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JAMES J. DAVIS. Secretary



C A R E O F C H IL D R E N SE R IES N o. 5
Bureau Publication N o. 83

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Federal Reserve Bank of St. Louis
Federal Reserve Bank of St. Louis

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Washington, May 2, 1921.
S i r : The following monograph on Breast Feeding has been prepared
by Ella Oppenheimer, M. D., for the Children’s Bureau, for the pur­
pose of aiding the efforts of doctors and nurses to encourage maternal
nursing. It is offered in the belief that the degree of maternal
nursing in the United States may be increased and that such increase
offers the hope of saving life in many cases and of improving infant
J u l i a C. L a t h r o p , Chief.
Hon. J a m e s J . D a v i s ,
Secretary o f Labor.
Federal Reserve Bank of St. Louis

Federal Reserve Bank of St. Louis

To the notable reduction in infant mortality during the past '
decade the encouragement of breast feeding, improved economic
conditions, purification of milk supplies, advancement of scientific
knowledge of the nutritional needs of infants, education of mothers
in the artificial feeding of infants, have all contributed. It is unneces­
sary to minimize the value of any of these other factors in order to
emphasize the point that breast feeding has been the most important
single factor.
The experience of centuries, as well as scientific laboratory studies,
has demonstrated that in nutritional properties, in purity and clean­
liness, in warmth, in protective powers against infection, and in the
assurance it gives a child of a mother’s care, human milk can never
be replaced adequately by artificial food. The nourishment of an
infant with anything other than the secretion of the human breast
is properly termed “ artificial feeding,” or “ substitute feeding.”
The problem is often one of the most difficult which the physician
encounters. The fact that the diet is other than the natural one
renders an absolute solution of the problem impossible, since science
has as yet been unable to construct a food which is exactly like
human milk, and each child is an individual to whom general rules
can apply only in a general way.
That successful maternal nursing is possible for the vast majority
of women has been amply proved. It was brought out strikingly
by the experience of the European countries during the recent war,
of France in 1870-71, of England during the cotton famine of
1861-1865, when maternal nursing was universally resorted to
because of the scarcity of food. In this country the possibilities
of breast feeding have been demonstrated by the increase in natural
feeding under the encouragement of physicians and inf ant-welfare
centers in many cities, and particularly by the recent breast-feeding
campaign in Minnesota, which reached practically every mother in
a given area and resulted in a per cent of breast feeding ranging
from 96 at the end of the second month to 72 at the end of the ninth
In Boston the Baby Hygiene Association met with such success
that of 6,000 infants under its supervision only 196 babies less than
6 months old were entirely artificially fed. .The statistics of the
Starr Center in Philadelphia are equally notable. In 1912-13 only
48 per cent of the babies under its care were breast fed. After six
years of insistence on breast feeding, of 92 infants whose mothers
had been cared for by the prenatal department, 90 were entirely
breast fed at 1 month of age, 1 was partially breast fed, and only 1
was bottle fed.
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The problem of breast feeding must be viewed in all its aspects.
In our complicated modern society there must be widespread empha­
sis among all classes not only on the importance of breast feeding
but also on the ways and means of making it successful. There are
many false opinions to be overcome, such as the statement fre­
quently made that modern woman has lost the ability to suckle her
young, and the feeling created as a result of the emphasis on the
importance of pure milk and pasteurization in infant feeding that
this is at least as good and often better than breast feeding.
The problem of insuring breast feeding for babies includes eco­
nomic, educational, and health aspects of far-reaching importance,
for the possibility of every mother nursing her child implies an
economic level which will make it unnecessary for the mother to go
into industry while she is bearing children; it implies a training
for motherhood which emphasizes not only the importance, but
also the reasons for breast feeding; and its fulfillment demands
sound physical and mental health of the mothers, based upon
adequate prenatal, obstetrical, and general health care.
Studies made in many different countries have demonstrated that the
death rate among the artificially fed is at all times higher than among
the breast fed; that where for any reason breast feeding is the custom,
the mortality rate is low in spite of other unfavorable factors; and
that when for any cause breast feeding is increased in a community
the infant mortality rate is lowered. The studies of the Children’s
Bureau in New ^Bedford, Mass., Akron, Ohio, Manchester, N. H.,
and Brockton, Mass., have demonstrated that in these cities the
mortality rate for the artificially fed is about three or four times as
great as for the breast fed— the rate varying according to hygienic,
economic, and industrial conditions. Again, in rural communities
studied b y the Children’s Bureau, breast feeding is almost universal.
In these communities, even with a very high mortality rate during
the first month of life because of inadequate maternal care, the death
rate from diarrheal diseases and the total infant mortality rate is low
because of the prevalence of maternal nursing. A lowland county
of North Carolina had an infant mortality rate of 56.3; a mountain
county of North Carolina, 80.4; a rural county in Kansas, 55; and
the town of Saginaw, Mich., 84.6.
In studies made in overcrowded and poverty-stricken districts of
London, New York, Chicago, and other large cities the fact is very
clearly brought out that where by race or custom it is the practice to
feed infants at the breast the infant mortality rate is lower, even
though the environment be highly insanitary. There is the instance
of the low infant death rate obtaining among Jews, Italians, Scotch,
and Irish when these races continue even under adverse circumstances
to feed their infants at the breast.
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Mortality figures alone, impressive though they are, do not tell the
whole story. An extensive study of school children and military
recruits in Germany pointed out that the good effect of breast feeding
was manifested in later childhood and even in adult life. Nutritional
disorders, not necessarily fatal but which permanently handicap the
individual, occur much more frequently among the artificially than
among the breast fed. These disorders render the infant much more
susceptible to infection and may produce deformities of a permanent
nature (rickets). Again, the chance for the survival of the premature,
delicate, or syphilitic infant is almost entirely dependent upon the
availability of breast milk as a food.
Changes in the breasts preparatory to lactation make their ap­
pearance early in pregnancy. These changes are gradual, manifest
themselves in enlargement of the breast tissue, especially of the nip­
ples, and in the secretion of a small amount of fluid, clear and watery
during the earlier months of pregnancy but toward the end of preg­
nancy and for the first few days after labor creamy in character.
On the third or fourth day after labor the secretion of true milk begins.
So closely correlated and so interdependent are the functions of
childbearing and suckling that the act of nursing hastens the return
of the pelvic organs to normal size and function.
Many efforts have been made to discover the factors which stimu­
late the breast to the secretion of milk, but as yet these are undeter­
mined. All that can be said is that the removal of the child from
the uterus probably releases into the blood stream a substance
which stimulates the breast glands to an activity for which they were
prepared by pregnancy. The glands once having secreted milk,
their continued secretion is largely a matter of the demand made
upon them. If a child does not suckle at the breast the secretion of
milk quickly subsides. If a child is feeble and fails to empty the
breast at each nursing the supply of milk may fail unless other means
of emptying are used. On the other hand, the complete emptying of
the breast b y a strong child will not only maintain a good supply but
will increase what was originally a poor supply. In other words, the
greater the demand the greater the supply. It therefore follows that
all factors in the child which lead to a diminution in the force of
suckling and the remedies therefor need consideration in any cam­
paign for promoting breast feeding. Such factors are:
1. Maturity and general development of the child: The premature
and the puny child b om at term frequently do not possess
strength enough for forceful suckling.
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2. General hygiene and technique of nursing.
Adequate quiet and sleep between feedings: Nursing by the
clock, preferably at three or four hour intervals. The im­
portance of this can hardly be overestimated. Too fre­
quent feeding of the baby results in a failure of appetite,
so that he takes a little milk often and never completely
empties the breast.
Nursing where there is a minimum amount of distraction for
the child: This factor is very important especially for the
nervous type of infant and for all infants as they grow
older. Distraction at the time of nursing tends to make a
child cease before the meal is complete, resulting in failure
to empty the breasts, and crying and restlessness before
the next nursing time.
Position of the child when nursing: It is important that the
child be held in such a manner that breathing is not inter­
fered with.
3. Physical abnormalities in the child, either local or general:
Such conditions as adenoids, harelip, cleft palate, and dis­
turbances of the central nervous system.
The remedy for these conditions is two-fold: The education of the
mother in the care of her child, preferably during pregnancy or
earlier, and the proper care of the mother during pregnancy and
labor. Such care will eliminate in large part the premature and
weak infant, and those physical abnormalities which are the result
of injuries at birth.
Fortunately, however, though this is the ultimate solution of the
problem, there are very satisfactory methods of emptying the breast
on which a weak or physically defective child fails. This matter is
especially important because the weak child needs, above all, breast
milk, and his very condition tends to diminish not only the amount
he takes but also the amount of milk available. A very valuable
technique has been worked out. This consists in instructing the
mother or nurse to express milk from the breast after each nursing
by the following method:
Scrub the hands and nails with soap, warm water, and a nailbrush
for at least one full minute. Wash the nipple with fresh absorbent
cotton and boiled water or a freshly made boric solution. Dry the
hands thoroughly on a clean towel and keep them dry. Have a
sterilized graduate glass tumbler or large-mouthed bottle to receive
the milk.
Grasp the breast gently but firmly between the thumb placed in
front and the remainder of the fingers on the under surface of the
breast. The thumb in front and the first finger beneath should rest
just outside of the pigmented area of the breast.
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2. With the thumb a downward pressing motion is made on the
front against the fingers on the back of the breast, and the thumb
in front and fingers behind are carried downward to the base of
the nipple.
3. This second act should end with a slight forward pull with
gentle pressure at the back of the hippie, which causes the milk to
flow out.
The combination of these three movements may be described as
u Back-down-out.”
It is not necessary to touch the nipple.
This act can be repeated 30 to 60 times a minute after some
Both breasts may be emptied if necessary, or they may be used
The milk should be covered at once by a sterile cloth held in place
by a rubber band and kept on ice until used.
It is to be given to the baby at the end of the next nursing. By
this method not only does the child get the nourishment which he
needs, but the complete emptying of the breasts increases the supply
of milk.
If at first sufficient milk is not available by suckling and expression,
as determined by weighing the child before and after feeding, artifi­
cial food can be given temporarily after each nursing. Experience
wuth many thousands of cases both in Minnesota and elsewhere has
demonstrated the value of this method. It has been shown to be
possible, too, by this means to reestablish the secretion of milk in the
breast after as long as six weeks’ inactivity. It is possible to express
milk from the breasts by other methods, such as by massage or the
breast pump, but the method described is probably the best way of
stripping the breasts.
As far as the mother herself is concerned, though the demand of a
strong suckling child or a substitute is the most important considera­
tion in maintaining an adequate milk supply, there are many others
to be taken into account in our modern life.
1. Adequate prenatal care and instruction for the mother.
(a) General:
Adequate nutritious diet, including a good supply o f 1
vitamines. This will not only maintain the nutri­
tion of the mother, but is a potent factor in the
development of a strong child.
Freedom from overwork either without or within the
Instruction during this period concerning the impor­
tance of breast feeding for the child and the means
of procuring it.
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Medical care, to prevent such conditions as eclampsia,
which is likely to interdict breast feeding; to pro­
mote general hygiene and physical well-being, par­
ticularly to remove foci of infection, such as in
teeth, which have been demonstrated to be factors
in the unsatisfactory production of breast milk;
to prepare for labor.
(b) Special:
Emphasis on care of the breasts to prepare them for
lactation. Where the nipples are small, attempts
to lengthen them may be made by slight traction
and molding, night and morning.
2. Lying-in period.
Good obstetrical care will eliminate birth injuries in both
mother and child, severe hemorrhage, and puerperal fever,
conditions likely to inhibit breast feeding.
3. Postnatal period.
Sufficient rest, freedom from anxiety, good general hygiene
with special emphasis on a nutritious diet are the factors
likely to insure a good milk supply.
4. Lactation period.
Good mental and physical hygiene during the period of lacta­
tion with all that this implies. This means adequate but
not too much food, and an abundance of fluids in the diet—
at least two quarts. The diet should be a good, mixed,
easily digested one, containing animal protein and foods
rich in vitamines, notably milk, eggs, butter, and fresh
Daily exercise, fresh air, and rest, but not indolence.
Freedom from worry and emotional excitement.
Chemical analysis was early resorted to as a means of determining
the quality of breast milk. Wide and varied application of this
method has shown that it has very marked limitations. It has been
found that the composition of milk varies in the same woman from
day to day, from nursing to nursing, and at different periods of the
same nursing. Any analysis, therefore, to be valid, must be made on
all the milk from the breast at a given time, or on samples taken at
the beginning, middle, and end of nursing, and the same result
must be obtained at least twice. It has also been found that the
quality of milk can not be gauged by its analysis alone. There are
marked variations in chemical composition, entirely -compatible
with growth and good digestion in the child; on the other hand' a
presumably normal chemical analysis may occur in a milk which is
indigestible and does not provide adequate stimulus for growth.
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The average composition of breast milk is generally given as
follows : 1




Per cent.
Per cent.
3.50 3.00 to 5.00
7.50 6.50 to 8.00
1* 2o 1.00 I/O 2.00
. 18 to . 25
87.55 89.32 to 84.75

In general, variations in quality determined by analysis fall into
three types:
1. All elements too high.
This type is most frequently found in women who do too little
and eat too much and too rich food.
2. Fat and sugar low, proteins high.
This type is usually found in women of the poorer classes v/ho
are overworked and underfed.
3. Fat and sugar very low, proteins very high.
This type is usually found in the highly strung, overeducated,
and highly civilized women of the larger cities, but may
be found in neurotic women of any class or community.
In recent years variations in the nutritional properties of human
milk have been shown to be due also to its vitamine content. The
vitamines of human milk are concentrated from the food taken by
the mother; if they are not present in sufficient quantities in her
food, the milk suffers. The effect of an insufficient amount or absence
of these substances in the milk is exhibited in the child. Scurvy, for
example, in the breast fed has been shown to develop because of the
deficiency of the antiscorbutic factor in the mother’s food. The
development of rickets in the breast fed has also been shown to be
due to a deficiency in the mother’s diet, reflected in the qualitv of
her milk.
Trouble with the breast itself may interfere with satisfactory
breast feeding. The presence of depressed nipples is a distinct handi­
cap , it may be remedied at times by the employment of a nipple
shield. Cracks or fissures in the nipples sometimes occur. These
render nursing very painful, and offer a convenient portal of entry
for infection. They may usually be prevented by the proper care of
the breasts during pregnancy, and during lactation by carefully
1 Holt’ The Diseases of Infancy and Childhood, p.-137.
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New York and London 1919.



washing the nipples with fresh boric acid solution before and after
each nursing. If fissures occur, compound tincture of benzoin
should be applied to them, and a nipple shield should be used
for nursing until the cracks heal. After nursing, the nipples
should be washed and dried. The shield should be carefully cleaned
and boiled before using. Mastitis, or infection of the breast, is
another complication. This can be prevented usually by the methods
just described for preventing and treating fissures. Its occurrence,
however, is an indication for rest to the breast involved, by nursing
the child at the other breast exclusively, emptying the infected breast,
if it becomes distended, by means of expression or a breast pump,
cold applications and incision when indicated. After the breast has
healed the child should be nursed at it again.
A normal breast-fed baby gains steadily from 4 to 8 ounces a week,
presents no symptoms of indigestion in the form of vomiting or
diarrhea, and has as a rule from 2 to 4 soft yellow movements a day.
There are, however, many deviations from such a course. The baby
may be constipated or its stools may be too frequent and green; it
may fail to increase in weight normally. Such symptoms are fre­
quently interpreted by the mother and often by the physician to
indicate unsuccessful breast feeding and the necessity for resorting
to artificial feeding. This conclusion is drawn from false premise,
for symptoms which would be alarming in an artificially fed baby
may be viewed with equanimity in the breast fed, so great is the
factor of safety in mother’s milk. Under such circumstances a care­
ful study of both mother and child, and, if indicated, of the milk, will
reveal causes which may be remedied. Overwork and underfeeding,
underwork and overfeeding, sometimes the absorption of poisons
from foci of infection and worry on the part of the mother, may change
the quality of the milk so that it will produce one or another type of
symptom in the child. The discovery of the cause and its removal
will often yield fruitful results.
A study of the child as well as of the mother may point the way to
the difficulty. Is his failure to gain due to the fact that he is not
vetting all of the available milk, or to the fact that the milk is
“ weak ” ?. Is he vomiting because he overflows from too full a stom­
ach or is the milk too rich or is there an obstruction of some kind ?
Are his frequent stools the effect of an overrich milk on a sensitive
intestine; are they the expression of some excitement on the part of
the mother or the baby; or are they “ starvation stools” ? Is his
constipation a reflection of the same condition in the mother; are his
own intestinal and abdominal muscles flabby; is the volume of his
food too small for the intestines to contract on satisfactorily; or is
there spasm of the anal sphincter? From a consideration of the
factors influencing the quality of milk it is obvious that the problem
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is social and economic as well as medical, and that for its understand­
ing and solution all these forces in the community must work together,
just as they must cooperate to prevent the occurrence of the difficult
case of breast feeding.
1. Educational.
Mothers :
All mothers should be instructed during pregnancy and
after the baby comes by means of literature, public
health nurses, and consultations. They should be in­
structed among other things in the importance of breast
feeding and in the means of promoting it, in which mat­
ters the prenatal nurse can be of great assistance.
Community :
The community in general should be interested through
lectures, newspaper propaganda, etc., in the fundamental
necessity of this phase of child welfare, so that—
(a) It will be possible for every mother who is able to
do so to nurse her child.
(b) There will be provision by the establishment of properly
supervised wet-nurse directories and institutions for col­
lecting and distributing bottled breast milk for the child
who needs breast milk and can not get it from its mother.
2. Economic and social.
Adequate income for the nursing mother and her family:
To provide adequate nourishment for the mother.
To eliminate the necessity for outside industrial work.
To provide for home help when necessary.
To eliminate strain and worry attached to inadequate
living conditions.
Aid in the adjustment of individual problems.
3. Medical.
High standards of care during pregnancy, labor, puerperium,
and period of lactation.
Careful study of both mother and child to discover and remedy
any causes of difficulty in breast feeding.

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Federal Reserve Bank of St. Louis