Breastfeeding is associated with reductions in morbidity and mortality among mothers and children.1,4 The Dietary Guidelines for Americans, American Academy of Pediatrics, and World Health Organization recommend exclusive breastfeeding for 6 months, with continued breastfeeding for at least 1 (Dietary Guidelines for Americans5) or 2 years (American Academy of Pediatrics,6 World Health Organization3), while complementary foods are introduced.

Benefits of longer breastfeeding durations have been documented3,4; however, limited studies describe US breastfeeding duration past 18 months.7 Using data from a nationally representative survey, we examined the prevalence and predictors of breastfeeding duration ≥24 months.

The National Survey of Children’s Health is an annual survey designed to provide estimates of health of noninstitutionalized children age 0 to 17 years.8 Data are obtained from parents and caregivers through web-based and paper surveys.

Using data from 2018 to 2020, analyses were limited to children aged 2 to 5 years (n = 21 691). Respondents were excluded if they never initiated breastfeeding (n = 3498), were missing values for breastfeeding duration (n = 490), or missing ≥1 covariate (n = 997). Our final analytic sample included 16 706 respondents with all lengths of breastfeeding duration.

Breastfeeding duration was estimated by asking the age when the child stopped breastfeeding (and assuming initiation at birth). If a respondent reported still breastfeeding, breastfeeding duration was estimated as the child’s age.

Covariates include: maternal age at child’s birth (≤30 vs >30 years), marital status of first reported primary caregiver (single versus married or cohabitating), highest education of adults in household (≤high school, any college, ≥college), low birth weight (<2500 vs ≥2500 g), child race or ethnicity as characterized by respondent (non-Hispanic white, non-Hispanic Black or African American, non-Hispanic other, Hispanic), child’s current health insurance coverage (yes versus no), and federal poverty level ([FPL] ≤185% vs >185% FPL). FPL missing values were multiply imputed per National Survey of Children’s Health guidelines.9 

The weighted prevalence of breastfeeding duration ≥24 months was analyzed for each covariate. Mother’s age, child’s race or ethnicity, and FPL were selected a priori to assess for possible interaction; no interactions were found. Adjusted odds ratios were calculated using logistic regression, controlling for all covariates. Breastfeeding rates were calculated at each month. Analyses account for complex sample design, adjusting for clustering, weighting, and stratification using SAS-callable SUDAAN (version 9.4). The Centers for Disease Control and Prevention determined that this secondary analysis of deidentified data was not human subjects research and did not require institutional review board review.

Among children aged 2 to 5 years who were ever breastfed, 11.5% were breastfed for ≥24 months. Breastfeeding rates declined rapidly by infant age, with a drop of ≥10 percentage points from 6 to 7 months and 12 to 13 months (Fig 1). Compared to mothers age >30 years, younger mothers were less likely to breastfeed for ≥24 months (aOR 0.57; 95% CI 0.45, 0.73) (Table 1). Non-married/non-cohabitating caregivers were less likely to breastfeed for ≥24 months than married or cohabitating caregivers (aOR 0.57; 0.40, 0.82). Non-Hispanic White children were less likely to breastfeed for ≥24 months than Hispanic children (aOR 0.70; 95% CI 0.51, 0.96). Compared to households with FPL ≤185%, households with FPL >185% were less likely to breastfeed for ≥24 months (aOR 0.67; 95% CI 0.48, 0.93).

FIGURE 1

Rate of any breastfeeding of children age 2 through 5 who report initiating breastfeeding, National Survey of Children’s Health, United States, 2018–2020.

FIGURE 1

Rate of any breastfeeding of children age 2 through 5 who report initiating breastfeeding, National Survey of Children’s Health, United States, 2018–2020.

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TABLE 1

Prevalence of Breastfeeding for ≥24 Months Among Children Age 2 to 5 Years Who Initiated Breastfeeding, National Survey of Children’s Health, United States, 2018–2020

 Weighted Percent of Children Breastfed for ≥24 months  Adjusted Odds Ratio (95% CI)  
 n %   
Total  1911 11.5  
Respondent factors     
 Age of mother at child's birth     
  ≤ 30 years 703 8.4 0.57 (0.45, 0.73) 
  >30 years 1208 14.3 Ref 
 Marital status of adult 1     
  Single  169 6.7 0.57 (0.40, 0.82) 
  Married or cohabitating  1742 12.2 Ref 
 Highest education of adults in household     
  High school (including vocational, trade or business school) or less  166 10.4 0.69 (0.42, 1.13) 
  Any college  335 9.4 0.74 (0.54, 1.00) 
  ≥College  1410 12.6 Ref 
Child factors       
 Low birth weight (<2,500g)        
  Yes  126 9.4 0.78 (0.55, 1.11) 
  No  1785 11.7 Ref 
 Race or ethnicity       
  non-Hispanic White 1182 10.2 0.70 (0.51, 0.96) 
  non-Hispanic Black or African American 62 8.9 0.66 (0.41, 1.07) 
  non-Hispanic Otherb 369 16.2 1.14 (0.79, 1.65) 
  Hispanic 298 13.0 Ref 
 Health insurance coverage at time of survey       
  No  73 11.4 1.00 (0.60, 1.67) 
  Yes  1838 11.5 Ref 
Household factors       
 Federal poverty level        
  >185%  1453 11.2 0.67 (0.48, 0.93) 
  ≤185%  458 12.3 Ref 
 Weighted Percent of Children Breastfed for ≥24 months  Adjusted Odds Ratio (95% CI)  
 n %   
Total  1911 11.5  
Respondent factors     
 Age of mother at child's birth     
  ≤ 30 years 703 8.4 0.57 (0.45, 0.73) 
  >30 years 1208 14.3 Ref 
 Marital status of adult 1     
  Single  169 6.7 0.57 (0.40, 0.82) 
  Married or cohabitating  1742 12.2 Ref 
 Highest education of adults in household     
  High school (including vocational, trade or business school) or less  166 10.4 0.69 (0.42, 1.13) 
  Any college  335 9.4 0.74 (0.54, 1.00) 
  ≥College  1410 12.6 Ref 
Child factors       
 Low birth weight (<2,500g)        
  Yes  126 9.4 0.78 (0.55, 1.11) 
  No  1785 11.7 Ref 
 Race or ethnicity       
  non-Hispanic White 1182 10.2 0.70 (0.51, 0.96) 
  non-Hispanic Black or African American 62 8.9 0.66 (0.41, 1.07) 
  non-Hispanic Otherb 369 16.2 1.14 (0.79, 1.65) 
  Hispanic 298 13.0 Ref 
 Health insurance coverage at time of survey       
  No  73 11.4 1.00 (0.60, 1.67) 
  Yes  1838 11.5 Ref 
Household factors       
 Federal poverty level        
  >185%  1453 11.2 0.67 (0.48, 0.93) 
  ≤185%  458 12.3 Ref 

a The National Survey of Children’s Health is administered collaboratively by the U.S. Census Bureau and the Health Resources and Services Administration’s Maternal and Child Health Bureau.

bIncludes American Indian or Alaska Native persons, Asian persons, Native Hawaiian persons, Other Pacific Islander persons, and persons of multiple races.

Only 11.5% of US children breastfed for ≥24 months. Breastfeeding rates decline sharply by child age, especially at 6 and 12 months. Results indicated significant differences in breastfeeding ≥24 months by maternal age, caregiver marital status, child race, and household income level. The strength of this analysis is the ability to assess longer breastfeeding duration among a nationally representative sample. Limitations include potential recall bias among mothers of older children and the heterogeneity of the non-Hispanic, other race group. Programmatic interventions and policies aimed at supporting breastfeeding duration could help persons who desire to breastfeed for ≥24 months.

Ms McGowan conceptualized and designed the study, drafted the manuscript, and conducted the analysis; Drs Hamner and Li conceptualized and designed the study and reviewed and revised the manuscript and analytic decisions; Dr Marks assisted with code for statistical analysis and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

aOR

adjusted odds ratios

FPL

federal poverty level

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