Breastfeeding and the mother–infant relationship—A review

doi:10.1016/j.dr.2008.07.001

Developmental Review

Volume 28, Issue 4, December 2008, Pages 503-521

https://doi.org/10.1016/j.dr.2008.07.001 Get rights and content

Abstract

A positive effect of breastfeeding on the mother–infant relationship is often assumed in the scientific literature, but this has not been systematically reviewed. This review aims to clarify the role of breastfeeding in the mother–infant relationship, which is conceptualized as the maternal bond toward the infant and infant attachment toward the mother. Our findings indicate that theoretical mechanisms through which breastfeeding may enhance the maternal bond or infant attachment (i.e., endocrine and sensory factors involved in breastfeeding) can be found in both humans and animal models. However, the few empirical studies investigating this association have not found convincing support for a relation between breastfeeding and the quality of the mother–infant relationship. We therefore conclude that assumptions on a positive role of breastfeeding on the mother–infant relationship are not supported by empirical evidence, and recommendation of breastfeeding should solely be based on its well-documented positive effects on infant and maternal health.

Introduction

Lactation is a defining characteristic of all mammals. In humans, breastfeeding has been related to improved maternal health (Labbok, 2001) and improved health and development of the infant (Anderson et al., 1999, Caspi et al., 2007, Hanson, 1998). The positive effects of breastfeeding on the mother–infant relationship have also been widely advocated. This relationship can be envisioned as consisting of two complementary facets: the maternal bond, or the mother’s tie to her infant, and infant attachment, defined as the infant’s tie to its caregiver.

Claims that breastfeeding positively affects the maternal bond and/or infant attachment have been put forward by various authors, not always accompanied by references or empirical evidence supporting such a claim. For example, a review on the benefits of breastfeeding concludes that “…breastfeeding enhances maternal–child attachment…” (Anholm, 1986, p. 8) without citing any scientific works relating breastfeeding to the maternal bond or infant attachment. More recent publications have made similar statements without providing empirical evidence (Aguayo, 2001, Leung and Sauve, 2005, Misri et al., 2000). Furthermore, mothers report choosing breastfeeding over bottle-feeding to improve the mother–infant relationship (Arora et al., 2000, Gijsbers et al., 2005). These types of claims and beliefs may have an important psychological impact on mothers who are unable to nurse (due to, for instance, breast surgery or jaw malformation of the infant). In these mothers, assumptions of the positive effects of breastfeeding on the mother–infant relationship put forward by scientists and nursing staff can induce feelings of guilt (Crouch and Manderson, 1995, Zetterström, 1999). In fact, a UK study reported that mothers intending to bottle-feed were, according to self-reports, likely to be charged with being a bad mother (Murphy, 1999). Given these possible psychological consequences for non-breastfeeding mothers, the importance of sound scientific evidence on the relationship between breastfeeding and the mother–infant relationship becomes all the more apparent.

This review aims to clarify the role of breastfeeding in the (development of) the mother–infant relationship. We commence by summarizing current knowledge on the concept, development, and assessment of the maternal bond and infant attachment. We then theorize how endocrine and sensory factors involved in breastfeeding may enhance the maternal bond or infant attachment. We summarize and evaluate the empirical studies on the relations between breastfeeding and the maternal bond and infant attachment. We finish this review with a discussion on general methodological problems and possible future directions for studying breastfeeding and (the development of) the mother–infant relationship.

Section snippets

The maternal bond and infant attachment: Definitions

We consider the mother–infant relationship as consisting of two complementary facets: the maternal bond, or the tie from mother to infant, and infant attachment, or the tie from infant to mother. Infant attachment entails the tie between infant and mother that develops from a distinct innate behavioral system, promoting mother–infant proximity (Bowlby, 1969/1982). The definition of the maternal bond is less clear. Klaus and Kennell (1976) introduced the term ‘maternal bonding’, defined as a

Theoretical support for a role of breastfeeding in the mother–infant relationship

Breastfeeding differs from bottle-feeding in a variety of ways. The hormones that stimulate milk production and milk ejection have, in animal models, been shown to affect maternal caregiving behavior and pair bonding. Furthermore, non-nutritive features of the mother–infant interaction during breastfeeding may promote infant attachment. Thus, breastfeeding may, in theory, affect the maternal bond or infant attachment.

In this section, we will discuss how factors inherent to breastfeeding may

Empirical studies on breastfeeding and the mother–infant relationship

A literature search was carried out in PsychInfo, Medline, and the International Bibliography for the Social Sciences for papers published after 1985 and written in English, combining the terms “bond^∗” and/or “attachment” with “breast?feed^∗”. The initial search yielded 328 papers, which, after reading the abstract of each paper and eliminating duplicate results, was reduced to 41 papers mentioning a relation between breastfeeding and the maternal bond or attachment. Out of these 41 papers, 22

General methodological constraints

As previously shown, there are theoretical mechanisms through which breastfeeding may promote the maternal bond or attachment. However, scientific support of this assumption is scarce. Again, this could indicate that breastfeeding does not affect the maternal bond or infant attachment, but may also be the result of the general lack of empirical studies on the subject and of methodological problems of these studies. In this section, we will further discuss general methodological issues

Conclusion

The scientific research carried out to date does not support the general assumption that breastfeeding has a positive effect on the quality of the mother–child relationship. When propagated, such an assumption may create unnecessary feelings of guilt in mothers unable to breastfeed. Recommendation of breastfeeding should therefore solely be based on its well-documented positive effects on infant and maternal health.

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The quality of mother-infant interactions is crucial for child development. Studies show that breastfeeding contributes to maternal sensitivity and the development of a positive mother-infant bond. Maternal mental health difficulties negatively impact both maternal sensitivity and breastfeeding. Thus, it is unclear whether breastfeeding contributes to the quality of mother-infant interactions independent from mental health. The purpose of this study is to examine the contribution of exclusive breastfeeding at 3 months postpartum to the quality of the mother-infant relationship at 6 months postpartum, controlling for maternal mental health in a community sample of mothers in Chile.
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The quality of mother-to-infant bonding (MIB) is a crucial determinant of nurturing behaviors and infant development, with bonding difficulties (MIBD) posing a substantial threat. While it is essential to identify MIBD risk factors, previous studies have generally examined MIBD at one time point, leaving the contributors to persistent MIBD uncertain. This study aims to discern longitudinal risk factors for persistent versus episodic MIBD.
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Breastfeeding and the mother-child relationship
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À la lecture des dernières études parues sur le sujet, l’allaitement maternel semble avoir des répercussions positives sur la relation mère-enfant. Toutefois, le lien d’attachement est complexe et dépend de nombreux facteurs, comme la proximité, le temps passé avec le bébé et la réussite du projet initial. Des implications pratiques pour les professionnels de santé peuvent être proposées pour favoriser le démarrage de cette relation.
The latest research suggests that breastfeeding has a positive impact on the mother-infant relationship. However, the attachment relationship is complex and depends on many factors, such as proximity, time spent with the baby and the success of the initial project. Practical implications for health professionals can be suggested to help start this relationship.
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The importance of breastfeeding for both maternal and infant health is well established. However, it remains the case that only a small percentage of infants are breastfed after the first six months of life. Maternal negative breastfeeding attitudes are associated with a reduced likelihood of breastfeeding an infant, but they are a malleable target for practitioner interventions. By adjusting perceptions, and therefore behaviours within the population, maternal and infant health outcomes may be improved. As such, it is important to understand whether certain types of mother might feel more negatively about breastfeeding. Here. we investigated the relationships between parenting styles, personality traits, and breastfeeding attitudes. In addition, we aimed to address the interrelated nature of parenting styles by identifying ‘types’ of mother who may feel more negatively about breastfeeding.
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More permissive and less uninvolved mothers felt positively about breastfeeding, but limited associations between personality factors and breastfeeding attitudes were found. We applied a cluster analytical approach to investigate whether there were particular ‘types’ of mothers in our sample, and if these showed systematic differences. Our analyses revealed two profiles, best described as ‘high nurturance’ (high scoring on authoritative and permissive) and ‘low nurturance’ (low scoring on these dimensions). These two types of mother showed significant differences along all four parenting styles, and our ‘high nurturance’ type was more conscientious and emotionally stable, and felt more positively about breastfeeding.
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Preterm birth and maternal sensitivity: Findings from a non-western country
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Citation Excerpt :
However, it should be noted that the underlying reason for this significant correlation could be that problem scores were already higher in the preterm group than in the term group, since problem scores were not found as a predictor of maternal sensitivity in hierarchical regression analysis. Finally, regarding the link between breastfeeding and maternal sensitivity and mother-child interactions, the literature has been inconclusive (Jansen, de Weerth, & Riksen-Walraven, 2008; Tharner et al., 2012). In this study, while the sensitivity scores of mothers who breastfed over six months were higher compared to ones breastfed less than six months, breastfeeding was not found as a predictor of maternal sensitivity in hierarchical regression analysis.
Although there are several studies on maternal sensitivity of preterm-born children conducted in Western countries, the factors affecting the sensitivity of mothers of preterm infants have not been investigated outside the Western context.
This study aimed to compare maternal sensitivity of preterm children at 18 months of corrected age with their healthy term-born peers and explore the factors associated with maternal sensitivity in a middle-income non-Western country. Moreover, the associations of maternal sensitivity with socio-demographic factors, maternal depression, and social-emotional competency and behavior problems of infants were investigated.
In total, 70 (40 preterm-born and 30 term-born) mother-child dyads participated in this study. An observation-based measurement tool, Maternal Sensitivity Scale, was used to assess maternal sensitivity. Social-emotional competency and behavior problems of infants were evaluated via The Turkish version of the Brief Infant-Toddler Social Emotional Assessment. Maternal depressive symptoms were assessed via the Beck Depression Inventory. In addition, a demographic information form was filled out by the mothers.
Maternal sensitivity scores of preterm infants were significantly lower compared to term infants. Depressive symptoms scores and employment status of mothers, socio-economic status (SES), gestational age, breastfeeding duration, and behavior problems of children were the factors related to maternal sensitivity scores. In hierarchical regression analysis, SES and gestational age were the strongest predictors of maternal sensitivity. After controlling SES and gestational age, maternal depressive symptoms scores negatively predicted maternal sensitivity scores.
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However, these results are not robust and small sample sizes could have played a role (Britton et al., 2006). Based on theoretical assumptions breastfeeding affects the endocrine system leading to the release of the hormones oxytocin and prolactin, which may promote maternal caregiving and indirectly improve the maternal bond and infant attachment (Jansen et al., 2008). Furthermore, breastfeeding is associated with reduced perceived stress and negative mood (Mezzacappa and Katlin, 2002) and increased calmness in mothers (Heinrichs et al., 2001).
In the popular and scientific literature an association between breastfeeding and attachment is often supposed although this has not been systematically investigated. This is the first review that provides a systematic overview of the current state of research on the association between breastfeeding and attachment. The objective is to determine whether breastfeeding is associated with child attachment as well as if maternal attachment is associated with breastfeeding behaviour.
A systematic electronic literature search for English language articles published from 1963 to 2019 using the databases Web of Science, PubMed, PsycInfo, and PsycArticles was conducted. Studies were included if (1) the association between breastfeeding and attachment of the child or maternal attachment style and breastfeeding was investigated, (2) participants were mothers or mother-child dyads, and (3) quantitative measures of breastfeeding and attachment were used. Study quality was rated using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.
Studies examining mothers or mother-child dyads were reviewed. Sample sizes varied between N = 60 and N = 8900 participants. On average, mothers were between 27.56 and 32.50 years old.
Eleven studies were eligible for inclusion. Of seven studies examining breastfeeding and child attachment, four found that a longer duration of breastfeeding was significantly associated with higher levels of attachment security after controlling for various covariates. No significant differences in attachment security between breastfeeding and bottle-feeding were reported, but one study found higher levels of attachment disorganization for bottle-feeding, although mean levels were below a clinically relevant level. The initiation of breastfeeding directly after childbirth was not related to child attachment. Of four studies examining maternal attachment and breastfeeding, three found a significant association between secure attachment of the mother and breastfeeding behaviour. Secure attached mothers initiated breastfeeding more often and preferred breast- over bottle-feeding than insecure attached mothers. Mixed results were found for breastfeeding duration. Most studies had limitations regarding adequate sample size, and valid and reliable measurement of breastfeeding.
The findings provide some evidence that breastfeeding might contribute to child attachment security. Furthermore, maternal attachment style might play a role in breastfeeding behaviour. However, more prospective studies are needed to draw a solid conclusion.
With regard to breastfeeding recommendations, health professionals should be aware of and communicate towards clients that the effect of breastfeeding on child attachment might be rather small. Screening of maternal attachment style as a part of maternity practice could be useful to support insecure attached mothers experiencing breastfeeding difficulties.

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Breastfeeding and the mother–infant relationship—A review

Abstract

Introduction

Section snippets

The maternal bond and infant attachment: Definitions

Theoretical support for a role of breastfeeding in the mother–infant relationship

Empirical studies on breastfeeding and the mother–infant relationship

General methodological constraints

Conclusion

Early Human Development

Hormones and Behavior

American Journal of Clinical Nutrition

NeuroImage

Hormones and Behavior

Obstetrics and Gynecology Clinics of North America

Trends in Pharmacological Sciences

Social Science and Medicine

Journal of Obstetric, Gynecologic, and Neonatal Nursing

Hormones & Behavior

Patient Education and Counseling

Biological Psychiatry

Physiology & Behavior

Brain Research

Brain Research Bulletin

Journal of pediatrics

Journal of Pediatrics

Pediatric clinics of North America

Journal of pediatrics

Journal of Pediatrics

Journal of Pediatrics

Peptides

Biological Psychiatry

Developmental Review

Parenting Stress Index manual

Parenting and alloparenting: The impact on attachment in humans bonding and attachment

Transition to child-care: Associations with infant–mother attachment, infant negative emotion, and cortisol elevation

Child Development

Patterns of attachment: A psychological study of the strange situation

Suppression of hypothalamic–pituitary–adrenal axis responses to stress in lactating women

Journal of Clinical Endocrinology and Metabolism

Suckling-induced attenuation of plasma cortisol concentrations in postpartum lactating women

Endocrine Research

Breastfeeding: A preventive approach to health care in infancy

Issues in Comprehensive Pediatric Nursing

Major factors influencing breastfeeding rates: Mother’s perception of father’s attitude and milk supply

Pediatrics

Comparative aspects of mother–child contact

Non-peptide oxytocin antagonist, L368,899®, reduces interest in infants and sexual behavior in rhesus monkeys when administered peripherally

Biological psychiatry

The origins of attachment theory: John Bowlby and Mary Ainsworth

Developmental Psychology

Prolactin stimulation of maternal caretaking behavior in female rats

Science

Central prolactin infusions stimulate maternal caretaking behavior in steroid-treated, nulliparous female rats

Proceedings of the National Academy of Sciences of the United States of America

Central infusions of the recombinant human prolactin receptor antagonist, S179D-PRL, delay the onset of maternal caretaking behavior in steroid-primed, nulliparous female rats

Endocrinology

Breastfeeding, sensitivity, and attachment

Pediatrics

A screening questionnaire for mother–infant bonding disorders

Archives of Women’s Mental Health

Neuroendocrine perspectives on social attachment and love

Psychoneuroendocrinology

Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism

Proceedings of the National Academy of Sciences of the United States of America

Maternal and perinatal factors influencing the duration of exclusive breastfeeding during the first 6 months of life

Journal of Human Lactation

Naturally occurring variations in maternal caretaking behavior in the rat are associated with differences in estrogen-inducible central oxytocin receptors

Proceedings of the National Academy of Sciences of the United States of America

Psychobiology of maternal behavior in human beings

Non-peptide oxytocin antagonist, L368,899^®, reduces interest in infants and sexual behavior in rhesus monkeys when administered peripherally