to the editor: Thank you for the informative article on the nutritional needs of toddlers that appeared in the November 1, 2006, issue of American Family Physician.¹ I am concerned, however, that there was no mention of nursing toddlers. Many of the women I assist with breastfeeding are nursing their babies into toddlerhood. Some parents do not mention this to their health care professional for fear of chastisement. Some physicians have told mothers that breast milk has no value after one year post-birth.

Several medical organizations recommend that babies continue to be breastfed through the toddler years.^2,3 Health professionals should know that the toddler who nurses even a few times a day receives a significant amount of calories, good quality protein, and immune factors from breast milk.⁴

Also, there is growing evidence that leptin in breast milk helps regulate appetite and future weight.^5,6 Children who are nursing self-regulate intake because breast milk changes in composition throughout the nursing. Toddlers are known for occasionally having capricious tastes and appetites. Nursing such a child while offering appropriate complementary foods is a bonus.

Parents may need reassurance that nursing children into the toddler years is an acceptable, normal, and healthy way to nurture and nourish their child and that it carries benefits into adult life.

in reply: I thank Ms. Gubala for pointing out that some women continue to breastfeed babies through the toddler years, and I am personally grateful that my wife breastfed all six of our children beyond their first year. I agree that physicians should not discourage this decision, as there is no evidence that breastfeeding toddler-age children is harmful.

Unfortunately, the evidence for the benefit of breastfeeding beyond 12 months of age is scant and of poor quality. Although the World Health Organization (WHO) recommends breastfeeding through 24 months of age, this guideline is based on expert consensus and lower-quality cohort studies.^1–4 WHO also focuses on developing countries, and notes that extended breastfeeding is controversial outside of sub-Saharan Africa and has been associated with malnutrition in some surveys.⁵

Although the American Academy of Pediatrics allows for breastfeeding beyond the first year of life, this should not be interpreted as a universal recommendation.⁶ Scientific data on nutritional or other benefits in this age group are lacking. Finally, although I agree that more evidence is supporting decreased obesity as a positive benefit of extended breastfeeding, a careful review of the Grummer-Strawn analysis mentioned by Ms. Gubala reveals that “longer duration” of breastfeeding means six to 12 months, with no measurement beyond 12 months.