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OBJECTIVE: We characterized breastfeeding concerns from open-text maternal responses and determined their association with stopping breastfeeding by 60 days (stopping breastfeeding) and feeding any formula between 30 and 60 days (formula use). METHODS: We assessed breastfeeding support, intentions, and concerns in 532 expectant primiparas and conducted follow-up interviews at 0, 3, 7, 14, 30, and 60 days postpartum. We calculated adjusted relative risk (ARR) and adjusted population attributable risk (PAR) for feeding outcomes by concern category and day, adjusted for feeding intentions and education. RESULTS: In 2946 interviews, 4179 breastfeeding concerns were reported, comprising 49 subcategories and 9 main categories. Ninety-two percent of participants reported ≥1 concern at day 3, with the most predominant being difficulty with infant feeding at breast (52%), breastfeeding pain (44%), and milk quantity (40%). Concerns at any postpartum interview were significantly associated with increased risk of stopping breastfeeding and formula use, with peak ARR at day 3 (eg, stopping breastfeeding ARR [95% confidence interval] = 9.2 [3.0–infinity]). The concerns yielding the largest adjusted PAR for stopping breastfeeding were day 7 “infant feeding difficulty” (adjusted PAR = 32%) and day 14 “milk quantity” (adjusted PAR = 23%). CONCLUSIONS: Breastfeeding concerns are highly prevalent and associated with stopping breastfeeding. Priority should be given to developing strategies for lowering the overall occurrence of breastfeeding concerns and resolving, in particular, infant feeding and milk quantity concerns occurring within the first 14 days postpartum.

OBJECTIVE: To estimate the global burden of malnutrition and highlight data on child feeding practices and coverage of key nutrition interventions. METHODS: Linear mixed-effects modeling was used to estimate prevalence rates and numbers of underweight and stunted children according to United Nations region from 1990 to 2010 by using surveys from 147 countries. Indicators of infant and young child feeding practices and intervention coverage were calculated from Demographic and Health Survey data from 46 developing countries between 2002 and 2008. RESULTS: In 2010, globally, an estimated 27% (171 million) of children younger than 5 years were stunted and 16% (104 million) were underweight. Africa and Asia have more severe burdens of undernutrition, but the problem persists in some Latin American countries. Few children in the developing world benefit from optimal breastfeeding and complementary feeding practices. Fewer than half of infants were put to the breast within 1 hour of birth, and 36% of infants younger than 6 months were exclusively breastfed. Fewer than one-third of 6- to 23-month-old children met the minimum criteria for dietary diversity, and only ∼50% received the minimum number of meals. Although effective health-sector–based interventions for tackling childhood undernutrition are known, intervention-coverage data are available for only a small proportion of them and reveal mostly low coverage. CONCLUSIONS: Undernutrition continues to be high and progress toward reaching Millennium Development Goal 1 has been slow. Previously unrecognized extremely poor breastfeeding and complementary feeding practices and lack of comprehensive data on intervention coverage require urgent action to improve child nutrition.

OBJECTIVES: The objectives were to describe weight loss in a multiethnic population of first-born, predominantly breastfed, term infants and to identify potentially modifiable risk factors for excess weight loss (EWL). METHODS: Data on prenatal breastfeeding intentions, demographic characteristics, labor and delivery interventions and outcomes, breastfeeding behaviors, formula and pacifier use, onset of lactogenesis, and nipple type and pain were collected prospectively. Logistic regression analyses identified independent predictors of EWL (≥10% of birth weight) by using a preplanned theoretical model. RESULTS: EWL occurred for 18% of infants who received no or minimal (≤60 mL total since birth) formula (n = 229), including 19% of exclusively breastfed infants (n = 134) and 16% of infants who received minimal formula (n = 95). In bivariate analyses, EWL was associated (P < .05) with higher maternal age, education, and income levels, hourly intrapartum fluid balance, postpartum edema, delayed lactogenesis (>72 hours), fewer infant stools, and infant birth weight. In multivariate logistic regression analysis, only 2 variables predicted EWL significantly, namely, intrapartum fluid balance (adjusted relative risk for EWL of 3.18 [95% confidence interval [CI]: 1.35–13.29] and 2.80 [95% CI: 1.17–11.68] with net intrapartum fluid balance of >200 and 100–200 mL/hour, respectively, compared with CONCLUSIONS: EWL was more common in this population than reported previously and was independently related to intrapartum fluid balance. This suggests that intrapartum fluid administration can cause fetal volume expansion and greater fluid loss after birth, although other mechanisms are possible.

Objective. Some mothers have difficulty initiating lactation even when highly motivated to breastfeed. The purpose of this study was to determine the incidence of and risk factors for suboptimal infant breastfeeding behavior (SIBB), delayed onset of lactation, and excess neonatal weight loss among mother-infant pairs in a population with high educational levels and motivation to breastfeed.Methods. All mothers residing in Davis, California, who gave birth to a healthy, single, term infant at 1 of 5 area hospitals during the 10-month recruitment period in 1999 were invited to participate if they were willing to attempt to breastfeed exclusively for at least 1 month. Lactation guidance was provided and data were collected in the hospital (day 0) and on days 3, 5, 7, and 14. Infant breastfeeding behavior was evaluated by trained lactation consultants using the Infant Breastfeeding Assessment Tool. Onset of lactation was defined based on maternal report of changes in breast fullness. Infant weight loss was considered excessive if it was ≥10% of birth weight by day 3.Results. Of the 328 eligible mothers, 280 (85%) participated in the study. The prevalence of SIBB was 49% on day 0, 22% on day 3, and 14% on day 7. SIBB was significantly associated with primiparity (days 0 and 3), cesarean section (in multiparas, day 0), flat or inverted nipples, infant status at birth (days 0 and 3), use of nonbreast milk fluids in the first 48 hours (days 3 and 7), pacifier use (day 3), stage II labor >1 hour (day 7), maternal body mass index >27 kg/m2 (day 7) and birth weight 72 hours) occurred in 22% of women and was associated with primiparity, cesarean section, stage II labor >1 hour, maternal body mass index >27 kg/m2, flat or inverted nipples, and birth weight >3600 g (in primiparas). Excess weight loss occurred in 12% of infants and was associated with primiparity, long duration of labor, use of labor medications (in multiparas), and infant status at birth. The risk of excess infant weight loss was 7.1 times greater if the mother had delayed onset of lactation, and 2.6 times greater if the infant had SIBB on day 0.Conclusions. Early lactation success is strongly influenced by parity, but may also be affected by potentially modifiable factors such as delivery mode, duration of labor, labor medications, use of nonbreast milk fluids and/or pacifiers, and maternal overweight. All breastfeeding mother-infant pairs should be evaluated at 72 to 96 hours’ postpartum.

The sample sizes of infants from the selected studies are shown in Tables 2-4, categorized by duration of breast-feeding, timing of introduction of solid foods, and use of infant formula or other milks. Table 5 shows the cross-tabulation by duration of breast-feeding and age of introduction of supplemental milk or formula. In total, 453 infants were included, of whom 226 were breast-fed for at least 12 months. Of these 226, 141 were not regularly given other milks or formula during the first year of life. Of the total sample, solid foods were introduced at 4 to 5 months to 42% (Table 3), at 6 to 7 months to 38%, at 8 to 9 months at 17%, and after 9 months to 2%. The samples were relatively homogeneous with respect to average maternal weight, height, and age. Mean pregnancy weight gain in the three studies reporting this ranged from 12.7 to 15.0 kg. Maternal educational levels were generally high: in the studies reporting this as a continuous variable, the overall mean was 15.4 ± 2.4 years of education. Mean birth weight ranged from 3414 to 3605 g. Characteristics of infants categorized by breast-feeding duration are shown in Table 6 (the group breast-fed for 4 to 5 month is not shown, because there were only 10 infants in this category). Mothers who breast-fed for 12 or more months were older and had higher parity and educational levels than mothers who breast-fed for less than 12 months, but birth weight did not differ significantly among groups.

Objectives. To evaluate the impact of introducing complementary foods to exclusively breast-fed infants at 4 vs 6 months on growth from 6 to 12 months, and to compare growth patterns of Honduran infants with those of breast-fed infants in the United States. Design. Randomized intervention trial from 4 to 6 months and longitudinal study of infants from birth to 12 months. Setting. Low-income communities in San Pedro Sula, Honduras. Subjects. Primiparous, breast-feeding mothers and their infants (n = 141) recruited from public maternity hospitals. Intervention. Infants were randomly assigned to exclusive breast-feeding to 6 months, or exclusive breast-feeding with addition of hygienically prepared, nutritionally adequate complementary foods at 4 months, with or without maintenance of baseline breast-feeding frequency. After 6 months, mothers continued to breast-feed and also fed their infants home-prepared foods after receiving instruction in appropriate feeding practices. Outcome Measures. Infant weight was measured monthly during the first year of life and infant length monthly from 4 to 12 months. Statistical Analysis. Growth parameters were compared between the Honduran and US cohorts using multiple-regression and repeated-measures analysis of variance. Stepwise multiple regression was used to identify determinants of infant growth. Results. There were no differences in growth patterns by intervention group. Mean birth weight of the Honduran infants was significantly less than that of a cohort of breast-fed infants in an affluent US population (n = 46) (2889 ± 482 vs 3611 ± 509 g), but the Honduran infants exhibited rapid catch up in weight in the first few months of life, and the cohorts were similar in weight by 3 months. Mean weight and length gain were similar to those of the US cohort from 4 to 9 months but were lower from 9 to 12 months. Mean length for age was significantly less than that of the US cohort from 4 to 12 months; this was attributable to the difference in maternal height (12 cm shorter in Honduras on average). Within the Honduran cohort, growth velocity of low birth weight infants ( Conclusions. In poor populations, when breast-feeding is exclusive for the first 4 to 6 months, continues from 6 to 12 months, and is accompanied by generally adequate complementary foods, faltering in weight does not occur before 9 months among infants born with birth weights of more than 2500 g.

Anthropometric data were collected monthly from birth to 18 months as part of the Davis Area Research on Lactation, Infant Nutrition and Growth study, which followed infants who were either breast-fed or formula-fed during the first 12 months. The two cohorts were matched for parental socioeconomic status, education, ethnic group, and anthropometric characteristics and for infant sex and birth weight, and neither group was given solid foods before 4 months. While mean weight of formula-fed infants remained at or above the National Center for Health Statistics median throughout the first 18 months, mean weight of breast-fed infants dropped below the median beginning at 6 to 8 months and was significantly lower than that of the formula-fed group between 6 and 18 months. In contrast, length and head circumference values were similar between groups. Weight-for-length z scores were significantly different between 4 and 18 months, suggesting that breast-fed infants were leaner. The groups had similar weight gain during the first 3 months, but breast-fed infants gained less rapidly during the remainder of the first year: cumulative weight gain in the first 12 months was 0.65 kg less in the breast-fed group. Length gain was similar between groups. These results indicate that weight patterns of breast-fed infants, even in a population of high socioeconomic status, differ from current reference data and from those of formula-fed infants. Thus, new growth charts based on breast-fed infants are needed.

Factors related to milk volume and sources of variance in intake were examined using data at 3 months from the longitudinal Davis Area Research on Lactation, Infant Nutrition and Growth study. Milk intake of 73 exclusively breast-fed infants was measured by 4-day test-weighing, correcting for insensible water loss. Total volume extracted was assessed by a combination of test-weighing and expression of breast contents during a subsequent 24-hour period. Residual milk volume was calculated as volume extracted minus intake. Intake, volume extracted, and residual milk volume averaged 818, 914, and 109 g/d, respectively. The interindividual coefficient of variation in intake (16.3%) was greater than within-individual day-to-day variation (8.9%). In comparing those with low (

To the Editor.— Although we find the study of Wallace et al1 interesting, we are concerned that their finding of decreased infant acceptance of postexercise breast milk due to increased lactic acid concentration will be misinterpreted to mean that there are disadvantages to exercising during lactation. It is important to emphasize that the subjects in their study underwent a maximum exercise test before collection of breast milk samples. Lactic acid levels in milk are likely to be much higher following maximum exercise than they would be after the more moderate levels of exercise needed to maintain fitness and enhance weight loss.

It is generally not difficult to meet protein requirements during the period of complementary feeding; in fact, there are concerns that in affluent populations protein intakes during infancy may be excessive. A recent report prepared for the International Dietary Energy Consultative Group1 reviewed protein and amino acid requirements of infants and children and reached …

A key question that has been inadequately explored is: to what extent does or might complementary feeding affect breast milk intake and total breastfeeding duration? We assume that maintaining breastfeeding is desirable, but in designing interventions to improve complementary feeding, the potential impact on breastfeeding frequency and breast milk intake is often ignored. To understand this issue, one needs to recognize what is already known: a. Recent estimates of the energy needs of infants, based on energy expenditure data,1 are 9% to 39% lower than previous estimates. The average requirements for breastfed infants, who require less energy than formula-fed infants, are 80 to 90 kcal/kg/d depending on age. Providing too much energy from complementary foods may result in a low …

WHO1,2 recommends exclusive breastfeeding during the first 4–6 months of life but limited information is available regarding the growth of infants fed according to the recommendation. The present study used data from the Euro-Growth Study to determine the growth of breastfed European infants who did or did not receive complementary foods from an early age, in comparison to growth of infants receiving formula before the age of 4 months. ### Study Population and Methods The Euro-Growth Study was a longitudinal, multicenter study using standardized methodology. Healthy term infants between 37 and 44 weeks' gestational age weighing >2500 g at birth3 were enrolled before 30 days of age. The cohort consisted of 2145 children from 21 study sites, who visited the study centers regularly up to 36 months of age for anthropometric measurements and for collection of nutritional data. Infants were …