99

Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011

Effect of initiation of breast-feeding within one hour of the delivery
on "maternal- infant bonding"
Himani, Baljit Kaur, Praveen Kumar
Abstract : Breast feeding is the feeding of an infant or young child with breast milk directly
from human breasts. Studies have been carried out on a number of variables e.g. health benefits of
breast feeding for neonate and mother. Maternal- infant bonding is one of the variables which is least
studied. The present study was undertaken to assess the effect of initiation of breast feeding within
one hour of the delivery on maternal- infant bonding. Two hundred and eighteen mother- infant dyads
were enrolled for the study and considered for analysis. Each group (control and experimental)
comprised of one hundred and nine mother-infant dyads. Mothers who initiated breast feeding after
one hour of the delivery were considered in the control group and the mothers in the experimental
group initiated breastfeeding within one hour of the delivery. Value of t at 24 hrs was -7.428 and at
48 hrs was -8.894. Significant difference p= 0.000 < 0.5 was found between the maternal infant
bonding scores of control and experimental group at 24 as well as 48 hours of the delivery. At 24
hours of the delivery, mean S.D of score was found 73.6 9.0 in the control group while the score
was 81.1 5.3 in the experimental group and at 48 hours it was 74.5 8.9 in control group and
83.3 5.3 in the experimental group. The result revealed that initiation of breast feeding within one
hour of delivery improves maternal- infant bonding. So, it is recommended that breast feeding should
be initiated within one hours of delivery.
Correspondence at :
Himani
Lecturer,
Sukhmani College of Nursing,
Dera Bassi, District: Patiala, Panjab.
Key words :
Breast feeding, Maternal- infant bonding,
Mother- infant dyad.
Background
Breast feeding is as old as human kind.
It is universally acknowledged to be the best
and complete food for infants as it fulfills
specific nutritional needs
1.
Extensive research
in the recent years, documents diverse and
compelling advantages of breast feeding to
infants, mothers, families and society. These
al so incl ude nutri tional, immunological,
devel opmental , psychol ogi cal , soci al ,
economic and environmental benefits.
2,3,4
100
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
Hospital team can have a significant
impact on the initiation and maintenance of
breast feeding, i f they have sufficient
knowledge of its benefits and the necessary
clinical management skills or habits.
5
In order
to ensure success in breast feeding, it is
impor tant that it be initiated as early as
possible during the neonatal period.
6
Right
after bir th the sucking reflex is most active
and babies are more aler t during the first 30-
60 minutes and if babies are put to mothers
breast within this period, chances of exclusive
breast feeding increase.
6
Earl y i niti ati on of breast feedi ng
enhances Maternal- infant Bondi ng.
6

Maternal -Infant bonding means the

development of the core relationship between
mother and child.
7
The bonding process
occurs in both infant and mother and has
tremendous implications for the childs future
development.
7
Maternal infant bonding is a
vital process which begins in early infancy and
continues over the next few years. The
bondi ng process has tremendous
implications for both mother and child and is
affected by many factors.
7
Many studies have
addressed the question of whether there is
what has been called a sensitive period for
parent- child contact in the first minutes, hours
and days of life that may alter the parents
behaviors with their infant later in the life.
8
In
each study, increasing the mother- infant time
together or increased suckling improves
caretaking by the mother.
8
Salariya et all also found that babies who
were first fed within 30 minutes of birth were
likely to remain breast feeding for longer.
9
The
relationship between early first contact of
mother and i nfant and outcome of
breastfeeding may be closely related to what
Klaus and Kennell (1976) describe as an early
sensitive period in the mother. This immediate
postpar tum period seems to be the time for
optimum attachment or bonding of the mother
to the infant.
9
A 1974 study at Brazil compared the
breastfeeding of two groups of 100 women.
The mothers of one group nursed their infants
immediatel y af ter bi r th and maintai ned
permanent contact throughout the hospital
stay with their infants in cribs by their beds.
The control group mothers had a glimpse of
their infants shortly after bir th and then visits
for approximately 30 minutes, every 3 hours,
7 times a day, beginning 12-14 hours after
birth. At 2 months, 77% of the experimental
group mothers were breastfeeding without
supplemental formula. In contrast, only 27%
of the control group mothers were
breastfeeding without formula supplements
at 2 months. Knowledge and suppor t must
also be considered causal factors in this study
as a special nurse worked with the mothers
of the experimental group to stimulate and
encourage breastfeeding.
10
Salaryia et al (1978) assigned 111
primiparous women intended to breastfeed
into groups matched for age and social class.
Half of the subjects had their infants put to
the breast within 10 minutes after bir th. The
other subjects began breastfeeding at four to
six hours after delivery. The early-initiation
group fed for an average of 161 days or about
40% longer than the 96 day average in the
101
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
other group. Each of these early contact
studies suppor ted the idea of a maternal
sensitive period in the first hour after bir th.
Prolonged breastfeeding appears to be one
of the outcomes of promoting early contact
of mother-infant pairs.
11
Breast feeding provides considerable
heal th benefits for mothers, babies and
economic benefits to the healthcare system.
12
Long term success and sustainability requires
a shift in attitude of both the public and health
professionals towards breast feeding. It is a
natural act but not necessarily an easy one to
i ni ti ate.
13,14,15
Enthusiastic suppor t and
involvement of health team in promotion and
practice of early initiation of breast feeding is
considered essential to achieve optimal health,
growth and development of new born baby
as well as mother and to improve maternal-
infant bonding . Factors that affect the
intention, initiation and duration of breast
feeding are complex and therefore to address
these factors, speci al i zed approach i s
required.
16
Hospital policies and routines
greatly influence breastfeeding success. The
peri -par tum hospital experience should
include adequate suppor t, instruction and
care to ensure the successful early initiation
of breastfeeding. Such management is part
of a continuum of care and education begin
during the pre-natal period that promotes
breastfeeding as the optimal method of infant
feeding and includes information about
maternal and infant benefits.
17
Though, it is impor tant to initiate breast
feeding to new born baby within 1 hour of
delivery, yet no studies have been done so
far in the Institute to see the effect of initiation
of breast feeding within 1 hour of delivery on
maternal-infant bonding. WHO recommends
that breast feeding should be initiated within
1 hour of delivery. So, the need aroused to
conduct the study and assess the effect of
initiation of breast feeding within 1 hour of
the delivery on maternal-infant bonding and
produce research based evidence.
Objective of the study
To assess the effect of initiation of
breast- feeding within 1 hour of delivery on
Maternal- Infant bonding.
Material and Methods
The quasi- experimental study was
conducted with the mothers and their new
born babies in the Obstetric Unit, Nehr u
Hospital, PGIMER, Chandigarh in August-
September 2009. PGIMER,Chandigarh is an
autonomous institute. It was established in
1962 as a referral centre and ter tiary level
institute This is one of the premier Institutes
of the country for impar ting medical, para-
medical education and conducting research.
Nehru Hospital with 1600 beds attached to
the Institute, provides indoor health care
facilities. The present study was conducted
in the Obstetric Unit which consist ofClean
Labour Room (CLR), Maternity Ward and
Gynecology Ward. Obstetric unit is situated
on the third level. Clean labour room and
Gynecology ward are in the D block and
Maternity Ward is in B Block.
Purposive sampling technique was
empl oyed to sel ect sampl e from the
population. During first phase the mothers
102
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
were contacted after one hour of the delivery
and asked whether they have initiated breast
feeding to their baby. If the breast feeding
was not initiated within one hour of the
delivery, mother- infant dyad was considered
in the control group. And if breast feeding
was initiated within one hour of the delivery,
mother- infant dyad was considered in the
experimental group. During the second
phase, the mothers were contacted within
one hour of the delivery and breast feeding
was initiated within one hour of the delivery
using the developed protocol i.e. mother-
i nfant dyad were considered i n the
experimental group. Protocol for the initiation
of breast feeding was devel oped by
consulting the exper ts and review of the
literature.
All the mothers with normal vaginal
delivery (period of gestation 36 weeks and
above) who were willing to par ticipate in the
study were considered eligible and included
in the study except the mothers and new
born babies in the exclusion criteria.
The mothers having the problems i.e.
Eclampsia, twin pregnancy, medical- surgical
diseases which interfered with the initiation
of breast feeding, post- partum haemorrhage
and post- par tum psychosis and the new
born babies with the problems i.e., pre-term
less than 36 weeks of gestation, birth weight
less than 1.8 Kg, APGAR less than 7 at 1
and 5 minutes, congenital malformations
which interfered with the breast feeding,
babies shifted to Neonatal Intensive Care Unit
(NI CU), babies with medi cal - surgical
problems where direct breast feeding is
contraindicated were excluded from the study.
The research tools included 1) Protocol
for the initiation of breast feeding, 2) Performa
for sample collection and identification data
sheet, 3) Tool to assess maternal- infant
bonding. Tool to assess maternal- infant
bondi ng i ncl uded Maternal Postnatal
Attachment Scal e (MPAS) [Condon and
Corkindale, 1998] which consisted of 19
questions. The Performa was modified as per
the need of the study. Reliability of the tool was
assessed by Cronbachs alpha. Its value was
0.7998 at 24 hours and 0.8118 at 48 hours.
The experiment was carried out in two
phases. During phase-I, the mothers were
contacted after one hour of the delivery asked
about the initiation of breast feeding. If the
breast feeding was not initiated within one hour
of the delivery, then the mother- infant dyad
was considered in the control group but if the
breast feeding was initiated within one hour of
the delivery, then the mother- infant dyad was
considered i n the experi mental group.
Identification perform was filled at one hour.
Performa for the assessment of maternal-
infant bonding was filled at 24 and 48 hours
of the delivery. During phase-II, the mothers
were contacted within one hour of the delivery.
Mother- infant dyads were considered in the
experimental group. Breast feeding was initiated
within one hour of the deliver y using the
developed protocol, Identification Per forma
was filled at one hour and the tool to assess
maternal- infant bonding was implemented
at 24 and 48 hours of the delivery.
Results
Two hundred and eighteen mother- infant
103
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
dyads were enrol led for the study and
considered for analysis. Each group (control
and experimental) comprised of one hundred
and nine mother-infant dyads. Analysis of
gathered data was done using differential and
inferential statistics.
Majority of the subjects were in the age
group of 21-25 years. Age of the study
subjects (mothers) in the control group
ranged between 19 to 38 years. Mean age
S.D was 26.2 4.1. Whereas in experimental
group the age of study subjects ranged
between 20 to 41 years. Mean age S.D
was 26.5 3.8. Per capita income of subjects
ranged between Rs 201/- Rs 25000/- per
month. Sixty- three (57.8%) subjects from
group had per capita income of Rs 501-
whereas fifty-one (46.8%), subjects from
experimental groups had per capita income
Rs 1000/- per month. In the control group,
per capita income per month ranged between
Rs 200/- to 25000/-, Mean S.D was
2867.6 4475.7. On the other hand, in the
experimental group, range was Rs 250/- to
25000/-, mean S.D was 4204.3 5784.6.
of the subjects were literate 36.7% subjects
from experiment group and 55.1% from
control group studied upto matriculation.
Most of the subjects i .e. 77.9% from
experimental group and 89.5% from control
group were house wives. More than half
(52.3%) of subjects from experiment group
and 66.9% from control group were from rural
background (Table 1).
In both the groups, more than half of
the study subjects were multigravida i.e.
65.1% from control group and 56.9% from
experimental group. More than 75% of study
subjects delivered between 37
+1
to 40 weeks
peri od of gestation in both control and
experimental groups. In control group, 12.8%,
subjects delivered between 36 to 37 weeks,
76.2% delivered br tween 37
+1
to 40 weeks
and 11.0% had period of gestation of 40
+1
weeks and above at the time of delivery. In
experimental group too, 15.6% subjects
delivered at period of gestation 36 to 37
weeks, 75.2% during 37
+1
to 40 weeks and
10 (9.2%) at 40
+1
weeks and above. In the
control group, 48 (44.1%) subjects, had baby
boy and 61 (55.9%) had baby girl while in
experimental group, 57 (52.3%) subjects, had
baby boy and 52 (47.7%) had baby girl.
(Table-2)
The comparison of maternal- infant
bonding was done at 24 and 48 hours of the
delivery and the scores were compared. In
control group, mean bonding score on
maternal- infant attachment scale at 24 hours
of the delivery ranged from 44.5- 89.2 with
mean score 73.6 9 and at 48 hours the
score ranged from 44.5- 92.2 with mean
S.D score 74.5 8.9. In the experimental
group, mean bonding score and range on
maternal- infant attachment scale at 24 hours
of the delivery between 62.4- 91.0 with mean
score 81.1 5.3 and while at 48 hours it
ranged from 62.8- 92.2 with mean score
83.26 5.3. The t- test for equality of means
was applied to assess maternal- infant bonding
at both 24 and 48 hours by assuming equal
variances. The value of t at 24 hours and at
48 hours was -7.428 and -8.894, respectively
104
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
p = 0.000 at both 24 hours and 48 hours.
This shows that there was si gni ficant
difference in bonding score in the control and
experimental group both at 24 hours and 48
hours of the delivery (Table 3)
Table 1- Socio- demographic profile of
the subjects.
SOCIO- DEMOGRAPHIC Control Group Experimental Group
PROFILE f (%) f (%)
N=109 N=109
Age Group
- 20 years 05 (04.6) 03 (02.8)
- 21- 25 years 57 (52.3) 49 (45.0)
- 2f (%)6- 30 years 34 (31.2) 43 (39.4)
- 31 years 13 (11.9) 14 (12.8)
Education (self)
- Till 10
th
60 (55.1) 40 (36.7)
- 10
th
to 10+2 and diploma 20 (18.3) 25 (22.9)
- Graduation and above 29 (26.6) 44 (40.4)
Occupation (self)
- House-wife 97 (89.0) 24 (22.1)
- Employed 12 (11.0) 76 (77.9)
Place (Habitat)
- Rural 73 (66.9) 57 (52.3)
- Urban 36 (33.1) 52 (47.7)
Per Capita Income
- Rs 500 19 (17.4) 16 (14.7)
- Rs 501 Rs 1000 63 (57.8) 51 (46.8)
- Rs 1001- Rs 2000 12 (11.0) 20 (18.3)
- = Rs 2001 15 (13.8) 22 (20.2)
Type of Family
- Joint 79 (72.5) 75 (68.8)
- Nuclear 30 (27.5) 34 (31.2)
105
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
Table 2 : Gravida status, gestation period and sex of baby of the subjects
VARIALES Control Group Experimental Group
f (%) f (%)
N=109 N=109
Gravida
- Primi Gravida 38 (34.9) 47 (43.1)
- Multi Gravida 71 (65.1) 62 (56.9)
Period of Gestation (in weeks)
- 36- 37 14(12.8) 17 (15.6)
- 37
+1
- 40 83(76.1) 82 (75.2)
- 40
+1
and above 12 (11.1) 10 (09.2)
Sex of baby
- Boy 48 (44.1) 57 (52.3)
- Girl 61 (55.9) 52 (47.7)
Table 3 : Maternal- infant bonding score at 24 and 48 hours
TIME Maternal- Infant bonding Score Value of t
Control Group Experimental Group
(N=109) (N=109)
Mean S.D Range Mean S.D Range
After 24 73.6 9.0 44.5- 89.2 81.1 5.3 62.4-91.0 -7.42
Hours of (p=0.000)
delivery
After 48 74.5 8.9 44.5-92.2 83.3 5.3 62.8-92.2 -8.894
hours of (p=0.000)
delivery
106
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
The significant higher level of maternal
i nfant bonding score was obser ved in
experimental group as compared to control
group in relation to gravida status and
gestation period of subjects. It was fur ther
observed that in control group, 8 (7.3%)
multigravida subjects had poor bonding as
they scored l ess than 60.2 whi l e no
primigravida subjects scored less than 60.2.
while on the other hand neither primigravida
subjects nor multigravida mothers in the
experimental group had poor bonding. As
per period of gestation it was bserved that
only eight subjects from control group had
poor bondi ng The perid of gestation of
5(4.6%) subjects was 37+1 to 40 weeks of
period of gestation while one subject (0.9%)
had 36 -37 weeks gestation and another two
(1.8%) subjects had 40+1 and more gestation
and non of the subjects in experiment group
had poor bonding.
The variables like maternal education,
occupation, habitat, per capi ta i ncome
presence of medical di sorders duri ng
pregnancy, sex of baby, pre lacteal feeds and
bir th weight of baby had on i mpact on
maternal infant bonding in both the groups.
Table 4 depicts the maternal- infant
bonding score of the subjects according to
reasons for not initiating breast feeding within
an hour of the delivery in the control group.
The reasons were lack of rooming in and non
willingness on mothers par t. There was
significant difference in the scores.
Table 4 : Maternal- infant bonding score as per reason for not initiating breast feeding
within an hour of delivery
GROUP Reasons Poor bonding Good bonding
f (%) f (%)
Control Lack of rooming-in 4 (5.1) 75 (94.9)
Mother not willing 4 (13.3) 26 (86.7)
p =0.007 <0.05 at df=1 (X
2
test)
Discussion
In spite of an increased focus on the
early initiation of breast feeding, the practice
of initiation of breastfeeding varies from
institution to institution. Studies have been
done to assess the effect of early initiation of
breastfeeding. But very few studies have
been done so far, to assess the effect of
initiation of breastfeeding within one hour of
the delivery on maternal- infant bonding.
Though W.H.O prescribes that breastfeeding
should be initiated within half hour of delivery,
but the practi ce vari es withi n different
institutions. PGIMER, Chandigarh is a referral
hospital and most of the complicated and high
risk cases come for the delivery, so in most of
107
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
the cases condition of mother is not stable
within half an hour after the delivery. But it is
possible to initiate breastfeeding within one
hour of the delivery. So this study was taken
up with the objective, to assess the effect of
initiation of breastfeeding within one hour of
delivery on maternal- infant bonding.
In the present study, mother- infant
dyads after normal vaginal delivery were
taken as the study subjects, as most of the
mothers deliver baby normally. For this
reason a number of other researchers have
also preferred to take subjects after normal
vagi nal del iver y. The study subjects
(mothers) in the present study were both
primigravida and multigravida.
Assessing maternal- infant bonding
has been a tremendous challenge among
researchers because it involves the study of
psychol ogy of the mother about her
attachment to the new born baby.
Researchers have studied other benefits of
early initiation of breastfeeding. In present
study, Maternal Postnatal Attachment Scale
(MPAS) was used to objectively assess
maternal- infant bonding on the basis of
feelings and behavioral responses of mother
towards her new born baby. The tool was
standardized but modified as per the need of
the study and af ter modification it was
checked for its reliability by Cronbachs
alpha. It was found reliable.
Studies depict that mother- baby
bonding is enhanced by breast feeding.
18
Sucking enhances the closeness and new
bond between mother and baby.
19
The
findings of the present study revealed that with
the initiation of breastfeeding within one hour
of delivery, bonding increases between the
mother and her new born baby. It is likely to
be caused by early skin-to-skin contact when
the mother breast feeds. The remarkable
change in the maternal behavior with just the
touch of the infants lip on the mothers nipple,
the reduction in the abandonment with early
contact, suckling and rooming- in and the
raised maternal oxytocin levels shor tly after
bir th in conjunction with known sensory
physiologic, immunologic and behavioral
mechanisms all contribute to maternal- infant
bonding.
4
A study was conducted to find out the
pattern and influence of socio- cultural factors
on breast feeding practi ces in the r ural
mothers of Darjeeling district. Result showed
that, 85.5% of the mothers initiated breast
feeding within 7-18 hours after delivery, 55%
of mothers got the information from their family
members. Education and socio-economic
status had a significant association with
duration of breast feeding.
20
Whereas in the
present study, house-wife mothers
predominated in both the groups. The findings
of the study revealed that there is no significant
difference in bonding scores of house-wife and
employed mothers as the number of employed
mothers was less.
In an another study conducted by Anteo
Di Napoli et al, to evaluate the effects of level
of education on the initiation and duration of
breast feeding. Results showed that a low level
of education, determines a negative effect on
the initiation and duration of breast feeding.
21
108
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
As researchers repor t that there i s a
significant effect of education and socio-
economic status of the mother on initiation
of breastfeeding and thus bonding, so in the
present study, bondi ng scores wi thin
mothers of different educational status and
socio-economic status were compared. The
fi ndi ngs of present study reveal ed no
significant difference in the bonding among
mothers of different groups. Findings also
indicate that gender of the baby does not
influence the bonding among mothers. The
results depict that giving pre-lacteal feed to
the baby also has no effect on the maternal-
infant bonding scores.
The resul ts of the present study
si gni fies that with the initiati on of
breastfeeding within one hour of delivery,
maternal- infant bonding is improved as
compared to initiation of breastfeeding after
one hour of delivery.
The present study depicts that the age
of the subjects ranged from 19 years to 41
years in both the groups. Majority of the
subjects i.e. 52.3% mothers in the control
group and 45% mothers in the experimental
group aged between 21- 25 years. Any
disease during pregnancy was present in
ver y few mothers during pregnancy i.e.
16.15% in the control group while 20.18%
i n the experimental group. The most
common disease which the subjects were
having was hypothyroidism in both the
groups. In control group, 76.15% mothers
had period of gestation between 37
+1
40
weeks while in the experimental group
75.23% mothers had period of gestation
between 37
+1
40 weeks. Study subjects were
comparable as per the bir th weight of the baby
in both the groups. On maternal infant
attachment scale, the mean net bonding scores
of mothers in control group was 73.6 at 24
hours and 74.5 at 48 hours whereas for
experimental group, it was 81.1 at 24 hours
and 83.2 at 48 hours of the delivery. The value
of t at 24 hours and 48 hours was -7.428 and
-8.894, respectively. Null hypothesis was
rejected (p= 0.000 < 0.05). Statistical
significant differences were seen between the
bonding scores of mothers who initiated
breast feeding within hour of the delivery and
the mothers who initiated breast feeding after
one hour of the delivery. Based on the findings,
the study recommends that breast feeding
should be initiated within one hour of the
delivery. A similar study using the same tool
after 6 weeks and one year of the delivery can
be taken up to provide fur ther impetus to the
findings. A similar study using inter view
technique along with the maternal-infant
bonding tool can be done to fur ther refine
the findings. The findings of the study provides
An evidence-based data for the improvement
of maternal- infant bonding. Hence feeding
in the first hour of delivery is recommended
to improve maternal infant bonding.
References
1. Odent M. Is Promoting Breastfeeding as
Useless as the Promotion of Love? [ Online]
PrimalHealth 1999. Available from URL: http://
www.birthpsychology.com/index.html.
2. American academy of pediatricians.
Breast feeding and the use of human milk.
Pediatrics 1997; 100(6): 1035.
109
Nursing and Midwifery Research Journal, Vol-7, No. 3, July 2011
3. American academy of pediatricians.
Breast feeding and the use of human milk.
Pediatrics 2005; 115 (2): 496-506.
4. Mehta S. Breast feed is best for babies
health. The Tribune 2005 Aug24.
5. Moreland J, Coombs J. Promoting and
supporting Breast feeding. American Family
Physician 2000; 61(7): 2093-100, 2103-4.
6. Anisfeld E, Curry MA, Hales DJ, et al.
Maternal- Infant bonding. A joint rebuttal
Pediatrics 1983; 72: 569-71.
7. Bowlby J. The making and breaking of
affecti onal bonds.I . Aetiol ogy and
psychopathology in the light of attachment
theory. Br J Psychiatry 1977; 130: 201-10.
8. Crowell JA, Feldman SS. Mothers
working models of attachment relationships and
mother and child behavior during separation and
reunion. Developmental Psychology 1991; 27:
597-605.
9. Williams TM, Joy LA, Travis L, Gotowiec
A, Blum-Steele M, Aiken Ls, et al. Transition to
motherhood: A longitudinal study. Infant Mental
Health Journal 1987; 8(3): 251-65.
10. Jelliffe D. B., & Jelliffe, E. F, P. The
uniqueness of human milk. American Journal
of Clinical Nutrition 1971; 24: 968-69.
11. Klaus, M.H., Kennell, J H, Plumb N,
Zuehlke, S. Human maternal behavior at the first
contact with her young. Pediatrics 1970; 46 (2)
: 187-192.
12. Cuno V.Lanni R.Scipione F. Effectiveness
of booklet on the duration of breast
feeding. Archives of Di sabl ed Chi ldfood
1997;76:500-4.
13. Cahill JB, Wagner CL. Challenges in breat
feeding, Neonatal concerns. Contemporary
pediatrics [Online] May 2002. Available from URL:
www.com/contped/authorinfo.isp?
14. Johnson D. Breast feeding in challenging
for mother and noenate. Gaining and growing :
Assuring Nutritional care of preterm infants [Onlin]
2005.Available from URL. www.compleat
mother.com
15. Rowe, J. Breast feeding supply and
demand. Nurisng Times 1985:51.
16. The national assembly f or Wal es.
Investing in a better star t: Promoting breast
feeding in Wales. [Online}: 2005. Available from
URL: http://www.Wales.govuk.
17. Lounds JJ. Borkowski JG, Whitman TL,
Maxwell SE, Weed K. Adolescent parenting and
attachment during infancy and early childhood.
Parenting : Science and Practice 2005;(5):19-117.
18. Pisacane A, Graziano L, Mazzarella G.
Breast feeding and urinary tract infection. Journal
of Pediatrics 1992; 120(1): 87-89.
19. Koletzko S, Sher man P, Corey M.
Breastfeeding protects against Crohns disease
(intestinal disorder). Role of infant feeding
practices in Development of Crohns disease in
childhood. British Journal 1989; 298: 1617-18.
20. Beaudry M, Dufour R, Marcoux S. Relation
between infant feeding and infections during the
first six months of life. Journal of Pediatrics 1995;
126: 191-97.
21. Breast feeding and lower respiratory tract
illness in the first year of life. British Medical
Journal 1989; 299: 935-49.