Growing Up with Breastfeeding

Ruth Lawrence’s (Ruthie’s) textbook, Breastfeeding: A Guide for the Medical Profession, was first published in 1980, and the ninth edition was published in 2022. The Lawrence children later came to refer to it as “the book” when it would again take over the dining room table and floor with stacks of research papers, all organized into the planned chapters, to be incorporated and referenced in the text. When banter, giggling, and teasing increased around the kitchen table about “the book,” Ruthie would remind us that she was “standing on the shoulders of giants.” That is, others (clinicians, scientists, researchers, authors, etc.) had come before doing much of the work to study, research, and understand how breast milk is the best food for infants. Each child experienced breastfeeding and was instructed in breastfeeding at the kitchen table and through watching our siblings be breastfed. I was lucky enough to receive additional education about breast milk and these “giants” from her; she facilitated introducing me to the contemporary individuals doing this work.

Before the first edition, Ruthie had already breastfed all nine of her children (1951–1968); giving her personal understanding of what was necessary for a mother to breastfeed a child and piquing her scientific interest in fathoming the biological nature of human milk (HM) and the benefits of breastfeeding for mother and infant. During this period, there were other individuals, events, initiatives, and groups who highlighted the importance of breast milk and breastfeeding to maternal–infant health. She fondly remembers Edith Jackson, MD, of Yale University School of Medicine who developed the first rooming-in unit in the United States, funded by a federal grant. Ruthie experienced the benefits of prenatal instruction, natural childbirth, and breastfeeding under Edith Jackson with the birth of a child during her internship at Yale (1950–1951). In 1956, the La Leche League (LLL) was formed by a group of women focused on giving breastfeeding help and support to new mothers. The International Childbirth Education Association was established in 1960 to support women in planning and experiencing childbirth and early infant childcare in the weeks after delivery. In 1979, the International Code of Breast-milk Substitutes Marketing was developed, and the International Baby Food Action Network (IBFAN) was formed.

When I was completing medical school and residency, with a paucity of information about breastfeeding in my formal instruction (1975–1983), I did learn something about breastfeeding through her physician/students from the University of Rochester Medical School and residency programs. Still much of my breastfeeding knowledge as a pediatrician came from my mother. She enthusiastically taught me the basics of breast milk and breastfeeding and delighted in sending me scientific articles on breast milk. (Of course, Ruthie expected that I would study these and be ready to answer her “quiz-like” questions.) She acknowledged and respected the many researchers investigating the composition of human milk and its nutritional, immunological, and antimicrobial effects. These included many of her giants: T. Fjellstedt, C. Marmet, E. Shell, O.S. Ogra, P.L. Ogra, D. Jeliffe, P. Jeliffe, R.E. Kleinman, W.A. Walker, M. Neville, R. Jensen, J.T. May, A.S. Goldman, L.A. Hanson, M.F. Picciano, and B. Lonnerdal, among others. During my pediatric infectious disease fellowship, studying herpes viruses and acquired immune deficiency syndrome (later known to be human immunodeficiency virus), Ruthie began asking me more pointed questions about various infections and the immune response. She understood the importance of asking the right questions in scientific research, yet there were more questions than answers. Most of her questions arose from real clinical situations, as she tried to provide individualized support for breastfeeding mothers and families or as part of formulating scientific hypotheses about breast milk and breastfeeding. People would call the University of Rochester Breastfeeding and Lactation Study Center, which she was on call 24/7, and occasionally she asked me to speak directly with a mother or clinician regarding their questions and concerns related to infection. (I would debrief the questions and my answers with her afterward.)

Between editions of the book, she tried to find the answers to her many questions about breast milk or breastfeeding. She would review important scientific articles and save them with particular questions or book chapters in mind, all catalogued in files and boxes. She often animatedly related stories of discussing her questions with her giants. One unique aspect of writing her book—Ruthie kept printed copies of each chapter of the last edition on which she scribbled new questions or ideas. When it came time to write the next edition (every 4–6 years), she would write out additions, deletions, and changes in cursive on yellow foolscap paper and cut and paste these with the unchanged printed sections, all organized for someone to type out. In this process, all her children and some of the grandchildren were able to help her with finding new or hard-to-find references, organization, typing, and proofreading or at the very least helped by “staying out her hair” and out of the dining room while she worked.

In the 1980s, there were numerous events, initiatives, and organizations in support of breastfeeding. The World Health Organization published the International Code of Marketing of Breastmilk Substitutes in 1981. In 1984, the International Society for Research in Human Milk and Lactation (ISRHML) convened for its first meeting, and the first Surgeon General’s Workshop on Breastfeeding occurred in Washington, DC. In 1985, the International Lactation Consultant Association (ILCA) and the Human Milk Bank Association of North America (HMBANA) were formed. WellStart International (1985) began important training for professionals on breastfeeding. At the University of Rochester, Ruth Lawrence formed the Breastfeeding and Lactation Study Center and a “warm line to directly answer BF questions for mothers and clinicians.” The Journal of Human Lactation was first published in 1985. There were other clinicians and scientists writing books on human milk and breastfeeding around the same period; Derrick and Patrice Jeliffe’s Human Milk in the Modern World (Oxford University Press, 1978) and Lactation: Physiology, Nutrition and Breastfeeding edited by Margaret Neville and Marianne Neifert (Springer, 1983).

The surge of research on human milk continued, and new professional groups emerged to support breastfeeding women in the 1990s. The Breastfeeding Promotion Committee began in 1990. In 1991, the World Alliance for Breastfeeding Action (WABA) formed as did the Baby-Friendly Hospital Initiative. The Academy of Breastfeeding Medicine was formed in 1994 to educate physicians on human milk and breastfeeding. In 1995, the National Alliance for Breastfeeding Advocacy began, and in 1998, the United States Breastfeeding Committee (USBC) was established. Within all these groups, like-minded physicians, scientists, and lactation consultants collaborated to research human milk and promote breastfeeding. The founders and members of these groups became the contemporary giants that Ruthie looked to as she wrote new editions of her book. Sometime in the early 1990s, Ruthie asked me to “help her” write the book chapters on the immunology of human milk and the occurrence of infections in the mother or child during breastfeeding. It seemed almost humorous to me that I could help my mother with her book, except that I knew how seriously she took the analysis and interpretation of scientific data to appropriately help and support breastfeeding mothers. Her book was an extension of her scientific and educational commitment to the science and art of breastfeeding.

With the explosion of information and knowledge on human milk, breastfeeding, and lactation came a significant need to educate health care professionals about this so that they could provide necessary care and support for breastfeeding mothers. WellStart created their “online modules,” and ABM began their course on “What Every Physician Needs to Know” (about breastfeeding) and their evidence-based clinical protocols on important breastfeeding topics. ISRHML published reports from their meetings every other year. In 2006, the International Breastfeeding Journal and the Breastfeeding Medicine journal began publication. Later Anne Eglash, MD, formed the Institute for the Advancement of Breastfeeding and Lactation Education using education-based methods to target the learner’s needs. Many other organizations focused on human milk and breastfeeding education as well (UNICEF, ILCA, LLL, IBFAN, etc.). I was fortunate to be able to join the ABM where I met many of Ruthie’s giants—the founders of ABM as well as the founders and contributors to WellStart, USBC, WABA, ILCA, ISRHML, HMBANA, and so on. At the annual meetings of ABM, there was always lively discussion and debate on any number of breastfeeding topics. Nascent research questions were devised, and differences of opinion were respectfully presented. I think those discussions facilitated my raising my own differences of opinion with my mother about breast milk, breastfeeding, or the book; of course, this was rare and always respectful!

As the first and primary author/editor of this large textbook on breastfeeding, Ruthie was a little stubborn about several things: first, she wanted the book to have a hard cover (like a real textbook); second, the cover was to include the recognized symbol of breastfeeding created by her friend Rosemary Disney (1923–2014); third, she felt the length of the book should not be limited to a certain number of pages, and finally she preferred to be the primary author of the book, not one she edited with many authors. I am not sure why she decided to later add my name as a co-author and co-editor. My role felt more like a dutiful son helping his mother.

The ninth edition is symbolic to Ruthie in that she raised nine children by first breastfeeding each one. The book is still dedicated to her deceased son, John Charles Lawrence, and deceased husband, Robert Marshall Lawrence, and health professionals everywhere who support women and families in breastfeeding their children. This ninth edition was challenged by the amount of currently available scientific and medical knowledge and the goal of providing both knowledge and tools to accurately and thoughtfully counsel and support breastfeeding mothers. It was not enough to present published evidence-based guidelines, protocols, and recommendations. Three recognized researchers and authors were chosen to be associate editors for the ninth edition; each was a faculty member of ABM with extensive direct clinical experience with breastfeeding and lactation: Dr. Lawrence Noble, Dr. Casey Rosen-Carole, and Dr. Alison M. Stuebe. Seven additional authors were invited to contribute their knowledge and experience in human milk and lactation: Dr. C Calderon-Rodriguez, Dr. M.J. Chen, Dr. K.B. Greenberg, Dr. I.L. Hand, Dr. H.M Johnson, Dr. K.B. Mitchell, and Dr. A. Noble. This added four new chapters and made the ninth edition over 1,000 pages, including appendices, glossary, and index. Ruthie and I are indebted to these vital contributors and the publishing specialists at Elsevier, Sarah Barth and Anne Snyder, who produced the ninth edition.

In 2024, Ruth E.A. Lawrence, MD, will celebrate her 100th birthday with 9 children, 18+ grandchildren, and countless in-laws, relatives, and “adopted” children in her family. Occasionally, Ruth Lawrence’s book Breastfeeding: A Guide for the Medical Profession has been referred to as “the” book on breastfeeding. Sometimes, people call her one of the “giants” of breastfeeding along with the giants she always refers to. She is proud to be the author and editor of a textbook on breastfeeding in its ninth edition. She does not like being referred to as a giant in this medical field, especially as she reminisces about her giants, many of whom are also her friends. As one of her children and a student of human milk and breastfeeding who grew up with breastfeeding, I was simply trying to be a good son helping my mother, and Ruthie has always been the giant in our family.