Occupational Therapy and Breastfeeding Promotion: Our Role in Societal Health

Recommendations for Exclusive Breastfeeding

Breastfeeding is the use of human milk for infant feeding and is an essential occupation for the health of infants, mothers, and society. The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) have recommended exclusive breastfeeding of infants for the first 6 mo of life to maximize the health benefits of feeding human milk (AAP, 2012; U.S. Department of Health and Human Services [HHS], 2011; WHO, 1998). AAP has also recommended continued breastfeeding beyond 6 mo for at least the 1st yr, and WHO has recommended continued breastfeeding after the introduction of complementary foods to age 2 yr and older (AAP, 2012; WHO, 1998). Engagement in exclusive breastfeeding supports individual and population health; therefore, in the United States the Healthy People 2020 initiative established the objective that 25.5% of infants be exclusively breastfed for the first 6 mo after birth (HHS, 2010). However, although 74.0% of infants born in the United States in 2006 were ever breastfed, a significantly lower proportion, 14.1%, were exclusively breastfed for the recommended 6 mo (HHS, 2010). Increasing engagement in the occupation of exclusive breastfeeding is an important public health goal for maximizing health outcomes, and occupational therapists can assist in achieving this societal goal.

Infant Health Benefits From Breastfeeding

Research on breastfeeding has documented the nutritional, immunologic, and developmental benefits of human milk for infants as well as the social, economic, and environmental advantages for families and society (Ip et al., 2007; Krogstrand & Parr, 2005; Lawrence & Lawrence, 2010; Philipp & Merewood, 2004; HHS, 2011). Of particular significance is the AAP’s (2012) recent acknowledgment of evidence that exclusive breastfeeding for 6 mo has protective health benefits exceeding those observed in infants exclusively breastfed for 4 mo. The Surgeon General’s Call to Action to Support Breastfeeding (HHS, 2011) summarized numerous studies demonstrating protective health effects of breastfeeding for infants, mothers, and society.

Breast milk has immunologic and anti-inflammatory properties that protect infants against a variety of diseases (Lawrence & Lawrence, 2010), whereas formula feeding has been associated with increased incidence of common childhood infections (Ip et al., 2007). Additional evidence has demonstrated that exclusive breastfeeding provides improved protection against respiratory tract infection, otitis media, and sepsis in premature infants compared with partial breastfeeding (AAP, 2012; Ip et al., 2007; Lawrence & Lawrence, 2010; HHS, 2011; Quigley, Kelly, & Sacker, 2007). Other notable infant benefits are the protective effects of breast milk against gastroenteritis and diarrheal disease, particularly in developing countries in which infant mortality is associated with an unsanitary water supply (Chen & Rogan, 2004; Ip et al., 2007; Kramer et al., 2001; Lawrence & Lawrence, 2010).

Another infant health benefit for reduced infant mortality is the association between breastfeeding and decreased rates of sudden infant death syndrome (McVea, Turner, & Peppler, 2000). McVea and colleagues (2000) found that bottle-fed infants are twice as likely to die of sudden infant death syndrome as breastfed infants. Evidence summarized in The Surgeon General’s Call to Action to Support Breastfeeding (HHS, 2011) suggests that exclusive breastfeeding is a particularly effective intervention for reducing infant mortality worldwide. Occupational therapists can add to this literature by examining differences between bottle-feeding and breastfeeding routines associated with health outcomes and identifying aspects of routines that are confounding factors with breastfeeding and health.

Breastfeeding is associated with decreased incidence of chronic health conditions such as obesity and asthma (Koletzko et al., 2009; Owen et al., 2008). Two recent meta-analytical studies found decreased odds of developing obesity in children who were breastfed, with stronger protective results for exclusive breastfeeding (Harder, Bergmann, Kallischnigg, & Plagemann, 2005; Owen et al., 2008). Breastfeeding also appears to be a protective factor in the prevention of asthma (Gdalevich, Mimouni, & Mimouni, 2001; Ip et al., 2007). Gdalevich et al. (2001) demonstrated an association between exclusive breastfeeding and lower rates of asthma in childhood. This protective effect was particularly noticeable when a family history of asthma existed (Gdalevich et al., 2001).

Research on the benefits of breastfeeding has also examined the relationship between breastfeeding and intelligence. Kramer et al. (2008) found that intelligence scores and teachers’ ratings, when adjusted for parental sociodemographic differences, are significantly higher for breastfed infants. Mortensen, Michaelsen, Sanders, and Reinisch (2002) demonstrated a relationship between breastfeeding duration and higher scores on the Verbal, Performance, and Full Scale Wechsler Adult Intelligence Scale. Breastfeeding also has benefits for motor and cognitive development in preterm infants, with infants who were breastfed scoring higher on the Bayley Scales of Infant and Toddler Development–II at age 6 mo (Feldman & Eidelman, 2003). Feldman and Eidelman (2003) also studied the relationship between parental physical touch and neurodevelopment and found that breastfeeding, in combination with physical touch, further increased cognitive scores. Further research is needed to better understand the health benefits of breastfeeding for the child, particularly factors such as touch or parenting style that are part of the social environment and contexts within which co-occupational engagement in exclusive breastfeeding occurs. In the next section, I review the health benefits that breastfeeding provides to the mother.

Maternal Health Benefits From Breastfeeding

Breastfeeding has immediate as well as longer term health benefits for the mother (Labbok, 2001). Some immediate benefits include decreased postpartum bleeding and faster return to prepregnancy weight. Another benefit is the contraceptive effect of breastfeeding and its contribution to appropriate spacing between births (Krause, Lovelady, Peterson, Chowdhury, & Østbye, 2010). Longer term benefits include decreased risk of diabetes, obesity, osteoporosis, and breast and ovarian cancer (Ip et al., 2007).

Breastfeeding is also suspected to be a protective factor for postpartum depression (Ip et al., 2007; HHS, 2011). Breastfeeding appears to lessen the hypothalamic–pituitary–adrenal response to physical or psychological stress (Heinrichs, Neumann, & Ehlert, 2002); Mezzacappa (2004) suggested that breastfeeding is associated with improved parasympathetic nervous system modulation, decreased stress responses, and fewer depressive symptoms. The Surgeon General’s Call to Action to Support Breastfeeding (HHS, 2011) emphasized the recent finding that breastfeeding and breastfeeding duration may be protective factors against postpartum depression (Dennis & McQueen, 2009; Jardri et al., 2006), as also demonstrated by Ip and colleagues (2007) in the meta-analysis completed for the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. However, because most studies did not assess the incidence of depression before pregnancy, reverse causality is possible. It may be that existing depression is associated with early discontinuation of breastfeeding or breastfeeding problems or, vice versa, that breastfeeding difficulties may increase the risk of postpartum depression for those women without a prior history (Ip et al., 2007).

Occupational therapists in a diversity of practice settings may provide intervention for clients who are pregnant and therefore have the opportunity to assist clients in developing routines supportive of exclusive breastfeeding. Occupational therapists using a preventive or health promotion approach can also address barriers to co-occupational engagement in exclusive breastfeeding within the social environment or context to prevent or lessen the risk of postpartum depression resulting from breastfeeding difficulties.

Societal Benefits From Breastfeeding

Breastfeeding also has health benefits for society. If the United States achieved increased initiation and duration of exclusive breastfeeding, the potential health care savings would be an estimated $13 billion annually (Ball & Wright, 1999; Weimer, 2001). In a recent study, Bartick and Reinhold (2010) demonstrated the potential for this $13 billion/yr saving if 90% of infants were exclusively breastfed for the recommended 6 mo. Another societal advantage of breastfeeding is decreased absenteeism from work for parents of young infants. Because breastfeeding is associated with decreased rates of many childhood illnesses, parents of breastfed infants miss fewer days of work because of a sick child. Families of breastfed infants thus have less loss of income resulting from sick leave (Cohen, Mrtek, & Mrtek, 1995). Breastfeeding also has environmental benefits, such as decreased energy expenditure for the production of artificial formula and decreased use of resources for the production and cleaning of bottle feeding equipment (AAP, 2012).

Environmental and contextual occupational therapy interventions that create opportunities for continued breastfeeding thus contribute to societal health. For instance, the occupational therapist may consult with a child care center or workplace to create a physical space for nursing or expressing breast milk or support the mother in advocating for time to express breast milk as part of her work routine. It is necessary for occupational therapists to know the evidence-based health benefits of breastfeeding to develop interventions that address the negative societal or maternal attitudes about breastfeeding that are part of the social environment. In the next section, I discuss the relationship between breastfeeding and areas of occupation of feeding, eating, child rearing, and health management and maintenance.

Implications for the Profession

Feeding and eating are critical occupations given the importance of nutrition for health across the life course. Although mothers, fathers, and other caregivers participate in feeding young children, I focus on the mother because of her biological and physiological role in breastfeeding. Feeding is identified as a primary occupation of mothering, important not only for nutrition but also for the biopsychosocial development of young children, including attachment (Olson, 2004; Whitcomb, 2012). Mothering or child rearing is the “provision of care and supervision that supports the developmental needs of a child” (American Occupational Therapy Association [AOTA], 2008, p. 631). Therefore, breastfeeding as an activity or method of feeding and provision of care transcends these areas of occupation.

Literature searches in occupational therapy journals identified relatively few articles over the past decade examining feeding and eating as an occupation of mothering, however. Similarly, breastfeeding as an activity or method of feeding has received minimal attention in the occupational therapy literature. The occupational therapy literature on feeding and eating has mainly addressed client factors and performance skills necessary for successful engagement in these occupations, an important role for occupational therapists; however, this focus often misses opportunities for broader support of mothers in activities such as breastfeeding by establishing performance patterns and modifying environments.

One reason for this lack of examination of breastfeeding in the occupational therapy literature may arise from its absence or ambiguity in occupational therapy’s definitions of eating and feeding. Eating and feeding are activities of daily living important for basic survival and for their meaning in family routines and cultural contexts. Eating is defined as “the ability to keep and manipulate food or fluid in the mouth and swallow it” (AOTA, 2008, p. 631). Mother–infant actions in feeding and eating have been described as the mother feeding and the infant eating, a constant interplay between two actors (Olson, 2004; Zemke & Clark, 1996). The mechanism of infant feeding in particular illustrates this interplay or blurring of occupations between actors, because methods of both bottle and breastfeeding require the infant to also maintain the nipple in the mouth while managing the fluid. Moreover, feeding is defined as “the process of setting up, arranging, and bringing food from the plate or cup to the mouth” (AOTA, 2008, p. 631). Although this definition does not explicitly include the breast as a mode of delivering food to the mouth, it can be implied that the breast or bottle serves the same purpose in feeding occupations.

Again, with young children in particular, blurring between feeding and eating exists. The mother sets up and arranges equipment and food for feeding, but with methods of breast and bottle feeding the infant participates in drawing the nipple into his or her mouth. This initial physiological action of the infant, rooting and sucking, further merges feeding and eating by the infant’s learning to actively draw the nipple into the mouth and the mother assisting in maintaining it there during swallowing. The interplay between two actors in eating and feeding occupations is often considered co-occupation, as are other caregiving occupations characterized by reciprocal, interactive, and nested activities (AOTA, 2008; Olson, 2004). Occupational therapy intervention typically addresses problems with initiating and sustaining breastfeeding within the areas of feeding and eating, yet breastfeeding as a provision of care is clearly consistent with the occupation of child rearing as well, offering opportunities to examine broader mothering roles and the family and societal contexts that surround successful engagement in breastfeeding.

Breastfeeding as a Co-Occupation Within the Social Environment

As indicated earlier, breastfeeding not only transcends several areas of occupation but also can be described as a co-occupation. Co-occupations have been defined as highly interactive occupations, such as occupations of mothering or child rearing, in which the mother and infant engage in synchronous interplay (Pierce, 2000, 2009; Zemke & Clark, 1996). Recognizing breastfeeding as co-occupation assists in the characterization of breastfeeding as transcending eating, feeding, child rearing, and health management and maintenance occupations. When breastfeeding is defined as a co-occupation, it supports an integrated view of the infant’s occupational engagement in relationship to the mother and, within a certain context, further demonstrates the importance of a top-down, contextual occupational therapy approach. Olson (2004) described co-occupation as the space in which the mother–infant relationship exists, acknowledging that environmental and contextual factors inhibit or facilitate the success of this relationship. Thus, the mother, family, and broader society all influence the ability of the infant to engage in breastfeeding because of attitudes and beliefs about breastfeeding present in the co-occupational space and social environment.

The social environment is constructed by relationships and expectations (AOTA, 2008), and the people, organizations, and populations present in the social environment hold values and beliefs about breastfeeding. Li, Rock, and Grummer-Strawn (2007) examined public attitudes about breastfeeding and found that despite information on the health benefits of breastfeeding, a large increase in the public perception that artificial formula provides the same health benefits as human milk occurred from 1999 to 2003. Beliefs about the appropriateness of breastfeeding in public are also inconsistent, with individuals who are older and have less education less likely to view public breastfeeding as appropriate (Li et al., 2004). Other studies have demonstrated that mothers themselves hold negative attitudes about breastfeeding, including its being inconvenient, socially isolating, and embarrassing (Scott, Shaker, & Reid, 2004; Stewart-Knox, Gardiner, & Wright, 2003). Moreover, cultural views on appropriate infant feeding practices are also related to mothers choosing not to breastfeed or deciding to discontinue breastfeeding sooner than planned (Tiedje et al., 2002).

These findings illustrate the need to analyze environments and contexts when occupational therapists evaluate and provide intervention to mothers and infants experiencing difficulties in establishing and maintaining breastfeeding. Occupational therapy interventions addressing client factors or performance skills necessary for breastfeeding, such as coordinated and efficient latching and sucking, may be irrelevant if the mother believes that breastfeeding is inconvenient or embarrassing. Therefore, occupational therapy interventions that include positive social support for breastfeeding and that help to minimize embarrassment over breastfeeding in public are particularly important for supporting mothers in continued breastfeeding. Occupational therapy research can help further identify and examine environmental and contextual barriers to breastfeeding and develop effective individual and societal interventions.

Breastfeeding as a Co-Occupation and Mental Health Promotion

The decision not to initiate breastfeeding or to discontinue breastfeeding earlier than recommended may occur as a result of influences from the environments and contexts and in the absence of mother or infant impairment in other client factors or performance skills necessary for successful breastfeeding. In this situation, the occupational therapy approach is that of health promotion. Health management and maintenance is defined as “developing, managing, and maintaining routines for health and wellness promotion” (AOTA, 2008, p. 631). The health benefits of breastfeeding for the mother and infant are well established, and as occupational therapists, we also recognize the health benefits of meaningful engagement in occupation. Therefore, breastfeeding is also significant as a co-occupation of health management and maintenance, including mental health promotion, because of the bonding or shared space of the mother and infant during breastfeeding.

Pickens and Pizur-Barnekow (2009) furthered the understanding of shared space in co-occupation by proposing a new definition of co-occupation involving shared physicality, shared emotionality, and shared intentionality embedded in shared meaning. They supported this definition with several propositions, one being that a spectrum of co-occupation exists, from essential to complex, with each type characterized by shared physicality, shared emotionality, and shared intentionality (Pickens & Pizur-Barnekow, 2009). Shared physicality is an innate component of breastfeeding, with the infant’s physiological and motor responses reciprocating the mother’s actions. Infant hunger and sucking behaviors elicit the mother’s occupational feeding response. Pickens and Pizur-Barnekow described breastfeeding as an essential co-occupation vital to growth and development and characterized most strongly by shared physicality and less so by shared emotionality and shared intentionality. However, Whitcomb’s (2012) recent conceptual examination of relationships among attachment, identity, and occupation supports an argument that infants also demonstrate shared emotionality and shared intentionality in the co-occupation of breastfeeding and suggests that breastfeeding may be a complex co-occupation as well as an essential one, important for mental health promotion across the life course.

Shared emotionality exists in breastfeeding when the mother recognizes the infant’s hunger cue and readily responds; for many mother–infant dyads, breastfeeding encompasses more than a nutritive act and becomes a means for soothing, bonding, and attachment. The mother’s nurturing response provides an opportunity for the infant to experience positive emotions. Clearly, shared emotionality is a component of the co-occupation of breastfeeding, and breastfeeding is also an occupational means of shared emotionality for both the mother and infant and therefore contributes to the outcome of mental health. This shared emotionality is often assumed to be positive, yet for some mother–infant dyads, barriers to breastfeeding disrupt or prevent positive shared emotionality, placing mothers and infants at risk of physical and mental health conditions. When occupational therapists use a top-down approach and support engagement in breastfeeding as a health promotion occupation, affective mental functions, emotional stability, and emotional regulation skills are developed through meaningful occupational engagement.

Breastfeeding also consists of shared intentionality between the mother and the infant. Although rooting and latching are actions of shared physicality, these reflexes quickly establish intention on the part of the infant. This intention during breastfeeding is broader than meeting nutritional needs and includes participating in an attachment relationship with the mother (Whitcomb, 2012). Within the breastfeeding co-occupational space, the infant has the opportunity to develop communication and self-regulation skills through sustained eye gaze, attentiveness to the mother’s face, and listening to the mother’s voice. The mother engages in breastfeeding with the initial intention of satisfying the infant’s hunger, yet the mother also more subtly intends to support the infant’s skill development for future occupation (Wilcock, 1993). Moreover, the mother’s broader goal of health for her infant is embedded in this everyday occupation of breastfeeding. In the moment of co-occupational engagement in breastfeeding, the infant likely does not recognize the health intentions of breastfeeding; however, this shared meaning of breastfeeding as a health behavior contributes to the infant’s future personal health behaviors.

Given occupational therapists’ unique understanding of occupational engagement, they have an opportunity to promote health by supporting breastfeeding. Considering the negative societal attitudes that exist about breastfeeding, it is important for occupational therapists to be knowledgeable about the evidence-based recommendations for duration of breastfeeding and the health benefits of breastfeeding.

Occupational Therapy and Promotion of Exclusive Breastfeeding

Engagement in the occupation of breastfeeding occurs in a social and physical environment positioned within a broader personal and cultural context. Occupational therapists have the opportunity to promote health through breastfeeding with occupation-based interventions supporting participation in breastfeeding routines both for infants at risk of feeding difficulties and for healthy-population families. Client-centeredness is an important construct of the profession, and although exclusive breastfeeding may not be possible, important, or meaningful for every mother, occupational therapists may play a role in educating families about the health benefits of breastfeeding and advocating for social norms or routines supportive of breastfeeding.

Interventions supporting breastfeeding routines are easily integrated into the occupational therapy process in settings in which occupational therapists already provide services to infants at risk for feeding difficulties. For example, practitioners working in early intervention and other community-based settings may encounter mothers hesitant to continue breastfeeding (after struggling to establish this co-occupation for themselves and their baby) if social norms exist about breastfeeding preventing father–infant bonding.

Occupational therapists can assist clients in viewing breastfeeding as part of a broader routine of family social participation that strengthens attachment. One possible intervention directed at performance patterns is helping create family routines in which the father bathes and diapers the infant before transitioning the infant to the mother for breastfeeding. Alternatively, the mother may transition the infant to the father after breastfeeding for burping or settling to sleep. When the occupational therapy approach includes establishing habits and routines such as these, social norms are also adjusted, lessening barriers to continued breastfeeding. The occupational therapy process can help families identify when environmental barriers such as social norms conflict with personal or cultural beliefs about breastfeeding and child rearing.

Occupational therapists also have opportunities to support breastfeeding routines for healthy-population families. Interdisciplinary collaboration with nursing, lactation, and other health professionals already involved in breastfeeding promotion is necessary for defining the role for occupational therapists, particularly in establishing and supporting breastfeeding routines. Through hospital and community programs, occupational therapists may consult with expectant parents participating in birth preparation programs traditionally led by other health professionals. Beyond their role in assessing and establishing breastfeeding routines, occupational therapists can offer client education regarding breastfeeding ergonomics; typical infant development related to arousal, self-regulation, and feeding; and psychosocial strategies for the role of parenting. Occupational therapists can also evaluate the physical and social environments of child care centers, places of employment, and public spaces to identify barriers to breastfeeding and create interventions such as quiet, clean breastfeeding spaces.

Muir (2012) recently described opportunities for occupational therapy in primary health care. Primary health care settings, particularly pediatricians’ offices and community health centers, offer further opportunities for occupational therapists in breastfeeding promotion with healthy populations. Health care reform, program development, and outcome studies will help further establish evidence for the role of occupational therapy in breastfeeding promotion.

Occupational therapists are called to expand their intervention approaches for the occupations of feeding and eating to encompass the co-occupational needs of infants, mothers, and families during child rearing and health management and maintenance. This top-down, contextual approach aligns occupational therapy services with broader societal health objectives and offers opportunities for emerging practice in health promotion. Occupational therapists have opportunities to expand their consultation and advocacy to healthy-population families to lessen environmental and contextual barriers to breastfeeding and assist with establishing breastfeeding routines. Initiatives such as these demonstrate occupational therapy’s value as an innovative, holistic profession and may also inform program and policy changes locally and nationally, contributing to the profession’s Centennial Vision of being a powerful, widely recognized, evidence-based, and science-driven profession meeting societal needs (AOTA, 2007).