Risk factors for breastfeeding problems in mothers who presented to two public healthcare centers in Kayseri province.
Despite many encouraging studies conducted in our country as in the whole world, the time of exclusive breastfeeding is below the desired level. According to the Turkish Population and Health Survey (TPHS) 2008 report 97% of all children were breastfed for a while. The rate of exclusive breastfeeding was found to be 69% in the first two months of life and 23.6% in the first 4-5 months (1). In the studies performed, the reasons for early discontinuation of breastfeeding included return of the mother to her work, the mother's thought that her milk was inadequate and lack of assistance by healthcare workers (2,3).
The time of exclusive breastfeeding and total breastfeeding time are affected negatively by problems arising from the mother or the infant during the lactation period. Problems arising from the mother usually occur in the first 1-2 weeks of lactation. The primary ones among these problems are related with the breast and sometimes reach a great extent inhibiting breastfeeding (4,5).
It has been reported that one or more of every three mothers experience one or more problems with breastfeeding (5,6). The most common problems related with the breast have been reported to include breast abscess and mastitis (33%), painful nipple/ nipple cracks (34-96%), excessive fullness in the breasts and inverted or flat nipple (2.5-10). In addition, mothers frequently (34,2%, 49.5%) complain they have insufficient breastmilk (2,10,11). For continuance of breastfeeding each mother and infant who have breastfeeding problems should be assisted urgently. In previous studies, it was shown that assistance given to mothers by healthcare workers who were experienced in this subject increased the breastfeeding time and breastfeeding success (7-9,12,13,14). This study was performed to determine the problems experienced by mothers during lactation and the risk factors which affect these problems.
Material and Method
This descriptive study was conducted with mothers who had infants aged between 24 and 60 months and who presented to 18 family health centers which are linked with Fevzi Cakmak and Talas Publich Health centers in Kayseri province because of any reason. Considering that the rate of the mothers who experienced extreme fullnes in the breast and painful nipple/cracked nipples was found to be 25%, the sample size was calculated as 288 at a level of 95% confidence interval with a tolerance value of 0,05 and it was planned to include 500 mothers in the study.
The questionnaire form which included questions related with descriptive information about the mothers and children and problems experienced during the lactation period was completed by face to face interview directed to the last child aged between 24 and 60 months who had been breastfed for a while after obtaining verbal consent from the mothers. Data collecting was continued until interviews with 500 mothers were completed.
Infants with a gestational age below 37 weeks at birth were considered as preterm, infants with a gestation age of 37-42 weeks at birth were considered as term and infants with a gestational age above 42 weeks were considered postmature. Infants with a birth weight below 2500 g were considered as low birth weight, infants with a birth weight of 2500-400 g were considered as normal birth weight and infants with a birth weight above 4000 g were considered as macrosomic.
Written consent was obtained from the Erciyes University Medical Faculty Clinical Researches Ethics Committee (2011/20) and Kayseri Provincial Directorate of Health and verbal consent was obtained from the mothers who were included in the study.
The data were analysed in the computer environment. The risk factors for dependent variables were evaluated by single and multiple logistic regression analysis. The Shapiro-Wilk test was used for the normal distribution of the data for numerical variables. The Mann Whitney U test was used in comparison of two groups. A p value of <0.05 was considered statistically significant.
54.2% of the children in the study group were male and 45.8% were female. The mean age was 35.7 [+ or -] 10.0 months. The majority of the children (%97.4) were born in a hospital and 38.6% were born by cesarean section. The rate of preterm infants was 8.6% and the rate of small for gestational age infants was 8.8%. While the rate of exclusive breastfeeding for the first six months was 60.8%, the rate of exclusive breastfeeding for less than 6 months was 32.0% (Table 1).
The mean age of the mothers was 29.8 [+ or -] 5.3 years. 75% of the mothers were housewives, 44.4% were primary or secondary school graduates and 59% had a moderate economical status. The mean number of children and breastfeeding duration were 2.0 [+ or -] 0.9 ve 17.7 [+ or -] 8.0 months, respectively. 88% of the mothers stated that they breastfed their babies in the first hour after delivery and 62.6% stated that they breastfed their babies 8-12 times a day for the first 6 months (Table 1).
The mothers stated that they mostly experienced (46.0%) painful and cracked nipple problem. 34.2% stated that they experienced insufficient milk supply and 29.8% stated that they experienced extreme milk supply which made it difficult to breasfeed their babies (Table 2).
The factors which increased the concern about insufficent milk supply in the mothers included being a housewife (3465-fold), moderate (2046-fold) or poor (2315-fold) economical status of the family, cesarean delivery (1680-fold), SGA infant (2000-fold), starting breastfeedig after the first hour after delivery (2291-fold) and a frequency of breastfeeding less than 8 a day (5861-fold) (p<0.005). The mother's age, education level, the order of birth of the infant, birth place and gestational age were not found to have an effect on concern about insufficient milk supply. A maternal age below 25 years and of 25-35 years increases the risk of occurence of painful and cracked nipples 2188-fold and 2665-fold, respectively. In mothers who gave birth by cesarean section, the risk of experience of painful and cracked nipples was found to be 1737-fold higher compared to the ones who gave birth by vaginal delivery. Premature delivery and breastfeeding less than 8 times a day increased the risk of occurence of painful and cracked nipples 1897-fold and 1841-fold, respectively (p<0.05) (Table 3).
It was observed that the mothers who experienced concerns about insufficient milk supply exclusively breastfed their infants for a shorter time and the total breastfeeding times were found to be shorter compared to the ones who did not experience this concern (16 months and 20 months, respectively) (p<0.001). In addition, it was found that the mothers who experienced a problem of flat and inverted nipples had a shorter total breastfeeding time (Table 4).
While an increase in the rates of starting breastfeeding was provided with breastfeeding programs conducted worldwide, small increases have been found in the rates of exclusive breastfeeding. In the lactation period, the duration of exclusive breastfeedbing and total breastfeeding times are affected negatively because of some problems related with the mother and the infant (11). Maternal problems related with breastfeeding mainly include problems related with the breasts (5).
One or more of every three mothers have been reported to experience problems related with breastfeeding (5,6,7,8). Painful and cracked nipples is one of the most common problems. In the literature, 34-96% of the mothers have been reported to experience a problem of painful nipples in the postnatal period (5,8,9,10,15). In our study, it was found that the mothers most commonly experienced a problem of painful and cracked nipples (46.0%) during the breastfeeding period. Painful nipple is a transient problem which generally occurs in the beginning of breastfeeding, but it is an important factor in early discontinuation of breastfeeding (4,5). Painful and cracked nipples mostly occur as a result of sucking trauma. Wrong placement of the baby to the breast, extreme fullness of the breast and candida infection lead to painful and cracked nipples (11). It is known that painful nipples may occur in mothers who breasfeed their infants (especially in primipar mothers and in the first 5-10 days postnatally) even though cracked nipples are not present (15,16). Li et al. (10) reported that primipar mothers experienced nipple problems with a higher rate compared to multipar mothers (170-fold) and the mothers in the 25-29 age group experienced nipple problems with a higher rate (111-fold). In our study, it was also observed that the mothers below the age of 35 years experienced a problem of painful and cracked nipples with a higher rate. However, the mother's being multipar or primipar was not a risk factor for painful and cracked nipples (Table 3).
It may be thought that a high number of breastfeeding may allow the infant to damage the nipple with a higher rate. However, it has been argued that limitation of the frequency of breastfeeding would lead to extreme fullness in the breast by inhibiting the milk let-down reflex and would complicate the infant-mother concordance (6,8,11,17). In a study performed by Gerd et al. (18) in Sweden, it was found that the mothers who breastfed their babies less than 5 times a day (82.9%) experienced more nipple problems compared to the mothers who breastfed their babies 6-10 times a day (39.2%). In our study, it was found that breastfeeding less than 8 times a day increased the risk of occurence of painful and cracked nipples 1841-fold (Table 3).
In our study, the risk of nipple problems increased 1737-fold in the mothers who gave birth by cesarean delivery compared to the ones who gave birth by vaginal delivery. This might have been resulted from the fact that the mothers who gave birth by cesarean section could not place the infant appropriately on the breast because of post-operative pain (19). In the Norvegian Mother and Child Cohort study, it was reported that the rates of breastfeeding in the first month were low in the mothers who gave birth by cesarean section (13).
Preterm infants may stay apart from their mothers for a while because they are kept in intensive care units for a certain time. In this condition, the nipples may be exposed to trauma when the mothers milk their breastmilk to be given to their infants and this may lead to painful and cracked nipples (4,20). In our study, it was found that preterm delivery increased the risk of painful and cracked nipples in the mother 11897-fold.
In our study, the other problem which the mothers most commonly faced was concern about insufficient milk supply (34.2%) (Table 2). In a study, it was found that the most common problem experienced by both primipar and multipar mothers was insufficient milk supply (37.5%) (15). It is difficult for mothers to decide if their milk is actually insufficient or not. Generally, most mothers produce more milk than their infants need. There are rare conditions where milk production is insufficient physiologically (3,11,16). In our study, the factors which increased the risk of insufficient milk supply included being a housewife (3465-fold), moderate (2046-fold) or poor (2315-fold) economical status of the family, cesarean delivery (1680-fold), SGA infant (2000-fold), starting breastfeedig after the first hour after delivery (2291-fold) and a number of breastfeeding less than 8 a day (5861-fold) (p<0.005) (Table 3). It was found that the mothers who experienced concerns about insufficient milk supply had shorter exclusive breastfeeding times and total breastfeeding times compared to the ones who did not experience such a problem (p<0.001) (Table 4). Similar to the results of our study, two different studies showed that low economic status of the family increased the maternal thought that their milk was insufficient and shortened the duration of breastfeeding (9,10). Although it was reported that the duration of breastfeeding was longer in families with lower income in the studies performed in our country, no information about insufficient milk supply was given (21,22,23).
It is known that lactation may be delayed in mothers who give birth by cesarean section (19). Studies have shown that mothers who give birth by cesarean section start breastfeeding later compared to the ones who give birth by vaginal delivery (24,25,26,27). Prolactin hormone which is necessary for milk production is released when the infant starts breastfeeding (28). Milk production and milk release reflex start lately, since the mothers who give birth by cesarean delivery start breastfeeding later. Thus, mothers think that their milk is insufficient and start to give their infants formulas additionally. In this condition, the breastfeeding frequency decreases and insufficient milk supply is possible (29). In our study, delivery by cesarean section, starting breastfeeding after the first hour postnatally and a daily mean number of breastfeeding less than 8 were found to be the risk factors for concern about insufficient milk supply
The birth weight of the baby affects the time of starting feeding. The facts that preterm or SGA infants are kept in intensive care units for a certain time, can not hold the breast strongly and experience other health problems decrease the rates of breastfeeding in these infants (20). Many studies have shown that SGA infants start breastfeeding later compared to non-SGA infants and they have a shorter time of exclusive breastfeeding (18,21,22). In our study, it was found that the infant's being SGA increased the concern about insufficient milk supply 2 fold.
Conclusively, it was found that mothers experienced different problems including mainly painful and cracked nipples and insufficient milk supply. Awareness of the healthcare professionals about the problems experienced during lactation and supports given by them may reduce these problems.
Conflict of interest: None declared.
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Habibe Sahin, Muge Yilmaz, Mualla Aykut *, Elcin Balci *, Mehmet Sagiroglu *, Ahmet Ozturk *
 Erciyes University, Faculty of Health Sciences, Division of Nutrition and Dietetics, Kayseri, Turkey
 Erciyes University, Medical Faculty, Department Public Health, Kayseri, Turkey
Address for Correspondence: Dr. Habibe Sahin, Erciyes University, Faculty of Health Sciences, Division of Nutrition and Dietetics, Kayseri, Turkey
E-mail: email@example.com Received: 06.09.2012 Accepted: 11. 20.2012
Table 1. Some properties of the mothers and children included in the study (n=500) Properties of Number (%) the children Gender Male 271 (54.2) Female 229 (45.8) Birth place Hospital 487 (97.4) Home 13 (2.6) Mode of delivery Vaginal 307 (61.4) Cesarean section 193 (38.6) Birth weight Normal 417 (83.4) SGA 44 (8.8) LGA 39 (7.8) Gestational week at birth Term delivery 449 (89.8) Preterm delivery 43 (8.6) Postmature delivery 8 (1.6) Exclusive breastfeeding Less than 6 months 160 (32.0) Six months 304 (60.8) Longer than 6 months 36 (7.2) Properties of the mothers Number (%) Education level Less than primary school 12 (2.4) Primary and 222 (44.4) secondary school High-school 183 (36.6) University 83 (16.6) Occupation Housewife 375 (75.0) Works outside home 98 (19.6) Works at home for 27 (5.4) making money Economical status of the family (2) Poor 66 (13.2) Moderate 295 (59.0) Well 139 (27.8) Number of children 1 2.0 [+ or -] 0.9 Breastfeeding duration 17.7 [+ or -] 8.0 (months)1. 2 The time of first breastfeeding In the first hour 440 (88.0) 1-24 hours 40 (8.0) After 24 hours 20 (4.0) Daily breastfeeding number Less than 8 68 (13.6) 8-12 313 (62.6) More than 12 119 (23.8) Parity Primipar 183 (36.6) Multipar 317 (63.4) (1) according to her self statement (2) n = 427 (the ones weaned) Table 2. Distribution of the problems faced by the mothers during lactation Problem (n=500) Number (%) Painful and cracked nipples 230 (46.0) Concern about insufficient breastmilk 171 (34.2) Excessive milk supply which would 149 (29.8) complicate breastfeeding Flat and inverted nipples 58 (11.6) Mastitis 46 (9.2) Extreme fullness in the breast 45 (9.0) Plugged milk ducts 41 (8.2) Table 3. Logistic regression analysis of the risk factors which affect experience of concern about insufficient milk supply and nipple problems by the mothers Factors Painful and cracked Concern about nipples OR (%95 GA) insufficient milk supply OR (%95 GA) Maternal age 35 years and above 1 1 25 years and below 2.188 (1.192-4.017) * 1.414 (0.753-2.657) 2.665 (1.662-4.273) * 1.582 (0.975-2.566) Maternal education High school and above 1 1 Below high school 0.708 (0.497-1.009) 1.194 (0.825-1.729) 8-12 arasi Maternal education Works at home for 1 1 making money Housewife 1.431 (0.647-3.166) 3.465 (1.174-10.225) * Works outside home 0.738 (0.308-1.771) 2.076 (0.656-6.575) Economical status of the family Well 1 1 Poor 1.274 (0.706-2.298) 2.315 (1.233-4.346) * Moderate 1.335 (0.888-2.008) 2.046 (1.292-3.240) * Parity Multipar 1 1 Primipar 0.960 (0.666-1.383) 0.905 (0.616-1.331 Birth place Home 1 1 Hospital 0.994 (0.329-3.000) 1.755 (0.477-6.465) Delivery mode Normal 1 1 Cesarean section 1.737 (1.208-2.499) * 1.680 (1.153-2.450) * Gtonal week at birth Term 1 1 Preterm 1.897 (1.002-3.592) * 1.286 (0.677-2.443) The time of starting breastfeeding TIn the first hour 1 1 Later 1.397 (0.813-2.399) 2.291 (1.329-3.949) * The time of starting breastfeeding More than 12 1 1 Less than 8 1.841 (1.006-3.366) * 5.861 (3.049-11.266) * 8-12 1.016 (0.664-1.555) 1.623 (0.994-2.650) * p<0.05 Table 4. Exclusive breastfeeding times of the mothers with and without breastfeeding problems (months) Problems Problems present Problems absent median (%25-%75) median (%25-%75) Exclusive breastfeeding times (n=500) Insufficient milk supply 6 (4-6) (1) 6 (6-6) (2) Excessive milk supply 6 (6-6) 6 (5-6) Extreme fullness in the breast 6 (5-6) 6 (5-6) Painful and cracked nipples 6(5-6) 6(5-6) Plugged milk ducts 6 (5-6) 6 (5-6) Mastitis 6 (5-6) 6 (5-6) Flat and inverted nipples 6 (5-6) 6 (5-6) Total breastfeeding times (n=427) (3) Insufficient milk supply 16 (10-23) 20 (15-24) Excessive milk supply 20 (14-24) 18 (12-24) Extreme fullness in the breast 18 (10-23.5) 18.5 (12-24) Painful and cracked nipples 18 (12-24) 18 (12-24) Plugged milk ducts 20.5 (12.5-24.5) 18 (12-24) Mastitis 18 (10-24) 20 (12-24) Flat and inverted nipples 15 (9.75-24) 20 (12-24) Problems P Exclusive breastfeeding times (n=500) Insufficient milk supply <0.001 Excessive milk supply 0.074 Extreme fullness in the breast 0.455 Painful and cracked nipples 0.560 Plugged milk ducts 0.178 Mastitis 0.904 Flat and inverted nipples 0.228 Total breastfeeding times (n=427) (3) Insufficient milk supply <0.001 Excessive milk supply 0.058 Extreme fullness in the breast 0.150 Painful and cracked nipples 0.236 Plugged milk ducts 0.494 Mastitis 0.125 Flat and inverted nipples 0.045 (1) Mean Rank (mean Standard score) = 197. (2) Mean rank = 267. (3) Excluding the ones who are still breastfeeding (73 children
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|Title Annotation:||Original Article|
|Author:||Sahin, Habibe; Yilmaz, Muge; Aykut, Mualla; Balci, Elcin; Sagiroglu, Mehmet; Ozturk, Ahmet|
|Publication:||Turkish Pediatrics Archive|
|Date:||Jun 1, 2013|
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