Randomized, Controlled Trial of a Prenatal and Postnatal Lactation
Consultant Intervention on Duration and Intensity of Breastfeeding up to
12 Months
Karen A. Bonuck, PhD*; Michelle Trombley, BA*; Katherine Freeman, DrPH*; and Diane McKee, MD‡
ABSTRACT. Objective. To determine whether an in-
dividualized, prenatal and postnatal, lactation consultant
intervention resulted in increased cumulative intensity
of breastfeeding up to 52 weeks.
Design. The randomized, nonblinded, controlled trial
recruited women from prenatal care. Baseline prenatal
interviews covered demographic data and breastfeeding
experience, intention, and knowledge. Interviews at 1, 2,
3, 4, 6, 8, 10, and 12 months after birth collected data on
weekly feeding patterns, infant illness, and infant health
care use.
Setting. Two community health centers serving low-
income, primarily Hispanic and/or black women.
Participants. The analytic sample included 304
women (intervention: n ⴝ 145; control: n ⴝ 159) with >1
postnatal interview.
Intervention. Study lactation consultants attempted 2
prenatal meetings, a postpartum hospital visit, and/or
home visits and telephone calls. Control subjects re-
ceived the standard of care.
Outcome Measures. Cumulative breastfeeding inten-
sity at 13 and 52 weeks, based on self-reports of weekly
feeding, on a 7-level scale.
Results. The intervention group was more likely to
breastfeed through week 20 (53.0% vs 39.3%). Exclusive
breastfeeding rates were low and did not differ according
to group. In multivariate analyses, control subjects had
lower breastfeeding intensity at 13 weeks (odds ratio
[OR]: 1.90; 95% confidence interval [CI]: 1.13–3.20) and 52
weeks (OR: 2.50; 95% CI: 1.48 – 4.21). US-born control
subjects had lowest breastfeeding intensity at 13 weeks
(OR: 5.22; 95% CI: 2.43–11.22) and 52 weeks (OR: 5.25;
95% CI: 2.44 –11.29). There were no significant differ-
ences in breastfeeding intensity among the US-born in-
tervention, foreign-born intervention, and foreign-born
control groups.
Conclusions. This “best-practices” intervention was
effective in increasing breastfeeding duration and inten-
sity. Breastfeeding promotion should focus on US-born
women and exclusive breastfeeding. Pediatrics 2005;116:
1413–1426; randomized, controlled trial, breastfeeding du-
ration, intensity of breastfeeding, exclusive breastfeeding,
lactation consultant.
From the Departments of *Epidemiology and Population Health and ‡Fam-
ily and Community Medicine, Montefiore Medical Center/Albert Einstein
College of Medicine, Bronx, New York.
Accepted for publication May 5, 2005.
doi:10.1542/peds.2005-0435
No conflict of interest declared.
Reprint requests to (K.A.B.) Department of Epidemiology and Population
Health, Montefiore Medical Center/Albert Einstein College of Medicine,
111 E 210th St, Bronx, NY 10467. E-mail: kbonuck@montefiore.org
PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad-
emy of Pediatrics.
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
ABBREVIATIONS. WIC, Supplemental Nutrition Program for
Women, Infants, and Children; OR, odds ratio; CI, confidence
interval; MILK, Moms Into Learning about Kids; LC, lactation
consultant; RA, research assistant.
T
he American Academy of Pediatrics recom-
mends exclusive breastfeeding for 6 months
and continuation of partial breastfeeding for
ⱖ12 months.1 The unique composition of breast
milk has essential nutrients that are absorbed more
readily than cow’s milk or infant formula into the
infant’s bloodstream. Breast milk confers increased
immune function and is associated with the growth
of human tissues, especially the brain.2 In the first 1
year of life, in particular, breastfeeding is associ-
ated with significantly fewer cases of otitis media,3–7
respiratory infections,7–12 and gastrointestinal ill-
nesses.12–15
Healthy People 2010 set a goal that 75% of infants
be breastfed in the early postpartum period, with
continued breastfeeding to 6 months for 50%.16
Breastfeeding rates are generally higher among older
women, women of greater income and education,
and women who are not black.17,18 From 1990 to 2001
there were dramatic increases in any breastfeeding to
69.5% (from 52%) in the hospital and 32.5% (from
18%) at 6 months. Exclusive breastfeeding during
this period increased to 46.3% (from 43.5%) in the
hospital and 17.2% (from 10.4%) at 6 months. The
greatest initiation gains were among women who
were black, younger (⬍20 years of age), high school
educated or less, and receiving Supplemental Nutri-
tion Program for Women, Infants, and Children
(WIC) benefits. At 6 months, exclusivity was lower
among black versus white non-Hispanic and His-
panic women (10.7% vs 18.7% and 16.2%, respec-
tively), younger women (10.3% for women ⬍20 years
of age vs 22% for women ⬎35 years of age), and
women lacking a college degree (24% for college vs
12.7% for high school).19 Recently published 2002
National Immunization Survey data found similar
results; Li et al18 recommended that strenuous public
health efforts target non-Hispanic black women and
socioeconomically disadvantaged groups.
A US Preventive Services Task Force meta-analysis
found that combined education, counseling, and
problem-solving were most effective for promoting
breastfeeding in the first 3 months, whereas ongoing
support through in-person visits or telephone con-
tacts increased duration to 6 months.20 Brief, small-
PEDIATRICS Vol. 116 No. 6 December 2005
1413
scale interventions and those without face-to-face
interactions were generally ineffective, according to
a systematic review.21 Hands-on assistance with
breastfeeding techniques, demand feeding, and post-
natal support are essential postpartum factors, ac-
cording to several reviews of controlled clinical tri-
als.22–24 Women value being shown how to feed their
infants, rather than being told how to, as found in
our previous work25 and by others.26 Support offered
by trained volunteers had no effect in a large, ran-
domized, clinical trial of women intending to breast-
feed,27 underscoring the value of offering postnatal
support routinely, compared with on demand.
Although the literature is replete with breastfeed-
ing-promotion intervention studies, few are good-
quality, randomized, controlled trials of best prac-
tices. In preparing its meta-analysis, the US
Preventive Services Task Force systematically re-
viewed studies of counseling or behavioral interven-
tions originating from clinicians’ practices. Eligible
studies included physician, nurse, lactation consul-
tant (LC), or peer counselor interventions occurring
in the clinic, hospital, or home or elsewhere. An
exhaustive search of 1996 –2001 articles yielded just
22 randomized, controlled trials, only 1 of which was
judged to be of good quality. Of these 22 studies, just
7 included follow-up monitoring for ⱖ4 months,
only 8 included both educational and supportive
elements, and just 2 provided both prepartum and
postpartum interventions.28
We conducted a randomized, nonblinded, con-
trolled trial of a breastfeeding-promotion interven-
tion, compared with standard care, in community
health centers where women received their prenatal
and postpartum care. The intervention combined
several best-practice interventions; it offered profes-
sional, one-on-one, skills-based, prenatal and postna-
tal education and support routinely. Intention to
breastfeed at prenatal baseline was assessed in both
groups. Weekly breastfeeding outcomes up to 12
months were assessed in both groups with a stan-
dardized tool that measured 7 levels of breastfeed-
ing, ranging from exclusive to none. The study was
conducted in the Bronx, New York, the US county
with the highest poverty rate and lowest median
household income. Nearly one half (48%) of the
Bronx population is Hispanic; just 15% of residents
identified themselves as non-Hispanic white in the
2000 US Census.29
METHODS
Recruitment and Eligibility
The Moms Into Learning about Kids (MILK) study was a ran-
domized, controlled trial of a multicomponent breastfeeding-pro-
motion intervention. Breastfeeding, infant health, and infant
health care utilization outcomes were tracked up to 12 months.
This article reports on breastfeeding outcomes. Prenatal care pa-
tients at 2 hospital-affiliated health centers in the Bronx, New
York, were recruited from August 2000 through November 2002.
At 1 site, a research assistant (RA) bilingual in English and Span-
ish recruited directly from the center’s mandatory prenatal class.
At the other center, social work staff members recruited interested
participants and passed contact information onto another bilin-
gual MILK RA.
Eligibility criteria included the following: English or Spanish
speaking, twin or singleton pregnancy, intent to keep the infant,
1414 TRIAL OFDownloaded
LACTATION CONSULTANT INTERVENTION
from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
plans to remain in the center and its affiliated hospital system for
prenatal and infant care up to 12 months, ⱖ2 contact telephone
numbers, and gestation before 24 weeks (to allow sufficient time
to deliver the 2-part prenatal intervention). Exclusion criteria in-
cluded HIV-positive status,30 chronic therapy with medications
incompatible with breastfeeding, and pregestational diabetes mel-
litus; diabetic prenatal patients were referred to a high-risk site for
care. Although they are not generally considered contraindica-
tions,1 women with human T-cell leukemia virus-1, breast reduc-
tion surgery, or hepatitis B or C were excluded, given some
controversy that might have predisposed affected women and
their health care providers against breastfeeding.
All study materials were translated professionally into Spanish.
These translations were checked for cultural concordance with
local dialects by native Spanish-speaking study staff members.
The study was approved by the medial center’s institutional re-
view board for the protection of human subjects.
Randomization and Referral for Intervention
After consent, eligible women who agreed to participate were
assigned randomly to the intervention or control group, with an
undisclosed blocking factor and stratification according to center.
The project’s biostatistical office generated and maintained a list of
random codes for subjects, corresponding to the intervention and
control assignment groups. A page with the subject’s identifica-
tion number, treatment assignment, and administrative informa-
tion (eg, date assigned) was generated for each subject. Each page
was secured in a sealed envelope and labeled externally with the
subject number, name of the study, and study contact information.
Series of envelopes were given to the RA at the site, with instruc-
tions to open the envelopes in sequence and to assign the women
to the corresponding intervention or control group.
After intervention group participants completed the baseline
interview, the MILK RA referred them to the study LC. The RA
shared basic demographic and contact information but did not
discuss the breastfeeding intentions, knowledge, or attitudes as-
sessed at the baseline interview. The LC then sought to arrange a
first meeting with the participant, either at the center during an
upcoming visit or at her home.
Trial Enrollment
As shown in Fig 1 (MILK Trial enrollment flow chart), a total of
382 women (385 mother/infant dyads, with 3 sets of twins) were
assigned randomly in the study (intervention: n ⫽ 188; control: n
⫽ 194). Of these, 21 mother/infant dyads were excluded at contact
for postnatal follow-up monitoring (intervention: n ⫽ 15; control:
n ⫽ 6). Exclusions included mothers of twins (a decision was made
after data collection was complete to exclude them from analyses;
intervention: n ⫽ 2; control: n ⫽ 1), women who chose to with-
draw from the study (intervention: n ⫽ 3; control: n ⫽ 2), and
women who miscarried or terminated their pregnancy (interven-
tion: n ⫽ 8; control: n ⫽ 2) after baseline assessment. Among the
remaining eligible women, 30 from each group (17% of the inter-
vention group and 16% of the control group) were lost to all
follow-up monitoring. The outcomes sample represents 79.6% of
Fig 1. Trial enrollment flow chart. *These 382 women included 3
women pregnant with twins, ie, 385 mother/infant dyads. Subse-
quently, these 3 mothers (2 in the intervention group and 1 in the
control group) were deemed ineligible, which resulted in 6 exclu-
sions from the analytic sample.
all those assigned randomly and 83.5% of eligible women after
exclusions. Data were not collected for women who were ap-
proached but did not enroll.
Therefore, a total of 304 women (intervention: n ⫽ 145; control:
n ⫽ 159) with ⱖ1 postnatal follow-up data point were included in
the final analysis (outcomes sample). The mean lengths of fol-
low-up periods for the outcomes sample were 41 weeks (SD: 16.3
weeks) for the intervention group and 44 weeks (SD: 13.9 weeks)
for the control group. At 13 weeks, follow-up data were available
for 90% of the outcomes sample intervention group and 92% of the
outcomes sample control group. Follow-up rates decreased but
remained comparable between the intervention and control
groups at 26 weeks (79% vs 87%), 39 weeks (70% vs 79%), 48
weeks (63% vs 67%), and 52 weeks (52% vs 59%). We compared
participants who were retained with those who were lost to fol-
low-up monitoring at those times, both within and across treat-
ment groups in terms of age, education, foreign birth, race/eth-
nicity, marriage/partner status, Medicaid, parity, prior
breastfeeding experience, and infant feeding intention at baseline.
None of these differences was statistically significant (data not
shown).
Data Collection
Data collection consisted of 1 prenatal baseline interview cov-
ering demographic data, previous breastfeeding experience, feed-
ing intention, and breastfeeding knowledge and 8 telephone in-
terviews, at 1, 2, 3, 4, 6, 8, 10, and 12 months after birth, to assess
infant feeding. The 1-month follow-up interview collected de-
tailed data about the immediate postpartum experience, including
infant feeding in the hospital and during the first week, the
infant’s health, and health care use. Interviews at months 2, 3, 4, 6,
8, 10, and 12 were briefer and focused primarily on weekly feed-
ing, infant health care, and health care use.
At the site where a MILK RA recruited directly from the pre-
natal class, the RA attempted to complete the baseline interview
just after recruitment or at the next prenatal visit. At the site that
relied on social work referrals, interested participants were met at
their next prenatal visit. Participants were given gift cards for
$20.00 after completion of the baseline interview, $40.00 after
completion of follow-up interviews at 1, 2, 3, and 4 months, and
$55.00 after completion of the remaining interviews.
Blinding
Neither the RA collecting breastfeeding outcome data nor the
study LCs providing the intervention were blinded with respect to
treatment group. However, the study protocol prohibited any
discussion or sharing of feeding data between the study RAs and
the study LCs.
Power Analysis
The power analysis was based on the following assumptions:
29% of mothers without the intervention would initiate breast-
feeding, compared with twice that proportion in the intervention
group. With these assumptions, 52 women per group, or 104
women total at each center, were needed to detect a difference
with ␣ ⫽ .05 and ␤ ⫽ .20 (2-tailed test).
Description of the Intervention
Prenatal
A study LC attempted 2 individual meetings with each inter-
vention group woman prenatally and postpartum hospital and
home visits and was available for telephone consultation up to 12
months. The initial prenatal meeting focused first on trust and
rapport and then educational content. The LC assessed feeding
intentions and discussed the benefits of breastfeeding. A flip-chart
depicting the physiologic features of breastfeeding and color pam-
phlets were reviewed. The second meeting addressed what to
expect after birth and specifics on how to initiate breastfeeding in
the hospital (eg, latch-on, positioning, importance of early initia-
tion, and demand feeding). Practice with a culturally appropriate
lactation doll and nipple was offered.
Postnatal
We sought to identify women in the hospital for LC visits
through daily faxes regarding women on the labor and delivery
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
floors of the hospital that served as the delivery site for both health
centers. LCs also telephoned intervention group women weekly as
their expected delivery date neared. Initial hospital and home
visits provided hands-on instruction in latching on, proper posi-
tioning, and other techniques to avoid common breastfeeding
complications, as well as pump use. After breastfeeding was es-
tablished, topics included frequency of feeding, confidence, stool-
ing patterns, determining adequate intake, and maternal nutrition.
If later contacts were made, they tended to focus on expressing
and storing milk, fatigue, nursing in public, returning to school or
work, and supplementing. The LCs helped mothers garner sup-
port from their families, schools, workplaces, and health care
providers.
Study LCs offered a nursing bra to women in the intervention
group, free of charge, to facilitate breastfeeding. Study LCs also
provided manual (Spring Express manual breast pump system;
Medela, McHenry, IL) or minielectric (Medela) breast pumps to
women, free of charge, in certain circumstances. Women who
were separated from their infants because of work, school, or
travel were given minielectric pumps. Women who were not
separated from their infants for long periods but wanted the
freedom to go out for several hours were given a manual pump.
The general policy of the study LCs was to discourage the use of
breast pumps in favor of nursing for women who were in contin-
ual proximity to their infants.
The 2 study LCs maintained detailed activity logs for the
women assigned to them. These logs recorded the dates and sites
(eg, clinic, home, or hospital) of all attempted and actual contacts
and telephone calls, duration of contact (minutes), supplies deliv-
ered, and content of contact.
Control group women had no contact with the study LCs.
Control subjects received the health center standard of care. At
one site, this included a mandatory prenatal care class, which did
not address infant feeding in any detail. At the other site, there
was no routine prenatal education. Neither site followed an estab-
lished protocol for breastfeeding education or support or offered a
private lactation space. Participants enrolled in WIC had the op-
portunity to visit with a breastfeeding coordinator at the WIC site,
although such use was not assessed specifically. Given the study
population’s diversity, it would be difficult to characterize a com-
munity “standard” with respect to breastfeeding.
Assessment of Breastfeeding Outcomes
Breastfeeding was measured through maternal self-report. At
each follow-up interview, participants reported breastfeeding sta-
tus for each week since their last interview or since hospital
discharge (at the first follow-up interview). Breastfeeding status
was assessed with the Index of Breastfeeding Status, a measure
that has been used by others.31–34 The Index of Breastfeeding
Status is a 7-level ordinal scale that measures the percentage of
breast milk an infant receives, compared with the total amount of
feedings. These 7 levels are mutually exclusive (level 1, 100%
breast milk; level 2, ⱖ80% breast milk combined with ⬍20%
artificial milk or solids; level 3, 50 – 80% breast milk and the rest
artificial milk or solids [ie, 2–5 of every 10 feedings are not breast
milk]; level 4, 50% breast milk and 50% artificial milk or solids;
level 5, 20 –50% breast milk and the rest artificial milk or solids
[5– 8 of every 10 feedings are not breast milk]; level 6, ⱕ20% breast
milk combined with ⬎80% artificial milk or solids; level 7, 100%
artificial milk or solids [includes weaned]). Exclusive breastfeed-
ing is defined as level 1. Exclusive formula feeding is defined as
level 7. Analyses that report majority (ⱖ50%) breastfeeding in-
clude levels 1 to 4. When data are presented as 5 feeding levels for
ease of presentation, levels 2 and 3 are combined, as are levels 5
and 6. For our study, exclusive breastfeeding was defined as no
artificial milk or solids. Intake of water, liquids other than artificial
milk, and vitamin drops was not assessed. The next section de-
scribes how these data were used to construct a measure of
breastfeeding intensity.
Statistical Analyses
We compared participants who were assigned randomly and
included in the final analyses (outcomes sample) with participants
who were assigned and not included in the final analyses, both
within and across treatment groups. The outcomes sample was
composed of women with ⱖ1 postnatal follow-up data point.
Differences between women assigned to the intervention group
ARTICLES 1415
and women assigned to the control group were tested for signif-
icance with t tests (for maternal age), ␹2 tests for dichotomous
outcomes, and the Mantel-Haenszel test for trend for breastfeed-
ing intention, a trichotomous ordinal variable. Descriptive statis-
tics are shown as mean (SD) or number (percentage).
All remaining data descriptions and analyses were based on the
outcomes sample of 304 women. Unadjusted differences between
the intervention and control groups were tested for significance as
described above. A comparison of baseline data from the 2 sites
found no significant differences for the 60 baseline variables as-
sessed, except that foreign birth was somewhat collinear with
site.35 Therefore, with data for the 2 sites pooled, multivariate
analyses controlled for foreign birth.
We created a breastfeeding intensity score over 52 weeks by
summing weekly scores (range of 1–7, with 7 being exclusive
formula feeding). For subjects with missing values before a given
week, we imputed the treatment group’s median value for that
week. Similarly, for subjects with missing values later than a given
week, we imputed the treatment group’s subsequent weekly me-
dian values. The sum of weekly intensity scores was derived for
each subject through week 13 (TOTAL13) and through week 52
(TOTAL52), with minimum to maximum ranges of 13 to 91 and 52
to 364, respectively.
Bivariate associations between each total intensity score and
variables related to breastfeeding were assessed with Wilcoxon
rank sum tests for dichotomous variables and Spearman rank
correlations for continuous variables. These variables included
Medicaid status, breastfeeding intention at baseline, logarithm of
age, age squared (to assess for a nonlinear effect of age), education,
marital status, race/ethnicity, country of origin (US mainland
versus other), prior breastfeeding, and recruitment site. Variables
with associations yielding P values of ⬍.20 were used in initial
multivariate models. Models were analyzed with and without (for
ease of interpretation) transformations of scale for non-normally
distributed variables, with backward stepwise multiple regres-
sion. There were no interaction terms in initial models. With data
from all subjects regardless of treatment group, covariates with
associations of P ⬍ .05 were retained in subsequent multivariate
models, to assess the significance of the intervention. Initial mod-
els were divided into those with (baseline parity of ⱖ1) and
without (entire sample) the prior breastfeeding variable.
We examined race/ethnicity and country of origin interactions
with treatment group, given our prior findings36 and interest in
determining whether specific subpopulations benefited differen-
tially from the intervention. This effect modification was signifi-
cant according to country of origin but not race/ethnicity. Unad-
justed TOTAL13 and TOTAL52 scores are presented for both the
entire sample and subjects with baseline parity of ⱖ1, stratified
according to treatment group and country of origin. Differences
according to treatment group and country of origin were analyzed
with analysis of variance, with Duncan multiple comparisons.
Lastly, both TOTAL13 and TOTAL52 were dichotomized at
their medians. Logistic regression models were derived with the
dichotomized intensity scores as outcomes and the set of signifi-
cant covariates, the treatment group, and the interaction between
treatment group and country of origin as independent factors.
Odds ratios (ORs) and 95% confidence intervals (CIs) are pre-
sented.
All significance testing was based on 2-tailed tests, with P ⬍ .05
denoting significance. Analyses used an intention-to-treat model.
Client tracking data were entered and maintained centrally by
study staff members, in an administrative database. Baseline and
follow-up interviews were scanned with Teleform Elite 8.0 soft-
ware (Cardiff Software, Bozeman, MT). Data were then trans-
ferred to SAS software, version 8.2 (SAS Institute, Cary, NC), for
analysis.
RESULTS
Baseline Characteristics
Baseline characteristics are shown in Table 1.
There were no significant differences between
women included in the final analysis of outcomes
and those assigned randomly but not included in the
final analysis, within or across treatment groups.
Unless otherwise specified, all remaining results are
reported for the outcomes sample.
The mean age of mothers was 25 years (SD: 6.23
years), 61.5% had a high school degree, 51.5% were
married or living with a partner, and nearly 40%
were foreign born. The sample was primarily His-
panic (57%) and black (36%). The majority (57%) of
women were receiving Medicaid. Nearly two thirds
(63%) had other children, and 70% reported prior
breastfeeding experience. Breastfeeding intentions
were as follows: breast milk only, 30%; combined
breast milk and formula, 49%; exclusive formula
feeding, 9%.
Twenty-six women completed the Spanish-lan-
guage version of the baseline instrument. Some

TABLE 1. Baseline Characteristics

Variable Values Percentage (No.)
Intervention Control Sample
Assigned* Outcomes† Assigned Outcomes Assigned Outcomes
(n ⫽ 188) (n ⫽ 145) (n ⫽ 194) (n ⫽ 159) (n ⫽ 382) (n ⫽ 304)
Age, y Mean ⫾ SD 25.68 ⫾ 6.38 25.48 ⫾ 6.39 24.84 ⫾ 5.86 24.99 ⫾ 6.09 25.25 ⫾ 6.13 25.22 ⫾ 6.23
High school Yes 58.5 (110) 58.6 (85) 63.4 (123) 64.2 (102) 61.0 (233) 61.5 (187)
Married/partner Yes 50.3 (94) 49.3 (71) 54.6 (106) 53.5 (85) 52.5 (200) 51.5 (156)
Foreign born Yes 44.1 (83) 44.1 (64) 34.5 (67) 35.2 (56) 39.3 (150) 39.5 (120)
Race/ethnic Black 35.6 (67) 35.9 (52) 38.7 (75) 36.5 (58) 37.2 (142) 36.2 (110)
Hispanic 54.8 (103) 56.6 (82) 55.2 (107) 56.6 (90) 55.0 (210) 56.6 (172)
Other 9.6 (18) 7.6 (11) 6.2 (12) 6.9 (11) 7.9 (30) 7.2 (22)
Medicaid Yes 53.7 (101) 52.4 (76) 58.2 (113) 61.0 (97) 56.0 (214) 56.9 (173)
Parity Other children 59.9 (109) 60.7 (85) 62.0 (116) 64.5 (98) 61.0 (225) 62.7 (183)
Breastfed before Yes 67.9 (74) 71.8 (61) 67.8 (80) 68.7 (68) 67.8 (154) 70.1 (129)
Intentions Only breast milk 33.0 (62) 28.9 (56) 32.4 (47) 28.3 (45) 30.9 (118) 30.3 (92)
Both 47.3 (89) 47.4 (92) 50.3 (73) 48.4 (77) 47.4 (181) 49.3 (150)
Only formula 8.5 (16) 10.3 (20) 7.6 (11) 9.4 (15) 9.4 (36) 8.6 (26)
Do not know 11.2 (21) 13.4 (26) 9.7 (14) 13.8 (22) 12.3 (47) 11.8 (36)
For each variable shown, both within-group differences and between-group differences among those assigned randomly versus those in
the outcomes data were tested for significance with ␹2 tests. None of these associations was significant at the .05 level.
* “Assigned” includes all women assigned randomly in the study.
† “Outcomes” includes mother/infant dyads included in the outcome data in the remaining tables. The following mother/infant dyads
were excluded from outcome analyses: women who lost the fetus (n ⫽ 9), lost custody/were separated from the infant (n ⫽ 1), changed
their minds (n ⫽ 5), or had twin births (n ⫽ 3) or for whom no breastfeeding outcome data were obtained (n ⫽ 60).

1416 TRIAL OFDownloaded

LACTATION CONSULTANT INTERVENTION
from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
women completed both English and Spanish ver-
sions of study instruments throughout the study.
Birth and Postpartum Experiences
Detailed data about the birth and immediate post-
partum experience were obtained at the 1-month
follow-up interview (Table 2). There were no signif-
icant differences between the groups in any of the
variables related to birth or infant morbidity, eg,
delivery time, infant discharged with mother, birth
type, low birth weight, time in NICU, or maternal
perception of newborn health problems. The health
centers’ affiliated hospital was the delivery site for
85% of births.
At the 1-month follow-up interview, we also ob-
tained data about when women considered their
feeding choice, prenatal care providers, and hospital
practices pertaining to feeding and onset of breast-
feeding. Again, there were no significant differences
between groups. Two thirds (67%) of women had
first thought about their feeding choice by the end of
the first trimester. However, less than one half (43%)
reported receiving advice about breastfeeding from
their prenatal care providers. Eighty-four percent
“roomed in” with their infants. Hospital staff mem-
bers asked 73% of women if they wanted to breast-
feed immediately after the birth. Although more
women in the intervention group (62%) attempted to
breastfeed in the first 4 hours, compared with control
subjects (52%), this difference was not significant.
There was no association between maternal percep-
tion of newborn illness and either breastfeeding
within the first 4 hours after birth or any subsequent
breastfeeding at 2, 4, or 13 weeks (data not shown).
Intervention Dose and Median Breastfeeding Intensity
Table 3 presents descriptive data on components
of intervention received, ie, “dose,” for the 145
women in the intervention group outcomes sample
and their corresponding TOTAL13 scores. Overall,
81% (n ⫽ 117) received any intervention. Sixty-four
percent had prenatal interventions, 63% had postna-
tal interventions, and 47% had both prenatal and
postnatal interventions. Approximately twice as
many women had a postnatal home visit (49%) or
telephone call (55%), compared with a hospital visit
(25%). Study LCs spent a mean of 111 minutes in
prenatal contact among the 93 women with any pre-
natal contact and a mean of 139 minutes in postnatal
contact among the 92 women with any postnatal
contact. Mean dose times averaged across all 145
women (ie, intention to treat) are also shown.
Unadjusted TOTAL13 scores are shown for partic-
ipants who received any of that intervention compo-
nent; women who received a hospital visit from the
LC might or might not have received home visits
and/or telephone calls. Scores were similar for
women who received 2 prenatal contacts (TOTAL13:
60.0), according to the protocol, compared with
women who received either 1 or 2 prenatal contacts
(TOTAL13: 61.0). Women who received a home visit
from the LC had a lower score (TOTAL13: 49.0),
indicative of greater breastfeeding, than did women
who did not. However, these unadjusted data must
be interpreted with caution.
To facilitate breastfeeding, women in the interven-
tion group were offered nursing bras and breast
pumps, free of charge. Nursing bras were given to
52 women. A total of 64 breast pumps (52 minielec-

TABLE 2. Birth and Postpartum Experiences

Variable Values Percentage (No.) P*
Intervention Control Sample
Study hospital (n ⫽ 301; missing: n ⫽ 3) Yes 84.0 (121) 85.4 (134) 84.7 (255) .750
No 16.0 (23) 14.6 (23) 15.3 (46)
Delivery time (n ⫽ 257; missing: n ⫽ 47) Day 53.3 (65) 42.2 (57) 47.5 (122) .076
Night 46.7 (57) 57.8 (78) 52.5 (135)
Left hospital with mother (n ⫽ 301; missing: n ⫽ 3) Yes 86.1 (124) 86.6 (136) 86.4 (260) .862
No 13.9 (20) 13.4 (21) 13.6 (41)
Birth type (n ⫽ 301; missing: n ⫽ 3) Vaginal 81.3 (117) 77.7 (122) 79.4 (239) .448
Cesarean 18.8 (27) 22.3 (35) 20.6 (62)
Birth weight (n ⫽ 301; missing: n ⫽ 3) Low birth weight 8.3 (12) 7.6 (12) 8.0 (24) .825
Normal weight 91.7 (132) 92.4 (145) 92.0 (277)
NICU (n ⫽ 301; missing: n ⫽ 3) Yes 14.6 (21) 12.1 (19) 13.3 (40) .526
No 85.4 (123) 87.9 (138) 86.7 (261)
Newborn health problems (n ⫽ 301; missing: n ⫽ 3) Yes 25.0 (36) 24.8 (39) 24.9 (75) .975
No 75.0 (108) 75.2 (118) 75.1 (226)
Roomed in (n ⫽ 301; missing: n ⫽ 3) Yes 83.3 (120) 84.1 (132) 83.7 (52) .862
No 16.7 (24) 15.9 (25) 16.3 (49)
First breastfeeding attempt (n ⫽ 263; missing: n ⫽ 41) 0–4 h 61.7 (82) 52.3 (68) 57.0 (150) .126
⬎4 h 38.2 (51) 47.7 (62) 43.0 (113)
Advised on breastfeeding by prenatal care provider Yes 43.1 (62) 43.3 (68) 43.2 (130) .964
(n ⫽ 301; missing: n ⫽ 3) No 56.9 (82) 56.7 (89) 56.8 (171)
Asked if wanted to nurse in delivery room by Yes 72.9 (97) 73.9 (116) 73.4 (213) .855
hospital staff (n ⫽ 290; missing: n ⫽ 14) No 27.1 (36) 26.1 (41) 26.6 (77)
When first considered how to feed infant (n ⫽ 299; Before pregnancy 21.7 (31) 18.6 (29) 20.1 (60) .956
missing: n ⫽ 5) First trimester 48.3 (69) 46.2 (72) 47.2 (141)
Later 30.1 (43) 35.3 (55) 32.8 (98)
* For each variable shown, both within-group differences and between-group differences for the assigned group versus the outcomes
sample were tested for significance with ␹2 tests. None of these associations was significant at the .05 level.

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020

ARTICLES 1417
TABLE 3. Intervention “Dose” and Breastfeeding Intensity at 13 Weeks
Intervention Subjects Receiving Dose* Dose Among All Median 13-wk
Intervention Subjects Breastfeeding Intensity
Percentage Dose Received, min, (n ⫽ 145), min, Scores† by Dose
(No.) Mean ⫾ SD Mean ⫾ SD Received
Prenatal
Any 64.1 (93) 110.70 ⫾ 25.82 65.1 ⫾ 57.53 61.0
2 prenatal visits 53.1 (77) 58.0 ⫾ 60.93 60.0
Postnatal
Any 63.4 (92) 138.92 ⫾ 74.96 78.2 ⫾ 87.00 54.5
Hospital visits 24.8 (36) 76.69 ⫾ 39.07 17.1 ⫾ 36.63 58.5
Home visits 49.0 (71) 73.31 ⫾ 32.51 32.4 ⫾ 42.17 49.0
Telephone calls 55.2 (80) 60.19 ⫾ 34.36 28.4 ⫾ 38.12 53.0
Prenatal and postnatal
Any 80.7 (117) 197.23 ⫾ 105.20 143.2 ⫾ 122.38 60.0
Both 46.9 (68) 78.2 ⫾ 87.00 58.5
* Data are based on the 145 intervention group women in the outcomes sample. Nineteen percent (n ⫽ 28) of intervention group women
in the outcomes sample did not have any contact with the LC.
† Higher values indicate greater intensity of formula feeding, and lower values indicate greater intensity of breastfeeding. The range of
intensity scores at 13 weeks was 13 to 91.

tric pumps and 12 manual pumps) were given out. A
few women required the use of a supplemental nurs-
ing system (n ⫽ 3) to induce lactation (data not
shown).
Weekly Breastfeeding Outcomes
Any Breastfeeding
Figure 2 presents data on any breastfeeding and
ⱖ50% breastfeeding, according to treatment group,
for selected weekly intervals up to 52 weeks. At 2
weeks, nearly 90% of the intervention group was
breastfeeding, compared with 65% of the control
group. The steepest decline in breastfeeding oc-
curred between 2 and 6 weeks, when rates decreased
by 15% and 10% in the intervention and control
groups, respectively. The intervention group was
significantly more likely to breastfeed at each week
up to and including week 20 (53.0% vs 39.3%; P ⬍
.028), with the exception of week 18. At 21 weeks (⬃5
months), 51.7% of the intervention group was still
breastfeeding. At the end of 12 months, 18% of the
intervention group and 15% of the control group
continued to breastfeed.
Breastfeeding of ⱖ50%
Significantly more women in the intervention
group gave ⱖ50% breast milk feedings in the first 1
week after birth (69% vs 47%; P ⬍ .001). More than
one half of the intervention group gave their infants
ⱖ50% breast milk through the first 6 weeks after
birth. Group differences remained significant for

Fig 2. Any and ⱖ50% breastfeeding, according to treatment group. Breastfeeding of ⱖ50% was significant up to and including week 9
(P ⬍ .03). Any breastfeeding was significant up to and including week 20 (P ⬍ .028), except for week 18.

1418 TRIAL OFDownloaded

LACTATION CONSULTANT INTERVENTION
from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
each week up to and including week 9 (45.8% vs
33.1%; P ⬍ .030).
Breastfeeding Intensity in Weeks 1 to 52
Figure 3 presents descriptive, unadjusted, weekly
feeding data for the intervention group (Fig 3A) and
the control group (Fig 3B). Data are shown for 5
levels of breastfeeding intensity, reduced from 7, ie,
exclusive breastfeeding, more breast milk than for-
mula, equal breast milk and formula, less breast milk
than formula, or exclusive formula feeding. Exclu-
sive breastfeeding rates, which peaked at 2 weeks
(intervention: 20%; control: 19%), decreased at 6
weeks (intervention; 15%; control: 16%), and contin-
ued to decline at 13 weeks (intervention: 9%; control:
11%), 26 weeks (intervention: 5%; control: 8%), and
52 weeks (intervention: 6%; control: 5%), were not
significantly different at any of the 52 weeks ob-
served (data not shown).
Table 4 presents unadjusted TOTAL13 and TO-
TAL52 scores stratified according to treatment group
and country of origin. Separate scores are shown for
participants according to parity (total sample vs par-
ity of ⱖ1 at baseline) to permit inclusion of the vari-
able for prior breastfeeding. US-born control subjects
had significantly higher scores than did the foreign-
born control, foreign-born intervention, or US-born
intervention groups (P ⬍ .05). No other treatment
groups, according to country of origin, differed sig-
nificantly from one another. Higher 52-week scores
for all groups indicated the progression to greater
formula feeding.
We performed multiple logistic regression analysis
of the dichotomized median breastfeeding intensity
scores, stratified according to week and parity. Re-
sults shown in Table 5 include the interaction be-
tween treatment group and country of origin. Effects
of the remaining covariates were essentially un-
changed in a logistic regression model excluding this
interaction. Thus, Table 5 presents only the treatment
group effect from that model. ORs adjusted for sig-
nificant covariates, 95% CIs, and estimated R2 values
are presented for the 4 models. The OR indicates the
“risk” of low versus high levels of breastfeeding,
compared with the reference category.
The intervention’s effect was modified signifi-
cantly by country of origin in multivariate analysis.
US-born control subjects had significantly greater
risk of low breastfeeding at 13 weeks in both the
entire sample (OR: 5.22; 95% CI: 2.43–11.22) and the
subsample (OR: 7.66; 95% CI: 2.75–21.36), compared
with the foreign-born women in the intervention
group. Similar results were found at 52 weeks.
Among the foreign-born women, there was no sig-
nificant difference between the intervention group
and the control group, neither of which differed from
US-born women in the intervention group. There-
fore, the intervention reduced the risk of low breast-
feeding among US-born women to the levels found
in foreign-born women.
In analyses without the interaction term, control
subjects had greater risk of low breastfeeding levels,
across the 4 models. ORs were greater at 52 weeks for
both the entire sample (OR: 2.50; 95% CI: 1.48 – 4.21)
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
and the subsample (OR: 4.47; 95% CI: 2.13–9.36),
compared with 13 weeks for both the entire sample
(OR: 1.90; 95% CI: 1.13–3.20) and the subsample (OR:
3.71; 95% CI: 1.81–7.59). As noted above, estimates
for covariates were essentially unchanged from the
model excluding the interaction between treatment
group and country of origin.
With respect to other significant covariates,
women intending to formula feed exclusively at
baseline had significantly greater risk of low breast-
feeding at 13 weeks in the entire sample (OR: 10.51;
95% CI: 2.97–37.15), compared with women intend-
ing exclusive breastfeeding, with similar results in
the other 3 models. Intent to combine formula and
breastfeeding was not associated significantly with
risk of low breastfeeding in 3 of the 4 models.
Women who were undecided about their feeding
choice had a greater risk of low breastfeeding at 13
and 52 weeks in the entire sample but not in the
subsample with parity of ⱖ1. Older age, both dichot-
omized at 24 years and as a continuous variable, was
associated with reduced risk of low breastfeeding.
Black women had significantly reduced risk of low
breastfeeding at 13 weeks (OR: 0.44; 95% CI: 0.24 –
0.79) and 52 weeks (OR: 0.37; 95% CI: 0.20 – 0.67),
compared with a Hispanic reference group. Among
women with other children, not having breastfed a
previous child was significant at 52 weeks (OR: 2.91;
95% CI: 1.24 – 6.83) but not 13 weeks.
DISCUSSION
We performed a randomized, controlled trial of an
individualized, LC, prenatal and postnatal, breast-
feeding-promotion intervention modeled on best
practices found in the literature. At 3 and 12 months,
control subjects receiving standard care in urban pri-
mary care health centers had 90% and 150% in-
creased risk of low breastfeeding, respectively, com-
pared with the intervention group. The intervention
group achieved the Healthy People 2000 goal of 50%
continued breastfeeding up to 5 or 6 months37 but
did not sustain this level at 6 months, which is the
Healthy People 2010 goal.16 By comparison, the con-
trol subjects’ 6-month breastfeeding rate of 33%
matched national survey data from one source exact-
ly19 and approximated the rate from another national
data source (36%).38 Unfortunately, we observed
similar rates of exclusive breastfeeding in the 2
groups, which suggests that the intervention was not
effective in helping women to breastfeed exclusively.
Exclusive breastfeeding, which peaked at 20% at 2
weeks in our study, was proposed as a Healthy
People 2010 goal in the mid-course review.39
Our most striking finding was the strength with
which country of origin modified the effect of treat-
ment group. Our previous work on feeding inten-
tions36 and other work on breastfeeding initiation40
and ever breastfeeding41 found that foreign-born
women in the United States are predisposed to
breastfeed, compared with their native-born counter-
parts. In this study, US-born women were 5 to 8
times as likely to have low breastfeeding intensity,
depending on observation period and parity, com-
pared with the foreign-born control, foreign-born in-
ARTICLES
1419
 Fig 3. Feeding mixture in weeks 1 to 26 for the intervention group (A) and the control group (B).

tervention, and US-born intervention groups. In fact,
the mean breastfeeding intensity scores for the latter
3 groups did not differ significantly from one an-
other. Therefore, our intervention was highly effec-
tive in raising the breastfeeding level of US-born
women to that of foreign-born women, whose scores
did not differ according to treatment group.
In contrast to the aforementioned results, race/
ethnicity did not modify the effect of treatment
group significantly. That is, the intervention was no
more effective among one racial/ethnic group than
another. Furthermore, in sharp contrast to recent
national studies,18,19 black women were 50% to 60%
more likely to have a high intensity of breastfeeding,
compared with a reference group of women who
identified themselves as Hispanic. Presumably, this
finding is related to demographic distributions in the
study’s locale, ie, New York City. New York City
experienced a 41% increase in the West Indian pop-
ulation between 1990 and 2000, nearly all of whom
identify themselves as black. West Indians repre-
sented 25% of the black population of New York City
in 2000.42 Compared with the United States, West
Indian nations have considerably higher rates of any
and exclusive breastfeeding and longer duration of
breastfeeding.43–47 Presumably, in areas with high
concentrations of immigrant groups from countries
where breastfeeding is the standard, there is likely to
be both greater acceptance of breastfeeding and in-
formal support.

1420 TRIAL OFDownloaded

LACTATION CONSULTANT INTERVENTION
from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
 TABLE 4. Unadjusted Breastfeeding Intensity Scores at 13 and 52 Weeks, According to Treatment
Group and Country of Origin
Intensity Score, Median (No.)
Intervention Control
US Born* Foreign Born* US Born* Foreign Born*
13 wk (range: 13–91)
All 61 (81) 51 (64) 88 (103) 53 (56)
Baseline parity of ⱖ1 49 (48) 43 (37) 87 (63) 51 (36)
52 wk (range: 52–364)
All 309 (81) 301 (64) 360 (103) 304 (56)
Baseline parity of ⱖ1 299 (48) 267 (37) 360 (63) 277 (36)
Median weekly intensity scores ranged from 1 (all breast milk) to 7 (all formula feeding). Higher scores
indicate greater formula feeding, whereas lower scores indicate greater breastfeeding. US born
denotes the US mainland and Hawaii. Given linguistic and cultural differences, participants born in
Puerto Rico were considered foreign born, although Puerto Rico is a US territory.
* The US-born control group differed significantly from all other groups at 13 and 52 weeks, both for
the entire sample and for the subsample with baseline parity of ⱖ1 (P ⬍ .05, analysis of variance,
Duncan’s multiple-comparisons test). No other groups differed significantly from one another.

In findings similar to ours, Celi et al40 found that
foreign-born women were more likely to initiate
breastfeeding than US-born women (OR: 3.2; 95% CI:
2.0 –5.2), in multivariate analyses controlling for
race/ethnicity. In addition, they found no material
difference in initiation rates among US-born white,
black, and Hispanic women.40 Those data and ours
differ from analyses of the National Survey of Family
Growth, which found that black women were 60%
less likely to have ever breastfed than were nonblack
women, even after controlling for country of origin.
Foreign-born women were 75% more likely than US-
born women to have ever breastfed in that study.41
The studies cited above were based on observa-
tional data. They are unable to predict who would
derive the most benefit from an intensive interven-
tion, such as the one tested in this study. Our find-
ings with regard to country of origin and race/eth-
nicity are valuable for targeting future interventions.
National data consistently place non-Hispanic black
women at greatest risk for not initiating or limiting
breastfeeding.18,19,41 We posit that race/ethnicity
may matter less than cultural background in deter-
mining who would benefit most from future inter-
ventions.
Our findings with regard to baseline feeding in-
tentions underscore the importance of prenatal coun-
seling to increase knowledge about the benefits of
breastfeeding (and risks of not doing so) and to
identify and to overcome perceived barriers to
breastfeeding. Compared with women who intended
to breastfeed their new infants exclusively, women
who intended only formula feeding were 10 to 14
times more likely, depending on observation period
and parity, to have low breastfeeding intensity. Con-
cerns about pain and breastfeeding in public and an
unsupportive work environment can be potential
barriers to breastfeeding, particularly among low-
income women.48,49 Individualized counseling, such
as that provided by the study LCs, can help women
strategize about how best to address these potential
barriers.
Data on breastfeeding duration and amount were
used to derive both short-term (13 weeks, ie, 3
months) and long-term (52 weeks) measures of
breastfeeding intensity. These outcome measures,
which represent cumulative rather than prevalent
feeding patterns, contrast with how data on breast-
feeding generally are collected and presented. Com-
pared with the intervention group, control subjects
had increased odds of low breastfeeding of 90% at 13
weeks and 150% at 52 weeks. Although intervention
contacts were concentrated in the early postpartum
period, cumulative data show how effects persisted
over the long term.
In our study, differences in breastfeeding out-
comes cannot be attributed to differences in the birth
and immediate postpartum experiences, which were
nearly identical for the 2 groups. Essentially the same
large proportions of women in the 2 groups had their
infants at the centers’ affiliated hospital, thus reduc-
ing the risk of bias associated with hospital practice.
In addition, this facilitated LC access to participants,
because we were notified about births at that hospi-
tal. Immediate postpartum experiences were similar,
in terms of women being asked if they wanted to
breastfeed in the delivery room and breastfeeding in
the first 4 hours after birth.
A particular strength of our study is the collection
of detailed weekly feeding data up to 52 weeks.
Surveys, particularly those based on large, popula-
tion-based samples, tend to assess only partial or
exclusive breastfeeding. Without a full assessment of
breastfeeding practices, it is difficult to tailor inter-
ventions. In addition, limited outcomes assessments
(eg, at 6, 12, and 16 weeks) can obscure and/or
distort true differences. For instance, our finding that
the intervention group reached the Healthy People
2000 goal of continued breastfeeding to 5 or 6 months
would have been obscured had we collected data
only at week 26 and not week 20 and week 21 (⬃5
months). Conversely, reporting a significant differ-
ence in ⱖ50% breast milk at week 26 (⬃4 months)
would have been a distortion, given the lack of sig-
nificance in intervening weeks 10 to 14 and from
week 17 up to week 52.
Our intervention was innovative, in that it com-
bined multiple skills-based and supportive compo-
nents, with early prenatal education and support and
immediate hospital and home availability. The US

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020

ARTICLES 1421
 1422
TABLE 5. Odds of Low Versus High Breastfeeding at 13 and 52 Weeks
Variable Values OR (95% CI)

TRIAL OFDownloaded
13 wk 52 wk

LACTATION
All (n ⫽ 304) Baseline Parity of ⱖ1 All (n ⫽ 304) Baseline Parity of ⱖ1
(n ⫽ 184) (n ⫽ 184)
Intent at baseline Undecided 3.04* (1.22–7.58) 2.52 (0.66–9.64) 3.02* (1.21–7.56) 3.30 (0.81–13.48)
Formula 10.51* (2.97–37.15) 14.20* (2.50–80.73) 10.05* (3.04–33.20) 11.08* (2.19–56.14)
Combined 1.57 (0.85–2.87) 1.21 (0.55–2.70) 2.22* (1.19–4.15) 2.36 (1.00–5.56)
Breast milk 1.00 1.00 1.00 1.00
Logarithm of age† Years 0.92* (0.88–0.96) 0.91* (0.86–0.98)
Age ⬍24 y 0.95 (0.90–1.01) 3.15* (1.83–5.42)
⬎24 y 1.00 1.00
Race/ethnicity Black 0.44* (0.24–0.79) 0.37* (0.20–0.67)
Other 1.75 (0.60–5.13) 1.40 (0.48–4.10)
Hispanic 1.00 1.00
Treatment group/country of origin‡ Control/US born 5.22* (2.43–11.22) 7.66* (2.75–21.36) 5.25* (2.44–11.29) 8.05* (2.84–22.78)
Control/foreign born 0.90 (0.40–2.04) 1.37 (0.42–4.48) 1.06 (0.47–2.40) 1.40 (0.43–4.56)
Intervention/US born 1.67 (0.78–3.53) 1.22 (0.41–3.67) 1.15 (0.54–2.45) 0.91 (0.30–2.74)

CONSULTANT INTERVENTION
Intervention/foreign born 1.00 1.00 1.00 1.00
Medicaid No 1.05 (0.61–1.82) 0.71 (0.41–1.23)
Yes 1.00 1.00
Breastfed before No 1.79 (0.79–4.04) 2.91* (1.24–6.83)
Yes NA 1.00 NA 1.00
Model r2 0.24 0.28 0.25 0.32
Treatment group§ Control 1.90* (1.13–3.20) 3.71* (1.81–7.59) 2.50* (1.48–4.21) 4.47* (2.13–9.36)
Intervention 1.00 1.00 1.00 1.00
Breastfeeding intensity scores were dichotomized at the median. ORs indicate the risk of low breastfeeding, compared with the reference category.
* P ⬍ .05.
† For ease of interpretation, we present the effect for age, although the model was analyzed with the logarithm of age.
‡ US born denotes the US mainland and Hawaii. Although Puerto Rico is a US territory, women born in Puerto Rico were classified as foreign born, given cultural and linguistic differences.
§ These treatment group ORs and 95% CIs were derived from an alternative logistic regression model that used the same set of significant covariates except that treatment group was used in place
of the treatment group-country of origin interaction terms. ORs and 95% CIs for covariates in the alternative logistic regression model were essentially unchanged from those shown.

from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020

Preventive Services Task Force meta-analysis found
that educational programs had the greatest effect of
any single intervention on both initiation (mean dif-
ference: 0.23%; 95% CI: 0.12– 0.34) and short-term
duration (mean difference: 0.39%; 95% CI: 0.27– 0.50).
In-person and/or telephone support increased short-
term duration (mean difference: 0.11%; 95% CI: 0.03–
0.19) and long-term duration (mean difference:
0.08%; 95% CI: 0.02– 0.16). Notably, the number of
subjects included in the meta-analysis of combined
effects of education and support for initiation (n ⫽
170), short-term duration of up to 3 months (n ⫽
163), and long-term duration of 4 to 6 months (n ⫽
168) was smaller than our outcomes sample of 304.28
Another strength of our intervention was the per-
sonalized continuity of care that our LCs provided
across the prenatal and postnatal periods. Our LCs
reported that taking the time to develop a rapport
with each woman contributed to their effectiveness.
Prenatal LC sessions lasted 1 to 2 hours, exceeding
the 15 to 30 minutes estimated at the study’s incep-
tion. This time investment during the prenatal period
is credited with the women trusting and accepting
LC support and advice in the postpartum period.25
Postnatally, women who received a home visit from
the LC had lower TOTAL13 scores (ie, greater breast-
feeding intensity) than did those who did not, which
suggests that home visits made an important contri-
bution to the intervention’s success. However, as
noted earlier, these unadjusted data must be inter-
preted with caution. Although results are suggestive,
additional analyses beyond the scope of this report
are needed to understand more completely the ef-
fects of various components of the intervention, con-
trolling for covariates such as prenatal feeding inten-
tions and parity.
A caveat to our work, and a question for future
research, is what impact, if any, pumped milk and
breast pumps have on breastfeeding. As noted ear-
lier, although study LCs generally discouraged
breast pump use unless the mother was separated
from her infant, breast pumps were provided free of
charge to intervention group women under certain
circumstances. We did not collect data on the source
of the infant’s breast milk. However, anecdotal data
from women in both groups suggested strong inter-
est in the use of breast pumps as a means of avoiding
inconvenience or the embarrassment of nursing in
public. Particularly for younger mothers (eg, ⬍18
years of age), breast pump use might have contrib-
uted to increased breastfeeding duration and inten-
sity.
This trial was based on an intention-to-treat
model. This model preserves the balance of random-
ization, is statistically conservative (biases toward
the null hypothesis), and simulates nonresearch sit-
uations. Reflecting the vulnerable population served
by the health centers, nearly 20% of the intervention
outcomes sample did not receive the intervention,
36% did not have a prenatal contact, and 37% did not
have a postnatal contact. Less than one half (47%)
had both prenatal and postnatal contacts. However,
we still found significant differences in breastfeeding
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
duration and intensity in this hard-to-reach, socio-
economically disadvantaged population.
In a prospective study, some loss to follow-up is
inevitable. Given the nature of our population and
the length of planned follow-up monitoring (52
weeks), we view our retention rates as a relative
success. Among the 304 women in our outcomes
sample, infant feeding data were obtained for 91% at
3 months, 83% at 6 months, 75% at 9 months, 65% at
11 months, and 56% at 12 months. Missing data
implications were minimized by several factors.
First, feeding patterns are most labile in the first 6
months, and feeding data were available for 83% of
participants through that time. Second, given the
trend toward increased formula feeding over time,
our imputation of the treatment group’s median
weekly value for missing weeks is statistically con-
servative. Third, the potential for bias was reduced
by the fact that participants lost to follow-up moni-
toring at 2, 3, 4, 6, 8, 10, and 12 months did not differ
from those retained at those months, with respect to
major covariates.
This was a labor-intensive intervention. Accord-
ingly, we sought to develop a general estimate of the
average cost per woman for this level of intervention,
assuming that the LC was a health center employee
and not a consultant. This estimate, which was based
on an intention-to-treat model and included costs for
travel, supplies, and labor (wage, indirect, and fringe
costs), in 2003 was $266 per woman throughout the
prenatal and postnatal periods. Additional informa-
tion on the calculation of this estimate was reported
elsewhere.35
Potential recall bias in maternal self-reports of
breastfeeding might have resulted in nondiffer-
ential misclassification or over-reporting of breast-
feeding. Nondifferential misclassification would
bias results toward the null hypothesis. Over-report-
ing of breastfeeding, particularly in the intervention
group, might occur if women provided socially de-
sirable answers, particularly if they developed a
strong relationship with the LC. Interestingly, in exit
interviews conducted for this study, some control
group women stated that the postpartum interviews
made them more conscious of how they fed their
infant. One woman in the control group stated spe-
cifically that she kept breastfeeding to 3 or 4 months
because she knew the interviewer would ask.25 Un-
der-reporting of breastfeeding is unlikely, given
similar feeding intentions at baseline. Mothers can
reliably recall breastfeeding duration over many
years,50,51 particularly for infants, with no difference
in accuracy of recall according to educational level,
parity, or number of children.52 No published work
validates maternal self-reports of varying levels of
breastfeeding intensity. Population-based studies re-
port either duration according to limited intensity
(exclusive versus nonexclusive) or duration (without
any intensity) and do not validate maternal self-
reports.
Related to this, some women found the Index of
Breastfeeding Status, which asks for estimates of
breast milk given to their infant, to be confusing.
Research staff members first asked whether the in-
ARTICLES
1423
fant received more breast milk than formula and
then tried to quantify the amount by asking how
many feedings of 10 this would correspond to for a
given week. One alternative would be to ask how
times per day or week, in the past 7 days, the infant
was fed each item from a list (eg, breast milk, for-
mula, 100% juice, sweet drinks, or infant cereal). This
approach, used in the Food and Drug Administra-
tion 1993–1994 Infant Feeding Practices Study53 and
its successor, which is currently underway in the
field, may provide a better estimate of the proportion
of all intake from breast milk. The disadvantage is
that this level of detail is likely to be unreliable over
longer recall periods, such as those used in our
study.
A limitation of our intervention was that study
LCs functioned as outside research consultants.
Therefore, it was incumbent on them to schedule the
prenatal intervention sessions at the clinic when
women were there for prenatal visits. With this vul-
nerable sample, for which there is an estimated
missed appointment rate of 40% for prenatal care
visits, scheduling these sessions was difficult. Fur-
thermore, the LCs did not have a routine presence or
dedicated office space and were not part of the wom-
en’s health care team. This impeded our ability to
make prenatal contacts and might have diminished
the potency of the intervention.
Another limitation of the intervention was the low
postpartum hospital contact rate (25%). Some
women, when telephoned at the hospital, declined a
LC visit at that time but were later seen at home
(home contact rate: 49%). This is consistent with our
observation that some women preferred to initiate
breastfeeding in the privacy of their homes, rather
than in the busy hospital setting. Other women de-
clined a visit altogether, either because they were
formula feeding exclusively or because they stated
that they did not need LC assistance. Delays in
timely notification of the birth and LC scheduling
problems also contributed to this low hospital con-
tact rate.
A trial similar to ours, a randomized, nonblinded,
clinical, controlled trial of prenatal and postnatal LC
support (including the hospital) among low-income
women, found significant differences in breastfeed-
ing duration until 2 months of age (37% for the
intervention group, compared with 9% for the con-
trol group).54 In contrast, treatment group differ-
ences persisted up to 20 weeks in our study (53% for
the intervention group, compared with 39% for the
control group). Furthermore, the potential for bias
was significant in that trial, because the study LC
assessed breastfeeding outcomes.
Recently published findings from randomized tri-
als of combined prenatal and postnatal interventions
show differences in outcomes according to the inten-
sity of the intervention. A randomized, controlled
trial of prenatal provider counseling, combined with
(primarily) phone availability of an LC postpartum,
had no effect on any breastfeeding or exclusive
breastfeeding (Netherlands).55 In a low-income US
Latina population, prenatal (n ⫽ 1), daily perinatal,
and postpartum home visits (n ⫽ 3) from a peer
1424 TRIAL OFDownloaded
LACTATION CONSULTANT INTERVENTION
from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
counselor resulted in lower but not statistically sig-
nificant differences in duration. 56 In a similar pop-
ulation, a more intensive intervention of prenatal
home visits (n ⫽ 3), daily hospital visits, and post-
partum home visits (n ⫽ 9) resulted in significantly
higher exclusive breastfeeding at 3 months (20.6% vs
1.4% of controls).57 Thus considerable effort will be
required to reach the proposed Healthy People 2010
goal of 60% exclusive breastfeeding at 3 months.
In the future, interventions must target exclus-
ivity, beginning in the prenatal period. Breastfeeding
intensity ratios (breast milk/all liquid nutrition)
over the first 6 months are associated strongly with
breastfeeding duration.58 In other work, prenatal in-
tent to combine breast milk and formula resulted in
shorter planned and actual duration,59 whereas in
our study a prenatal intention other than exclusive
breastfeeding was associated significantly with low
breastfeeding intensity at 3 and 12 months. Further-
more, protective effects are dose-responsive.12,15,60,61
Minimal breastfeeding may not be protective.12 A
meta-analysis of hospitalizations for treatment of
lower respiratory tract disease found a summary
relative risk of 0.28 (95% CI: 0.14 – 0.54) conferred
by exclusive breastfeeding for ⬎4 months.62 There
may be a threshold effect for certain outcomes, be-
cause 3 vs 6 months of exclusive breastfeeding were
equivalent in several measures (not hospitalization)
in a large cohort.63 However, the most recent state-
ments from the American Academy of Pediatrics
and the World Health Organization define the opti-
mal duration of exclusive breastfeeding as 6
months.1,14
Goals and interventions targeted toward sustained
exclusive breastfeeding are more relevant than those
focused solely on any breastfeeding. The primary
message of the National Breastfeeding Awareness
Campaign, a multimedia effort launched in 2004, is
that exclusive breastfeeding for 6 months reduces an
infant’s risk of ear infections, gastrointestinal ill-
nesses, and respiratory illnesses and may prevent
obesity.64 Our findings support the focus of and need
for such a nationwide effort. In addition, individual-
ized continuity of care provided by interventions
such as ours are indicated to achieve the pending
Healthy People 2010 goals of 25% exclusive breast-
feeding at 3 and 6 months, as proposed at the last
interim review (Rosie Li, MD, PhD, written commu-
nication, March 4, 2005).
Our study LCs had the proper skills and profes-
sional orientation to deliver the intervention. How-
ever, they were hampered by their consultant status.
A routine clinic and hospital presence (ie, “round-
ing”) would most likely increase prenatal and post-
natal contact rates, particularly for hard-to-reach
populations. The intervention’s effectiveness would
likely increase with prenatal care provider encour-
agement; mothers receiving such encouragement are
less likely to discontinue feeding ⱖ50% breast milk
at 3 months.65 We think that routinely offered, indi-
vidualized, breastfeeding education and support,
with clinician encouragement, in the prenatal period
and continued support throughout the postpartum
period up to 12 months will result in a higher inten-
sity of breastfeeding in the short and long term. In
socioeconomically disadvantaged populations, na-
tive-born women are at particular risk for low inten-
sity of breastfeeding.
ACKNOWLEDGMENTS
This study was supported by grants from the United States
Department of Agriculture, the Maternal and Child Health Bu-
reau, and the Agency for Healthcare Quality and Research.
REFERENCES
1. American Academy of Pediatrics, Section on Breastfeeding. Breastfeed-
ing and the use of human milk. Pediatrics. 2005;115:496 –506
2. Lawrence R. A Review of the Medical Benefits and Contraindications to
Breastfeeding in the United States. Arlington, VA: Maternal and Child
Health Bureau; 1997
3. Aniansson G, Alm B, Andersson B, et al. A prospective cohort study on
breastfeeding and otitis media in Swedish infants. Pediatr Infect Dis J.
1994;13:183–188
4. Pisacane A, Impagliazzo N, De Caprio C, Criscuolo L, Inglese A, Pereira
de Silva MC. Breastfeeding and tonsillectomy. BMJ. 1996;312:746 –747
5. Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM.
Exclusive breastfeeding for at least 4 months protects against otitis
media. Pediatrics. 1993;91:867– 872
6. Knishkowy B, Palti H, Adler B, Tepper D. Effect of otitis media on
development: a community based study. Early Hum Dev. 1991;26:
101–111
7. Alho OP, Koivu M, Sorri M, Rantakallio P. Risk factors for recurrent
acute otitis media and respiratory infection in infancy. Int J Pediatr
Otorhinolaryngol. 1990;19:151–161
8. Burr ML, Limb ES, Maguire MJ, et al. Infant feeding, wheezing, and
allergy: a prospective study. Arch Dis Child. 1993;68:724 –728
9. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and
infections during the first six months of life. J Pediatr. 1995;126:191–197
10. Pisacane A, Graziano L, Zona G, et al. Breastfeeding and acute lower
respiratory infection. Acta Paediatr. 1994;83:714 –718
11. Sinha A, Madden J, Ross-Degnan D, Soumerai S, Platt R. Reduced risk
of neonatal respiratory infections among breastfed girls but not boys.
Pediatrics. 2003;112(4). Available at: www.pediatrics.org/cgi/content/
full/112/4/e303
12. Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity
between breast-fed and formula-fed infants. J Pediatr. 1995;126:696 –702
13. Baker D, Taylor H, Henderson H. Inequality in infant mortality: causes
and consequences in England in the 1990s. J Epidemiol Community
Health. 1998;52:451– 458
14. Kramer MS, Kakuma R. The Optimal Duration of Exclusive Breastfeeding:
A Systematic Review. Geneva, Switzerland: World Health Organization;
2002
15. Raisler J, Alexander C, O’Campo C. Breastfeeding and infant illness: a
dose-response relationship. Am J Public Health. 1999;90:1478 –1479
16. US Department of Health and Human Services. Healthy People 2010.
Washington, DC: US Department of Health and Human Services, Public
Health Service, Office of the Assistant Secretary for Health; 2000
17. Li R, Grummer-Strawn L. Racial and ethnic disparities in breastfeeding
among United States infants: Third National Health and Nutrition
Examination Survey, 1988 –1994. Birth. 2002;29:251–257
18. Li R, Darling N, Maurice E, Barker L, Grummer-Strawn LM. Breastfeed-
ing rates in the United States by characteristics of the child, mother, or
family: the 2002 National Immunization Survey. Pediatrics. 2005;115(1).
Available at: www.pediatrics.org/cgi/content/full/115/1/e31
19. Ryan AS, Wnejun Z, Acosta A. Breastfeeding continues to increase into
the new millennium. Pediatrics. 2002;110:1103–1109
20. US Preventive Services Task Force. Behavioral Intentions to Promote
Breastfeeding: Recommendations and Rationale. Rockville, MD: Agency for
Healthcare Research and Quality; 2003. Available at: www.ahrq.gov/
clinic/3rduspstf/brstfeed/brfeedrr.htm. Accessed February 2, 2005
21. de Oliveria MIC, Camacho LAB, Tedstone AE. Extending breastfeeding
duration through primary care: a systematic review of pre-natal and
post-natal interventions. J Hum Lact. 2001;17:326 –343
22. Renfrew MJ, Lang S, Woolridge MW. Early versus delayed initiation of
breastfeeding. Cochrane Database Syst Rev. 2000;(2):CD000043
23. Renfrew MJ, Lang S, Martin L, Woolridge MW. Feeding schedules in
hospitals for newborn infants. Cochrane Database Syst Rev. 2000;(2):
CD000090
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
24. Dyson L, McCormick F, Renfrew MJ. Interventions for promoting the
initiation of breastfeeding. Cochrane Database Syst Rev. 2005;(3)
25. Memmott M, Bonuck K. Mother’s reactions to a skills-based breastfeed-
ing promotion intervention. Matern Child Nutr J. 2006: In press
26. Hoddinott P, Pill R. A qualitative study of women’s views about how
health professionals communicate about infant feeding. Health Expect.
2000;3:224 –233
27. Graffy J, Taylor J, Williams A, Eldridge S. Randomised controlled trial
of support from volunteer counselors for mothers considering breast
feeding. BMJ. 2004;328:26
28. Guise JM, Palda V, Westhoff C, et al. The effectiveness of primary-care
based interventions to promote breastfeeding: systematic evidence re-
view and meta-analysis for the US Preventive Services Task Force. Ann
Fam Med. 2003;1:70 – 80
29. Bosworth W. Discovering the Bronx: using census data to highlight
social problems and achievements in a major urban area. Available at:
www.lehman.edu/deannss/bronxdatactr/discover/bxtime.htm. Ac-
cessed October 14, 2005
30. Read JS, American Academy of Pediatrics, Committee on Pediatric
AIDS. Human milk, breastfeeding, and transmission of human immu-
nodeficiency virus type 1 in the United States. Pediatrics. 2001;112:
1196 –1205
31. Damato EG, Dowling DA, Madigan EA, Thanattherakul C. Duration of
breastfeeding for mothers of twins. J Obstet Gynecol Neonatal Nurs.
2005;34:201–209
32. Anderson GC, Chiu SH, Morrison B, Burkhammer M, Ludington-Hoe
SM. Skin-to-Skin Care for Breastfeeding Difficulties Postbirth. New Bruns-
wick, NJ: Johnson & Johnson; 2005
33. Cadwell CM. Defining breastfeeding in research. In: Cadwell K, ed.
Reclaiming Breastfeeding for the United States: Protection, Promotion, and
Support. Sudbury, MA: Jones & Bartlett; 2002:81– 89
34. Moore E. Randomized Controlled Trial of Early Mother-Infant Skin-to-Skin
Contact on Breastfeeding Success. Nashville, TN: Vanderbilt University
School of Nursing; 2003. Dissertation
35. Bonuck K. Economic Benefits of a Breastfeeding Promotion Intervention: A
Controlled Clinical Trial—Final Report to USDA Food and Nutrition Re-
search Program. Washington, DC: US Department of Agriculture; 2004.
Project 43-3AEM-9-80102
36. Bonuck KA, Freeman K, Trombley M. Country of origin and race/
ethnicity: impact on breastfeeding intentions. J Hum Lact. 2005;21:
320 –326
37. US Department of Health and Human Services. Healthy People 2000:
National Health Promotion and Disease Prevention Objectives. Washington,
DC: Government Printing Office; 1990:379 –380. US Department of
Health and Human Services publication PHS 91–50212
38. Centers for Disease Control and Prevention. Breastfeeding: data and
statistics: breastfeeding practices—results from the National Immuni-
zation Survey. Available at: http://origin.cdc.gov/breastfeeding/
data/NIS_data. Accessed October 14, 2005
39. US Department of Health and Human Services. Healthy People
2010 midcourse review: 16 –19. Breastfeeding. Available at
www.healthypeople.gov/data/midcourse/comments/faobjective.asp?
id⫽16&subid⫽19. Accessed October 14, 2005
40. Celi AC, Rich-Edwards JW, Richardson MK, Kleinman KP, Gillman
MW. Immigration, race/ethnicity, and social and economic factors as
predictors of breastfeeding initiation. Arch Pediatr Adolesc Med. 2005;159:
255–260
41. Forste R, Weiss J, Lippincott E. The decision to breastfeed in the United
States: does race matter? Pediatrics. 2001;108:291–296
42. US Bureau of the Census. 1990 US Census Data. Washington, DC: US
Bureau of the Census; 1990. STF3, Tables P008 and P033
43. Shane B. Survey report: Jamaica. Popul Today. 1989;17(11):5
44. Scarlett D, Cargill M, Lyn-Sue J, Richardson S, McCaw-Binns A. Breast-
feeding prevalence among six-week-old infants at University Hospital
of the West Indies. West Indian Med J. 1996;45:14 –17
45. Nichols S, Dillon-Remy M, Thomas-Murray T, Baker N. Socio-
demographic and health system factors in relation to exclusive breast-
feeding in Tobago. West Indian Med J. 2002;51:89 –92
46. Perez-Escamilla R. Breastfeeding patterns in nine Latin American and
Caribbean countries. Bull Pan Am Health Organ. 1993;27:32– 42
47. Galler JR, Ramsey FC, Harrison RH, et al. Infant feeding practices in
Barbados predict altered growth. J Nutr. 1998;128:1328 –1335
48. Mitra AM, Khoury AJ, Hinton AW, Carothers C. Predictors of breast-
feeding intention among low income women. Matern Child Health J.
2004;8:65–70
49. Bentley ME, Dee DL, Jensen JL. Breastfeeding among low income
African-American women: power, beliefs and decision making. J Nutr.
2003;133:305S–309S
ARTICLES 1425
50. Kark JD, Troya G, Friedlander Y, Slater PE, Stein Y. Validity of maternal
reporting of breastfeeding history and the association with blood lipids
in 17 year olds in Jerusalem. J Epidemiol Community Health. 1984;38:
218 –225
51. Troy LM, Michels KB, Hunter DJ, et al. Self-reported birthweight and
history of having been breastfed among younger women: an assessment
of validity. Int J Epidemiol. 1996;25:122–127
52. Eaton-Evans J, Dugdale AE. Recall by mothers of the birth weights and
feeding of their children. Hum Nutr Appl Nutr. 1986;40:171–175
53. Scariati PD, Grummer-Strawn LM, Fein SB. A longitudinal analysis of
infant morbidity and the extent of breastfeeding in the United States.
Pediatrics. 1997;99(6). Available at: www.pediatrics.org/cgi/content/
full/99/6/e5
54. Brent NB, Redd B, Dworetz A, D’Amico F, Greenberg J. Breastfeeding in
a low-income population: program to increase incidence and duration.
Arch Pediatr Adolesc Med. 1995;149:798 – 803
55. Kools EJ, Thijs C, Kester AD, van den Brandt PA, de Vries H. A
breast-feeding promotion and support program a randomized trial in
the Netherlands. Prev Med. 2005;40:60 –70
56. Chapman DJ, Damio G, Young S, Perez-Escamilla R. Effectiveness of
breastfeeding peer counseling in a low-income, predominantly Latina
population: a randomized controlled trial. Arch Pediatr Adolesc Med.
2004;158:897–902
57. Anderson AK, Damio G, Young S, Chapman DJ, Perez-Escamilla R. A
randomized trial assessing the efficacy of peer counseling on exclusive
breastfeeding in a predominantly Latina low-income community. Arch
Pediatr Adolesc Med. 2005;159:836 – 841
58. Piper S. Use of an intensity ratio to describe breastfeeding exclusivity in
a national sample. J Hum Lact. 2001;17:227–232
59. Chezem J, Friesen C, Boettcher J. Breastfeeding knowledge, breastfeed-
ing confidence, and infant feeding plans: effects on actual feeding
practices. J Obstet Gynecol Neonatal Nurs. 2003;32:40 – 47
60. Heinig JM. Host defense benefits of breastfeeding for the infant: effect of
breastfeeding duration and exclusivity. Pediatr Clin North Am. 2001;48:
105–123
61. Oddy WH, Sly PD, de Klerk NH, et al. Breastfeeding and respiratory
morbidity in infancy: a birth cohort study. Arch Dis Child. 2003;88:
224 –228
62. Bachrach V, Schwarz E, Bachrach LR. Breastfeeding and the risk of
hospitalization for respiratory disease in infancy: a meta-analysis. Arch
Pediatr Adolesc Med. 2003;157:237–243
63. Kramer MS, Guo T, Platt RW, et al. Infant growth and health outcomes
associated with 3 compared with 6 mo of exclusive breastfeeding. Am J
Clin Nutr. 2003;78:291–295
64. US Department of Health and Human Services, National Women’s
Health Information Center. Womenshealth.gov. Available at:
www.4woman.gov. Accessed October 7, 2005
65. Taveras EM, Capra AM, Braverman PA, et al. Clinician support and
psychosocial risk factors associated with breastfeeding discontinuation.
Pediatrics. 2003;112:108 –115

Keeping the United States in the Race

“What if we were really having a national discussion about what is most

important to the country today and on the minds of most parents? I have no doubt
that it would be a loud, noisy dinner-table conversation about why so many U.S.
manufacturers are moving abroad—not just to find lower wages, but to find
smarter workers, better infrastructure and cheaper health care. It would be about
why in Germany, 36 percent of undergrads receive degrees in science and engi-
neering; in China, 59 percent; in Japan, 66 percent; and in America, only 32 percent.
It would be about why Japanese on bullet trains can get access to the Internet with
cellphones, and Americans get their cell phone service interrupted five minutes
from home. It would be about why U.S. 12th graders recently performed below the
international average for 21 countries in math and science, and it would be about
why, in recent years, U.S. industry appears to have spent more on lawsuits than on
R&D. Yes, we’d be talking about why the world is racing us to the top, not the
bottom, and why we are quietly falling behind.”

Friedman TL. New York Times. October 14, 2005

Noted by JFL, MD

1426 TRIAL OFDownloaded

LACTATION CONSULTANT INTERVENTION
from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020
Randomized, Controlled Trial of a Prenatal and Postnatal Lactation Consultant
Intervention on Duration and Intensity of Breastfeeding up to 12 Months
Karen A. Bonuck, Michelle Trombley, Katherine Freeman and Diane McKee
Pediatrics 2005;116;1413
DOI: 10.1542/peds.2005-0435

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/116/6/1413
References This article cites 42 articles, 15 of which you can access for free at:
http://pediatrics.aappublications.org/content/116/6/1413#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Metabolic Disorders
http://www.aappublications.org/cgi/collection/metabolic_disorders_s
ub
Nutrition
http://www.aappublications.org/cgi/collection/nutrition_sub
Breastfeeding
http://www.aappublications.org/cgi/collection/breastfeeding_sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020

Randomized, Controlled Trial of a Prenatal and Postnatal Lactation Consultant
Intervention on Duration and Intensity of Breastfeeding up to 12 Months
Karen A. Bonuck, Michelle Trombley, Katherine Freeman and Diane McKee
Pediatrics 2005;116;1413
DOI: 10.1542/peds.2005-0435

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/116/6/1413

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2005
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on November 16, 2020