Journal of Human Lactation

Breastfeeding provides beneficial health outcomes for infants and their mothers, and increasing its practice is a national priority in many countries. Despite increasing support to exclusively breastfeed, the prevalence at 6 months remains low. Breastfeeding behavior is influenced by a myriad of determinants, including breastfeeding attitudes, knowledge, and social support. Effective measurement of these determinants is critical to provide optimal support for women throughout the breastfeeding period. However, there are a multitude of available instruments measuring these constructs, which makes identification of an appropriate instrument challenging.

Our aim was to identify and critically examine the existing instruments measuring breastfeeding attitudes, knowledge, and social support.

A total of 16 instruments was identified. Each instrument’s purpose, theoretical underpinnings, and validity were analyzed.

An overview, validation and adaptation for use in other settings was assessed for each instrument. Depth of reporting and validation testing differed greatly between instruments.

Content, construct, and predictive validity were present for most but not all scales. When selecting and adapting instruments, attention should be paid to domains within the scale, number of items, and adaptation.

The Ten Steps to Successful Breastfeeding outline maternity practices that protect, promote, and support breastfeeding and serve as the foundation for the Baby-Friendly Hospital Initiative.

This systematic review describes interventions related to Step 3 of the Ten Steps, which involves informing pregnant women about the benefits and management of breastfeeding. Our main objective was to determine whether prenatal clinic- or hospital-based breastfeeding education increases breastfeeding initiation, duration, or exclusivity.

The electronic databases MEDLINE and CINAHL were searched for peer-reviewed manuscripts published in English between January 1, 2000, and May 5, 2016. Bibliographies of relevant systematic reviews were also screened to identify potential studies.

Thirty-eight studies were included. The research studies were either randomized controlled trials or quasi-experimental studies conducted in developed or developing countries. Findings suggest that prenatal interventions, delivered alone or in combination with intrapartum and/or postpartum components, are effective at increasing breastfeeding initiation, duration, or exclusivity where they combine both education and interpersonal support and where women’s partners or family are involved. However, varying study quality and lack of standardized assessment of participants’ breastfeeding intentions limited the ability to recommend any single intervention as most effective.

Future studies should test the strength of maternal breastfeeding intentions, assess the role of family members in influencing breastfeeding outcomes, compare the effectiveness of different health care providers, and include more explicit detail about the time and full cost of different interventions.

Breastfeeding is an important public health initiative. Low-income women benefiting from the U.S. Department of Agriculture’s Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are a prime population for breastfeeding promotion efforts.

This study aims to determine factors associated with increased likelihood of breastfeeding for WIC participants.

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement guided the systematic review of literature. Database searches occurred in September and October 2014 and included studies limited to the previous 10 years. The following search terms were used: low-income; WIC; women, infants, and children; breastfeeding; breast milk; and maternal and child health. The criterion for inclusion was a study sample of women and children enrolled in the WIC program, thereby excluding non-United States–based research.

Factors that increased the likelihood of breastfeeding for WIC participants included sociodemographic and health characteristics (n = 17); environmental and media support (n = 4); government policy (n = 2); intention to breastfeed, breastfeeding in hospital, or previous breastfeeding experience (n = 9); attitudes toward and knowledge of breastfeeding benefits (n = 6); health care provider or social support; and time exposure to WIC services (n = 5).

The complexity of breastfeeding behaviors within this population is clear. Results provide multisectored insight for future research, policies, and practices in support of increasing breastfeeding rates among WIC participants.

Breastfeeding is a major public health issue in terms of its benefits to both mothers and infants. Despite recommendations, breastfeeding initiation and duration are low in many industrialized countries. Although human milk is viewed as the most appropriate food for infants, when it is perceived as contaminated, doubts about its quality can lead to negative behaviors concerning breastfeeding. This is especially true when mothers are taking medication.

The aim of this review is to evaluate the data in the literature on the knowledge, representations, attitudes, and behaviors of women with regard to taking medication while breastfeeding. These elements should aid our understanding of how the mothers’ behaviors are constructed in this situation.

The authors conducted a scoping review to map and analyze the available data from literature sources regarding breastfeeding mothers’ knowledge, representations, attitudes, and behaviors about medicines. A staged approach to the scoping review was used.

Eighteen studies met the selection criteria. They described safety behaviors like noninitiation, duration reduction, breastfeeding cessation, and refusal to take medication in order to breastfeed. Most showed a conflict between taking medication and breastfeeding. Because the knowledge, representations, and attitudes behind such behaviors have received very little study, it is difficult to explain how these behaviors are constructed.

The results of this review confirm the need for a qualitative study to explore the knowledge, representations, and attitudes of breastfeeding women faced with taking medications, so that we can understand their connection with observed behaviors and take appropriate educational action.

Childhood sexual abuse (CSA) can have a serious effect on general and obstetric health. Breastfeeding includes several triggers for memories of abuse experiences, which will likely influence decisions about breastfeeding and its implementation in daily life. This is important since breastfeeding improves maternal well-being and bonding with the child.

As breastfeeding strongly influences the long-term health of children, we investigated experiences with breastfeeding in women with a history of CSA.

Data on breastfeeding were collected within a research project designed to compare labor and delivery experiences in women with a history of CSA to women without such antecedents. Data from 85 women having experienced CSA and 170 controls pair-matched for maternal age, children’s age, and nationality were evaluated. The clinical record of pregnancy and a self-administered questionnaire were used to collect data.

Although the prevalence of breastfeeding was similar in women with and without CSA experiences (96.5% vs. 90.6%), women exposed to CSA more often described complications associated with breastfeeding (77.7% vs. 67.1%, p = .08). Mastitis (49.4% vs. 27.6%, p < .01) and pain (29.4% vs. 18.8%, p = .15) were reported significantly more often by women after CSA. For 20% of women after CSA, breastfeeding was a trigger for memories of CSA. Furthermore, 58% of women with CSA reported dissociation when breastfeeding.

In addition to the growing list of potential health consequences of CSA experience, this experience seems to be associated with an increased number of problems when breastfeeding. However, most women with a history of CSA intend to breastfeed despite particular challenges related to CSA. A support protocol tailored to the specific needs of these women during pregnancy and the lactation period may help to improve breastfeeding and the early mother–child relationship.

According to the Centers for Disease Control and Prevention, 39.1% of African American infants are breastfed at 6 months. However, few studies have explored the breastfeeding experiences of African American women who successfully breastfeed to 6 months or longer durations.

The goal of this qualitative study was to explore the long-term breastfeeding experiences of low-income African American women using the positive deviance approach.

African American women with breastfeeding experience were recruited through Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding peer counselors. Eligibility criteria included being age 18 or older, currently participating in WIC, and having breastfed one child for at least 6 months in the past 2 years. Semistructured, in-depth interviews were conducted with 11 participants. Interviews were audio-recorded and professionally transcribed. Transcripts were then analyzed for emerging themes using thematic analysis in NVivo software.

Participants had on average three children each, with an average length of breastfeeding of 10.5 months per child. Four main themes developed: (a) deciding to breastfeed, (b) initiating breastfeeding, (c) breastfeeding long-term, and (d) expanding breastfeeding support. Participants offered culturally tailored suggestions to improve breastfeeding support for other African American women: prenatal discussions of breastfeeding with health care providers, African American lactation support personnel and breastfeeding support groups, and African American breastfeeding promotion in print and digital media.

Women who participated in this study breastfed for longer durations than the national average for African Americans. Findings can inform practice and research efforts to improve breastfeeding rates in this population using lessons learned from successful women.

Extended breastfeeding duration is common in India. Extended breastfeeding protects the infant from infectious disease and promotes child spacing. In the 1990s, the median breastfeeding duration in India was 24 months.

This study aimed to investigate the median duration of breastfeeding in India and to identify the factors associated with extended breastfeeding to 24 months as recommended by the World Health Organization.

This cross-sectional data analysis used nationally representative data from the 2011–2012 Indian Human Development Survey II. The outcome in this study was extended breastfeeding defined as breastfeeding to 24 months or more. Multivariate logistic regression was used to identify the factors associated with extended breastfeeding.

The median duration of breastfeeding was 12 months; approximately 25% of women breastfed 24 months or more. Women were at greater odds of breastfeeding 24 months or more if the infant was a boy compared with a girl, if the women lived in a rural area compared with an urban area, if the women were married at a young age (< 17 vs. 20 years or older at marriage), and if the delivery was assisted by a friend or relative compared with a doctor.

The median duration of breastfeeding has decreased by 50% from 1992–1993 to 2011–2012. The women who continue to breastfeed 24 months or more tend to be more traditional (i.e., living in rural areas, marrying young, and having family/friends as birth attendants). Further research to study the health effect of decreased breastfeeding duration is warranted.

African American mothers lag behind in breastfeeding initiation. Research is needed to gain an understanding of potential reasons for breastfeeding disparities.

This study explored breastfeeding exposure, attitudes, and intentions of African American and Caucasian college students by race and gender.

Women and men (696) attending college, who were younger than 45 years and without children, were included in this study. Survey data were collected using a demographic questionnaire and the Iowa Infant Feeding Attitude Scale.

Overall, students demonstrated favorable attitudes regarding breastfeeding but viewed formula feeding as more practical. Students who were Caucasian and female and experienced breastfeeding exposure demonstrated higher breastfeeding attitudes and intent. Breastfeeding exposure and attitudes contributed 32% of the variance in breastfeeding intentions. The odds of experiencing breastfeeding exposure and positive breastfeeding attitudes were approximately 3 times higher for Caucasian students than for African American students.

External factors demonstrated a stronger association with breastfeeding intentions. The link with race and gender appears to operate through their effect on attitudes and exposure. More research is needed to identify strategies to improve breastfeeding exposure and attitudes among African Americans.

Men’s attitudes toward public breastfeeding may influence a woman’s decisions about breastfeeding and her perceived comfort with public breastfeeding.

This study aimed to evaluate factors associated with men’s visual perception of images of public breastfeeding.

A 95-item online survey was administered to 502 U.S. men ages 21 to 44. Respondents were presented with four images of women breastfeeding and asked to evaluate agreement with 15 adjectives describing each image. Based on factor analysis, 13 of these adjectives were combined to create the Breastfeeding Images Scale for each image. An 8-item Situational Statements Scale and the 17-item Iowa Infant Feeding Attitude Scale (IIFAS) were used to assess breastfeeding knowledge and attitudes. Multiple regression was used to evaluate the association between breastfeeding attitudes and knowledge and the Breastfeeding Images Scale.

The image depicting a woman breastfeeding privately at home had the highest mean score of 71.95, 95% confidence interval (CI) [70.69, 73.22], on the Breastfeeding Images Scale, compared with 61.93, 95% CI [60.51, 63.36], for the image of a woman breastfeeding in a public setting. The overall mean scale score for the IIFAS was 56.99, 95% CI [56.27, 57.70], and for the Situational Statements Scale was 28.80, 95% CI [27.92, 29.69]. For all images, increasing breastfeeding knowledge and attitudes measured by the IIFAS and the Situational Statements Scale were associated with a more positive perception of the image.

Images of public breastfeeding are viewed less favorably by men in the sample than are images of private breastfeeding. Knowledge and attitudes toward breastfeeding are positively associated with perception of breastfeeding images.

Despite well-known recommendations from national and international bodies including the World Health Organization, few mothers achieve the goal of breastfeeding exclusively for 6 months. Half of mothers stop breastfeeding due to biomechanical issues in the first month, despite increasing support from lactation consultants. Osteopaths worldwide work with these babies, but there is little empirical evidence for this type of treatment.

This study aimed to determine the efficacy of an osteopathic treatment coupled with usual lactation consultations on infants’ ability to latch. Secondary objectives included assessment of nipple pain and mothers’ perceptions of the effect of treatment.

We conducted a single blind, randomized controlled trial at a mother-to-mother support group between January and December 2015. Data were collected at four different times over a 10-day period (T0-T10) from 97 mother–infant dyads using the LATCH assessment tool, a visual analog scale (VAS) to document mothers’ nipple pain, and a de novo questionnaire for breastfeeding management and potential treatment side effects.

There were consistent statistical and clinical differences in the mean LATCH scores between the treatment and the control groups (p < .001). However, no significant differences in the VAS scores were reported over time (p = .713). Mothers reported no serious or unexpected side effects during the follow-up period.

This study is one of the first to bring together lactation consultants and osteopaths to address infants with biomechanical sucking difficulties. Findings support the hypothesis that the addition of osteopathy to regular lactation consultations is beneficial and safe.

Peer milk sharing, the noncommercial sharing of human milk from one parent or caretaker directly to another for the purposes of feeding a child, appears to be an increasing infant-feeding practice. Although the U.S. Food and Drug Administration has issued a warning against the practice, little is known about how people who share human milk handle and store milk and whether these practices are consistent with clinical safety protocols.

This study aimed to learn about the milk-handling practices of expressed human milk by milk-sharing donors and recipient caretakers. In this article, we explore the degree to which donors and recipients adhere to the Academy of Breastfeeding Medicine clinical recommendations for safe handling and storage.

Online surveys were collected from 321 parents engaged in peer milk sharing. Univariate descriptive statistics were used to describe the safe handling and storage procedures for milk donors and recipients. A two-sample t-test was used to compare safety items common to each group. Multivariate ordinary least squares regression analysis was used to examine sociodemographic correlates of milk safety practices within the sample group.

Findings indicate that respondents engaged in peer milk sharing report predominantly positive safety practices. Multivariate analysis did not reveal any relationship between safety practices and sociodemographic characteristics. The number of safe practices did not differ between donors and recipients.

Parents and caretakers who participate in peer human milk sharing report engaging in practices that should reduce risk of bacterial contamination of expressed peer shared milk. More research on this particular population is recommended.

Mothers of preterm infants often are at risk of expressing an inadequate amount of milk for their infants and the use of galactogogues is often considered. Domperidone is a widely used galactogogue with little information available to guide clinicians regarding initiation, timing, and duration of treatment.

The primary objective of this study was to determine whether administration of domperidone within the first 21 days after delivery would lead to a higher proportion of mothers achieving a 50% increase in the volume of milk at the end of 14 days of treatment compared with mothers receiving placebo.

Eligible mothers were randomized to one of two treatment arms: Group A—domperidone 10 mg orally three times daily for 28 days; or Group B—placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days.

A total of 90 mothers of infants ≤ 29 weeks gestation were randomized. Mean milk volumes at entry were similar for both groups. More mothers achieved a 50% increase in milk volume after 14 days in Group A (77.8%) compared with Group B (57.8%), odds ratio = 2.56, 95% confidence interval [1.02, 6.25], p = .04.

A greater number of mothers experienced a 50% or more increase in human milk volume, but the absolute increase in milk volume was modest.

For very-low-birth-weight (VLBW) infants, breastfeeding may no longer be an immediate option. Mothers often turn to mechanically expressing their milk with a breast pump to provide their infants human milk.

This study aimed to describe mothers’ experiences expressing milk for their VLBW infants in a level 3 neonatal intensive care unit.

Qualitative, phenomenological methods were used to better understand the milk expression experiences of 17 mothers of VLBW infants. In-depth interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using Colaizzi’s seven-step protocol, and themes were identified to illustrate the lived experience of the mothers.

Five global themes emerged from interviews with mothers. However, this article focuses on one global theme, “I had one job and that was to make milk,” and the supporting subthemes: (1) “I was heartbroken,” (2) “Pumping is a full-time thing,” and (3) “I literally sacrificed nights.”

This study provides insight into the complex experience that mothers in the southeastern United States undergo when expressing milk for their VLBW infants.

Breastfeeding rates among urban, low-income populations are lower than the national average, and social support can affect breastfeeding initiation and duration both positively and negatively.

This study aimed to determine the effect of the presence of a support person and breastfeeding knowledge and attitudes of that person on a mother’s feeding choice and perceived level of support for her choice.

Questionnaires were administered to 192 mothers receiving care for their infants in the Pediatric Practice at University Hospitals Rainbow Babies and Children’s Hospital in Cleveland, Ohio, along with 74 adults accompanying these mothers. Data on demographics, feeding characteristics, and breastfeeding knowledge and attitudes were collected.

Analysis of the entire group of mothers found that breastfeeding-supportive knowledge and attitudes were an independent predictor of exclusive breastfeeding (odds ratio [OR] = 1.89, 95% confidence interval [CI] [1.38, 2.60]) and any breastfeeding (OR = 2.28, 95% CI [1.62, 3.21]). The presence of an accompanying adult was not related to feeding choice. Analysis of the subgroup of mothers with surveyed accompanying adults found independent predictors of any breastfeeding include maternal intention to breastfeed (OR = 23.68, 95% CI [1.48, 377.6]) and breastfeeding-supportive knowledge and attitudes of the mother (OR = 2.71, 95% CI [1.36, 5.40]) and the accompanying adult (OR = 2.78, 95% CI [1.17, 6.60]). The only independent predictor of exclusive breastfeeding was maternal intention to breastfeed (OR = 7.64, 95% CI [2.22, 26.3]). The majority of mothers (91%) felt supported, regardless of presence or absence of an accompanying adult.

These findings emphasize the importance of breastfeeding education for mothers and their support persons.

The demographic of today’s university student includes breastfeeding mothers. Few studies have examined the breastfeeding experience that women face upon their return to school.

The purpose of this research was to explore the breastfeeding experience of students on a university campus.

This qualitative study used semistructured interviews. Responses were audiotaped, transcribed, and coded according to common themes using MAXQDA software.

A total of eight women were interviewed for the study. All women reported “feelings of isolation” and expressed concern over “what will others think.” In addition, “nowhere to breastfeed” and “challenges of pumping” emerged as common barriers to breastfeeding. Regrettably, “forced decisions” emerged as a major theme, with four out of eight women reporting having to supplement with formula because they returned to school.

Student breastfeeding mothers are faced with emotional and physical challenges upon their return to school. Lack of space to breastfeed or pump as well as lack of support on campus are the main reasons that students stop breastfeeding prematurely. A day care facility on campus that accepts young infants, a Baby-Friendly space, and enhanced education are required to support student mothers in their choice to breastfeed.

Workplace lactation support has become increasingly important because returning to work is associated with discontinuing breastfeeding and women in the workforce are increasing.

This study examined workplace lactation support among Milwaukee County businesses 5 years after implementation of the Affordable Care Act’s Break Time for Nursing Mothers provision.

A cross-sectional survey of Milwaukee County businesses was conducted in the summer of 2015 that inquired about workplace policies, lactation spaces, and other lactation resources offered. Business supports were stratified based on employer sizes: large (> 500 employees), medium (50-499 employees), and small (20-49 employees). A lactation amenity score was calculated for each business based on lactation resources available.

Three hundred surveys were distributed and 71 businesses voluntarily completed the survey. Small employers were excluded from statistical analysis due to fewer responses (n = 8). Overall, 87.3% (n = 55) of respondents reported providing access to a multiuser space for lactation and 65.1% (n = 41) reported providing a designated lactation space. Large employers (n = 30) were more likely than medium employers (n = 33) to provide a designated lactation space for breastfeeding or expressing (86.7% vs. 45.5%, p < .001). Large employers’ mean amenity score was significantly higher than that of medium employers (3.37 vs. 2.57, p = .014), and they were also more likely to offer additional supports including access to a lactation consultant, classes, and materials (46.7% vs. 12.1%, p < .01).

Large employers provide more lactation support than medium employers in Milwaukee County. All employers, regardless of size, need to increase additional lactation support for women in the workplace.

Prior research in high-income countries finds that young mothers tend to breastfeed their infants for shorter durations than older mothers; however, there are gaps in our understanding of the processes by which age influences breastfeeding.

The primary objective of this study was to test the mediating effects of parity and education attainment on the association between maternal age and two breastfeeding outcomes: total duration and duration of exclusive breastfeeding.

This study was a secondary data analysis of the IFPS II, a prospective, longitudinal study of ~ 4,900 American mothers. Robust and bias-corrected regression analyses tested the direct effect of age and the indirect effects of age through parity and education for each outcome of interest.

Parity and education attainment together explain nearly all of the association between maternal age and both measures of breastfeeding duration. The mediating role of education is significantly larger than parity for both outcomes.

These findings indicate that maternal age primarily indexes parity and education but contributes minimally to breastfeeding duration via a direct effect. The findings have implications for intervention development and targeting strategies.

Weight loss is universal for exclusively breastfed newborns in the first few days after birth. Many newborns exclusively breastfed during birth hospitalization receive formula in the first month after discharge and thus cease exclusive breastfeeding. However, the relationship between early weight loss and subsequent cessation of breastfeeding and exclusive breastfeeding is unknown.

This study aimed to determine the relationship between newborn weight loss and duration and exclusivity of breastfeeding among newborns breastfed exclusively during the birth hospitalization.

Retrospective cohort study at Kaiser Permanente Northern California hospitals between 2009 and 2013. The main predictor variable was weight loss during birth hospitalization. The main outcomes were cessation of breastfeeding and cessation of exclusive breastfeeding in the first 25 days after discharge.

Among our sample, 83,344 were exclusively breastfed during birth hospitalization. At 25 days after discharge, 15.6%, 95% confidence interval (CI) [14.6%, 16.6%], of those delivered vaginally and 17.6%, 95% CI [14.5%, 20.6%], of those delivered by cesarean section were estimated to have completely ceased breastfeeding; 57.0%, 95% CI [55.5%, 58.4%], and 57.9%, 95% CI [53.6%, 61.8%], respectively, had ceased exclusive breastfeeding. Survival curves depicting rates of breastfeeding cessation through 1 month did not differ by degree of weight loss or by weight loss trajectory. However, curves depicting rates of exclusive breastfeeding demonstrated significantly more formula use among those with more weight loss at discharge.

Among those exclusively breastfed during birth hospitalization, weight loss nomograms may help identify newborns at higher risk of cessation of exclusive breastfeeding. Lactation support targeted to those with exacerbated weight loss trajectories may improve duration of exclusive breastfeeding.