Breastfeeding and Infant Feeding

Feeding practices during the first year of life are important because they lay the foundation for food consumption throughout the life and influence subsequent growth, development, and morbidity.⁴⁵

Breastfeeding

Healthy People 2010 Goal

Increase the proportion of mothers who breastfeed their babies

•  in the early postpartum period from 64% to 75%
•  at 6 months from 29% to 50%
• at 1 year from 16% to 25%⁷

Advantages of Breastfeeding

Breastfeeding is the preferred method of infant feeding, providing optimal nutrition with all required nutrients in the right form and amount, along with many other health benefits.⁴⁶ 

Breastfeeding: 

• Provides infants with biologically active components formula does not contain.  For example, breastmilk contains leptin, a hormone that plays a role in energy regulation and utilization in the fasting state and affects angiogenesis, wound healing, hematopoiesis, bone metabolism systems, and the neuroendocrine and immune systems.⁴⁷ 
• provides immunological benefits resulting in less infant illness^{46,48,49,50,51,52,} decreased health care expenditures ^53,54,55 and decreased maternal absenteeism from work.^49,56
• Costs less than formula feeding.^55,57 
• develops a special maternal-infant bond.⁵⁸  
• may decrease risk of breast cancer.^59,60,61 
• may protect against the development of childhood and adolescent obesity ^62,63,64
• Provides exposure to the flavors of the maternal diet, which may facilitate acceptance of solid foods ^65,66

Breastfeeding Prevalence

Breastfeeding rates increased from 1989 to 1995.  The increases were greatest among women least likely to breastfeed:

• African American mothers
• younger (< 25 years of age) mothers
• low income mothers
• first time mothers
• grade school educated mothers
• mothers living in the South Atlantic region
• mothers of low birth weight infants
• mothers who participated in WIC ^67,68

Breastfeeding in the Hospital and at 6 months of Age by Race, 1989-1995

Ryan AS. (1997) The resurgence of breastfeeding in the United States. Pediatrics. 99(4)  http://www.pediatrics.org/cgi/content/full/99/4/e12

Factors Influencing Decision to Breastfeed

Most women make the decision on whether to breast or bottle feed before birth.  This decision is usually the infant feeding method that the mother practices.⁶⁹ 

The decision whether to breastfeed stems from a variety of factors including cultural community, and familial values, norms, and support networks.⁶⁹

The most important member of the social support network for Black women was close friends, while for white and Hispanic women male partners and maternal mothers were most important.^67,69  Support from the baby's father influenced not only the initiation of breastfeeding but also the duration of breastfeeding.⁶⁹  Other factors influencing the decision regarding infant feeding method include prenatal education, peer counseling, and support from non-health care professionals.^58,67,70,71  Mothers who are given positive advice about breastfeeding are much more likely to breastfeed.⁶⁹  

Mothers choosing to formula feed tend to concentrate primarily on how the decision will affect them especially with regards to the mechanics of feeding (e.g. convenience, comfort, assistance with feeding).  In contrast, the primary issue for mothers choosing to breastfeed is for the baby's well-being (i.e. providing the healthiest nutrients and promoting a strong bond with the infant).⁶⁹

Breastfeeding Adolescents

Rates of breast feeding are lower for minority adolescents, especially African Americans.  In one study, Latina and African American adolescent mothers demonstrated an understanding of the benefits of breastfeeding.

Although maternal infant bonding was an important reason for breastfeeding, some expressed apprehension that the baby would get too attached to them.

Benefits of breastfeeding appear to be less salient for those who decided to formula feed and some even questioned the accuracy of the benefits.  Factors influencing Latina and African American adolescents infant feeding method decision included:

• Perception that breastfeeding was painful.
• discomfort with breastfeeding, especially in public;  "nasty," "embarrassing," and "attention seeking" expressed teen's feelings about breastfeeding in public.
• Social support network, including the teen's mother, health care professionals, friends, relatives, teachers, and baby's father; however, most viewed the decision as ultimately theirs. 
• Breastfeeding myths
• Certain foods (such as chocolate, orange juice, corn, and greens) must be eliminated from the diet.
• emotions affect the breast milk (Latina adolescents).
• Health benefits for the infant.
• Promotion of mother-infant bonding.

Barriers to continuing breastfeeding once initiated included

• problems faced by many new breastfeeding mothers such as
  • pain
  • difficulty learning techniques of positioning and latch-on
  • fatigue
  • medical complications
• returning to school.⁷²

Infant Feeding Practices

Basic Infant feeding Guidelines ^51,73,74

1. Breastmilk or iron-fortified infant formula for the first 12 months.
2. Solid foods should be added to the infant's diet at 4-6 months of age when
1. the infant can sit with support and has the head and trunk control to indicate desire for food by opening his mouth and leaning forward and satiety by leaning back or away from food.
2. the extrusion reflex has disappeared. 
3. Solid foods should be offered by spoon, not in the bottle.
4. Foods high in added sugar such as fruit drinks, soda, and baby food desserts and other sweets should be avoided.
5. Transition to a modified adult diet should occur gradually over the second six months of life.
6. Cup should be introduced by about 6 months of age.
7. Infants and toddlers should not have continuous access to a bottle throughout the day or be put to bed with a bottle, as this increases risk of early childhood caries.  Additionally, excessive intake of caloric liquids can decrease appetite for solid foods.
8. Infant should be weaned from the bottle at about one year of age.

Early introduction to solids increases risk of allergies and insulin dependent diabetes in susceptible infants, poor nutrient absorption, diarrhea, and aspiration with coughing and gagging.  Early introduction to solids can be considered  "force feeding" of infant who is developmentally not ready and thus cannot convey satiety.  Late introduction of solids may result in inadequate energy, vitamin, and mineral intake to support optimal growth, and difficulty accepting solids later due to missed developmental milestones.⁷³

Ethnic variations in infant feeding practices

Ethnicity has been reported to influence the age when mothers introduce solid foods to their infants in several but not all studies of infant feeding practices.⁷⁵ 

Age at introduction to solids reflects social, cultural, and economic factors.  The practice of putting a baby to bed with a bottle varies by ethnicity. ⁷⁶

Asian/Pacific Islander Infant Feeding Practices

In Hawaii, early introduction to water, use of sweetened beverages and baby-food desserts; delayed introduction to a cup; early introduction to solid foods; use of baby-food dinners; and delayed progression to table foods was common and differed by ethnicity.  

Percent of mothers, according to ethnic group, who introduced food item at recommended time, 1990 Hawaii Infant Feeding Survey

^*a Popular fruit-flavored sugar syrup

(Source: Goldberg DL, Novotny R, Kieffer E, Mor J, Thiele M. (1995) Complementary feeding and ethnicity of infants in Hawaii. J Am Diet Assoc. 95:1029-1031.)

African American Infant Feeding Practices

Early introduction to solids, feeding cereal in a bottle, and early introduction to juice are common infant feeding practices among African American women.^45,77,78,79  In one study, low income African American mothers revealed that 32% had introduced some solids by 7 to 10 days postpartum and 77% at 8 weeks postpartum.⁴⁵ 

Factors associated with early introduction to solids included

• maternal age less than 19 at 10 days postpartum.
• employment or returning to school at 8 weeks postpartum.
• formula feeding at 8 weeks.45

Reasons for early introduction of solids ^77,78,79

• Infant shows signs of hunger (e.g., drinks vigorously).
• Infant's small size.
• To help infant sleep better.
• Infant cries or is irritable.
• To improve infant's health (prevent illness).
• Infant signals a disinterest in breastmilk or formula.
• Infant signals an interest in food.
• Lack of confidence in formula.
• Complementary food cleans infant's mouth from formula.
• Mother wants to try something new.
• Infants of this age need food or are ready for food.
• Others recommend giving water/solid foods.
• It is believed a fat baby is a healthy baby.
• Eagerness to have the infant eat solid foods as soon as possible.
• Advice from family member, especially grandmother.

Reasons for adding cereal to the bottle with the formula were the beliefs that

• Milk does not satisfy the infant's hunger or nutrition needs.
• Cereal promotes absorption of the milk by thickening the formula and slowing down its progress through the body ^45,79

Some African American mothers felt that eating "real food" was important and reported pre-masticating food.⁴⁵  Many also believed that the infant's nutritional needs were the same as their own.