Dr. Keren Epstein-Gilboa PhD, MEd, BSN, RP, RN, FACCE, LCCE, IBCLC, RLC, explains what the research tells us about the establishment of secure attachment systems through physiological breastfeeding patterns.

Understanding and being understood

Breastfeeding is far more than a mere means of feeding, tongue movement, or the act of providing milk. The interactions between the members of the breastfeeding unit form the basis of an intricate mother-child relationship with long term developmental implications for children, parents and families. Most significantly, it appears that the interactions associated with breastfeeding help parents learn how to understand and respond to their offspring (Epstein-Gilboa, 2006, 2009). The sense of being understood and supported is central to healthy development.

The foundation of one’s feelings about the self and others is formed in the relationship between the primary caregiver and infant (Grossman, Grossman, &  Kindler, 2005; Main, 2000). The quality of interactions in the significant relationship influences child development in multiple domains (Ranson, & Urichuk, 2008). The longstanding influence of the early relationship is demonstrated by findings which indicate that the quality of interaction in early childhood is carried on to the next generation by influencing parenting capacities later in life (Strathearn, Fonagy, Amico, & Montatgue, 2009).  

One’s perception of the early relationship with the primary caregiver has been compared to internal maps or working models of interaction (Bretherton, & Munholland, 1999). Signs of emerging internal models are apparent in infancy (Johnson, Dweck, & Chen, 2007). The internal model provides one with information about, expectations and means of, engaging with others. Intrinsic factors such as temperament and parenting interventions that suit the infant’s in-born traits contribute to children’s views of the world and to their behaviors (Seifer, et al., 2014; Thomas, & Chess, 1977). Many longstanding models agree that optimal caregiving behavior includes the ability to observe, interpret and match responses to infants’ and children’s social and emotional needs.

The exact way that parents support infants and children varies according to different theories. Examples of longstanding paradigms explaining social and emotional development in humans include, but are not limited to, separation individuation (Mahler, Pine, & Bergman, 1975), object relations (sample theorists, Klein, 1932 in 1997; Weininger 1992; Winnicott, 1958), Stern’s (1985) theory of the interpersonal world of the infant, and attachment theory (Ainsworth, 1979; Bowlby, 1969).

Physiological Breastfeeding Patterns and Establishment of Secure Attachment Systems
Ken Tackett

Quality of attachment

Ainsworth (1979) and Bolwby’s (1969) early insights about attachment theory continue to influence theoretical and clinical work. This theory suggests that infants and children send cues to their primary caregivers about their underlying needs. The primary caregiver’s capacity to consistently match their responses to the child’s needs contributes to the quality of the attachment that one will retain throughout life. Synchrony between parent responses and child needs is denoted as sensitive or attuned in this model. Attuned or sensitive parenting styles lead to the development of secure attachment systems. A secure quality of attachment is enhanced when the infant and young child is able to remain physically close to the parent and to boomerang back and forth as they explore the world around them. Infants’ and children’s ability to rely on the primary caregiver is internalized as a sense of security and trust in relationships that is extended to others outside of the significant relationship. The internal model in this case includes a positive sense of self: one may depend on others and relationships are worthwhile.

Human infants will also develop emotional attachments to primary caregivers who display low levels of sensitivity as demonstrated by periodical or rare attention to their cues. However, insensitive parenting contributes to the development of insecure attachment systems that negatively affect children’s well-being and behaviors (Sirois, Millings, & Hirsch, 2016; Fearon, Bakermans-Kranenburg, van Ijzendoorn, Lapsley, & Roisman, 2010). The child with an insecure quality of attachment may have difficulties with relationships and with other essential functions. The internal message in an insecure attachment system is that one is unable to rely on others. Consequently, some of these children appear overly independent as they attempt to cope with the world on their own.

Current research on neurobiology reinforces older notions about the importance of parental sensitivity for child development, as well as the consequences of insensitive parenting. Evidence suggests that sensitive parenting enhances positive brain development in infancy and early childhood, while insensitive parenting has the opposite effect (Kok, et al., 2015; Schore, & Schore, 2008; Sethna, et al., 2017). Brain growth is most rapid during the first three years of life. The first few months of life are the most significant of the three years. Warm and responsive interaction will cause brain cells to connect to one another and ensure optimal cerebral function. In contrast, recurring infant or child trauma or lack of responsive care will interfere with the normal brain development. Thus, current research reinforces older notions about the influence of sensitive interaction on the formation of positive working models of interaction.

Parental development

It is interesting to note that the act of parenting also contributes to brain development in the caregiver and influences their capacity for sensitivity (Kim, 2016). The caregiver’s representation of their own experiences of being parented, attachment style and other past events influence their present parenting abilities (Mayseless, 2006) with associated brain circuitry (Swain, et al., 2014) and hormonal effects (Feldman, & Bakersman-Kranenburg, 2017; Strathearn, et al., 2009). Interaction with the infant may alter the parent’s brain development and function. Sensitive maternal-infant interaction is associated with mutual firing and enhanced synaptic connection formation in mothers’ and infants’ brains (Schore, & Schore, 2008). In addition, parental cerebral development and associated parenting behavior are also influenced by and affect hormonal changes (Champagne, & Curley, 2016; Swain, et al., 2014). A hormone of interest is oxytocin that is secreted during proximal interaction and helps parents develop sensitive parenting styles (Feldman, & Bakersman-Kranenburg, 2017). It appears that the actions that take place during parenting sustain the system and may enhance parents’ ability to display sensitivity and continue the cycle.

Thus, research on infants, children and parents indicates clearly that parental sensitivity to child cues plays a central role in facilitating healthy social emotional development. Another important implication of this research is that acts that take place during parent-child exchanges may contribute and enhance vital functions. Breastfeeding exemplifies a context that facilitates the development of sensitivity in parents with positive implications for child development (Epstein, 1993; Epstein-Gilboa, 2006, 2009).

Physiological Breastfeeding Patterns and Establishment of Secure Attachment Systems
Ken Tackett

Physiological breastfeeding

This discussion refers to physiologically based breastfeeding patterns that include an initial period of exclusivity and nursing into early childhood. These patterns provide an optimal context for infant and child initiated cue exhibition and parental matching (Epstein-Gilboa, 2006, 2009). Infants and children initiate cues to start and finish breastfeeding multiple times during the day and night. In addition, breastfeeding partners display intricate interactional cues with deep emotional meaning to one another during the breastfeeding session. The frequency and recurring nature of breastfeeding sessions seem to enhance the development of parental sensitivity as well as to help mothers cope with ambivalence and to gain a competence, closeness, intimacy, uniqueness and compensation for perceived negative events (Epstein-Gilboa, 2006, 2009, 2014).

Physiological breastfeeding patterns are accompanied by proximity behaviors such as touching, holding, carrying, baby wearing and maternal-child proximal sleeping arrangements (Epstein-Gilboa, 2006, 2009). Proximity behaviors enable breastfeeding mothers and their babies to continue experiencing synchronous interchanges. The proximity associated with breastfeeding also enables infants and older nursing children to boomerang back and forth to the breastfeeding safe place. This behavior facilitates the establishment of a secure base associated with attachment theory (Bowlby, 1969).

lying down to breastfeed
Ken Tackett

Proximity during and in between breastfeeding facilitates ongoing tactile interactions and mutual regard that characterize the interchanges associated with breastfeeding (Epstein, 1993; Epstein-Gilboa, 2006, 2009). These exchanges have important implications for the development of maternal sensitivity and child well-being. Mutual gazing and touch are associated with the secretion of oxytocin (Feldman, 2012). During lactation, the hormones prolactin and oxytocin that produce and eject breast milk (Augustine, et al., 2017) provide additional impetus for sensitivity due to their association with parenting behaviors (Feldman, & Bakersman-Kranenburg, 2017). The moderating effects of hormones on maternal scripts (Champagne, & Curley, 2016; Feldman, & Bakersman-Kranenburg, 2017; Swain, et al., 2014) likely combine with the cognitive and behavioral implications of recurring breastfeeding sessions and advance the development of sensitive mothering styles.

The recurrence of breastfeeding and associated proximity patterns not only facilitate the development of sensitivity in the breastfeeding mother but also seem to enhance responsiveness and synchrony in the supportive parent and siblings (Epstein-Glboa, 2006, 2009). Family members internalize the sensitive interaction due to observations of actions in the breastfeeding unit and active mirroring of responsive interchanges in their own interactions with the infant and with others. Older children have the opportunity to replicate their own earlier experiences as former nurselings and to actualize their secure attachment systems with one another, parents and the breastfeeding sibling. As children grow they re-create the feelings associated with security established through cue based breastfeeding with their peers and others outside the family.

Thus, physiological breastfeeding patterns seem to facilitate sensitive parenting styles and family interaction required for healthy social and emotional development. The sense of being understood established through cue based and sensitive breastfeeding extends in between nursing sessions and is replicated in the child’s interchanges with others. The ongoing cue based physiological breastfeeding sessions seem to facilitate an optimal context for the development of secure attachment systems.


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Keren Epstein-GilboaKeren Epstein-Gilboa has been working with families in the transition to parenting for over three decades. Her PhD is in developmental psychology with a focus on pregnancy, breastfeeding, infant, early childhood and parental development and mental health. She is a Registered Psychotherapist, Registered Nurse, a Lamaze Certified Childbirth educator and an International Board Certified Lactation Consultant. She was certified as an IBCLC in 1988 when the lactation consulting profession was in its infancy.  She is a retired La Leche League Leader and most importantly, a former breastfeeding mother. She combines a practice in individual, couple and family psychotherapy, lactation consulting, childbirth education and birth support with work as a university lecturer teaching undergraduate courses in psychology. Her peer reviewed publications include a book, book chapters and articles. Her original work reviews the psychology of pregnancy, pregnancy loss, birth and breastfeeding with special attention to infant, early childhood and parental development, and maternal-child and family interaction. Her book Interaction and Relationships in Breastfeeding Families is published by Praeclaurus Press.

Interaction and Relationships in Breastfeeding Families