BF: Artificial Nipple and Duration of Breastfeeding (2008)

Citation:

Chaves RG, Lamounler JA, Cesar CC. Factors associated with the duration of breastfeeding, J Pediatr (Rio J) 2007; 83 (3): 241-246. 

PubMed ID: 17486198
 
Study Design:
Longitudinal cohort
Class:
B - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To determine rates of exclusive breastfeeding and of complementary feeding
  • To identify variables that may interfere with breastfeeding practices in Itauna, MG, Brazil. 
Inclusion Criteria:

Women giving birth at the maternity unit of the Manoel Goncalves de Souza Moreira Hospital (Itauna, Brazil). 

Exclusion Criteria:

None reported.

Description of Study Protocol:

Recruitment

Not reported

Design

Longitudinal cohort: Moms and babies followed for the first 12 months after birth, or until breastfeeding ceased (whichever took place first)

Statistical Analysis

Survival analysis procedures applied to duration of exclusive breastfeeding and breastfeeding; breastfeeding curves plotted (Kaplan-Mayer method) and compared using log rank testing. Effects of co-variables on breastfeeding duration using Cox regression modeling (included in multivariate analysis if correlation had an outcome P<0.25). Significance level 5%.

Data Collection Summary:

Timing of Measurements

Pilot study conducted first; questionnaire data collected from 20 women at maternity unit by researcher and assistants; quality control measures carried out weekly for eight weeks, then fortnightly after eight weeks. 

Data collected from medical records and from interviews during immediate post-natal period in the maternity unit. After discharge, mothers were followed-up with via telephone or home visits for data collection interviews.

Dependent Variables

Breastfeeding status (WHO):

  • Exclusive breastfeeding: Child fed human milk exclusively, no other liquids or solids
  • Predominant breastfeeding: Child is fed human milk and other liquids (water, teas, juices, medications), no other types of milk
  • Full breastfeeding: Exclusive breastfeeding plus predominant breastfeeding
  • Complementary feeding: Child is fed human milk plus other solid or semi-solid foods
  • Breastfeeding: Child is fed human milk, irrespective of whether or not other foods are also given
  • Full weaning: Complete cessation of breastfeeding

Independent Variables

  • Origin, skin color
  • Health insurance, pre-natal care
  • Maternal age
  • Marital status
  • Breast surgery
  • Number of pregnancies and births
  • Gestational age, sex, birth weight of child
  • Family income, electricity consumption, sanitation
  • Maternal and paternal education
  • Maternal employment, maternity leave
  • Family support
  • Knowledge of breastfeeding techniques, intention of breastfeeding
  • Time passed between birth and first breastfeed
  • Use of medication, alcohol, tobacco by mom
  • Intervurrent conditions
  • Use of pacifier

Control Variables

Timing of measurements

Description of Actual Data Sample:

 

Initial N

246 women

Attrition (final N)

155 women

Age

Not reported

Ethnicity

Not reported

Other relevant demographics

Not reported

Anthropometrics

Not reported

Location

Itauna, Brazil

 

Summary of Results:

Prevalence rates of exclusive breastfeeding at one, four, and six months of life were 62.6, 19.5, and 5.3%, respectively. Full breastfeeding for one, four, and six months of life were 77.2, 42.3, 15%. Prevalence rates of overall breastfeeding for one, two, six, and 12 months were 93.5, 75.2, 58.9, 33.7%, respectively. 

Mean duration of exclusive breastfeeding was 40 days; for full-breastfeeding 95 days. Mean duration of breastfeeding was 237 days. 

 
RR (95% CI)
Significance
Multivariate analysis model 1-Variables negatively associated with duration of exclusive breastfeeding
Intention to breastfeed (±24 months)
 <12 months
 12-23 months
 
1.67 (1.20-2.33)
1.74 (1.23-2.47)
 
 
0.002
0.002
Birth weight child (<2500g)
1.92 (1.11-3.33)
0.019
Use of pacifier
1.49 (1.11-2.00)
0.007
Multivariate analysis model 2-Variables positively associated with shorter breastfeeding duration
Maternal age (<20 years)
1.89 (1.17-3.06)
0.009
Number pre-natal consultations (N)
 <5
 5-9
  
0.71 (0.34-1.51)
0.33 (0.19-0.58)
  
0.379
0.000
Delay before first breastfeed (>6 hours)
1.95 (1.03-3.67)
0.038
Use alcohol or tobacco
1.92 (1.29-2.85)
0.001
Use of pacifier
2.99 (2.04-4.38)
0.000
 

 

Author Conclusion:

Breastfeeding rates in Itauna, Brazil are well below those recommended by WHO. Principle variables with a negative relationship with duration of exclusive breastfeeding and of complementary feeding are related to mother and baby healthcare, and therefore, interventions are possible.

Funding Source:
Other: no data
Reviewer Comments:
  • No health, demographic information for moms or babies reported 
  • No mean values for independent variables reported. no information on questionnaire or interview 
  • No anthrompometric data (GWG, pre-pregnancy BMI, etc). Not clear how often data was collected (every month, or every three months?).
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? N/A
3. Were study groups comparable? No
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? No
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? No
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? No
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? No
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? No
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? Yes
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes