Journal of Pediatric Nursing 38 (2018) 27–32

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

The Effects of Breastfeeding in Infants With Phenylketonuria

Engin Kose, MD a,⁎, Betul Aksoy, MD b, Pinar Kuyum, MD b, Nilhan Tuncer, RD c,
Nur Arslan, Prof a, Yesim Ozturk, Prof b
a
Dokuz Eylul University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Metabolism, Izmir, Turkey
b
Dokuz Eylul University Faculty of Medicine, Department of Pediatric Gastroenterology, Izmir, Turkey
c
Dokuz Eylul University Faculty of Medicine, Department of Nutrition and Dietetics, Izmir, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: In the early years of phenylketonuria (PKU) treatment, mothers and healthcare professionals often de-
Received 9 May 2017 cide to discontinue breastfeeding after the diagnosis of PKU in infants. It was believed to be the only effective way
Revised 12 October 2017 to monitor the infant's intake and allow for precise titration and measurement of the intake of phenylalanine
Accepted 13 October 2017 (Phe). In the early 1980s, with the determination of low concentration of Phe in breast milk, breast milk supple-
Available online xxxx
mented with Phe-free formula has become an acceptable dietary treatment for infants with PKU. Today,
breastfeeding is encouraged and well established in PKU patients.
The aim of the present study is to investigate the prevalence and duration of breastfeeding, the effect of
breastfeeding on serum Phe levels, and weight gain in infants with PKU.
Design and Methods: Data were collected from chart reviews. Medical records of 142 children with PKU diagnosed
via the national neonatal screening program were analyzed retrospectively.
Results: Of the 41 infants with complete medical records, 40 (97.6%) were breastfed following delivery whereas
only one (2.4%) was bottle fed. After the diagnosis, breastfeeding was continued in 25 (61%) infants with phenyl-
alanine-free amino acid based protein substitute. The mean duration of breastfeeding was 7.4 ± 4.0 (1–15)
months. Serum Phe concentration of breastfed infants (280 ± 163 μmol/L) was significantly lower than
non-breastfed infants (490 ± 199 μmol/L) (p b 0.001). Mean monthly weight gain in the first year of life
was significantly higher in breastfed patients (493 ± 159 g/month) compared to non-breastfed patients
(399 ± 116 g/month) (p = 0.046).
Conclusion: In the first year of life, weight gain and serum Phe levels were more favorable in breastfed in-
fants with PKU compared to non-breastfed infants with PKU.
© 2017 Elsevier Inc. All rights reserved.

Background cognitive–neurological development is preserved essentially normal

Phenylketonuria (PKU) is a congenital disorder of the phenylalanine
(Phe) metabolism caused by mutations in the liver enzyme, phenylala-
nine hydroxylase, encoded by the phenylalanine hydroxylase (PAH)
gene (OMIM 261600) (Blau, van Spronsen, & Levy, 2010). Phenylalanine
hydroxylase deficiency results in the inability to convert Phe to tyrosine,
leading to increased phenylalanine concentrations in blood and central
nervous system. The dietary treatment of PKU is based on the restriction
of Phe intake in order to maintain blood Phe concentrations within the
recommended range (MacDonald, Rocha, van Rijn, & Feillet, 2011). Un-
less the affected child is maintained on a strict low-phenylalanine diet,
PKU leads to mental retardation, seizures, behavioral problems, and
other neurological symptoms. In contrast, when identified via newborn
screening and if treatment is initiated before one month of age,
⁎ Corresponding author.
E-mail address: enginkose85@hotmail.com (E. Kose).
(Vockley et al., 2014). Individuals with PKU must maintain a life-long
protein-restricted diet (Feillet & Agostoni, 2010).
Breastfeeding provides an ideal food for healthy growth and devel-
opment of infants and children. Optimal breastfeeding practice includes
timely initiation of breastfeeding, exclusive breastfeeding for the first
six months and continued breastfeeding up to the age of two years
and beyond along with appropriate complementary feeding (World
Health Organization [WHO], 2003). Unfortunately, exclusive
breastfeeding for the first six months of life affects the cognitive–neuro-
logical development of patients with PKU as the Phe in breast milk can-
not be converted to tyrosine by the phenylalanine hydroxylase enzyme
in liver. Formerly, the standard of care for infants diagnosed with PKU
was immediate discontinuation of breastfeeding to maintain appropri-
ate Phe levels with the combination of standard commercial infant for-
mulas and phenylalanine-free amino acid based protein substitute. In
1980, with the discovery of lower Phe levels in human breast milk com-
pared to standard commercial infant formulas, breastfeeding has begun

https://doi.org/10.1016/j.pedn.2017.10.009
0882-5963/© 2017 Elsevier Inc. All rights reserved.
28 E. Kose et al. / Journal of Pediatric Nursing 38 (2018) 27–32

to replace the standard commercial formula in protein-restricted diet of

patients with PKU (Ernest, McCabe, Neifert, & O'Flynn, 1980; Motzfeldt,
Lilje, & Nylander, 1999). Today, breastfeeding is encouraged and well
established in PKU patients (Banta-Wright, Shelton, Lowe, Knafl, &
Houck, 2012; Kanufre et al., 2007; van Rijn et al., 2003).
Previous studies showed that breastfed infants with PKU had no sig-
nificant differences in weight gain, daily Phe intake and mean serum
Phe concentrations compared to bottle-fed infants with PKU (Cornejo
et al., 2003; Demirkol et al., 2001; Kanufre et al., 2007). On the other
hand, recently Banta-Wright et al. (2012) revealed that mean serum
Phe level in breastfed infants is lower than bottle-fed infants with PKU.
In this study, our aim was to determine the prevalence and duration
of breastfeeding, the effect of breastfeeding on serum Phe levels, and
weight gain in infants with PKU. We also aimed to investigate the fac-
tors related to duration of breastfeeding in infants with PKU to provide
information to better evaluate the effect of breastfeeding in infants with
PKU, a subject for which limited results have been reported previously
in the literature.

Methods

Design

The data for this study were collected by means of a retrospective

chart review. Medical records were analyzed from 2008 to 2016 period
for patients with classic PKU (serum Phe level above N 1200 μmol/L at
diagnose) admitted to Pediatric Nutrition and Metabolism Unit, a baby
friendly hospital located in the Aegean Region in western Turkey. Pa-
tients with incomplete records or insufficient data were excluded
from the study (Fig. 1). This study has been granted approval by the Uni-
versity Research Ethics Board.
Study Population.
The medical charts of 142 children with PKU admitted to our center
were analyzed retrospectively. Infants with incomplete medical records
(weight data, feeding information and serum Phe level), missing demo-
graphic data (parental consanguinity, gross annual household income, Fig. 1. Consort flow diagram and reasons for exclusion.

maternal education level, parity of the mother, place of residence, first

breastfeeding experience of the mother), irregular follow-up (the
study included only patients who were examined at least once a
month) and low adherence to diet (patients who were not fed accord-
ing to diet list and/or patients who were fed both breast milk, commer-
cial formula and phenylalanine-free amino acid based protein
substitute) were excluded from the study (Fig. 1). Forty-one of the sub-
jects had complete medical records and were enrolled in the study.
Setting
Infants were categorized as breastfed and non-breastfed according
to the type of feeding after PKU diagnosis. Infants who were fed with
the combination of commercial formula (Aptamil®, Milupa [1.4 g pro-
tein and 60 mg Phe in 100 mL]; Bebelac® [1.4 g protein an 58 mg Phe
in 100 mL]) and phenylalanine-free amino acid based protein substitute
(PKU Anamix Infant®, Nutricia; Comida-PKU A®, ComidaMed) after the
diagnosis of PKU were included in the non-breastfed group. Infants who
continued to be breastfed together with the phenylalanine-free amino
acid based protein substitute after the diagnosis of PKU were included
in the breastfed group. In breastfed group, phenylalanine-free amino
acid based protein substitute was given after each breastfeeding. In
non-breastfed group, combination of commercial formula and phenyl-
alanine-free amino acid based protein substitute was served at each
feeding. At least every month, all patients diet lists were adjusted and
the volume of phenylalanine-free amino acid based protein substitute
and commercial formula were revised. In non-breastfed group, daily
protein consumption was determined according to dietary reference in-
take (DRI). Amount of Phe consumed was adjusted between 40 and 70
mg/kg/day according to serum Phe level.
Data Collection
Demographic data (according to the information provided by the
family and medical records; age at the time of diagnosis, gender, paren-
tal consanguinity, gross annual household income, maternal education
level) and clinical and laboratory findings (based on physical examina-
tion, clinical and dietitian's records of infants who were assessed at least
once a month; birth weight, daily weight gain of patients during the
breastfeeding period, monthly weight gain in the first year of life, dura-
tion of breastfeeding, serum Phe level) of the patients were document-
ed. No clinical application and absence of serum Phe values recorded at
least once a month were defined as insufficient medical records and
were determined as exclusion criteria. In the analysis of mean Phe levels
(data were collected from the electronic document management sys-
tem of the hospital), newborn-screening and confirmatory diagnostic
serum Phe levels which were N 1200 μmol/L and skewed the data
were excluded for each patient. For the study, all data were collected
by physicians working in the pediatric nutrition and metabolism
department.
Data Analysis
Statistical data analyses were performed with the SPSS computer
software (version 15.0; SPSS, Chicago, IL). While categorical data were
expressed as number, percentage (%), continuous data were expressed
as mean ± standard deviation (minimum-maximum). Kolmogorov-
Smirnov test was performed to examine the normality of parameters.
Categorical variables (gender, parental consanguinity, gross annual
 E. Kose et al. / Journal of Pediatric Nursing 38 (2018) 27–32 29

household income, place of residence, maternal education level, parity Table 2

of the mother, breastfeeding experience of the mother) were assessed Demographic findings of infants with phenylketonuria.

using Chi-square while parametric and non-parametric continuous var- Parameters Breastfed infants Non-breastfed p
iables (daily and monthly weight gain of patients, serum Phe levels, (n = 25) infants (n = 16)
birth weight percentile) were assessed using Mann-Whitney U test Gender (F/M), n (%) 14/11 (56/44) 7/9 (43.8/56.2) 0.328
and t-test, respectively. Repeated measures ANOVA was performed for Diagnosis age (day), mean ± 18.8 ± 10.8 21.1 ± 7.5 (10–34) 0.217
the analysis of weight gain of breastfed and non-breastfed in the first SD (min-max) (3–36)
Parental consanguinity, n (%) 13 (52) 7 (43.8) 0.606
year of life. A p-value b 0.05 was considered significant.
Gross annual household
incomea, n (%)
Results b$8000 16 (64) 10 (62.5) 0.707
$8000–$16,000 4 (16) 4 (25)
Demographic Data of Patients N$16,000 5 (20) 2 (12,5)
Place of residence, n (%)
Urban 14 (56) 7 (43.8) 0.530
Forty-one infants diagnosed with PKU were enrolled in the study. Of Rural 11 (44) 9 (56.2)
these, 21 (51.2%) were female and 20 (48.8%) were male. The mean age Maternal education level, n (%)
at the time of diagnosis was 19.7 ± 1.5 days (3–36). Comparison of No education 1 (4) 0 (0) 0.806
Primary school 14 (56) 9 (56.3)
breastfed and non-breastfed infants with PKU revealed no significant
Secondary school 3 (12) 2 (12.5)
difference regarding gender and age at the time of diagnosis. There High school 2 (8) 2 (12.5)
was no difference between the two groups in terms of demographic Univesity 5 (20) 3 (18.7)
characteristics (parental consanguinity status, gross annual household Parity of mother, n (%)
income, place of residence, maternal education level, parity and Primipara 13 (52) 9 (56.3) 0.522
Multipara 12 (48) 7 (43.7)
breastfeeding experience of the mother) (Table 1).
First breastfeeding experience 18 (72) 11 (68.8) 0.547
of mother, n (%)
Prevalence and Duration of Breastfeeding of Patients
F: female, M: male, $: US dollar. SD: Standard deviation, min: minimum, max:maximum.
a
Turkey's national income per capita in 2008 and 2016 were $7736 and $9364,
Forty (97.6%) infants were breastfed prior to the PKU diagnosis respectively.
whereas only one (2.4%) was bottle-fed. After the diagnosis of PKU,
breastfeeding was continued in 25 (61%) infants combined with a phe-
nylalanine-free amino acid based protein substitute. In 16 (39%) infants, Analysis of Serum Phe levels
mothers stopped breastfeeding and continued to feed with the combi-
nation of commercial formula and phenylalanine-free amino acid Serum Phe concentrations of breastfed infants during the
based protein substitute. The mean duration of breastfeeding was 7.4 breastfeeding period [280 ± 163 μmol/L (90–720)] were significantly
± 4.0 (1–15) months. The mean duration of breastfeeding of primipara lower than that of non-breastfed infants [490 ± 199 μmol/L (210–
mothers [5.8 ± 3.7 (1 − 12) months] was significantly shorter than 900)] (p b 0.001) (data not shown in the table). When patients were
multipara mothers [9.1 ± 3.5 (3–15) months] with PKU-diagnosed in- stratified in three categories as low (b 120 μmol/L), normal (120–360
fants (p = 0.035) (Table 2). No other relationship was detected be- μmol/L) and high (N 360 μmol/L) for mean Phe levels (Banta-Wright et
tween other demographic characteristics (gross annual household al., 2012) as shown in Fig. 2, a significant association was observed be-
income, place of residence, first breastfeeding experience of the moth- tween the type of feeding and the mean Phe level category (χ2(2) N
er) and the duration of breastfeeding (data not shown in the table). = 10.544, p = 0.005). Breastfed infants were more likely to have nor-
mal mean Phe levels.

Table 1
Demographic findings of infants with phenylketonuria.
Assessment of Weight
Parameters Breastfed infants (n Non-breastfed infants
= 25) (n = 16)
During the breastfeeding period, while mean daily weight gain of
Gender (F/M), n (%) 14/11 (56/44) 7/9 (43.8/56.2) breastfed patients [24.5 ± 6.4 g/day (10–35)] was significantly lower
Diagnosis age (day), mean ± SD 18.8 ± 10.8 (3–36) 21.1 ± 7.5 (10–34) than non-breastfed patients [30.9 ± 9.0 g/day (10–40)] (p = 0.009),
(min-max)
Parental consanguinity, n (%) 13 (52) 7 (43.8)
mean monthly weight gain at the end of the first year of life was signif-
Gross annual household incomea, n icantly higher in breastfed patients [493 ± 159 g/month (300–900)]
(%)
b$8000 16 (64) 10 (62.5)
$8000–$16,000 4 (16) 4 (25)
N$16,000 5 (20) 2 (12,5)
Place of residence, n (%)
Urban 14 (56) 7 (43.8)
Rural 11 (44) 9 (56.2)
Maternal education level, n (%)
No education 1 (4) 0 (0)
Primary school 14 (56) 9 (56.3)
Secondary school 3 (12) 2 (12.5)
High school 2 (8) 2 (12.5)
Univesity 5 (20) 3 (18.7)
Parity of mother, n (%)
Primipara 13 (52) 9 (56.3)
First breastfeeding experience of 18 (72) 11 (68.8)
mother, n (%)

F: female, M: male, $: US dollar. SD: Standard deviation, min: minimum, max:maximum. Fig. 2. Frequency differences between breastfed and non-breastfed infants with PKU and
a
Turkey's national income per capita in 2008 and 2016 were $7736 and $9364, Phe level categories of low (b120 μmol/L), normal (120–360 μmol/L), and high (N360
respectively. μmol/L). * χ2(2) N = 10.544, p = 0.005.
30 E. Kose et al. / Journal of Pediatric Nursing 38 (2018) 27–32
compared to non-breastfed patients [399 ± 116 g/month (200–700)]
(p = 0.046) (Table 3).
No statistically significant difference was found in terms of birth
weight and birth weight percentile between the breastfed and non-
breastfed groups. Although the weight of infants in the 6th month of
life was lower in the breastfed group [7.3 ± 0.9 kg (6.0–9.6)] compared
to the non-breastfed group [7.9 ± 0.98 kg (6.1–10.5)], it was found to be
significantly higher among breastfed infants [10.3 ± 1.1 kg (8.3–12.9)]
compared to non-breastfed infants [9.6 ± 0.83 kg (8.5–11.5)] at the
end of the first year of life (F(1, 36) = 3.47, p = 0.022; F(1, 38) =
4.17, p = 0.034) (Table 3) (Fig. 3).
Discussion
The determination of more favorable serum Phe levels in breastfed
infants than non-breastfed infants is the most important finding of
this study. Moreover, although previous studies did not reveal any effect
of breastfeeding on the weight of infants with PKU (Cornejo et al., 2003;
Kanufre et al., 2007), this study indicates a positive effect of
breastfeeding on weight gain in infants with PKU during the first year
of life.
Frequency of initiation and duration of breastfeeding may vary from
country to country. For example, Banta-Wright et al. (2012) reported
the incidence of breastfeeding at the time of PKU diagnosis as 77% in
USA. In another study performed in USA and Canada, initial
breastfeeding rate was observed to be 86% in patients with PKU
(Banta-Wright, Press, Knafl, Steiner, & Houck, 2014). In our study, we
observed that the rate of breastfeeding before PKU diagnosis was as
high as 97.6%. Our results are consistent with the study (Yalçın, Yalçın,
& Kurtuluş-Yiğit, 2014) performed in the healthy population in Turkey
in which the initial breastfeeding rate was 98.7%. The World Health Or-
ganization recommends breastfeeding up until 2 years or beyond
(World Health Organization [WHO], 1990). However, the rate of contin-
ued breastfeeding is not satisfactory in almost any country. In infants
with PKU, breastfeeding is more complicated than the healthy popula-
tion. Despite evidence supporting that combination of breast milk
with phenylalanine-free amino acid based protein substitute is compat-
ible with the effective dietary management of PKU, few mothers contin-
ue breastfeeding after PKU diagnosis.
In Turkey, mean duration of breastfeeding in PKU patients was re-
ported as 9.6 and 10.8 months (Demirkol et al., 2001; Huner &
Demirkol, 1996). In another study conducted in Netherlands, a mean
duration as short as 2.5 months of breastfeeding was reported, and an
Italian study demonstrated median one month of breastfeeding in pa-
tients with PKU (Agostoni, Verduci, Fiori, Riva, & Giovannini, 2000;
van Rijn et al., 2003). Consistent with the literature, our study showed
Table 3
Clinical and laboratory findings of patients with phenylketonuria.
Parameters
Mean daily weight gain of patients during the breastfeeding period (g/day), mean ± SD (min-max)
Mean monthly weight gain in the first year of life (g/month), mean ± SD (min-max)
Body weight (kg), mean ± SD (min-max)
Birth
3th month
6th month
9th month
12th month
Mean birth weight percentilea, mean ± SD (min-max)
SD: Standard deviation, min: minimum, max: maximum.
a
based on WHO growth standards.
b
Statistically significant.
continued breastfeeding in 61% of the infants after PKU diagnosis, and
mean duration of breastfeeding (7.4 months) was shown to be longer
than that in European studies although shorter than the other reports
from Turkey.
Previous studies have revealed the factors that influence initiation
and continuation of breastfeeding in many countries. Breastfeeding
practices are strongly influenced by social/economic factors such as
the type of residence and delivery locations (Senarath et al., 2012). Fac-
tors concerning the healthcare system such as antenatal home visits by
public health midwife, newborn care and lactation management train-
ing programs also affect the breastfeeding approach (Rempel, 2004;
Shawky & Abalkhail, 2003). Yalçın et al. (2014) reported that the rate
of long-term breastfeeding is higher among mothers who live in the
East regions of Turkey where mothers have high parity, limited educa-
tion and large families. Also, a negative correlation between high-in-
come and breastfeeding is observed, explained by the loss of
continuing the traditional breastfeeding culture and the increasing
availability and promotion of infant formulas.
According to another review performed in Scotland, the duration of
breastfeeding shows a strong and consistent association with maternal
age and education level (Scott & Binns, 1999). Banta-Wright, Kodadek,
Steiner, and Houck (2015) revealed that breastfeeding duration in pri-
mipara mothers with PKU infants was shorter than multipara mothers
with PKU infants. In the same study, demographic data were analyzed
but the effect of demographic characteristics on breastfeeding was not
evaluated. Consistently, we found a shorter breastfeeding duration in
primipara mothers compared to multipara mothers. In our study, no dif-
ference was seen between breastfed and non-breastfed patients with
PKU in terms of parental consanguinity status, maternal education
level, gross annual household income, place of residence and
breastfeeding experience of the mother.
The effect of breastfeeding on serum Phe levels in patients with PKU
has been investigated previously, and lower serum Phe levels were seen
in most of the breastfed infants compared to non-breastfed infants
(Cornejo et al., 2003; Huner & Demirkol, 1996; van Rijn et al., 2003).
On the other hand, a recent study revealed similar serum Phe levels in
breastfed and non-breastfed patients with PKU. However, the frequency
distributions revealed that a greater portion of breastfed infants with
PKU had Phe levels within the normal range (120–360 μmol/L) and
were less likely to have low Phe levels (b120 μmol/L) than non-
breastfed infants with PKU (Banta-Wright et al., 2012). Our study
shows that not only lower serum Phe levels but also normal range Phe
levels are more frequently detected in breastfed infants with PKU.
While no significant differences were observed in terms of weight
gain between breastfed and non-breastfed infants with PKU in previous
studies (Cornejo et al., 2003; Kanufre et al., 2007; van Rijn et al., 2003),
Breastfed infants (n = 25) Non-breastfed infants (n = 16) p
24.5 ± 6.4 (10–35) 30.9 ± 9.0 (10–40) 0.009b
493 ± 159 (300–900) 399 ± 116 (200–700) 0.046b
3.3 ± 0.4 3.0 ± 0.7 0.499
(2.3–3.9) (1.30–3.60)
6.1 ± 0.98 5.97 ± 0.6 0.962
(4.5–8.5) (4.8–6.8)
7.3 ± 0.9 7.9 ± 0.98 0.022b
(6.0–9.6) (6.1–10.5)
8.64 ± 0.8 8.57 ± 0.71 0.654
(7.0–10.2) (7.7–9.9)
10.3 ± 11.1 9.6 ± 0.83 0.034b
(8.3–12.9) (8.5–11.5)
41.9 ± 21.9 35.8 ± 17.8 0.551
(2.17–85.88) (3.47–59.9)
 E. Kose et al. / Journal of Pediatric Nursing 38 (2018) 27–32
Fig. 3. Weight growth curve of phenylketonuria infants with breastfed and non-breastfed. There was a significant effect on the daily weight gain in the 6th month of life at the p b 0.05 level
for non-breastfed compared to the breast-fed infants *[F(1, 36) = 3.47, p = 0.022]. There was a significant effect on the monthly weight gain in the first year of life at the p b 0.05 level for
breastfed compared to the non-breastfed infants **[F(1, 38) = 4.17, p = 0.034].
our study revealed a higher weight gain in non-breastfed infants than
breastfed infants at 6 months of age. This could be explained by the
high-calorie content of standard commercial formulas as well as higher
plasma levels of insulin-like growth factor-1 and insulin in bottle-fed in-
fants (Ziegler, 2006). Surprisingly, at the end of the first year of life,
monthly weight gain of breastfed patients was found to be higher
than non-breastfed infants with PKU. We thought that this may be the
long-term results of bioactive molecules in human breast milk which
provide protection against infection and inflammation and also contrib-
ute to immune maturation, organ development, and healthy microbial
colonization.
The present study has several limitations. Firstly, the small number
of subjects included in the subgroups limited the ideal comparison be-
tween breastfed and non-breastfed patients with PKU. Secondly, exam-
ination of patients at least once a month may have caused poor control
of serum Phe level in bottle-fed infants with PKU. Thirdly, growth dur-
ing the first months of life and serum Phe levels depends on various pa-
rameters. We cannot rule out that the factors such as infections,
treatment compliance, socio-cultural conditions which were not includ-
ed in our study might have affected growth and serum Phe levels.
Fourthly, we did not assess the height growth in our patients. Height
growth is better indicator to assess long-term nutritional status. Finally,
maternal factors such as maternal age, marital status, employment and
smoking status which are associated with breastfeeding were not eval-
uated in our study.
Conclusion and Future Study
As a result, we may conclude that weight gain is more favorable in
breastfed infants with PKU than non-breastfed infants at the end of
the first year of life. Also, continued breastfeeding together with phenyl-
alanine-free amino acid based protein substitute ensures maintaining
serum Phe levels within normal limits. Our findings support that
human breast milk can be safely delivered to PKU infants. Future re-
search should include longitudinal prospective studies with larger sam-
ples and include expanded demographic characteristics such as
maternal age, marital status, employment, smoking status, socio-cultur-
al conditions and not only weight but also height and BMI index of pa-
tients to confirm our findings.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
31
Acknowledgements
This research received no specific grant from any funding agency in
the public, commercial, or non-profit sectors.
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