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Breastfeeding to 24 Months – There’s More to Learn

January 11, 2023

In a recently released Research Briefs in Pediatrics, Marks and colleagues describe the prevalence and predictors of breastfeeding duration ≥24 months (10.1542/peds.2022-058503). This information is highly relevant to pediatricians, especially since both the American Academy of Pediatrics and the World Health Organization recommend exclusive breastfeeding through 6 months with introduction of complementary foods at that time and continued breastfeeding through age 24 months.1,2 Pediatricians are in a unique position to support mothers and families in reaching this goal, particularly since negative societal stigma affect mothers who breastfeed beyond infancy.3 The more we can understand about predictors and prevalence, the better we can support families. In this article, the authors used 2018-2020 data from the National Survey of Children’s Health, an annual survey of children ages 0-17 years, and included children ages 2-5 years; after excluding any who did not initiate breastfeeding and those with missing values for duration or co-variables, 16,697 respondents with varying durations of breastfeeding were included in the analysis.

Among those ever breastfed, the prevalence of breastfeeding at 24 months was 7.3%. Since national rates of breastfeeding initiation ranged from 81.1% to 83.2% in the earliest birth years of this cohort4, and this result describes only those who began breastfeeding, it’s important to realize that the rate of breastfeeding at 24 months is actually lower in the US population as a whole. Nonetheless, we can learn a lot from this analysis. Among mothers who initiated breastfeeding, several sociodemographic factors were associated with not continuing breastfeeding through 24 months. The analysis was stratified by income level, i.e., data were analyzed separately for those living below and above the federal poverty level, due to a significant interaction between age and income level that could have confused the results. For those living at <185% of federal poverty level, maternal age <30 years, being single rather than cohabiting or married, and being non-Hispanic Black/African American (as compared to Hispanic) were significantly associated with not continuing through 24 months. For those living at >185% of federal poverty level, maternal age <30 years and being non-Hispanic white or Black/African American (as compared to Hispanic) were similarly associated with not continuing breastfeeding through 24 months.

As the authors suggest, and as has been widely documented, African Americans face multiple barriers to breastfeeding due to systemic and structural racism, with rates of breastfeeding initiation, duration and continuation impacted, so unfortunately the association with duration less than 24 months is aligned.4-6 The association, however, of not continuing to breastfeed to 24 months for non-Hispanic white mothers has not been previously described, and explanatory hypotheses don’t come readily to mind. Younger age, however, is a well described risk factor for lower rates of breastfeeding initiation, duration and continuation4, but I have begun to wonder how maternal age actually interacts with breastfeeding so that we can revise strategies and support to better include younger mothers. The answer is not completely obvious. In one study, which was a secondary analysis of longitudinal data from the Infant Feeding Practices Study II (IFPS II) including almost 5,000 mothers, the authors concluded, “maternal age primarily indexes parity and education but contributes minimally to breastfeeding duration via a direct effect.”7

In the current study in Pediatrics, parity was not examined, but interestingly educational level was not significantly associated with continuing breastfeeding to 24 months. However, in an analysis of data from “Listening to Mothers III”, a national survey including 1,598 mothers, breastfeeding supportive practices were differentially implemented by age, with younger mothers reporting less lactation help and fewer evidence-based practices such as rooming in.8 I could not find newer studies on this topic, but the available information made me wonder if “ageism” (discrimination by age) could be a factor contributing to the significant association here and elsewhere of younger age with lower breastfeeding rates. This would imply that as providers we need to examine our own potential prejudices, and make sure that teen mothers and younger mothers get the same high-quality advice and guidance as mothers closer to us in age. While Research Briefs are by definition brief, there is an abundance of food for thought here! Please let us know your thoughts on this timely topic. 

References:

  1. Meek JY, Noble L, Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics. 2022;150(1)
  2. Breastfeeding Recommendations. World Health Organization. <https://www.who.int/health-topics/breastfeeding#tab=tab_2> Accessed 12/17/2022
  3. Jackson JE, Hallam JL. 'It's quite a taboo subject': an investigation of mother's experiences of breastfeeding beyond infancy and the challenges they face. Women Health. 2021 Jul;61(6):572-580. doi: 10.1080/03630242.2021.1938790. Epub 2021 Jun 10. PMID: 34112061
  4. Breastfeeding Rates by States and Sociodemographics. Breastfeeding Among U.S. Children Born 2012-2019, CDC National Immunization Survey. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/data/nis_data/results.html Accessed 12/16/2022
  5. Butler M, Allen JA, Hoskins-Wroten J, Sanders-Bey T, Venegas RN, Webb I, Ragland K. Structural Racism and Barriers to Breastfeeding on Chicagoland's South Side. Breastfeed Med. 2021 Feb;16(2):112-115. doi: 10.1089/bfm.2020.0311. Epub 2020 Dec 14. PMID: 33316176; PMCID: PMC7891221
  6. Hemingway S, Forson-Dare Z, Ebeling M, Taylor SN. Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism. Breastfeed Med. 2021 Feb;16(2):150-155. doi: 10.1089/bfm.2020.0306. Epub 2021 Feb 4. PMID: 33539272
  7. Whipps MD. Education Attainment and Parity Explain the Relationship Between Maternal Age and Breastfeeding Duration in U.S. Mothers. J Hum Lact. 2017 Feb;33(1):220-224. doi: 10.1177/0890334416679385. Epub 2016 Dec 20. PMID: 28135484
  8. Sipsma HL, Jones K, Nickel NC. Hospital practices to promote breastfeeding: The effect of maternal age. Birth. 2017 Sep;44(3):272-280. doi: 10.1111/birt.12284. Epub 2017 Mar 21. PMID: 28322008
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