Exploring and Influencing the Knowledge and Attitudes of Health Professionals Towards Extended Breastfeeding

Abstract

Background:

Although many U.S. professional health organizations have policy statements that support the breastfeeding of children beyond one year (extended breastfeeding), the actual attitudes of health workers towards this practice have not been explored. The purposes of this study were (1) to explore the knowledge and attitudes of various U.S. health professionals towards extended nursing and (2) to pilot an educational display for U.S. health professionals to promote their knowledge and attitudes towards extended breastfeeding.

Methods:

A total of 84 participants in a New York City academic medical center provided responses to a structured self-administered questionnaire given before and after an educational display.

Results:

Respondents reported negative attitudes towards extended breastfeeding at baseline, with negative attitudes increasing as the age of the breastfed child increased. After education, the percentage of participants who found breastfeeding acceptable for 1- or 2-year-old children increased from 61% to 89% (p < 0.001). Acceptability of 3- or 4-year-old children breastfeeding increased from 22% to 41% (p < 0.001).

Conclusions:

Viewing educational media concerning older nursing children may lead to more positive attitudes towards extended breastfeeding among healthcare professionals.

Introduction

Extensive research has shown the benefits of breastfeeding (also called “nursing”). This research has revealed that breastfeeding can reduce the risk of otitis media, respiratory infections, specific types of cancer in mother and child, and other adverse health outcomes.^1,2 The findings of these investigations have proven valuable, but the majority of them have been limited in scope to children under 1 year of age, so that some believe that breastfeeding is valuable only during infancy. However, the benefits of breastfeeding may not cease once a child turns 1 year of age. Nursing beyond the first year can be termed “extended,” “long-term,” or “prolonged” breastfeeding.

Research specifically targeting long-term breastfeeding has been minimal, especially in the developed world, and more exploration is warranted. However, results from the existing studies have resulted in the World Health Organization recommending that globally infants should be exclusively breastfed for the first 6 months of life and thereafter should receive complementary foods while breastfeeding continues for up to 2 years of age or longer.³ It has been established that a breastfeeding toddler can receive approximately one-third of his or her daily calorie and protein requirements from breastmilk, as well as significant amounts of vitamins and minerals.⁴ Additionally, longer durations of breastfeeding may be associated with increased immunity,^5,6 decreased risk for childhood obesity,⁷ and decreased risk for type 2 diabetes.⁸ Longer durations of breastfeeding may also be associated with a reduced risk of premenopausal breast cancer⁹ and type 2 diabetes for mothers.¹⁰ Many cultures support breastfeeding into the third year of life or beyond,¹¹ and anthropologists suggest that the biological age for human weaning is anywhere between 2.5 and 7 years of age.¹² According to the United Nations Children's Fund, it is estimated that 49% of children worldwide are breastfed beyond the first year (to 23 months).¹³ Centers for Disease Control and Prevention data suggest that only 8% of American children are breastfed beyond the first year (to 18 months).¹⁴ This comparatively low rate of prolonged breastfeeding may indicate that long-term nursing is a less culturally acceptable practice in the United States.

Several professional American health organizations have statements that support extended breastfeeding (including the American Academy of Pediatrics [AAP],² the American Association of Family Physicians,¹⁵ the American Dietetic Association,¹⁶ the National Association of Pediatric Nurse Practitioners,¹⁷ and the American Public Health Association¹⁸). The AAP has also stated that there is no upper limit to breastfeeding duration and no evidence of psychological or developmental harm when breastfeeding is continued to 3 years of age or longer.² Yet, even in light of these statements, some health professionals may be allowing culturally based expectations to guide their opinions regarding long-term nursing.^19,20 Indeed, mothers who practice extended nursing rate the reduction in social approval as the most significant disadvantage to their breastfeeding experience, with the percentage of women experiencing social stigma increasing as the age of the child increases.²⁰ And, although social stigma from the general public is perhaps more understandable (approximately 33% of the U.S. adult population agree with the statement, “One year old children should not be breastfed by their mothers”²¹), stigmatization from a healthcare professional may have weightier consequences. Lack of understanding from a healthcare provider may harm the patient–provider relationship by inhibiting openness, thus limiting a healthcare professional's ability to offer the best advice/practice to a patient. Healthcare professionals should be adequately informed about the potential benefits, barriers, recommendations, and problems associated with extended breastfeeding in order to provide anticipatory guidance and the best care to families.^15,19,22,23 This knowledge may not be widespread, however.

In a survey of practicing pediatricians, only 66% reported making recommendations that were in line with the AAP recommendation that breastfeeding should occur until at least 1 year.²⁴ In another survey of both pediatric residents and pediatric practitioners, 53% of residents and 73% of practitioners reported that they received “no” or “less than adequate” preparation to support breastfeeding mothers during their residency training.²⁵ Additionally, nearly half (49%) of the surveyed pediatricians reported being called upon to provide breastfeeding support more often than they had anticipated at the end of their residency programs.²⁵ Considering that approximately one out of every 13 U.S. children engage in extended breastfeeding,¹⁴ a significant portion of children may not be receiving the best care possible from their healthcare provider.¹⁹ What is more, the promotion of extended breastfeeding to likely families (perhaps families that have nursed to at least 9 months) may be an effective means to reduce rates of childhood obesity, type 2 diabetes, and premenopausal breast cancer.^7–10

Several investigations have examined the attitude and knowledge levels of health professionals concerning infant breastfeeding (Williams and Hammer²⁶ and Hellings and Howe,²⁷ to name a few); however, to the best of our knowledge, no study has extensively assessed the knowledge and attitudes of healthcare professionals regarding extended breastfeeding. Researchers and professional organizations alike have suggested the use of media images to help normalize breastfeeding, including extended breastfeeding.^2,23 Historically, photography has been used extensively to effect change regarding public perceptions: Franklin Delano Roosevelt utilized it during the Great Depression to mobilize public opinion in support of poor rural farmers. (Dorothea Lange's Migrant Mother was one photograph that was highly successful in accomplishing this task).²⁸ One of the hallmarks of public health is the collaborative use of multiple disciplines.²⁹ For the social normalization of long-term breastfeeding, a combination of photography and scientific literature may prove effective, as one study²³ has suggested:

Societal attitudes are likely to become more favorable as the act of breastfeeding older infants and toddlers becomes more visible. An important strategy might be greater inclusion of media images of older infants and toddlers in breastfeeding promotional materials. It may also help to more widely publicize the recommendations of professional organizations regarding breastfeeding for a year or longer and the evidence which these recommendations are based (p. 316).

Therefore, the purpose of this study was (1) to examine the knowledge and attitudes of healthcare professionals concerning extended nursing and (2) to pilot an educational display for U.S. health professionals to promote their knowledge and attitudes towards extended breastfeeding.

Subjects and Methods

The Institutional Review Board of the State University of New York Downstate Medical Center (Brooklyn, NY) reviewed and approved the study protocol. A convenience sample of individuals present in a New York City academic medical center on a single day between the hours of 11 a.m. and 8:00 p.m. was used for this study. All research participants were recruited via flyers, e-mail announcements, and word of mouth. Respondents participated voluntarily and completed all survey instruments anonymously. Individuals were required to be at least 18 years of age, as well as a current or future member of a health-related profession to participate (i.e., physician, midwife, medical resident, nursing student, public health student, etc.). Non–health-related professionals/students were excluded from the study. Research participants were given an Information Sheet, which explained the purpose and format of the study, as well as any potential risks or benefits and other options besides participation. Implied consent was given by participant completion of the study questionnaires.

Photographs from the private collection of the lead researcher (L.C.-C.) were used as part of the educational display. Prior to this study, as a photographer and artist, she had photographed over 50 volunteer families who engaged in extended breastfeeding. The appropriate photography consent/release forms were signed by all participants on behalf of themselves and their children. Twenty-two photographs from the collection were used for the pilot (for examples, see Figs. 1 and 2). The photographs, along with extended breastfeeding facts and quotes from scientific journal articles, textbooks, and lay literature, were displayed within a controlled area. Twenty-two topics were covered, including child-led weaning, professional recommendations, health benefits for mother and child, social stigma, extended breastfeeding in other cultures/societies, anticipatory guidance suggestions, and others. As an example, under the topic of nutritional benefits, viewers were informed that breastmilk can provide a 23-month-old child with 75% of his or her daily vitamin A needs, 94% of the daily vitamin B12 needs, and 76% of the daily folate needs.⁴ All facts and assertions were readily cited.

FIG. 1.

Photograph from the educational display. Breastfeeding child, 33 months old. © Lauren Cockerham-Colas.

FIG. 2.

Photograph from the educational display. Breastfeeding child, 28 months old. © Lauren Cockerham-Colas.

Two identical survey instruments, a Pre-Survey and a Post-Survey, were used to assess knowledge and attitude levels regarding extended breastfeeding. Questions on the Pre- and Post-Surveys were identical, with the exception of four additional questions on the Post-Survey requesting feedback on the exhibit. The final survey instrument contained a total of five knowledge assessment questions and 20 attitude assessment questions. The attitude assessment questions were hypothesized to measure eight different attitudes towards extended breastfeeding: perceptions of normalcy, acceptability of the practice, feelings of embarrassment regarding extended breastfeeding, perceptions on how long-term breastfeeding affects a child's and/or mother's physical health, perceptions on how long-term breastfeeding affects a child's and/or mother's psychological health, and anticipated actions one would take concerning encouragement to wean. The knowledge assessment questions were formulated to gauge the knowledge of common facts pertaining to long-term breastfeeding. Attitude assessment questions used a 5-point Likert scale format for responses, whereas knowledge question response options were either true–false or multiple choice. The survey questions were developed by the researchers following review of existing breastfeeding literature. In order to confirm content and face validity, the survey was reviewed by a pediatrician and a behavioral scientist possessing expertise in the domain of attitude formation and change. Their feedback concerning content and clarity were considered and incorporated into the final survey instrument.

At the start of the study, each participant received a Pre-Survey, a Post-Survey, and an Information Sheet. To ensure confidentiality and protect anonymity, questionnaires were precoded with unique identification numbers that also allowed for pairing between Pre- and Post-Surveys. The Post-Survey was sealed within an envelope, and the participant was asked not to open and complete it until after viewing the educational display. Prior to viewing the display, the participant was asked to complete the Pre-Survey and then placed it within a manila envelope held by a researcher. Following submission of the Pre-Survey, participants were allowed to view the exhibit. Viewing of the exhibit took between 5 and 20 minutes. After viewing the display, subjects were asked to open their sealed envelope and complete the enclosed Post-Survey. Completion of each survey took approximately 5 minutes.

To examine the relationship between select characteristics of the study population and breastfeeding attitudes using before-questionnaire responses, χ² tests were performed. The efficacy of the pilot display was evaluated by performing paired t tests between before–after questionnaire responses for each participant. All analyses were performed using the statistical software package SPSS version 17.0 (SPSS, Inc., Chicago, IL), with statistical significance set at a two-sided α level of 0.05.

Results

The convenience sample consisted of nurses, physicians, midwives, medical students, medical residents, public health students, and other professionals/students in health-related fields (i.e., occupational therapy students, administrators, etc.) (Table 1). A total of 91 subjects completed various portions of the Pre-Survey. Post-Survey responses ranged anywhere between 81 to 84 subjects, depending on the question asked.

Table 1.

Distribution of Selected Characteristics of Study Population

Population characteristic	Number (%)
Sex (n = 81)
Male	21 (25.9%)
Female	60 (74.1%)
Age (n = 85)
20–29 years	43 (50.6%)
30–49 years	28 (32.9%)
>50 years	14 (16.5%)
Occupation (n = 89)
Nurse	8 (9.0%)
Physician	3 (3.4%)
Midwife	4 (4.5%)
Medical resident	3 (3.4%)
Medical student	21 (23.6%)
Midwifery student	1 (1.1%)
Nursing student	3 (3.4%)
Public health student	18 (20.2%)
Other^a	23 (25.8%)
Multiple degrees^b	5 (5.6%)
Parent (n = 81)
No	54 (66.7%)
Yes	27 (33.3%)
Of parents, were children breastfed? (n = 25)
No	2 (8.0%)
Yes	23 (92.0%)
At the job where I work I notice female patients breastfeeding their children (n = 82)
Never	32 (39.0%)
Sometimes	20 (24.4%)
Often	7 (8.5%)
Very often	5 (6.1%)
Not applicable	18 (22.0%)
In the community where I live I notice women breastfeeding their children (n = 82)
Never	25 (30.5%)
Sometimes	43 (52.4%)
Often	8 (9.8%)
Very often	6 (7.3%)

“Other” includes occupational therapy student (n = 3), faculty (n = 3), administrator (n = 2), occupational therapist (n = 2), data analyst (n = 1), informatics (n = 1), staff (n = 1), physician assistant student (n = 1), premed (n = 1), medical school applicant (n = 1), postdoc (n = 1), project manager (n = 1), public relations (n = 1), graduate student (n = 1), student (n = 1), and undisclosed (n = 2).

“Multiple degrees” includes midwifery student/nurse (n = 1), professor/nurse (n = 1), professor/public health student (n = 1), research associate/public health student (n = 1), and medical resident/public health student (n = 1).

In general, baseline attitudes towards extended breastfeeding were negative among healthcare professionals (see the “Pre” categories in Table 2). Only 22.3% thought that it was acceptable for 3- or 4-year-old children to be breastfed by their mother, and 64.5% responded that they would encourage a woman breastfeeding her 3- or 4-year-old child to wean. Negative attitudes towards extended breastfeeding increased as the age of the child increased: 60.5% thought that it was acceptable for a 1- or 2-year-old child to breastfeed, but only 11.4% thought that it was acceptable for a child over 4 years of age to breastfeed.

Table 2.

Pre- and Post-Intervention Responses for Attitude Questions and Paired t Test Results

		Disagree		Neither agree nor disagree		Agree
Statement	n ^*	Pre	Post	Pre	Post	Pre	Post	Paired t test p value
1. I think that breastfeeding a child beyond 1 year of age is normal.	90	26.6%	9.5%	15.6%	14.3%	57.8%	76.2%	< 0.001
2. I think that it is acceptable for 6-month-old infants to be breastfed by their mothers.	91	3.3%	0%	3.3%	0%	93.4%	100%	0.055
3. I think that it is acceptable for 1- or 2-year-old children to be breastfed by their mothers.	91	18.7%	4.9%	20.9%	6.1%	60.5%	89.1%	< 0.001
4. I think that it is acceptable for 3- or 4-year-old children to be breastfed by their mothers.	90	54.4%	25.0%	23.3%	34.5%	22.3%	40.5%	< 0.001
5. I think that it is acceptable for children older than 4 years of age to be breastfed by their mothers.	79	67.1%	39.7%	21.5%	32.5%	11.4%	27.7%	< 0.001
6. I would be embarrassed if a mother breastfed her infant (less than 1 year of age) in front of me.	91	97.8%	95.2%	1.1%	0%	1.1%	4.8%	0.003
7. I would be embarrassed if a mother breastfed her 1- or 2-year-old child in front of me.	91	70.4%	81.0%	14.3%	7.1%	15.4%	11.9%	0.018
8. I would be embarrassed if a mother breastfed her child of 3 years or older in front of me.	91	45.1%	58.4%	18.7%	19.0%	36.3%	22.6%	< 0.001
9. I would encourage a woman breastfeeding her 6-month-old infant to wean.	82	79.3%	86.7%	14.6%	3.6%	6.1%	9.7%	0.401
10. I would encourage a woman breastfeeding her 1- or 2-year-old child to wean.	82	30.5%	66.7%	34.1%	16.7%	35.3%	16.7%	< 0.001
11. I would encourage a woman breastfeeding her 3- or 4-year-old child to wean.	90	21.2%	32.1%	22.2%	34.5%	64.5%	33.4%	< 0.001
12. I would encourage a woman breastfeeding a child older than 4 years of age to wean.	91	16.5%	29.7%	13.2%	27.4%	70.4%	42.8%	< 0.001
13. In general, I think breastfeeding a 1- or 2-year-old child would benefit a child's physical health.	89	15.7%	6.0%	29.2%	11.9%	55.1%	82.1%	0.001
14. In general, I think breastfeeding a child of 3 years or older would benefit a child's physical health.	82	43.9%	11.9%	37.8%	41.7%	18.3%	46.5%	0.001
15. In general, I think breastfeeding a 1- or 2-year-old child could cause psychological harm to the child.	90	70%	81.9%	24.4%	14.5%	5.5%	3.6%	0.012
16. In general, I think breastfeeding a child of 3 years or older could cause psychological harm to the child.	91	39.6%	66.3%	25.3%	18.1%	35.2%	15.6%	0.001
17. In general, I think breastfeeding a 1- or 2-year-old child would benefit a mother's physical health.	91	23.1%	7.2%	45.1%	23.8%	31.9%	69.0%	0.001
18. In general, I think breastfeeding a child of 3 years or older would benefit a mother's physical health.	81	44.4%	17.9%	39.5%	40.5%	16.1%	41.6%	0.001
19. In general, I think breastfeeding a 1-or 2-year-old child could cause psychological harm to the mother.	82	71.9%	89.5%	23.2%	6.0%	4.9%	3.6%	0.024
20. In general, I think breastfeeding a child of 3 years or older could cause psychological harm to the mother.	91	48.4%	71.1%	36.3%	20.5%	15.4%	8.4%	< 0.001

On the surveys, respondents had the choice of strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree. Here, “strongly disagree” and “disagree” were combined to become “disagree.” “Strongly agree” and “agree” were combined to become “agree.”’ The “neither agree nor disagree” category was not modified.

n is the number respondents who answered on the Pre-Survey.

The pilot display significantly improved attitude and knowledge levels regarding extended breastfeeding across virtually all variables (the exception being questions that pertained to breastfeeding 6-month-old infants). Attitudes towards acceptability of breastfeeding 1- or 2-year-old children increased from approximately 60% to 89% (t₈₁ = –6.313, p < 0.001), and respondents who would encourage the weaning of children 4 years and older decreased from 70% to 43% (t₈₃ = 4.309, p < 0.001). Participant attitudes towards the benefits of breastfeeding also improved: The percentage who agreed that breastfeeding a child 3 years of age or older would benefit the child's physical health increased from 18.3% to 46.5% (t₇₆ = –6.918, p < 0.001). Regarding knowledge levels, only 16% at baseline correctly answered that approximately half of the world's children are breastfed beyond 1 year; however, after viewing the exhibit, 61% answered this question correctly (t₇₆ = –7.958, p < 0.001). Results for the remaining variables can be found in Tables 2 and 3.

Table 3.

Pre- and Post-Intervention Responses for Knowledge Questions and Paired t Test Results

		Percentage selecting correct answer
Statement	n ^*	Pre	Post	Paired t test p value
Professional health organizations in my field recommend that breastfeeding stop once a child turns 1 year. (Options: true/false/don't know. Correct answer: False)	81	30.9%	58.3%	< 0.001
In general, should a woman who becomes pregnant stop breastfeeding her older child? (Options: yes/no/don't know. Correct answer: No)	81	38.3%	77.1%	< 0.001
Rates of premenopausal breast cancer are ___ in women who breastfeed beyond 1 year of age. (Options: higher/lower/unchanged. Correct answer: Lower)	81	64.2%	86.1%	< 0.001
Approximately what percentage of children in the United States is breastfed beyond 1 year? (Options: 2%, 8%, 23%, 37%, 49%. Correct answer: 8%)	82	17.1%	66.7%	< 0.001
Approximately what percentage of children worldwide is breastfed beyond 1 year? (Options: 2%, 8%, 23%, 37%, 49%. Correct answer: 49%)	82	15.9%	61.4%	< 0.001

n is the number respondents who answered on the Pre-Survey.

Statistically significant differences were found between parents and non-parents: 81.5% of non-parents agreed that they would encourage the weaning of a child older than 4 years, in comparison with only 48.1% of parents [χ²(2) = 9.61, p = 0.008]. Parents were more likely than non-parents (77.8% vs. 48.1%) [χ²(2) = 6.496, p = 0.039] to agree that “breastfeeding beyond 1 year of age is normal.” Additionally, parents were more likely than non-parents to agree with the statement, “I think that it is acceptable for 3- or 4-year-old children to be breastfed by their mothers” (46.2% vs. 13.0%) [χ²(2) = 11.125, p = 0.004]. Among the variables examined, there were no differences in responses between age groups, between men and women, or among the different occupations (even when the occupations were regrouped into various forms).

Discussion

Our investigation into the attitudes of healthcare professionals towards long-term breastfeeding reveals that, in general, attitudes are quite negative, with negative attitudes increasing as the age of the child increases. In particular, there was a pronounced decline in support for breastfeeding that occurred between the 1- and 2-year-old age category and the 3-year-old and older categories, prior to intervention. For example, the number of health professionals who stated that they would encourage weaning rose from 35% in the 1- or 2-year-old category to 65% in the 3- or 4-year-old category, and those agreeing that breastfeeding would benefit a child's physical health diminished from 55% in the 1- or 2-year-old category to 18% in the 3-year-old or older category. This pattern held true across nearly every variable assessed, whether it was levels of embarrassment, acceptability, encouragement to wean, benefits to a child's physical health, or harm to a child's psychological health. With each category there was a fall in support of at least 25%. Perhaps this significant decline in support occurring between the 1- or 2-year-old age category and the 3-year-old or older category was due to a misinterpretation of the AAP and/or World Health Organization breastfeeding statements—individuals may believe that the 1-year and 2-year recommendation, respectively, are maximums, and therefore their support for breastfeeding beyond these ages was unlikely. There may also be culturally biased expectations in regard to child development at work. It should be noted that this ebb in support continued, although not as prominently, each time the child's age increased, indicating a decreased affinity towards the idea of breastfeeding increasingly older children. This observation is consistent with the findings of Kendall-Tackett and Sugarman,²⁰ who found that the percentage of women experiencing social stigma increased as the age of the breastfeeding child increased (their study examined the social consequences of breastfeeding among 179 women who had breastfed beyond the age of 6 months—the average age of weaning in their study population ranged from 2.5 to 3 years). It also appears to validate the anecdotal stories shared by numerous long-term breastfeeding mothers who stated that they received negative feedback and encouragement to wean from healthcare providers.^19,30

The non-parents in our study were more likely than the parents to hold unfavorable attitudes towards extended breastfeeding (only 48% of non-parents vs. 78% of parents agreed with the statement, “I think that breastfeeding a child beyond 1 year of age is normal”). Perhaps the greater acceptability among parents is due to their personal experience with breastfeeding and a potentially increased likelihood of having seen older breastfeeding children. Parents may also have a heightened awareness and acceptance of a child's developmental stages gained from their first-hand experience. Previous studies among healthcare professionals have produced inconsistent results in regard to breastfeeding attitudes among parents: Williams & Hammer²⁶ found no difference in attitudes towards breastfeeding between parent and non-parent pediatricians-in-training, whereas Ingram³¹ found primary care health professional parents to have more positive attitudes towards breastfeeding than the non-parents. In addition, it also appears that most health professionals are fairly comfortable with women breastfeeding in front of them, as 70% of those surveyed stated that they would not be embarrassed to see a 1- or 2-year-old child breastfeed. Although the percentage notably decreases for children older than 3 years, the numbers still remain somewhat high (45%), which is encouraging.

Based on the question concerning weaning during pregnancy, it appears that the initial knowledge level of our population may have been lower than that of another healthcare professional population. Brodribb et al.³² posed to a group of Australian general practitioners-in-training a similar knowledge question regarding pregnancy and weaning; a significantly higher percentage of their study population responded correctly in comparison to our study population (56% vs. 39%). This discrepancy in knowledge that was observed is likely due to their population being solely composed of doctors (and the corresponding high level of medical training that they received) and our population being composed of students and professionals in varied health-related professions (and their varied levels of health training). The discrepancy may also be attributable to cultural differences between the United States and Australia.

Our study reveals that the attitudes of health professionals towards extended breastfeeding are generally negative, but it also indicates those attitudes can become more positive by viewing images of older nursing children along with cited quotes and facts pertaining to the practice. Attitudes regarding perceptions of normalcy, acceptability, physical health, weaning, psychological health, and feelings of embarrassment were all improved significantly by viewing our combination of photographs and texts. Knowledge levels concerning extended breastfeeding also increased significantly through viewing our pilot. Hence, although the existing attitude and knowledge levels of those in health-related professions appear to be negative, there is hope for significant improvement through the use of educational materials. It should be noted, however, that there was one area that our exhibit failed to influence: the incremental rise in disapproval that occurred as a child's age increased. Post-intervention, only 28% of respondents found it acceptable for children older than 4 years to breastfeed, in comparison to 41% of respondents for children 3 or 4 years old, 89% of respondents for children 1 or 2 years old, and 100% of respondents for children 6 months old. This seems to indicate that the cultural beliefs that oppose breastfeeding an increasingly older child are very strong and are likely to continue without intervention. The few studies that have looked at extended breastfeeding attitudes have consistently revealed increased discomfort with breastfeeding increasingly older children. Williams and Hammer²⁶ found that pediatricians-in-training were more likely to be embarrassed if a mother breastfed her toddler in front of them than if a mother breastfed her infant in front of them. Libbus and Bullock³³ found the same trend regarding embarrassment among employers. Our study also confirmed this trend regarding embarrassment. Perhaps only when breastfeeding older children becomes more visible and commonplace in our society will we see this tendency begin to change. In looking at the opposite end of the spectrum, it was interesting to observe the moderate (although not statistically significant) impact that the educational display had in shifting attitudes favorably towards breastfeeding 6-month-old babies. It may very well be that in the general population, increasing awareness of long-term breastfeeding can inadvertently promote and improve societal acceptance of nursing infants. This is a possibility that is worthy of future research.

There were several limitations to this study—namely, the small sample size, the use of a convenience sample, the high number of students, and the high number of participants in “other” health-related fields. (It is interesting that our analysis found no difference in responses when we compared professionals and students. We also found no difference in responses between the “others” group, who may have had limited health training [i.e., data analyst, informatics, project manager, etc.], and the groups who likely had extensive health training [i.e., nurses, medical residents, public health students, etc.].) Because of these limitations, the findings in this study should not necessarily be extrapolated to represent the attitude and knowledge levels of all U.S. healthcare professionals. Additionally, there were only a limited number of actual physicians (including pediatricians) who participated in the study, so the attitudes demonstrated in our study population may be different from those possessed by professionals whose sole work is with children. As our study did not include follow-up, we do not know if the shift towards more positive breastfeeding attitudes will remain over time if not reinforced. Future research should include follow-up assessments to gauge if post-intervention positive breastfeeding attitudes persist or return to baseline.

In light of these limitations, our study still provides some enlightening, albeit preliminary, insight into the breastfeeding attitudes possessed by current and future U.S. health workers. Future research should be targeted to gauge the attitudes of pediatricians specifically, towards extended breastfeeding, as this is the group that would be most likely to encounter nursing children over the age of 1 year. Additionally, future research should examine the attitude and knowledge levels of the general American society to gain a better understanding of how they feel towards this practice. To our knowledge, this is the first published study that has attempted to extensively examine the extended breastfeeding knowledge and attitude levels of any population.

Conclusions

In some ways, the findings of this study are rather disconcerting, especially when one considers that many health authorities explicitly support breastfeeding beyond the first year. There is unfortunately a clear discrepancy between what professional health organizations recommend and what is actually believed and practiced. Perhaps more than any other place, mothers who engage in long-term nursing should receive support and encouragement from those in the health field; unfortunately, however, this does not appear to be the case. Already, almost one out of every 13 children in the United States is breastfed beyond the first year,¹⁴ and as infant breastfeeding rates continue to increase nationally,³⁴ it is inevitable that the number of long-term breastfeeding children will also increase—U.S. health workers must be adequately prepared to support these extended nursing families. Interventions, like the one from our study that incorporated photography and relevant scientific facts, may prepare health workers for the task at hand by normalizing attitudes and increasing knowledge levels.

As time goes on, researchers may continue to discover benefits to extended breastfeeding, and if this is the case, then long-term breastfeeding might be a viable tool useful in preventing disease and promoting health. However, it will only be able to be used as such if it is accepted by society. Health professionals have historically led the way in changing breastfeeding attitudes, sometimes for the better and sometimes for the worse.³⁴ Within the realm of extended breastfeeding there exists an opportunity to mold societal attitudes for the better. In order to do so, however, we as health professionals must first examine and adjust our own prevailing beliefs and assumptions—only then can our culture begin to view “extended breastfeeding” as, simply, “breastfeeding.”

Footnotes

Disclosure Statement

No competing financial interests exist.

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