Breastfeeding

By Oliver Ki Kek Yee

0321435
Learning Objectives

● Factors that contribute to successful initiation and maintenance of breastfeeding

The Factors

1. Smoking (Yay or nay)

2. Mode of delivery (Vaginal vs Cesaerean)
3. Parity (Multi. vs primi.)
4. Dyad connections (Skin-to-skin/rooming-in vs no skin-to-skin/rooming-in)
5. Maternal education attainment (Highest vs lowest category)
6. Breastfeeding education (Yay or nay)
Smoking

● Studies were focused on smoking during pregnancy, and its effects on breastfeeding
initiation and maintenance
● Results from multiple studies concluded that there is a direct correlation to increased
relative risk of initiation and maintenance of breastfeeding; with mothers whom DO
NOT partake in intrapartum smoking.
● The studies investigated breastfeeding initiation, maintenance and maintenance after
a 4 month follow-up period.
Mode of Delivery

● There are a lot of factors apart from just vaginal vs cesaerean.

○ Within vaginal - spontaneous vs induced, or forceps or vacuum assistance vs no assistance.
○ Within cesaerean - elective/not in labor vs nonselective/in labor.
● Without going into too many specifics, the general consensus is that vaginal delivery,
leads to higher relative risk of initiating, maintaining and maintenance until 4 month
follow-up of breastfeeding.
Parity

● The various studies that aimed at comparing multiparous women and primiparous
women with respect to initiation of breastfeeding found a largely heterogenous result,
of which the averaged RR value show that there was NO significant difference.
● HOWEVER, with respect to both continuation and continuation at the 4 month
follow-up; found that multiparous women had a higher RR value than the later.
Dyad Connections

● Mother-infant dyad separation generally focused on 2 outcomes :

○ Early skin-to-skin contact vs not
○ Rooming-in vs not
● When analysed as a single metric, the positive dyad connections were associated with
increased initiation, continuation and continuation at 4 months follow-up for
breastfeeding.
● Sensitivity analyses of studies examining skin-to-skin and rooming-in separately
found that the association was stronger for initiation.
Maternal Education Attainment

● Measurement and categorisation of maternal education status is variable and often

dependent on the country in which the various studies were conducted in; so for
analysis of this data, the comparison made use of the highest education level vs the
lowest.
● Although the studies varied in magnitudes, the general consensus is that participants
with the highest maternal education category, was a higher likelihood of early
initiation, continuation and continuation after 4 month follow-up for breastfeeding.
Breastfeeding Education

● This is studied for both parents, not just mothers, as paternal breastfeeding education
also plays a role.
● These include breastfeeding classes, peer counselling on breastfeeding, and lactation
consultation.
● Interventions at clinic/hospital/clinicians were excluded.
● The studies concluded that there is a positive correlation between the breastfeeding
education efforts, and the participants’ initiation, continuation, and continuation after
4 month follow-up of breastfeeding.
Factors associated with
breastfeeding maintenance at 6
months in adolescent mothers.
Analysis of variables subjected to
Poisson hierarchical regression
analysis
Factors associated with
breastfeeding maintenance
at 12 months in adolescent
mothers. Analysis of
variables subjected to
Poisson hierarchical
regression analysis
Factors associated with
breastfeeding maintenance
at 24 months in adolescent
mothers. Analysis of
variables subjected to
Poisson hierarchical
regression analysis
Other factors

1. Marital status,
2. Participation in an education program for nutritional supplements for mothers,
infants, and children,
3. Unwanted pregnancies,
4. Delivery of a low birth–weight infant,
5. Postpartum depression.
6. Breastfeeding attitudes/perceptions.
Postpartum Depression
● Objective:
○ A qualitative systematic review was conducted to examine the relationship between postpartum
depressive symptomatology and infant-feeding outcomes.
● Results:
○ Women with depressive symptomatology in the early postpartum period may be at increased risk for
poor breastfeeding.
● Conclusion:
○ Depressive symptomatology in postpartum period negatively influences infant-feeding outcomes.
Low Fetal Birth Weight
● Objective:
○ Determine barriers to successful establishment and maintenance of breastfeeding in very-low-
birthweight (VLBW) infants. Both in the hospital and after discharge and the changes in those barriers
over time.
● Design:
○ Qualitative, longitudinal study of a secondary analysis of a previously reported RCT of a breastfeeding
support intervention that examined infants weighing <1500g at birth.
● Main outcome measures:
○ Barriers to successful establishment and maintenance of breastfeeding during discharge from neonatal
ICU, at discharge home, at 1, 3, 6, and 12 month follow up for corrected age; or until weaning from
breastfeeding.
Low Fetal Birth Weight
● Results
○ At NICU discharge, low milk volume was the greatest breastfeeding barrier.
○ During the period from discharge home and at 1 month and 3 months, the infants' compromised
physical status was the largest barrier to breastfeeding.
○ Data from the 6- and 12-month time periods indicated that the provision of complementary feeding
was the greatest barrier to breastfeeding; it was most prevalent in the period following NICU discharge
and before discharge home.
○ Across all time periods, nipple and breast problems were most prevalent at NICU discharge, whereas
poor technique was a barrier at 1 month.
○ Mothers' compromised emotional status was greatest at discharge from the NICU and diminished
thereafter.
WHO Recommendations
Immediate support to initiate and establish breastfeeding Feeding practices and additional needs of infants

1. Early and uninterrupted skin-to-skin contact between mothers and infants 1. Mothers should be discouraged from giving any food or fluids other than
should be facilitated and encouraged as soon as possible after birth. breast milk, unless medically indicated.
2. All mothers should be supported to initiate breastfeeding as soon as possible 2. Mothers should be supported to recognize their infants’ cues for feeding,
after birth, within the first hour after delivery. closeness and comfort, and enabled to respond accordingly to these cues
3. Mothers should receive practical support to enable them to initiate and with a variety of options, during their stay at the facility providing maternity
establish breastfeeding and manage common breastfeeding difficulties. and newborn services.
4. Mothers should be coached on how to express breast milk as a means of 3. For preterm infants who are unable to breastfeed directly, non-nutritive
maintaining lactation in the event of their being separated temporarily from sucking and oral stimulation may be beneficial until breastfeeding is
their infants. established.
5. Facilities providing maternity and newborn services should enable mothers 4. If expressed breast milk or other feeds are medically indicated for term
and their infants to remain together and to practise rooming-in throughout infants, feeding methods such as cups, spoons or feeding bottles and teats
the day and night. This may not apply in circumstances when infants need to may be used during their stay at the facility.
be moved for specialized medical care. 5. If expressed breast milk or other feeds are medically indicated for preterm
6. Mothers should be supported to practise responsive feeding as part of infants, feeding methods such as cups or spoons are preferable to feeding
nurturing care. bottles and teats.
WHO Recommendations

Creating an enabling environment

1. Facilities providing maternity and newborn services should have a clearly written breastfeeding policy that is routinely
communicated to staff and parents.
2. Health-facility staff who provide infant feeding services, including breastfeeding support, should have sufficient knowledge,
competence and skills to support women to breastfeed.
3. Where facilities provide antenatal care, pregnant women and their families should be counselled about the benefits and
management of breastfeeding.
4. As part of protecting, promoting and supporting breastfeeding, discharge from facilities providing maternity and newborn
services should be planned for and coordinated, so that parents and their infants have access to ongoing support and receive
appropriate care.
References

1. Cohen, Sarah S. et al., Factors Associated with Breastfeeding Initiation and Continuation: A Meta-Analysis, The Journal of Pediatrics,
Volume 203, 190 - 196.e21
2. Muelbert M, Giugliani ERJ. Factors associated with the maintenance of breastfeeding for 6, 12, and 24 months in adolescent mothers.
BMC Public Health. 2018;18(1):675. Published 2018 May 31. doi:10.1186/s12889-018-5585-4
3. Centers for Disease Control. Rates of any and exclusive breastfeeding by socio-demographics among children born in 2012. CDC National
Immunization Survey.
4. Taylor JS, Cabral HJ. Are women with an unintended pregnancy less likely to breastfeed? J Fam Pract. 2002; 51:431–6.
5. Callen J, Pinelli J, Atkinson S, Saigal S. Qualitative analysis of barriers to breastfeeding in very-low-birthweight infants in the hospital and
postdischarge. Adv Neonatal Care. 2005; 5:93–103.
6. Dennis CL, McQueen K. The relationship between infant–feeding outcomes and postpartum depression: a qualitative systematic review.
Pediatrics. 2009; 123:e736–51.
7. WHO Recommendations : Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services
THANK
YOU.