A description of lactation counseling practices that are used with obese mothers.

Maternal overweight and obesity are associated with failure to initiate breastfeeding successfully and to sustain breastfeeding adequately. The purpose of this study was to describe how health care providers counsel obese mothers about breastfeeding. The authors surveyed (by telephone or in-person interview) health care providers who counsel mothers about breastfeeding in rural upstate New York (n = 89). They also surveyed lactation consultants (n = 31) from New York, New Jersey, Florida, Nebraska, California, and Texas by e-mail. The authors found that the majority of health care providers surveyed neither believed that there was a difference in the success rate between obese mothers and normal-weight mothers nor advised obese mothers differently about breastfeeding. Given the excess risk for premature lactation failure among obese women, these findings suggest that those who care for such women need to be made aware of this risk so that they can develop and provide appropriate services.

Opening School-Based Health Centers in a Rural Setting: Effects on Emergency Department Use.

BACKGROUND: Previous studies of urban school-based health centers (SBHCs) have shown that SBHCs decrease emergency department (ED) utilization. This study seeks to evaluate the effect of SBHCs on ED utilization in a rural setting. METHODS: This retrospective, controlled, quasi-experimental study used an ED patient data set from the Bassett Healthcare Network in rural New York to compare ED visits between school-aged children from 12 SBHC schools before and after the SBHC opening. Time series analysis was used to determine trends in SBHC schools and 2 control schools without SBHCs over the 18-year study period. RESULTS: ED visit incidence densities for all 12 school districts combined showed a significant increase in ED visits post-SBHC (Rate ratio (RR) = 1.15; p < .0001). This increase may, in part, be explained by the upward trend of ED visits in the region, as seen in the small, but significant, positive slope (RR = 0.0033, p < .0001) for control schools. There was variation in the change in incidence density post-SBHC among school districts, with increases in 78% of schools. CONCLUSIONS: The opening of SBHCs in rural settings results in a slight, but significant, increase in ED use, which is contrary to previous cross-sectional studies in urban settings.

Breastfeeding duration and weight gain trajectory in infancy.

BACKGROUND AND OBJECTIVES: Short breastfeeding duration may exacerbate accelerated early growth, which is linked to higher obesity risk in later life. This study tested the hypothesis that infants at higher risk for obesity were more likely to be members of a rising weight-for-length (WFL) z score trajectory if breastfed for shorter durations. METHODS: This prospective, observational study recruited women from an obstetric patient population in rural central New York. Medical records of children born to women in the cohort were audited for weight and length measurements (n = 595). We identified weight gain trajectories for infants' WFL z scores from 0 to 24 months by using maximum likelihood latent class models. Individual risk factors associated with weight gain trajectories (P ≤ .05) were included in an obesity risk index. Logistic regression analysis was performed to investigate whether the association between breastfeeding duration (<2 months, 2-4 months, >4 months) and weight gain trajectory varied across obesity risk groups. RESULTS: Rising and stable weight gain trajectories emerged. The obesity risk index included maternal BMI, education, and smoking during pregnancy. High-risk infants breastfed for <2 months were more likely to belong to a rising rather than stable weight gain trajectory (odds ratio, 2.55; 95% confidence interval, 1.14-5.72; P = .02). CONCLUSIONS: Infants at the highest risk for rising weight patterns appear to benefit the most from longer breastfeeding duration. Targeting mothers of high-risk infants for breastfeeding promotion and support may be protective against overweight and obesity during a critical window of development.

High prepregnant body mass index is associated with poor lactation outcomes among white, rural women independent of psychosocial and demographic correlates.

To determine whether high prepregnant body mass index (BMI) is associated with later onset of lactogenesis II (LGII) and shorter duration of breastfeeding, we questioned 151 women about their demographic and psychosocial characteristics during pregnancy and about the onset of LGII during days 1 to 5 postpartum. Compared to women with earlier (< 72 hours) onset of LGII, those with later onset had a higher BMI (P < .05), a higher proportion of primiparity (P < .01), and a lower infant score on the Mother-Baby Assessment (P < .05). Prepregnant BMI (P < .04) and primiparity (P < .005) were each associated with later onset of LGII, but only primiparity remained significant when both factors were considered simultaneously. These results suggest that, in addition to those who have just delivered their first infant, those with higher prepregnant BMI values also warrant extra support to decrease their risk of early discontinuation of breastfeeding.

Interventions to increase the duration of breastfeeding in obese mothers: the Bassett Improving Breastfeeding Study.

OBJECTIVE: Maternal obesity is associated with poor breastfeeding outcomes, yet no intervention has been developed to improve them. To ascertain whether increased breastfeeding support or provision of a breast pump is a feasible, effective intervention to improve breastfeeding, we enrolled obese women who intended to breastfeed in two randomized trials. METHODS: In Bassett Improving Breastfeeding Study (BIBS) 1, 40 women received targeted breastfeeding support in the hospital and via telephone or usual care. Information regarding breastfeeding was collected via telephone for 7 days after delivery and at 30 and 90 days postpartum. In BIBS 2, 34 obese mothers received a manual or electric breast pump to use for 10-14 days or no pump; data collection was similar. RESULTS: In both experiments, randomization failed to distribute women of differing postpartum body mass index adequately among the treatment groups. When analyses were adjusted for this, there was no difference in BIBS 1 between targeted and usual care groups and in BIBS 2 among the treatment groups in the proportion of women still breastfeeding at the times studied. CONCLUSIONS: In future studies of obese women, stratified randomization may be necessary. Further development of interventions to help obese women achieve optimal breastfeeding outcomes is required.

Excessive weight gain during pregnancy is associated with earlier termination of breast-feeding among White women.

High prepregnant BMI is associated with reduced initiation and duration of breast-feeding (BF). To examine how gestational weight gain (GWG) might modify this association, over a 9-y period, we identified all women (n = 2783) who had attempted to breast-feed their newborns. From their medical records, we categorized them by prepregnant BMI [as underweight (<19.8 kg/m2), normal-weight (19.8-26.0 kg/m2), overweight (26.1-29.0 kg/m2) or obese ( >29.0 kg/m2)] and GWG [as below, within, or above the amount recommended by the Institute of Medicine]. Women with a normal BMI who gained within these recommendations served as the reference group in regression analyses, which were adjusted for confounding factors. Both normal-weight (P < 0.05) and obese (P < 0.01) women who exceeded the recommended GWG had higher odds of failing to initiate BF (defined as continuing to breast-feed at 4 d postpartum). Underweight (P < 0.05), overweight (P < 0.05), and obese (P < 0.01) women who exceeded the recommendations for GWG as well as obese women who gained within the recommendations (P < 0.01) had a higher risk of early discontinuation of exclusive BF. Only obese women who gained within or exceeded the recommendations (P < 0.01) for GWG had a higher risk of early discontinuation of any BF. Excessive GWG was associated with a measure of failure to initiate and/or sustain BF in all categories of prepregnant BMI. Thus, in addition to conceiving at a healthy weight, gaining the recommended amount of weight during pregnancy is also important for successful BF.

Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum.

OBJECTIVE: The population subgroups with the highest proportion of overweight and obese women often are characterized by the lowest rates of initiation and shortest durations of breastfeeding. We previously documented that these 2 population-level trends may be related. In a population of white women who lived in a rural area, we observed that prepregnant overweight and obesity were associated with failure to initiate and also to sustain lactation. The means by which being overweight or obese negatively affect lactational performance is unknown and likely to be multifactorial in origin, including the simple mechanical difficulties of latching on and proper positioning of the infant. In addition, we have shown that prepregnant body mass index (BMI) is negatively associated with the timing of lactogenesis II, the onset of copious milk secretion. Although the effects of obesity on the prolactin response to infant suckling have never been studied, we postulated that maternal obesity could compromise this important response. We proposed that this might occur because obesity alters the 24-hour spontaneous release of prolactin and also because prolactin secretion is blunted in response to various stimuli among obese subjects. The fall in progesterone concentration that occurs immediately postpartum is the trigger for the onset of copious milk secretion, but maintenance of prolactin and cortisol concentrations is necessary for this trigger to be effective. Adipose tissue concentrates progesterone. We proposed that this additional source of progesterone would lead to consistently higher progesterone concentrations among obese compared with normal-weight women. This, in turn, would lead to a delay in reaching the appropriate concentration to trigger the onset of lactogenesis II. We tested the hypotheses that a reduced prolactin response to suckling and higher-than-normal progesterone concentration in the first week after delivery might be among the means by which maternal overweight could compromise early lactation. METHODS: We enrolled 40 mothers of term infants from the same population that we studied previously. We measured serum prolactin and progesterone concentrations by radioimmunoassay before and 30 minutes after the beginning of a suckling episode at 48 hours and 7 days after delivery. We used path analysis to develop a parsimonious multivariate prediction of the prolactin response to suckling at 48 hours and 7 days postpartum. RESULTS: As expected, prolactin values decreased from 48 hours to 7 days postpartum. Women who were overweight or obese (using the Institute of Medicine's cutoff for women of a BMI >26 kg/m2) before conception had a lower prolactin response to suckling than normal-weight women at 48 hours but not at day 7. In multivariate analyses, overweight/obesity, primiparity, and birth weight were negatively associated with the prolactin response to suckling at 48 hours. After adjustment for confounding by time since delivery and the duration of the nursing episode, only overweight/obesity remained a significant negative predictor of prolactin response to suckling at day 7. Concentrations of progesterone decreased dramatically from 48 hours to 7 days postpartum but did not differ between normal-weight and overweight/obese women at either time. In addition, the decreases in progesterone concentrations from 48 hours to 7 days postpartum did not differ between the prepregnant BMI groups. CONCLUSION: The unique and important finding from this study is that overweight/obese women had a lower prolactin response to suckling. This would be expected to compromise the ability of overweight/obese women to produce milk and, over time, could lead to premature cessation of lactation. These findings are important because, during our observation period (just before and after lactogenesis II, the time of onset of copious milk secretion), the prolactin response to suckling is more important for milk production than it is later in lactation. We have previously shown that a high proportion of the overweight and obese women in women in this population who give up on breastfeeding do so at this time. This finding thus provides evidence of a biological basis for this association, and additional study of it is likely to be informative. We postulated that there would be consistently higher progesterone concentrations in the early postpartum period among obese compared with normal-weight women because adipose tissue is an extraplacental source of this hormone. This hypothesis was not supported in this study because there were no significant differences between normal-weight and overweight/obese women in progesterone concentrations at either 48 hours or 7 days postpartum. The values that we observed at these times were similar to those reported by others in the early postpartum period. The findings from this study add plausibility to our observation that initiation, not just duration of breastfeeding, is negatively affected by maternal overweight/obesity. Although women should begin pregnancy at a healthy weight and gain reasonably during gestation, not all will. Pediatricians can help overweight/obese women to succeed at breastfeeding by targeting them for contact with a lactation consultant before discharge from the hospital to be sure that they have received optimal advice on breastfeeding techniques. In addition, early contact with the mother after discharge--by calling her at home to offer her support and counseling for breastfeeding, by scheduling the first pediatric visit earlier than for other patients, or by enlisting the assistance of public health nurses for a home visit if this is possible--would help overweight/obese women to continue to breastfeed. Being overweight or obese is negatively associated with the prolactin response to suckling in the first week postpartum and, thus, may contribute to early lactation failure.