Facilitators and Barriers of Wet Nursing from Antiquity to the Present: A Narrative Review with Implications for Emergencies

Abstract

Background:

If maternal breastfeeding is not possible, wet nursing allows infants to receive the nutrition and protection against disease that breastfeeding provides. Such protection may be particularly valuable in emergencies. However, while wet nursing is recommended in the Operational Guidance on Infant and Young Child Feeding in Emergencies it is underutilized. This narrative review aimed to develop an understanding of wet nursing practice across time and location, and why wet nursing is currently so little supported to inform interventions to support wet nursing in emergencies.

Method:

Medline and Embase were searched for “wet nursing,” “cross-nursing,” “shared breastfeeding,” and “non-maternal nursing”. Included articles were inductively analyzed to identify positive and negative factors associated with previous wet nursing practice.

Results:

This review included 74 records. Our analysis of the wet nursing literature includes historical and contemporary themes with milk kinship and wet nursing as risky being shared themes across time periods. Our analysis revealed that it is how wet nursing is undertaken that influences whether it benefits women, children, and societies or not. Facilitators and barriers to wet nursing in emergencies related to infant mortality rates, cultural and individual support for wet nursing, availability of wet nurses, and resources to support wet nursing.

Conclusion:

Understanding the conditions under which wet nursing has positive outcomes and what can be done to facilitate beneficial wet nursing practices will assist in enabling wet nursing to be more commonly implemented in emergencies.

Background

Breastfeeding is the biological norm and exclusive breastfeeding during the first 6 months of life provides infants with the nutrients necessary for normal health, growth, and development.¹ Breast milk also supplies the antibodies and other immune factors needed to foster immunological competence, thus directly protecting against infection and strengthening the infant's immune system.¹ The importance of breastfeeding to child survival is such that if all infants initiated breastfeeding within the first hour of life, exclusively breastfed from birth to 6 months old, and continued breastfeeding until 2 years or more, the lives of >800,000 children younger than 5 years could be saved every year.^1,2 Breastfeeding also provides longer-term protection from obesity and noncommunicable diseases.^1,3,4 Conversely, there are many risks associated with premature cessation of breastfeeding.

In some situations, however, maternal breastfeeding is not an option. In this case, wet nursing—when a woman other than the child's biological mother breastfeeds a child—is a way for the infant to receive the nutrition and protection against disease that breastfeeding provides.^5,6 Breastfeeding, and thus wet nursing, is even more important for protecting infant health when resources are limited and hygiene is poor, such as during emergencies, when nonbreastfed infants are at greater risk of serious illness and death.^7–9 Providing infant formula in emergencies is challenging and fraught with risk, including “spillover” to the wider community.^7–11 Accordingly, the World Health Organization (WHO) and UNICEF's 2003 Global Strategy for Infant and Young Child Feeding, as well as the Emergency Nutrition Network's (ENN) Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE), state that wet nursing should be considered if infants cannot be breastfed by their mothers.^6,12

However, emergency responders, health workers, and governments generally lack knowledge and confidence in wet nursing as an emergency intervention.^8,9,13 In practice, this means that wet nursing is seldom included in the policy and is underutilized.^8,9 For example, an audit of COVID-19 maternal and newborn care guidelines from 101 countries found that despite WHO recommending wet nursing when mothers were unable to breastfeed, only three countries included wet nursing in their COVID-19 guidelines.¹⁴

This narrative review explores wet nursing practice across different historical periods and settings to help develop an understanding of the current lack of support for wet nursing. Facilitators and barriers to wet nursing are identified with the aim of informing interventions to support wet nursing in emergencies.

Method

Medline and Embase were searched for literature on wet nursing up to March 29, 2023 using the terms “wet nursing,” “cross-nursing,” “shared breastfeeding,” and “non-maternal nursing” with exclusions for “milk sharing” and “milk bank” and nonhuman results. A total of 268 articles were identified. After filtering for duplicates, 160 records were retained for screening. First, records were screened by abstract. Inclusion criteria were as follows: (1) articles in English, and (2) articles that discuss experiences of wet nursing that can reflect the associated facilitators and/or barriers to the practice. Thirty-two articles were excluded as they were in a language other than English, and 35 articles that were not about wet nursing were also excluded. Twelve articles did not have an abstract and the full text of these articles could not be obtained. A full-text assessment was undertaken for the remaining 81 articles. A full text was not found for six articles. Five articles did not discuss wet nursing. A further four articles were identified after they were cited in retrieved literature.

Results

The 74 articles included in this review are summarized in Supplementary Appendix S1. Thirty-nine articles focused on the history of wet nursing from ancient times until the beginning of the 20th century, whereas 35 articles were concerned with contemporary wet nursing from 1981 until 2022.

The articles were analyzed with an inductive approach to identify themes and subthemes describing wet nursing practice in historical and contemporary articles. In conducting this analysis, particular attention was paid to wet nursing practices or contexts that were beneficial or detrimental to the health and well-being of infants or wet nurses with these highlighted in the review summary. From this, a summary of positive and negative wet nursing experiences was derived.

Historical articles on wet nursing

Historical articles described wet nursing practice as far back as ancient times and were mostly reviews from a specific point of view. For example, there were case studies focused on a particular village or even one family, where authors described how this family chose wet nurses and how they were treated. These cases give an in-depth view of wet nursing practice and the factors that affected it during these periods. The authors of the historical reviews used a wide range of resources including ancient writings, handwritten diaries of health care professionals, remedy books, advertisements for wet nurses, neonatal hospitals records, death registries, and court transcripts.

From these historical articles, we can see that wet nursing has been a longstanding practice in societies since ancient times and has occurred primarily when the mother was unable to breastfeed owing to death or physical limitations.^15–17 However, the nature and perspectives toward wet nursing varied across societies and periods, and wet nursing served various purposes, such as preserving infant lives after maternal death, providing relief to mothers during illness, facilitating marital relations, and increasing fertility by avoiding lactational amenorrhea.^15,18,19

Religious perspectives

Four articles focused on religious perspectives of wet nursing.^5,20–22 These articles describe Islamic and Jewish views as supporting the practice and recognizing it in the holy scriptures.^5,20–22 The wet nursing of Jewish historical figures such as Moses, Isaac, Rebecca, Samuel, and Joshua are recounted and emphasized that wet nursing was crucial for infants' survival.²⁰ Islamic rules for wet nursing are described including the relationship built between the nursed child and the wet nurse (milk kinship), and the obligation of fathers to employ a wet nurse and provide her with an adequate salary in cases when the mother is unable to breastfeed.^5,21,22

Although no articles focused solely on Christian views of wet nursing, it was nonetheless addressed within some articles.^19,23,24 Christianity was noted as having different views between and within denominations.²³ For example, wet nursing was encouraged among the Roman Catholic population because of the taboo on sexual relations while breastfeeding.^{4,15,23,25–27} Hence, wives could continue marital relations with their husbands by using a wet nurse.^15,23,27 In Catholic communities in Italy, it was common to use a wet nurse if the family was wealthy enough to pay her.^23,28,29 It was noted that the Catholic church considered that character traits could be transmitted through breast milk and forbade Christians from wet nursing Jews' or Muslims' babies.^19,30 At the beginning of the 20th century in Greece, when commercial wet nursing declined, a close relative usually helped in breastfeeding the child and the Greek Orthodox church honored her.²⁴

Position of a specific physician

Some articles focused on physicians' opinions, which were at times contradictory.^30–33 Some physicians supported wet nursing and recognized wet nurses' rights.^31,32 In February 1859, the Lancet published a letter by Mr. Acton that argued for the importance of allowing young unmarried lactating women to act as wet nurses for babies whose mothers were unwell.³¹ He argued that this would represent a mutual benefit for both the nursed child and the unmarried wet nurse by giving her a chance to improve her life and consequently, bring benefit to the whole community.³¹ Another article described the work of the Italian physician Dr Bernardino Ramazzini, and his book “Diseases of Workers” published in 1713.³² Dr. Ramazzini had great empathy for wet nurses and asserted the psychological state of the wet nurse might impact breast milk quality.³² He advised against forcing wet nurses into sexual abstinence and frequent feeding of children during the night as both would adversely affect wet nurses' mental health.³²

On the contrary, some physicians were opposed to wet nursing, especially as a profession.^30,33 Gutierrez de Godoy from Spain (1629) and Olavarrieta from Peru (1791) demeaned wet nurses by linking them to what they saw as growing mixed-race underclasses.^30,33 They were supporters of the belief in “pure blood” and encouraged mothers from the elite class to breastfeed their children rather than employ a wet nurse from the lower classes.^30,33

Wet nurses' characteristics

From ancient times, medical authors were concerned with recommendations for the “best” wet nurses and applied various standards including wet nurses' age, diet, health, body shape, and the health and age of wet nurses' children.^{24,26,28,29,34,35}

It is notable that some recommendations for wet nurses were common across time and settings.^28,29 Wet nurse's physical and mental health was often a focus with texts stating that the wet nurse should be sober and free of disease.^{15,26,28,29,34,36} The diseases mentioned included gastrointestinal conditions, tuberculosis, scurvy, hysteria, epilepsy, rheumatism, and sexually transmitted infections, especially syphilis.^26,29 Skin conditions like scabies and eczema were also sometimes noted as of concern, as were wet nurses' body and breast shape.^15,29,34

Regarding wet nurses' age, there was little variation between authors over time, with 20–30 years generally considered the ideal age for wet nurses.^{15,19,26–29,34,36,37} Specifications for the age of the wet nurse's child age (usually a maximum of 8–10 months) were made in a number of European countries and the United States during the 19th century, based on concerns about the milk “getting old,” lacking important nutrients and even being harmful if the wet nurse's baby was older than 10 months.^{15,19,27,29,34,36,37}

Oribasius, a 4th-century Byzantine physician, tested the physical properties of wet nurses' milk and recommended strategies to improve its quality, such as prescribing a particular diet and physical activity in case the milk was thick, watery, scarce, or “ruined.”³⁴

Some medical authors went further and included wet nurses' morals in recommendations, maintaining that wet nurses with bad tempers or inappropriate habits would transfer these traits to nursed children through their milk.^29,37,38 Others added race and ethnic origin as criteria and claimed that women of specific races or ethnicities produced breast milk of superior quality and quantity.^29,37

Invasive procedures

Some recommendations obliged invasive examinations of the wet nurse to ensure she fulfilled criteria.^29,38–40 Polish sources (1780–1800) advised midwives to check a wet nurse's vagina to see if she had inserted a sponge to hide gonorrhea discharge.⁴⁰ In 19th century Brazil, enslaved wet nurses were to “undergo a rigorous examination” to receive a “quality certificate.”.³⁸ Such examinations were also undertaken on local women who served as wet nurses for the children of European officers in colonial India during the 19th century.³⁹

Recommendations not always followed

Some articles were skeptical as to whether recommendations were really applied and case studies suggest that they might be overlooked, especially in urgent situations.^15,28,29,41 One such case is the employment of four wet nurses by Sir Roger Townshend of Raynham, England in the 1600s despite the ages of the wet nurses' children not meeting contemporary recommendations.⁴¹ These wet nurses were either friends of his wife or servants in his parents' house; seemingly trust between the family and the wet nurses mattered more than medical recommendations.⁴¹ Similarly, the notebook of Dr. J.Y. Simpson in Edinburgh containing details of >700 wet nurses for whom he mediated employment during the mid-19th century suggested that many guidelines were disregarded.¹⁵

Wet nurses in neonatal care settings

Before wet nursing, the preferred infant feeding method in foundling hospitals for abandoned infants was dry nursing, where bread was soaked in milk or water to create what was known as “pap.”⁴² In some foundling hospitals, dry nursing resulted in infant mortality rates close to 100%.⁴² Institutional wet nursing was an innovation first implemented in Milan in 787 AD.^15,43 In many cases, foundling hospitals were linked to maternity hospitals.⁴³ Unmarried mothers were contacted and offered social assistance in return for serving as resident wet nurses in the foundling hospital.⁴³ In-house wet nurses were hired in foundling hospitals in France, England, Switzerland, Australia, and the United States during the 19th century.^{25,37,42–44} Wet nursing was provided to sick neonates who usually had sick mothers who could not breastfeed them in maternity and children's hospitals.^37,43 It could be said that foundling hospitals employing resident wet nurses were the starting point of neonatal medicine.⁴³

The wet nursing dilemma

Although the literature describes parents and health professionals acknowledging that wet nursing was the only safe alternative to breastfeeding and that dry nursing entailed unacceptably high risks, negative attitudes toward wet nursing were also a common theme, especially with respect to 19th-century commercial wet nursing in the United States, Latin America, and colonial India.^{5,15,25,35,37,39,45–49}

Conflicted views toward wet nurses

A hierarchical relationship between families and wet nurses contributed to negative attitudes toward wet nurses who were from lower social classes, were slaves, or were indigenous citizens in a colonized area.^{25,37,39,44,45,48,49} In the United States, physicians who recommended wet nursing as the best choice also warned against wet nurses' bad behavior and poor hygiene.³⁷ Some American physicians chose women for wet nursing services according to their race but overlooked this in case of emergencies and shortages in the supply of wet nurses.³⁷ Slave owners in colonial Brazil acknowledged enslaved wet nurses' value through better treatment and higher wages (which some wet nurses later used to buy their freedom), but wet nurses were nevertheless separated from their infants.⁴⁸

European families hired local wet nurses in colonial India to help the new European mothers cope with the hot weather; these wet nurses received higher salaries than normal servants.^39,45 Nevertheless, medical doctors warned in their handbooks against wet nurses' habits and morality and advised the mothers to scrutinize them closely.^39,45 A similar tone was found in literature from Europe and Australia.^{15,27,35,44,49}

Possible reasons for the negative views

Some of the conflicted views of wet nursing, particularly commercial wet nursing, might have arisen from a correlation between the practice and elevated infant mortality rates in some contexts.^19,27,50,51 Physicians from various countries blamed wet nurses for high infant deaths in some foundling hospitals in cases where the wet nurse took several babies to feed at the same time.^{15,17,19,37,44,48} As described previously, there was the notion that wet nurses were untrustworthy and that unless they were being supervised, would give breastfed babies paps and other foods.^25,37,49 Villegas et al. suggested that the difference in care the wet nurses offered to wet nursed infants compared with their own children might have resulted in this variation in mortality rates.⁵¹

Other authors were skeptical that suboptimal wet nursing practices could have been the sole reason for infant deaths.^19,24,27,49 There were often confounding factors; for example, foundling children's health status was often compromised owing to severe maternal poverty and malnutrition.^19,24,49,51 In many cases, they were preterm or small for gestational age births and thus at higher risk and more vulnerable than normal healthy children raised with their biological mothers.^19,24,27,49

Wet nurses were sometimes criticized as exploiting their bodies for financial gain.^46,52 The Renaissance movement in Europe idealized mothers' role in raising their children and stigmatized wet nurses as well as mothers who failed to breastfeed their babies.^33,35,46 Finally, some mothers, feeling that they had failed to feed their children where the wet nurse succeeded, might have felt jealous of their wet nurses, as illustrated in case studies of some American mothers in the 19th century.³⁷

Respectful views toward wet nurses

It is worth noting that the attitudes to wet nurses were not always conflicted. In some contexts, wet nurses were highly respected and honored.^15,41,45,52 For example, in 17th century Spain, wet nurses had a special position inside the monarchy and were considered children's saviors; they wore special clothing, and their children were treated as siblings of the royal children.⁵² Similarly, during the 19th century, wealthy Indian families treated wet nurses as part of the family; they lived with the nursed children until adulthood and were sometimes considered mothers when the biological mother died.⁴⁵ Respectful relationships between wet nurses and the children's families were evident also in the United Kingdom during the 17th century.^15,41 Sir Townshend of Raynham employed women from his trust circle, which demonstrated the closeness of the wet nurses to his family.⁴¹

Dr. Simpson's notebook showed that wet nurses had social power and could negotiate their employment conditions, for example, by choosing to have the baby in their home or to reside in the house of the baby's family.¹⁵ Health professionals usually mediated the employment of wet nursing for the elite and royal families, as documented in Dr. Simpson's notebook, and was also seen in the Spanish monarchy where maternity and pediatric health staff chose wet nurses.^15,52

Motives for wet nursing

Although at times, hiring wet nurses was a fashion, there have also been other needs and motives underlying the use of wet nurses.^25,27,37,49 On the one hand, for example, in Europe, it was common for wealthy and upper class women to hire wet nurses instead of breastfeeding their infants because they thought that breastfeeding would ruin their bodies.^23,25,47 On the other, as previously described, both foundling hospitals and sick mothers who were unable to breastfeed their children had no other safe child-feeding option.^37,43

In addition, the Industrial Revolution had a great impact on the social and economic structure in Western countries.^23,25,36,47 For many women from the working classes who had to spend long hours working in factories, a wet nurse was the only safe alternative to breastfeeding their infants.^{16,25,27,36,37,47} Even after the development of infant formula in the early 1900s, the Chicago Board of Health in the United States still advised mothers to hire a wet nurse rather than bottle feed because they recognized the importance of breastfeeding and the risks that non-breastfed infants faced.³⁷

Given that breastfeeding has a contraceptive effect (lactational amenorrhea), wet nurses were sometimes used so that women would regain fertility sooner after birth, a decision usually made by husbands.^25,36,47 Similarly, in communities where sexual relations during breastfeeding were taboo, husbands often chose to hire a wet nurse.^25,36,47 The corollary was that some women decided to work as wet nurses after having their own children, thus using continued breastfeeding as a natural birth control method.^25,36,47

Fate of wet nurses' children

In some times and places, children of wet nurses were separated from their mothers and deprived of breastfeeding because the wet nursed children's parents wanted to ensure that their child received all the wet nurse's breast milk.^{17,37,44,48,49,53,54} Enslaved wet nurses in the Americas had to leave their infants with a relative who usually dry nursed them with nutritionally inadequate starchy food.^17,48,53,54 Similarly, in European countries, wet nursing mothers had to give up their children to other wet nurses who were receiving lower wages.^{25,37,44,46,49} Poor and vulnerable mothers had few other choices.^17,44,49 Articles from England and Australia described a phenomenon known as “baby farming” where women accepted and dry nursed large numbers of infants with resultant high mortality rates.^25,44,46,49

In some settings, efforts were made to protect wet nurses and their children from the consequences of separation.¹⁷ One example was Father Pineda in Guatemala who advocated against forcing local women to serve as wet nurses, a practice that was forbidden by royal authorities in 1609.¹⁷ He showed how the health of wet nurses' children was impacted because of the inappropriate feeding they received while separated from their mothers.¹⁷ Elsewhere, provisions were made for wet nurses to reside in foundling hospitals with their infants.⁴³ Regulations to protect wet nurses' children are discussed in the next section.

Regulations

Throughout history, there have been regulations controlling wet nursing.^{15,19,24,36,37,42,47,48,50,51} Contracts for wet nurses existed in Roman Egypt and ancient Greece.¹⁹ After wet nursing became a profession in Europe in the 18th and 19th centuries, specific regulations were created to satisfy the growing demand for wet nursing, address high infant mortality rates, and respond to cultural and political pressure.¹⁹

Wet nursing bureaux were established in France and Sweden in the 18th century.^36,42 The French bureau was created to address high mortality rates of abandoned infants by employing wet nurses to replace artificial feeding, thereby reducing the foundling mortality rate from 100% to 31%.⁴² The Swedish bureau inspected wet nurses to ensure that they were suitable for the role.³⁶

As noted previously, there were correlations between commercial wet nursing and an increase in infant mortality rates in the 19th century, especially when wet nurses took care of several children at the same time.^19,27,50 Authorities assumed that some wet nurses fed the infants pap, and legal measures were implemented to prohibit this practice.^19,50 In the United Kingdom, a campaign against “baby farming” resulted in the Infant Life Protection Act requiring wet nurse's homes to be registered and regularly inspected.¹⁹ The London Foundling Hospital made a protocol that any wet nurse who had had two children die in her care would not be assigned to a third child.⁴⁷

France had far-reaching wet nursing regulations, including the 1715 Law of Louis XIV.^19,50 Wet nurses were required to have a mayor's certificate, and would be punished and her husband fined if she wet nursed more than one child at a time.¹⁹ The most stringent regulation on wet nursing, Senator Theophile Roussel's law (1874), was created in response to high infant mortality rates resulting from dry feeding.^19,50 Even before parents left their children in a wet nurse's care, the law mandated that they register with the police, and wet nurses were required to submit to a medical examination before receiving their licenses.⁵⁰ Although the law was onerous, it was argued that since wet nurses who cared for foundling children were paid by the government, there was a duty of care to protect infants wet nursed at the taxpayers' expense.⁵⁰ In addition, beliefs around pure blood and milk kinship might have played a role in facilitating public acceptance of the law.⁵⁰

Some legislation protected wet nurses' rights and those of their own babies.^24,37,51 Regulations in León province, Spain (1880) stated that abandoned infants assigned to lactating mothers could be cared for with the wet nurse's own children.⁵¹ In 1914, the United States Children's Bureau recognized and recommended that a wet nurse would likely be more at ease and in a better mental state if she were permitted to keep her child and nurse it alongside the child of her employer.³⁷ The state of Maryland responded to this recommendation in 1916 by banning the separation of wet nurses from their infants for the first 6 months after birth, which led to a reduction in the mortality rate of wet nurses' children from 33% to 12.5%.³⁷ During the 1920s, Greek law stated that a wet nurse's child should be more than 3 months old before she was employed, and also that there should be childcare spaces in factories where women worked.²⁴

End of wet nursing as a profession

By the beginning of the 20th century, wet nursing as a profession had markedly declined in Europe and elsewhere.^{5,19,23,29,35–37,44,49} Authors owe that to the dramatic changes in both the perceived need for and the availability of wet nurses.^{15,19,23,29,35–37,44,49} Milk sterilization by Louis Pasteur and the production of commercial infant food by Henri Nestle initiated the sequence of events that ended the commercial practice of wet nursing.^{19,35–37,44} The infant food industry had the greatest impact in communities where wet nursing already had a conflicted reputation, as in the United States.^{19,35–37,44,53,55} Social factors played a role, including child-raising views based on mothering theory and Methodism, which encouraged parent–child attachment.^15,25,36 The same influence came from medical professionals who focused on the importance of breastfeeding for the mothers' health.²³ These changes reduced the demand for wet nurses.³⁶

Economic and legislative changes also affected the number of women who were willing to work as wet nurses.^25,36 For example, straw-plaiting and lacemaking became popular jobs for women in England during the 18th century; given the negative views of wet nursing, many women opted for these occupations instead.^25,36 In France, many women declined to apply for wet nursing positions because of the restrictive legislation described previously.^19,36,50

Although professional wet nursing declined, wet nursing as an informal practice continued and is still practiced, particularly among close relatives and trusted friends.^29,52,56 Charity and kindness have become the main motives of current wet nursing practice.^{24,38,56–58}

Milk kinship

Milk kinship describes the familial relationship created between wet nurses, nursed children, and their families, and is acknowledged in different cultures.^{4,5,24,45,57,59} In the Spanish royal family, wet nurses and their children became part of the monarchical structure.⁵² Historically, Greek mothers searched for wet nurses whose children had the same sex as their children because they believed in milk kinship and wanted to avoid consanguineous marriages.²⁴ In India, Hindu families honored wet nurses even after their deaths by giving presents for their souls, a practice reserved for family members.^4,45

The concept of milk kinship is deeply embedded within Islam, which has detailed rules about how milk kinship is created and between whom.^5,18,57,59 The creation of a milk kinship relationship requires five feeds where the nursed child should show signs of satisfaction like falling asleep or pulling away from the breast.^5,57,59 After these five feeds, the wet nurse becomes a milk mother and her children become milk siblings to the nursed child; thus, marriage between them is forbidden.^5,18,57,59 Milk kinship can be a barrier to wet nursing practice especially when there is no available lactating relative of the child, as was found in a Nigerian study.^5,60 There is potential for misunderstanding the Islamic rules, and authors emphasized the importance of appropriate documentation such as the “MyRadhaah” card, which records wet nursing relationships in the State of Selangor, Malaysia.^57,59

Wet nursing as risk

It had long been understood that breastfeeding, including by a wet nurse, was protective against communicable diseases.^15,27,40 During epidemics, it was observed that infants who were breastfed or wet nursed had better survival rates than other infants for diseases including smallpox, cholera, meningococcal meningitis, and tuberculosis.^15,27,40,61

However, wet nurses were also accused of transmitting infections.^40,62 Concern about the possibility of a wet nurse infecting an infant with a disease was a theme in both historical and contemporary literature, despite differences in the diseases of concern, screening procedures, and treatments.^40,46,62,63

In historical literature, syphilis was a disease commonly of concern.^40,46,62,63 Up until the late 1800s, little was known about the pathogenesis of syphilis.⁴⁰ In many cases, the transmission of syphilis was actually from the nursed child to the wet nurse.^40,62,63 The infection could be transmitted from asymptomatic pregnant women to their fetuses; once born, these syphilitic newborns transmitted the infection to their wet nurses who in turn, might pass on it to their children and families.^40,62,63 This was described as a tragedy where the wet nurse was given death in exchange for helping to preserve life.^40,62

At present, human immunodeficiency virus (HIV) is the main infection of concern related to breast milk.^38,40 Human T-lymphotropic virus can be a risk in regions where it is prevalent while cytomegalovirus is considered a high risk for premature newborns and immunocompromised infants.^38,40,64

Contemporary articles from African and Latin countries considered wet nursing a risky practice, especially when participants were unaware of the potential hazards, including the risk of infection transmission from wet nurses to children and vice versa.^38,65–70 Articles from Brazil and Peru also considered exposure to drugs wet nurses may be using including medications, tobacco, alcohol, and recreational drugs.^38,69

Literature covering contemporary settings

Contemporary articles in this review extend from 1981 until 2022. Most of them are cross-sectional in design with different methods including questionnaires, surveys, interviews, and focus groups.

Wet nursing as an alternative

In 2003, in the context of HIV, wet nursing was considered one of the potential infant feeding options when maternal breastfeeding was not an option.^71–79 Seven articles discussed attitudes toward wet nursing in this context from African countries.^{71–73,75–78} Most of these articles were cross-sectional studies that recruited pregnant and lactating mothers from hospitals and clinics.^71,75,77,78 Factors favoring wet nursing included when wet nursing was common practice in the community, a close lactating relative to the child was available, wet nursing was acceptable to the infected mother, and infant formulas were unaffordable, especially in rural areas.^{65,71,72,74–76} On the contrary, wet nursing was refused as an alternative when the practice was uncommon, no close relatives were lactating, potential wet nurses refused testing, and mothers had to reveal their HIV status and face stigmatization.^{65,71,72,74–78} To overcome these barriers, most articles suggested that relactating grandmothers would make the best wet nurses in these communities.^72,74–77

Over time, antiretroviral therapy succeeded in reducing the risk of mother-to-child transmission to only 1% and it was also acknowledged that mortality rates increased among nonbreastfed infants.^4,80 Subsequent guidance on HIV and infant feeding in 2010 and 2016 no longer referred to wet nursing, but encouraged maternal breastfeeding.⁸⁰

Contemporary cultural attitudes toward wet nursing

Nineteen articles described attitudes toward wet nursing in modern settings. Eleven of these investigated wet nursing practices in different communities, and five came across wet nursing while studying breastfeeding practices among the recruited participants. These articles demonstrate that wet nursing is still practiced in many different cultures including in Asian, South American, and African countries.^{60,74,81–83} They noted that wet nursing is most often practiced within a family setting with relatives, although sometimes neighbors or friends might also be involved.^{38,58,67,77,81,84} Reasons to keep wet nursing practice among relatives were trust, relationship cohesion, and avoiding milk kinship with outsiders.^{18,38,57,60,67,69,84} Other facilitators were religious and cultural support, increased awareness of breastfeeding importance, and mothers' absence owing to work or study.^{18,38,57–59,68,74,82,84}

On the contrary, the unavailability of breastfeeding relatives was considered a barrier to wet nursing.^60,74,84 This was more evident in urban settings than in rural regions, as the relations with extended family members are often limited in cities.^60,84 Wet nursing tended to be rejected in communities that believed that breast milk could transfer genetic diseases.⁷⁶

Three articles focused on how the history of slavery and wet nursing impacted current attitudes toward breastfeeding within the African American community.^53–55 They asserted that the trauma of slavery, forced wet nursing and infant separation was transferred between generations, creating a negative connotation not only for wet nursing but also for maternal breastfeeding that persists until the present.^53–55

Wet nursing in emergencies

Four articles described the implementation of wet nursing in emergency settings if maternal breastfeeding is not possible.^8,9,13,85 They noted that infants separated from their biological mothers need feeding alternatives, and that wet nursing is proposed as a potential solution in the OG-IFE, but that practical guidelines on wet nursing are lacking.^8,9

Two studies described wet nursing experiences and challenges in Rohingya refugee camps in Bangladesh.^13,85 Challenges included the difficulty of finding a willing wet nurse if none is present among close family members, and the lack of acceptance of wet nursing by both the baby's and the wet nurse's families.^13,85 A further challenge was night feeding, which was resolved by storing expressed breast milk in ice boxes if it needed to be kept for more than 6–8 hours.¹³ It was noted that there is usually a limited electricity supply and inadequate storage facilities in emergency settings, which can pose challenges.¹³ The importance of breastfeeding counseling and mediation by health professionals or community leaders to find solutions to wet nursing challenges was also described.^13,85

Positive and negative wet nursing experiences

Our analysis of articles on historical and contemporary wet nursing practice revealed that whether wet nursing benefited or was detrimental to women, children, and society, and therefore how wet nursing was viewed, depended very much on how it was practiced. Table 1 summarizes positive and negative wet nursing experiences as identified in this review.

Table 1.

Positive and Negative Wet Nursing Experiences Identified in the Literature Review

Positive wet nursing experiences	Negative wet nursing experiences
Wet nursing in response to a genuine need for infants whose mothers have died or who are unable to breastfeed in the short or long term because of illness or insufficient milk^43,56	Wet nursing as a fashion, precluding maternal breastfeeding and unnecessarily separating mothers and infants^23,49
Reduced infant mortality rate (in comparison with artificial feeding)^42,43	Increased infant mortality rate (in comparison with maternal breastfeeding)⁵¹
Protection of infants against infectious disease via wet nursing⁴⁰	Transmission of infections from wet nurses to wet-nursed infants and vice versa^62,63
Wet nurses permitted and encouraged to keep their own child with them and to tandem feed their child and the wet-nursed child^37,42	Separation of wet nurses and their children resulted in suffering for both and illness and death in wet nurses' infants^49,53
Wet nurses respected and valued⁵²	Wet nurses disrespected and denigrated^33,37
Warm relationships developed or strengthening of relationships between the wet nurse and her family and the family of the wet nursed child^41,52	Wet nurses and their children rejected or mistreated by the family whose infant is wet nursed^33,37
Social or material support for wet nurses enabling them to support their families⁵²	Commodification of wet nursing resulting in poor care of wet nursed infants associated with increased rates of illness and death^48,53
Women choosing wet nursing as a natural contraceptive or for altruistic reasons⁴⁷	Women being coerced or compelled to wet nurse^49,53
Reasonable and effective regulations on wet nursing^37,42	Intrusive or unreasonable testing or restrictions on wet nurses and wet nursing^29,40

Discussion

Our review of historical and contemporary wet nursing revealed that wet nursing is a complex practice profoundly impacted by context and culture. As given in Table 1, wet nursing is not a universal good or a universal evil, rather how it is undertaken impacts whether it benefits women, children, and society. We observed that wet nursing was beneficial when wet nurses were respected and supported, wet nursing was appropriately implemented in response to a genuine need for an alternative to maternal breastfeeding, and infant mortality was reduced.

In contrast, the practice of wet nursing was detrimental when wet nurses lacked support, faced coercion or denigration, or were separated from their own infants. Furthermore, adverse effects were observed when wet nursing took precedence over maternal breastfeeding, when commercial incentives overrode child wellbeing, when infectious diseases were transmitted between wet nurses and infants, and when infant mortality rates were elevated. We propose that it is this complexity and mixed history that has resulted in the current situation where wet nursing is often not well understood or supported as an emergency infant feeding intervention.

Assuming that positive wet nursing practices and contexts assist in facilitating wet nursing and negative wet nursing practices the converse, facilitators and barriers of wet nursing in emergency contexts were developed. These facilitators and barriers are in relation to the infant feeding environment; cultural, religious, and individual support for wet nursing; availability of wet nurses; and resources for supporting wet nursing as given in Table 2.

Table 2.

Facilitators and Barriers of Wet Nursing Identified in the Literature Review

Facilitators of wet nursing	Barriers to wet nursing
Infant feeding environment
High background infant mortality rates	Low background infant mortality rates
Lack of availability or feasibility of infant formula feeding, high level of knowledge of the resources required, and risks associated with formula feeding especially in emergencies	Easy availability of infant formula and lack of knowledge of the resources required and risks associated with formula feeding, especially in emergencies
Low background rates of infectious diseases that may be transmitted via breastfeeding	High background rates of infectious diseases that may be transmitted via breastfeeding, particularly HIV
Cultural, religious, and individual support for wet nursing
Emergency responders having knowledge about and confidence in breastfeeding (including wet nursing)	Emergency responders lacking knowledge and confidence in breastfeeding (including wet nursing)
Cultural and/or religious support for wet nursing	Cultural prejudice against wet nurses and wet nursing (including a community history of coercion into wet nursing)
Islamic legal support for the rights of children to be breastfed including via wet nursing	Having to take Islamic milk kinship into account in wet nursing arrangements
Availability of wet nurses
Wet nurses available who are known to and trusted by the parents of the child requiring a wet nurse	No relative or known wet nurse available
Wet nurses available who can stay close by the infant to facilitate easy breastfeeding	The only wet nurses available cannot stay close to the infant, making frequent feeding (and especially night feeding) difficult
Resources for supporting wet nursing
Testing of wet nurses and wet nursed infants for diseases of concern available	No testing for diseases of concern available.
Appropriate supervision of wet nursing arrangements to ensure the health and well-being of wet nursed infant, wet nurse's infant, and wet nurse	Lack of supervision of wet nursing arrangements or inappropriate (e.g., intrusive or nonevidence-based) supervision
Policy or regulation that protects the health and well-being of wet nurses, wet nursed children, and wet nurses' infants	Absence of policy or regulation that protects the health and well-being of wet nurses, wet nursed children, and wet nurses' infants
Appropriate guidance or policy support for wet nursing	Lack of appropriate guidance or policy support for wet nursing or policy overtly opposed to wet nursing
Social, health, or other support and assistance available to wet nurses	No social or other support and assistance available for wet nurses
Resources to safely express and store expressed breast milk (to enable breast milk feeding of infants overnight in the absence of the wet nurse)	Lack of resources to safely store expressed breast milk

Implications of identified facilitators and barriers

A major facilitator of wet nursing is high infant mortality rates, which is a common situation in emergencies.¹³ This means that emergencies are a context in which support for wet nursing may be higher than usual. However, emergencies are also a time when donations and untargeted distributions of infant formula are common, which would undermine wet nursing.¹⁰ Thus, it is evident that emergency responders need to understand the importance of breastfeeding, the risks of formula feeding, the need to prevent donations and untargeted distributions of infant formula, and what is required to support breastfeeding and formula feeding in emergencies. Implementation of emergency planning, policies, and training based on the OG-IFE and the WHO International Code are needed.¹⁰

The availability of a suitable wet nurse is critically important to the success of wet nursing. A close family or trusted community member to act as a wet nurse makes wet nursing more acceptable. Ensuring that all involved are aware of what is being asked of them, what support will be provided, and crucially, that the arrangement is freely entered into, is extremely important. Breastfeeding counseling should be deployed to assist with this. Logistical arrangements such as where the nursed child will be fed and night feedings are factors that affect the feasibility of wet nursing and may be another reason why having a relative such as a grandmother act as a wet nurse is beneficial.⁷⁶ Where it is not possible for wet nurse and infant to be co-located overnight, resources for the expression and storage of expressed breast milk may assist.¹³ Although Islamic recognition of wet nursing familiarizes the Muslim communities with the practice, milk kinship can be a barrier. This factor needs to be considered and taken into account in identifying who might be a suitable wet nurse, in record keeping and with the involvement of trusted religious leaders.^57,59

Although wet nursing as an intervention targets the health of disadvantaged infants who cannot receive breast milk from their own mothers, it is crucial to provide support for the wet nurse and her child. This support could be in a variety of forms including additional food or other compensation for the wet nurse's time and effort. However, providing support is not a straightforward matter, for example, compensation could result in women being coerced by their families into wet nursing, so further research is needed to determine how best this can be managed in different contexts.

The risk of transmission of infectious diseases, particularly HIV, is perhaps the most significant barrier to wet nursing. Testing protocols as a part of wet nursing facilitation will assist in addressing this concern and ensuring that infants and wet nurses are protected. More generally, policy and guidance for emergency responders should take into account the factors that contribute to positive wet nursing experiences and facilitate the practice.

Strengths and limitations of the review

The main strength of this review is its comprehensive description of articles that address wet nursing spanning through historical periods to contemporary times. A limitation is that non-English articles were excluded.

Conclusion

Throughout history, wet nursing has been common in many societies. Depending on the way it was practiced and supported, it could be beneficial to infants and women, or it could be harmful for wet nurses' infants and exploitative of women. Understanding the circumstances in which wet nursing has positive outcomes and what can be done to facilitate beneficial wet nursing practices will assist in enabling wet nursing to be more commonly implemented in emergencies.

Authors' Contribution

K.A.: Methodology, literature search, formal analysis, writing—original draft preparation. B.B.: Conceptualization, methodology, writing—review and editing, supervision. S.M.: Conceptualization, methodology, writing—review and editing, supervision. K.G.: Conceptualization, methodology, writing—review and editing, supervision.

Footnotes

Disclosure Statement

The authors have declared that no competing interests exist.

Funding Information

This research was funded by the Australian Government Research Training Program (RTP) Scholarship and Macquarie University Research Excellence Stipend Scholarship.

Supplementary Material

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