HHS Public Access Author manuscript Author Manuscript
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19. Published in final edited form as: Breastfeed Rev. 2016 November ; 24(3): 25–32.
From royal wet nurses to Facebook: The evolution of breastmilk sharing Kelley L Baumgartel [PhD Postdoctoral Scholar], Targeted Research and Academic Training of Nurses in Genomics, University of Pittsburgh, School of Nursing, Department of Health Promotion and Development
Author Manuscript
Larissa Sneeringer [Undergraduate Student], and University Research Mentorship Program, University of Pittsburgh, School of Nursing Susan M Cohen [DNSAssociate Professor] University of Pittsburgh, School of Nursing, Department of Health Promotion and Development
Abstract
Author Manuscript
Wet-nursing was an essential practice that allowed for infant survival after many mothers died in childbirth. The story of wet-nursing is complicated by both religious pressures and cultural expectations of women. It is likely that these historical practices have shaped our current social, political and legislative environments regarding breastfeeding. The aim of this article is to provide a historical perspective on the practice of wet-nursing, with a focus on: 1) social views of wet nurses, 2) breastmilk evaluation and 3) the ideal wet nurse. Historical perspectives from Ancient Egypt, Ancient Greece and Rome, 19th and 20th century America and current practices are examined. An appreciation for the evolution of breastmilk sharing provides clinicians and lactation advocates with the historical origins which provided the template for current practice as it relates to donor milk, breastfeeding culture and relevant legislation.
Keywords wet nurse; breastmilk sharing; breastmilk; breastfeeding; donor milk
Author Manuscript
Wet-nursing, the practice of a woman feeding a child at the breast who is not biologically her child, was a practical way to provide nutrition for infants and reinforce social class distinctions. The history of wet-nursing, a story complicated by mixed views of women and an appreciation for infant life, provides the platform from which current donor breastmilk banks and milk sharing practices are derived The standards for ideal wet nurses changed with the evolving needs for wet nurses, as did the evaluation methods to ensure high quality breastmilk. These historical practices and standards have influenced clinical practice, legislation and social attitudes regarding donor milk and milk sharing. Currently, certified breastmilk banks have allowed for the organised distribution of milk to vulnerable infants whose mothers are unable to provide the prescribed volume. Additionally,
Telephone: 412-523-8731, [email protected].
Baumgartel et al.
Page 2
Author Manuscript Author Manuscript
peer-to-peer milk sharing, though not recommended by the European Milk Banking Association, Human Milk Banking Association of North America nor La Leche League International, due to the risk of contamination and other safety concerns, is becoming increasingly popular with the advent of online social support. An appreciation for the history of wet-nursing, particularly its social context, helps clinicians and breastfeeding advocates better understand how current trends are shaped. For this manuscript, ‘wet-nursing’ includes both exclusive and non-exclusive breastfeeding (feeding baby at the breast), as this broader inclusion allows for a more comprehensive historical appreciation for wet-nursing throughout history. With access to the University of Pittsburgh’s Special Collections and Rare Book Library, we were able to inform the historical story of wet-nursing. The historical books relevant to this topic were American-based; therefore, this manuscript has an American focus. Though the intent of this article is not to provide a comprehensive history of wet-nursing, we will emphasise the following shared elements, from Ancient Egypt to modern practices: 1) social view of the wet nurse, 2) tests of milk quality and 3) the ideal wet nurse. An interpretation of this historical influence on current social practices, including milk banks and milk sharing, is provided.
ANCIENT EGYPT Social view of wet nurses
Author Manuscript
Breastfeeding provided infants with protection from dehydration and minimised exposure to contaminated food and thus became essential for infant survival in Egypt’s hot climate. An infant’s health was believed to be in constant danger from Labartu, a female demon, so incantations were recited to protect the mother, infant and wet nurse (Fildes, 1986). Like infant mortality, maternal mortality was very high in ancient Egypt (Wells 1975). The subsequent reliance on wet nurses to provide nutrition for orphaned infants increased and wet nurses were promoted to the level of worship (Fildes, 1988). Wet nurses are often depicted in Egyptian illustrations at near God-like status, wearing headdresses similar to Hathor, the goddess of fertility (Fildes, 1986).
Author Manuscript
A social distinction between classes, emphasised by the use of wet nurses, is first recorded in this time period, as royalty primarily used wet nurses to feed their infants. Immediately after a queen gave birth, her infant was given to the wet nurse, who then breastfed the infant. Royal wet nurses were carefully selected, highly respected and are shown on guest lists at events. Unlike royal Egyptian families, the poor would breastfeed their own infants and seek a wet nurse only if the mother died in childbirth or was unable to breastfeed. Animal milk such as camels, goats, sheep and cows was also used to feed infants as an artificial feeding and as additional food once the child was several months old (Fildes, 1986). Breastmilk evaluation During the time of ancient Egypt, the milk’s scent provided valuable information on its quality. Ideal breastmilk smelled like ‘powder of manna’, while inferior breastmilk smelled like ‘snj of fish’. Cures for poor quality breastmilk included warming the bones of a Xru fish in oil and rubbing the wet nurse’s back. Spells and incantations were recited to increase and protect the wet nurse’s milk (Fildes, 1986).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 3
The ideal wet nurse
Author Manuscript
The ideal wet nurse was a woman who was able to produce the best nutrition for an infant, based on specific characteristics. She was unmarried, so could not have sexual intercourse and/or become pregnant (both of which would spoil her milk). Wet nurses should also only breastfeed one child at a time. Additionally, she was on a regulated diet so her milk would not become unsuitable for the child. There was a great preference in some cultures for milk produced by a woman who had a son (Fildes, 1986).
ANCIENT GREECE AND ROME Social view of wet nurses
Author Manuscript
The Roman philosophers Plutarch and Gellius recognised the bond established between mother and infant through breastfeeding. A fear developed that the wet nurse may compromise this bond and Plutarch concluded that a mother should be excused from breastfeeding only when ill or if more children were desired (Fildes, 1988). Despite these recommendations, wet nurses were commonly used by the wealthy during Ancient Greece and Rome during mid-1st millennium BC, more commonly known as the Classical era. Wet nurses held a high status in the household and were often responsible for the child’s care until adulthood. A wet nurse during ancient Rome was often a slave who would nurse for a wage and ultimately gain her freedom (Fildes, 1986). Breastmilk evaluation
Author Manuscript
Ancient Greek and Roman practice permitted the employment of a wet nurse only after her milk was subjected to the sweet bay leaf test. If the milk droplet retained its form after being dropped on the leaf, it was considered optimal breastmilk. Milk believed to be indigestible would fail this test if the milk droplet dissolved immediately or was watery (Fildes, 1986; Obladen, 2012). This test served as a way to distinguish between the quality of milk produced by individual wet nurses and optimised opportunities for those women who produced quality breastmilk. The ideal wet nurse Ancient Greek beliefs held that breastmilk was a product of menstrual blood not shed during pregnancy. This led to the instruction that wet nurses should not be employed if pregnant or menstruating because their milk would be compromised (Fildes, 1988). The ideal wet nurse should be Greek, have brown hair and a calm temper (Obalden, 2012).
Author Manuscript
MIDDLE AGES Social view of wet nurses The profession of wet-nursing re-emerged as desirable in Europe in the 14th and 15th centuries when noble and upper-class women hired wet nurses to feed their infants. Wet nurses subsequently became highly respected, well paid and received both food and lodging for their services. Defects in the child’s disposition were often attributed to the wet nurse (Fildes, 1988). During the Middle Ages, wet-nursing continued to serve as an indicator of social class, and many wet nurses were slaves or ex-slaves (Obalden, 2012). In Western Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 4
Author Manuscript
Europe, wealthy and noble families often employed wet nurses because breastfeeding was inconvenient and women could regain their fertility (Fildes, 1986). Unlike the rich, poor families could not afford the services of a wet nurse and breastfed their infants themselves (Fildes, 1988). It was not recommended to give infants animal milk because it was believed this would cause the child to become ‘animal-like’. Animal milk was still used in time of need when a mother could not breastfeed and couldn’t afford a wet nurse. (Fildes, 1986). Breastmilk evaluation
Author Manuscript
Ideal breastmilk should have a good odour, be continuous and hold its shape when placed on a rock or sword (Fildes, 1988). If an infant presented with an illness, the cause was commonly attributed to either the wet nurse (Obladen, 2012) or her diet (Fildes, 1988). The infant’s treatment focused on the wet nurse, as her milk was blamed for the child’s illness (Fildes, 1988). Wet nurses with a poor milk supply were instructed to eat fennel seed, cumin, lettuce, ginger and white pepper (Ruhrah, 1925). The ideal wet nurse The ideal wet nurse who lived during the Middle Ages had specific attributes, including: being primiparous, young, brunette and having birthed a son. Wet nurses were chosen by the infant’s father (Obladen, 2012) and moved into the family’s home so their habits could be closely monitored, as it was believed that a compromised lifestyle could spoil their milk. Lifestyle behaviours that were believed to compromise breastmilk included the wet nurse’s diet, exercise, general conduct and sexual activity. If the wet nurse contaminated her milk with these actions, she paid a fine and was punished by the town. Most importantly, the ideal wet nurse during the Middle Ages was a socially favoured woman with a good disposition, who ate and drank in moderation (Fildes, 1988).
Author Manuscript
19TH CENTURY Social view of wet nurses
Author Manuscript
The impact of the Reformation in Europe permeated Puritan theology and manifested in sermons devoted to the ‘evils’ of non-breastfeeding mothers. These sermons taught that nonbreastfeeding mothers who chose to hire a wet nurse were selfish and did not breastfeed for a variety of reasons, including: desire to maintain a social life, preference for non-restrictive clothing and a lack of love for both her child and God (Fildes 1988; Apple, 1987). Breastfeeding had become a religious duty: ‘Oh confider, how comes our milk? Is it not by the direct prouidence of God? Why prouides he it, but for the child? The mothers then that refuse to nurse their owne children, doe they despise God’s prouidence? Doe they deny God’s will?’ (Clinton, 1975, p. 10). Subsequently, the employment of a wet nurse as a symbol of social class began to decrease, though this change was mostly observed in France. As artificial feeding methods improved and became safer, wet-nursing became less common. In America, cows’ milk was now required to be bottled, pasteurised, sealed and refrigerated, making it safer and more convenient for infants to consume (Wolf, 2001). Scientists in the 1800s began to develop formula that resembled human milk. Liebig’s infant food was the first patented formula in
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 5
Author Manuscript
1865, which consisted of cows’ milk, wheat, malt flour and potassium carbonate (Stevens, Patrick & Pickler, 2009). Food preservation, a newly developed technique, allowed for the creation of powdered, condensed and evaporated milk and many mothers fed these milks to their infants as a cheaper alternative (Stevens, Patrick & Pickler, 2009). Breastfeeding also saw a decline during this time, as formulas and preserved milks were a more convenient alternative. Public health officials still promoted breastfeeding as the best option for infant nutrition and offered medical research that instructed new mothers to breastfeed to reduce the risk of milk fever, an often fatal infection (Fildes, 1986). Formula was regarded as a last resort, as the best substitute for mother’s milk was a wet nurse (Wolf, 2001; Clinton, 1975).
Author Manuscript
During this time, few hospitals existed that were paediatric-specific and the few that existed were not suitable for neonates (Obalden, 2012). It was not until 1928 that the first unit for infants was opened with a milk kitchen and in-house wet nurses. A midwifery textbook from the mid-19th century warns of the danger of formula: ‘… it [artificial nursing] is admitted by all to be the worst of the various methods proposed for nourishing a child’ (Cazeaux, 1866, p. 958). In the United States, wet nurses were poor women in desperate circumstances and the social class distinction remained (Wolf, 2001). Physicians preferred wet nurses to artificial feeding; however, parents frequently objected to this recommendation because wet nurses were viewed as immoral and unruly. They were commonly women who were forced to sell their milk because they were unwed mothers and subsequently abandoned by their family (Wolf, 2001). Breastmilk evaluation
Author Manuscript Author Manuscript
Ideal breastmilk was thin and plentiful (Underwood, 1827); therefore, the thick consistency of colostrum was considered unfavourable and discarded (Cazeaux, 1866). This practice allowed wet nurses who were producing mature milk to provide their services while the mother was expressing and disposing of colostrum. Colostrum was either expressed by other women using a sucking glass or consumed by an older ‘lusty’ child (Fildes, 1986). Ideal breastmilk during this time was also sweet and had a blue tint (Underwood, 1827). A test for breastmilk quality included the placement of a few drops of milk in a spoon. The droplet should be opaque, homogeneous and without an odd odour or taste. If possible, the milk should be subjected to microscopic examination, which should reveal a thick layer of cream. Recommendations are also made to weigh the infant both before and after a feeding to estimate milk intake, a practice which continues today. This recommendation was first made by European obstetricians and spread to other countries, since it was considered a way to measure the health of a newborn (Weaver, 2010). In Italy during this time, milk was subjected to evaluation by leaving drops of milk on a white cloth to dry in the shade. The colour of the dried milk would be evaluated to determine what to expect from the infant: yellow for choleric intemperance, black for melancholia, mouldy or unsweet milk for calm infants (Whitaker, 2000). Wet nurses could remedy bad milk by avoiding certain foods, including: wine, onion, garlic, saffron and salt. Additionally, renouncing work or any exertions with a preference for calmness and rest was believed to optimise milk quality (Whitaker, 2000). Wet nurses were often supervised by physicians for adequate milk production. Employers also oversaw the work of the wet nurse to ensure proper development
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 6
Author Manuscript
and health of their child and to make certain the wet nurse was not supplying her children more nourishment than the infant they were employed to feed (Golden, 1996). The ideal wet nurse
Author Manuscript
A recognition of the lactation continuum is noted during this period, since breastmilk produced by a woman before 2 months postpartum (Cazeaux, 1866) or 6 months (Underwood, 1827) was considered advantageous to the child’s ‘digestive powers’ (Cazeaux, 1866, p. 953). In cases of maternal illness or death, a wet nurse was selected by a physician, a serious medical decision that required intense scrutiny to minimise disease transmission (Epps, 1843). The physician was tasked with identifying a suitable wet nurse (Whitaker, 2000) and a physical examination was performed on the potential wet nurse to ensure her physical health (Epps, 1843). In America, wet nurse bureaus were started in major cities, which required that all wet nurse applicants receive physical examinations to receive a certificate of health. Those who were in need of a wet nurse then paid $5.00, and the bureaus found and certified someone for them (Wolf, 2001). Ideal characteristics of a potential wet nurse included women who: were non-menstruating, good-tempered, had small nipples, good teeth, florid gums, were sober, clean, enjoyed children and rested (Underwood, 1827). The ideal wet nurse should also consume a specific diet, be willing to take daily walks outside, be between 20–35 years old (Underwood, 1827), should not be a first-time mother, should have a large chest with bluish veins on her breasts that indicate an abundant supply, be lively, sexually continent, well-formed and be moderately sized (Whitaker, 2000). The wet nurse should not exhibit any unpleasant tendencies (Cazeaux, 1866), as milk from an angry wet nurse could cause extreme infant colic and even death (Whitaker, 2000).
Author Manuscript
20TH CENTURY Social view of wet nurses In the 1900s, wealthy women were more likely to hire a wet nurse, as these women viewed breastfeeding as restrictive (Golden, 1996). This need for wet nurses, combined with an increased use of artificial feeding practices resulted in two conflicting results: 1) wet nurses became a last resort for medical practices and their role was marginalised and 2) wet nurses who were hired in desperation were able make high demands for their services. Wet nurses in America in the early 1900s earned nearly five times more than a paediatric nurse (Apple, 1987). The early 20th century experienced resurgence in wet-nursing, and the practice remained a sign of wealth; however, few families could afford their services and the demand for wet nurses decreased.
Author Manuscript
By the mid-20th century, the American Medical Association promoted bottle-feeding as the best feeding method and endorsed wet-nursing only when bottle feeding failed, further reducing the demand for wet-nursing. Contradictory advice was propagated, with familiar slogans like ‘breast is best’, followed by descriptions of breastmilk inadequacy. Despite an adequate milk supply, mothers were advised that bottle-fed infants were no less healthy or happy than breastfed babies (Apple, 1987).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 7
Author Manuscript
The dairy industry was not yet overseen by the federal government and as a result, cows’ milk was often full of harmful bacteria. Wealthy women could afford pasteurised milk, while poor women could not adhere to expensive formula recommendations and instead breastfed or fed the child home-prepared foods when they were considered old enough to be introduced to other foods. Physicians developed formula based on a percentage system of lipids, sugar and proteins that would later be marketed to rich women as an ideal food for infants. As formula became more popular, advertisements appeared in women’s magazines and displayed phrases such as ‘No more wet nurses’, which illustrates the formula manufacturers’ view of their competition (Apple, 1987).
Author Manuscript
The 20th century introduced a public health campaign to combat prematurity, an event that was once privately mourned (Golden, 1996). As neonatology advanced, the importance of breastmilk was emphasised for this vulnerable population. One neonatologist, Dr Owen Wilson, purchased breastmilk from wet nurses and helped to reduce infant mortality rates in his practice (Golden, 1996). This is an early example of donor breastmilk as a valued commodity. Breastmilk evaluation
Author Manuscript
Breastmilk analysis became common in the late 1890s and into the 20th century, and many doctors based their diagnoses and therapy on the milk’s composition. Ideal milk was 3–4% fat, 6–7% sugar, and 1–2% protein (Wolf, 2001). Nursing curricula in a Chicago school included a class devoted to the microscopic evaluation of human milk (Wolf, 2001). However, once formula became the mainstay infant feeding method in the mid-20th century, the consensus in the medical community of ideal milk was determined not by the physical attributes of breastmilk, but rather formula composition that was based on a percentage system of milk components (Apple, 1987). The notion of ideal milk shifted from observable or measurable breastmilk qualities to bovine-based milk that was contaminant-free. Ideal wet nurse Although the practice of wet-nursing in America was not as common during the 20th century, the notion of an ‘ideal’ nurse remained central to those who were in need of one. A suboptimal wet nurse was a thin woman who was nervous, irritable and emotional. It was believed that emotional women could poison the milk and such women were excused from breastfeeding (Apple, 1987). The wet nurses’ babies were frequently examined and, if her children were healthy, the milk was assumed to be of good quality (Wolf, 2001).
21ST CENTURY Author Manuscript
Social view of wet nurses or milk donors Today, the need for a traditional wet nurse has decreased in developed nations likely due to: 1) a remarkably low maternal mortality rate and/or 2) the availability of infant formula. The rate of preterm births, however, has increased and it is likely that the number of infants born preterm will continue to rise as neonatology advances and more premature infants survive. Breastmilk provides these infants with protection from infections during their neonatal stay and long-term protection against many childhood diseases (Schanler et al., 2011). A caveat
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 8
Author Manuscript
to providing breastmilk for such high risk infants is that mothers who deliver this early often experience compromised milk supply due to stress and underlying pathologic disease processes (Hale & Hartmann, 2007). To circumvent this obstacle, the use of donor milk has gained popularity to provide preterm infants with protective nutrition until the mother can produce an adequate supply of breastmilk. Though we rarely refer to women who donate breastmilk as ‘wet nurses’, we have established organised breastmilk banks, where women can donate milk for other infants. Donor breastmilk banking is a promising practice, whose roots are unequivocally based in the ancient practice of wet-nursing.
Author Manuscript
Unfortunately, specialised formulas are marketed for premature babies in the NICU. They are advertised as containing nutrients found in breastmilk, including DHA, Leutin and vitamin E which sustain growth and stimulate brain, eye, and immune system development. Such formulas intrude on protocols such as Baby-Friendly that are set up in hospitals to encourage mothers to breastfeed or pump milk for their infants (Baby-Friendly USA, 2012). If the mother is unable to supply her own milk, this formula also competes with donor milk, which is the next best nutritional choice for the baby (American Academy of Pediatrics, 2012). Donor milk allows sick and vulnerable infants to receive the benefits of breastmilk and thus have a better chance for survival (Human Milk Banking Association of North America, 2012). Breastmilk evaluation and the ideal milk donor
Author Manuscript Author Manuscript
Breastmilk composition is variable between women (Ballabio et al., 2008) and some of the historical notions of milk quality based on the expresser (wet nurse) may have modern scientific support. Historically, the image of an ideal wet nurse was complicated by social constructs, including hair colour, parity, sexual arousal and infant gender. The modern corollaries to these lifestyle variables, which do impact breastmilk composition, include: medications, diet, alcohol or drug consumption, exercise and tandem nursing (Hale & Hartmann, 2007). According to the Human Milk Bank Association of America, women who wish to donate their breastmilk must be: in good general health, willing to undergo a blood test, not regularly use medications or herbal supplements and willing to donate at least 100 ounces of milk (Human Milk Banking Association of North America, 2015). Additionally, milk donated to certified milk banks in Europe and North America undergoes similar screening and pasteurisation processes (European Milk Bank Association & Human Milk Banking Association of North America, 2015). Potential donors must not: have a positive blood test result for HIV, HTLV, hepatitis B/C or syphilis, use illegal drugs, smoke or use tobacco products, have received an organ or blood transfusion in the last 12 months or regularly have more than two ounces of alcohol per day. Even more interesting is that some historical variables that were seen as ideal characteristics of wet nurses, which seem outrageous today, are potentially important predictors of milk composition. For example, the levels of bioactive lipids present in milk are significantly different based on infant gender, with milk expressed from women who delivered males having higher energy content than milk expressed by women with female infants (Thakkar et al., 2013).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 9
Author Manuscript
PEER-TO-PEER MILK SHARING
Author Manuscript
Perhaps the modern-day corollary to wet nurses are women who donate their milk to certified milk banks. However, we would be remiss if we excluded the ever-growing community of peer-to-peer milk sharing options. Milk banks serve high-risk infants who are prescribed human milk by a physician or nurse practitioner (Gribble, 2013). The World Health Organization (WHO) recommends cross-feeding or wet-nursing when breastfeeding and milk expression aren’t possible (WHO, 2003). Furthermore, WHO recommends that non-breastfed infants be monitored by the health and social welfare system, as they ‘… constitute a risk group’ (WHO, 2003 p. 10). There are many infants who are unable to receive breastmilk from their mother, due to: adoption, breast hypoplasia, insufficient glandular tissue, HIV-positivity, maternal death, early breastfeeding challenges and infants with ankyloglossia (Martino & Spatz, 2014). While creating a demand for human milk, these do not meet the traditional clinical requirements for prescribed donor breastmilk. Social view of milk sharing
Author Manuscript
Some mothers who are unable to breastfeed or express enough breastmilk have limited options. Milk banks usually supply human milk to NICU infants or those prescribed donor milk by a physician. While employing a wet nurse has been close to extinct since the 1900s (Stevens, Patrick, & Pickler, 2009), wet-nursing still exists in the form of shared breastmilk. Because wet nurses were historically employed and paid, a parallel can be drawn between wet-nursing and waged milk donors. Mothers can sell expressed milk by the ounce either to for-profit milk banks or directly to women looking to feed their infant. Direct purchases usually occur online, on websites like Human Milk for Human Babies and Eats on Feets. These online communities promote altruistic milk sharing, where no fee is involved with the sharing of human milk and serve nearly 50,000 members in 50 countries (Martino & Spatz, 2014).
Author Manuscript
The US Food and Drug Administration, La Leche League International, HMBANA and EMBA have expressed concern with online milk sharing due to the risk of receiving unsafe breastmilk (Perrin et al., 2014; European Milk Bank Association & Human Milk Banking Association of North America 2015). These concerns are related to the known risk of purchasing milk online, as this milk carries a high risk of contamination compared with donor milk (Keim et al., 2013). Approximately 3.3% of HMBANA donors test positive for a viral/bacterial disease (Cohen, Xioing & Sakamoto, 2010), 60% of internet-purchased milk is damaged during transport and 45% is unsafe (Geraghty et al., 2013). Similar safety research on commerce-free milk sharing is unavailable, but milk sharing advocates are steadfast in proclaiming that the benefits of human milk outweigh any potential risks. As a result, both the HMBANA and EMBA do not recommend milk sharing outside of certified milk banks (European Milk Bank Association & Human Milk Banking Association of North America, 2015). Mothers who choose to be altruistic milk sharers value their human milk and the health of the infant their milk is feeding and/or the idea that they’re helping a mother who is struggling. This connection motivates these donors to avoid harm associated with milk sharing (Perrin et al., 2016).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 10
Author Manuscript
It seems that the social differences between milk donors and recipients seen through history remain among milk sharing program participants; however, milk donors have more education and higher reported incomes than milk recipients (Palmquist & Doehler, 2014). This is counter to the history of poor and marginalised wet nurses serving rich mothers. Milk recipients also experience a higher caesarean-section rate and report lower levels of breastfeeding support when compared with milk donors on milk-sharing sites (Palmquist & Doehler, 2014). Ideal milk donor
Author Manuscript
The online community provides an open forum for milk recipients and donors to connect. Many milk donors who participate in peer-to-peer milk programs have never donated to milk banks and one reason for this is that milk donors report that they prefer knowing exactly where their milk goes and what the recipients’ circumstances are (Gribble, 2013). As a result, and similar to historical preferences for specific wet nurses, milk donors report personal characteristics that might make their milk more appealing to potential recipients, including milk attributes (milk bank certified), donor lifestyle (regarding smoking/alcohol, diet, caffeine) and no medications/supplements (Perrin et al., 2014). The ‘ideal’ milk donor has evolved into a personal connection within milk sharing programs, open to the needs and preferences of individual mothers.
CONCLUSION Implications for clinicians and breastfeeding advocates
Author Manuscript
Consistent themes, including tests for breastmilk quality and the ideal wet nurse, emerge through the history of wet-nursing and these influences still permeate modern practices of milk donation. Some of the historical notions that not all breastmilk is created equal, as indicated by tests of milk quality, are confirmed by modern lactation science that shows great milk variability between women. The evolution of milk sharing continues to change with improved knowledge of lactation science, the advent of social networking and an increasing number of donor milk banks. An appreciation for the history of milk sharing by breastfeeding advocates will inform policy and clinical protocols surrounding this ancient practice.
Author Manuscript
While there are references to international milk banking practices, we recognise that this historical manuscript mostly describes American recommendations and milk banking practices. Overall, the teleological and historical importance of wet-nursing has led to the continuation of this ancient practice through the institution of donor breastmilk banks and milk sharing. Research has focused on both the acute and long-term outcomes of donor milk administration in infants who survived as a result of neonatal advances. Milk sharing and purchasing continues to become increasingly popular with the advent of online communities and increased awareness of the advantages of human milk over formula. Future research may explore the molecular mechanism for breastmilk composition which may contribute to the great variability of milk composition observed between women. These profiles may lead to the identification of modern-day ‘ideal’ wet nurses who would yield optimal breastmilk for a matched infant.
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 11
Author Manuscript
References
Author Manuscript Author Manuscript Author Manuscript
American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012; 129(3):e827–e841. [PubMed: 22371471] Apple, R. Mothers and medicine: A social history of infant feeding 1890–1950. Wisconsin Publications in the History and Science of Medicine; London, England: 1987. Baby-Friendly USA. About us. 2012. Retrieved from https://www.babyfriendlyusa.org/about-us Ballabio C, Bertino E, Coscia A, Fabris C, Fuggetta D, Molfino S, … Restani P. Immunoglobulin-A profile in breast milk from mothers delivering full term and preterm infants. International Journal of Immunopathology and Pharmacology. 2008; 20(1):119–128. Cazeaux, P. A theoretical and practical treatise on midwifery: Including the diseases of pregnancy and parturition and the attentions required by the child from birth to the period of weaning. Philadelphia, USA: Lindsay & Blakiston; 1866. Centers for Disease Control. Maternal mortality and related concepts. 2007. Retrieved from http:// www.cdc.gov/nchs/data/series/sr_03/sr03_033.pdf Clinton, E. The Countesse of Lincolnes nurserie. Amsterdam, Netherlands: Theatrum Orbis Terrarum; 1975. (Original work published 1628) Cohen RS, Xiong SC, Sakamoto P. Retrospective review of serological testing of potential human milk donors. Archives of Disease in Childhood. Fetal and Neonatal Edition. 2010; 95(2):F118–120. [PubMed: 20231217] Epps, J. Domestic homeopathy; or rules for the domestic treatment of the maladies of infants, children, and adults, and for the conduct and treatment during pregnancy, confinement, and suckling. Otis Claap; Boston, USA: 1843. European Milk Bank Association & Human Milk Banking Association of North America. Milk Sharing A statement from the European Milk Bank Association (EMBA) and the Human Milk Banking Association of North America (HMBANA) [PDF file]. 2015. Retrieved from http:// www.europeanmilkbanking.com/images/news/EMBA%20HMBANA%20Milk%20Sharing %20Statement%20FINAL%20January%202015.pdf Fildes, V. Breasts, bottles and babies. Edinburgh, Scotland: Edinburgh University Press; 1986. Fildes, V. Wet nursing: A history from antiquity to the present. New York City, USA: Basil Blackwell Inc; 1988. Geraghty SR, McNamara KA, Dillon CE, Hogan JS, Kwiek JJ, Keim SA. Buying human milk via the internet: Just a click away. Breastfeeding Medicine. 2013; 8(6):474–478. [PubMed: 23971685] Golden, J. A social history of wet nursing in America: From breast to bottle. New York, USA: Press Syndicate of the University of Cambridge; 1996. Gribble KD. Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2013; 42:451–461. Hale, T., Hartmann, P. Textbook of human lactation. Amarillo, USA: Hale Publishing LP; 2007. Human Milk Bank Association of North America. Donate milk: Do you want to donate your surplus milk to help a sick or fragile infant?. 2015. Retrieved from https://www.hmbana.org/donate-milk Keim SA, Hogan JS, McNamara KA, Gudimetla V, Dillon CE, Kwiek JJ, Geraghty SR. Microbial contamination of human milk purchased via the internet. Pediatrics. 2013; 132(5):e1227–e1235. [PubMed: 24144714] Martino K, Spatz DL. Informal milk sharing: What nurses need to know. MCN The American Journal of Maternal Child Nursing. 2014; 39(6):369–374. [PubMed: 25333804] Obladen M. Regulated wet nursing: Managed care or organized crime? Neonatology. 2012; 102:222– 228. [PubMed: 22833013] Obladen M. Early neonatal special care units and their scientific achievements. Neonatology. 2012; 102:89–97. [PubMed: 22653040] Palmquist A, Doehler K. Contextualizing online human milk sharing: Structural factors and lactation disparity among middle income women in the US. Social Science & Medicine. 2014; 122:140– 147. [PubMed: 25441326]
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 12
Author Manuscript Author Manuscript
Perrin MT, Goodell LS, Allen JC, Fogleman A. A mixed-methods observational study of human milk sharing communities on Facebook. Breastfeeding Medicine. 2014; 9(3):128–134. [PubMed: 24490980] Perrin MT, Goodell LS, Fogleman A, Pettus H, Bodenheimer AL, Palmguist AE. Expanding the supply of pasteurized donor milk: Understanding why peer-to-peer milk sharers in the United States do not donate to milk banks. Journal of Human Lactation. 2016; 32(2):229–37. [PubMed: 26905342] Ruhrah, J. Pediatrics from the past. New York, USA: 1925. Incipit practica puerorum passions puerorum adhuc in cunabulis iacentium. (Original work published 12th–15th centuries) Schanler RJ. Outcomes of human milk-fed premature infants. Seminars in Perinatology. 2011; 35(1): 29–33. [PubMed: 21255704] Stevens EE, Patrick TE, Pickler R. A history of infant feeding. The Journal of Perinatal Education. 2009; 18(2):32–39. Thakkar SK, Giuffrida F, Cristina CH, De Castro CA, Mukherjee R, Tran LA, … Destaillats F. Dynamics of human milk nutrient composition of women from Singapore with a special focus on lipids. American Journal of Human Biology. 2013; 25(6):770–779. [PubMed: 24105777] Underwood, M. A treatise on the diseases of children with directions for the management of infants from the birth. Printed for Callow and Wilson; London, England: 1827. Weaver LT. In the balance: Weighing babies and the birth of the infant welfare clinic. Bulletin of the History of Medicine. 2010; 84(1):30–57. [PubMed: 20632732] Wells C. Ancient obstetric hazards and female mortality. Bulletin of the New York Academy of Medicine. 1975; 51(11):1235–1249. [PubMed: 1101997] Whitaker, ED. Measuring mamma’s milk: Fascism and the medicalization of maternity in Italy. Ann Arbor, USA: University of Michigan Press; 2000. Wolf, JH. Don’t kill your baby: Public health and the decline of breastfeeding in the nineteenth and twentieth centuries. Columbus, USA: Ohio State University Press; 2001. World Health Organization. Global strategy for infant and young child feeding; WHO Library. 2003. p. 10Retrieved from http://apps.who.int/iris/bitstream/10665/42590/1/9241562218.pdf?ua=1&ua=1
Author Manuscript Author Manuscript Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Author Manuscript
Author Manuscript Drop milk on sweet bay of leaf Maintains its shape and remains motionless
Will dissolve immediately and have physical attributes of water Not pregnant Non-menstruating Brown hair Phlegmatic temper
Test was employed to choose the best wet nurse — those whose milk failed would not be employed
Smells like ‘powder of manna’
Smells of ‘snj of fish’
Woman who has given birth to a son
Warm bones of a xru-fish in oil and rub on the wet nurse’s back
Good milk
Bad milk
Ideal wet nurse
Remedy for bad milk
High status in the household Used by wealthy families
Royalty
Smell
Milk evaluation method
Wet nurse social status
Ancient Greece & Ancient Rome
Ancient Egypt
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19. Limit sex, eat in moderation and behave appropriately
Primiparous brunette Woman who has given birth to a son
Physical attributes resemble water
Maintains a crystal shape
Drop of milk on a sword
Highly respected Well paid and received food/ lodging
Middle Ages
Avoid strong foods Renounce work and any exertion
Non-menstruating Good-tempered Small nipples Good teeth Florid gums Sober Clean Enjoys children Rested Age 20–35 years Primiparous Large chest with blue veins
Colostrum
Transitional and mature milk only Sweet with a blue tint Thick cream layer Italy: Dried milk’s colour would provide information on infant disposition
Thin and plentiful Italy: drop of milk on a white cloth
Poor women who were socially marginalised
19th Century
Author Manuscript
Factors influencing the selection of wet nurses through history.
Reduce wet nurse’s exposure to agitation and/or sexual arousal
Women not predisposed to passion or emotion Wet nurses’ babies were examined, with healthy babies preferred
Imbalance of fat, sugar, protein
3–4% fat 6–7% sugar 1–2% protein
Microscopic evaluation Later: formula-based percentage system
Social class distinction
20th Century
No longer relevant
Breastmilk donors who are eligible for breastmilk donation
Ineligible breastmilk donors
Breastmilk expressed from women who have undergone the screening process Pasteurised Breastmilk
Donor screening Milk pasteurisation
No longer relevant
21st Century
Author Manuscript
Table 1 Baumgartel et al. Page 13
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19. Published in final edited form as: Breastfeed Rev. 2016 November ; 24(3): 25–32.
From royal wet nurses to Facebook: The evolution of breastmilk sharing Kelley L Baumgartel [PhD Postdoctoral Scholar], Targeted Research and Academic Training of Nurses in Genomics, University of Pittsburgh, School of Nursing, Department of Health Promotion and Development
Author Manuscript
Larissa Sneeringer [Undergraduate Student], and University Research Mentorship Program, University of Pittsburgh, School of Nursing Susan M Cohen [DNSAssociate Professor] University of Pittsburgh, School of Nursing, Department of Health Promotion and Development
Abstract
Author Manuscript
Wet-nursing was an essential practice that allowed for infant survival after many mothers died in childbirth. The story of wet-nursing is complicated by both religious pressures and cultural expectations of women. It is likely that these historical practices have shaped our current social, political and legislative environments regarding breastfeeding. The aim of this article is to provide a historical perspective on the practice of wet-nursing, with a focus on: 1) social views of wet nurses, 2) breastmilk evaluation and 3) the ideal wet nurse. Historical perspectives from Ancient Egypt, Ancient Greece and Rome, 19th and 20th century America and current practices are examined. An appreciation for the evolution of breastmilk sharing provides clinicians and lactation advocates with the historical origins which provided the template for current practice as it relates to donor milk, breastfeeding culture and relevant legislation.
Keywords wet nurse; breastmilk sharing; breastmilk; breastfeeding; donor milk
Author Manuscript
Wet-nursing, the practice of a woman feeding a child at the breast who is not biologically her child, was a practical way to provide nutrition for infants and reinforce social class distinctions. The history of wet-nursing, a story complicated by mixed views of women and an appreciation for infant life, provides the platform from which current donor breastmilk banks and milk sharing practices are derived The standards for ideal wet nurses changed with the evolving needs for wet nurses, as did the evaluation methods to ensure high quality breastmilk. These historical practices and standards have influenced clinical practice, legislation and social attitudes regarding donor milk and milk sharing. Currently, certified breastmilk banks have allowed for the organised distribution of milk to vulnerable infants whose mothers are unable to provide the prescribed volume. Additionally,
Telephone: 412-523-8731, [email protected].
Baumgartel et al.
Page 2
Author Manuscript Author Manuscript
peer-to-peer milk sharing, though not recommended by the European Milk Banking Association, Human Milk Banking Association of North America nor La Leche League International, due to the risk of contamination and other safety concerns, is becoming increasingly popular with the advent of online social support. An appreciation for the history of wet-nursing, particularly its social context, helps clinicians and breastfeeding advocates better understand how current trends are shaped. For this manuscript, ‘wet-nursing’ includes both exclusive and non-exclusive breastfeeding (feeding baby at the breast), as this broader inclusion allows for a more comprehensive historical appreciation for wet-nursing throughout history. With access to the University of Pittsburgh’s Special Collections and Rare Book Library, we were able to inform the historical story of wet-nursing. The historical books relevant to this topic were American-based; therefore, this manuscript has an American focus. Though the intent of this article is not to provide a comprehensive history of wet-nursing, we will emphasise the following shared elements, from Ancient Egypt to modern practices: 1) social view of the wet nurse, 2) tests of milk quality and 3) the ideal wet nurse. An interpretation of this historical influence on current social practices, including milk banks and milk sharing, is provided.
ANCIENT EGYPT Social view of wet nurses
Author Manuscript
Breastfeeding provided infants with protection from dehydration and minimised exposure to contaminated food and thus became essential for infant survival in Egypt’s hot climate. An infant’s health was believed to be in constant danger from Labartu, a female demon, so incantations were recited to protect the mother, infant and wet nurse (Fildes, 1986). Like infant mortality, maternal mortality was very high in ancient Egypt (Wells 1975). The subsequent reliance on wet nurses to provide nutrition for orphaned infants increased and wet nurses were promoted to the level of worship (Fildes, 1988). Wet nurses are often depicted in Egyptian illustrations at near God-like status, wearing headdresses similar to Hathor, the goddess of fertility (Fildes, 1986).
Author Manuscript
A social distinction between classes, emphasised by the use of wet nurses, is first recorded in this time period, as royalty primarily used wet nurses to feed their infants. Immediately after a queen gave birth, her infant was given to the wet nurse, who then breastfed the infant. Royal wet nurses were carefully selected, highly respected and are shown on guest lists at events. Unlike royal Egyptian families, the poor would breastfeed their own infants and seek a wet nurse only if the mother died in childbirth or was unable to breastfeed. Animal milk such as camels, goats, sheep and cows was also used to feed infants as an artificial feeding and as additional food once the child was several months old (Fildes, 1986). Breastmilk evaluation During the time of ancient Egypt, the milk’s scent provided valuable information on its quality. Ideal breastmilk smelled like ‘powder of manna’, while inferior breastmilk smelled like ‘snj of fish’. Cures for poor quality breastmilk included warming the bones of a Xru fish in oil and rubbing the wet nurse’s back. Spells and incantations were recited to increase and protect the wet nurse’s milk (Fildes, 1986).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 3
The ideal wet nurse
Author Manuscript
The ideal wet nurse was a woman who was able to produce the best nutrition for an infant, based on specific characteristics. She was unmarried, so could not have sexual intercourse and/or become pregnant (both of which would spoil her milk). Wet nurses should also only breastfeed one child at a time. Additionally, she was on a regulated diet so her milk would not become unsuitable for the child. There was a great preference in some cultures for milk produced by a woman who had a son (Fildes, 1986).
ANCIENT GREECE AND ROME Social view of wet nurses
Author Manuscript
The Roman philosophers Plutarch and Gellius recognised the bond established between mother and infant through breastfeeding. A fear developed that the wet nurse may compromise this bond and Plutarch concluded that a mother should be excused from breastfeeding only when ill or if more children were desired (Fildes, 1988). Despite these recommendations, wet nurses were commonly used by the wealthy during Ancient Greece and Rome during mid-1st millennium BC, more commonly known as the Classical era. Wet nurses held a high status in the household and were often responsible for the child’s care until adulthood. A wet nurse during ancient Rome was often a slave who would nurse for a wage and ultimately gain her freedom (Fildes, 1986). Breastmilk evaluation
Author Manuscript
Ancient Greek and Roman practice permitted the employment of a wet nurse only after her milk was subjected to the sweet bay leaf test. If the milk droplet retained its form after being dropped on the leaf, it was considered optimal breastmilk. Milk believed to be indigestible would fail this test if the milk droplet dissolved immediately or was watery (Fildes, 1986; Obladen, 2012). This test served as a way to distinguish between the quality of milk produced by individual wet nurses and optimised opportunities for those women who produced quality breastmilk. The ideal wet nurse Ancient Greek beliefs held that breastmilk was a product of menstrual blood not shed during pregnancy. This led to the instruction that wet nurses should not be employed if pregnant or menstruating because their milk would be compromised (Fildes, 1988). The ideal wet nurse should be Greek, have brown hair and a calm temper (Obalden, 2012).
Author Manuscript
MIDDLE AGES Social view of wet nurses The profession of wet-nursing re-emerged as desirable in Europe in the 14th and 15th centuries when noble and upper-class women hired wet nurses to feed their infants. Wet nurses subsequently became highly respected, well paid and received both food and lodging for their services. Defects in the child’s disposition were often attributed to the wet nurse (Fildes, 1988). During the Middle Ages, wet-nursing continued to serve as an indicator of social class, and many wet nurses were slaves or ex-slaves (Obalden, 2012). In Western Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 4
Author Manuscript
Europe, wealthy and noble families often employed wet nurses because breastfeeding was inconvenient and women could regain their fertility (Fildes, 1986). Unlike the rich, poor families could not afford the services of a wet nurse and breastfed their infants themselves (Fildes, 1988). It was not recommended to give infants animal milk because it was believed this would cause the child to become ‘animal-like’. Animal milk was still used in time of need when a mother could not breastfeed and couldn’t afford a wet nurse. (Fildes, 1986). Breastmilk evaluation
Author Manuscript
Ideal breastmilk should have a good odour, be continuous and hold its shape when placed on a rock or sword (Fildes, 1988). If an infant presented with an illness, the cause was commonly attributed to either the wet nurse (Obladen, 2012) or her diet (Fildes, 1988). The infant’s treatment focused on the wet nurse, as her milk was blamed for the child’s illness (Fildes, 1988). Wet nurses with a poor milk supply were instructed to eat fennel seed, cumin, lettuce, ginger and white pepper (Ruhrah, 1925). The ideal wet nurse The ideal wet nurse who lived during the Middle Ages had specific attributes, including: being primiparous, young, brunette and having birthed a son. Wet nurses were chosen by the infant’s father (Obladen, 2012) and moved into the family’s home so their habits could be closely monitored, as it was believed that a compromised lifestyle could spoil their milk. Lifestyle behaviours that were believed to compromise breastmilk included the wet nurse’s diet, exercise, general conduct and sexual activity. If the wet nurse contaminated her milk with these actions, she paid a fine and was punished by the town. Most importantly, the ideal wet nurse during the Middle Ages was a socially favoured woman with a good disposition, who ate and drank in moderation (Fildes, 1988).
Author Manuscript
19TH CENTURY Social view of wet nurses
Author Manuscript
The impact of the Reformation in Europe permeated Puritan theology and manifested in sermons devoted to the ‘evils’ of non-breastfeeding mothers. These sermons taught that nonbreastfeeding mothers who chose to hire a wet nurse were selfish and did not breastfeed for a variety of reasons, including: desire to maintain a social life, preference for non-restrictive clothing and a lack of love for both her child and God (Fildes 1988; Apple, 1987). Breastfeeding had become a religious duty: ‘Oh confider, how comes our milk? Is it not by the direct prouidence of God? Why prouides he it, but for the child? The mothers then that refuse to nurse their owne children, doe they despise God’s prouidence? Doe they deny God’s will?’ (Clinton, 1975, p. 10). Subsequently, the employment of a wet nurse as a symbol of social class began to decrease, though this change was mostly observed in France. As artificial feeding methods improved and became safer, wet-nursing became less common. In America, cows’ milk was now required to be bottled, pasteurised, sealed and refrigerated, making it safer and more convenient for infants to consume (Wolf, 2001). Scientists in the 1800s began to develop formula that resembled human milk. Liebig’s infant food was the first patented formula in
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 5
Author Manuscript
1865, which consisted of cows’ milk, wheat, malt flour and potassium carbonate (Stevens, Patrick & Pickler, 2009). Food preservation, a newly developed technique, allowed for the creation of powdered, condensed and evaporated milk and many mothers fed these milks to their infants as a cheaper alternative (Stevens, Patrick & Pickler, 2009). Breastfeeding also saw a decline during this time, as formulas and preserved milks were a more convenient alternative. Public health officials still promoted breastfeeding as the best option for infant nutrition and offered medical research that instructed new mothers to breastfeed to reduce the risk of milk fever, an often fatal infection (Fildes, 1986). Formula was regarded as a last resort, as the best substitute for mother’s milk was a wet nurse (Wolf, 2001; Clinton, 1975).
Author Manuscript
During this time, few hospitals existed that were paediatric-specific and the few that existed were not suitable for neonates (Obalden, 2012). It was not until 1928 that the first unit for infants was opened with a milk kitchen and in-house wet nurses. A midwifery textbook from the mid-19th century warns of the danger of formula: ‘… it [artificial nursing] is admitted by all to be the worst of the various methods proposed for nourishing a child’ (Cazeaux, 1866, p. 958). In the United States, wet nurses were poor women in desperate circumstances and the social class distinction remained (Wolf, 2001). Physicians preferred wet nurses to artificial feeding; however, parents frequently objected to this recommendation because wet nurses were viewed as immoral and unruly. They were commonly women who were forced to sell their milk because they were unwed mothers and subsequently abandoned by their family (Wolf, 2001). Breastmilk evaluation
Author Manuscript Author Manuscript
Ideal breastmilk was thin and plentiful (Underwood, 1827); therefore, the thick consistency of colostrum was considered unfavourable and discarded (Cazeaux, 1866). This practice allowed wet nurses who were producing mature milk to provide their services while the mother was expressing and disposing of colostrum. Colostrum was either expressed by other women using a sucking glass or consumed by an older ‘lusty’ child (Fildes, 1986). Ideal breastmilk during this time was also sweet and had a blue tint (Underwood, 1827). A test for breastmilk quality included the placement of a few drops of milk in a spoon. The droplet should be opaque, homogeneous and without an odd odour or taste. If possible, the milk should be subjected to microscopic examination, which should reveal a thick layer of cream. Recommendations are also made to weigh the infant both before and after a feeding to estimate milk intake, a practice which continues today. This recommendation was first made by European obstetricians and spread to other countries, since it was considered a way to measure the health of a newborn (Weaver, 2010). In Italy during this time, milk was subjected to evaluation by leaving drops of milk on a white cloth to dry in the shade. The colour of the dried milk would be evaluated to determine what to expect from the infant: yellow for choleric intemperance, black for melancholia, mouldy or unsweet milk for calm infants (Whitaker, 2000). Wet nurses could remedy bad milk by avoiding certain foods, including: wine, onion, garlic, saffron and salt. Additionally, renouncing work or any exertions with a preference for calmness and rest was believed to optimise milk quality (Whitaker, 2000). Wet nurses were often supervised by physicians for adequate milk production. Employers also oversaw the work of the wet nurse to ensure proper development
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 6
Author Manuscript
and health of their child and to make certain the wet nurse was not supplying her children more nourishment than the infant they were employed to feed (Golden, 1996). The ideal wet nurse
Author Manuscript
A recognition of the lactation continuum is noted during this period, since breastmilk produced by a woman before 2 months postpartum (Cazeaux, 1866) or 6 months (Underwood, 1827) was considered advantageous to the child’s ‘digestive powers’ (Cazeaux, 1866, p. 953). In cases of maternal illness or death, a wet nurse was selected by a physician, a serious medical decision that required intense scrutiny to minimise disease transmission (Epps, 1843). The physician was tasked with identifying a suitable wet nurse (Whitaker, 2000) and a physical examination was performed on the potential wet nurse to ensure her physical health (Epps, 1843). In America, wet nurse bureaus were started in major cities, which required that all wet nurse applicants receive physical examinations to receive a certificate of health. Those who were in need of a wet nurse then paid $5.00, and the bureaus found and certified someone for them (Wolf, 2001). Ideal characteristics of a potential wet nurse included women who: were non-menstruating, good-tempered, had small nipples, good teeth, florid gums, were sober, clean, enjoyed children and rested (Underwood, 1827). The ideal wet nurse should also consume a specific diet, be willing to take daily walks outside, be between 20–35 years old (Underwood, 1827), should not be a first-time mother, should have a large chest with bluish veins on her breasts that indicate an abundant supply, be lively, sexually continent, well-formed and be moderately sized (Whitaker, 2000). The wet nurse should not exhibit any unpleasant tendencies (Cazeaux, 1866), as milk from an angry wet nurse could cause extreme infant colic and even death (Whitaker, 2000).
Author Manuscript
20TH CENTURY Social view of wet nurses In the 1900s, wealthy women were more likely to hire a wet nurse, as these women viewed breastfeeding as restrictive (Golden, 1996). This need for wet nurses, combined with an increased use of artificial feeding practices resulted in two conflicting results: 1) wet nurses became a last resort for medical practices and their role was marginalised and 2) wet nurses who were hired in desperation were able make high demands for their services. Wet nurses in America in the early 1900s earned nearly five times more than a paediatric nurse (Apple, 1987). The early 20th century experienced resurgence in wet-nursing, and the practice remained a sign of wealth; however, few families could afford their services and the demand for wet nurses decreased.
Author Manuscript
By the mid-20th century, the American Medical Association promoted bottle-feeding as the best feeding method and endorsed wet-nursing only when bottle feeding failed, further reducing the demand for wet-nursing. Contradictory advice was propagated, with familiar slogans like ‘breast is best’, followed by descriptions of breastmilk inadequacy. Despite an adequate milk supply, mothers were advised that bottle-fed infants were no less healthy or happy than breastfed babies (Apple, 1987).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 7
Author Manuscript
The dairy industry was not yet overseen by the federal government and as a result, cows’ milk was often full of harmful bacteria. Wealthy women could afford pasteurised milk, while poor women could not adhere to expensive formula recommendations and instead breastfed or fed the child home-prepared foods when they were considered old enough to be introduced to other foods. Physicians developed formula based on a percentage system of lipids, sugar and proteins that would later be marketed to rich women as an ideal food for infants. As formula became more popular, advertisements appeared in women’s magazines and displayed phrases such as ‘No more wet nurses’, which illustrates the formula manufacturers’ view of their competition (Apple, 1987).
Author Manuscript
The 20th century introduced a public health campaign to combat prematurity, an event that was once privately mourned (Golden, 1996). As neonatology advanced, the importance of breastmilk was emphasised for this vulnerable population. One neonatologist, Dr Owen Wilson, purchased breastmilk from wet nurses and helped to reduce infant mortality rates in his practice (Golden, 1996). This is an early example of donor breastmilk as a valued commodity. Breastmilk evaluation
Author Manuscript
Breastmilk analysis became common in the late 1890s and into the 20th century, and many doctors based their diagnoses and therapy on the milk’s composition. Ideal milk was 3–4% fat, 6–7% sugar, and 1–2% protein (Wolf, 2001). Nursing curricula in a Chicago school included a class devoted to the microscopic evaluation of human milk (Wolf, 2001). However, once formula became the mainstay infant feeding method in the mid-20th century, the consensus in the medical community of ideal milk was determined not by the physical attributes of breastmilk, but rather formula composition that was based on a percentage system of milk components (Apple, 1987). The notion of ideal milk shifted from observable or measurable breastmilk qualities to bovine-based milk that was contaminant-free. Ideal wet nurse Although the practice of wet-nursing in America was not as common during the 20th century, the notion of an ‘ideal’ nurse remained central to those who were in need of one. A suboptimal wet nurse was a thin woman who was nervous, irritable and emotional. It was believed that emotional women could poison the milk and such women were excused from breastfeeding (Apple, 1987). The wet nurses’ babies were frequently examined and, if her children were healthy, the milk was assumed to be of good quality (Wolf, 2001).
21ST CENTURY Author Manuscript
Social view of wet nurses or milk donors Today, the need for a traditional wet nurse has decreased in developed nations likely due to: 1) a remarkably low maternal mortality rate and/or 2) the availability of infant formula. The rate of preterm births, however, has increased and it is likely that the number of infants born preterm will continue to rise as neonatology advances and more premature infants survive. Breastmilk provides these infants with protection from infections during their neonatal stay and long-term protection against many childhood diseases (Schanler et al., 2011). A caveat
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 8
Author Manuscript
to providing breastmilk for such high risk infants is that mothers who deliver this early often experience compromised milk supply due to stress and underlying pathologic disease processes (Hale & Hartmann, 2007). To circumvent this obstacle, the use of donor milk has gained popularity to provide preterm infants with protective nutrition until the mother can produce an adequate supply of breastmilk. Though we rarely refer to women who donate breastmilk as ‘wet nurses’, we have established organised breastmilk banks, where women can donate milk for other infants. Donor breastmilk banking is a promising practice, whose roots are unequivocally based in the ancient practice of wet-nursing.
Author Manuscript
Unfortunately, specialised formulas are marketed for premature babies in the NICU. They are advertised as containing nutrients found in breastmilk, including DHA, Leutin and vitamin E which sustain growth and stimulate brain, eye, and immune system development. Such formulas intrude on protocols such as Baby-Friendly that are set up in hospitals to encourage mothers to breastfeed or pump milk for their infants (Baby-Friendly USA, 2012). If the mother is unable to supply her own milk, this formula also competes with donor milk, which is the next best nutritional choice for the baby (American Academy of Pediatrics, 2012). Donor milk allows sick and vulnerable infants to receive the benefits of breastmilk and thus have a better chance for survival (Human Milk Banking Association of North America, 2012). Breastmilk evaluation and the ideal milk donor
Author Manuscript Author Manuscript
Breastmilk composition is variable between women (Ballabio et al., 2008) and some of the historical notions of milk quality based on the expresser (wet nurse) may have modern scientific support. Historically, the image of an ideal wet nurse was complicated by social constructs, including hair colour, parity, sexual arousal and infant gender. The modern corollaries to these lifestyle variables, which do impact breastmilk composition, include: medications, diet, alcohol or drug consumption, exercise and tandem nursing (Hale & Hartmann, 2007). According to the Human Milk Bank Association of America, women who wish to donate their breastmilk must be: in good general health, willing to undergo a blood test, not regularly use medications or herbal supplements and willing to donate at least 100 ounces of milk (Human Milk Banking Association of North America, 2015). Additionally, milk donated to certified milk banks in Europe and North America undergoes similar screening and pasteurisation processes (European Milk Bank Association & Human Milk Banking Association of North America, 2015). Potential donors must not: have a positive blood test result for HIV, HTLV, hepatitis B/C or syphilis, use illegal drugs, smoke or use tobacco products, have received an organ or blood transfusion in the last 12 months or regularly have more than two ounces of alcohol per day. Even more interesting is that some historical variables that were seen as ideal characteristics of wet nurses, which seem outrageous today, are potentially important predictors of milk composition. For example, the levels of bioactive lipids present in milk are significantly different based on infant gender, with milk expressed from women who delivered males having higher energy content than milk expressed by women with female infants (Thakkar et al., 2013).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 9
Author Manuscript
PEER-TO-PEER MILK SHARING
Author Manuscript
Perhaps the modern-day corollary to wet nurses are women who donate their milk to certified milk banks. However, we would be remiss if we excluded the ever-growing community of peer-to-peer milk sharing options. Milk banks serve high-risk infants who are prescribed human milk by a physician or nurse practitioner (Gribble, 2013). The World Health Organization (WHO) recommends cross-feeding or wet-nursing when breastfeeding and milk expression aren’t possible (WHO, 2003). Furthermore, WHO recommends that non-breastfed infants be monitored by the health and social welfare system, as they ‘… constitute a risk group’ (WHO, 2003 p. 10). There are many infants who are unable to receive breastmilk from their mother, due to: adoption, breast hypoplasia, insufficient glandular tissue, HIV-positivity, maternal death, early breastfeeding challenges and infants with ankyloglossia (Martino & Spatz, 2014). While creating a demand for human milk, these do not meet the traditional clinical requirements for prescribed donor breastmilk. Social view of milk sharing
Author Manuscript
Some mothers who are unable to breastfeed or express enough breastmilk have limited options. Milk banks usually supply human milk to NICU infants or those prescribed donor milk by a physician. While employing a wet nurse has been close to extinct since the 1900s (Stevens, Patrick, & Pickler, 2009), wet-nursing still exists in the form of shared breastmilk. Because wet nurses were historically employed and paid, a parallel can be drawn between wet-nursing and waged milk donors. Mothers can sell expressed milk by the ounce either to for-profit milk banks or directly to women looking to feed their infant. Direct purchases usually occur online, on websites like Human Milk for Human Babies and Eats on Feets. These online communities promote altruistic milk sharing, where no fee is involved with the sharing of human milk and serve nearly 50,000 members in 50 countries (Martino & Spatz, 2014).
Author Manuscript
The US Food and Drug Administration, La Leche League International, HMBANA and EMBA have expressed concern with online milk sharing due to the risk of receiving unsafe breastmilk (Perrin et al., 2014; European Milk Bank Association & Human Milk Banking Association of North America 2015). These concerns are related to the known risk of purchasing milk online, as this milk carries a high risk of contamination compared with donor milk (Keim et al., 2013). Approximately 3.3% of HMBANA donors test positive for a viral/bacterial disease (Cohen, Xioing & Sakamoto, 2010), 60% of internet-purchased milk is damaged during transport and 45% is unsafe (Geraghty et al., 2013). Similar safety research on commerce-free milk sharing is unavailable, but milk sharing advocates are steadfast in proclaiming that the benefits of human milk outweigh any potential risks. As a result, both the HMBANA and EMBA do not recommend milk sharing outside of certified milk banks (European Milk Bank Association & Human Milk Banking Association of North America, 2015). Mothers who choose to be altruistic milk sharers value their human milk and the health of the infant their milk is feeding and/or the idea that they’re helping a mother who is struggling. This connection motivates these donors to avoid harm associated with milk sharing (Perrin et al., 2016).
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 10
Author Manuscript
It seems that the social differences between milk donors and recipients seen through history remain among milk sharing program participants; however, milk donors have more education and higher reported incomes than milk recipients (Palmquist & Doehler, 2014). This is counter to the history of poor and marginalised wet nurses serving rich mothers. Milk recipients also experience a higher caesarean-section rate and report lower levels of breastfeeding support when compared with milk donors on milk-sharing sites (Palmquist & Doehler, 2014). Ideal milk donor
Author Manuscript
The online community provides an open forum for milk recipients and donors to connect. Many milk donors who participate in peer-to-peer milk programs have never donated to milk banks and one reason for this is that milk donors report that they prefer knowing exactly where their milk goes and what the recipients’ circumstances are (Gribble, 2013). As a result, and similar to historical preferences for specific wet nurses, milk donors report personal characteristics that might make their milk more appealing to potential recipients, including milk attributes (milk bank certified), donor lifestyle (regarding smoking/alcohol, diet, caffeine) and no medications/supplements (Perrin et al., 2014). The ‘ideal’ milk donor has evolved into a personal connection within milk sharing programs, open to the needs and preferences of individual mothers.
CONCLUSION Implications for clinicians and breastfeeding advocates
Author Manuscript
Consistent themes, including tests for breastmilk quality and the ideal wet nurse, emerge through the history of wet-nursing and these influences still permeate modern practices of milk donation. Some of the historical notions that not all breastmilk is created equal, as indicated by tests of milk quality, are confirmed by modern lactation science that shows great milk variability between women. The evolution of milk sharing continues to change with improved knowledge of lactation science, the advent of social networking and an increasing number of donor milk banks. An appreciation for the history of milk sharing by breastfeeding advocates will inform policy and clinical protocols surrounding this ancient practice.
Author Manuscript
While there are references to international milk banking practices, we recognise that this historical manuscript mostly describes American recommendations and milk banking practices. Overall, the teleological and historical importance of wet-nursing has led to the continuation of this ancient practice through the institution of donor breastmilk banks and milk sharing. Research has focused on both the acute and long-term outcomes of donor milk administration in infants who survived as a result of neonatal advances. Milk sharing and purchasing continues to become increasingly popular with the advent of online communities and increased awareness of the advantages of human milk over formula. Future research may explore the molecular mechanism for breastmilk composition which may contribute to the great variability of milk composition observed between women. These profiles may lead to the identification of modern-day ‘ideal’ wet nurses who would yield optimal breastmilk for a matched infant.
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 11
Author Manuscript
References
Author Manuscript Author Manuscript Author Manuscript
American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012; 129(3):e827–e841. [PubMed: 22371471] Apple, R. Mothers and medicine: A social history of infant feeding 1890–1950. Wisconsin Publications in the History and Science of Medicine; London, England: 1987. Baby-Friendly USA. About us. 2012. Retrieved from https://www.babyfriendlyusa.org/about-us Ballabio C, Bertino E, Coscia A, Fabris C, Fuggetta D, Molfino S, … Restani P. Immunoglobulin-A profile in breast milk from mothers delivering full term and preterm infants. International Journal of Immunopathology and Pharmacology. 2008; 20(1):119–128. Cazeaux, P. A theoretical and practical treatise on midwifery: Including the diseases of pregnancy and parturition and the attentions required by the child from birth to the period of weaning. Philadelphia, USA: Lindsay & Blakiston; 1866. Centers for Disease Control. Maternal mortality and related concepts. 2007. Retrieved from http:// www.cdc.gov/nchs/data/series/sr_03/sr03_033.pdf Clinton, E. The Countesse of Lincolnes nurserie. Amsterdam, Netherlands: Theatrum Orbis Terrarum; 1975. (Original work published 1628) Cohen RS, Xiong SC, Sakamoto P. Retrospective review of serological testing of potential human milk donors. Archives of Disease in Childhood. Fetal and Neonatal Edition. 2010; 95(2):F118–120. [PubMed: 20231217] Epps, J. Domestic homeopathy; or rules for the domestic treatment of the maladies of infants, children, and adults, and for the conduct and treatment during pregnancy, confinement, and suckling. Otis Claap; Boston, USA: 1843. European Milk Bank Association & Human Milk Banking Association of North America. Milk Sharing A statement from the European Milk Bank Association (EMBA) and the Human Milk Banking Association of North America (HMBANA) [PDF file]. 2015. Retrieved from http:// www.europeanmilkbanking.com/images/news/EMBA%20HMBANA%20Milk%20Sharing %20Statement%20FINAL%20January%202015.pdf Fildes, V. Breasts, bottles and babies. Edinburgh, Scotland: Edinburgh University Press; 1986. Fildes, V. Wet nursing: A history from antiquity to the present. New York City, USA: Basil Blackwell Inc; 1988. Geraghty SR, McNamara KA, Dillon CE, Hogan JS, Kwiek JJ, Keim SA. Buying human milk via the internet: Just a click away. Breastfeeding Medicine. 2013; 8(6):474–478. [PubMed: 23971685] Golden, J. A social history of wet nursing in America: From breast to bottle. New York, USA: Press Syndicate of the University of Cambridge; 1996. Gribble KD. Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2013; 42:451–461. Hale, T., Hartmann, P. Textbook of human lactation. Amarillo, USA: Hale Publishing LP; 2007. Human Milk Bank Association of North America. Donate milk: Do you want to donate your surplus milk to help a sick or fragile infant?. 2015. Retrieved from https://www.hmbana.org/donate-milk Keim SA, Hogan JS, McNamara KA, Gudimetla V, Dillon CE, Kwiek JJ, Geraghty SR. Microbial contamination of human milk purchased via the internet. Pediatrics. 2013; 132(5):e1227–e1235. [PubMed: 24144714] Martino K, Spatz DL. Informal milk sharing: What nurses need to know. MCN The American Journal of Maternal Child Nursing. 2014; 39(6):369–374. [PubMed: 25333804] Obladen M. Regulated wet nursing: Managed care or organized crime? Neonatology. 2012; 102:222– 228. [PubMed: 22833013] Obladen M. Early neonatal special care units and their scientific achievements. Neonatology. 2012; 102:89–97. [PubMed: 22653040] Palmquist A, Doehler K. Contextualizing online human milk sharing: Structural factors and lactation disparity among middle income women in the US. Social Science & Medicine. 2014; 122:140– 147. [PubMed: 25441326]
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Baumgartel et al.
Page 12
Author Manuscript Author Manuscript
Perrin MT, Goodell LS, Allen JC, Fogleman A. A mixed-methods observational study of human milk sharing communities on Facebook. Breastfeeding Medicine. 2014; 9(3):128–134. [PubMed: 24490980] Perrin MT, Goodell LS, Fogleman A, Pettus H, Bodenheimer AL, Palmguist AE. Expanding the supply of pasteurized donor milk: Understanding why peer-to-peer milk sharers in the United States do not donate to milk banks. Journal of Human Lactation. 2016; 32(2):229–37. [PubMed: 26905342] Ruhrah, J. Pediatrics from the past. New York, USA: 1925. Incipit practica puerorum passions puerorum adhuc in cunabulis iacentium. (Original work published 12th–15th centuries) Schanler RJ. Outcomes of human milk-fed premature infants. Seminars in Perinatology. 2011; 35(1): 29–33. [PubMed: 21255704] Stevens EE, Patrick TE, Pickler R. A history of infant feeding. The Journal of Perinatal Education. 2009; 18(2):32–39. Thakkar SK, Giuffrida F, Cristina CH, De Castro CA, Mukherjee R, Tran LA, … Destaillats F. Dynamics of human milk nutrient composition of women from Singapore with a special focus on lipids. American Journal of Human Biology. 2013; 25(6):770–779. [PubMed: 24105777] Underwood, M. A treatise on the diseases of children with directions for the management of infants from the birth. Printed for Callow and Wilson; London, England: 1827. Weaver LT. In the balance: Weighing babies and the birth of the infant welfare clinic. Bulletin of the History of Medicine. 2010; 84(1):30–57. [PubMed: 20632732] Wells C. Ancient obstetric hazards and female mortality. Bulletin of the New York Academy of Medicine. 1975; 51(11):1235–1249. [PubMed: 1101997] Whitaker, ED. Measuring mamma’s milk: Fascism and the medicalization of maternity in Italy. Ann Arbor, USA: University of Michigan Press; 2000. Wolf, JH. Don’t kill your baby: Public health and the decline of breastfeeding in the nineteenth and twentieth centuries. Columbus, USA: Ohio State University Press; 2001. World Health Organization. Global strategy for infant and young child feeding; WHO Library. 2003. p. 10Retrieved from http://apps.who.int/iris/bitstream/10665/42590/1/9241562218.pdf?ua=1&ua=1
Author Manuscript Author Manuscript Breastfeed Rev. Author manuscript; available in PMC 2017 September 19.
Author Manuscript
Author Manuscript Drop milk on sweet bay of leaf Maintains its shape and remains motionless
Will dissolve immediately and have physical attributes of water Not pregnant Non-menstruating Brown hair Phlegmatic temper
Test was employed to choose the best wet nurse — those whose milk failed would not be employed
Smells like ‘powder of manna’
Smells of ‘snj of fish’
Woman who has given birth to a son
Warm bones of a xru-fish in oil and rub on the wet nurse’s back
Good milk
Bad milk
Ideal wet nurse
Remedy for bad milk
High status in the household Used by wealthy families
Royalty
Smell
Milk evaluation method
Wet nurse social status
Ancient Greece & Ancient Rome
Ancient Egypt
Breastfeed Rev. Author manuscript; available in PMC 2017 September 19. Limit sex, eat in moderation and behave appropriately
Primiparous brunette Woman who has given birth to a son
Physical attributes resemble water
Maintains a crystal shape
Drop of milk on a sword
Highly respected Well paid and received food/ lodging
Middle Ages
Avoid strong foods Renounce work and any exertion
Non-menstruating Good-tempered Small nipples Good teeth Florid gums Sober Clean Enjoys children Rested Age 20–35 years Primiparous Large chest with blue veins
Colostrum
Transitional and mature milk only Sweet with a blue tint Thick cream layer Italy: Dried milk’s colour would provide information on infant disposition
Thin and plentiful Italy: drop of milk on a white cloth
Poor women who were socially marginalised
19th Century
Author Manuscript
Factors influencing the selection of wet nurses through history.
Reduce wet nurse’s exposure to agitation and/or sexual arousal
Women not predisposed to passion or emotion Wet nurses’ babies were examined, with healthy babies preferred
Imbalance of fat, sugar, protein
3–4% fat 6–7% sugar 1–2% protein
Microscopic evaluation Later: formula-based percentage system
Social class distinction
20th Century
No longer relevant
Breastmilk donors who are eligible for breastmilk donation
Ineligible breastmilk donors
Breastmilk expressed from women who have undergone the screening process Pasteurised Breastmilk
Donor screening Milk pasteurisation
No longer relevant
21st Century
Author Manuscript
Table 1 Baumgartel et al. Page 13
