Validation of the Breastfeeding Score-A Simple Screening Tool to Predict Breastfeeding Duration

Predicting early cessation of exclusive breastfeeding using machine learning techniques

BACKGROUND

Identification of mother-infant pairs predisposed to early cessation of exclusive breastfeeding is important for delivering targeted support. Machine learning techniques enable development of transparent prediction models that enhance clinical applicability. We aimed to develop and validate two models to predict cessation of exclusive breastfeeding within one month among infants born after 35 weeks gestation using machine learning techniques.

METHODS

Utilizing a nationwide dataset from Statistics Denmark, including infants born between the 1st of January 2014 and the 31st of December 2015, we employed random forest machine learning to develop two predictive models. The first model included 11 well-established factors associated with cessation of exclusive breastfeeding within one month. The second model was expanded to include 21 additional factors associated with complications during pregnancy and delivery that potentially impede breastfeeding. Feature importance was applied to elucidate the factors driving model predictions.

RESULTS

The dataset comprised 110,206 infants and 106,835 mothers. The first model predicted cessation of exclusive breastfeeding within one month with an area under the receiver operating curve of 62.0% (95% confidence interval 61.3% - 62.7%) and an accuracy of 60.4% (95% confidence interval 59.8% - 61.0%). The second model predicted cessation of exclusive breastfeeding within one month with an area under the receiver operating curve of 62.2% (95% confidence interval 61.5% - 62.9%) and an accuracy of 60.0% (95% confidence interval 59.3% - 60.6%). In both models, birthplace, maternal education, delivery mode, and maternal body mass index were the most important factors influencing the overall model performance.

CONCLUSIONS

The two models could not accurately predict cessation of exclusive breastfeeding within one month among infants born after 35 weeks gestation. Contrary to our expectations, including additional factors in the model did not increase model performance.

Breastfeeding Self-Efficacy, a Predictor of Early Cessation of Exclusive Breastfeeding Among Mothers Giving Birth Preterm

The aim was to describe the prevalence of exclusive breastfeeding among mothers of premature infants and investigate the extent to which breastfeeding self-efficacy is associated with early cessation of exclusive breastfeeding. The study population consisted of 136 mother-infant dyads with information on the outcome of exclusive breastfeeding and exposure of self-efficacy, recruited between September 2016 and February 2018. Data were collected via questionnaires with follow-up at 6 months. The statistical analysis included descriptive analysis with survival curves and logistic regression analysis. At 2 months, 101 (74%) premature infants were exclusively breastfed; at 4 and 6 months, 82 (60%) and 41 (30%), respectively. Higher levels of self-efficacy were significantly associated with breastfeeding exclusively for 2 months ( P = .03). In multivariate analysis, mothers who had a low level of early self-efficacy toward breastfeeding had 2½ times higher odds of breastfeeding cessation before 2 months (odds ratio = 2.63, 95% confidence interval: 1.16-5.96). The risk did not change when adjusted for potential confounders. Breastfeeding self-efficacy is an early predictor of exclusive breastfeeding for 2 months of the premature infant. Health professionals should use self-efficacy as a prognostic factor to identify mothers at risk of early cessation of breastfeeding and support those with low self-efficacy to increase duration of exclusive breastfeeding.

Breastfeeding Self-Efficacy: A Systematic Review of Psychometric Properties Using COSMIN

BACKGROUND

Breastfeeding self-efficacy has been proven to play a predictive role in enhancing breastfeeding initiation and continuation. Breastfeeding self-efficacy measurement tools have facilitated healthcare professionals' early identification and support of women at higher risk of early discontinuation of breastfeeding.

RESEARCH AIM

The aim of this study was to assess the psychometric properties of breastfeeding self-efficacy measurement tools.

METHOD

A systematic review was carried out in three phases. Phase One comprised a systematic literature review performed in PubMed, SCOPUS, Web of Science, and Cochrane Database of Systematic Reviews from February 2021 to January 2023, including 36 studies for final analysis. Phase Two provided a quality appraisal of the psychometric properties of each of the seven breastfeeding self-efficacy measurement tools, according to COnsensus-based Standards for the selection of health Measurement Instrument checklist (COSMIN) guidelines. Phase Three summarized and graded the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) modified approach.

RESULT

The included articles comprised 9,225 participants and seven breastfeeding self-efficacy measurement tools. The Breastfeeding Self-Efficacy Scale, Breastfeeding Self-Efficacy Scale - Short Form (BSES-SF), and Prenatal Breastfeeding Self-Efficacy Scale were supported by Grade A evidence sustaining their validity and reliability to assess breastfeeding self-efficacy in the continuum of maternity care. The BSES-SF is the most feasible tool in clinical practice and the most utilized internationally, available in 15 languages.

CONCLUSION

This systematic review provided a Grade A recommendation on breastfeeding measurement tools that will be helpful both for clinical and research purposes.Registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021238450).

Women during Lactation Reduce Their Physical Activity and Sleep Duration Compared to Pregnancy

Sleep, mental health and physical activity are fundamental for wellbeing, and some of these factors are interrelated. However, these aspects are not usually considered during pregnancy and lactation, which are particularly vulnerable periods. Therefore, our aims were to conduct a cross sectional study to assess the psychological capital, quality of life, sleep hygiene and physical activity in a cohort of women during pregnancy and lactation periods. Women were recruited from Spanish maternity and lactation non-profit associations and social networks through an online platform with the following inclusion criteria: pregnancy (in any period of gestation) or breastfeeding period (≤6 months postpartum). The cohort was categorized into ≤12 weeks of gestation (n = 32), >12 weeks of gestation (n = 119) and lactation (n = 60). The women self-reported the sociodemographic data, obstetric complications and full breastfeeding or mixed practices. In addition, women responded to the psychological capital instrument, the health survey form, the Pittsburg sleep quality index and the pregnancy physical activity questionnaire. Overall, the groups were similar in sociodemographic variables. Women in the lactation period perceived lower social support compared to the gestation period. No statistically differences were found between groups in the psychological capital nor in the general health survey form. However, the models adjusted by employment and civil and economic status and perceived social support, demonstrated that the sleep duration negatively associated with the lactation period (β = 1.13 ± 0.56; p-Value = 0.016), and the household tasks were associated with this period (β = 2147.3 ± 480.7; p-Value < 0.001). A decrease in physical daily activities were associated with both the end of gestation and the lactation periods. In addition, the decreasing total activity was associated with the lactation period (β = 1683.67 ± 688.05; p-Value = 0.016). In conclusion, during lactation, the poorer sleep and physical activity, together with a lower social support of the woman, may lead to deficient mental health adjustment. Our data suggest that women are at higher risk of vulnerability in lactation compared to the gestation period.

A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants

Objectives: Lingual frenotomies for the purpose of improving infant breastfeeding remain controversial, whereas maxillary frenotomies are even more so given the scant data and differing opinions on the matter. This study aimed at further elucidating the effect that maxillary frenula have on breastfeeding difficulties in infants. Methods: A retrospective chart review was performed on infants approximately aged 0-3 months who presented to a tongue tie/breastfeeding clinic from January to December of 2019. All analyzed infants had both lip and tongue ties classified by a clinician. Data on pre-frenotomy pain scores, lingual Coryllos classification, maxillary Kotlow classification, post-frenotomy complications, and breastfeeding success were captured. Results: Of the 316 infants, 224 underwent their first procedure at the tongue tie/breastfeeding clinic. Two hundred eleven out of 224 infants received a lingual frenotomy only, whereas the remaining 13 (5.8%) underwent both lingual and maxillary frenotomy procedures. Of the group of 211, 207 (98.1%) had successful feeding after 1 procedure; the remaining 4 underwent revision procedures to achieve successful feeding. All maxillary frenulum releases (n = 13) led to successful feeding without the need for revision procedures. Coryllos and Kotlow classification scores were significantly higher in the infants receiving both a maxillary and lingual frenulum release as compared with those receiving solely a lingual frenulum release. Conclusions: The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding, calling into question the relative necessity of performing maxillary frenulum releases for breastfeeding difficulties.

Factors Associated with (Exclusive) Breastfeeding Duration-Results of the SUKIE-Study

The WHO European Region has the lowest exclusive breastfeeding (EBF) rates at 6 months in the world. In Austria, 55.5% of infants are EBF at the age of one week, although breastfeeding initiation is 97.5%. The study was conducted in 2019/2020 and considered 1214 mothers of legal age, who received four online questionnaires during their child's first year of life. The influence of different variables on total/exclusive breastfeeding duration were analysed by using a Cox model (Extension of the Cox Proportional Hazards Model) with time-dependent covariates. Multivariate analyses showed a significant influence of maternal BMI, lifestyle factors, such as smoking, and breastfeeding support on total breastfeeding duration. Remarkable differences in the median duration of any breastfeeding were found for breastfeeding support, where mothers breastfed twice as long. Support came primarily from hospital staff, the midwife and the partner. A higher monthly household net income, delivery in a baby-friendly certified hospital (BFH) and breastfeeding support were associated with a longer EBF duration. Obese mothers started feeding infant formula earlier and had a higher risk of early weaning. The results offer valuable insights into the importance of breastfeeding-friendly structures such as BFHs, a focus on breastfeeding aftercare and support of the mother to promote and protect breastfeeding.

Maternal Variants in the MFGE8 Gene are Associated with Perceived Breast Milk Supply

Background: The World Health Organization recommends exclusive breastfeeding for ≥6 months, but many mothers are unable to meet this goal. A major reason why mothers undergo early, unplanned breastfeeding cessation is perceived inadequate of milk supply (PIMS). We hypothesized that defining genetic polymorphisms associated with PIMS could aid early identification of at-risk mothers, providing an opportunity for targeted lactation support. Materials and Methods: This prospective observational cohort study followed 221 breastfeeding mothers for 12 months, collecting medical, demographic, and breastfeeding characteristics. Eighteen mammary secretory genes were assessed for single-nucleotide polymorphisms in 88 women (45 with PIMS and 43 with perceived adequate milk supply [PAMS]), matched by age/race/parity. Hierarchical regressions were used to assess the ability of genotype to aid PIMS prediction. Results: Mothers with PIMS exclusively breastfed for a shorter period (7 ± 12 weeks; p = 0.001) and reported lower milk production (17.6 ± 13.3 oz/day; p = 0.001), and their infants displayed reduced weight-for-length Z-score gains (0.74 ± 1.4; p = 0.038) relative to mothers with PAMS (22 ± 19 weeks; 27.03 ± 12.2 oz/day; 1.4 ± 1.5). Maternal genotype for the rs2271714 variant within milk fat globule EGF and factor V/VIII domain containing gene (MFGE8) was associated with PIMS status (p = 0.009, adjusted p = 0.09, likelihood ratio = 9.33) and duration of exclusive breastfeeding (p = 0.009, adjusted p = 0.09, χ² = 9.39). Addition of MFGE8 genotype to a model employing maternal characteristics (age, parity, previous breast-feeding duration, body mass index, education, and depression status) significantly increased predictive accuracy for PIMS status (p = 0.001; χ² = 13.5; area under the curve = 0.813 versus 0.725). Conclusions: Genotyping one lactogenic gene aided identification of mothers at risk for PIMS. If validated in a larger cohort, such an approach could be used to identify mothers who may benefit from increased lactation support.

Development of a breastfeeding duration risk nomogram for use in postpartum Chinese women

Previous studies have investigated influencing factors of early discontinuation of breastfeeding, but few studies have developed an easy-to-use tool to identify risk of breastfeeding cessation at 6 months after birth. This research team aimed to develop and validate an exclusive breastfeeding duration risk nomogram in Chinese mothers. A longitudinal cohort survey was conducted. Data were collected from 394 postpartum women in three hospitals in Hubei Province, China from December 2017 to December 2018. The LASSO regression model was used to screen for optimized factors in an exclusive breastfeeding duration model. Multivariable logistic regression was applied to construct a prediction model. Discrimination and calibration were assessed using a C-index and calibration curve, and internal validity was established using bootstrapping validation. Factors integrated in the prediction risk nomogram were monthly household income (odds ratio [OR] = 1.31, 95% confidence interval [CI]: [0.95, 1.80]), experiences of breastfeeding (OR = 1.23, 95% CI: [0.92, 1.63]), attitude (OR = 1.72, 95% CI: [0.94, 3.16]), self-efficacy (OR = 2.45, 95% CI: [1.40, 4.29]), perceived insufficient milk supply (OR = 0.12, 95% CI: [0.06, 0.25]) and postpartum depression (OR = 0.06, 95% CI: [0.02, 0.17]). The model displayed good discrimination with a C-index of 0.87 (95% CI: [0.84, 0.91]) and good calibration. The C-index interval validation was confirmed to be 0.86. This study resulted in the development of a novel nomogram with good accuracy to aid healthcare professionals in assessing the probability of a mother discontinuing exclusive breastfeeding at the breast before 6 months.

Breastfeeding Practice and Association between Characteristics and Experiences of Mothers Living in Bangkok

Although the benefits of breastfeeding are widely recognized, only 14% of mothers in Thailand exclusively breastfed their children during the first six months of their lives in 2019, which dropped from 23% in 2016. This study aimed to assess the prevalence of exclusive breastfeeding (EBF) up to six months, current breastfeeding patterns, and key determinants that influence six-month EBF among mothers residing in Bangkok, Thailand. A cross-sectional study was conducted using a self-administered questionnaire survey. In total, 676 healthy mothers living in Bangkok, whose most recent child was between 6 and 18 months old, were recruited. Descriptive statistics, univariable analysis by Chi-square test, and multivariable logistic regression were performed to assess the association between six-month EBF and maternal characteristics and experiences of using maternal health services. The prevalence of six-month EBF of infants in Bangkok was 41%. The key determinants that influenced six-month EBF included: maternal age of more than 30 years; higher education level; higher maternal income; multi-parity; exposure to breastfeeding advice during pregnancy; intention to breastfeed for a long duration (≥6 months) during pregnancy; experience of six-month EBF in the previous child. This study draws health professionals' and policy makers' attention to further promote breastfeeding in particular types of mothers.

Development and validation of a predictive model of exclusive breastfeeding at hospital discharge: Retrospective cohort study

BACKGROUND

The benefits of breastfeeding for both mother and newborn have been widely demonstrated. However, breastfeeding rates at discharge are lower than recommended, so being able to identify women at risk of not breastfeeding at discharge could allow professionals to prioritise care.

OBJECTIVE

To develop and validate a predictive model of exclusive breastfeeding at hospital discharge.

DESIGN

Retrospective cohort study on women who gave birth between 2014 and 2019 in Spain.

DATA SOURCES

The data source was a questionnaire distributed through the Spanish breastfeeding associations. The development of the predictive model was made on a cohort of 3387 women and was validated on a cohort of 1694 women. A multivariate analysis was performed by means of logistic regression, and predictive ability was determined by areas under the ROC curve (AUC).

RESULTS

80.2% (2717) women exclusively breastfed at discharge in the derivation cohort, and 82.1% (1390) in the validation cohort. The predictive factors in the final model were: maternal age at birth; BMI; number of children; previous breastfeeding; birth plan; induced birth; epidural analgesia; type of birth; prematurity; multiple pregnancy; macrosomia; onset of breastfeeding within the first hour; and skin-to-skin contact. The predictive ability (ROC AUC) in the derivation cohort was 0.76 (CI 95%: 0.74-0.78), while in the validation cohort it was 0.74 (CI 95%: 0.71-0.77).

CONCLUSIONS

A predictive model of exclusive maternal breastfeeding at hospital discharge has been developed, based on thirteen variables, with satisfactory predictive ability in both the derivation cohort and the validation cohort according to the Swets' criteria. This model can identify women who are at high risk of not breastfeeding at hospital discharge.

Association between Maternal Postpartum Depression, Stress, Optimism, and Breastfeeding Pattern in the First Six Months

Early breastfeeding cessation is a major public health problem. Several factors can affect breastfeeding pattern, and psychological aspects have been poorly explored. We hypothesize that psychological factors and breastfeeding pattern have a relationship. We have assessed in mothers during the first six months of lactation if breastfeeding pattern is associated with maternal stress, postpartum depression, and dispositional optimism, and if these psychological factors play a role on breastfeeding adherence. In total, 711 women participated, answering online the following questionnaires: sociodemographic, perceived stress scale, Edinburgh postpartum depression scale, life orientation test, and breastfeeding adherence score. Women were categorized according to infant feeding practices as exclusive breastfeeding (EBF) or mixed breastfeeding (MBF). The EBF group had a lower score of perceived stress compared to those giving MBF (first month: EBF = 1.5 [1.1; 1.9], MBF = 1.8 [1.5; 2.0]; p-Value = 0.030; third month: EBF = 1.6 [1.2; 2.0], MBF = 1.8 [1.5; 2.4]; p-Value = 0.038) and also had a lower score of postpartum depression (third month: EBF = 8.0 [6.0; 11.0], MBF = 11.0 [9.0; 15.0]; p-Value = 0.001). The breastfeeding adherence score showed a positive correlation with maternal perceived stress (first month: ρ = 0.27; p-Value = 0.018), and postpartum depression (third month: ρ = 0.30; p-Value < 0.001), and a negative correlation with maternal dispositional optimism (second month: ρ = −0.20; p-Value = 0.028). MBF was positively associated with breastfeeding adherence score (odd ratio (OR) = 1.4 [1.2–1.6]; p-Value < 0.001) and with postpartum depression (OR = 1.1 [1.0; 1.1]; p-Value = 0.020). In the third month of breastfeeding, women with MBF exhibited higher perceive stress and postpartum depression compared to those with EBF and no difference in dispositional optimism. The maternal psychological aspects are associated with breastfeeding pattern. Evaluation of maternal psychological concerns and providing support to lactating mothers may help improving breastfeeding adherence.

Determinants of Full Breastfeeding at 6 Months and Any Breastfeeding at 12 and 24 Months among Women in Sydney: Findings from the HSHK Birth Cohort Study

The aim of this study was to report on breastfeeding duration up to 24 months and determine the predictors of breastfeeding duration among women in South Western Sydney, one of the most culturally diverse and socioeconomically disadvantaged regions of New South Wales (NSW), Australia. Mother–infant dyads (n = 1035) were recruited to the Healthy Smiles Healthy Kids birth cohort study. Study data were collected through telephone interviews at 2, 4, 8, 12, and 24 months postpartum. Cox proportional hazards models were used to determine factors associated with the risk of stopping full breastfeeding at six months and any breastfeeding at 12 and 24 months. The majority of mothers (92.3%) had initiated breastfeeding. At six months, 13.5% of infants were fully breastfed, while 49.9% received some breast milk. Only 25.5% and 2.9% of infants received some breast milk at 12 and 24 months, respectively. Lower maternal education level, lower socioeconomic status, full-time employment, maternal smoking during pregnancy, and caesarean delivery were associated with increased risk of stopping full breastfeeding at six months and any breastfeeding at 12 and 24 months. Older maternal age and partner’s preference for breastfeeding were associated with an increased likelihood of continuing any breastfeeding at 12 and 24 months. These findings present a number of opportunities for prolonging breastfeeding duration in disadvantaged communities in NSW.