Risk Factors for Suboptimal Infant Breastfeeding Behavior, Delayed
Onset of Lactation, and Excess Neonatal Weight Loss
Kathryn G. Dewey, PhD; Laurie A. Nommsen-Rivers, MS, RD, IBCLC; M. Jane Heinig, PhD, IBCLC; and
Roberta J. Cohen, PhD
ABSTRACT. Objective. Some mothers have difficulty
initiating lactation even when highly motivated to
breastfeed. The purpose of this study was to determine
the incidence of and risk factors for suboptimal infant
breastfeeding behavior (SIBB), delayed onset of lacta-
tion, and excess neonatal weight loss among mother-
infant pairs in a population with high educational levels
and motivation to breastfeed.
Methods. All mothers residing in Davis, California,
who gave birth to a healthy, single, term infant at 1 of 5
area hospitals during the 10-month recruitment period in
1999 were invited to participate if they were willing to
attempt to breastfeed exclusively for at least 1 month.
Lactation guidance was provided and data were collected
in the hospital (day 0) and on days 3, 5, 7, and 14. Infant
breastfeeding behavior was evaluated by trained lacta-
tion consultants using the Infant Breastfeeding Assess-
ment Tool. Onset of lactation was defined based on ma-
ternal report of changes in breast fullness. Infant weight
loss was considered excessive if it was >10% of birth
weight by day 3.
Results. Of the 328 eligible mothers, 280 (85%) partic-
ipated in the study. The prevalence of SIBB was 49% on
day 0, 22% on day 3, and 14% on day 7. SIBB was signif-
icantly associated with primiparity (days 0 and 3), cesar-
ean section (in multiparas, day 0), flat or inverted nip-
ples, infant status at birth (days 0 and 3), use of nonbreast
milk fluids in the first 48 hours (days 3 and 7), pacifier
use (day 3), stage II labor >1 hour (day 7), maternal body
mass index >27 kg/m2 (day 7) and birth weight <3600 g
(day 7). Delayed onset of lactation (>72 hours) occurred
in 22% of women and was associated with primiparity,
cesarean section, stage II labor >1 hour, maternal body
mass index >27 kg/m2, flat or inverted nipples, and birth
weight >3600 g (in primiparas). Excess weight loss oc-
curred in 12% of infants and was associated with primi-
parity, long duration of labor, use of labor medications
(in multiparas), and infant status at birth. The risk of
excess infant weight loss was 7.1 times greater if the
mother had delayed onset of lactation, and 2.6 times
greater if the infant had SIBB on day 0.
Conclusions. Early lactation success is strongly influ-
enced by parity, but may also be affected by potentially
modifiable factors such as delivery mode, duration of
labor, labor medications, use of nonbreast milk fluids
and/or pacifiers, and maternal overweight. All breast-
feeding mother-infant pairs should be evaluated at 72 to
From the Department of Nutrition, University of California, Davis, Davis,
California.
Received for publication Sep 9, 2002; accepted May 8, 2003.
Address correspondence to Kathryn G. Dewey, PhD, Department of Nutri-
tion, University of California, One Shields Ave, Davis, CA 95616-8669.
E-mail: kgdewey@ucdavis.edu.
PEDIATRICS (ISSN 0031 4005). Copyright 2003 by the American Acad-
emy of Pediatrics.
Downloaded from by guest on February 7, 2017
96 hours postpartum. Pediatrics 2003;112:607 619; breast-
feeding, infant suck, lactogenesis, cesarean delivery.
ABBREVIATIONS. BMI, body mass index; IBFAT, Infant Breast-
feeding Assessment Tool; SIBB, suboptimal infant breastfeeding
behavior; NBM, nonbreast milk; RR, relative risk; IV, intravenous;
IM, intramuscular.
T
he first week postpartum is a critical period for
the establishment of breastfeeding. Normally,
the amount of milk produced is minimal for
the first 1 to 2 days postpartum, but increases dra-
matically by 23 days postpartum as lactogenesis
II occurs in response to the drop in progesterone
after delivery.1 During this time, both the mother
and the infant are learning how to breastfeed. Socio-
cultural factors are strongly associated with the ini-
tiation of breastfeeding, but lactation problems are
common even among mothers who are highly moti-
vated to breastfeed. Problems such as delayed onset
of lactation2 and suboptimal breastfeeding behavior
among newborns, especially those exposed to labor
medications during delivery,3 are frequently re-
ported. If the situation is not handled appropriately,
inadequate milk transfer can lead to excessive infant
weight loss, dehydration, and serious medical com-
plications, even death.4 Some reports suggest that the
incidence of breastfeeding malnutrition has in-
creased as shorter hospital stays have become more
common.5 Although serious adverse outcomes are
rare, lactation difficulties during the first week post-
partum are associated with greater risk of early ter-
mination of breastfeeding6,7 and lower breastfeeding
success with subsequent children.6
On average, breastfed newborns in industrialized
countries lose 5% to 7% of birth weight in the first
few days of life.8,9 Most clinicians judge weight loss
to be of concern when it exceeds 10% of birth
weight. There has been very little research on the
incidence of excess weight loss or the lactation prob-
lems associated with it. In a hospital-based study in
Italy, 8% of exclusively breastfed newborns lost
10% of birth weight during the first 3 to 5 days.9
The investigators determined that 26% of these cases
were attributable to inadequate maternal milk vol-
ume and 74% were attributable to poor breastfeeding
technique by either the mother or infant. Delayed
onset of milk production (72 hours postpartum)
was reported by 31% of breastfeeding mothers in
Connecticut.2 Several risk factors have been associ-
PEDIATRICS Vol. 112 No. 3 September 2003 607
ated with delayed onset, including primiparity,2,10,11
cesarean section delivery,2,11,12 stress during labor
and delivery,2,10,13 maternal diabetes,14 and high ma-
ternal body mass index (BMI).2,15 These studies have
demonstrated that physiologic factors, not just be-
havioral factors, can strongly influence early lacta-
tion success.
To date, no study has documented all of the key
breastfeeding outcomes simultaneously during the
first week postpartum (infant breastfeeding behav-
ior, onset of milk production, and infant weight loss),
and none has used a community-based sample of
women. Because of this lack of information, we un-
dertook a prospective, community-based study of
early lactation success in a population where moti-
vation to breastfeed exclusively is very high. Our
objectives were to determine the incidence of, and
the risk factors associated with, poor lactation out-
comes in the absence of sociocultural barriers to ex-
clusive breastfeeding.
METHODS
Study Design and Recruitment of Subjects
All mothers who gave birth between February and December,
1999 were recruited for the study if they met the following selec-
tion criteria: a) residence in Davis, California; b) mother willing to
attempt to breastfeed exclusively for at least 1 month; c) single
infant 37 weeks gestation, with no significant perinatal morbid-
ity; d) English-speaking; and e) phone in the home. Subjects were
recruited from 5 area hospitals that collectively deliver 95% of all
births to women residing in Davis. Before and during the recruit-
ment period, the study was publicized throughout the community
via newspaper articles, contacts with health care providers, and
letters sent to pregnant women. Recruitment occurred by contact-
ing each of the 5 hospitals daily, 7 days a week, to identify
potential subjects, who were then visited in the hospital by a
member of the research team, usually within 24 hours after deliv-
ery (94%). Mothers who delivered at another hospital or at home
were also potentially eligible for the study if we were notified of
the birth within 72 hours.
On recruitment, an International Board Certified Lactation
Consultant and a research assistant completed the initial inter-
view, measured the infants weight, collected relevant data from
the medical chart and observed the infant breastfeeding (whenev-
er possible). The lactation consultant provided breastfeeding guid-
ance emphasizing a) correct positioning and latching on to the
breast, b) the importance of demand feeding and avoidance of
supplements, and c) contact information if difficulties or questions
arose. On days 3, 7, and 14 (counting 0 24 hours as day 0) subjects
were visited in their homes (or in the hospital if they had not yet
been discharged by day 3) to collect additional data and provide
ongoing lactation guidance. In addition, mothers were contacted
by phone on day 5. Guidance provided by the 7 lactation consult-
ants was standardized through an initial training period and by
weekly meetings to discuss challenging cases. The research pro-
tocol was approved by the Human Subjects Review Committee at
the University of California, Davis.
Data Collection
At the time of the hospital visit, information was collected from
the medical record concerning the duration of stage I labor (from
the time regular contractions began to cervical dilation of 10 cm)
and stage II labor (from full dilation to the delivery of the infant),
as well as mode of delivery, labor medications, presence of meco-
nium in amniotic fluid, infant resuscitation, gravida, parity, preg-
nancy weight gain, and infant birth weight. The accuracy of scales
used to measure birth weight in each hospital was checked using
standard weights at the beginning of the study and every 3
months thereafter. During the hospital interview, information was
collected from the mother regarding: a) the interval without sleep
before delivery; b) infant feeding patterns since birth (when first
put to breast; infant interest in nursing; number of breastfeeds; use
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of supplemental fluids such as water, glucose water, or formula;
and use of a pacifier); c) presence of a support person during labor
and delivery; d) previous experience breastfeeding; and e) her
confidence in her ability to exclusively breastfeed her infant for at
least 4 weeks (on a scale from 1 no confidence to 5 very
confident). During the breastfeeding observation, the lactation
consultant recorded data on nipple type (normal versus flat or
inverted), maternal and infant positioning, suckling behaviors and
mothers report of pain during the feeding. The Infant Breastfeed-
ing Assessment Tool (IBFAT)16 was used to rate the infants
breastfeeding behavior. The IBFAT includes ratings for arousal,
rooting, time to latch and feed well (fixing), and suckling effec-
tiveness, each worth 0 to 3 points (0 did not exhibit target
behavior; 3 readily exhibited target behavior) for a total maxi-
mum score of 12. Matthews16 reported interrater reliability for the
IBFAT to be 91% between mothers and trained observers. To
enhance the accuracy of recall data collected during subsequent
contacts, each mother was provided with nursing diary forms for
the next 7 days and encouraged to record the timing of each
feeding, the infants breastfeeding behavior, the time when her
breasts first felt noticeably fuller, and any supplements given to
the infant.
As soon as possible after completing 72 hours postpartum (ie,
on day 3), each mother was visited to collect information on: a) the
infants breastfeeding behavior and nursing frequency; b) her level
of breast fullness (on a scale from 1 no change, to 3 noticeably
fuller, to 5 uncomfortably full) and the approximate time post-
partum when breast fullness first reached 3 (if this had occurred);
c) supplemental fluids given to the infant during each of the past
3 days; d) use of a pacifier; e) the level of support she received for
breastfeeding from family and friends (1 most not supportive;
2 some supportive, some not; 3 a lot of support); and f) any
difficulties or discomfort she experienced with breastfeeding. The
infants weight was measured on an electronic scale accurate to
the nearest gram, which was validated daily using standard
weights. The lactation consultant observed a breastfeed, recording
the same type of information as described above for day 0, includ-
ing the IBFAT items, and provided lactation guidance. When onset
of milk production was not apparent by the day 3 visit, a fol-
low-up visit was arranged for the next day. All cases of infant
weight loss 10% of birth weight were brought to the attention of
the infants pediatrician. The lactation consultant worked in con-
junction with the pediatrician in providing appropriate follow-up
care for these infants.
Mothers were contacted by phone on day 5 to collect recall data
for days 3 and 4 regarding the same questions described above for
the day 3 visit. At the day 7 visit, this information was again
collected by recall for days 5 and 6. The day 7 visit also included
a breastfeeding observation and completion of a brief medical
history for the mother. The day 14 visit included measurement of
maternal height (to the nearest mm, using a portable stadiometer)
and weight (to the nearest 100 g, using an electronic scale).
Data Analysis
Data were analyzed using the SAS System for Windows, Re-
lease 8.1 (SAS Institute Inc, Cary, NC). The main outcome vari-
ables were:
1. Suboptimal infant breastfeeding behavior (SIBB) day 0: IB-
FAT score 10 at the breastfeeding observed during the first 24
hours postpartum. This cutoff was chosen because we were
interested in identifying any behavior that was suboptimal.
2. SIBB day 3: IBFAT score 10 at the day 3 visit.
3. SIBB day 7: IBFAT score 10 at the day 7 visit.
4. Delayed onset of milk production: Breasts not noticeably fuller
(3 on the scale of 15) by 72 hours postpartum. We previously
demonstrated that the time postpartum when breasts were first
noticeably fuller was strongly correlated with milk volume on
day 5 (r 0.66; P .0001) and the first appearance of milk
casein (r 0.49; P .0001), a biochemical marker of lactogen-
esis.10 In a separate preliminary study of several markers of the
time postpartum when milk transfer to the infant first exceeded
15 g per feed, breast fullness level 3 was closest in average
timing (53 hours for breast fullness; 58 hours for intake 15 g)
and showed the highest correlation with this indicator (r 0.60;
n 23, unpublished data). Based on these two studies, we
concluded that the breast fullness marker was the best choice
for studies in which test-weighing is not feasible. Others have
 since validated using maternal recall to assess onset of milk
production.17,18
5. Excess infant weight loss day 3: Weight loss of 10% or more
since birth. Infants who consumed 2 oz of nonbreast milk
(NBM) fluids in the first 72 hours were excluded (n 27), as
this could influence weight loss patterns.
Bivariate associations between the 5 outcome variables de-
scribed above and the 27 independent variables shown in Table 1
were examined using 2 tests. Multiple logistic regression analysis
was used to control for associations among the independent vari-
ables. Stepwise selection was used to construct the preliminary
models (P level for inclusion or removal 0.10). As described
below, the independent variables for each preliminary model were
chosen based on whether: a) there was a theoretical basis for an
association between the independent variable and the outcome; b)
the independent variable preceded the outcome variable in occur-
rence; and c) there was little possibility of reverse causation. In
addition to the main effects of the 27 independent variables,
potential interaction effects with parity were examined if: 1) there
was a theoretical basis to suspect an interaction, and 2) the biva-
riate analyses suggested that the association of an outcome with a
given independent variable differed in primiparas versus multip-
aras. In preliminary analyses, potential interactions with delivery
mode were also examined, but these were not included in the
regression models because there was little evidence that the asso-
ciation of the outcomes with any of the independent variables
differed in mothers with vaginal versus cesarean section delivery.
Associations with site of delivery were examined, but they were
not significant for any of the outcomes. The final models included
main effects significant at P .05 and interactions significant at
P .10. Estimated relative risks (RRs) and 95% confidence inter-
vals were calculated from the adjusted odds ratios of these final
models, following the procedures described by Zhang and Yu.19
Post hoc analysis of significant interaction effects was done using
the contrast option in SAS Proc Logistic.
For the logistic regressions examining SIBB on day 0, the age of
the infant at the time of the IBFAT assessment (in hours) was
forced into the model. Of the 27 independent variables, 19 vari-
ables were judged eligible for inclusion. The variables excluded
(and the reasons) were a) pregnancy weight gain and prenatal
breast enlargement (no theoretical basis); b) use of NBM fluids in
first 24 or 48 hours, pacifier use on days 0 to 2 and nipple type on
day 7 (did not precede the outcome); and c) nursing frequency on
day 0 and breastfeeding confidence (possible reverse causation).
The interactions meeting the criteria for initial inclusion in the
stepwise logistic regressions were parity with delivery mode and
parity with nipple type.
For the logistic regressions examining SIBB on day 3, 23 inde-
pendent variables were eligible for inclusion (pregnancy weight
gain, prenatal breast enlargement, breastfeeding confidence, and
nipple type on day 7 were excluded). The models were run both
with and without SIBB on day 0, using a path analysis approach.
When SIBB on day 0 was included in the model, the interaction of
parity with SIBB on day 0 was also evaluated. No other interac-
tions met the criteria for initial inclusion. For SIBB on day 7, the
same variables were included except that nipple type on day 7
rather than on day 0 was used (nipple type was not assessed on
day 3). The models were run both with and without breastfeeding
confidence on day 0. No interactions met the criteria for inclusion.
For the logistic regressions examining delayed onset, 26 inde-
pendent variables were included (nipple type on day 7 was ex-
cluded). The models were run both with and without SIBB on days
0 and 3. In addition, the interactions of parity with the following
variables met the criteria for initial inclusion in the models: a)
maternal BMI, b) duration of stage II labor, c) birth weight cate-
gory, and d) SIBB on day 3.
For the logistic regressions examining excess infant weight loss,
the same 26 variables were included. The regressions were run
both with and without delayed onset and SIBB on day 0 or day 3.
In addition, the interactions of parity with the following variables
met the criteria for initial inclusion in the models: a) use of labor
pain medications, b) total duration of labor, and c) maternal rating
of exhaustion during labor.
RESULTS
In total, 386 mother-infant pairs were screened
during the recruitment period. Of these, 58 were
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ineligible for the study and 48 refused to participate.
The reasons for ineligibility were a) did not plan to
breastfeed exclusively for at least 1 month (n 17),
b) preterm delivery (n 13), c) did not speak English
(n 12), d) perinatal morbidity (n 9), e) multiple
birth (n 3), f) moving within 1 month (n 3), and
g) no phone (n 1). The reasons for refusal were a)
not interested (n 26), b) time constraints (n 16),
c) refused anthropometric measurements (n 4), d)
mother ill (n 1), and e) religious restrictions (n
1). The analysis is based on the 280 subjects who
were enrolled in the study, of whom 271 remained in
the study on day 3 postpartum. Nine subjects were
lost to follow-up on day 3 because they could not be
contacted (n 3) or they dropped out because of
time constraints/inconvenience (n 3), infant illness
(n 2), or lack of interest (n 1).
The characteristics of the 280 mother-infant pairs
are shown in the frequency column of Table 1. Mean
maternal age was 30.6 4.7 years, and 56% of the
mothers were primiparous. The ethnic/racial break-
down was 78% non-Hispanic white, 11% Hispanic,
8% Asian, and 3% black. Average educational level
was high (16.6 2.1 years), reflecting the fact that
Davis is a university town. Attitudes toward breast-
feeding were strongly positive: average values were
11.0 5.4 months for intended duration of breast-
feeding, 4.6 0.7 (out of 5) for confidence in ability
to breastfeed exclusively, and 2.9 0.3 (out of 3) for
support for breastfeeding from family and friends.
Labor and delivery outcomes are shown by parity
in Table 2. The cesarean section rate was 14%, and
44% of mothers had an unmedicated labor and de-
livery. Primiparas had a longer duration of labor,
were more likely to have a cesarean section and to
receive regional anesthesia, narcotic analgesia and
pitocin, and were less likely to breastfeed the infant
within the first hour than multiparas.
Average breastfeeding frequency was 8.3 4.0
feeds on day 0 (adjusted for the time of the inter-
view) and 10.5 3.2 feeds on day 2. Water or glucose
water supplementation was infrequent (2% on day 0
and 3% on day 2). Supplements of infant formula
were given to 9% of infants on day 0 and 10% of
infants on day 2. Pacifiers were used by 6% of sub-
jects on day 0 and 19% of subjects on day 2.
Onset of milk production, as judged by breast
fullness, is shown in Fig 1. For the majority of women
(59%), milk production began at 49 to 72 hours
postpartum. Delayed onset (72 hours) was experi-
enced by 22% of the women (33% of primiparas vs
8% of multiparas, P .0001).
Figure 2 shows the distribution of weight change
between birth and day 3 (excluding those who con-
sumed 2 oz of NBM fluids during the first 72
hours). On average, infants lost 5.5 3.8% of birth
weight. Only 5% of infants gained weight. The ma-
jority (82%) lost 10% of birth weight, but 12% lost
10% of birth weight.
We were able to assess infant breastfeeding behav-
ior in 79% of infants on day 0, in 89% of infants on
day 3, and in 81% of infants on day 7. Nearly half
(49%) of the infants assessed had SIBB on day 0, but
ARTICLES 609
TABLE 1. Independent Variables and Their Associations With Breastfeeding Outcomes
Independent Variable Frequency Incidence of Poor Outcome
No. (%)
SIBB Day 0 SIBB Day 3 SIBB Day 7 Delayed Milk Excess Weight
% % % Onset % Loss %
Maternal factors
Parity
Primiparous 156 (56) 57** 26* 17 34*** 16*
Multiparous 124 (44) 40 17 10 8 8
Age, y
30 118 (42) 55 26 20** 25 13
30 162 (58) 45 19 10 20 13
Education
Less than college degree 49 (19) 42 18 21 20 12
College degree 213 (81) 50 23 12 22 12
Pregnancy weight gain
14 kg 149 (53) 50 18 13 17** 12
14 kg 131 (47) 48 26 14 29 13
BMI, d 14
27.0 kg/m2 164 (68) 48 21 8** 16** 9**
27.0 kg/m2 76 (32) 42 26 24 33 20
Labor and delivery
Delivery mode
Spontaneous vaginal 221 (79) 47 21 12 16*** 10*#
Assisted vaginal 20 (7) 43 21 23 42 11
Scheduled cesarean 11 (4) 63 22 13 27 25
Urgent cesarean 28 (10) 68 30 18 56 29
Labor pain management
None 123 (44) 45 19** 12 16*** 8**
Regional anesthesia 60 (21) 56 13 18 22 14
IV/IM analgesia 49 (18) 43 30 12 14 9
Both regional and IV/IM 48 (17) 60 35 13 48 26
Labor augmented
No 192 (69) 46 20 12 18** 11
Yes 88 (31) 57 26 17 32 16
Length of labor, h
6 83 (30) 50 22 11 11*** 10**
614 108 (38) 44 23 13 21 7
14 88 (32) 55 21 16 36 22
Stage II labor
1 h 187 (67) 47 22 11* 16*** 10*
1 h 93 (33) 55 22 19 36 18
Interval without sleep
18 h 175 (63) 45* 20 11 18** 11
18 h 104 (37) 57 26 17 29 13
Postpartum hemorrhage medication(s) given
No 101 (36) 50 23 10 16* 12
Yes 179 (64) 49 21 15 26 13
Infant factors
Sex
Male 149 (53) 50 22 16 22 13
Female 131 (47) 49 22 11 24 12
Birth weight
3600 g 130 (46) 51 22 18 20 11
3600 g 150 (54) 47 22 10 25 14
Gestational age
3739 wk 153 (55) 52 23 13 22 13
4041 wk 127 (45) 47 21 14 23 12
Apgar, 1-min##
7 63 (23) 48 14* 20 24 10
7 212 (77) 50 24 12 22 14
Oxygen support
None 227 (81) 49 22 14 23 15**
Given postdelivery 53 (19) 49 20 14 20 2
Amniotic fluid appearance
Clear 228 (81) 52 22 15 21 13
Colored 52 (19) 38 21 9 30 12
Breastfeeding
Prenatal breast enlargement
None or a little 92 (35) 42** 20 12 19 12
A lot 172 (65) 65 25 17 25 13
Nipple type, d 0
Both everted 252 (91) 47** 19*** 13 20** 12
Flat or inverted 26 (9) 70 50 25 44 15
Nipple type, d 7
Both everted 239 (93) 48** 19*** 10*** 19*** 10***
Flat or inverted 18 (7) 87 75 64 56 45

610 RISK FACTORS FOR EARLY LACTATION DIFFICULTIES

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TABLE 1. Continued
Independent Variable Frequency Incidence of Poor Outcome
No. (%)
SIBB Day 0 SIBB Day 3 SIBB Day 7 Delayed Milk Excess Weight
% % % Onset % Loss %
Breastfeeding confidence rating, d 0
5 74 (27) 60** 31** 30*** 29 14
5 (highest rating) 205 (73) 45 19 8 20 12
Breastfed within 1 h of birth
No 77 (28) 56 28 13 29* 14
Yes 202 (72) 47 20 14 19 12
Nursing frequency, d 0
8 feeds/24 h 139 (50) 51 24 12 24 11
8 feeds/24 h 138 (50) 40 16 16 17 15
NBM fluids, first 24 h of life
None given 239 (89) 49 20** 12** 21* 14*
Any given 30 (11) 58 36 30 35 0
NBM fluids, first 48 h of life
None given first 48 h 219 (81) 50 18** 11** 19** 12
Any given first 48 h 53 (19) 51 36 27 36 13
Pacifier use, d 02
No 220 (81) 51 19** 12 21 13
Yes 50 (19) 46 36 21 30 12
* P .10, ** P .05, *** P .001 by 2 analysis.
Unless otherwise noted, continuous variables were dichotomized by dividing at the median (rounded to the nearest whole number).
Numbers are based on full sample. Missing data result in varying sample sizes by outcome.
Definitions of poor outcomes: SIBB, IBFAT score 10; delayed milk onset, breast fullness 3 through first 72 hours postpartum; excess
infant weight loss, weight loss 10% of birth weight by 72 to 96 hours of life (excludes infants who consumed 2 oz of NBM fluids in
first 72 hours).
The usual cutoff for overweight is 25 kg/m2, but because these women were measured at only 2 weeks postpartum, a higher cutoff (27
kg/m2) was used.
P .04 with a dichotomous comparison (vaginal vs cesarean section delivery).
# P .009 with a dichotomous comparison (vaginal vs cesarean section delivery).
P .05 with a dichotomous comparison (regional vs no regional anesthesia).
IV/IM route of administration.
Long Stage II labor is conventionally defined as 1 hour.
18 h was chosen as the cutoff, based on the assumption that at least 6 hours of sleep in 24 hours is the norm.
Divided at 3600 g based on the results of Chapman and Pe rez-Escamilla.2
## There was too little variability in Apgar score at 5 minutes to examine its association with the outcome variables.

TABLE 2. Labor and Delivery Outcomes by Parity

Primiparous Multiparous Overall
No. of subjects 156 124 280
Duration of labor, mean SD
Total labor (h) 15 14 10 13* 13 13
Stage II labor (h) 1.3 1.2 0.6 0.9* 1.0 1.1
Other labor and delivery variables, No. (%)
Cesarean section delivery 30 (19) 9 (7)* 39 (14)
Use of regional anesthesia 70 (45) 38 (31)* 108 (39)
Use of IV/IM analgesia 72 (46) 25 (20)* 97 (35)
Unmedicated labor and delivery 56 (36) 67 (54)* 123 (44)
Use of pitocin during labor 59 (38) 29 (23)* 88 (31)
Breastfed within 1 h 104 (67) 98 (79)* 202 (72)
SD indicates standard deviation.
* P .05, primiparous versus multiparous.

this percentage decreased to 22% on day 3 and 14%
on day 7.
Table 3 shows the associations among the 5 dichot-
omous outcomes. Compared with infants with opti-
mal breastfeeding behavior, infants with SIBB on day
0 were 1.8 times more likely to have SIBB on day 3,
and 2.6 times more likely to have excess weight loss.
The association of SIBB on day 0 with delayed onset
of milk production was not significant, but mothers
of infants with SIBB on day 3 were 2.6 times more
likely to have delayed onset than mothers of infants
with optimal breastfeeding behavior on day 3. SIBB
on day 0 was not associated with SIBB on day 7, but
infants with SIBB on day 3 were 2.9 times more likely
to have SIBB on day 7. The risk of excess infant
weight loss was 7.1 times greater if the mother had
delayed onset of milk production. Among the 30
infants with excess weight loss, 63% of their mothers
had delayed onset of milk production, compared
with 13% of the 210 infants who did not have excess
weight loss.
Table 1 shows the bivariate associations of each of
the independent variables with the 5 dichotomous
outcomes. It is important to note that there were
significant associations among many of the indepen-
dent variables (not just the obvious associations,
such as maternal age with parity, or cesarean section
with use of labor pain medications). For example,

ARTICLES 611
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Fig 1. Onset of breast fullness.

Fig 2. Percentage weight change, birth to day 3.

TABLE 3. Bivariate Associations Among Breastfeeding Outcomes

Incidence of Poor Outcome
SIBB Day 0 SIBB Day 3 SIBB Day 7 Delayed Milk Onset Excess Weight Loss
Cases/N (%) Cases/N (%) Cases/N (%) Cases/N (%) Cases/N (%)
Overall 109/221 (48.9) 53/241 (22.0) 29/213 (13.6) 62/271 (22.9) 30/240 (12.5)
By outcome group
Infant breastfeeding behavior, d 0
Adequate 14/94 (14.9)** 12/81 (14.8) 19/106 (17.9) 7/95 (7.4)**
Suboptimal 26/95 (27.4) 12/89 (13.5) 28/106 (26.4) 19/97 (19.6)
Infant breastfeeding behavior, d 3
Adequate 69/149 (46.3)** 14/152 (9.2)** 30/188 (16.0)*** 20/175 (11.4)
Suboptimal 26/40 (65.0) 12/45 (26.7) 22/53 (41.5) 8/43 (18.6)
Infant breastfeeding behavior, d 7
Adequate 77/146 (52.7) 33/171 (19.3)** 32/184 (17.4)** 18/164 (11.0)**
Suboptimal 12/24 (50.0) 12/26 (46.2) 12/29 (41.4) 6/20 (30.0)
Milk onset
Normal 78/165 (47.3) 30/189 (15.9)*** 17/169 (10.1)** 11/193 (5.7)***
Delayed 28/47 (59.6) 22/52 (42.3) 12/44 (27.3) 19/47 (40.4)
Infant weight loss
Normal 78/166 (47.0)* 35/190 (18.4)* 14/160 (8.8)** 28/210 (13.3)***
Excessive 19/26 (73.1) 8/28 (28.6) 6/24 (25.0) 19/30 (63.3)
2 analysis.
Definitions of poor outcomes: SIBB, IBFAT score 10; delayed milk onset, breast fullness 3 through first 72 hours postpartum; excess
weight loss, weight loss 10% of birth weight by 72 to 96 hours of life (excludes infants who consumed 2 oz of NBM fluids in first 72
hours).
* P .10, ** P .05, *** P .001.

women with a BMI 27 kg/m2 (n 76) were signif-
icantly more likely to have had a cesarean delivery
(22 vs 10%; P .007), use NBM fluids on day 0 (17 vs
7%; P .02) and in the first 48 hours of life (29 vs
13%; P .002), be 30 years of age (55 vs 33%; P
.001), and not be a college graduate (28 vs 14%; P
.01), as compared with women with a BMI 27
kg/m2 (n 164). Thus, for each of the outcome
variables the description of the bivariate results will
be followed immediately by the multivariate results.
Only variables meeting the criteria for inclusion in
the multivariate models will be mentioned (though
all independent variables are shown in Table 1).
In the bivariate analyses, SIBB on day 0 was sig-

612 RISK FACTORS FOR EARLY LACTATION DIFFICULTIES

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TABLE 4. Logistic Regression Analysis of Risk Factors for
SIBB on Day 0 (N 220)*
Variable RR 95% CI
Flat or inverted nipples 1.56 1.021.90
Cesarean section parity
Multiparous/vaginal 1.00
Multiparous/cesarean section 2.46 1.312.74
Primiparous/vaginal 1.72 1.282.09
Primiparous/cesarean section 1.68 1.062.24
Clear amniotic fluid 1.55 1.051.98
CI indicates confidence interval.
* Controlling for hours since birth when breastfeeding assessed
(P .005).
nificantly associated (P .05) with primiparity, ce-
sarean section, use of regional anesthesia during la-
bor, and flat or inverted nipples. In the multiple
logistic regression (Table 4), the association with flat
or inverted nipples remained significant (RR: 1.56)
and there was a significant interaction between par-
ity and delivery mode: those at lowest risk were
multiparous mothers with vaginal deliveries (RR:
1.0), with all other subgroups (multiparous mothers
with cesarean sections [RR: 2.46]; primiparous moth-
ers with either vaginal [RR: 1.72] or cesarean section
[RR: 1.68] delivery) being at significantly higher risk
for SIBB. In addition, the risk of SIBB was higher
among infants whose amniotic fluid at delivery was
clear rather than stained with meconium (RR: 1.55).
SIBB on day 3 was significantly associated with the
following variables in the bivariate analyses: use of
labor pain medications (particularly intravenous
[IV]/intramuscular [IM] analgesia), flat or inverted
nipples, lower maternal breastfeeding confidence,
use of NBM fluids in the first 48 hours and pacifier
use. In the multiple logistic regression (Table 5,
Model 1), the significant variables were flat or in-
verted nipples (RR: 3.02), NBM fluids in the first 48
hours (RR: 2.26), pacifier use (RR: 1.95) and an Apgar
score 7 at 1 minute of age (RR: 2.10). When SIBB on
day 0 was included (Model 2), the RRs for NBM
fluids and pacifier use were not reduced, but the RR
for flat or inverted nipples was somewhat lower
(2.57) and the RR for Apgar score was no longer
P Value significant. In addition, there was a significant inter-
.04 action between parity and SIBB on day 0: the latter
.03 was a significant predictor of SIBB on day 3 among
primiparas (P .02) but not among multiparas (P
.02 .82).
.001
.047
In bivariate analyses, SIBB on day 7 was signifi-
.03 cantly associated with maternal age 30 years, ma-
ternal BMI 27 kg/m2, flat or inverted nipples on
day 7, lower maternal breastfeeding confidence, and
use of NBM fluids in the first 48 hours. In the mul-
tiple logistic regression excluding breastfeeding con-
fidence (Table 6, Model 1), the associations with ma-
ternal BMI (RR: 2.58), flat or inverted nipples (RR:
6.57) and use of NBM fluids (RR: 2.55) remained
significant, and in addition there were significant
associations with stage II labor 1 hour (RR: 3.11)
and birth weight 3600 g (RR: 2.69). Neither SIBB
day 0 nor SIBB day 3 was significantly associated
with SIBB day 7 in the multiple logistic regression
analyses. When breastfeeding confidence was in-
cluded in the model (RR: 4.10), the results for the
other variables were generally similar (Model 2) ex-
cept that birth weight became marginally significant
and use of NBM fluids was no longer significant. The
association with breastfeeding confidence (assessed
on day 0) could be attributable to reverse causation,
but this is less likely for SIBB on day 7 than for SIBB
on days 0 and 3 because there was no significant
association between SIBB on day 0 and SIBB on day
7 (Table 3).
Delayed onset of milk production was signifi-
cantly associated with the following variables in the
bivariate analyses: primiparity, greater pregnancy
weight gain, maternal BMI 27 kg/m2, cesarean de-
livery (particularly an urgent cesarean section), use
of labor pain medications, augmentation of labor
with pitocin, longer duration of labor (both total and
stage II), a longer interval without sleep before de-
livery, flat or inverted nipples, and use of NBM

TABLE 5. Logistic Regression Analysis of Risk Factors for SIBB on Day 3

Model 1Without SIBB Day 0 in the Model (N 239)
Variable RR 95% CI P Value
Flat or inverted nipples, d 0 3.02 1.794.11 .0004
NBM fluids, first 48 h 2.26 1.363.30 .003
Pacifier use 1.95 1.103.00 .03
Apgar score 7 at 1 min 2.10 1.053.58 .04
Model 2With SIBB Day 0 in the Model (N 189)
Variable RR 95% CI P Value
Flat or inverted nipples, d 0 2.57 (2.88)* 1.223.96 .02
NBM fluids, first 48 h 3.08 (3.13)* 1.784.40 .0004
Pacifier use 2.74 (2.49)* 1.494.00 .003
Apgar score 7 at 1 min 1.48 (1.46)* 0.682.69 .30
Parity SIBB day 0 .10
Multiparous/not SIBB 1.00
Multiparous/SIBB 0.88 0.262.32 .83
Primiparous/not SIBB 0.93 0.312.31 .90
Primiparous/SIBB 2.39 1.163.86 .02
CI indicates confidence interval.
* RR for this variable when SIBB day 0 not in the model, but analysis limited to same group of subjects
(N 189).

ARTICLES 613
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 TABLE 6. Logistic Regression Analysis of Risk Factors for SIBB on Day 7
Model 1 (N 198)
Variable RR 95% CI P Value
Flat or inverted nipples, d 7 6.57 3.168.88 .0001
Stage II labor 1 h 3.11 1.445.48 .005
Birth weight 3600 g 2.69 1.214.87 .018
Maternal BMI 27 kg/m2 2.58 1.075.22 .035
NBM fluids, first 48 h 2.55 1.044.92 .041
Model 2With Breastfeeding Confidence in Model* (N 198)
Variable RR 95% CI P Value
Flat or inverted nipples, d 7 5.09 1.968.15 .003
Stage II labor 1 h 3.16 1.435.61 .006
Birth weight 3600 g 2.31 0.994.42 .052
Maternal BMI 27 kg/m2 3.84 1.687.00 .003
Maternal confidence 5 4.10 1.837.48 .001
CI indicates confidence interval.
* Maternal confidence in ability to breastfeed exclusively for at least 4 weeks (1 no confidence to 5
very confident), assessed on day 0.

fluids in the first 48 hours. In the multiple logistic
regression (Table 7, Model 1), the significant vari-
ables were long duration of stage II labor (RR: 2.26),
cesarean delivery (RR: 2.01), high maternal BMI (RR:
2.46), flat or inverted nipples (RR: 2.26) and the in-
teraction of parity with birth weight. The latter in-
teraction is shown in Fig 3, which illustrates that a
primiparous mother is at greatest risk for delayed
onset if she has a large infant, whereas giving birth to
a larger infant is not a significant risk factor for
delayed onset among multiparas. In models using a
path analysis approach, SIBB on day 0 did not enter
the model, but SIBB on day 3 was a significant pre-
dictor of delayed onset in the logistic regression
(RR: 2.66). With SIBB on day 3 included (Model 2),
the RR for flat or inverted nipples became nonsignif-
icant and the RR for cesarean delivery became mar-
ginally significant (the latter was because of the
smaller sample size for Model 2, not to a decrease in
the magnitude of the RR for cesarean section).
Excess infant weight loss was significantly associ-
ated with the following variables in bivariate analy-
ses: maternal BMI 27 kg/m2, cesarean delivery, use
of labor pain medications (particularly regional an-
esthesia), longer duration of labor (14 hours), infant
not given oxygen postdelivery, and flat or inverted
nipples on day 7. In the multiple logistic regression
(Table 8, Model 1), the significant variables were
longer duration of labor (RR: 2.41), infant not given
oxygen (RR: 8.33), and the interaction of parity with
use of labor pain medications. The latter interaction
revealed that labor pain medications were a risk
factor for excess infant weight loss among multiparas
(RR: 4.06) but not primiparas; among women who

TABLE 7. Logistic Regression Analysis of Risk Factors for Delayed Onset of Milk Production
Model 1Without SIBB Day 3 in the Model (N 240)
Variable RR 95% CI P Value
Stage II labor 1 h 2.26 1.243.57 .01
Cesarean section 2.01 1.003.31 .05
Maternal BMI 27 kg/m2 2.46 1.453.64 .002
Flat or inverted nipples, d 0 2.26 1.083.56 .03
Parity birth weight .03
Multiparous/3600 g 1.00
Multiparous/3600 g 2.13 0.576.07 .25
Primiparous/3600 g 5.98 2.659.92 .0001
Primiparous/3600 g 2.86 1.046.34 .04
Model 2With SIBB Day 3 in the Model (N 216)
Variable RR 95% CI P Value
Stage II labor 1 h 2.22 (2.03)* 1.163.63 .02
Cesarean section 1.99 (1.87)* 0.873.47 .095
Maternal BMI 27 kg/m2 2.00 (2.11)* 1.073.22 .03
Flat or inverted nipples, d 0 1.58 (2.06)* 0.583.12 .34
Parity birth weight .02
Multiparous 3600 g 1.00
Multiparous 3600 g 2.50 (2.06)* 0.557.99 .23
Primiparous 3600 g 7.53 (7.42)* 3.1612.39 .0001
Primiparous 3600 g 3.14 (3.27)* 1.007.66 .05
SIBB d 3 2.66 1.493.98 .002
CI indicates confidence interval.
* RR for this variable when SIBB day 3 not in the model, but analysis limited to same group of subjects
(N 216).

614 RISK FACTORS FOR EARLY LACTATION DIFFICULTIES

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Fig 3. Percentage of mothers with delayed onset of
milk production, by parity and infant birth weight,
adjusted for mode of delivery, duration of stage II
labor, maternal BMI, and flat or inverted nipples (bars
with different letters are significantly different, P
.05). Vertical bars: birth weight 3600 g; horizontal
bars: birth weight 3600 g. N 69 primiparas with
infants 3600 g, 61 primiparas with infants 3600 g, 40
multiparas with infants 3600 g and 71 multiparas
with infants 3600 g.
did not receive labor pain medications, primiparity
was a risk factor (RR: 4.51) for excess infant weight
loss. In models using a path analysis approach, SIBB
on day 3 did not enter the model, but both SIBB on
day 0 and delayed onset were significant predictors
of excess infant weight loss in logistic regressions.
With delayed onset in the model (but not SIBB on
day 0, see Model 2), the RR for duration of labor
became nonsignificant, but those for infant oxygen
and the interaction of parity with labor pain medi-
cations remained significant. With both delayed on-
set (RR: 6.13) and SIBB on day 0 (RR: 2.43) included
(Model 3), none of the other variables was a signifi-
cant predictor of excess weight loss. However, the
nonsignificant P values for infant oxygen and the
above interaction were primarily attributable to the
smaller sample size for Model 3, as the RRs for these
variables did not decrease when SIBB on day 0 was
added to the model if confined to the same group of
subjects (N 191).
DISCUSSION
These results indicate that lactation difficulties
during the first week postpartum are not uncom-
mon, even among women who are highly motivated
to breastfeed exclusively and receive good lactation
guidance. In this sample of 280 mother-infant pairs,
SIBB was observed in 49% on day 0, in 22% on day 3,
and in 14% on day 7. Delayed onset of lactation
occurred in 22% of women, and 12% of the infants
lost 10% of birth weight. These outcomes were
strongly linked. For example, infants of mothers with
delayed onset of lactation were 7.1 times more likely
to have excess weight loss, and those with SIBB on
day 0 were 2.6 times more likely to have excess
weight loss than infants without these risk factors. In
fact, of the 26 infants with excess weight loss who
had a breastfeeding assessment done on day 0, all
but 2 had either SIBB or a mother with delayed onset
(or both). Thus, 92% of such cases could be predicted
on the basis of these 2 evaluations combined.
The incidence of delayed onset in our population
was somewhat lower than observed in a sample of
breastfeeding women in Connecticut (31%),2 which
could be explained by the more comprehensive lac-
tation guidance provided in our study. On the other
hand, the incidence of excess infant weight loss in
our study was greater than that observed in a sample
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of 686 exclusively breastfed infants born in a breast-
feeding-friendly hospital in Italy (8%).9 In that hos-
pital, no study infant received glucose or formula
during the first 3 days of life (compared with 21% of
infants in our study), and newborns were normally
discharged on day 3 or 4 if delivered vaginally (com-
pared with within the first 2 days in our study).
These practices may prevent some cases of excess
weight loss by promoting frequent breastfeeding and
ensuring that mothers receive lactation guidance be-
yond the first 24 hours postpartum.
The multivariate analyses illustrate that parity,
events during labor and delivery, and characteristics
of the mother and infant have strong effects on SIBB,
delayed onset of lactogenesis, and excess infant
weight loss. Table 9 summarizes the risk factors iden-
tified. Primiparas were at greater risk than multipa-
ras for all outcomes except SIBB on day 7. The greater
risk of SIBB on day 3 among primiparas was evident
only among those whose infants already had SIBB on
day 0, whereas SIBB on day 0 was not a risk factor for
SIBB on day 3 among multiparas. This implies that
multiparas whose infants have SIBB on day 0 are able
to improve the situation, presumably because of
their past breastfeeding experience, whereas first-
time mothers need special assistance to do so. The
relationship between primiparity and excess infant
weight loss was mediated by the greater risk of de-
layed onset and SIBB on day 0 among primiparas.
The group at lowest risk for excess infant weight loss
was multiparas with an unmedicated labor and de-
livery. The strong associations we observed between
parity and early lactation success are consistent with
other studies showing that primiparity or lack of
previous breastfeeding experience are risk factors
for delayed onset of lactation2,10,11 or excess infant
weight loss.9
Cesarean section delivery was a risk factor for
SIBB on day 0 and delayed onset of lactation. Other
investigators have also reported that cesarean section
is linked with delayed onset2,11,12 and excess infant
weight loss,9 although not all studies have shown an
association with difficulties initiating lactation.20
With adequate guidance, mothers who have a cesar-
ean section can generally overcome early breastfeed-
ing problems and successfully establish breastfeed-
ing.21
A long duration of stage II labor predisposed
ARTICLES 615
 TABLE 8. Logistic Regression Analysis of Risk Factors for Excess Infant Weight Loss by Day 3*
Model 1Without Delayed Onset or SIBB Day 0 in the Model (N 239)
Variable RR 95% CI P Value
Cesarean section 2.18 0.854.56 .10
Labor 14 h 2.41 1.144.57 .02
Infant not given oxygen 8.33 1.2530.54 .03
Parity labor pain medications .04
Multiparous/none 1.00
Multiparous/medications 4.06 0.8514.06 .08
Primiparous/none 4.51 0.9714.98 .05
Primiparous/medications 2.75 0.5510.90 .21
Model 2With Delayed Onset in the Model (N 239)
Variable RR 95% CI P Value
Cesarean section 1.60 0.524.00 .40
Labor 14 h 2.03 0.854.25 .11
Infant not given oxygen 8.01 1.1430.54 .04
Parity labor pain medications .05
Multiparous/none 1.00
Multiparous/medications 3.80 0.7613.89 .10
Primiparous/none 2.86 .5411.57 .21
Primiparous/medications 1.53 0.267.69 .63
Delayed onset of lactation 6.12 2.9110.01 .0001
Model 3With Delayed Onset and SIBB Day 0 in the Model (N 191)
Variable RR 95% CI P Value
Cesarean section 0.87 (1.03) 0.232.69 .83
Labor 14 h 1.93 (1.96) 0.754.24 .17
Infant not given oxygen 6.33 (6.14) 0.9121.97 .06
Parity labor pain medications .20
Multiparous/none 1.00
Multiparous/medications 2.79 (2.94) 0.5210.68 .23
Primiparous/none 2.07 (2.44) 0.368.97 .40
Primiparous/medications 1.50 (1.68) 0.257.30 .66
Delayed onset of lactation 6.13 (5.74) 2.799.33 .0001
SIBB, day 0 2.43 0.975.21 .06
CI indicates confidence interval.
* Excludes infants who consumed 2 oz of NBM fluids.
Cesarean section is included in the model to control for mode of delivery when considering the effect
of labor pain medications.
RR for this variable when SIBB day 0 not in the model, but analysis limited to same group of subjects
(N 191).

mothers to delayed onset of lactation and infants to
SIBB on day 7 (though not on day 0 or 3). The
association with delayed onset is consistent with
findings of previous studies.2,10 We also found a
2.4-fold greater risk of excess infant weight loss
among mothers with a total duration of labor 14
hours, which was explained by the link to delayed
onset. We have previously shown that a long dura-
tion of labor is stressful to both the mother and the
infant, resulting in higher cortisol levels in both.10
Higher cortisol levels have been linked to delayed
onset of lactation.10,22 The highest incidence of de-
layed onset in our study (56%) was observed among
mothers who had an urgent cesarean section (as
compared with 27% among those with a scheduled
cesarean section). This relationship with urgent ce-
sarean section delivery, which is undoubtedly the
most stressful delivery experience, has also been re-
ported by Chapman and Pe rez-Escamilla.2
The influence of labor pain medications on breast-
feeding has been controversial. In the bivariate anal-
yses, we found that SIBB on day 0 was more common
among those whose mothers received regional anes-
thesia during labor, SIBB on day 3 was more com-
mon among those whose mothers received IV or IM
analgesia during labor, and delayed onset of lacta-
tion was more common in mothers who received
both regional and IV/IM labor medications. None of
these associations remained significant in the multi-
variate analyses when controlling for mode of deliv-
ery and other variables. However, within the sub-
group of infants delivered vaginally, IV/IM
analgesia was a significant predictor of SIBB on day
3 in multivariate analyses (P .03; data not shown).
Moreover, there was a significant association be-
tween labor medications and excess infant weight
loss among multiparas, even after controlling for
mode of delivery, duration of labor, and other po-
tential confounders. Because of variability in the type
and timing of dosage of medications used, it is dif-
ficult to determine which medications are responsi-
ble for this association, but the data suggest that
regional anesthesia is more likely than IV/IM anal-
gesia to affect infant weight loss. It is possible that
administration of IV fluids during labor, which is
more common in women given labor pain medica-
tions, increases the hydration status of the newborn
and leads to greater weight loss subsequently. How-

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TABLE 9. Summary of Risk Factors for SIBB, Delayed Onset of Lactogenesis, and Excess Infant Weight Loss
Risk Factor
SIBB Day 0 SIBB Day 3
Primiparity (if SIBB d 0)
Cesarean section [in
multiparas]
Long labor
Labor pain medications
High maternal BMI
Flat or inverted nipples
NBM fluids, first 48 h
Pacifier use
Birth weight
Infant status* (via SIBB d 0)
* Did not receive oxygen, had clear amniotic fluid, or had Apgar score 7 at 1 minute.
ever, this would not explain why we saw the asso-
ciation between labor pain medications and excess
weight loss only in multiparas. Previous studies have
focused on the relationship between labor medica-
tions and infant suckling behavior or breastfeeding
duration, not infant weight loss. Some have shown
an association,3,23,24 whereas others have not.25,26
Our data suggest that the association may not be
evident among primiparas (who are at higher risk for
early lactation difficulties regardless of labor medi-
cations), but may be significant among multiparas.
Conflicting results may also be attributable to the
potential indirect effects of labor medications on
breastfeeding via their influence on duration of labor
and the mode of delivery, which would not be evi-
dent when controlling for the latter variables. In a
recent systematic review of unintended effects of
epidural medications during labor, Lieberman and
ODonoghue27 concluded that epidurals increase the
duration of labor and reduce the likelihood of a
spontaneous vaginal delivery, particularly in primip-
aras.
Maternal obesity has been linked to impaired lac-
togenesis in both animal and human studies,15 but
the mechanisms for this relationship are unclear. We
found that women with a BMI 27 kg/m2 were 2.5
times more likely to have delayed onset of lactation
than women with a lower BMI, and their infants
were 3 times more likely to have SIBB on day 7
(though not on day 0 or 3). Because women in our
study with a higher BMI differed in many ways from
those with lower BMI (eg, age, education, use of
NBM fluids), we cannot completely rule out behav-
ioral factors, but when these variables were included
in the analyses the RRs associated with high BMI did
not decrease. Endocrinologic aberrations linked with
overweight are a possible cause of delayed onset of
lactation. In rats, impaired lactogenesis in obese
dams has been linked with altered regulation of glu-
cose, the primary substrate for milk synthesis.28
Nonetheless, with lactation guidance the vast major-
ity of overweight women are able to successfully
establish exclusive breastfeeding.
Flat or inverted nipples were associated with SIBB
on days 0, 3, and 7, and with delayed onset of lacta-
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Outcome
SIBB Day 7 Delay Excess Weight Loss
(if birth
unmedicated) (via
delay and SIBB d 0)
(via delay)
(in multiparas)
(partly via SIBB d 0)
(via SIBB d 3)
(lower weight) (higher weight, in
primiparas only)
tion. This implies that a woman with flat or inverted
nipples should receive special assistance until the
infant is able to latch on effectively. The effect of
early use of NBM fluids and/or pacifiers on breast-
feeding success has been controversial. Because of
the possibility of reverse causation (ie, infants doing
poorly at the breast are more likely to be offered
supplements) and potentially confounding variables
(such as lower motivation to breastfeed exclusively
among women who use supplements or pacifiers), it
has been difficult to determine the causal pathway
underlying the inverse associations found in obser-
vational studies.29 Our results showed that infants
who were given NBM fluids in the first 48 hours or
offered pacifiers were 2 to 3 times more likely to have
SIBB on days 3 and 7, even after controlling for their
breastfeeding score on day 0. Because there is no
medical reason to give supplemental fluids to nor-
mal, healthy breastfed newborns during the first 48
hours, and we controlled for suckling difficulties on
day 0, these findings support the hypothesis that
supplemental fluids and pacifiers can interfere with
the establishment of effective breastfeeding. On the
other hand, we did not find a relationship between
excess infant weight loss and supplemental fluids or
pacifier use. Thus, if there is an effect of such prac-
tices on breastfeeding behavior, with appropriate
lactation guidance it may be short-lived or too subtle
to affect other outcomes, except perhaps in high-risk
mother-infant pairs. Kramer et al29 concluded that
pacifier use is a marker of breastfeeding difficulties,
not a true cause of cessation of breastfeeding by 3
months. However, they did not specifically examine
the effect of pacifier use during the first week of life,
when the infant is learning how to suckle effectively.
A lower infant birth weight was associated with
SIBB on day 7, but high infant birth weight (3600 g)
was associated with delayed onset of lactation
among primiparas (though not among multiparas),
even when controlling for duration of labor. One
possible explanation for the latter finding is that
delivering a large infant is more difficult (particular-
ly for primiparas) regardless of the duration of labor,
and leads to greater maternal and/or infant stress.
Our findings regarding birth weight and delayed
ARTICLES 617
onset conflict with those of Chapman and Pe rez-
Escamilla,2 who found a higher risk of delayed onset
in mothers of infants with birth weight 8 lb. How-
ever, they did not examine this relationship only
within the primiparas.
Curiously, several indicators reflective of better
infant status at birth were associated with a greater
risk of poor outcomes in our study. Clear amniotic
fluid (vs meconium staining) was associated with
SIBB on day 0, 1-minute Apgar score 7 was asso-
ciated with SIBB on day 3, and no use of oxygen (ie,
resuscitation by mask or blow-by) was associated
with excess infant weight loss. All 3 of these indica-
tors were strongly interrelated, which is to be ex-
pected given that infants with low Apgar scores or
evidence of stress (eg, meconium-stained amniotic
fluid) were much more likely to be given oxygen.
One possible explanation is that, when controlling
for other risk factors linked with infant status (such
as cesarean section, birth weight, and duration of
labor), there is a benefit to administering oxygen that
has a positive influence on recovery from the birth
experience and thus breastfeeding. This is not to
imply that all infants should receive oxygen at birth,
but simply that breastfeeding outcomes may be en-
hanced by administration of oxygen to high-risk in-
fants. With regard to meconium staining, another
possible explanation is that infants who pass meco-
nium sooner are less likely to have high bilirubin
levels30 and thus are more interested in breastfeed-
ing.31 It is also possible that these associations are
simply attributable to chance.
CONCLUSIONS
The results of this study reinforce the need for
special attention and follow-up of mother-infant
pairs at risk for breastfeeding difficulties during the
first week postpartum. High-risk groups include pri-
miparas (particularly those delivering large infants),
mothers who have a long labor or deliver by cesar-
ean section (particularly an urgent cesarean section),
multiparas who receive labor medications, over-
weight mothers, women with flat or inverted nip-
ples, and infants with SIBB during the first 24 hours.
These findings imply that modifications of the labor
and delivery experience that reduce the duration of
labor (both total and stage II) and increase the like-
lihood of a spontaneous, unmedicated vaginal deliv-
ery should improve early lactation success. The re-
sults also provide support for the recommendation
to avoid supplemental fluids unless medically indi-
cated32 and to discourage pacifier use during the first
week of life. Given that early lactation difficulties
were common even in women who were highly mo-
tivated to breastfeed and received lactation guidance
during the hospital stay, it is essential that all breast-
feeding mother-infant pairs be followed up at 72 to
96 hours postpartum. At the follow-up evaluation,
mothers should be asked if their milk has come in,
and if the answer is no, be provided with immediate
assistance by a health care provider trained in lacta-
tion management. With appropriate assistance,
nearly all women with delayed onset of lactation can
eventually establish an adequate milk supply, but
618 RISK FACTORS FOR EARLY LACTATION DIFFICULTIES
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the phenomenon should be taken seriously not only
because it can lead to excess infant weight loss in the
short-term, but because it has been linked with
shorter breastfeeding duration.33
ACKNOWLEDGMENTS
The study was funded by National Institutes of Health grant
RO1 HD35962 and the World Health Organization (Department of
Nutrition for Health and Development).
We thank all of the mothers and infants who participated in the
study, as well as our dedicated team of International Board Cer-
tified Lactation Consultants (Karen Farley, Ann Gorrell, Laura
Ortiz, Jeanette Panchula, and Carla Turoff) and research assistants
(Swati Deshpande, Cindy Duke, Kathy Harris, Beth Tohill, Nanise
Tomlinson, and Tracey Wang). We also thank the staff at the
participating hospitals (Sutter Davis Hospital, Woodland Memo-
rial Hospital, Kaiser Permamente Hospitals of Sacramento, and
the University of California at Davis Medical Center) for their
cooperation with recruitment procedures. We thank Janet Peerson
for her statistical guidance.
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IS PRIMARY CARE RESEARCH A LOST CAUSE?

Primary care is in crisis. . . the field has failed to hold its own among medical
specialties. This is the conclusion of a group gathered under the auspices of the
Robert Wood Johnson Foundation, the deliberations of which are summarized in a
series of papers published in the February 4, 2003, issue of the Annals of Internal
Medicine. . . This gathering of family practice leaders and investigators (the World
Organization of Family Doctors) represented all continents of the world. They set
out to produce a statement on the future prospects of primary care researchand
did so. But a series of commissioned papers intended to launch discussion at the
conference also revealed the loss of directionand confidencethat primary care
research is presently experiencing. Very few examples of good family practice
research were presented. . . According to those in Kingston, primary care research-
ers see themselves, their subject, and their task as being different from those of
others specialists. They felt misunderstood by mainstream academia, funding
bodies, and journal editors. . . These arguments are quasi-mystical nonsense. Blam-
ing others for failing to make an impact will do little to win the hearts and minds
of skeptics.

Lancet. 2003;361:977

Noted by JFL, MD

ARTICLES 619
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 Risk Factors for Suboptimal Infant Breastfeeding Behavior, Delayed Onset of
Lactation, and Excess Neonatal Weight Loss
Kathryn G. Dewey, Laurie A. Nommsen-Rivers, M. Jane Heinig and Roberta J. Cohen
Pediatrics 2003;112;607
DOI: 10.1542/peds.112.3.607
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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, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
0031-4005. Online ISSN: 1098-4275.

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 Risk Factors for Suboptimal Infant Breastfeeding Behavior, Delayed Onset of
Lactation, and Excess Neonatal Weight Loss
Kathryn G. Dewey, Laurie A. Nommsen-Rivers, M. Jane Heinig and Roberta J. Cohen
Pediatrics 2003;112;607
DOI: 10.1542/peds.112.3.607

The online version of this article, along with updated information and services, is located
on the World Wide Web at:
/content/112/3/607.full.html

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, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2003 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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