Hanne Kronborg

The influence of psychosocial factors on the duration of breastfeeding

Aim: A study was undertaken to examine to what extent psychosocial factors are related to the length of breastfeeding. Methods: A cohort of Danish mothers giving birth to a single child was followed up for four months. Information on mother and baby including psychosocial variables was obtained from a self-report questionnaire. Breastfeeding status was subsequently monitored by a health visitor. Results: A total of 471 (88%) mothers participated, 98.7 % initiated breastfeeding and after four months 277 (59%) were still exclusive breastfeeding; 99 mothers, 51% of those who stopped, stopped within the first five weeks. In Cox regression analyses the duration of breastfeeding showed a positive association with mothers schooling ( p=0.002), her intention to breastfeed ( p=0.001), previous experience with breastfeeding ( p<0.001), self-efficacy with respect to breastfeeding ( p<0.001), her confidence in breastfeeding ( p=0.012) and knowledge about breastfeeding ( p=0.001). The effect of the mothers knowledge depended on the parity of the child. Among primiparous mothers high knowledge was associated with long duration of breastfeeding, but this association was not found among the multiparous. Conclusions: To help the mothers who would like to breastfeed their baby, we must improve our ability to identify mothers at risk of early cessation. Mothers schooling, her intention, self-efficacy and earlier breastfeeding experience can be used as early predictors. An intervention should aim at improving the self-efficacy and resources of these mothers, with a focus on practical knowledge. The first five weeks, when the largest proportion of the cessations occurred, require special attention.

Effect of early postnatal breastfeeding support: a cluster-randomized community based trial

Aim: To assess the impact of a supportive intervention on the duration of breastfeeding.

How Are Effective Breastfeeding Technique and Pacifier Use Related to Breastfeeding Problems and Breastfeeding Duration

BACKGROUND Inconsistent findings leave uncertainty about the impact of pacifier use on effective breastfeeding technique. The purpose of this study was to investigate how breastfeeding technique and pacifier use were related to breastfeeding problems and duration of breastfeeding. METHODS Data were collected from the intervention group of a randomized trial in which health visitors followed up with mothers for 6 months after childbirth. The health visitors classified the breastfeeding technique at approximately 1 week after birth and repeated the observation if a correction was necessary. Effective technique included positioning, latch, sucking, and milk transfer. Data on breastfeeding problems and pacifier use were obtained from self-reported questionnaires. The study population included 570 mother-baby pairs with complete information on breastfeeding technique and pacifier use. The primary outcome was duration of exclusive breastfeeding. RESULTS One-half of the mothers showed ineffective breastfeeding technique at the first\ observation, most frequently ineffective position (61%) and latch (52%). In the unadjusted analysis, only sucking and milk transfer were associated with breastfeeding duration. In the adjusted analysis, ineffective technique was significantly associated with mothers reporting early breastfeeding problems, which thereby influenced the breastfeeding duration. Pacifier use had an independent negative impact on duration of breastfeeding. A single correction of the breastfeeding technique was not associated with duration or occurrence of problems. CONCLUSIONS Observation of breastfeeding technique may help mothers in the stage of when they are establishing breastfeeding to avoid early and later problems, but breastfeeding technique is less useful in predicting breastfeeding duration. Use of a pacifier should be avoided in the first weeks after birth.

Breastfeeding Support in Neonatal Intensive Care A National Survey

Background: The incidence of breastfeeding of preterm infants is affected by the support provided at the hospital and in the neonatal intensive care unit (NICU). However, policies and guidelines promoting breastfeeding vary both nationally and internationally. Objectives: The aim of this survey was to describe breastfeeding support in Danish NICUs, where approximately 98% of mothers initiate lactation. Methods: A national survey of all 19 Danish NICUs was conducted in 2009. Four NICUs were at designated Baby-Friendly hospitals, and 5 had a lactation consultant. In all NICUs, it was possible for some parents to stay overnight; 2 units had short restrictions on parents’ presence. Five NICUs had integrated postpartum care for mothers. Breastfeeding policies, written guidelines, and systematic breastfeeding training for the staff were common in most NICUs. Seventeen NICUs recommended starting breast milk expression within 6 hours after birth, and mothers were encouraged to double pump. Most NICUs aimed to initiate skin-to-skin contact the first time the parents were in the NICU, and daily skin-to-skin contact was estimated to last for 2-4 hours in 63% and 4-8 hours in 37% of the units. The use of bottle-feeding was restricted. Conclusions: The Danish NICUs described the support of breastfeeding as a high priority, which was reflected in the recommended policies for breast milk pumping, skin-to-skin contact, and the parents’ presence in the NICU, as well as in the restricted use of bottle-feeding. However, support varied between units, and not all units supported optimal breastfeeding.

Breastfeeding Progression in Preterm Infants Is Influenced by Factors in Infants, Mothers and Clinical Practice: The Results of a National Cohort Study with High Breastfeeding Initiation Rates

Background and Aim Many preterm infants are not capable of exclusive breastfeeding from birth. To guide mothers in breastfeeding, it is important to know when preterm infants can initiate breastfeeding and progress. The aim was to analyse postmenstrual age (PMA) at breastfeeding milestones in different preterm gestational age (GA) groups, to describe rates of breastfeeding duration at pre-defined times, as well as analyse factors associated with PMA at the establishment of exclusive breastfeeding. Methods The study was part of a prospective survey of a national Danish cohort of preterm infants based on questionnaires and structured telephone interviews, including 1,221 mothers and their 1,488 preterm infants with GA of 24–36 weeks. Results Of the preterm infants, 99% initiated breastfeeding and 68% were discharged exclusively breastfed. Breastfeeding milestones were generally reached at different PMAs for different GA groups, but preterm infants were able to initiate breastfeeding at early times, with some delay in infants less than GA 32 weeks. Very preterm infants had lowest mean PMA (35.5 weeks) at first complete breastfeed, and moderate preterm infants had lowest mean PMA at the establishment of exclusive breastfeeding (36.4 weeks). Admitting mothers to the NICU together with the infant and minimising the use of a pacifier during breastfeeding transition were associated with 1.6 (95% CI 0.4–2.8) and 1.2 days (95% CI 0.1–2.3) earlier establishment of exclusive breastfeeding respectively. Infants that were small for gestational age were associated with 5.6 days (95% CI 4.1–7.0) later establishment of exclusive breastfeeding. Conclusion Breastfeeding competence is not developed at a fixed PMA, but is influenced by multiple factors in infants, mothers and clinical practice. Admitting mothers together with their infants to the NICU and minimising the use of pacifiers may contribute to earlier establishment of exclusive breastfeeding.

Factors associated with exclusive breastfeeding of preterm infants. Results from a prospective national cohort study.

Background and Aim Evidence-based knowledge of how to guide the mothers of preterm infants in breastfeeding establishment is contradictive or sparse. The aim was to investigate the associations between pre-specified clinical practices for facilitating breastfeeding, and exclusive breastfeeding at discharge as well as adequate duration thereof. Methods A prospective survey based on questionnaires was conducted with a Danish national cohort, comprised of 1,221 mothers and their 1,488 preterm infants with a gestational age of 24–36 weeks. Adjusted for covariates, the pre-specified clinical practices were analysed by multiple logistic regression analyses. Results At discharge 68% of the preterm infants were exclusively breastfed and 17% partially. Test-weighing the infant, and minimizing the use of a pacifier, showed a protective effect to exclusive breastfeeding at discharge (OR 0.6 (95% CI 0.4–0.8) and 0.4 (95% CI 0.3–0.6), respectively). The use of nipple shields (OR 2.3 (95% CI 1.6–3.2)) and the initiation of breast milk expression later than 48 hours postpartum (OR 4.9 (95% CI 1.9–12.6)) were associated with failure of exclusive breastfeeding at discharge. The clinical practices associated with an inadequate breastfeeding duration were the initiation of breast milk expression at 12–24 hours (OR 1.6 (95% CI 1.0–2.4)) and 24–48 hours (OR 1.8 (95% CI 1.0–3.1)) vs. before six hours postpartum, and the use of nipple shields (OR 1.4 (95% CI 1.1–1.9)). Conclusion Early initiation of breast milk pumping before 12 hours postpartum may increase breastfeeding rates, and it seems that the use of nipple shields should be restricted. The use of test-weighing and minimizing the use of a pacifier may promote the establishment of exclusive breastfeeding, but more research is needed regarding adequate support to the mother when test-weighing is ceased, as more of these mothers ceased exclusive breastfeeding at an early stage after discharge.

Antenatal training to improve breast feeding: a randomised trial

OBJECTIVE to assess the effect of an antenatal training programme on knowledge, self-efficacy and problems related to breast feeding and on breast-feeding duration. DESIGN a randomised controlled trial. SETTING the Aarhus Midwifery Clinic, a large clinic connected to a Danish university hospital in an urban area of Denmark. PARTICIPANTS a total of 1193 nulliparous women were recruited before week 21+6 days of gestation, 603 were randomised to the intervention group, and 590 to the reference group. INTERVENTION we compared a structured antenatal training programme attended in mid-pregnancy with usual practice. MEASUREMENTS data were collected through self-reported questionnaires sent to the womens e-mail addresses and analysed according to the intention to treat principle. The primary outcomes were duration of full and any breast feeding collected 6 weeks post partum (any) and 1 year post partum (full and any). FINDINGS no differences were found between groups according to duration of breast feeding, self-efficacy score, or breast-feeding problems, but after participation in the course in week 36 of gestation women in the intervention group reported a higher level of confidence (p=0.05), and 6 weeks after birth they reported to have obtained sufficient knowledge about breast feeding (p=0.02). Supplemental analysis in the intervention group revealed that women with sufficient knowledge breast fed significantly longer than women without sufficient knowledge (HR=0.74 CI: 0.58-0.97). This association was not found in the reference group (HR=1.12 CI: 0.89-1.41). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE antenatal training can increase confidence of breast feeding in pregnancy and provide women with sufficient knowledge about breast feeding after birth. Antenatal training may therefore be an important low-technology health promotion tool that can be provided at low costs in most settings. The antenatal training programme needs to be followed by postnatal breast-feeding support as it is not sufficient in itself to increase the duration of breast feeding or reduce breast-feeding problems.

Obesity and early cessation of breastfeeding in Denmark.

BACKGROUND Obesity is associated with early cessation of breastfeeding. Breastfeeding is multi-factorial, and several factors contribute to this association. Our aim was to investigate to what extent socio-demographic and psychosocial characteristics, parity and prenatal conditions could explain the association between high BMI and early cessation of breastfeeding. METHODS We used data from a randomized trial of 1597 Danish mothers of singleton infants. Self-reported maternal postnatal weight and height were available from 1375 (86%). High BMI was defined as body mass index ≥ 32 kg/m(2) at ~17 days after delivery. Outcome was cessation of exclusive breastfeeding by 17 weeks post-partum used in proportional hazards regression models. RESULTS In the unadjusted analysis, mothers with high post-partum BMI compared with other mothers had a significantly higher rate of cessation of exclusive breastfeeding, and were more frequently characterized by socio-demographic, psychosocial, perinatal and behavioural factors known to increase the risk of early breastfeeding cessation. In the adjusted analyses (n = 1226), the association between BMI and duration of exclusive breastfeeding depended on parity (P = 0.03). Among primiparae, high BMI was associated with nearly double the risk of early cessation of exclusive breastfeeding (HR = 1.74, 95% CI 1.21-2.50). Among multiparae, the association disappeared when adjusted for socio-demographic factors and previous breastfeeding experience (HR = 0.89, 95% CI 0.62-1.28). CONCLUSION Parity and previous breastfeeding experience are important factors to include when studying the association between BMI and breastfeeding duration. Intervention to extend the duration of lactation among obese mothers should focus on those with no or little previous breastfeeding experience.

Predictors for early introduction of solid food among Danish mothers and infants: an observational study.

BackgroundEarly introduction of complementary feeding may interfere with breastfeeding and the infant’s self-controlled appetite resulting in increased growth. The aim of the present study was to investigate predictors for early introduction of solid food.MethodsIn an observational study Danish mothers filled in a self-administered questionnaire approximately six months after birth. The questionnaire included questions about factors related to the infant, the mother, attachment and feeding known to influence time for introduction of solid food. The study population consisted of 4503 infants. Data were analysed using ordered logistic regression models. Outcome variable was time for introduction to solid food.ResultsAlmost all of the included infants 4386 (97%) initiated breastfeeding. At weeks 16, 17–25, 25+, 330 infants (7%); 2923 (65%); and 1250 (28%), respectively had been introduced to solid food. Full breastfeeding at five weeks was the most influential predictor for later introduction of solid food (OR = 2.52 CI: 1.93-3.28). Among infant factors male gender, increased gestational age at birth, and higher birth weight were found to be statistically significant predictors. Among maternal factors, lower maternal age, higher BMI, and being primipara were significant predictors, and among attachment factors mother’s reported perception of the infant as being temperamental, and not recognising early infant cues of hunger were significant predictors for earlier introduction of solid food. Supplementary analyses of interactions between the predictors showed that the association of maternal perceived infant temperament on early introduction was restricted to primiparae, that the mother’s pre-pregnancy BMI had no impact if the infant was fully breastfed at week five, and that birth weight was only associated if the mother had reported early uncertainty in recognising infant’s cues of hunger.ConclusionsBreastfeeding was the single most powerful indicator for preventing early introduction to solid food. Modifiable predictors pointed to the importance of supporting breastfeeding and educating primipara and mothers with low birth weight infants to be able to read and respond to their infants’ cues to prevent early introduction to solid food.

Parental experiences of early postnatal discharge: A meta-synthesis

OBJECTIVE the aim of this study was to investigate new parents׳ experiences of early postnatal discharge. DESIGN a meta-synthesis including 10 qualitative studies was conducted using Noblit and Hare׳s method of meta-synthesis development. SETTING qualitative studies performed in western countries from 2003-2013 were included. PARTICIPANTS the 10 included studies involved 237 mothers and fathers, first time parents as well as multiparous. FINDINGS we identified four overlapping and mutually dependent themes reflecting the new parents׳ experiences of early postnatal discharge: Feeling and taking responsibility; A time of insecurity; Being together as a family; and Striving to be confident. The mothers׳ and fathers׳ experiences of responsibility, security and confidence in their parental role, were positively influenced by having the opportunity to be together as a family, receiving postnatal care that included both parents, having influence on time of discharge, and getting individualised and available support focused on developing and recognising their own experiences of taking care of the baby. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE the new parents׳ experiences of early discharge and becoming a parent were closely related. Feeling secure and confident in the parental role was positively or negatively influenced by the organisation of early discharge. This underscores the importance of the way health professionals support new mothers and fathers at early postnatal discharge.