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Transitions in Breastfeeding: Daily Parent Diaries Provide Evidence of Behavior Over Time
Jennifer L. Bodnarchuk, Warren O. Eaton and Patricia J. Martens
J Hum Lact 2006; 22; 166
DOI: 10.1177/0890334406286992
The online version of this article can be found at:
http://jhl.sagepub.com/cgi/content/abstract/22/2/166
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Original Research
Transitions in Breastfeeding: Daily Parent Diaries
Provide Evidence of Behavior Over Time
Jennifer L. Bodnarchuk, PhD, Warren O. Eaton, PhD,
and Patricia J. Martens, IBCLC, PhD
Abstract
This study addressed a key question for assessing breastfeeding duration: at what point is an
infant considered no longer exclusively breastfed or no longer breastfed at all? Mothers provided longitudinal infant feeding data via daily checklists. Transitions between exclusive to
partial breastfeeding and partial to no breastfeeding were compared across 11 time periods for
10 age groups of infants. Daily transitions between exclusive and partial breastfeeding were
common, especially for infants 6 months of age and younger, and transitions from partial to
no breastfeeding occurred much more quickly than transitions from exclusive to partial breastfeeding. Ages at supplementation and weaning calculated in 1-day or 7-day spans correlated
highly (intraclass correlation = .99). These results support the Breastfeeding Definitions and
Data Collection Periods guideline recently developed by the Breastfeeding Committee for
Canada and may bring the breastfeeding research and clinical communities closer to a consensus on the definition of breastfeeding over time. J Hum Lact. 22(2):166-174
Keywords: exclusive breastfeeding, partial breastfeeding, longitudinal study, infant feeding
transitions, diary method
Breast milk can quite readily be described as broadspectrum medicine as well as nutrition,1(p 411) and it and
Received for review June 28, 2005; revised manuscript accepted for publication October 2, 2005.
This research was funded by the Social Sciences and Humanities Research
Council of Canada Research Grant 410-2001-0467 to Warren O. Eaton.
No reported competing interests.
Jennifer L. Bodnarchuk recently completed her PhD in Developmental
Psychology at the University of Manitoba, Winnipeg, Canada. Warren O.
Eaton is a professor of Developmental Psychology at the University of
Manitoba and directed the 3-year longitudinal Milestones study on which this
research is based. Patricia J. Martens is the director and a senior researcher
at the Manitoba Centre for Health Policy as well as an associate professor
in the Department of Community Health Sciences, University of Manitoba.
The authors thank Linda Romphf, IBCLC, for her valuable help during
analysis interpretation and manuscript preparation; Wendy Guenette, Dene
Ryz, Amy De Jaeger, and Carolyn Barg for their vital assistance with the
project; and the families for their enthusiastic participation. Address correspondence and requests for reprints to Jennifer L. Bodnarchuk, PhD, e-mail:
jbodnarchuk@mts.net.
J Hum Lact 22(2), 2006
DOI: 10.1177/0890334406286992
Copyright 2006 International Lactation Consultant Association
166
have been fed only breast milk in the past 7 days but
who received a temporary supplementation sometime
since birth.
Both the BCCs guideline and the classification scheme
developed by Labbok and Krasovec6 are straightforward,
yet Labbok and Krasovecs original plea has not
received widespread application,9-10 and it is too early to
know whether the BCC guidelines are useful. Part
of the difficulty in using these schemes may be that they
are designed for use at 1 point in time (eg, the infant
was exclusively breastfed at 3 months of age).7 Use of
these schemes over time is not appropriate because we
cannot label a 2-year-old toddler as exclusively breastfed when he or she was exclusively breastfed up to 4
months of age. For the community of breastfeeding
researchers and clinicians to move closer to an agreedon operational definition of breastfeeding duration,
more information is needed. The purpose of the current
study was to address 1 key question for such a definition: at what point can we say that an infant is no longer
exclusively breastfed or no longer breastfed at all?
At first, the answer may seem to be, for example, to
ask mothers to retrospectively provide the age at which
their infants were no longer breastfed or exclusively
breastfed.12 Although this seems simple enough at the
outset, once researchers consider that breastfeeding
does not always follow a uniform progression from
exclusive to partial to none,7,13-15 the picture becomes
more complicated. The reversible nature of feeding
patterns makes it difficult to define 1 point in time
when exclusive or partial breastfeeding has ended.
If the strictest definition of the duration of exclusive
breastfeeding were used, that is, exclusive breastfeeding ends the day any other liquid or solid is given, then
most infants would not be exclusively breastfed beyond
their hospital stay after delivery.16-18 While such supplementation in the hospital may affect later breastfeeding and health and developmental outcomes,16,18-21
a different definition that accounts for resumed exclusive breastfeeding would be useful for most researchers.
If mother-infant pairs can resume exclusive breastfeeding after partial breastfeeding for a given length of
time, then how do we assign an end point to exclusive
breastfeeding? Perhaps after a certain duration of partial breastfeeding, the majority of mother-infant pairs
will not return to exclusive breastfeeding, and there
may be a similar period for the transition from partial
to no breastfeeding. It would be useful for breastfeeding researchers and clinicians to know whether such a
transitional period is closer to a week or a month in
167
time. However, what that time span is, and how reliable it may be, has not been addressed to our knowledge until now.
Methods
Participants and Procedure
168
Bodnarchuk et al
169
Comparison Samples
n (%)
City of Winnipeg, %
Province of Manitoba, %
0 (0.0)
104 (28.5)
29 (8.0)
56 (15.3)
176 (48.2)
16.7
29.3
9.0
20.1
25.0
21.4
28.8
9.5
19.8
20.6
25 (6.9)
46 (12.6)
71 (19.5)
97 (26.6)
102 (28.0)
24 (6.6)
Birth weight, g
Birth length, cm
Gestational age, wk
No. of monthly checklists
returned
Percentage of days
completed
Age at start of checklist
completion, mo
Age at end of checklist
completion, mo
x- SD
Range
3510 520
52 3
39.8 1.5
8.0 3.4
1640 5130
43 61
33.9 44.3
1 15
96.0 8.9
49.7 100
3.6 2.3
1.0 12.3
9.9 3.4
2.5 17.8
170
Bodnarchuk et al
Table 3. Supplementation: Percentage of Infants for Whom the Transition From Exclusive to Partial Breastfeeding Was Reversed, by Age
of Infant and Size of Moving Window
Window Size, d
Age of Infants, mo
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
11-12
10
11
119
198
219
203
189
198
174
160
146
111
26.1
23.2
28.8
24.1
11.6
5.0
6.3
2.5
2.7
3.6
19.3
18.2
16.0
11.3
4.8
1.5
2.3
1.9
2.1
0.9
19.3
14.1
12.3
6.4
2.6
1.0
1.7
1.9
1.4
0.9
16.8
9.6
10.0
3.0
1.6
0.0
1.1
1.9
0.7
0.9
15.1
9.1
8.7
2.0
1.1
1.0
0.6
0.0
0.0
0.0
12.6
6.6
6.4
2.0
1.1
0.5
0.0
0.0
0.0
0.0
8.4
5.1
4.1
2.0
0.5
0.0
0.0
0.0
0.0
0.0
1.7
2.0
1.8
1.5
0.0
0.0
0.0
0.0
0.0
0.0
4.2
3.0
2.3
0.5
0.0
0.0
0.0
0.0
0.0
0.0
5.9
2.5
2.3
0.5
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Table 4. Weaning: Percentage of Infants for Whom the Transition From Partial to No Breastfeeding Was Reversed, by Age of Infant and
Size of Moving Window
Window Size, d
Age of Infants, mo
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
11-12
10
11
119
198
219
203
189
198
174
160
146
111
0.0
1.0
0.5
3.0
2.6
1.0
2.9
3.8
3.4
4.5
0.0
0.0
0.5
1.0
1.6
0.5
1.7
1.9
2.1
2.7
0.0
0.0
0.5
0.5
0.5
0.5
0.6
1.9
1.4
0.0
0.0
0.0
0.5
0.5
0.5
0.5
0.6
1.3
1.4
0.0
0.0
0.0
0.0
0.0
0.5
0.0
0.6
0.6
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.6
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.6
0.6
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
more often than did older infants and that more transitions occurred during shorter windows: the highest
percentages appear in the upper left of the matrix, and
a block of zeros occupies the lower right. In general,
day-to-day (ie, a 1-day window) patterns were the
most variable: 28.8% (95% CI, 22.7%-34.8%) of 4- to
5-month-old infants transitioned back and forth between
exclusive and partial breastfeeding 2 or more times
when considered with 1-day windows, and 26.1%
(95% CI, 18.0%-34.1%) of 2- to 3-month-old infants
did so. That is, for example, after exclusive breastfeeding,
they were partially breastfed for a day or more, and on
a subsequent day, they returned to exclusive breastfeeding. After 4 continuous days (ie, window sizes 4-11)
of partial breastfeeding, we know with 95% confidence that less than 5% of infants older than 5 months
(ie, 5-6 to 11-12 months of age) transitioned back
to exclusive breastfeeding. Conversely, Table 3 shows
that 16.8% (95% CI, 10.0%-23.6%) of 2- to 3-monthold infants continued to transition in spans of 4 days
171
100
90
80
70
Weaning
60
50
40
30
Supplementation
20
10
0
2
10
11
12
13
14
15
Figure 1. Supplementation and weaning using a 1-day and 7-day moving window: percentage of infants breastfed by age of infant in
months. Black line = 1-day window; gray line = 7-day window.
172
Bodnarchuk et al
173
174
Bodnarchuk et al
References
1. Fredrickson D. Commentary: breastfeeding study design problems
health policy, epidemiologic and pediatric perspectives. In: StuartMacadam P, Dettwyler KA, eds. Breastfeeding: Biocultural Perspectives.
New York, NY: Aldine de Gruyter; 1995:405-418.
2. Stuart-Macadam P, Dettwyler KA, eds. Breastfeeding: Biocultural
Perspectives. New York, NY: Aldine de Gruyter; 1995.
3. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.
4. Canadian Paediatric Society, Dietitians of Canada and Health Canada.
Nutrition for healthy term infants. Ottawa, Canada: Minister of Public
Works and Government Services; 1998. Available at: http://www.phacaspc.gc.ca/dca-dea/publications/pdf/infant_e.pdf. Accessed October 2,
2005.
5. World Health Organization. Protecting, Promoting and Supporting
Breast-Feeding: The Special Role of Maternity Services: A Joint
WHO/UNICEF Statement. Geneva: The Organization; 1989.
6. Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Stud Fam Plann. 1990;21:226-230.
7. Martens PJ. Real world breastfeeding definitions: where the clinician meets the survey researcher. In: Auerbach KG, ed. Current
Issues in Clinical Lactation 2000. Sudbury, Mass: Jones and Bartlett;
2000:37-41.
8. Armstrong HC. International recommendations for consistent breastfeeding definitions. J Hum Lact. 1991;7:51-54.
9. Labbok MH, Coffin CJ. A call for consistency in definition of breastfeeding behaviors. Soc Sci Med. 1997;44:1931-1932.
10. Labbok MH, Belsey M, Coffin CJ. A call for consistency in defining
breast-feeding. Am J Public Health. 1997;87:1060-1061.
11. The Breastfeeding Committee for Canada. The National Authority for
the WHO/UNICEF Baby-Friendly Hospital Initiative in Canada.
Breastfeeding Definitions and Data Collection Periods. 2004. Available
at: http://www.breastfeedingcanada.ca/pdf/BCC%20Breastfeeding%20
Def%20June%2004.pdf. Accessed October 2, 2005.
12. Arbon S, Byrne J. The reliability of a breastfeeding questionnaire.
Breastfeed Rev. 2001;9:23-32.
13. Marquis GS, Diaz J, Bartolini R, De Kanashiro HC, Rasmussen KM.
Recognizing the reversible nature of child-feeding decisions: breastfeeding, weaning, and relactation patterns in a shanty town community
of Lima, Peru. Soc Sci Med. 1998;47:645-656.
14. Piwoz EG, De Kanashiro HC, De Romana GL, Black RE, Brown KH.
Potential for misclassification of infants usual feeding practices using
24-hour dietary assessment methods. J Nutr. 1995;125:57-65.
15. Zohoori N, Popkin BM, Fernandez ME. Breast-feeding patterns in the
Philippines: a prospective analysis. J Biosoc Sci. 1993;25:127-138.
16. Blomquist HK, Jonsbo F, Serenius F, Persson LA. Supplementary
feeding in the maternity ward shortens the duration of breast feeding.
Acta Paediatr. 1994;83:1122-1126.
17. Kurinij N, Shiono PH. Early formula supplementation of breastfeeding. Pediatrics. 1991;88:745-750.
18. Saarinen KM, Juntunen-Backman K, Jarvenpaa AL, et al. Supplementary
feeding in maternity hospitals and the risk of cows milk allergy:
a prospective study of 6209 infants. J Allergy Clin Immunol.
1999;104:457-461.
19. de-Rooy L, Hawdon J. Nutritional factors that affect the postnatal
metabolic adaptation of full-term small- and large-for-gestational-age
infants. Pediatrics. 2002;109:E42.
Resumen
Este estudio considera una pregunta clave de evaluacin de la lactancia materna: hasta que punto se considera que el bebe no recibe lactancia materna exclusiva
o no amamanta? Las madres dieron datos longitudinales
de la alimentacin de sus hijos por medio de un diario
de actividades. Se compararon transiciones de lactancia
exclusiva a parcial y de parcial a no lactancia en 11
perodos en 10 grupos etarios de bebes. Las transiciones
diarias de lactancia exclusiva a parcial fueron muy
comunes, especialmente en los bebes de 6 meses o
menores, y las transiciones de parcial a no lactancia
ocurrieron mucho mas rpido que las transiciones de
lactancia exclusiva a parcial. Se correlacionaron fuertemente (correlacin entre clases = .99) las edades de
suplementacin y cesacin de la lactancia materna que
se calcularon en perodos de 1 da y 7 das. Estos resultados apoyan las Definiciones de Lactancia Materna y la
Gua de Perodos de Recoleccin de Datos desarrollada
recientemente por el Comit de Lactancia Materna de
Canad y puede acercar ms las comunidades de investigacin de lactancia y clnicas para llegar con el tiempo
a un consenso en la definicin de lactancia materna.