Variables Impacting Breastfeeding Duration


Research confirms that a woman's misunderstanding of normal child development is an important, and often over-looked, cause for abandoning breastfeeding. Though these issues are covered in depth in The Roadmap to Breastfeeding Success online course, we must be aware of the other, complex variables that may impact a woman's ability to initiate breastfeeding and to continue to breastfeed.

Demographic variables
Demographic variables that make women less likely to begin and continue breastfeeding include: prenatal smoking (Bertino et al., 2012); lower socio-economic, racial or ethnic status; having an unplanned pregnancy or not having a partner; being less-educated (Li et al., 2008); participating in a WIC program (Thulier & Mercer, 2009); and being obese, which is associated with a delay in milk coming in (Stuebe et al., 2014).


Social Variables

Other research moves demographic data to a wider screen by identifying particular social variables that impact initiation and duration of breastfeeding: worries about breastfeeding in public (Stuebe & Bonuck, 2011); lack of partner support and marital distress (Stuebe & Bonuck, 2011; Hinsliff-Smith et al., 2014); giving birth at a non-Baby-Friendly hospital; and returning to work.

We know that breastfeeding rates increase when pregnant women get together with successful breastfeeding mothers. In addition, an important study demonstrates that women who observe breastfeeding role models through videos (and who receive praise from their partners or their own mothers for breastfeeding) have significantly higher levels of confidence in and commitment to breastfeeding than do mothers who lack this kind of support (Kingston, 2008).

It is important to ask what kind of help and support new mothers need. A study from China showed that a grandparent in the home, among other variables, is associated with shorter breastfeeding duration (Liu et al., 2013). Research in Japan showed that the more fathers were involved with care of their infant the less anxiety their partners had—but the more formula the baby received (Ito et al., 2013). Both of these studies may indicate that loved ones need to be shown ways other than feeding to connect with a baby and help a new mother.

Biological Variables
Biological variables that impact breastfeeding include: a mother having physical challenges such as sore nipples, engorgement, mastitis, or plugged ducts before a baby is four weeks of age.

Remember that a woman who identifies any breastfeeding concerns at day 3 and 7 postpartum is less likely to be successfully breastfeeding at 2 months (Wagner et al., 2013). Mothers with early complaints need careful follow-up and ongoing support.

Interesting work by Kathleen Kendall-Tackett makes a connection between a woman’s experience of postpartum pain and its impact on breastfeeding (Kendall-Tackett, 2007). She explains that pain increases the body’s inflammatory process. This inflammatory process causes neuro-hormonal changes that are associated with depression. Kendall-Tackett concludes that pain from c-sections, or with breastfeeding, may create the conditions that result in postpartum depression.

Studies also show that mothers who have pain the first two weeks postpartum—and do not receive the help they need—are more likely to have postpartum depression at two months (Watkins et al., 2011). These studies confirm the importance of getting immediate lactation help for women having postpartum pain.

As one would expect, physical problems in the baby—such as prematurity, illness, or tongue-ties—also contribute to decreased breastfeeding duration and require both special medical care and more lactation support.

Psychological Variables
Though more research has been focused on how psychological variables impact the initiation rather than the duration of breastfeeding (De Jager et al., 2012), current literature suggests that at least four psychological issues influence breastfeeding success: postpartum depression, a mother’s intention and confidence to breastfeed, her sensitivity to her baby, and maternal-child attachment.

Postpartum depression occurs in 13% of mothers (Borra et al., 2014). Work by Kathleen Kendall-Tackett and others explores how the hormones of pregnancy help protect women from postpartum depression, a process, they say, that explains why women who breastfeed have a lower incidence of depression (Kendall-Tackett, 2010). 

In addition, other research shows that women with postpartum depression or anxiety often misread their baby’s body language (Arteche et al., 2011). Studies show that a woman with postpartum depression or anxiety can accurately identify her baby’s distressed face, as do mothers without these psychological conditions. However, the depressed or anxious mother will see her baby’s neutral face as distressed. And, this same mother seems unable to see her baby’s happy face (Arteche et al., 2011) Therefore, helping a mother with postpartum depression accurately read her baby’s body language may increase both that mother’s confidence and her breastfeeding duration.

Second, a women’s intention to breastfeed is a contributing factor to breastfeeding duration. Women who decide prenatally to breastfeed are more likely to be successful breastfeeding mothers (Meedya et al., 2010). Besides identifying an expectant woman's intention to breastfeed, helping her also say how long she plans to breastfeed has been shown to be important.

However, it is important to bear in mind that if a woman intends to breastfeed, and then is unsuccessful in meeting her breastfeeding goals, she will suffer a higher incidence of depression than if she had not intended to breastfeed in the first place (Borra et al., 2014). This research reinforces the need for immediate and effective breastfeeding support as soon as any breastfeeding problem arises.

Lack of confidence leads many women to give up breastfeeding when there are challenges to overcome. Fortunately, work by Dr. T. Berry Brazelton and others (Kadivar & Mozafarinia, 2013) demonstrates the remarkable power of using the baby’s behavior to enhance the confidence of young parents (Brazelton & Sparrow, 2006; Nugent et al., 2007).

Third, research indicates that prenatal women who establish their intention to breastfeed exhibit increased sensitivity to their infants’ cues. In addition, these mothers show an increase in both their duration of breastfeeding and in their exclusive breastfeeding rates (Thulier & Mercer, 2009; Tharner et al., 2012).

Helping a father experience his baby’s ability to interact, or a mother see her baby’s ability to turn toward her face when she calls her name, are techniques that have been shown to increase parent-child bonding and to boost parent confidence. Other studies show that mothers who are highly confident about breastfeeding are more likely to be exclusively breastfeeding at one week and at four months postpartum (Blyth et al., 2009).

Fourth and finally, the issue of maternal-child attachment and breastfeeding is important, both to parents and to the health care providers who serve them. A 2012 study used the well-accepted Ainsworth Sensitivity Scales to assess the impact of breastfeeding on attachment and continued breastfeeding. Mothers who breastfeed to six months demonstrate the highest levels of maternal sensitivity and secure attachment to their baby (Tharner et al., 2012).

REFERENCES:
Arteche, A., et al. (2011). The effects of postnatal maternal depression and anxiety on the processing of infant faces. Journal of Affective Disorders, 133(1-2), 197-203.

Bertino, E., Varalda, A., Magnetti, F., Nicola, D., Cester, E., Occhi, L., Perathoner, C., Pradi, G., Soldi, A. (2012). Is breastfeeding duration influenced by maternal attitude and knowledge? A longitudinal study during the first year of life. Journal of Maternal-Fetal and Neonatal Medicine, 25(53), 32-36.

Blyth, R., Creedy, D., Dennis, C. et al. (2009). Effects of maternal confidence on Breastfeeding duration: An application of Breastfeeding self-efficacy theory. Birth, 29 (4), 278-284.

Borra, C., Iacovau, M. & Sevilla, A. (2014). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intention. Maternal Child Health Journal, Retrieved from http://link.springer.com/article/10.1007%2Fs10995-014-1591-z#page-1

Brazelton, T. & Sparrow, J. (2006). Touchpoints: Birth to 3. New York, NY: Perseus.

De Jager, E., Skouteris, H., Broadbent, J., Amir, L, Mellor, K. (2013). Psychological correlates of exclusive breastfeeding: A systematic review. Midwifery, 29(5), 506-518.

Hinsliff-Smith, K., Spencer, R., Walsh, D. (2014). Realities, difficulties, and outcomes for mothers choosing to breastfeed: Primigravid mothers’ experiences in the early postpartum period (6-8 weeks). Midwifery, 30(1), 14-19.

Ito, J., Fujiwara, T., Barr, R. (2013). Is paternal infant care associated with breastfeeding? A population-based study in Japan. Journal of Human Lactation, 29(4), 491-9.

Kadivar, M. & Mozafarinia, M. (2013). Supporting fathers in a NICU: Effects of the HUG Your Baby program on father’s understanding of preterm infant behavior. Journal of Perinatal Education, 22(2), 113-119.

Kendall-Tackett, K. (2010). Four research findings that will change what we think about perinatal depression. Journal of Perinatal Education, 19(4), 7-9.

Kendall-Tackett, K. (2007). A new paradigm for depression in new mothers: The central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal, 2(6).

Kingston, D., Dennis, C., Sword, W. (2007). Exploring breastfeeding self-efficacy. Journal of Perinatal and Neonatal Nursing, 21(3), 207-215.

Li, R., Fein, S., et al. (2008). Why mothers stop breastfeeding: Mothers’ self-reported reasons for stopping during the first year. Pediatrics 122, S69-76.

Liu, P., Qiao, L., Xu, F., Zhang, M., Want, Y., Binns, C. (2013). Factors associated with breastfeeding duration: a 30-month cohort study in northwest China. Journal of Human Lactation, 29(2), 253-9.

Meedya, S., Fahy, K., Kable, A. (2010). Factors that positively influence breastfeeding duration to 6 months: A literature review. Women Birth, 23(4), 135-145.

Nugent, K., Keefer, C., Minear, S., Johnson, L. (2007). Understanding newborn behavior and early relationships: The Newborn Behavioral Observation System Handbook. Baltimore, MD: Paul H. Brookes Publishing Company.

Stuebe, A., Horton, B., Chetwynd, E., Watkins, S., Grewen, K., Meltzer-Brody, S., (2014). Prevalence and risk factors for early, undesired weaning attributed to lactation dysfunction. Journal of Women’s Health, 23(5), 404-12.

Stuebe, A., Bonuck, K. (2011). What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and belief in a diverse urban population. Breastfeeding Medicine, 6(6), 413-420.

Tharner, A., Lujil, M., Raat, H., Ijzendoorn, M., Bakermans-Kranenburg, M., Moll, H., Jaddoe, V., Hofman, A., Verhulst, F., Tiemeier, H. (2012). Breastfeeding and its relation to maternal sensitivity and infant attachment. Journal of Developmental & Behavioral Pediatrics, 33(5), 396-404.

Thulier, D. & Mercer, J. (2009). Variables associated with Breastfeeding duration. Journal of Obstetric, Gynecologic, & Neonatal Nursing, May/June 38(3), 259-268.

Wagner, E., Chantry, C., Dewey, K., Nommsen-Rivers, A. (2013). Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics, 132(4), e 865-875.


Watkins, S., Meltzer-Brody, S., Zolnoun, D., Stuebe, A. (2011). Early breastfeeding experiences and postpartum depression. Obstetrics & Gynecology, Aug 118 (2 Pt 1), 214-21.





















Calming a Baby at Night

It was an honor to be called into this Australian home by the grandmother of a charming 5-month-old baby, Julius. I had met Grandmother in the US while she was attending a conference. We had planned to make time for dinner when Jim and I traveled to her part of the world, but I was delighted to have THIS special invitation also.

She explains that her grandson (her first) has been a "handful" since birth. His mother and father had eagerly anticipated their child's birth and had prepared themselves for early parenthood with education, family support, and all the necessities of a cheerful nursery.

Though they understood that this stage of life could be challenging, they simply cannot believe the level of sustained exhaustion and confusion they've experienced so far.

Julius's mother has committed to breastfeeding. Though she has adequate milk supply, this child is constantly on the breast. That is because the breast has been the only way she knew to comfort her son when he "got going." Lately, even the breast will not calm him down, though. When he is obviously tired at night the parents take turns walking him, rocking him, and singing (until hoarse) to him. Sometimes all of these actions make NO difference. Consoling him and getting him to sleep seem impossible.

When Julius would finally get to sleep, he would sleep soundly for 45 minutes, stir, and then wake up screaming. These dedicated, sensitive parents had seldom seen their child sleep more than one hour at a stretch in all his five months of life.

Clearly this is a crisis. Mom is ready to give up breastfeeding. Dad is struggling to be faithful to his job responsibilities and to care for both his wife and their young one.

I have spent decades hearing and responding to stories like this one, and I've developed a template for evaluating, diagnosing, and treating families in a sleep predicament.

I begin by understanding that children do not sleep well for one (or all) of three main reasons:

  • Developmental Issues
  • Child-Centered Issues
  • Parent-Centered Issues

Developmental Issues refer to the fact that when healthy children during infancy and early childhood have a developmental surge (e.g., they are about to learn something new), they predictably have difficulty with their sleep patterns. Dr. Brazelton refers to these developmental surges as Touchpoints, and I used this information in developing my Roadmap to Breastfeeding Success.
Predictable surges in a baby's development include:
  1. The 2-week-old’s normal increase in crying
  2. The 1-month-old's developing clear Deep and Light sleep patterns
  3. The 4-month-old's increased distractibility while nursing
  4. The 6-month-old's drive to eat solids
  5. The 9-month-old's separation/stranger anxiety
  6. The 12-month-old's learning to walk
  7. The 18-month-old's second round of separation/stranger anxiety
  8. The 2-year-old's negativism 
Parents can be taught to anticipate these development surges, and to appreciate them as SUCCESSES in their child's development. However, parents also need to know how to help their baby through these new, up-at-night activities without increasing breastfeeding as the only way to comfort the child. Although this may sound counter-intuitive, mothers may need to learn strategies beyond the breast—precisely in order to keep breastfeeding!

Child-Centered Issues refer to a child's basic temperament. Initially, parents do not recognize that some challenging behaviors are temperament-driven. Though Thomas and Chess originally enumerated eight aspects of temperament, I find the following characteristics most relevant to issues of a child's sleep habits: intensity, persistence, sensitivity, and regularity. Helping parents appreciate their child's temperament will increase their ability to make plans that take their particular child's personality into account, rather than imaging how to handle the hypothetical "average" baby.

Parent-Centered Issues refer to the presence (or not) of depression, family stress (such as family violence, alcoholism), and unrealistic parent (and family) expectations. Significant pregnancy losses (miscarriages or infertility) increase parental anxiety, as does a mother's need to return to work sooner than she would like. Remember that fathers as well as mothers can suffer from postpartum depression. All of these factors can be considered "Parent-Centered Issues."

I hear a brief history from the grandmother, the mother, and the father. Clearly this was a planned pregnancy in a stable family that is blessed with ample extended family support. There were some challenges at birth but no significant history of pregnancy loss, and symptoms of depression are present in neither mother nor father. 

So far I gather from this story that one "diagnosis" is sleep association. Since birth, this child has associated breastfeeding with getting from Active sleep back to Deep sleep. 

Initially, Julius is playing contentedly, swiping at a toy in front of him. When he makes a hint of a whimper, his mother immediately leans over, readjusts his blanket, pats him, reassures him, and coaxes him back to his mobile. Though seemingly playing contentedly, his behavior changes significantly when I sit beside him. He glances at me—and immediately moves his arms rigidly to his side and looks at his mother. He then looks back to midline, seemingly ignoring his toy, me, and his "mum" as she and I talk. I "broadcast" his actions and suggest that they show impressive sensitivity for a baby this age. Both parents agree that Julius has always been quick to notice changes in his environment and that he initially retreats from strangers.

During this quiet time I explain to parents how a child's temperament, as well as Active and Deep sleep patterns, contribute to sleep issues. A sensitive child needs his parents to respond more often and more quickly. And, a very attentive mother (as this mother clearly is) may continue to respond so quickly that the child does not learn to contribute to his own settling. As is often the case, this duo has found breastfeeding to be an effective and convenient way to settle a baby, and the baby has been taught to associate breastfeeding with going from Active to Deep sleep. 

My teacup makes a bit of a clang when I set it down on the glass-top table. Julius startles, and then suddenly breaks into THE MOST intense, persistent cry I have seen in a child this age. I am good at calming babies, but I cannot "break through" the intensity and persistence of Julius’s cry.

So the diagnosis becomes clearer:
  • Developmental Issues Emerging cognitive burst expected around 4-5 months. Inability to get from Active to Deep sleep without breastfeeding.
  • Child-Centered Issues Sensitive, intense, persistent temperament traits (ALL characteristics that will bring this child GREAT success later in life).
  • Parent-Centered Issues An extremely sensitive mother who is increasingly (and understandably) anxious.
I conclude that the need for this baby, at this age, is for his parents to take a loving but less robust response to helping him settle and to helping him transition from Active to Deep sleep.

"When you respond to him, you now 1) talk to him, 2) look at him, 3) pat him, 4) pick him up, 5) rock him, 6) breastfeed him. When you put him to bed now, start by dropping off 1) and 2). For a few nights go to him without speaking and glance to the side. Then take your other loving actions as needed. When Julius becomes accustomed to more limited consoling, drop off 6) and then 5). You will be bringing out the best in him by helping Julius learn to contribute to his own calming. Also, when he awakens at night, take this same approach so that he will learn to wiggle back into Deep sleep, on his own. Teaching Julius ‘self-regulation’ will help both him and you.”

The intensely crying Julius immediately gives Mum a chance to practice. She turns her gaze slightly to the side and calms him without speaking. Julius looks puzzled, but he is quickly ready to play again. The strategy of doing more by doing less is working!

I called this mother three days later and was delighted with the results she reported. Julius is now sleeping from 10 PM to 4 AM, at which time he wakes up to breastfeed. The parents hear him stir in Active sleep but leave him to find his own way back to Deep sleep. Mum reports, "Yesterday I felt like a new woman. I made some cookies, took the baby for a walk, and was singing when my husband got home from work." She shares that she now hesitates a moment before responding to her son—and sees his increased “self-regulation” capabilities as both reassuring and exciting.


In closing the phone conversation, I review upcoming developmental changes that are likely to impact this remarkable little guy's sleep again, and I discuss how his parents can best respond to the milestones ahead. The success they are all starting to experience will provide a reliable foundation for this loving family's future parenting successes!

The Co-Sleeping Controversy

Excerpt from the online course,  
Roadmap to Breastfeeding Success: 
Teaching Child Development to Extend Breastfeeding Duration 

 One problem with this controversy is that the terms “bed-sharing” and “co-sleeping” are often interchanged. “Co-sleeping” means that the baby sleeps in close proximity to the mother—and either on the same surface, or not. “Bed-sharing” means that the baby sleeps on the same surface, and in the same bed, as the parent.

A 2013 study concluded that “infants who share a bed with their parents during the first three months of life increase their risk of SIDS by five times – even if the parents don’t smoke, don’t use alcohol, and are exclusively breastfeeding” (Carpenter et al., 2013). The American Academy of Pediatrics recommends “room-sharing” (AAP, 2011), as does the Canadian Public Health Agency (Public Health Agency of Canada, 2012). Both these professional groups conclude that it is safe for a mother to feed the baby in her bed and then return the baby to the baby’s bed for sleeping.

However, given the fact that the release of oxytocin increases relaxation and promotes sleepiness in a breastfeeding mother, it is not surprising that studies show that 45% (AAP, 2011) to 80% (Rigda et al., 2000) of mothers report falling asleep with their babies at some point. Another study confirms that mothers are hesitant to tell their health care provider that they do, in fact, choose to sleep with their baby, or that they sometimes fall asleep with their baby at night (Kendall-Tackett et al., 2010).

Given the complexity of the data on bed-sharing, co-sleeping and room sharing, it is not surprising that other leaders in lactation and pediatrics draw different conclusions from the SIDS and sleep-related death literature, and from the literature on breastfeeding and infant sleep.

Dr. William Sears (Sears, n.d.), Dr. Nils Bergman (Morgan, et al., 2011), Professor Helen Ball of the Parent-Infant Sleep Lab (Ball, 2011), the UK’s National Childbirth Trust (NCT, n.d.), the Australian Breastfeeding Association (ABA, n.d.), and Dr. James McKenna of the University of Notre Dame’s Mother-Baby Behavioral Sleep Laboratories (McKenna, 2014) all conclude that there are important benefits of co-sleeping and that parents should make their own decision based on all available facts.

These professionals believe that close proximity to the mother is critical to the early growth and development of babies and that this closeness boosts a baby’s immune system, helps a baby regulate her temperature, and promotes both ease of arousing to breastfeed and breastfeeding duration. In addition, these leaders cite studies that suggest mothers and babies sleep better together. Because they agree that breastfeeding offers protection against SIDS, they do not recommend co-sleeping for formula-fed babies. They also join the American Academy of Pediatrics in discouraging co-sleeping (AAP, 2011) . . .

   if the baby is exposed to smoking in the home;
   if the mother smoked prenatally;
   if the adult has consumed alcohol, illicit drugs, or sleep-inducing drugs;
   if the adult is experiencing extreme fatigue;
   if the adult is obese;
   if the bed is excessively soft, or contains pillows or loose blankets;
   if there is a possibility that the baby might over-heat;
   if the bed is also shared by a sibling or pet.
In addition, UNICEF discourages co-sleeping for babies born prematurely (UNICEF, n.d.).

Breastfeeding advocates may wish that expert guidelines were clearer and simpler. It would help us all if the sleep literature reached firm, universal conclusions that BOTH enhance breastfeeding initiation and duration, AND promote safe sleep. However, because the literature and recommendations are ambiguous and highly qualified, and vary from state to state and country to country (Blair, 2008), those who promote breastfeeding must stay aware of this controversial issue and provide a range of up-to-date resources to parents who are considering where their baby will sleep (UNICEF, n.d; NC Healthy Start Foundation, May, 2014; ABA, n.d).

REFERENCES:
AAP Task Force on SIDS. (2011). SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics. 128(5), e1341-1367.

Ball, H. (2011). Bed-sharing and co-sleeping: Research overview. Retrieved from

Blair, P. (2008). Putting co-sleeping into perspective. Journal de Pediatria. 84(2).

Carpenter, R., McGarvey, C., Mitchell, E., Tappin, D., Vennemann, M., Smuk, M. & Carpenter, J. (2013). Bed sharing when parents do not smoke: Is there a risk of SIDS? An individual level analysis of five major case-control studies. British Medical Journal 3(5).

Kendall-Tackett, K., Cong, Z. & Hale, T. (2010). Mother-infant sleep locations and nighttime feeding behavior. Clinical Lactation 1, 27-31.


Morgan, E., Horn, A. & Bergman, N. (2011). Should neonates sleep alone? Biological Psychiatry. 70(9), 817-825.

NC Healthy Start Foundation. (May, 2014). Infant Safe Sleep/SIDS. Retrieved from http://www.nchealthystart.org/public/babysleep/multimedia.htm

NCT. (n.d.). Co-sleeping and bed-sharing. Retrieved from http://www.nct.org.uk/sites/default/files/Co-sleeping%20and%20bed-sharing.pdf

Public Health Agency of Canada. (2012). Preventing sudden infant deaths in Canada. Retrieved from

Rigda, R., McMillen, I. & Buckley, P. (2000). Bed-sharing patterns in a cohort of Australian infants during the first six months after birth. Journal of Paediatric Child Health 36, 117-121.



UNICEF. (n.d.). Caring for your baby at night: A guide for parents. Retrieved from http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/caringatnight_web.pdf

By Jan Tedder, BSN, FNP, IBCLC 11/8/20114
©HUG Your Baby 2014