How does extreme heat impact on breastfeeding? 

Soaring temperatures from the newly declared El Niño have seen much of the Mediterranean and North Africa living in 40°C weather for prolonged number of days. And it looks like this weather is not settling anytime soon – El Niño episodes usually last between nine to 12 months.  

According to the World Meteorological Organization (WMO), these heatwave events have increased sixfold since the 1980s, driven by the naturally occurring El Nino and exacerbated by human-induced warming from greenhouse gases. They’re calling for more investment in heat health planning and early warning systems. 

This is exactly why the work of HIGH Horizons is critical. We must protect our most vulnerable and understand how high temperatures impact maternal, newborn and child health.  

breast is best, even in the heat

Exclusive breastfeeding for the first six months (no food or other liquids except for breastmilk) is a life-saving practice for children, and provides protection against many childhood illnesses. Although millions of women live in hot or tropical climates, the role of environmental heat as a barrier to exclusive breastfeeding has not often been considered. Until now! 

Researchers from the CHAMNHA (The Climate, Heat and Maternal and Neonatal Health in Africa) consortium, which includes the London School of Hygiene & Tropical Medicine (LSHTM), Aga Khan University Kenya (AKU) and the Institut de Recherche en Sciences de la Sante (IRSS), and several other universities, have investigated the impact of heat on breastfeeding through systematic reviews, ethnographic studies, and epidemiological studies. 

We asked four members of the CHAMNHA team to summarise their findings so far.

What is the role of heat in the practices of breastfeeding and are there specific concerns of women and providers? – Insight from CHAMNHA 

Sari Kovats, Associate Professor at LSHTM; Veronique Filippi, Professor of Maternal Health & Epidemiology at LSHTM, Dr Cherie Part, Research Fellow at LSHTM & Dr Adelaide Lusambili, Associate Professor at Africa International University. 

The child suffers from the heat as well as the mother… If you lie him down too, it’s just crying. He doesn’t know what to do. It’s just suffering. Even to breastfeed him/her, it is difficult

Postpartum mother, Delga, Burkina Faso taken from a CHAMNHA study

Breastfeeding advice is provided by health workers, peers and family circles, and cultural beliefs can be highly influential on maternal intention to breastfeed exclusively. Healthcare providers and relatives sometimes advise that water supplementation is needed in hot weather. A systematic review of studies on infant hydration led by CHAMNHA found no evidence that infants under the age of six months require supplementary food or fluids in hot weather conditions. Nine studies were found in different  low- and middle – income countries and there is a need for additional research that also assess the welfare and hydration of the mother. Breastmilk quality may also change in hot weather, the exact reason is still unclear but it’s likely that heat plays a part, as well as the effect of changes in feeding routine.  

CHAMNHA recently published a study investigating the impacts of heat on mothers’ breastfeeding behaviours in Bobo-Dioulasso, Burkina Faso. Over 860 postpartum women were interviewed three times over 12 months. They told about the activities they had carried out the previous day and the time spent on each activity. The study looked at the relationships between women’s activities and temperature from the local weather station and found that women spent less time breastfeeding when it was hot, equating to 25-minutes less on the warmest compared to the coolest days of the year. For infants over 4 months old, hot weather had an even greater impact on the time spent breastfeeding. Women were less likely to exclusively breastfeed their very young infants (0-3 months old) in extreme hot weather. Instead, as temperatures increased, women provided supplementary fluids, mainly water, to their young infants.  

This finding is supported by interviews with mothers, family members and health workers in rural communities in Kenya and Burkina Faso that have also found that heat has a significant effect on exclusive breastfeeding. Mothers report that high temperatures cause discomfort and increase irritability and exhaustion. Babies were reported to be too uncomfortable to sleep or to breastfeed. In Kilifi, Kenya, mothers reported that while breastfeeding in the heat, they had to remove their clothes, causing their babies to be unlatched from the breast. The impact on babies was perceived to be amplified by the indoor heat and household air pollution from cooking.  

Very often mothers want to be alone, they want to get some fresh air, so I find that babies are neglected during the heat. When it’s hot, the mother herself is not free-spirited. She doesn’t want to go near her baby, because if she does, the heat increases. As a result, the desire to breastfeed with love disappears.

Health professional, Delga, Burkina Faso

Our study in Burkina Faso also showed that higher temperatures did not reduce the amount of time women spent on household chores or informal work. These findings are echoed in the conversations with women in Kilifi, who report that their workload is not reduced during high temperatures and in some cases is increased because tasks take more time, for example, women must walk farther to fetch water. This can mean there is less time for childcare or breastfeeding.  

Access to cooling and shading should be for everyone. Temperatures can increase locally due to deforestation and poor urban design. Understanding how housing quality influences newborn health, especially in hot low-resourced settings, is crucial. In many parts of Africa, people live in small, poorly ventilated houses without windows and with roofs made of heat-trapping materials. Adapting building materials to counteract rising ambient temperatures is important as well as increasing access to reliable electricity which will reduce individual exposures to high temperatures.  

Our research clearly shows more needs to be done to discourage water or other fluid supplementation when promoting exclusive breastfeeding of infants below six months old. Families and health workers can be reminded that exclusive breastfeeding is recommended even in hot conditions. Measures should be taken to ensure that mothers have adequate nutrition and are not dehydrated. Improved guidance involves healthcare providers who are critical to inform and guide pregnant and postpartum mothers and families on how to avoid dehydration and heat illness among neonates. 

Learning from CHAMNHA and adapting to HIGH Horizons

There’s much for HIGH Horizons to take away from this research and apply in the current work.  

Our HIGH Horizons social scientists are conducting research in South Africa, Sweden, and Zimbabwe – they’ll talk to mothers about their environment and how heat impacts their own health, childcare and breastfeeding. This insight, combined with existing evidence sources, will be used to develop messages that can be integrated into health services, apps, and early notification/warning systems. These messages will help increase women’s and community knowledge of behaviours to provide the best possible care to their infants during periods of during extreme heat. For example, the importance of exclusive breastfeeding, the importance of supporting women to breastfeed during heat, the need to prepare and ensure water is available to hydrate the mother, and the optimum frequency and duration of breastfeeding during heatwaves. 

El Niño events will keep occurring every two to seven years, and in between many countries still face prolonged episodes of high heat. But the outlook isn’t all bleak. Thanks to consortiums like CHAMNHA and a global collaborative effort – we are building adaptions and mitigation strategies to minimise the harmful impact on maternal, newborn and child health. That includes empowering women with the information and support they need to exclusively breastfeed, no matter the weather.  

Learn more about the work of CHAMNHA