Early
Termination
of Breast-Feeding:
Identifying
Those
at Risk
Howard
H. Loughlin,
MD, Nancy
E. Clapp-Channing,
RN, MPH,
Stephen
H. Gehlbach,
MD, MPH,
John
C. Pollard,
MD, and
Thomas
M. McCutchen,
MD
From Valley Pediatrics, Fayetteville, and the Department of Community and Family
Medicine,
Duke University Medical Center, Durham, North CaroilnaABSTRACT. In a private pediatric practice, 94 infants
who were breast-feeding were followed for the first 2
months of life in order to define the frequency of cessation of breast-feeding and to identify factors that would
pre-dict mothers and infants at risk for early cessation.
At 8 weeks, 30% of the mothers had stopped nursing.
Factors associated with cessation were: maternal lack of confidence in breast-feeding (P
<
.001); anticipated du-ration of nursing less than 6 months (P = .002); ratings by the nursery staff of infant’s excessive crying (P =.007), infant’s demanding personality (P = .007), trouble with feeding (P = .001), and future trouble with feeding (P = .004). Together, these factors predicted 77% of the
mothers who terminated breast-feeding. Supplementing
with formula before the 2-week office visit also led to
termination of breast-feeding by 8 weeks (P = .006). This
decision was frequently made without medical advice.
Nearly 64% (14/22) of the mothers who added formula
within the first 2 weeks did so without contacting the
pediatric practice. Pediatrics 1985;75:508-513; breast-feeding, ambulatory care.
A consensus exists that breast-feeding is the best
method for feeding the term newborn.1’2 Most
au-thorities feel that breast-feeding should be
contin-ued through as much of the first year of the infant’s
life as possible.1’2
Primary care physicians know that not all
moth-ers who begin breast-feeding their infants have
successful experiences. A growing body of literature
indicates that many “crises” occur during the first
weeks or months of infants’ lives and that these,
not infrequently, lead to early cessation of
breast-feeding.35
Received for publication Aug 15, 1983; accepted April 16, 1984. Reprint requests to (H.H.L.) Valley Pediatrics, 1213 Walter
Reed Rd, Fayetteville, NC 28304.
PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the
American Academy of Pediatrics.
It is believed that successful breast-feeding is
dependent on multiple factors relating to the
mother, the infant, and to the supporting
environ-ment.6 Newton and Newton7’8 and Call9 have
pointed out that personality characteristics and
attitudes of mothers as well as demographic
char-acteristics are associated with the outcome of
breast-feeding. Circumstances surrounding labor,
delivery, and the early postpartum period are felt
to be important for the initiation of successful
breast-feeding.5 Maternal and infant health have
also been suggested as important. Houston5 has
summarized much of the work on the multiple
factors that are felt to affect the success of lactation,
and Lawrence’#{176} has emphasized the importance of being alert to clinical situations that raise the like-lihood of difficulties with nursing; however, there are few studies that have attempted to identify specific indicators of risk for problems with breast-feeding.
We sought to document the following in our
pediatric practice: (1) the frequency of cessation of breast-feeding during the first 2 months of an
in-fant’s life; and (2) the characteristics of mothers
and babies that place them at “high risk” for early cessation of breast-feeding.
METHODS
Study Site
The study was conducted in Fayetteville, NC, at
Valley Pediatrics, a three-person private pediatric
practice and at Cape Fear Valley Hospital, a 500-bed community hospital with 4,200 births per year.
Fayetteville has a population of 60,000 and is
lo-cated in a county with a population of 245,000.
There is a racial mix within the practice
patients are approximately evenly divided into
three groups: military, Medicaid, and privately in-sured.
Postpartum routines at Cape Fear Valley
Hos-pital were moderately supportive of breast-feeding.
In the postpartum period, the mother was allowed to breast-feed her infant in the delivery room at the
discretion of her obstetrician and in the recovery
room if the infant was stable. If caesarean section
was required, the infant was brought to the mother
for nursing as soon as she was in her room ad
alert.
Rooming-in was available to the mothers for
either four hours or 21 hours per day at the mother’s
option. If the mother chose not to have her baby room-in, the infant was brought to her on a four-hour schedule and left for approximately one-half
hour. Water was brought to the mother for her to
offer the infant at the end of the nursing. Infant
care instruction and support for nursing were of-fered by nursery personnel primarily, with instruc-tional booklets on breast-feeding and support pro-vided by nurses from the pediatric practice. A phy-sician from the practice visited the mother daily to report on the infant’s status and support the breast-feeding. During the discussions and instruction about breast-feeding, mothers were requested not
to give formula supplements during the first 2
weeks of nursing. Usually, newborns were
dis-charged on the third day of life, and the mothers were given discharge packs of formula. An appoint-ment for a 2-week visit to the pediatric practice was made, and mothers were encouraged to call sooner if problems occurred.
Study Design
From September 1981 to November 1982, all
mothers on their first postpartum day were asked
to participate in the study if they met the following criteria: (1) they had delivered term infants identi-fled by the pediatrician as healthy at 24 hours of
age; (2) they were breast-feeding their infants; (3)
they were planning to return to Valley Pediatrics for their baby’s care.
Postpartum Hospital Assessment. Mothers com-pleted an initial hospital questionnaire giving age, race, education, occupation, and information on the pregnancy, delivery, and general health; rating their confidence in breast-feeding; describing their home environment including estimates of the level of support for their breast-feeding; and
an-swering a 23-item self-esteem profile.”
Socioeco-nomic status was computed using Green’s
stan-dardized rating of maternal education and paternal
12
On the second or third postpartum day, the
nurse’s aide, licensed practical nurse (LPN), or
registered nurse (RN) from the nursery staff who
had had closest contact with the mother and had observed the “nursing dyad” completed a five-item
questionnaire describing the infant’s behavior and
predicting the likelihood of future feeding problems.
(See Table 1 for sample items.)
Postpartum Office Assessment. At the routine 2-, 4-, and 8-week office visits, the mother completed self-administered, follow-up questionnaires
provid-ing interval health histories for herself and the
baby; describing the level of support provided by
those around her; and stating her current method
of feeding (breast only, supplementation, formula only). (See Table 1 for sample items.)
Supplemen-tation was defined as any addition of formula,
re-gardless of quantity, reported by the mother.
The baby was then weighed and examined by one
of the physicians. Data were analyzed using
x2
andKruskal-Wallis tests.
RESULTS
Study Population
A total of 108 breast-feeding women were asked
to participate in this study. Thirteen subjects were
TABLE 1. Selected Hospital and Office Questionnaire Items Completed by Mother and Nursery Staff*
MOTHER (in hospital):
Duration, confidence, and support
1. How long do you plan to [breast] feed the baby? (No.
of months)
2. How confident do you feel about feeding your baby? (very worried-very confident)
3. How helpful has the baby’s father been in supporting your feeding choices? (not at all helpful-very helpful)
NURSERY STAFF:
Infant behavior
1. Compared with the average baby, how much crying
does this baby do? (much more-much less)
2. Compared with the average baby, how would you rate this baby’s personality? (very demanding-very
easy-going)
3. Compared with the average baby, what kind of feeder is this baby? (very slow, “pokey feeder”-very fast, “acts starved”)
4. Compared with the average baby, how much trouble
has this baby had with feeding? (much more trouble-much less trouble)
5. Compared with the average baby, how much trouble
would you expect this baby to have with feeding in the future? (much more trouble-much less trouble)
MOTHER (in office):
Level of support:
1. How helpful has the baby’s father been? (never
help-ful-almost always helpful)
2. How helpful have other people been in caring for the baby? (never helpful-almost always helpful)
* All items are five-point scales except duration of
excluded for insufficient data: eight had no hospital questionnaire, and five were missing the follow-up
questionnaires. Only one mother declined to
partic-ipate. There were 94 participants with mean age of
27 years and average education 14.5 years.
Ninety-two percent of the participants were white and 57%
were employed during the pregnancy. Analysis of
differences between the participants and those
ex-cluded for insufficient data showed that the
partic-ipating mothers were significantly better educated,
more often primiparous, and planned to stay out of work longer.
One quarter of participating mothers reported problems with pregnancy, labor, and delivery; these
problems were not serious (morning sickness,
“swelling,” urinary tract infections, breech
presen-tation, “long labor,” and fetal distress). Seventeen
percent of mothers and 24% of infants were
re-ported to have had health problems in the first 2
weeks postpartum. Most of these were minor.
Mothers reported colds, flu, headaches, insomnia,
sore nipples, and mastitis; the problems of infants
included colds, conjunctivitis, diarrhea, and
“fussi-ness.”
Duration of Breast-Feeding
At the 2-week visit, 71 of 94 (76%) mothers were exclusively breast-feeding, 16 (17%) were
supple-menting, and seven (7%) had switched to formula.
By the 4- and 8-week visits, the number of mothers
exclusively breast-feeding had decreased to 63% and 48%, respectively. In all, 30% of the mothers had switched to formula by 8 weeks (Table 2).
The rate of supplementing remained relatively
stable at 21% at 4 weeks and 18% at 8 weeks.
Supplementing frequently led to exclusive formula-feeding. Thirty-eight percent of babies who were receiving supplements at 2 weeks were being fed “formula only” by 4 weeks, and 60% of the mothers had switched to formula by 8 weeks.
The 27 mothers who had switched to formula by
the 8-week visit were considered early terminators of breast-feeding. Postpartum responses to antici-pated duration of breast-feeding were recorded for
25 of these women. Five women stated in their
TABLE 2. Percentage Distribution of Feeding Methods
(n = 94)
Breast 100 76
Supplement . . . 17
Formula . . . 7
Lost to follow-up . . .
Total 100 100 100
Hospital Weeks Postpartum
2wk 4wk 8wk
63 48
21 18
16 29
5
100
hospital questionnaire that they intended to stop
breast-feeding before 8 weeks; two of the five
planned to breast-feed for 6 weeks and change to
formula coincident with their return to work, and
they did so. The other three women planned to
breast-feed for 1 month, but all three had switched to formula prior to the 1-month visit. Thus, 23 of the 25 women stopped breast-feeding earlier than had been anticipated. By comparison, only one of
58 mothers who were continuing to breast-feed at
8 weeks had planned to breast-feed for less than 2
months.
Of the group of 27 mothers who stopped
breast-feeding by 8 weeks, nine were already
supplement-ing with formula at the 2-week office visit, seven had switched to formula only, and 11 were still breast-feeding. Among women who were using sup-plements, four cited infant hunger or insufficient milk production as the reason for supplementing, two said they had been ill, one wanted the baby’s father to participate, and one said she was using supplements in anticipation of returning to work.
Although these women had been advised in the
hospital not to use supplements during the first 2 weeks of breast-feeding, five of the nine added supplements without contacting the pediatric prac-tice. Overall, of the mothers who had added
supple-ments or switched to formula within 2 weeks, 64%
(14/22) had done so without contacting anyone in the practice.
Reasons cited by the seven mothers who had
switched to formula-feeding included infant hunger or feeding difficulty in four cases and a need to return to work in one instance. This latter mother breast-fed for only four days although she antici-pated remaining out of work for 2 months.
Of the 11 infants who were still being exclusively breast-fed at the 2-week visit, six showed poor weight gain. Five of these babies were at or below
birth weight. Mean weight gain for the 11 infants
was 18 g/day since discharge compared with an
average daily gain of 40 g for the 62 infants who breast-fed for longer than 2 months. Reasons why women in this group eventually switched to for-mula-feeding included hungry or crying infants in four instances, and cracked or bleeding nipples in two.
Predictors
total study sample are shown in Table 3. The five-point scale items reported as percentages were col-lapsed into dichotomous variables on the basis of clinical applicability and used for the remaining
analyses. Low confidence was defined as anything
less than “reasonably confident,” excessive crying
as more than “average amounts of crying,” trouble
with feeding as more than “average amounts of
trouble,” etc. Anticipated duration of breast-feeding
was dichotomized to below and at or above the
median.
Both the mothers who continued breast-feeding and those who did not were mostly white, were
mid-20s in age, had technical school/partial college
ed-ucation, were employed in clerical/skilledjobs, were
middle class, and had good self-esteem. Of the
mothers who were going back to work, there was
no difference between the groups in the median time of their expected return. There were no sig-nificant differences between the groups in frequen-cies of planned pregnancies, previous children, or prior breast-feeding experience. Rates of reported problems with pregnancy/labor and delivery expe-riences were low overall and similar for both groups. Paternal support of breast-feeding was universally high. There was no significant difference in whether the mothers had had rooming-in.
Six of the 22 items showed a statistically
signifi-cant difference between the two groups. Women
who had stopped breast-feeding expected to breast-feed for a shorter period of time
(x2
= 9.884,df
=1, P = .002) and expressed lower confidence in
breast-feeding
(x2
= 12.997, df = 1, P < .001). Thenursery staff rated these mothers’ infants as crying
more
(x2
7.21, df = 1, P = .007), being moredemanding
(x2
= 7.21, df = 1, P = .007), havingmore trouble feeding
(x2
= 10.341, df= 1, P = .001),and predicted more trouble breast-feeding in the
future
(x2
8.295, df = 1, P = .004).The median anticipated duration of breast-feed-ing for 25 women who indicated their intentions on the postpartum questionnaire and stopped within 2
months was 5 months with a range of 1 to 11
months. Sixty percent expected to breast-feed less
than 6 months compared with only 24% of women
who continued to breast-feed. Anticipated duration was unrelated to anticipated return to work, but was correlated significantly with low confidence in breast-feeding (r = .34). Of 88 mothers who rated
their confidence in breast-feeding, 74 expressed
confidence. The 14 mothers who were less than
confident were significantly more likely to stop by 8 weeks (71% v 23%, P
<
.05).The nursery staff rated 82% to 93% of all the infants as crying an average amount or less, having “easy” personalities, and having no trouble with
TABLE 3. Maternal and Infant Characteristics for Feeding Visit for 94 Mothers Who Began Breast-Feeding
Outcomes at Eight-Week
Continued to Breast- Stopped Breast- Total Sample
Feed Feeding (n = 94)
(n=67) (n=27)
Mean maternal age (yr) 27.4 26.7 26.9
Mean maternal education (yr) 14.6 14.4 14.5
Socioeconomic status 74.4 73.1 73.5
Self-esteem 77.0 75.4 76.7
Anticipated duration of breast-feed- 6 5 6
ing (mo) (median)*
Anticipated time before return to 3 2 3
work (mo) (median) (n = 37)
Low confidence in breastfeedingk 7% 37% 16%
White race 94% 89% 92%
Pregnancy planned 68% 70% 69%
Previous children 50% 33% 45%
Previous breast-feeding (n = 40) 87% 67% 82%
Problems with pregnancy 25% 19% 23%
Problems with labor and delivery 23% 37% 27%
Caesarean section (n = 6) 8% 4% 7%
Father provided little support for 15% 15% 15%
breast-feeding
Rooming-in 60% 48% 56%
Nursery staff rating of infants:
Excessive crying 10 35 18
Demanding personality* 10 35 18
Slow feeder 5 15 8
Trouble with feeding* 3 27 11
Future trouble with feeding* 2 19 7
feeding. The infants for whom they
did
see a “prob-lem” were significantly more likely to be exclusively formula-fed by 2 months.The six risk factors that predict early termination have clinical utility. Calculations were made of the
sensitivities and predictive values of the factors
that identified mothers who were at increased like-lihood of stopping breast-feeding before the baby was 2 months old. Sensitivity is the percentage of
mothers who terminated breast-feeding early that
were correctly identified by the risk factor. Of the 27 mothers who were feeding only formula at the 8-week visit, ten expressed a lack of confidence in their ability to breast-feed on the hospital question-naire. The sensitivity of this risk factor is 10/27, or
37%.
Predictive value is the percentage ofpatients who report the factor and who stop breast-feeding early. Of 14 mothers who reported lack of confidence, ten stopped breast-feeding early. The predictive value of the factor is 10/14 or 71% compared with a rate of early termination of 27/89 or 30% for the entire breast-feeding population. Sensitivities and predic-tive values for each of the statistically significant risk factors can be seen in Table 4.
Taken individually, none of the six risk factors predicts early termination with a high degree of
sensitivity. Anticipated duration of less than 6
months is the best single predictor with a sensitivity of 60%. However, using the presence of any of the six factors to predict problems, sensitivity can be improved to 77% (see Table 4). The “cost” of this improved identification of mothers who terminate breast-feeding early is increasing the number of babies mislabeled as being at risk. False-positive
results increase, and the predictive value for the
combined factors is 45%.
DISCUSSION
Approximately 30% of mothers who began
breast-feeding stopped within the first 2 months. This is prior to the time that authorities feel is optimal, and in more than 90% of cases, this was before the mother’s anticipated weaning. Contrary to our expectation, anticipated duration did not correlate with whether the mother would return to work or when this would occur. The high correla-tion of anticipated duration of nursing with mater-nal confidence suggests that it is an indirect
mea-surement of confidence and/or commitment to
breast-feeding. Although the specific underlying causes for lack of confidence or reasons for brief anticipated duration of breast-feeding may not be known, the predictive value of this information makes it clinically useful. Many factors currently felt to be important in the success of
breast-feed-ing,5”3 such as socioeconomic status, method of
delivery, rooming-in, maternal and infant health, and attitudes of friends and family toward breast-feeding, did not in this study relate to the likelihood of cessation within the first 2 months. This may have been due, in part, to sample size or to the relative homogeneity of the study population, but our findings are consistent with the conclusions of Entwisle et al’4 that a woman’s “prenatal
inten-tions-assumed to be the consequence of a long
socialization history prior to pregnancy-were the strongest predictors of breast-feeding success in the first month.”
The strong relationship between nursery staff ratings of feeding problems and cessation of breast-feeding is not surprising for clinicians. The specific factors that the nurses weighed in their evaluations and predictions about breast-feeding were not ex-plicit, but discussions with them suggest that ob-servations of the maternal-infant interaction, par-ticularly the mother’s patience and tolerance of infant “fussiness,” were important considerations. Although the five items were not standardized nor formally evaluated for reliability and validity, the
TABLE 4. Predictive Values and Sensitivity of Six Factors Related to Cessation of
Breast-Feeding
N Predictive
Value
N(%)
Sensitivity
N(%)
Anticipated duration of breast-feeding less than 6 mo
83* 15/29 (52) 15/25 (60)
Lack of confidence in breast-feeding 88 10/14 (71) 10/27 (37)
Nursery staff rating of infant: Excessive crying
Demanding personality Trouble with feeding Future trouble with feeding
84 84 84
84
9/15 (60)
9/15 (60)
7/9 (78) 5/6 (83)
9/26 (35)
9/26 (35)
7/26 (27)
5/26 (19)
Any of above 6 factors 83 20/44 (45) 20/26 (77)
* Five participants were lost to follow-up at 8 weeks; remaining difference less than 89 is
results of this study give evidence that they were
predictive.
Seventeen percent of the mothers used formula supplements before the 2-week visit. It is not clear what motivated the supplementation, but maternal
illness, breast problems, fatigue, possible
misunder-standing of normal nursing patterns with resulting concern that the baby was not getting enough milk, and the desire to get the baby “used to the bottle”
were all reported by the mother. The members of
our practice advise against early supplementation. The relationship of supplementation to early ces-sation of breast-feeding suggests the importance of intervention strategies to discourage early supple-mentation. Some studies have suggested that the giving of discharge formula packs,’5 as was done in our hospital at the time of this study, tacitly en-courages the use of formula.
Health care workers agree that, when possible, the delivery setting and the clinical practice should be structured for optimal support of breast-feed-ing.5”6”7 This study suggests that by asking the mother and nursery staff six short questions before hospital discharge, it is possible to identify more than 75% of mothers at high risk for early cessation of breast-feeding. Determination of maternal con-fidence and anticipated duration of breast-feeding, as well as the obtaining of nursery staff assessment of feeding problems, should become routine proce-dures. Because mothers frequently make decisions to change feeding methods in the first 2 weeks of the baby’s life without consulting the pediatric practice, the study suggests that earlier contact and support would be desirable. Future studies are
nec-essary to test intervention strategies based on these
predictive factors.
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