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Prevalence of breast-feeding in the Norwegian Mother and Child Cohort Study and health service-related correlates of cessation of full breast-feeding

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First, to describe the prevalence of both full and partial breast-feeding during the first 6 months; second, to study the associations between selected health service-related factors and cessation of full breast-feeding at three time intervals. Retrospective questionnaires, 6 months after birth. The Norwegian Mother and Child Cohort Study (MoBa). In total, 29 621 women. While 96·6 %, 94·0 %, 90·8 %, 86·9 %, 83·8 % and 80·0 % of the infants were breast-fed at 1, 2, 3, 4, 5 and 6 months, respectively, the corresponding proportions for full breast-feeding were 84·6 %, 79·1 %, 70·9 %, 44·0 %, 16·7 % and 2·1 %. An increased risk of cessation of full breast-feeding during the first month was associated with supplementation during the first week of life with water (relative risk (RR) 1·77; 95 % CI 1·52, 2·06), sugar water (RR 1·73; 95 % CI 1·49, 2·00) or formula (RR 5·99; 95 % CI 5·58, 6·42). An increased risk was also associated with Caesarean delivery (RR 1·08; 95 % CI 1·00, 1·16) and breast-feeding problems (RR 1·56; 95 % CI 1·45, 1·67). Between months 1 and 3, the risk of cessation of full breast-feeding remained elevated in the case of supplementation during the first week of life with water (RR 1·29; 95 % CI 1·14, 1·45), sugar water (RR 1·48; 95 % CI 1·34, 1·64) or formula (RR 1·18; 95 % CI 1·07, 1·29). The same applied to Caesarean delivery (RR 1·15; 95 % CI 1·06, 1·25). Supplementation during the first week, breast-feeding problems and Caesarean delivery are associated with early cessation of full breast-feeding. The results support a cautious approach to supplementation during the first week of life.
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Public Health Nutrition: page 1 of 11 doi:10.1017/S1368980010001771
Prevalence of breast-feeding in the Norwegian Mother and
Child Cohort Study and health service-related correlates of
cessation of full breast-feeding
Anna-Pia Ha
¨ggkvist
1,2
, Anne Lise Brantsæter
1
, Andrej M Grjibovski
3,4,5
,
Elisabet Helsing
6
, Helle Margrete Meltzer
1
and Margaretha Haugen
1,
*
1
Department of Food Safety and Nutrition, Norwegian Institute of Public Health, PO Box 4404 Nydalen,
NO-0403 Oslo, Norway:
2
National Resource Centre for Breastfeeding, Division of Obstetrics and
Gynaecology, Rikshospitalet, Oslo University Hospital, Oslo, Norway:
3
Department of Infectious Diseases
Epidemiology, Norwegian Institute of Public Health, Oslo, Norway:
4
International School of Public Health,
Northern State Medical University, Arkhangelsk, Russia:
5
Institute of Community Medicine,
University of Tromsø, Tromsø, Norway:
6
Former Regional Officer for Nutrition, WHO, Copenhagen, Denmark
Submitted 28 October 2009: Accepted 17 May 2010
Abstract
Objective: First, to describe the prevalence of both full and partial breast-feeding
during the first 6 months; second, to study the associations between selected
health service-related factors and cessation of full breast-feeding at three time
intervals.
Design: Retrospective questionnaires, 6 months after birth.
Setting: The Norwegian Mother and Child Cohort Study (MoBa).
Subjects: In total, 29 621 women.
Results: While 96?6%, 94?0%, 90?8%, 86?9%, 83?8 % and 80?0 % of the infants
were breast-fed at 1, 2, 3, 4, 5 and 6 months, respectively, the corresponding
proportions for full breast-feeding were 84?6%,79?1%,70?9%, 44?0%,16?7 % and
2?1 %. An increased risk of cessation of full breast-feeding during the first month
was associated with supplementation during the first week of life with water
(relative risk (RR) 1?77; 95 % CI 1?52, 2?06), sugar water (RR 1?73; 95 % CI 1?49,
2?00) or formula (RR 5?99; 95 % CI 5?58, 6?42). An increased risk was also asso-
ciated with Caesarean delivery (RR 1?08; 95 % CI 1?00, 1?16) and breast-feeding
problems (RR 1?56; 95 % CI 1?45, 1?67). Between months 1 and 3, the risk of
cessation of full breast-feeding remained elevated in the case of supplementation
during the first week of life with water (RR 1?29; 95 % CI 1?14, 1?45), sugar water
(RR 1?48; 95 % CI 1?34, 1?64) or formula (RR 1?18; 95 % CI 1?07, 1?29). The same
applied to Caesarean delivery (RR 1?15; 95 % CI 1?06, 1?25).
Conclusions: Supplementation during the first week, breast-feeding problems and
Caesarean delivery are associated with early cessation of full breast-feeding. The
results support a cautious approach to supplementation during the first week of life.
Keywords
Breast-feeding
Full breast-feeding cessation
Supplementation during first
week of life
Caesarean delivery
Breast-feeding problems
Breast-feeding, and in particular exclusive breast-feeding
as defined in Table 1, provides optimal infant nutri-
tion
(1–3)
. Human milk contains numerous immunological
components that directly protect infants. Studies have
shown that exclusive breast-feeding reduces the risk of
infectious diseases in the respiratory, gastrointestinal and
urinary tracts
(4–8)
, and that it protects premature children
from neonatal sepsis and necrotizing enterocolitis
(9–11)
.In
addition, the immunological components of human milk
support the development and maturation of the infant’s
own immune system, which may explain some of the long-
term health benefits observed in breast-fed children
(12)
.
Recent studies have also indicated long-term health benefits
of lactation for the mother, such as a reduced risk of breast
cancer
(1,2)
.
Breast-feeding is influenced by a variety of factors. These
include sociodemographic, biomedical, health service-
related, psychosocial and cultural factors, as well as public
breast-feeding policy
(13,14)
. The factors associated with
cessation of any breast-feeding are well documented
(14–16)
,
while less is known about the factors associated with the
cessation of exclusive breast-feeding and full breast-
feeding. Fully breast-fed infants are defined as those who
are either exclusively breast-fed or who receive water-
based supplementation, but no solid food or formula
(Table 1). Current WHO recommendations
(3)
highlight
SPublic Health Nutrition
*Corresponding author: Email Margaretha.Haugen@fhi.no rThe Authors 2010
the desirability of 6 months of exclusive breast-feeding.
This necessitates studies of the factors associated with the
cessation of exclusive or full breast-feeding.
The Norwegian health authorities recommend exclu-
sive breast-feeding for the first 6 months of life, echoing
the WHO recommendation
(3,17)
. Almost all mothers in
Norway initiate breast-feeding (98 %)
(18)
. Some 80 % still
breast-feed at 6 months, but only 9 % do so exclusively.
The largest decrease in exclusive breast-feeding, from
63 % to 46 %, occurs between 3 and 4 months
(18)
.
Early supplementation with infant formula, water or
water-based supplements like sugar water is associ-
ated with a shorter duration of exclusive or full breast-
feeding
(8,19–23)
. However, supplementation with water
or sugar water has been studied less than formula sup-
plementation
(19,20,22)
. Knowledge about the possible
influence of other health service-related factors is limited.
Few studies have reported associations between the
duration of exclusive or full breast-feeding and breast-
feeding problems, transfer to a neonatal intensive care
unit (NICU) or the size of the birth institution
(24–27)
.In
addition, studies investigating the association between
delivery by Caesarean section (CS) and cessation of
exclusive or full breast-feeding have also been incon-
clusive
(23,24,28)
.
To the best of our knowledge, no previous study has
examined the association between these health service-
related factors and cessation of full breast-feeding among
mothers who are still breast-feeding. Moreover, many
previous studies have ignored the fact that these asso-
ciations may differ at different points in time during the
first 6 months after birth. The Norwegian Mother and
Child Cohort Study (MoBa), a large, prospective preg-
nancy cohort, enables examination of both issues.
The objectives of the present study were: (i) to describe
the prevalence of full and partial breast-feeding during
the first 6 months in mothers participating in MoBa; and
(ii) to study the associations between health service-
related factors and cessation of full breast-feeding among
mothers still breast-feeding at three different time inter-
vals during the first 6 months.
Materials and methods
Study population and sample
The data set is part of the MoBa cohort, initiated and
maintained by the Norwegian Institute of Public Health.
In brief, MoBa is a pregnancy cohort that in the years from
1999 to 2008 has included ,107 000 pregnancies. Women
were recruited to the study through a postal invitation in
connection with a routine ultrasound examination offered
to all pregnant women in Norway during weeks 17–18 of
gestation. The participation rate was 43 %
(29)
. Three ques-
tionnaires (Q1–Q3) were completed during pregnancy, and
the first questionnaire after birth (Q4) was completed at
6months.Therespectiveresponseratesforquestionnaires
Q1–Q4 were 95 %, 93 %, 92 % and 97 %. The self-completed
questionnaires covered health, chemical and physical fac-
tors in the environment, nutrition, lifestyle and background
factors
(29)
(the questionnaires may be downloaded from
http://www.fhi.no). The cohort database is linked to the
Medical Birth Registry of Norway (MBRN)
(30)
. The study
was approved by the Regional Committee for Ethics in
Medical Research and the Norwegian Data Inspectorate
(29)
.
At the time of the present analysis, Q4 was available
for 40 805 mother–infant pairs (taken from the quality-
assured data file (version 3) made available for research
in 2007). Our study sample included all participants who
had answered both Q1 and version b of Q4. The infants
were born during the period 2002–2005. Triplets and sec-
ond twins were excluded. Pairs of twins were represented
by twin 1. There was no difference in breast-feeding pre-
valence between twin 1 and twin 2 during the first 6 months
(all P.0?05). Mothers who did not answer all questions
about infant nutrition (questions 15–18 in Q4) were exclu-
ded, resulting in a final sample of 29 621 (Fig. 1).
Variables
The breast-feeding data are based on three questions
about infant nutrition in Q4. The questions were asked
retrospectively 6 months after birth. The first question
asked about infant feeding during the first week after
birth and offered the following alternatives: ‘breast milk’,
SPublic Health Nutrition
Table 1 Definitions of breast-feeding based on WHO definitions
(53,54)
Exclusive breast-feeding Must receive breast milk but may receive ORS, drops,
syrups, vitamins, minerals or medicines
Cannot receive solid or semi-solid foods, formula or other
non-human milk or water/water-based drinks/fruit juices,
daily or weekly
Predominant breast-feeding Must receive breast milk and water, water-based drinks or
fruit juices, and may receive ORS, drops, syrups,
vitamins, minerals or medicines
Full breast-feeding
Any breast-feeding
Cannot receive solid or semi-solid foods, formula or other
non-human milk, daily or weekly
Partial breast-feeding* Must receive breast milk combined with either solid or
semi-solid foods, formula or other non-human milk
ORS, oral rehydration salt.
*Partial breast-feeding is similar to ‘complementary feeding’ in the WHO document
(54)
.
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2 A-P Ha
¨ggkvist et al.
‘water’, ‘sugar water’, ‘infant formula’, ‘other’ and ‘don’t
know’. The second question was: ‘What kind of milk did
your baby receive at months 0, 1, 2, 3, 4, 5 and 6?’ The
possible answers were: ‘breast milk’, ‘formula’ and ‘other
milk’. For both of these questions more than one liquid
could be marked. The last question was: ‘In which month
did you start giving complementary food to the child?’
The answers to this final question covered seventeen
different food items, which were collapsed into one
complementary food variable.
The breast-feeding categories used in the present study
were based on WHO definitions (Table 1). The category
‘exclusive breast-feeding’ could only be studied the first
week of life, as the use of water, water-based drinks and
fruit juice in the period 0–5 months was not included in
all versions of the questionnaire. The ‘full breast-feeding’
variable used in the regression analysis describes infant
feeding ‘since birth’, except for supplementation during
the first week of life. In the present article, ‘breast-feeding’
must be understood as ‘breast milk feeding’, as no data
were available on the feeding practice.
The following health service-related factors were
investigated: (i) use of supplementation during the first
week of life; (ii) CS delivery; (iii) breast-feeding problems;
(iv) transfer to NICU; and (v) size of birth institution. Data
about the use of supplements during the first week of life
and breast-feeding problems are derived from Q4. Infor-
mation on CS delivery, transfer to NICU and size of birth
institution are taken from the MBRN. Breast-feeding pro-
blems for which health personnel were contacted during
the first month after birth were combined into a dichot-
omous variable, which was coded as ‘no’ if there were
no problems and ‘yes’ if the mother reported (i) mastitis,
(ii) sore nipples or (iii) other undefined breast-feeding
problems. The breast-feeding problems were of such
severity that health personnel were contacted during the
first month after birth. Supplementation during the first
week of life was classified into four categories: ‘only breast
milk’, ‘breast milk and water’, ‘breast milk and sugar water’
and ‘breast milk and infant formula’. Five categories were
offered for size of institution (number of births per year):
,500, 500–1499, 1500–2999, .3000 and unknown. Three
categories were offered for transfer to NICU: ‘no’, ‘yes’ and
‘unknown’, while delivery method was assessed by refer-
ence to a dichotomous variable: ‘vaginal’ or ‘Caesarean
section’.
Pre-pregnancy BMI and smoking status were derived
from Q1, administered in weeks 17–18 of gestation.
SPublic Health Nutrition
n 29 621
Cessation of any breast-feeding at
1 month, n 767
Did not initiate breast-feeding, n 385
n 29 236
n 28 469
n 23 972
n 19 080
Cessation of full breast-feeding at 1 month
and any breast-feeding at 3 months,
n 4497
Cessation of full breast-feeding at
3 months and any breast-feeding at
6 months, n 4892
Participants included in
breast-feeding
prevalence (Fig. 2)
Breast-feeding at 0
month and still breast-
feeding at 1 month
(Table 3)
Full breast-feeding at 1
month and still breast-
feeding at 3 months
(Table 4)
Full breast-feeding at 3
months and still breast-
feeding at 6 months
(Table 5)
Participants who
initiated breast-feeding
(Table 2)
Answered early version of Q4, n 7642
n 40 805
Not answered Q1, n 1303
21 triplets and 577 second twins, n 598
Not answered infant food questions in Q4,
n 1641
Fig. 1 Flow diagram for inclusion of participants for the study from the Norwegian Mother and Child Cohort
Prevalence of breast-feeding in MoBa 3
Educational level, household income, smoking status
during lactation and marital status were derived from Q4.
Birth year, sex and birth weight of the infant, plurality,
maternal age, parity and place of residence were obtained
from the MBRN
(30)
. Birth-weight data not available from
the MBRN (n72) were calculated using data taken from
maternal reports in Q4. We used data on smoking during
pregnancy in the analysis of full breast-feeding cessation
during the first two time intervals, and for the full breast-
feeding cessation between 3 and 6 months we used
smoking data from Q4.
Statistical analysis
Pearson’s x
2
test was used to test for differences between
proportions. Multivariable Poisson regression with robust
variance estimates was used to calculate relative risk (RR)
with 95 % confidence interval for cessation of full breast-
feeding, at the different time intervals and for all health
service-related factors, with and without adjustment for
maternal age, maternal education, smoking, marital status,
region of birth, household income, birth year, pre-pregnancy
BMI, parity, sex of the infant, birth weight and plurality.
We first examined the associations between the selected
health service-related factors and cessation of full breast-
feeding, for each month. Due to the similarity of the findings
for months 1 to 6 (data not shown), only three outcomes
were selected: cessation of full breast-feeding during the
first month, cessation in the time interval between months 1
and 3, and cessation in the time interval between months 3
and 6. Only mothers fully breast-feeding at month 1 were
included in the second regression analysis (Table 4), and
only the mothers fully breast-feeding at month 3 were
included in the third regression analysis (Table 5). The cri-
teria for inclusion in the groups are shown in Fig. 1.
All analyses were performed using the SPSS statistical
software package version 14 (SPSS Inc., Chicago, IL,
USA). Poisson regression was analysed using the STATA
statistical software package version 10 (StataCorp, College
Station, TX, USA).
Results
Participants who were excluded for not having answered
the infant feeding questions (n1641) did not differ from
the other participants with regard to maternal character-
istics, but were more likely to be smokers (P50?019).
The prevalence of full breast-feeding during the first
week was 81?7% (n24 210). The proportion of those
exclusively breast-feeding was 70?5% (n20?872), while
11?3% (n3338) were predominantly breast-feeding.
Among those who did not fully breast-feed, 17?0% (n5026)
were partially breast-feeding and 1?3% (n385) were not
breast-feeding at all.
The women who did not initiate breast-feeding (n385)
exhibited lower educational level, higher pre-pregnancy
BMI, greater incidence of smoking, greater number of CS
deliveries, greater number of twin births and lower infant
birth weights than the women who initiated breast-feeding.
No differences were found with regard to maternal age,
household income, parity and infant gender (Table 2).
While 80?0 % of the children were breast-fed at 6 months,
only 2?1 % were fully breast-fed at this point in time. There
was a pronounced decline in full breast-feeding starting
from 3 months, with a 26?9 % decline (from 70?9% to
44?0 %) between 3 and 4 months and a further 27?3%
decline (from 44?0 % to 16?7 %) between 4 and 5 months
(Fig. 2).
An increased risk of cessation of full breast-feeding
during the first month of life was associated with sup-
plementation with water, sugar water or formula during
the first week of life, CS delivery and breast-feeding
problems, but not institution size. Transfer to NICU was
associated with a lower risk. Supplementation with for-
mula was associated with a sixfold risk of cessation of full
breast-feeding during the first month (RR 5?99; 95 % CI
5?58, 6?42; Table 3).
CS delivery and supplementation with water, sugar
water or formula during the first week of life were still
associated with an increased risk of cessation of full
breast-feeding in the time interval between months 1 to 3.
The greatest risk was associated with supplementation
with sugar water during the first week of life (RR 1?48;
95 % CI 1?34, 1?64; Table 4).
Supplementation with water or sugar water during the
first week was still associated with the risk of cessation of
full breast-feeding in the time interval between months 3
to 6 (RR 1?02; 95 % CI 1?01, 1?02; Table 5).
Discussion
The key finding of the present study is the association
between supplementary feeding with formula, water or
sugar water during the first week of life and the increased
risk of cessation of full breast-feeding, not only during the
first month but also in months 1 to 3 of life.
The main strengths of the study include the large sample
size and the link to the MBRN. Participants were recruited
from both urban and rural regions, and represented all age
and socio-economic groups. Further, the study enables
the investigation of important factors associated with the
cessation of full breast-feeding, as well as adjustment for
various confounders. In contrast to most other studies of
cessation of full breast-feeding, we studied health service-
related factors by reference to mothers who were still
breast-feeding. Moreover, our examination of the associa-
tions of these factors for different time intervals after birth
differs from most other studies, which presented hazard
ratios during the first 6 months. Proportionality of hazards
during the whole period of observation is a necessary
assumption for such analyses, which was not the case in
SPublic Health Nutrition
4 A-P Ha
¨ggkvist et al.
the present study. In addition, the use of risk ratios facil-
itates better interpretation of the results and avoids over-
estimation of the risk when events are common, which
might be the case when logistic regression is used and
when results are presented as odds ratios
(31)
.
A limitation of the present study was the retrospective
approach, which implied a 6-month recall of infant
nutrition. The long recall period may have caused over-
estimation of the duration of full breast-feeding
(32)
.
However, Merten et al. reported no differences in the
proportion of fully breast-fed infants when comparing
24 h recall and retrospective data
(19)
. Finally, we cannot
rule out the possibility that unmeasured confounders may
have influenced the associations.
The participation rate in MoBa is only 43 %
(29)
. The
potential bias due to self-selection in MoBa was recently
evaluated by Nilsen et al.
(33)
; no statistically relative dif-
ferences in association measures were found between
participants and the total population regarding eight
exposure–outcome associations evaluated.
The primary aim of the present study was to describe
breast-feeding prevalence in the MoBa cohort. The find-
ings regarding initiation of breast-feeding and breast-
feeding prevalence closely mirror the findings made in
the representative Norwegian Infant Nutrition Survey
(SPEDKOST) of children born in 1998
(34)
.
SPEDKOST (n2383) also employed retrospective
questionnaires administered 6 months after birth to col-
lect data on infant nutrition. However, it reported on
‘exclusive breast-feeding’, which was defined as including
water and thus differs slightly from ‘full breast-feeding’ as
used in the present study. In SPEDKOST, the prevalence
SPublic Health Nutrition
Table 2 Sample characteristics of mothers by reference to breast-feeding initiation in the Norwegian Mother and Child Cohort Study,
2002–2005
All participants Did not initiate breast-feeding Initiated breast-feeding
(n29 621) (n385) (n29 236)
n%n%n%P*
Age (years) 0?324
#24 3274 11?142 10?9 3232 11?1
25–34 21 025 71?0 260 67?5 20 765 71?0
$35 4598 15?572 18?7 4526 15?5
Missing 724 2?411 2?9 713 2?4
Education (years) ,0?001
#12 11 545 39?0 203 52?7 11 342 38?8
13–15 12 246 41?3 124 32?2 12 122 41?5
$16 5177 17?545 11?7 5132 17?6
Missing 653 2?213 3?4 640 2?2
Pre-pregnancy BMI (kg/m
2
),0?001
,18?5 812 2?715 3?9 797 2?7
18?5–24?9 18 436 62?2 167 43?4 18 269 62?5
25?0–29?9 6581 22?2 111 28?8 6470 22?1
$30?0 2910 9?880 20?8 2830 9?7
Missing 882 3?012 3?1 870 3?0
Smoking during pregnancy ,0?001
Non-smokers 26 528 89?6 321 83?4 26 207 89?6
Occasional smokers 931 3?116 4?2 915 3?1
Daily smokers 1954 6?645 11?7 1909 6?5
Missing 208 0?73 0?8 205 0?7
Household income (NOK) 0?403
,500 000 7357 24?8 105 27?3 7252 24?8
$500 000 19 726 66?6 244 63?4 19 482 66?6
Missing 2538 8?636 9?4 2502 8?4
Parity 0?106
0 13 228 44?7 192 49?9 13 036 44?6
1 10 604 35?8 128 33?2 10 476 35?8
$2 5789 19?565 16?9 5724 19?6
Method of delivery ,0?001
Vaginal 25 696 86?7 272 70?6 25 424 87?0
Caesarean section 3925 13?3 113 29?4 3812 13?0
Gender of the infant 0?381
Boy 14 632 49?4 177 46?0 14 455 49?5
Girl 14 265 48?2 197 51?2 14 068 48?1
Missing 724 2?411 2?9 713 2?4
Plurality ,0?001
Single child 29 055 98?1 368 95?6 28 687 98?1
Twins 566 1?917 4?4 549 1?9
Birth weight (g)
.2500 28 600 96?6 319 82?9 28 281 96?7,0?001
#2500 1021 3?466 17?1 955 3?3
*Pvalue calculated using Pearson’s x
2
test.
Prevalence of breast-feeding in MoBa 5
of full breast-feeding was only 1–2 % higher than that of
exclusive breast-feeding (B Lande, personal communication).
Accordingly, the data on exclusive and full breast-feeding in
the two studies can be compared, even if the terms have
been defined slightly differently. The only material difference
in breast-feeding prevalence between SPEDKOST and
MoBa can be observed at 6 months: SPEDKOST shows 7 %
exclusive breast-feeding while MoBa shows only 2?1% full
SPublic Health Nutrition
0
10
20
30
40
50
60
70
80
90
100
0123456
Completed months
Proportion of infants (%)
Fig. 2 Prevalence of full (), partial ( ) and no breast-feeding (&) during the 6 months after birth for 29 621 women in the
Norwegian Mother and Child Cohort Study, 2002–2005
Table 3 Health service-related factors and cessation of full breast-feeding in mothers still breast-feeding during the first month after birth
(total n28 469), Norwegian Mother and Child Cohort Study, 2002–2005
Cessation of full breast-feeding
n%n% Crude RR 95 % CI Adjusted RR* 95 % CI
Infant feeding first week
Only breast milk 20 555 72?2 1259 6?11?00 Reference 1?00 Reference
Breast milk and water 1520 5?3 168 11?11?80 1?54, 2?10 1?77 1?52, 2?06
Breast milk and sugar water-1960 6?2 188 10?71?74 1?51, 2?02 1?73 1?49, 2?00
Breast milk and formula-
-
4636 16?3 1877 40?56?61 6?20, 7?05 5?99 5?58, 6?42
Delivery method
Vaginal 24 837 87?1 2819 11?41?00 Reference 1?00 Reference
Caesarean section 3632 12?9 673 18?51?63 1?51, 1?76 1?08 1?00, 1?16
Breast-feeding problems first month
No 24 784 87?2 2757 11?11?00 Reference 1?00 Reference
Yes 3685 12?9 735 19?91?79 1?67, 1?93 1?56 1?45, 1?67
Transfer to NICU
No 24 228 85?1 2912 12?01?00 Reference 1?00 Reference
Yes 2261 7?9 374 16?51?38 1?25, 1?52 0?75 0?68, 0?83
Unknown 1980 7?0 206 10?40?87 0?76, 0?99 0?86 0?75, 0?98
Size of institution (births per year)
,500y3439 12?1 357 10?41?00 Reference 1?00 Reference
500–1499 7517 26?4 939 12?51?20 1?07, 1?35 1?08 0?97, 1?22
1500–2999 5416 19?0 711 13?11?30 1?12, 1?43 1?05 0?92, 1?20
.3000 7456 26?2 909 12?21?17 1?05, 1?32 1?03 0?90, 1?16
Unknown 4641 16?3 576 12?41?20 1?06, 1?35 1?45 0?87, 2?40
RR, relative risk; NICU, neonatal intensive care unit.
*Adjusted for the other variables in the table and maternal age, maternal education, smoking during pregnancy, marital status, region of birth, household
income, birth year, pre-pregnancy BMI, parity, sex of the infant, birth weight and plurality.
-Sugar water could include water.
-
-
Formula-fed could include sugar and/or water.
yIncluding 207 births outside institution.
6 A-P Ha
¨ggkvist et al.
breast-feeding. The lower prevalence at 6 months observed
in MoBa may be explained by differences in the questions
asked about infant feeding at that point in time.
We observed a large decline in the incidence of full
breast-feeding starting at 3 months (Fig. 2). One possible
explanation could be that the traditional practice of
SPublic Health Nutrition
Table 4 Health service-related factors and cessation of full breast-feeding in mothers still breast-feeding between 1 and 3 months after birth
(total n23 972), Norwegian Mother and Child Cohort Study, 2002–2005
Cessation of full breast-feeding
nn % Crude RR 95 % CI Adjusted RR* 95 % CI
Infant feeding first week
Only breast milk 18 570 2627 14?11?00 Reference 1?00 Reference
Breast milk and water 1310 232 17?71?25 1?11, 1?41 1?29 1?14, 1?45
Breast milk and sugar water-1471 334 22?71?61 1?45, 1?78 1?48 1?34, 1?64
Breast milk and formula-
-
2621 472 18?01?27 1?16, 1?39 1?18 1?07, 1?29
Delivery method
Vaginal 21 200 3132 14?81?00 Reference 1?00 Reference
Caesarean section 2772 553 19?21?29 1?19, 1?40 1?15 1?06, 1?25
Breast-feeding problems first month
No 21 245 3206 15?11?00 Reference 1?00 Reference
Yes 2727 459 16?81?12 1?02, 1?22 1?09 0?99, 1?19
Transfer to NICU
No 20 527 3084 15?01?00 Reference 1?00 Reference
Yes 1749 324 18?51?23 1?10, 1?37 0?96 0?85, 1?08
Unknown 1696 257 15?21?01 0?90, 1?13 0?98 0?86, 1?11
Size of institution (births per year)
,500y2965 488 16?51?00 Reference 1?00 Reference
500–1499 6269 1007 16?10?98 0?88, 1?08 1?02 0?91, 1?13
1500–2999 4518 676 15?00?91 0?82, 1?01 1?02 0?90, 1?17
.3000 6323 915 14?50?88 0?79, 0?97 1?05 0?93, 1?19
Unknown 3897 579 14?90?90 0?81, 1?01 1?58 0?97, 2?59
RR, relative risk; NICU, neonatal intensive care unit.
*Adjusted for the other variables in the table and maternal age, maternal education, smoking during pregnancy, marital status, region of birth, household
income, birth year, pre-pregnancy BMI, parity, sex of the infant, birth weight and plurality.
-Sugar water could include water.
-
-
Formula-fed could include sugar and/or water.
yIncluding 207 births outside institution.
Table 5 Health service-related factors and cessation of full breast-feeding in mothers still breast-feeding between 3 and 6 months after birth
(total n19 080), Norwegian Mother and Child Cohort Study, 2002–2005
Cessation of full breast-feeding
nn % Crude RR 95 % CI Adjusted RR* 95 % CI
Infant feeding first week
Only breast milk 14 969 14 477 96?71?00 Reference 1?00 Reference
Breast milk and water 1034 1014 98?11?01 1?00, 1?02 1?01 1?00, 1?02
Breast milk and sugar water-1067 1049 98?31?02 1?01, 1?03 1?02 1?01, 1?02
Breast milk and formula-
-
2010 1945 96?81?00 0?99, 1?01 1?00 0?99, 1?01
Delivery method
Vaginal 17 017 16 508 97?01?00 Reference 1?00 Reference
Caesarean section 2063 1977 95?80?99 0?98, 1?00 0?99 0?98, 1?00
Breast-feeding problems first month
No 16 978 16 448 96?91?00 Reference 1?00 Reference
Yes 2102 2037 96?91?00 0?99, 1?01 1?00 0?99, 1?00
Transfer to NICU
No 16 441 15 943 97?01?00 Reference 1?00 Reference
Yes 1291 1233 95?50?98 0?97, 1?00 1?00 0?99, 1?00
Unknown 1348 1309 97?11?00 0?99, 1?01 1?00 0?99, 1?00
Size of institution (births per year)
,500y2323 2251 96?91?00 Reference 1?00 Reference
500–1499 4942 4786 96?81?00 0?99, 1?01 1?00 0?99, 1?00
1500–2999 3596 3487 97?01?00 0?99, 1?01 1?00 0?99, 1?00
.3000 5096 4927 96?71?00 0?99, 1?01 1?00 0?98, 1?00
Unknown 3123 3034 97?21?00 0?99, 1?01 1?00 0?94, 1?07
RR, relative risk; NICU, neonatal intensive care unit.
*Adjusted for the other variables in the table and maternal age, maternal education, smoking during pregnancy, marital status, region of birth, household
income, birth year, pre-pregnancy BMI, parity, sex of the infant, birth weight and plurality.
-Sugar water could include water.
-
-
Formula-fed could include sugar and/or water.
yIncluding 207 births outside institution.
Prevalence of breast-feeding in MoBa 7
introducing solid food between months 4 and 6 is still in
use. The Norwegian health authorities amended its infant
feeding advice in 2001, and have since then recommended
exclusively breast-feeding during the first 6 months.
The breast-feeding initiation rate of 98?7% is higher
than in most industrial countries, but comparable to other
Nordic countries, some European countries and Australia.
The proportion of any breast-feeding at 6 months (80?0%)
is among the highest in Europe and the industrialized
world
(35,36)
. The proportion of fully breast-fed infants at
4months(44?0 %) equals the European averag e, while a
rate of 2?1% for fully breast-fed at 6 months seems low
compared with other European countries
(36)
. However,
differences in data collection, breast-feeding definitions and
participant selection make comparison difficult.
Supplementary feeding with water, sugar water or
formula during the first week of life was associated
with an increased risk of cessation of full breast-feeding
during the first month. A sixfold higher risk was observed
where the infant received formula (Table 3). A repre-
sentative survey from the USA reported a strong asso-
ciation between supplementation (formula or/and water)
in the maternity unit and not being exclusively breast-fed
at week 1
(37)
. Moreover, several studies have linked the
use of formula during the first week to shorter overall
duration of exclusive or full breast-feeding
(19,23,38,39)
.
Perez-Escamilla et al. identified an association between
shorter duration of exclusive breast-feeding and pre-
lacteal feeds with water but not feeds with water-based
liquids such as tea, juice or sugar water
(22)
. On the other
hand, Nylander et al. identified links between supple-
mentation with sugar water and a shorter duration of
exclusive breast-feeding
(40)
, where exclusive breast-
feeding was defined as in Table 1 (G Nylander, personal
communication). In our study we also found an associa-
tion between supplementation with formula, water or
sugar water during the first week and cessation of full
breast-feeding between 1 and 3 months (Table 4). This
suggests a late effect on cessation of full breast-feeding of
supplementation during the first week. To the best of our
knowledge, such late associations have not been descri-
bed previously. In a Spanish study, no differences were
found regarding the introduction of formula at 8, 12, 16
and 20 weeks when a group receiving sugar water as a
supplement was compared with a control group receiving
no supplementation
(20)
.
The associations between cessation of full breast-
feeding and supplementation with water or sugar water
remained statistically significant in the time interval 3–6
months, but were very weak and thus of no clinical
relevance (Table 5).
One feasible explanation for the associations between
supplementation during the first week of life and cessation
of full breast-feeding reported here is that supplementa-
tion during the first week is an indicator of delayed lac-
togenesis or problems with the initiation of breast-feeding
not reported or included in our category of breast-feeding
problems. Alternatively, supplementation during the first
week may disturb the normal lactation physiology, and
lead to reduced milk production and cessation of full
breast-feeding. The associations may also be explained
by unknown factors.
In the present study we did not obtain any information
about the amount of formula administered, any reason
why supplement was given or the frequency of its use.
It has been reported that the increased risk of cessation
of full breast-feeding associated with formula supple-
mentation can be modified by altering the frequency of
supplementation
(21)
. Supplementation with infant for-
mula may also occur when maternal motivation to breast-
feed exclusively is lacking.
Avoidance of supplementation without medical indi-
cation is one step in the WHO/UNICEF ten steps for a
Baby-Friendly Hospital Initiative (BFHI)
(41)
. This is an
important tool for reducing unnecessary supplementation
by promoting early breast-feeding, feeding on demand,
rooming-in and avoiding the use of a pacifier
(19,37,42,43)
.
Today, the majority of infants born in Norway are born
in a BFHI-designated hospital. Nevertheless, 29?5 % of the
infants in our study were not exclusively breast-fed
during the first week of life. However, this figure is low
compared with other European countries and the USA,
where 63–70 % of infants receive supplements in the
maternity units
(37,38,43)
.
The question arises whether there are medical reasons
for introducing supplements to nearly one-third of the
infants in our study sample. Supplementation for medical
reasons has been reported to have no influence on
duration of exclusive breast-feeding
(39)
, although non-
medical reasons are reported to be the most common
cause of supplementation
(21,23,26)
. Water has no nutri-
tional value and there is no medical indication for use,
while sugar water may include glucose polymers given
as a treatment for hypoglycaemia. Supplementation with
formula may have health implications for the infant
(related to early introduction of foreign proteins to the
mucosa/gut) and should, according to WHO, be con-
sidered only when indications are convincing
(44,45)
.
We found that CS was associated with a higher risk of
cessation of full breast-feeding during the first month
(Table 3) and between months 1 and 3 (Table 4). This is
in line with several previous studies
(26,28,46)
. CS has also
been associated with delayed initiation of breast-feeding
and late onset of lactation
(47–49)
. However, not all studies
have found an association between CS and cessation
of full breast-feeding shortly after birth, or between CS
and a shorter overall duration of exclusive breast-
feeding
(23,24,27,50)
. The results of studies are difficult to
compare regarding the association between CS and
breast-feeding due to differing CS delivery rates and post-
delivery practices. In Norway, CS is predominantly used
in connection with medical and obstetric high-risk
SPublic Health Nutrition
8 A-P Ha
¨ggkvist et al.
conditions, and not upon maternal request. The CS rate in
the present study was 12?9 % while the national CS rate in
Norway is approximately 15 %
(51)
. CS has been described
as an obstacle to early breast-feeding initiation also in
BFHI-designated hospitals, and separation of mothers
and infants after CS should be avoided when possible and
uninterrupted and prolonged skin-to-skin contact should
be facilitated after birth
(47)
.
In the present study, 12?9 % of the mothers reported
breast-feeding problems during the first month. These
included mastitis, sore nipples and other undefined breast-
feeding problems (Table 3). The breast-feeding problems
were of such severity that health personnel were contacted.
Breast-feeding problems were associated with a higher
risk of cessation of full breast-feeding during the first month
(Table 3). Studies that have examined the association
between various breast-feeding problems (such as poor
latch-on or nipple problems) have observed a shorter
duration of exclusive or full breast-feeding during the first
6 months
(24,25,27)
. Severe breast-feeding problems are
almost always very painful, and may lead to cessation of
full breast-feeding due to poor latch-on and consequent
reduced milk production. However, our results showed
that if mothers succeeded in breast-feeding fully during
the first month despite experiencing breast-feeding pro-
blems, there was no associated increased risk of cessation
of full breast-feeding during later time intervals. This
supports the concept of a critical period during the first
few weeks after birth during which breast-feeding women
require more intensive follow-up and support.
There was a lower risk of cessation of full breast-
feeding by the end of the first month when the infant was
transferred to an NICU after birth (Table 3). This may
be explained by the high prevalence of milk banks in
Norway and the corresponding high use of human milk,
especially for infants with birth weights of less than
1500 g
(9,52)
. Mothers may also be more concerned about
full breast-feeding when the infant is ill immediately after
birth. Alternatively, these mothers may receive more help
with breast-feeding.
Conclusions
Despite almost universal initiation of breast-feeding and
a high proportion of breast-feeding, very few mothers
reported full breast-feeding at 6 months in this large
cohort of Norwegian women. The most pronounced
decline in full breast-feeding occurred between months
3 and 4. Supplementary feeding with water, sugar water
or formula during the first week, CS and breast-feeding
problems were associated with cessation of full breast-
feeding during the first month. Associations were also
observed between cessation of full breast-feeding
between months 1 and 3 and supplementation during the
first week and CS.
In the context of the WHO guidelines to exclusively
breast-feed for 6 months, our results suggest that supple-
mentary feeding with water, sugar water or formula
during the first week, breast-feeding problems and CS
should be used as indicators for giving breast-feeding
mothers extra support and follow-up during hospital
stay and after discharge. These findings also support a
restrictive approach to supplementation during the first
week of life and warrant further study of the necessity of
such supplementation.
Acknowledgements
The MoBa Study was supported by the Norwegian Min-
istry of Health, the National Institutes of Health/National
Institute of Environmental Health Sciences (grant no.
N01-ES-85433), the National Institutes of Health/National
Institute of Neurological Disorders and Stroke (grant no. 1
UO1 NS 047537-01) and the Norwegian Research Council/
Functional Genomics (grant no. 151918/S10). The authors
declare that they have no competing interests. All authors
have made a substantial contribution to the study concept
and design. A.-P.H. is the main author and performed
the statistical analyses in collaboration with A.L.B. A.M.G.
was responsible for the statistical analysis. All authors
contributed to drafting and critically revised the manuscript.
Laura Haiek is acknowledged for her valuable reading of
the final manuscript.
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SPublic Health Nutrition
Prevalence of breast-feeding in MoBa 11
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... The prevalence of breastfeeding in Norway is high (Häggkvist et al., 2010), and in this study 89% of the infants were still breastfed at six months, either exclusively or in addition to other food. After birth, PFASs are transferred to the child through breastmilk (Kärrman et al., (Fromme et al., 2010). ...
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Background Per- and polyfluoroalkyl substances (PFAS) are associated with negative health effects, and exposure during fetal life and infancy are of concern. A subgroup of PFAS, linear and branched perfluoroalkane sulfonic acids (PFSA), have significant differences in biochemical reactions, bioaccumulation and potential toxic exposure effects, and data on transfer of PFSA isomers from mother to baby through placenta or in breastmilk are scarce. Objectives The objective was to investigate differences in branched and linear PFSA isomers in never-pregnant, pregnant and postpartum women and infants. Methods Serum concentrations of branched and linear, perfluorohexane sulfonate (PFHxS), perfluoroheptane sulfonate (PFHpS) and perfluorooctane sulfonate (PFOS) were measured in never-pregnant women (n = 158), pregnant and postpartum women (n = 114) and their infants (n = 94) at age six months. Results There was a linear relation between maternal PFSA concentrations in pregnancy week 18 and the infant at age six months. The PFSA concentrations in maternal and infant serum varied with a factor up to 20. The maternal branched/ linear PFHxS ratio increased in the latter part of pregnancy (+45%) and remained high postpartum, and was substantially lower in the infants. Branched/linear PFHpS ratio increased during pregnancy and was highest in the infants, while the branched/linear PFOS ratio decreased in the mothers and was high in the infants. Discussion The linear relations between PFSA concentrations in infants aged six months and mothers in pregnancy week 18 confirm that pregnancy and lactation are major excretion routes for PFSA, but accumulate in the infant. The observed great variability in PFSA burden among mothers and infants, as well as the reduced maternal transfer of branched PFHxS isoforms and increased transfer of branched PFOS isoforms compared to the respective linear isoforms to the infant, might impact adverse health effects associated with PFSA exposure, but this should be confirmed in future studies.
... In this sense, it is worth comparing the context of our study with others such as Norway. Not only is there a greater pro-breastfeeding awareness in Norway, but there are social and labour policies that facilitate family life, with greater health benefits associated with BF, and additionally the training of health professionals is promoted [21,73,75,76]. On the other hand, in our context, midwives have not identified any policy or labour measures to promote EBF. ...
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The aim of this study is to describe the perspectives of Primary Care midwives regarding factors that benefit or are detrimental to exclusive breastfeeding (EBF) within the health system and public policies. The study was carried out in Tenerife (Canary Islands, Spain) and is based on qualitative methodology. Twenty in-depth interviews were carried out with midwives who work in Primary Care centres in Tenerife, using a content analysis approach. The transcript data were then encoded following an inductive approach. The factors, according to midwives, that affect EBF, with regard to the healthcare system, are related to training of healthcare professionals in breastfeeding and their support to women during pregnancy, childbirth and postnatal care. Regarding public policies, midwives believe the maternity leave periods in Spain, together with a lack of laws and social policies to protect EBF are detrimental. The findings from our study show that there is a need to boost training and the role of professionals in EBF and, at the same time, promote protective policies that foster equality, favouring, among other issues, the work-life balance.
... The median age of milk sampling was 33 days (10th-90th percentile: 18-57) and more than 90% were sampled between two weeks old and before the child reached 2 months of age. In Norway, the prevalence of full breastfeeding during this period is more than 80% while the median duration of breastfeeding is 11-12 months (Häggkvist et al., 2010). Mothers were encouraged to avoid electrical pumping equipment and were asked to register details on how and when the milk was sampled (Eggesbø et al., 2011). ...
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The prevalence of cryptorchidism has increased over the past decades, yet its origins remain poorly understood. Testis descent is dependent on androgens and likely affected by endocrine disrupting compounds (EDCs), targeting the androgen receptor (AR). We investigated the association between anti-androgenic activity, not derived from natural hormones, in maternal breast milk and impaired testis descent among boys. We performed a case-control study based on 199 breast milk samples from 94 mothers of cryptorchid boys and 105 random non-cryptorchid boys participating in the Norwegian HUMIS (Human Milk Study) cohort. For each participant, apolar, and polar fractions were extracted, and combined to reconstitute a mixture. Anti-androgenic activity was measured in all three fractions using the human cell-based in vitro anti-AR CALUX® assay and expressed in μg of flutamide equivalent, a well-known antiandrogen. Results from fraction analyses were compared among boys with cryptorchidism and controls using multiple logistic regression, controlling for appropriate confounders identified using a directed acyclic graph. Children's daily exposure to anti-androgenic EDCs through breastfeeding was estimated to 78 μg flutamide eq./kg of body weigh/day. The activity was higher in the polar fraction (1.48 ± 1.37 μg flutamide eq./g of milk) mainly representing non-persistent chemicals, in contrast to other fractions. However, the activity in the polar extracts was decreased when in mixtures with the apolar fraction, indicating synergistic interactions. No significant difference in the activity was observed according to cryptorchid status for polar, apolar or mixed breast milk fractions. The study showed anti-androgenic activity in nearly all human milk samples, and at levels higher than the advisory threshold. However, no significant association was observed between cryptorchidism and antiandrogenic activity measured in either polar, apolar, or mixture fractions derived from breast milk.
... Having established these premises, numerous factors have been described that positively influence both the onset and the duration of breastfeeding: higher maternal education [15,16], parity [17], full term delivery [2], vaginal delivery [18,19], skin-to-skin contact between mother and child immediately after birth [20], previous experience, non-separation of the mother-child binomial, and the breastfeeding education received [21][22][23]. ...
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Background: Breastfeeding is the gold standard of infant feeding due to the many advantages it offers to both the child and the mother. Objective: To identity the main reasons for cessation of breastfeeding reported by mothers during the first year of life. Design: A prospective cohort study was conducted, recruiting 970 infants from a university hospital in Spain. The main maternal variables studied were maternal age, parity, educational level, work occupation, smoking habit, weeks of gestation at birth, birth weight, feeding type, and duration of breastfeeding. All participants were followed for one year to determinate the duration of breastfeeding and to gather reasons for abandoning breastfeeding. Results: At six months, the percentage of breastfeeding experienced a decline of 50%, and only 24.5% of these mothers maintained breastfeeding. Up to 15.8% of the mothers decided to give up exclusive breastfeeding by their own choice, whereas 15.4% did so because they suspected low milk production. Work-related causes represent the third reason of abandonment. Conclusions: Our results highlight the need to improve the health policies for the promotion, protection, and support for the initiation and maintenance of breastfeeding. In particular, our results highlight the importance of researching women's low milk production and work-related factors, with particular emphasis on improving conciliation measures.
Article
STUDY QUESTION Are children conceived by ART or born to subfertile parents more susceptible to upper or lower respiratory tract infections (URTI, LRTI)? SUMMARY ANSWER ART-conceived children had a higher frequency of and risk of hospitalization for respiratory infections up to age 3, which was only partly explained by parental subfertility. WHAT IS KNOWN ALREADY Some studies report increased risks of infections in children conceived by ART. Results for URTIs and LRTIs are inconclusive, and the contribution of underlying parental subfertility remains unclear. STUDY DESIGN, SIZE, DURATION We included 84 102 singletons of the Norwegian Mother, Father and Child Cohort Study (MoBa) born between 1999 and 2009. Mothers reported time-to-pregnancy at recruitment and child history of, frequency of and hospitalization for, respiratory infections when the child was 6, 18 and 36 months old by questionnaires. Subfertility was defined as having taken 12 or more months to conceive. The Medical Birth Registry of Norway (MBRN) provided information on ART. URTI included throat and ear infections, while LRTI included bronchitis, bronchiolitis, respiratory syncytial virus and pneumonia. PARTICIPANTS/MATERIALS, SETTING, METHODS We used log-binomial regression to estimate risk ratios (RR) and 95% CI of any respiratory tract infection and hospitalization, and negative-binomial regression to calculate incidence rate ratios (IRR) and 95% CI for number of infections. We compared children conceived by ART, and naturally conceived children of subfertile parents, to children of fertile parents (<12 months to conceive) while adjusting for maternal age, education, BMI and smoking during pregnancy and previous livebirths. We accounted for dependency between children born to the same mother. MAIN RESULTS AND THE ROLE OF CHANCE A total of 7334 (8.7%) singletons were naturally conceived by subfertile parents and 1901 (2.3%) were conceived by ART. Between age 0 and 36 months, 41 609 (49.5%) of children experienced any URTI, 15 542 (18.5%) any LRTI and 4134 (4.9%) were hospitalized due to LRTI. Up to age 3, children conceived by ART had higher frequencies of URTI (adjusted IRR (aIRR) 1.16; 95% CI 1.05–1.28) and hospitalizations due to LRTI (adjusted RR (aRR) 1.25; 95% CI 1.02–1.53), which was not seen for children of subfertile parents. Children conceived by ART were not at higher risks of respiratory infections up to age 18 months; only at age 19–36 months, they had increased risk of any LRTI (aRR 1.16; 95% CI 1.01–1.33), increased frequency of LRTIs (IRR 1.22; 95% CI 1.02–1.47) and a higher risk of hospitalization for LRTI (aRR 1.35; 95% CI 1.01–1.80). They also had an increased frequency of URTIs (aIRR; 1.19; 95% CI 1.07–1.33). Children of subfertile parents only had a higher risk of LRTIs (aRR 1.09; 95% CI 1.01–1.17) at age 19–36 months. LIMITATIONS, REASONS FOR CAUTION Self-reported time-to-pregnancy and respiratory tract infections by parents could lead to misclassification. Both the initial participation rate and loss to follow up in the MoBa limits generalizability to the general Norwegian population. WIDER IMPLICATIONS OF THE FINDINGS ART-conceived children might be more susceptible to respiratory tract infections in early childhood. This appears to be only partly explained by underlying parental subfertility. Exactly what aspects related to the ART procedure might be reflected in these associations need to be further investigated. STUDY FUNDING/COMPETING INTEREST(S) Funding was received from the Swiss National Science Foundation (P2BEP3_191798), the Research Council of Norway (no. 262700), and the European Research Council (no. 947684). All authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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2020 г., № 1 Scientific journal «Current problems of health care and medical statistics» 2020 г., № 1 1 Министерство здравоохранения Архангельской области, г. Архангельск 2 ФГБОУ ВО «Северный государственный медицинский университет» Министерства здравоохранения Российской Федерации, г. Архангельск Введение. В Российской Федерации до настоящего времени в учреждениях службы родовспоможения не оценивается результативность мероприятий по организации грудного вскармливания; детские молочные смеси (ДМС) назначаются в т.ч. здоровым новорожденным. Цель исследования: изучить динамику показателей грудного вскармливания и использования детских молочных смесей в межрайонных центрах родовспоможения второго уровня Архангельской области (МРЦ). Материалы и методы. Выполнено статистическое исследование способом документального наблюдения. Использованы данные отчетной формы № 32 (вкладыш к форме № 32-В, табл.1000») «Сведения о регионализации акушерской и перинатальной помощи в родильных домах (отделениях) и перинатальных центрах» 8 МЦР II уровня Архангельской области за 2013-2017 гг. Собраны данные о показателях грудного вскармливания, об объемах использования ДМС, на основе которых рассчитаны значения показателя «средний расход смесей (в кг) на 1 новорожденного». Использованы метод описательной статистики, аналитический метод. Результаты. В 2013-2017 гг. в МЦР II уровня на фоне увеличения доли нормальных родов с 26,5% до 35,4% охват новорожденных грудным вскармливанием снизился с 94,9% до 89,6%. Общий расход ДМС сократился на 1,6% (с 236,7 кг в 2013 г. до 233,0 кг в 2017 г.). Средний расход ДМС на 1 новорожденного увеличился на 60,7% (с 0,028 кг в 2013 г. до 0,045 кг в 2017 г.). Выводы. Снижение показателей грудного вскармливания при выписке детей из МРЦ и одновременный рост расхода смесей в среднем на одного ребенка отражают низкую результативность работы специалистов службы родовспоможения в поддержку исключительно грудного вскармливания, определяют необходимость изменения подходов к организации питания новорожденных в раннем неонатальном периоде. Ключевые слова: грудное вскармливание; новорожденные; межрайонные центры родовспоможения; детские молочные смеси. Научно-практический рецензируемый журнал «Современные проблемы здравоохранения и медицинской статистики» 2020 г., № 1 Scientific journal «Current problems of health care and medical statistics» 2020 г., № 1 Background. Breastfeeding organization has not yet been evaluated in obstetric care facilities in Russia. Infant formula are prescribed to healthy newborn. Aim of the study: to assess the effectiveness of the organization of breastfeeding and the practice of using infant formula in inter-district centers (II level) for obstetric care in the Arkhangelsk region (North-West Russia). Materials and methods. A statistical study by the method of documentary observation was done. We used the data of medical statistical reporting form No. 32 "Information on the regionalization of obstetric and perinatal care in maternity hospitals (departments) and perinatal centers " (insert to form No. 32-B, table 1000) of 8 inter-district centers (II level) for obstetric care of the Arkhangelsk region for 2013-2017. Data on using infant formula by medical workers were collected separately; indicators "average consumption of infant formula (in kg) per 1 newborn" were calculated. Method of descriptive statistics, analytic method were used in this study. Results. In 2013-2017 the proportion of normal births in inter-district centers (II level) for obstetric care in the Arkhangelsk region increased from 26.5% to 35.4% respectively; the coverage of newborns by exclusively breastfeeding decreased from 94.9% to 89.6% respectively. The total consumption of infant formula decreased by 1.6% (from 236.7 kg in 2013 to 233.0 kg in 2017). The average consumption of infant formula per 1 newborn increased by 60.7% (from 0.028 kg in 2013 to 0.045 kg in 2017). Conclusions. Reduction in the coverage of newborns by exclusively breastfeeding and increase in the average consumption of infant formula per newborn, indicate the violation of principles of neonatal care; and determine the need to change approaches to the newborns' feeding organization in the early neonatal period.
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To determine the association between human milk (HM) intake and risk of necrotizing enterocolitis (NEC) or death among infants 401 to 1000 g birth weight. Analysis of 1272 infants in the National Institute of Child Health and Human Development Neonatal Network Glutamine Trial was performed to determine if increasing HM intake was associated with decreased risk of NEC or death. HM intake was defined as the proportion of HM to total intake, to enteral intake and total volume over the first 14 days. Known NEC risk factors were included as covariates in Cox proportional hazard analyses for duration of survival time free of NEC. Among study infants, 13.6% died or developed NEC after 14 days. The likelihood of NEC or death after 14 days was decreased by a factor of 0.83 (95% confidence interval, CI 0.72, 0.96) for each 10% increase in the proportion of total intake as HM. Each 100 ml kg(-1) increase in HM intake during the first 14 days was associated with decreased risk of NEC or death (hazard ratio, HR 0.87 (95% CI 0.77, 0.97)). There appeared to be a trend towards a decreased risk of NEC or death among infants who received 100% HM as a proportion to total enteral intake (HM plus formula), although this finding was not statistically significant (HR 0.85 (95% CI 0.60, 1.19)). These data suggest a dose-related association of HM feeding with a reduction of risk of NEC or death after the first 2 weeks of life among extremely low birth weight infants.
Article
To evaluate factors associated with initiation and duration of breastfeeding in Italy, 1601 (73%) respondents among 2192 randomly selected mothers were interviewed within 1 mo of delivery. Mothers who started breastfeeding (85%) were followed-up for 12 mo. A compliance rate of 100% was obtained. At multiple logistic regression analysis, mother having been breastfed herself (p < 0.01), nursing guidance in the maternity ward (p = 0.01) and higher social class (p = 0.03) were positively associated with initiation of breastfeeding. We found that 42%, 19%, 10% and 4% mothers were still breastfeeding at 3, 6, 9 and 12 mo after delivery, respectively. Cox multiple regression analysis showed a negative association between duration of breastfeeding and pacifier use (p < 0.01), and a positive association with a higher level of maternal education (p = 0.04). Formula supplementation in the maternity ward (given to 30% of infants) was associated with a shorter duration of exclusive breastfeeding (p = 0.03). Mothers need support with breastfeeding, particularly those from lower social backgrounds and with lower levels of education. Early use of the pacifier should be discouraged.
Article
Problem Breastfeeding rates and related hospital practices need improvement in Italy and elsewhere. Training of staff is necessary, but its effectiveness needs assessment. Context Eight hospitals in different regions of Italy. Design Controlled, non-randomised study. Data collected in three phases. Training after the first phase ill group 1 hospitals and after the second phase in group 2. Strategies for change Training of trainers and Subsequent training Of health workers with a slightly adapted version of the 18 hour Unicef Course Oil breastfeeding management and promotion. Key measures for improvement Hospital practices, knowledge of 571 health workers, and breastfeeding rates at discharge, three, and six months in 2669 mother and baby pairs. Effects of change After training hospitals improved their compliance with the "ten steps to successful breast feeding," from an average of 2.4 steps at phase one to 7.7 at phase three. Knowledge scores of health professionals increased from 0.41 to 0.72 in group 1 (training after phase one) and from 0.53 to 0.75 in group 2 (after phase two). The rate of exclusive breast feeding at discharge increased significantly after training: 41% to 77% in group 1 mid 23% to 73% in group 2, as did the rates of full (exclusive plus predominant) breast feeding at three months (37% to 50% in group 1 v 40% to 59% in group 2) and any breast feeding at six months (43% to 62% in group 1 v 41% to 64% in group 2 ). Lessons learnt Training for at least three days with a course including practical sessions and counselling skills is effective in changing hospital practices, knowledge of health workers, and breastfeeding rates.
Article
Self-selection in epidemiological studies may introduce selection bias and influence the validity of study results. To evaluate potential bias due to self-selection in a large prospective pregnancy cohort in Norway, the authors studied differences in prevalence estimates and association measures between study participants and all women giving birth in Norway. Women who agreed to participate in the Norwegian Mother and Child Cohort Study (43.5% of invited; n = 73 579) were compared with all women giving birth in Norway (n = 398 849) using data from the population-based Medical Birth Registry of Norway in 2000–2006. Bias in the prevalence of 23 exposure and outcome variables was measured as the ratio of relative frequencies, whereas bias in exposure-outcome associations of eight relationships was measured as the ratio of odds ratios. Statistically significant relative differences in prevalence estimates between the cohort participants and the total population were found for all variables, except for maternal epilepsy, chronic hypertension and pre-eclampsia. There was a strong under-representation of the youngest women (<25 years), those living alone, mothers with more than two previous births and with previous stillbirths (relative deviation 30–45%). In addition, smokers, women with stillbirths and neonatal death were markedly under-represented in the cohort (relative deviation 22–43%), while multivitamin and folic acid supplement users were over-represented (relative deviation 31–43%). Despite this, no statistically relative differences in association measures were found between participants and the total population regarding the eight exposure-outcome associations. Using data from the Medical Birth Registry of Norway, this study suggests that prevalence estimates of exposures and outcomes, but not estimates of exposure-outcome associations are biased due to self-selection in the Norwegian Mother and Child Cohort Study.
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Infant feeding decisions affect maternal and child health outcomes, worldwide. Even in settings with clean water and good sanitation, infants who are not breast-fed face an increased risk of infectious, as well as non-infectious morbidity and mortality. The decision not to breast-feed can also adversely affect mothers' health by increasing the risk of pre-menopausal breast cancer, ovarian cancer, type II diabetes, hypertension, hyperlipidemia and cardiovascular disease. Clinicians who counsel mothers about the health impact of infant feeding and provide evidence-based care to maximize successful breast-feeding, can improve the short and long-term health of both mothers and infants.
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Firstly, this review was performed to assess the effect of breastfeeding on infections during infancy in industrialized countries. Secondly, the effect of duration and exclusiveness of breastfeeding were explored. Studies were identified using Medline, Cochrane Library, Science Citation Index and by a manual search from bibliographies of articles from August 1986 to January 2008. Follow-up, case-control and randomized controlled trial (RCT) studies performed in an industrialized country, published in English, with breastfeeding as a determinant, with overall infections, gastrointestinal or respiratory tract infections as a major outcome, and at least 40 participants in the study were included. Using Bauchner's criteria published in a review in 1986, two reviewers and a peer reviewer assessed the internal validity of those studies. Twenty-one studies that met the inclusion and internal validity criteria were included. These included 16 follow-up and four case-control studies and one RCT. Four out of five studies observed decreased effects on overall infections in breastfed infants. With regard to gastrointestinal infections, six out of eight studies suggested that breastfeeding had a protective effect. Thirteen out of 16 studies concluded that breastfeeding protects infants against respiratory tract infections. Five studies combined duration and exclusiveness of breastfeeding. All studies observed a protective dose/duration-response effect on gastrointestinal or respiratory tract infections. These studies strongly suggest that breastfeeding protects infants against overall infections, gastrointestinal and respiratory tract infections in industrialized countries. The optimal duration of exclusive breastfeeding for protection against infectious diseases needs to be studied in more detail.
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Milk banks in Norway have a long tradition of using raw milk. This is a practice the authors hope to continue as they see it as the best choice until a child's own mothers' milk production is sufficient. Not only will the premature babies benefit from having milk from the bank, but if a mother, for any reason, can not supply her baby while it's in the hospital her baby should be offered milk from a bank. In Norway, with a high breastfeeding rate this can be done at many hospitals. J Hum Lact. 25(2):206-210
Article
We sought to assess whether breastfeeding-related hospital practices reported by mothers were associated with achievement of their intentions to exclusively breastfeed. We used data from Listening to Mothers II, a nationally representative survey of 1573 mothers who had given birth in a hospital to a singleton in 2005. Mothers were asked retrospectively about their breastfeeding intention, infant feeding at 1 week, and 7 hospital practices. Primiparas reported a substantial difference between their intention to exclusively breastfeed (70%) and this practice at 1 week (50%). They also reported hospital practices that conflicted with the Baby-Friendly Ten Steps, including supplementation (49%) and pacifier use (45%). Primiparas who delivered in hospitals that practiced 6 or 7 of the steps were 6 times more likely to achieve their intention to exclusively breastfeed than were those in hospitals that practiced none or 1 of the steps. Mothers who reported supplemental feedings to their infant were less likely to achieve their intention to exclusively breastfeed: primiparas (adjusted odds ratio [AOR] = 4.4; 95% confidence interval [CI] = 2.1, 9.3); multiparas (AOR = 8.8; 95% CI = 4.4, 17.6). Hospitals should implement policies that support breastfeeding with particular attention to eliminating supplementation of healthy newborns.
Article
Factors influencing early formula supplementation in breast-fed neonates were examined among 726 women who were delivered of their first child in one of three metropolitan Washington, DC, hospitals. Thirty-seven percent of breast-fed neonates were given supplementary formula in the hospital. Mothers who gave birth at a university hospital were more likely to breast-feed exclusively (adjusted odds ratio 3.5; 95% confidence limit 2.1 to 5.9), after adjustment for maternal demographics, hospital factors (such as time of first breast-feed, demand feeding, delivery type, and rooming-in), and the maternal breast-feeding commitment. Aside from delivery hospital, a strong predictor of formula use was the time between birth and initiation of the first breast-feed. The longer a mother waited to initiate breast-feeding the more likely she was to use formula; the adjusted odds ratios for women who initiated breast-feeding 2 to 6 hours, 7 to 11 hours, and 12 or more hours postpartum were 1.1, 0.5, and 0.2, respectively. Feeding the baby on demand, having a vaginal delivery, deciding to breast-feed before pregnancy, having a college education, and being married also were moderately, though significantly, predictive of exclusive breast-feeding. The findings suggest that hospital influences can promote formula use and indirectly shorten breast-feeding duration, particularly those hospital practices that delay early initiation of breast-feeding.