M. Jane Heinig

Differences in morbidity between breast-fed and formula-fed infants

To determine whether breast-feeding is protective against infection in relatively affluent populations, morbidity data were collected by weekly monitoring during the first 2 years of life from matched cohorts of infants who were either breast fed (BF) (N = 46) or formula fed (FF) (N = 41) until at least 12 months of age. Cohorts were matched for characteristics such as birth weight and parental socioeconomic status, and we controlled for use of day care in data analysis. Mean maternal educational level was high (16 years) in both groups. In the first year of life the incidence of diarrheal illness among BF infants was half that of FF infants; the percentage with any otitis media was 19% lower and with prolonged episodes (> 10 days) was 80% lower in BF compared with FF infants. There were no significant differences in rates of respiratory illness; nearly all cases were mild upper respiratory infections. Morbidity rates did not differ significantly between groups in the second year of life, but the mean duration of episodes of otitis media was longer in FF than BF infants (8.8 +/- 5.3 vs 5.9 +/- 3.5 days, respectively; p = 0.01). These results indicate that the reduction in morbidity associated with breast-feeding is of sufficient magnitude to be of public health significance.

HOST DEFENSE BENEFITS OF BREASTFEEDING FOR THE INFANT Effect of Breastfeeding Duration and Exclusivity

Breastfeeding confers lifesaving protection against infectious illness among disadvantaged populations. As a result, breastfeeding promotion has an important part in child health programs throughout the world. In this article, the evidence regarding the host defense benefits of breastfeeding for term infants of normal birth weight is reviewed, with an emphasis on recent information from industrialized countries regarding how the degree and duration of breastfeeding affect infant health.

Health Advantages of Breast Feeding for Infants: a Critical Review

I N F A N T M O R B I D I T Y . . . 93 A C U T E I N F E C T I O U S I L L N E S S . . 93 G A S T R O I N T E S T I N A L DISEASES . . 94 N E C R O T I Z I N G E N T E R O C O L I T I S . . 95 R E S P I R A T O R Y DISEASES . . 96 O T I T I S M E D I A . . . 91 B A C T E R A E M I A A N D M E N I N G I T I S . . . 98 I N F A N T B O T U L I S M . . . 98 U R I N A R Y T R A C T I N F E C T l O N . . 98 C H R O N I C I L L N E S S . . . 99

Barriers to Compliance With Infant-Feeding Recommendations Among Low-income Women

Focus groups were used to examine relationships among maternal beliefs, feeding intentions, and infant-feeding behaviors among 65 Women, Infants and Children-eligible (28 English-speaking and 37 Spanish-speaking) mothers. Participants shared common beliefs that breast-feeding was beneficial; nevertheless, many believed that early introduction of formula and solid foods was unavoidable in certain situations. Medical providers and Women, Infants and Children staff were sources of infant-feeding information, and the Spanish-speaking mothers attempted to adhere to the guidance. However, the English-speaking mothers often ignored this advice if it was not perceived as working for the family’s circumstances. Mothers, believing that providers would not understand that they were compelled to reject infant-feeding recommendations, would not ask for assistance when facing difficulties. Instead, mothers relied on relatives and others for infant-feeding guidance. Educational efforts should acknowledge mothers’ true circumstances, target support to each situation, and emphasize the health value of complementary foods rather than their association with infant motor development.

Health effects of breast feeding for mothers: a critical review

Lactation results in a number of physiological adaptations which exert direct effects on maternal health, some of which may confer both short and long term advantages for breast feeding mothers. Breast feeding in the early postpartum period promotes a more rapid return of the uterus to its prepregnant state through the actions of oxytocin. Breast feeding may also lead to a more rapid return to prepregnancy weight. Among studies that had good data on duration and intensity of lactation, the majority show a significant association between lactation and weight loss. However, there is no evidence that lactation prevents obesity. Lactation also affects glucose and lipid metabolism. The long term effects of these adaptations are unknown but may have implications for preventing subsequent development of diabetes and heart disease. Lactation delays the return of ovulation and significantly reduces fertility during the period of lactational amenorrhoea. This process is linked with feeding patterns and may therefore be affected by practices such as scheduled feedings and the timing of introduction of complementary foods. While the evidence from epidemiologic studies is mixed, several large studies have shown that extended lactation is associated with reduced risk of premenopausal breast, ovarian and endometrial cancers. Although bone mineralization declines during lactation, repletion takes place after weaning. As a result, breast feeding does not appear to cause long term depletion of bone nor does it increase risk of osteoporosis. Many of the physiological effects of lactation are dependent on the stimulation of the hypothalamic-pituitary axis and milk removal and thus may vary with infant feeding practices. Well controlled studies are needed that include detailed information regarding infant feeding practices in addition to the total duration of any breast feeding. Future feeding recommendations should reflect careful consideration of how such practices affect both infant and maternal health.Lactation results in a number of physiological adaptations which exert direct effects on maternal health, some of which may confer both short and long term advantages for breast feeding mothers. Breast feeding in the early postpartum period promotes a more rapid return of the uterus to its prepregnant state through the actions of oxytocin. Breast feeding may also lead to a more rapid return to prepregnancy weight. Among studies that had good data on duration and intensity of lactation, the majority show a significant association between lactation and weight loss. However, there is no evidence that lactation prevents obesity. Lactation also affects glucose and lipid metabolism. The long term effects of these adaptations are unknown but may have implications for preventing subsequent development of diabetes and heart disease. Lactation delays the return of ovulation and significantly reduces fertility during the period of lactational amenorrhoea. This process is linked with feeding patterns and may therefore be affected by practices such as scheduled feedings and the timing of introduction of complementary foods. While the evidence from epidemiologic studies is mixed, several large studies have shown that extended lactation is associated with reduced risk of premenopausal breast, ovarian and endometrial cancers. Although bone mineralization declines during lactation, repletion takes place after weaning. As a result, breast feeding does not appear to cause long term depletion of bone nor does it increase risk of osteoporosis. Many of the physiological effects of lactation are dependent on the stimulation of the hypothalamic-pituitary axis and milk removal and thus may vary with infant feeding practices. Well controlled studies are needed that include detailed information regarding infant feeding practices in addition to the total duration of any breast feeding. Future feeding recommendations should reflect careful consideration of how such practices affect both infant and maternal health.

Clinical lactation practice: 20 years of evidence

Lactation consultants depend on a vast multidisciplinary knowledge base to support their practices. To coincide with the 20-year anniversary of the International Lactation Consultant Association, the authors sought to highlight the knowledge base to demonstrate how practice has been affected. Using standard databases, they extracted English-language scientific literature related to breastfeeding and maternal and infant health outcomes; factors associated with breastfeeding initiation, exclusivity, and duration; lactation physiology; common breastfeeding challenges; breastfeeding practices within vulnerable populations; health professional support of breastfeeding; and breastfeeding practices in developing countries of Africa. Summaries of research are provided to demonstrate scientific method and knowledge evolution. As the knowledge of the biological, behavioral, and environmental factors that affect breastfeeding continues to grow, researchers and lactation consultants will identify additional research areas. Thus, the cycle of describing and explaining phenomena, testing interventions to improve practice, and ultimately improving breastfeeding outcomes worldwide will continue.

Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss

Even mothers who strongly want to breast feed their infants could have difficulty getting started. This prospective community-based study was an attempt to identify risk factors other than sociocultural barriers that arerelated to poor lactation outcomes. Risk factors were sought for suboptimal infant breastfeeding behavior (SIBB), delayed lactation, and excessive neonatal weight loss. Participants gave birth to a healthy single infant at term and were willing to try breast feeding exclusively for at least 30 days. Trained lactation consultants provided guidance in such areas as correct positioning, demand feeding, and avoidance of supplements, and also evaluated infant breastfeeding behavior using the Infant Breast-feeding Assessment Tool. Weight loss exceeding 10% of birth weight on day 3 was considered excessive. The mean maternal age was 30.6 years and 56% of mothers were primiparous. Nearly 80% of subjects were non-Hispanic whites. The average educational level was high. These mothers expressed strongly positive attitudes toward breast feeding. SIBB was found in 49% of infants at baseline, 22% on day 3 and 14% on day 7. It correlated significantly with primiparity on days 0 and 3, with cesarean section (day 0 in multiparas), and with flat or inverted nipples. Other significant correlates of SIBB included using nonbreast milk fluids in the first 2 days of life, use of a pacifier, stage II labor lasting longer than 1 hour, and a maternal body mass index (BMI) greater than 27 kg/m 2 . Lactation was delayed in 22% of women, more frequently in primiparas, after cesarean section, and women having a prolonged second stage of labor, a high material BMI, flat or inverted nipples, or (in primiparas) a birth weight greater than 3600 g. Excessive weight loss was observed in 12% of neonates. It correlated with primiparity, a long labor, the use of labor medication (by multiparas), and infant status at birth. Excessive weight loss was 7.1-fold more likely if lactation was delayed and 2.6-fold more likely if SIBB was present on the first day of life.

Educational Intervention to Modify Bottle-feeding Behaviors among Formula-feeding Mothers in the WIC Program: Impact on Infant Formula Intake and Weight Gain

OBJECTIVE Formula-fed infants gain weight faster than breastfed infants. This study evaluated whether encouraging formula-feeding caregivers to be sensitive to infant satiety cues would alter feeding practices and reduce infant formula intake and weight gain. DESIGN Double-blind, randomized educational intervention, with intake and growth measured before (at 1 to 2 months) and after (4 to 5 months) the intervention. SETTING Women, Infants, and Children (WIC) clinics in Sacramento, California. PARTICIPANTS 836 caregivers of young infants were screened; 214 were eligible, and 104 agreed to participate. INTERVENTION Intervention subjects received education promoting awareness of satiety cues and discouraging bottles containing more than 6 ounces before 4 months of age; intervention and control groups received education regarding introduction and feeding of solid food after 4 months of age. MAIN OUTCOME MEASURES Formula intake (mL/24 hours) and weight gain (g/week). ANALYSIS Differences between groups evaluated using 2-way analysis of covariance (ANCOVA). RESULTS Sixty-one subjects completed baseline records, 44 attended class, and 38 completed the study. Despite a positive response to the educational intervention, there was no change in bottle-feeding behaviors (formula intake at 4 to 5 months was more than 1100 mL/day in both groups). Infant growth in the intervention group was greater than in the control group (P < .01), contrary to the hypothesis. CONCLUSIONS AND IMPLICATIONS The intervention improved knowledge of the key messages, but further research is needed to understand barriers to modifying bottle-feeding behaviors.

Maternal Request for In-hospital Supplementation of Healthy Breastfed Infants among Low-income Women

Background: While hospital policies and medical issues are important factors in determining exclusive breastfeeding rates, medically unnecessary supplementation of infants is likely to be due, in part, to maternal request for formula. Objectives: The goal of this project was to gain an understanding of the facilitating factors and decision-making processes surrounding maternal request for formula in the early postpartum period. Methods: A series of 12 focus groups were conducted among 97 English- and Spanish-speaking low-income participants in California’s Supplementary Nutrition Program for Women, Infants, and Children (WIC). Mothers were asked to share their in-hospital infant-feeding experiences. Results: The overarching theme that emerged was “lack of preparation” for what the early postpartum period would be like. Specifically, the decisions to formula feed fell into the following categories: inadequate preparation for newborn care (the need for rest and unrealistic expectations about infant behavior), lack of preparation for the process of breastfeeding, and formula as a solution to breastfeeding problems. Cultural factors were not mentioned as reasons for supplementation. Conclusion: Interventions to promote in-hospital exclusive breastfeeding must address mothers’ real and perceived barriers, specifically mothers’ expectations related to breastfeeding and infant behavior.

Diagnostic Value of Signs and Symptoms of Mammary Candidosis among Lactating Women

Mammary candidosis in lactating women is not well defined and is most often presumptively diagnosed by signs and symptoms. This study evaluates the sensitivity, specificity, positive predictive value, and likelihood ratios of signs and symptoms of mammary candidosis based on the presence of Candida species on the nipple/areola or in the milk. In this prospective cohort study, the nipple/areola skin and milk of 100 healthy breastfeeding mothers were cultured from each breast at 2 weeks postpartum, and mothers were interviewed regarding signs and symptoms associated with mammary candidosis between 2 and 9 weeks postpartum. Positive predictive value for Candida colonization was highest when there were 3 or more signs or symptoms simultaneously or when flaky or shiny skin of the nipple/areola was reported together or in combination with breast pain. J Hum Lact. 20(3):288-295.