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Departments of Anthropology and International Health, Emory University, Atlanta, GA 30322
1To whom correspondence should be addressed. E-mail: dsellen{at}emory.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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KEY WORDS: • breastfeeding • child survival • public health policy • infant feeding • cross-cultural
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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–5)
. Recent
randomized trials lend strong support to the hypothesis that delaying
the introduction of complementary foods until 6 mo often benefits
infants and mothers through reduced disease exposure, increased breast
milk intake and lengthened birth intervals (4
,6
–9)
. Such
data focus attention on the scheduling and frequency of suckling and on
the nutritional quality and timing of introduction of nonbreast milk
substances (10
–13)
. The data suggest that a specific
subset of the potentially infinite variety of possible breastfeeding
and complementary feeding practices is optimal across a range of
settings (14
,15)
.
It is logical to assume that recommendations based on comparison of
clinical outcomes reflect an adaptive pattern naturally selected to
optimize the sometimes-conflicting biological interests of infants,
mothers, kin and affines (16
–21)
. Questions arise,
however, about the extent to which current recommendations based on
clinical observation fit with actual care-giving behaviors across
the breadth of human societies and about the acceptability and
feasibility of compliance in specific cultural contexts. It is
estimated that in developing countries, where the relative benefits of
optimal feeding are greatest, fewer than one-half of children
< 4 mo of age are exclusively breastfed (22)
and the
median duration of any breastfeeding is only 18 mo (23)
.
Globally, it has been estimated that 85% of mothers do not conform to
current recommendations (24)
. Attempts to improve maternal
and child health are often frustrated because normative practices
differ quite markedly from recommended ones for a number of reasons.
For example, perceived milk insufficiency, work activities and lack of
social support often undermine maternal intentions to initiate and
maintain breastfeeding (25
–29)
. In some settings,
ethnographic studies show that scientific claims about the benefits of
exclusive and continued breastfeeding lack local credibility because
they conflict with local understandings of the best strategies to
enhance child survival (30
–32)
. These include delayed
initiation of breastfeeding, use of prelacteals, discarding of
colostrum, early introduction of water, herbal teas and nutritive
liquids and the delayed use of semisolids and solid foods
(24
,33
–38)
. Thus, in many contemporary societies, a
complex mix of material and ideological factors seem to constrain
patterns of child feeding.
The scientific knowledge upon which our current child-feeding
recommendations are based is only recently acquired and remains limited
(39)
. It would be useful to know to what extent
populations primarily dependent on nonindustrial traditional modes of
subsistence achieved optimal infant-feeding patterns and to
identify any common factors that undermine optimal feeding in
nonindustrial modern and postmodern settings (24
,40
–42)
.
Clearly, there are advantages to developing policy directives broadly
concordant both with evolved, species-typical patterns and the
collective folk wisdom of human societies, if such could be
characterized. This article summarizes much of the available data on
weaning patterns in recent and contemporary nonindustrial societies and
assesses the extent to which these patterns match current public health
nutrition recommendations.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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was screened for records that
included information on weaning practices (indexed under category 862:
"weaning and food training") to construct a database of weaning
indicators. The resulting database was augmented with information
located with a retrospective snowball search of the anthropological
literature conducted using the Eureka database of the Tozzer library,
Harvard University. In both approaches, all information on the timing
of three key milestones in weaning process (age at first introduction
of liquids and solids and age at termination of breastfeeding) was
coded into a series of summary variables for use in statistical
analysis. A nonindustrial society was defined as one that remained
marginal to the emerging capital-intensive industrial world system
at the time of ethnographic or ethnohistorical description. Populations
were excluded from analysis if there was any evidence of industrial
production, a predominantly cash-based economy or demographic
transition (increase in child survival and reduction in fertility) at
the time of observation.
Descriptive weaning data for 133 culturally distinct, nonindustrial
groups were extracted from 172 sources (44)
. To correct
for pseudoreplication, estimates for the same culture observed within a
10-y period were aggregated or averaged for analysis as a single
observation series. To capture spatial-temporal variation,
estimates for populations of the same culture living in different
places or at different times > 10 y apart were treated as
independent. An algorithm to derive a single estimate of average ages
at each weaning milestone for each distinct population was implemented
as follows: 1) Any available survival estimate of median age
at a weaning milestone was retained for analysis; 2) if no
median estimate was available, a modal or mean age estimate was used;
3) where only a range of ages was reported, the midpoint of
the reported range was calculated; 4a) reports for the same
culture group based on data gathered no > 10 y apart were
averaged for analysis as a single observation; 4b) the
midpoint of the pooled range of ages at milestones was calculated as
the mean of the midpoint values of the original reports; 4c)
if no midpoint values were available for one or all reports on a single
population or in cases in which information on weaning was presented in
different formats by the different primary sources (e.g., one source
would report a range of age at termination of breastfeeding, whereas
another would cite a single age value), the midpoint of the pooled
maximum earliest and latest ages of the milestone was used;
4d) if only a single age estimate for earliest, latest or
average age at milestone was available, it was used as the best
estimate; and 5) data pertaining to several populations of
the same ethnic group living in different places or at different times
> 10 y apart were treated as independent (fieldwork dates
were used to make this determination if available, otherwise dates of
publication were used). All estimates were rounded to the nearest
one-half month before analysis because this was the most frequently
reported level of precision. Each case in the final sample, therefore,
represented a set of measures taken from populations distinguishable in
space, time and ethnic identity as defined by Western-trained
observers.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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).Age-specific estimates of the proportion of children partially or
predominantly breastfed were rare and most reports cited either a
single age at which weaning events or transitions typically occurred,
specified a range of typical ages or specified a full range of ages.
Given the paucity of the data on variation in ages at weaning
transitions within populations, the distribution of best estimates of
typical ages at weaning transitions were examined across populations.
Taken together, the data on introduction of nonbreast milk substances
suggest that in > 70% of nonindustrial populations, children
were typically supplemented with nonbreast milk liquids before 6 mo of
age and often within a few weeks of birth (Fig. 1
). Children were typically fed complementary solid foods before 6 mo in
> 50% of these populations, and the central tendency for
transition to solid foods fell between 5 and 6 mo of age in this sample
(Table 2
). Children were typically breastfed to 
30 mo (Fig. 2
), and beyond 24 mo y in 60% of these populations.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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. True statistical estimates of the median
breastfeeding duration were only available for 11 populations and less
than five sources reported medians, means or modes of ages at
introduction of nonbreast milk liquids and/or solid foods. No
independent means by which to test whether the midpoint of the reported
ranges is a reliable and comparable estimate of the average timing of
milestones in the weaning transition are available.
Second, reliance on the reports of others to construct indirect
estimates of proxies for weaning renders construct validity
questionable. No means exist to check veracity, control for observer
and measurement biases or to ensure direct comparability of the data
from different sources. It is difficult to assess the validity of the
point estimates used, and for most populations in the sample, these
measures can never be replicated. Male ethnographers, whose level of
training on issues of nutrition, childcare and demography varied
greatly, collected most of the data in the middle of the last century.
Many accounts describe weaning food choice and preparation in detail
and elaborate on child care issues, but others do not, and it is often
unclear how much information was obtained by observation, from
discussions with mothers themselves or from male informants and
community leaders. Nevertheless, use of a large and exhaustive sample
of cultures should minimize errors due to nonsystematic reporting bias.
Third, the sample was not randomly selected and no attempt was made to
control for Galton’s problem of the nonindependence of cultures
(46)
. However, no strong cultural biases are evident in
the final sample, which seems to represent a broad set of regional and
ethnic cases.
Current knowledge suggests that exclusive breastfeeding to 6 mo of age
and partial breastfeeding beyond 2 y of age is compatible with
good health and nutrition for most children within a population
(39)
. Average ages at introduction of solid foods and
cessation of breastfeeding in this sample are remarkably concordant
with current recommendations (Table 2)
, and one is tempted to infer
that the average child in a nonindustrial population was weaned on a
schedule similar to that recommended on the basis of the best available
clinical evidence. If this were true, it would corroborate the
hypothesis that current recommendations represent a global optimum
across a range of human social and ecological contexts and suggest that
optimal practices are attainable by a majority of mother–infant pairs.
It would raise the possibility that understanding the sociocultural
factors that supported optimal feeding practices in past nonindustrial
populations and continue to do so in some contemporary ones may suggest
solutions to improve young child feeding in a broader spectrum of
postmodern societies.
At least two considerations temper such an interpretation. First, the
range of variation between population estimates is considerable and
begs explanation. Although recent analyses (44)
find no
cross-cultural support for the hypothesis (47
–49)
that human weaning practices are directly influenced by type of
subsistence or the availability of foods appropriate for weaning, the
variation may have been related to differences in how women’s work
constrains the quality of child care and feeding
(28
,50
–54)
. In a classic study, Nerlove (55)
showed that infants tend to begin supplementary foods earlier in
cultures in which women are more active in subsistence. Modern
ethnographies of weaning focus on the biosocial costs and benefits of
alternative weaning practices within populations (56
–64)
.
Further examination of variation across nonindustrial populations may
shed light on the basic cultural organizational factors that inhibit or
facilitate optimal feeding. Meanwhile, we should assume that although
breastfeeding was more often of long duration in nonindustrial
populations, timely complementary feeding rates were almost as variable
as among modern populations, affected by the modern global economy.
Second, for a majority of societies in the sample, it is not possible
to ascertain what proportion of children was fed optimally. Even in
those populations for which the typical ages at weaning transition
concord with current recommendations, we cannot know what proportion of
children followed this typical pattern and we cannot assume it was a
majority even when reported age ranges are narrow. Moreover, our
ignorance of the shape of the within-population distribution around
the reported central tendency of each indicator severely hampers
interpretation of the wide standard deviations indicated in Table 2
.
Assumptions that the same socioecological determinants drive both
cross-cultural and intracultural variability and that the observed
cross-population patterns, therefore, reflect the distribution of
variation at the individual level remain untested and are prone to
ecological fallacies.
Despite these severe limitations of interpretation, the results extend
previous attempts to characterize adaptive, normative or optimal
patterns of human weaning. Classical evolutionary biological approaches
have focused on the adaptive aspects of weaning in relation to life
history and aimed to infer a human pattern from analysis of nonhuman
primate data. Cross-species comparisons have generated several
models to predict ages at which primates are adapted to terminate
lactation, which include: 1.5 times the length of gestation
(65)
, eruption of first molar teeth (66
,67)
,
tripling (68)
or quadrupling (69)
of birth
weight and attainment of one-third adult weight
(70
,71)
. Unfortunately, the range of variation in weaning
patterns within and between species of nonhuman primates has yet to be
fully described and explained (72
,73)
, and no model
reliably predicts age at weaning for all primate species. When applied
to humans, each model yields a wide range of predicted values due to
variation in birth and body weights across populations
(42)
, most likely because they do not incorporate the
modifying effects of diet, work activities, culture, social
organization and technology. Independent characterization of
species-typical values for human weaning parameters will facilitate
evolutionary analyses of human life history traits (74)
.
The idea that a return to traditional, natural or ancestral diets may
be healthy has tremendous appeal and may be a powerful motivator for
behavior change. However, extreme care must be taken when invoking
evolutionary arguments to develop recommendations for young child
nutrition. Advocacy of evolved patterns of child feeding as models for
current practice is not justified in the absence of clinical evidence
of their health benefits to mothers and children. The present results
do not suggest that all nonindustrial populations naturally practiced
optimal child feeding or that all children in such societies were
optimally fed. Fossil, archaeological and ethnographic studies generate
conflicting views of the adequacy of ancestral diets at different times
and places and do not usually consider the differing dietary needs of
individuals over the life course (48
,75
–78)
. Assumptions
about the lag between current and past lifestyles and risk exposures
remain unexamined (79
–81)
. Anatomically modern humans
occupied a broad range of foraging habitats during the last 130,000
y, and during the last 10,000 y, domesticated food production, trade
and increased social stratification influenced food availability and
work activity in most populations (82
,83)
. Such changes
might be expected to shift the optima for infant-feeding practices
and arbitrary selection of ethnographic data and an inappropriate focus
on the upper tails of the distribution of reported ages at weaning may
lead to apparent discrepancies between normative and recommended
practice.
In conclusion, the results have implications for the design of interventions to improve child-feeding practices. Evidence that typical feeding practice was and often continues to be within the optimal range defined from clinical observations among some non industrial populations will be useful in promoting exclusive and prolonged breast-feeding. Examination of how social, economic and technological factors combined to support optimal feeding practices in such populations may suggest new strategies for child survival interventions and elucidate the mechanisms through which modernity erodes the quality of child care and feeding. It is clear that systems of beliefs surrounding breastfeeding, weaning and childcare vary dramatically between cultures, undergo rapid change over time within cultures and are contested among different individuals in a community at any given point in time. Both material factors (such as the structure of women’s work and household availability of foods) and culturally constructed concepts (such as health and nutrition; infancy and child development; religion; social identity of children; and proper social relations among children, parents, caregivers and others) modify beliefs and practice. Given these sources of variation, it is striking that statistical signals indicate that normative practice among some nonindustrial populations may have been close to the optimum.
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ACKNOWLEDGMENTS |
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Manuscript received December 5, 2000. Initial review completed February 5, 2001. Revision accepted July 26, 2001.
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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