The Meaning of “Breastfeeding” Is Changing and So Must Our Language About It

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.

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 breast^a 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 language ¹¹	NIS question ⁸	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
		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 old^a	“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)?

This wording combines language from Healthy People 2020⁶ and the American Academy of Pediatrics.⁷

NIH, National Immunization Survey.

Discussion

Our recent research^10,12–15 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.

Footnotes

Disclosure Statement

No competing financial interests exist.

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