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Focus on ZERO TO THREE Fellows

In this issue, we are honored and delighted to hear from ZERO TO THREE Fellowship Academy member Dr. Zohreh Zarnegar about a topic of deep concern to her: the “clear and compelling duty and responsibility to endorse, support, and promote breastfeeding for every mother who is able to feed her baby during the first year of life.” Drawing from personal experience and a depth of professional knowledge and work with families, Zohreh shares her passion for supporting infants and mothers, and the families, communities, and countries in which they live.

Author bio:

Zohreh Zarnegar, PhD, MS, MA, is a pediatric neuro-psychologist serving young children and their families in California since 1982. She provides mentoring and training for health care professionals around the world who serve families with young children exposed to traumatic experiences and children diagnosed with Fetal Alcohol Spectrum Disorder. In 1998 she proposed and lead the Infant-Early Childhood and Family Mental Health Program (ICARE) in Los Angeles County. She is a ZERO TO THREE Graduate Fellow (2002–2003), California Endorsed Infant-Family Child Mental Health (IFECMH) Specialist-Reflective Practice Facilitator & Mentor, a Child Trauma Academy Fellow, and a human rights activist.

Why Should We Support Breastfeeding?

by Dr. Zohreh Zarnegar

I was quite young when I learned about the importance of mother’s milk.

When I was growing up, I knew a child who was not born to our mother, yet my siblings and I were told he was our brother because our mother breastfed him. He was the son of my mother’s best friend who was born around the same time as my older brother. His mother could not breastfeed him and, out of affection for her friend, my mother volunteered to feed him along with her own newborn, my older brother.

Later on, I learned that what happened in my family was not an exception, but a necessary common practice in many ancient cultures that continues today. Current scientific evidence affirms the wisdom of this practice, confirming that mother’s milk is the best natural source of nutrients and has substantial benefits for the overall development of babies. (1)

However, further literature review of the importance of breastfeeding in various cultures (e.g., Hausman, 2003) reveals that in the United States, since formula feeding was introduced in the 1920s, the choice of how to feed infants has taken on social, racial, and economic dimensions, generating a conflict for mothers who wish to breastfeed their babies.

Six Critical Reasons for Promoting Breastfeeding

Excluding situations in which a mother is not able to, or advised not to, breastfeed her newborn baby (in cases to prevent transmission of infectious diseases) (2), through this writing, I will present some of the many short- and long-term benefits of mother’s milk for the health and well-being of babies that I have learned over the years. My hope is to offer a strong rationale for using our resources to teach, support, promote, advocate, and exemplify breastfeeding as much as possible.

  1. Overwhelming research findings (e.g., World Health Organization, 2003, point to the fact that around the world, babies who are breastfed are more likely to survive and thrive than babies who are fed alternative baby-food.
  2. Many researchers (3) report that, in comparison to the other babies, breastfed babies, especially pre-term ones, are healthier, have fewer allergies, and have a better immune system to prevent illnesses that are prevalent among babies than those who are not breastfed. Breastfed babies fight diseases when they occur, such as diarrhea and other digestive and infectious diseases, and are hospitalized less often.
  3. The higher nutritional quality of mother’s milk in comparison to formula is scientifically proven. Breastfed babies grow steadily. The lactose in mother’s milk helps with absorption of minerals and calcium. It is also a preventive factor for childhood obesity, type 2 diabetes, gastrointestinal problems, and lactose deficiency, which may result in malabsorption and intolerance syndrome. Such diseases are rare among exclusively breastfed infants. (4) In third world countries, the formula is pushed by the formula companies. In addition, lack of oversight by the health authorities, increased professional pressures, and the increased need for baby formula—which is expensive and thus over-diluted with unsafe water—has replaced mother’s milk. These babies end up hungry and malnourished, and they get childhood diseases such as diarrhea and dehydration, which are primary causes of infant mortality worldwide. (5)
  4. Whole brain development is a concept describing growth and development of the brain’s different functions, some of which explained here briefly:
    1. For infants, breastfeeding has been shown to have direct beneficial impact on self-regulation (easy to soothe, regulated feeding and sleep-awake cycles). In turn, benefits to breastfeeding mothers include mood and affect regulation, stress reduction, and more responsive and effective parenting (6).
    2. Babies’ social–emotional development is also positively affected by breastfeeding. Direct physical contact between the baby and the mother during breastfeeding is a joyful shared experience. Hearing each other’s heartbeat, skin-to-skin touching, and feeling each other’s body temperature during the breastfeeding are all sensory inputs that are soothing and provide a sense of emotional safety, security, and warmth which a bottle of baby formula would not. (Bottle-fed babies may still experience some of these sensations if held closely by the mother, although, in my experience, mothers often give the infant the bottle feed herself/himself as soon as the infant is able to hold it, so the infant doesn’t receive the benefits of being held.)
    3. Similarly, mother’s voice and baby’s responses through sounds and movements are critical for sensory development and language learning. In addition, the face-to-face eye contact between the baby–mommy dyad while breastfeeding provides a right brain to right brain communication—a significant exercise in baby’s brain development and a factor in organizing a template for the baby’s future relational interactions, view of the world (e.g., trust vs. mistrust), and emotional development.
    4. Higher mental capacity, cognitive development, and learning were found to be directly related to breastfeeding through various studies, including the PROBIT study. These findings were ground breaking in that PROBIT was a scientific study, controlled for many factors such as familial and environmental factors that could have potentially confounded the results. (7)
  5. Breastfeeding mothers also enjoy immediate, short, and long-term benefits not reported in formula-fed babies: (8)
    1. Improved health, and reduced risk of developing diseases, such as diabetes, cardiovascular, hypertension, and metabolic and reproductive cancer.
    2. Stronger bonding between mother and the baby as breastfeeding mothers become more attuned and responsive to the baby’s cues and needs.
    3. Better weight re-stabilizing during breastfeeding.
    4. Reducing another pregnancy during baby’s first developmentally significant perinatal months.
  6. Financial benefits for the families of breastfeeding mothers are reported by researchers. For example, in 2018, Kelly Bonyata reported savings of about $3,000.00 per year for families that breastfeed in comparison to the formula-feeding ones. Similarly, health care cost analyses by other researchers (9) present a substantial financial savings as well as saving many lives.

Barriers to Breastfeeding

In the United States, the rate of breastfeeding has risen from 75% in 2011 to 81% in 2018(9). However, some factors continue to obstruct some mothers’ ability to breastfeed their babies. These include:

  • mother’s return to work
  • negative beliefs about breastfeeding
  • health issues of the mother
  • lack of cultural, community, and spousal support
  • health issues of the infant
  • number of children in the family (first baby is fed longer than the subsequent ones)

The Need for Worldwide Breastfeeding Champions

Subjecting a mother to shame or making her feel guilty for her decision not to breastfeed her baby for personal or health related reason(s) would not benefit the mother, the baby, or their relationship. Instead, professionals and policymakers have a clear and compelling duty and responsibility to endorse, support, and promote breastfeeding for every mother who is able to feed her baby during the first year of life.

My mother’s gift of kindness to her best friend made a lasting impression on me, as have the thousands of mothers and newborns whom I have had the privilege to serve in various capacities. Virtually every mother I’ve met wants what is best for her baby. At the international level, however, the challenges to breastfeeding remain wide, where clinical, as well as social, geopolitical, and economic issues are affecting the lives of children and decisions of their parents. Personally, I propose to put the welfare of children above all else. My commitment is to ensure that mothers around the world have every support at the family and community level they need to give their children the gift of their own breastmilk.


  1. Fildes, V. (1988). Breasts, bottles, and babies: A history of infant feeding. Medical Anthropology Quarterly2(3), 306–308. Fildes, V. (1995). The culture and biology of breastfeeding: A historical review of Western Europe. In P. S. Macadam & K. A. Dettwyler (Eds.), Breastfeeding: Biocultural perspectives (pp. 101–126). New York, NY: Aldine De Gruyter. Hausman, B. L. (2003). Mother’s milk: Breastfeeding controversies in American culture. New York, NY: Routledge. Leung, A. K., & Sauve, R. S. (2005). Breast is best for babies. Journal of the National Medical Association97(7), 1010–1019. [PubMed: 16080672]. World Health Organization. (2003). Global Strategy for Infant and Young Child Feeding. Geneva, Switzerland: WHO and UNICEF.
  2. Centers for Disease Control and Prevention. (2006). When should a mother avoid breastfeeding? Atlanta, GA. [cited September 23, 2018]. Retrieved from www.cdc.gov/breastfeeding/pdf/. World Health Organization (2004). HIV transmission through breastfeeding: A review of available evidence. Geneva, Switzerland: World Health Organization and UNICEF.
  3. Quigley, M. A., Kelly, Y. J., & Sacker, A. (2007). A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Pediatrics119, e837–e842. Chien, P. F., & Howie, P. W. (2001). Breast milk and the risk of opportunistic infection in infancy in industrialized and non-industrialized settings. Advances in Nutritional Research10, 69–104. [PubMed: 11795054.]
  4. Beyerlein, A., Toschke, A. M. & von Kries, R. (2008). Breastfeeding and childhood obesity: Shift of the entire BMI distribution or only the upper parts? Obesity (Silver Spring), 16, 2730–2033. Brandtzaeg, P. (2003). Mucosal immunity: Integration between mother and the breast-fed infant. Vaccine21(24), 3382–3388. [PubMed: 12850345]. Chirico, G., Marzollo, R., Cortinovis, S., et al. (2008). Antiinfective properties of human milk. Journal of Nutrition138(9), 1801s–1806s. [PubMed: 18716190]. Grummer-Strawn, L. M., & Mei, Z. (2004). Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics113, e81–e86. Newburg, D. S., & Walker, W. A. (2007). Protection of the neonate by the innate immune system of developing gut and of human milk. Pediatric Research61(1), 2–8. [PubMed: 17211132].
  5. Ellis-Petersen, H. (2018, February 27). How formula milk firms target mothers who can least afford it. The Guardian. Scanlan, M. (2018). Battle of the bottle in developing countries. Why is infant formula use so high in developing countries despite breast being best and what can be done. Global trends in exclusive breastfeeding. The Nutrition Press, January 15, 2018. Retrieved from thenutritionpress.com/battle-of-the-bottle-in-developing-countries/. Ebrahim, G. J. (1986). Infant feeding in the third world. Postgraduate Medical Journal,62,93–96.
  6. Martin, C. R., Ling, P-R., & Blackburn, G. L. (2016). Review of infant feeding: Key features of breast milk and infant formula. Nutrients, (8), 279, 1–11. Doi:10.3390/nu8050279. Rolland-Cachera, M. F., Deheeger, M., Akrout, M., et al. (1995). Influence of macronutrients on adiposity development: A follow up study of nutrition and growth from 10 months to 8 years of age. International Journal of Obesity and Related Metabolic Disorders19, 573–578. U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition, Office of Nutritional Products, Labeling and Dietary Supplements. (2002, April 11). Health professionals letter on Enterobacter sakazakii infections associated with use of powdered (dry) infant formulas in neonatal intensive care units. Retrieved from http://www.cfsan.fda.gov/%7Edms/inf-ltr3.html. Accessed May 19, 2017.
  7. Amin, S. B., Merle, K. S., Orlando, M. S., Dalzell, L. E., & Guillet, R. (2000). Brainstem maturation in premature infants as a function of feeding type. Pediatrics106 (2 Pt 1), 318–322.
  8. Kramer, M. S., Aboud, F., Mironova, E., et al. (2008). Breastfeeding and child cognitive development: New evidence from a large randomized trial. Archives of General Psychiatry65(5), 578–584. [PubMed: 18458209].
  9. Godfrey, J. R., & Lawrence, R. A. (2010). Toward optimal health: The maternal benefits of breastfeeding. Journal of Women’s Health19(9), 1597–602. Dieterich, C. M., Felice, J. P., O’Sullivan, E., & Rasmussen, K. M. (2013). Breastfeeding and health outcomes for the mother-infant dyad. Pediatric Clinics of North America, 60(1), 31–48. doi:10.1016/j.pcl.2012.09.010.
  10. Bonyata, K. (2018). Financial costs of not breastfeeding …or cost benefits of breastfeeding. Retrieved from https://kellymom.com/pregnancy/bf-prep/bfcostbenefits/. Ball, T. M., & Wright, A. L. (1999). Health care costs of formula-feeding in the first year of life. Pediatrics103(4), 870–876. [PubMed: 10103324]. Bartick, M., Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: A pediatric cost analysisPediatrics125(5), e1048–e1056. United States Breastfeeding Committee. Economic benefits of breastfeeding [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.
  11. Centers for Disease Control and Prevention. (2016). Breastfeeding Report Card –– United States. Atlanta, GA. [cited July 10, 2018]. Retrieved from www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf.

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