common language to describe how infants were being fed. In contrast, the terms that we propose would permit women who feed breast milk, their healthcare providers, and interested researchers to discuss and label behaviors less ambiguously. This could facilitate more functional conversations about these behaviors and the research needed to (1) distinguish the ways babies fed expressed breast milk differ from babies fed solely at the breast; (2) ascertain the extent, duration, and consequences of breast milk sharing; and (3) more clearly understand the relationships between mothers' milk production and outcomes for their own health and well-being.
To conduct research on the determinants and consequences of these various behaviors, we need clearly defined terms. For example, what we now describe as “breastfeeding duration” corresponds to “duration of breast milk feeding” and what we now describe as “exclusive breastfeeding duration” corresponds to “duration of exclusive breast milk feeding.” Both “breastfeeding” and “exclusive breastfeeding” now lack clear inference to feeding the infant at the breast, as well as to whose breast milk is fed to a specific infant.
In contrast, our proposed terms for these behaviors are explicit about what is being measured and during what period. We also offer definitions of terms related to the proportion of feeds that are expressed from his/her mother's own breast or shared by another mother, purchased from another mother, or obtained from a donor to a milk bank. This set of terms is not meant to convey that feeding at the breast is equivalent to feeding expressed breast milk from a cup or bottle, which is a subject of current research. These terms are instead meant to provide a set of tools, which the scientific community has not had until now, that can be used to study this question. These terms also provide a means to improve communication among and between healthcare providers, researchers, mothers, and members of the lay public.
Conclusions
The terms proposed in this study are more specific than those in current use. These terms are not intended to convey a value judgment about any of the behaviors described, but rather to provide an improved means of describing the wide variety of behaviors now encompassed by the word “breastfeeding.” These terms highlight the need for increased specificity in the terms used for national breastfeeding surveillance. Finally, these terms do not conflict with international recommendations and, in fact, provide a way for these recommendations to be made more specific should the organizations that make these recommendations choose to do so.
Disclosure Statement
No competing financial interests exist.
In women's conversations with one another and their clinicians, “breast” milk is the term most commonly used and is the term used in this study. In the lactation research community, however, the term “human” milk is preferred to distinguish the milk produced by women from that produced by other mammals (e.g., cow's milk or goat's milk).
References
- 1.Innocenti Declaration: On the protection, promotion and support of breastfeeding. Available at www.unicef.org/programme/breastfeeding/innocenti.htm (accessed May1, 2017)
- 2.World Health Organization. Infant and Young Child Nutrition: Global Strategy on Infant and Young Child Feeding. Geneva, Switzerland: World Health Organization, 2002 [Google Scholar]
- 3.Rasmussen KM, Geraghty SR. The quiet revolution: Breastfeeding transformed with the use of breast pumps. Am J Public Health 2011;101:1356–1359 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Geraghty SR. Photo album of pumped breastmilk. Breastfeed Med 2011;6:433–434 [DOI] [PubMed] [Google Scholar]
- 5.Geraghty SR, McNamara KA, Dillon CE, et al. Buying human milk via the internet: Just a click away. Breastfeed Med 2013;8:474–478 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Healthy People 2020, MICH-21. Available at www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives (accessed May2, 2017)
- 7.Johnston M, Landers S, Noble L, et al. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827–e841 [DOI] [PubMed] [Google Scholar]
- 8.NIS Survey Methods: Wording of the Breastfeeding Questions. Available at www.cdc.gov/breastfeeding/data/nis_data/survey_methods.htm#modalIdString_CDCTable_0 (accessed May2, 2017)
- 9.Felice JP, Rasmussen KM. Breasts, pumps and bottles, and unanswered questions. Breastfeed Med 2015;10:412–415 [DOI] [PubMed] [Google Scholar]
- 10.O'Sullivan E. Distinguishing Between Feeding Human Milk at the Breast and From a Bottle. Ithaca, NY: Cornell University, 2016 [Google Scholar]
- 11.Centers for Disease Control and Prevention. 2014. Breastfeeding Report Card. Available at www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf (accessed May1, 2017)
- 12.Garner CD. Obese Women's Experiences Breastfeeding and Health Professional's Experiences Providing Breastfeeding Care. Ithaca, NY: Cornell University, 2015 [Google Scholar]
- 13.Geraghty SR, Sucharew H, Rasmussen KM. Trends in breastfeeding: It is not only at the breast anymore. Matern Child Nutr 2013;9:180–187 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Felice JP, Geraghty SR, Quaglieri CW, et al. “Breastfeeding” but not at the breast: Mothers' descriptions of providing pumped human milk to their infants via other containers and caregivers. Matern Child Nutr 2017. [Epub ahead of print]; DOI: 10.1111/mcn.12425 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Felice JP, Geraghty SR, Quaglieri CW, et al. “Breastfeeding” without baby: A longitudinal, qualitative investigation of how mothers perceive, feel about, and practice human milk expression. Matern Child Nutr 2017. [Epub ahead of print]; DOI: 10.1111/mcn.12426 [DOI] [PMC free article] [PubMed] [Google Scholar]