Perinatal and socioeconomic determinants of breastfeeding duration in very preterm infants

AIM: To describe the impact of prematurity, size at birth, neonatal disorders and the families' socioeconomic status (SES) on breastfeeding duration in mothers of very preterm infants. METHODS: Prospective population-based cohort study. Data on breastfeeding, registered in databases in two Swedish counties in 1993-2001, were matched with data from two national registries: the Medical Birth Registry and Statistics Sweden. Mothers of 225 very preterm singleton infants were identified and included. RESULTS: Seventy-nine percent of the mothers breastfed at 2 months, 62% at 4 months, 45% at 6 months, 22% at 9 months and 12% at 12 months. Prematurity, size at birth and neonatal disorders did not show an effect on breastfeeding duration. Being adversely exposed to any of the SES factors (maternal education, unemployment benefit, social welfare and equivalent disposable income in the household) was significantly associated with earlier weaning up to 6 months of infants' postnatal age. CONCLUSIONS: This study shows new and noteworthy results concerning breastfeeding duration in mothers of very preterm infants, which was not influenced by degree of prematurity, size at birth or neonatal disorders but was affected by SES. This highlights the need for improved support of socioeconomically disadvantaged mothers, during and after the hospital stay.     

Which mothers wean their babies prematurely from full breastfeeding? An Australian cohort study

Aim:  To identify the maternal and infant characteristics associated with an early transition from full breastfeeding to complementary or no breastfeeding during the first 2 months of life in a large, representative cohort of Australian infants.
Method:  Multinomial logistic modelling was performed on data for infants with complete breastfeeding and sociodemographic data (N = 4679) including maternal age, education, smoking, employment, pregnancy and birth outcomes.
Results:  Ninety-one percent of women initiated breastfeeding. Sixty-nine percent of infants were being fully breastfed at 1 month, and 59% were fully breastfed at 2 months. Maternal characteristics – age less than 25 years, smoking in pregnancy, early full-time postnatal employment and less educational attainment – were associated with early breastfeeding cessation. Infant factors – multiple birth, caesarean birth, infant or first birth – were associated with a transition to complementary breastfeeding in the first postnatal month.
Conclusion:  Breastfeeding duration is substantially affected by breastfeeding outcomes in the first postpartum month. The first month is an important window for evidence-based interventions to improve rates of full breastfeeding in groups of women identified as at risk of early breastfeeding cessation.     

Child health care uptake among low-income and immigrant families in a Swedish county

Aim: To study the uptake of child health care among low‐income and immigrant families in the county of Uppsala, Sweden, to investigate whether these families received extra attention as proposed in the Swedish Child Health Services (CHS) state‐of‐the‐art consensus document from the year 2000. Methods: Data were collected for 25 024 infants born 1998–2006 from the database of statistics of the Child Health Care Unit in Uppsala and socio‐demographic indicators from Swedish national registers. Disposable income was divided into quartiles. Country of birth of the mother was categorized into four regions with two subgroups each, mothers with or without a Swedish‐born partner. Analysis was conducted by Cox regression and linear regression models. Results: Small differences between Swedish vs. immigrant and high vs. low‐income families were detected. Low‐income mothers (RR 0.78) as well as mothers born in all country of birth regions with an immigrant partner (RR 0.28–0.95) had lower rates of participation in parental groups. Conclusion: The CHS provided basic child health care to almost all infants including children in immigrant and low‐income Swedish families. However, the results did not indicate that disadvantaged families received the extra attention proposed in the consensus document.     

Parental region of birth, socio-economic status and infants' exposure to second-hand smoke

Aim: To investigate the impact of parental region of birth on the risk of exposure to second‐hand smoke for infants. Methods: The smoking habits, according to child health records, of parents of 14 431 infants in Uppsala county, Sweden, born during 1997–2001, were investigated with logistic regression in the presence of socio‐economic and demographic confounders from national registers. Results: Fathers born outside of Sweden smoked more often than Swedish‐born fathers irrespective of region of birth (adjusted odds ratios [ORs] 1.77–3.02). Mothers born in Africa (adjusted OR 0.29, 95% CI 0.15–0.58) and Asia (adjusted OR 0.53, 95% CI 0.40–0.70) smoked less often than Swedish‐born mothers. Single parenthood, low income and mother's age ≤24 years increased the risk for parental smoking. Conclusion: The present study indicates that the risk of smoking in immigrant parents of infants is influenced by the smoking patterns in the region of birth. Smoke cessation interventions targeting fathers are particularly important in immigrant‐dense neighbourhoods in Sweden.     

Full breastfeeding and paediatric cancer

Aim:   It has been suggested that there is an inverse association between breastfeeding and the risk of childhood cancer. We investigated the association between full breastfeeding and paediatric cancer (PC) in a case control study in Spain.
Methods:   Maternal reports of full breastfeeding, collected through personal interviews using the Paediatric Environmental History, were compared among 187 children 6 months of age or older who had PC and 187 age-matched control siblings.
Results:   The mean duration of full breastfeeding for cases were 8.43 and 11.25 weeks for controls. Cases had been significantly more often bottle-fed than controls (odds ratio (OR) 1.8; 95% confidence interval (CI) 1.1–2.8). Cases were significantly less breastfed for at least 2 months (OR 0.5; 95% CI 0.3–0.8), for at least 4 months (OR 0.5; 95% CI 0.3–0.8), and for 24 weeks or more (OR 0.5; 95% CI 0.2–0.9).
Conclusions:   Breastfeeding was inversely associated with PC, the protection increasing with the duration of full breastfeeding. Additional research on possible mechanisms of this association may be warranted. Meanwhile, breastfeeding should be encouraged among mothers.     

Breastfeeding duration and postpartum psychological adjustment: role of maternal attachment styles

Aim:   Depressive and anxiety symptoms are common in new mothers. The aim of this study is to explore the link between postpartum psychological adjustment and feeding preferences of the mothers.
Methods:   Sixty mothers and newborns were enrolled in this prospective, longitudinal study. Maternal depressive symptoms were screened by the Edinburgh Postpartum Depression Scale (EPDS), and maternal anxiety level was assessed by the State-Trait Anxiety Inventory at 1 month postpartum. The Multidimensional Scale of Perceived Social Support was used for the assessment of maternal social support. The Adult Attachment Scale was used to determine the attachment style of the mother. Infants were examined and evaluated at 1 and 4 months of life.
Results:   All mothers started breastfeeding their infants postpartum; 91% and 68.1% continued exclusive breastfeeding at 1 and 4 months, respectively. The first-month median EPDS score of mothers who breastfeed at the fourth month was statistically significantly lower than those who were not breastfeeding (6 and 12, respectively) ( P  = 0001). The first-month median EPDS score of mothers with secure attachment was lower than the median score of mothers with insecure attachment (5 and 9, respectively) ( P  < 0001). Exclusive breastfeeding rate was not statistically different among mothers with secure and insecure attachment styles. The median state and trait anxiety scores and social support scores of mothers were not different between groups according to breastfeeding status.
Conclusions:   This study has shown an association between higher EPDS scores and breastfeeding cessation by 4 months after delivery.     

Breastfeeding is an essential complement to vaccination

Aim:  This article explores the role of breastfeeding in different aspects of vaccination in the first 6 months when infants are still developing: (1) pain management; (2) immunomodulation of infants' vaccine responses; (3)metabolism of thimerosal.
Methods:  Major databases were searched for studies that addressed outcomes of related issues.
Results:  Studies reveal that breastfeeding can: (1) help mothers and infants to cope with the stressful situations that accompany parenteral vaccines; (2) improve response to vaccines in the still maturing immunologic and enterohepatic systems of infants; (3) influence physiologic parameters that can change metabolism of ethylmercury derived from some vaccines.
Conclusion: Health promotion that supports vaccinations should also emphasize early initiation and maintenance of exclusive breastfeeding up until 6 months for maximum protection of the infants with a possible beneficial effect on the vaccine response. Paediatric professionals should inform mothers of the proven benefits of breastfeeding and its importance in complementing vaccination and lowering stress and the risk of untoward reactions on susceptible infants.     

Environmental tobacco smoke exposure as a risk factor for infections in infancy

Aim:  This prospective observational study investigated the effect of environmental tobacco smoke (ETS) on frequency and severity of common infantile infections.
Methods:  In a representative sample of 926 infants, parental smoking was recorded at months 1 and 9 postpartum, and all infantile infectious episodes were recorded at 1, 3, 6, 9 and 12 months postpartum.
Results:  Both parents were regular smokers all through the first year in 107 (11.6%), at least one smoked regularly or occasionally in 492 (53.1%), and parents did not smoke at all in 327 (35.3%) families. Among mothers, 168 (18.1%) smoked perinatally. Infantile ETS exposure was associated with increased frequency of total infectious episodes (p = 0.025) and hospitalizations for infection (p = 0.007). In ETS exposed infants, birth in autumn and presence of siblings contributed to increased frequency of most infections and of hospital admissions for infection. By contrast, exclusive breastfeeding protected against the effect of ETS on total infantile infections (OR 0.982, 95% CI 0.965–0.999; p = 0.036), hospital admissions for infection (OR 0.980, 95% CI 0.961–0.999; p = 0.036) and thrush (OR 0.973, 95% CI 0.951–0.996; p = 0.022).
Conclusion:  Our findings point to harmful effect of ETS on infantile health and further suggest that this effect may be enhanced or diminished by other factors. ETS should be regarded as a preventable risk factor for infections in infancy.     

Maternal obesity and initiation and duration of breastfeeding: data from the longitudinal study of Australian children

The aim of this paper is to investigate whether the lower rate of breastfeeding at 6 months by overweight and obese mothers is primarily due to these women giving up breastfeeding in the first week postpartum using a cross-sectional population survey. The sample is children from the infant cohort (about 12 months of age) of Wave 1 (2004) of the Longitudinal Study of Australian Children for whom breastfeeding and maternal information were available ( n  = 3075). Definitions used: normal-weight body mass index (BMI, kg/m²) 20 to <25, overweight BMI 25 to <30, obese BMI ≥30. Breastfeeding initiation was 95.1% for normal-weight women, 92.8% for overweight women and 87.1% for obese women. At 6 months, 64% of normal-weight women were breastfeeding, compared with 54% of overweight and 44% of obese women. On multivariate analysis, for women who initiated breastfeeding, overweight women had an odds ratio (OR) of 1.52 [95% confidence interval (CI) 1.02, 2.28] and obese women had an OR of 2.54 (95% CI 1.70, 3.79) of stopping breastfeeding by 1 week compared with normal-weight women (adjusted for maternal age, education, smoking, level of socio-economic disadvantage, caesarean birth, admission to special care nursery). For women who breastfed for at least 1 week, overweight women had an adjusted OR of 1.26 (1.04, 1.53) and obese women had an adjusted OR of 1.38 (1.10, 1.73) of ceasing to breastfeed before 6 months, compared with normal-weight women. In conclusion, among overweight/obese women who initiate breastfeeding, higher rates of cessation of breastfeeding in both the immediate postpartum period and in the first 6 months contribute to the shorter duration.     

Gestational diabetes and offspring body disproportion

Aim:  It has been demonstrated that females born large for gestational age (LGA) in weight but not length are at increased risk of being obese at childbearing age. We addressed the question whether women with gestational diabetes mellitus (GDM) are at increased risk of giving birth to such infants.
Methods:  Birth characteristics of 884 267 infants of non-diabetic mothers and 7817 of mothers with GDM were analysed. LGA was defined as birth weight or birth length >2 standard deviation scores for gestational age. Multiple logistic regression analysis was performed.
Results:  The odds ratio (OR) for a woman with GDM to give birth to an LGA infant that was heavy alone was four times increased (OR: 3.71, 95% CI: 3.41–4.04). Furthermore, in the population of mothers giving birth to LGA infants, the proportion heavy alone was 68% in the group of women with GDM compared with 64.4% in the group of non-diabetic women. The risks were independent of gender of the foetus.
Conclusion:  Women with GDM have an almost four times higher risk of delivering an LGA infant that is heavy alone. The noted disproportion between weight and length in infants of such mothers may have an impact on the risk of later obesity.     

Monitoring breastfeeding rates in Italy

Aim : to determine the rates of initiation and duration of breastfeeding in Italy in 1995 and 1999, and to examine the adherence to the ten steps to successful breastfeeding recommended by WHO. Methods : Two cohorts of mothers who delivered healthy infants in November 1995 ( n = 2400) or November 1999 ( n = 3500) were interviewed by telephone within 4 wk of delivery when their infants were 3 months of age. Type of breastfeeding was classified according to the WHO definitions. Adherence to the WHO ten steps was evaluated. Results : Initiation and duration of breastfeeding increased during the 1995–1999 period ( p < 0.0001). The rate of breastfeeding at discharge and when the infants where 3 months of age was 83% and 42% in 1995, and 89% and 66% in 1999. The rate of exclusive/predominant breastfeeding at discharge was higher in 1999 than 1995 (78% vs 72%).
Conclusion : An increase in initiation and duration of breastfeeding through the first 3 months of age occurred in Italy during the 1995–1999 period, but both breastfeeding duration and observance of the WHO's ten steps are not completely satisfactory yet.     

Hospitalization in adolescence affects the likelihood of giving birth: a Swedish population-based register study

Aim: To examine the effect of hospitalization during adolescence on the likelihood of giving birth.
Methods: 142 998 women born in 1973–75 were followed with the help of the Swedish Medical Birth Register (MBR) and the Swedish Total Population Register (TPR) up until the end of 2000 with respect to their likelihood of giving birth. All analyses were adjusted for parental socio-economic characteristics and factors related to the studied women's own birth.
Results: The likelihood of giving birth between 20 and 27 years of age was positively affected by hospitalization at least once during adolescence according to the Swedish Hospital Discharge Register (HDR); adjusted hazard ratio (HR) = 1.32, 95% confidence interval: 1.29–1.35. Women hospitalized due to genitourinary diseases, respiratory diseases, abdominal problems and abuse of alcohol and drugs were more likely to have given birth during the study period, while hospitalizations according to cerebral palsy and congenital malformations tended to decrease childbearing. Women hospitalized due to psychiatric diseases had an increase likelihood of given birth at 20–24 years but a reduced thereafter.
Conclusion: A majority of the causes of hospitalization during adolescence increased the likelihood of giving birth between ages 20 to 27.     

Buddhist nuns on the move: an innovative approach to improving breastfeeding practices in Cambodia

The benefits of initiating breastfeeding in the first hour of life and exclusively breastfeeding thereafter are well documented. However, little is known about how best to promote these practices. In this study, we assess the impact of Buddhist nuns and wat (pagoda) grannies on optimal breastfeeding behaviours in rural Cambodia. We did so by interviewing randomly selected mothers of infants less than 6 months of age. A total of 440 mothers in programme and control communities completed the baseline survey (before programme start-up), and 467 mothers responded 1 year later. Mothers' exposure to breastfeeding promotion activities was high. At follow-up, 76% of mothers in programme communities indicated that nuns had advised them about breastfeeding, 73% received a home visit and 72% reported attending an educational session. At baseline, mothers in programme communities were 11% more likely (RR = 1.11, CI: 0.74–1.68) than mothers in control communities to initiate breastfeeding in the first hour of life. At follow-up, they were 62% more likely (RR = 1.62, CI: 1.30–2.01) to do so. Similarly, at baseline, mothers in programme communities were 54% more likely (RR = 1.54, CI: 1.21–1.96) than mothers in control communities to breastfeed exclusively in the previous 24 h. At follow-up, they were 81% more likely (RR = 1.81, CI: 1.49–2.21) to do so. Programme planners may consider using community-based volunteers as one strategy to improve breastfeeding practices and child survival.     

Breastfeeding duration and exclusivity associated with infants' health and growth: data from a prospective cohort study in Bavaria, Germany

Aim: To investigate the relationship between breastfeeding and infant health and to describe growth in the first 9 months.
Methods: Mothers delivering a baby in April 2005 were recruited throughout Bavaria, Germany, for a prospective birth cohort study. These mothers reported breastfeeding data, health and growth data of 1901 infants assessed by a physician in questionnaires on day 2–6, and in months 2, 4, 6 and 9. Subjects were healthy term infants with a birth weight ≥2500 g. We compared 475 infants breastfed exclusively for ≥6 months (group A), 870 infants breastfed fully/exclusively ≥4 months, but not exclusively ≥6 months (group B) and 619 infants not breastfed/breastfed <4 months (group C).
Results: In multivariate analysis ≥6 months of exclusive breastfeeding reduced significantly the risk for ≥1 episode of gastrointestinal infection(s) during months 1–9 compared to no/<4 months breastfeeding (adjusted odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.44–0.82). The application of the World Health Organization (WHO) – child growth standards showed lower weight-for-length z-scores in first days of life in group C versus groups A and B, whereas in months 6/7 group C showed the highest scores.
Conclusion: Differences in child growth depending on breastfeeding duration should be investigated further. Concerning health outcomes our findings support the recommendation for ≥6 months of exclusive breastfeeding.     

Prenatal and postnatal parental smoking and acute otitis media in early childhood

Aim:  To explore the associations between acute otitis media in early childhood and prenatal and postnatal tobacco smoke exposure.
Methods:  Subjects were 32 077 children born between 2000 and 2005 in the Norwegian Mother and Child Study with questionnaire data on tobacco smoke exposure and acute otitis media up to 18 months of age. Multivariate regression models were used to obtain adjusted relative risks for acute otitis media.
Results:  Acute otitis media was slightly more common in children exposed to parental smoking. The incidence from 0 to 6 months was 4.7% in unexposed children and 6.0% in children exposed both prenatally and postnatally. After adjusting for postnatal exposure and covariates, the relative risk for acute otitis media 0–6 months when exposed to maternal smoking in pregnancy was 1.34, 95% confidence interval: 1.06–1.69. Maternal smoking in pregnancy was associated with acute otitis media up to 12 months of age. Compared with non-exposed children, there was a slightly increased risk of recurrent acute otitis media for children exposed both prenatally and postnatally with a relative risk of 1.24, 95% confidence interval: 1.01–1.52.
Conclusion:  Even in a cohort with relatively low exposure levels of parental smoking, maternal smoking in pregnancy was associated with an increased risk of acute otitis media in early childhood.     

Quantitative detection of HCMV-DNA in saliva from infants and breast milk on real-time polymerase chain reaction

Background:  The role of breast milk in viral transmission has not been fully studied. To determine the effect of breast milk on the establishment of primary human cytomegalovirus (HCMV) infection in term infants, HCMV-DNA was measured in breast milk and infant saliva.
Methods:  The study population consisted of 48 healthy term infants and their mothers. The copy number of HCMV-DNA in the infants' saliva and mothers' milk was measured on quantitative real-time polymerase chain reaction (PCR).
Results:  HCMV-DNA was detected in both saliva and breast milk from 21 infant–mother pairs, in milk only from four pairs, in saliva only from 12 pairs, and in neither from 11 pairs. HCMV-DNA was first detected in the saliva of 10 infants at age 4 months, seven infants at 7 months, 13 infants at 10 months, and three infants at 12 months. The viral loads peaked 4–10 months after birth, and thereafter decreased or became negative. The peak copy number and rate of HCMV-DNA detection in saliva were significantly related to peak copy number and rate of detection in the corresponding breast milk.
Conclusion:  Thus, HCMV passed through breast milk 1–7 months after delivery affects the persistence and level of HCMV-DNA in infant saliva and is the most important route of primary infection.     

Perinatal risk factors for early childhood onset type 1 diabetes in Austria – a population-based study (1989–2005)

Background:  To investigate the rapid increase in incidence of type 1 diabetes mellitus (T1DM) in children <5 yr in Austria.
Methods:  Data of children born between 1989 and 2005 (n = 444) from the T1DM children incidence registry were linked with birth certificates (n = 1 407 829).
Results:  Age of mother, level of education, birth weight, birth length, body mass index, and APGAR score at 10 min were not significant. Boys have about 25% higher risk than girls [hazard ratio = 0.75, 95% confidence interval (CI): 0.62–0.91]. The risk of developing diabetes increases over time significantly (1989–1991 vs. 2001–2005, hazard ratio = 2.86, 95% CI: 2.07–3.94). The linear effect of parity is borderline significant (p = 0.045), with lower risks for second and later born siblings. Marital status is significant [hazard ratio = 0.73, 95% CI: 0.57–0.90)]. Native-born children exhibit twice as high risk as non-native children (hazard ratio = 0.51, 95% CI: 0.37–0.71). Birth weight shows a positive but not significant effect on risk of T1DM.
Conclusions:  In this very young and rapidly increasing cohort of diabetic children <5 yr of age, no association with birth weight but with year of birth, gestational age, nationality and parity could be observed.     

Real-Time Breastfeeding Documentation: Timing of Breastfeeding Initiation and Outpatient Duration

BackgroundCurrent breastfeeding guidelines promote initiating breastfeeding ≤1 h after birth to establish long-term breastfeeding. Previous studies dichotomized initiation to ≤1 h versus subsequent hours combined. There are limited data evaluating the effect of initiation in each subsequent hour on breastfeeding duration. Our objective was to evaluate the association between breastfeeding initiated at ≤1 h versus the subsequent 23 hours after birth and outpatient breastfeeding duration.MethodsIn this retrospective cohort study, we analyzed real-time, discretely documented electronic health record (EHR) breastfeeding data for 3315 infants born at a university center and followed to age ≥12 mo at 27 university primary care clinics. The primary outcome was breastfeeding duration. The exposure variable was hour of breastfeeding initiation within 24 h postnatally. Data were analyzed by univariable and multivariable linear regression separately for infants born by vaginal versus cesarean delivery.ResultsIn adjusted models, initiating breastfeeding during each hour from age >1 to ≤6 h and during ages >6 to ≤24 h was not associated with decreased breastfeeding duration versus initiating breastfeeding at ≤1 h after birth for infants born via vaginal or cesarean delivery.ConclusionsDelaying breastfeeding initiation to >1 to ≤24 h after birth is not associated with decreased breastfeeding duration compared with initiating breastfeeding at ≤1 h after birth. Integration of breastfeeding measures into inpatient and outpatient EHR discrete data fields may clarify best practices that support long-term breastfeeding as a public health imperative.     

Small body size at birth and behavioural symptoms of ADHD in children aged five to six years

Background:  Behavioural disorders with a neurodevelopmental background, such as attention deficit hyperactivity disorder (ADHD), have been associated with a non-optimal foetal environment, reflected in small body size at birth. However, the evidence stems from highly selected groups with birth outcomes biased towards the extreme low end of the distribution in birth weight. Whether a similar association exists among the normal range of term birth is unclear.
Methods:  The ADHD Rating Scale was filled in by the biological mothers and fathers of children aged five to six years who were born healthy at term. Information on weight (kg), height (cm), head circumference (cm), and gestational age at birth were obtained from hospital records, and the ponderal index (kg/m³), a commonly used measure of thinness, and head circumference-to-length ratio were calculated.
Results:  Behavioural symptoms of ADHD were predicted by a lower ponderal index, a smaller head circumference, and a smaller head circumference-to-length ratio ( β 's: −.12 to −.14, p 's < .05). Adjustments for length of gestation, mother's age, tobacco and alcohol use during pregnancy, pre-pregnancy body mass index (BMI), or parity, the monthly gross income of the family, child's BMI at the age of five to six years or gender did not change the associations.
Conclusion:  These results suggest that physiological adaptation in utero , indicated by small body size at birth, within term gestational range may increase the susceptibility to behavioural symptoms of ADHD.