Characteristics of breastfeeding practices Katherine Shealy,¹ MPH, IBCLC, RLC Judith Labiner-Wolfe,² PhD Sara Fein,² PhD Laurence Grummer-Strawn,¹ PhD ¹ Centers for Disease Control and Prevention ² Food and Drug Administration

Background Health professionals providing breastfeeding education infrequently observe normal and effective breastfeeding (in its ‘natural habitat’) Anticipatory guidance provided about breastfeeding may not reflect actual experiences of breastfeeding dyads Experiences that are inconsistent with teaching points given to pregnant women and new mothers about breastfeeding can be confusing and discouraging

Background, continued Social Cognitive Theory suggests that dissonance between behavioral expectations and actual experience would lead to termination of the behavior Little research exists documenting typical breastfeeding over time Infants who only receive breast milk when it is expressed and fed by bottle (exclusive pumping, or EP) have not previously been documented as a population

Objectives Describe major characteristics of typical breastfeeding education Identify the major aspects of breastfeeding behavior related to individual practices and patterns over time

Data characteristics Characteristics of breastfeeding behaviors – Detailed information was gathered in each survey as long as respondents indicated they were still breastfeeding A more detailed breastfeeding module was also completed once per respondent upon termination of breastfeeding

Data characteristics Sample cohort consists of breastfeeding mothers at each sample period m2 n=1466, m12 n=462 Includes mothers who are: Exclusively breastfeeding Breastfeeding & formula-feeding Breastfeeding & complementary feeding Breastfeeding, formula-feeding, & complementary feeding

Percent of women who met their own breastfeeding goal* Yes No *Self-reported answer of “yes” to the question: “Did you breastfeed as long as you wanted to?”

Typical breastfeeding education Teaches how-to & biology of breastfeeding Includes anticipatory guidance re: Frequency of feeds per day Always feed both breasts at each feed Length of feeds Inter-feed interval Fosters sense of uniformity and predictability across all breastfeeding dyads Generally does not address variation among individuals

Clinical Experience Clinicians note wide variation among healthy, adequately nourished dyads in: Frequency of feeds per day Always feed both breasts at each feed Length of feeds Inter-feed interval Predictability is that there can be wide variation from one dyad to another

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Mean breastfeedings per day by survey month 5th Percentile 95th Percentile Neonatal 9 6 13 m2 8 5 12 m3 m4 m5 7 4 10 m6 m7 m9 3 m10 2 m12 1

Infant typically nursed from both breasts by survey month 64% 57% 41% 29% 6% 2%

Average length of feeds by survey month

Mean longest interval between feeds per 24h by survey month

Conclusions Although most women in the sample began breastfeeding, the majority did not meet their own breastfeeding goals Current anticipatory guidance may not match actual experiences of breastfeeding dyads Anticipatory guidance that matches actual experiences may help women feel more successful at breastfeeding and play a part in helping women meet their own breastfeeding goals Unclear if dissonance reflects pathology or normal variation – further exploration needed

Conclusions, continued Frequency of feeds/day diminishes gradually, still a factor during complementary feeding Proportion of infants typically nursing one side increases over time, while those typically nursing both sides at a feed remains relatively stable Possible because those receiving only pumped milk also slightly declined Small but consistent percentage of infants receive breast milk only when it is expressed and fed by bottle Mean length of feeds decreases across the year Longest interval between feeds doubles over the first year

Conclusions, continued Advice versus experience Most mothers begin breastfeeding 8-12 times per 24 hours, consistent with professional advice Many dyads continue high-frequency feeds past when professional advice would anticipate Better understanding of dissonance between advice and experience can improve breastfeeding outcomes and maternal child health

Thank You Contact information: Katherine Shealy, MPH, IBCLC, RLC kshealy@cdc.gov http://www.cdc.gov/breastfeeding