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AN ABSTRACT OF THE THESIS OFMelanie Tharp, for the Master of Science degree in Food and Nutrition, presented on November 16, 2021, at Southern Illinois University Carbondale. TITLE: A SURVEY OF PHYSIOLOGICAL FACTORS ON BREASTFEEDING DURATION AND EXCLUSIVITYMAJOR PROFESSOR: Dr. Dawn NullBreastfeeding an infant is the current best recommendation for infant feeding, but only about a quarter of infants are breastfed until the suggested age of 6 months exclusively and 12 months with complementary foods. In this study, the objective was to find what determinants there are in women choosing to breastfeed and what barriers that exist to cause early cessation of breastfeeding. Current studies suggest that more research be done on the physiological factors such as weight and the presence of hormone problems that affect breastfeeding. The study focused on the physiological factors that may affect breastfeeding outcomes, in this study, duration and exclusivity. It was hypothesized that both duration and exclusivity would be lower in the women with the physiological risk factors. Participants were adult breastfeeding mothers. The data was collected through the use of an online survey exploring breastfeeding practices and physiological factors. A total of 507 participants started the survey with data from participants who did not complete at least 50% of the survey were excluded leaving 437 participants in the final sample. Overall, the sample had higher than average income, education, and age. There were no significant relationships found between the physiological factors studied and the duration of breastfeeding. However, there was a significant relationship found between formula use and exercise which suggests a lower formula use with more exercise. Suggestions for future studies include considering ethnicity and using a stronger study design to be able to find cause and effect relationships between physiological factors and breastfeeding outcomes.

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Background: Breastfeeding is widely recognised as the ideal approach for improving child survival and feeding new-born babies and young infants. The World Health Organisation (WHO) recommends exclusive breastfeeding (EBF) for the first 6 months of life with timely introduction of complementary foods at 6 months and continued breastfeeding for up to two years and beyond. The feeding practices of mothers are widely influenced by different factors which may be embedded within different contexts of life. Aim: This study explored the infant feeding practices of mothers and/or caregivers of infants below the age of 6 months. Method: This cross sectional study was conducted in four provinces in South Africa. In total, 40 health facilities were randomly selected in the four provinces and visited including metropolitan and non-metropolitan health facilities over the geographical area of the provinces. Fixed structured interviews were conducted and data on the feeding practices of mothers were collected using a questionnaire which had both open and closed-ended questions. Qualitative data were coded under different themes. The sample size comprised of mothers and/or caregivers of babies aged 6 months and below. A 24-hour recall was completed for all infants. Dietary intake and diversity were assessed using the FAO dietary diversity list consisting of 12 different food groups. Descriptive statistics, crosstabs and Pearson chi-square tests were used. Results: A total of 580 mothers/caregivers of infants below the age of 6 months were interviewed. Ninety-five % (n=551) were biological mothers. A total of 490 (85%) were breastfeeding at the time of the interviews. Ninety % had initiated breastfeeding during the first hour after delivery. At the time of the study, 12% (n=4) of the women were practising exclusive breastfeeding (EBF) for the recommended 6 months. Sixteen % (n=90) were not breastfeeding at the time the interviews were conducted. More than two thirds (64%) had exclusively breastfed their infants but stopped at the time of the interviews and 36% (n=32) did not breastfeed their babies at all. Twelve % (n=4) of the mothers stopped breastfeeding from as early as one month. The most cited reasons by the participants for breastfeeding cessation were the need to return to work or school. Reasons for not breastfeeding at all included the mothers HIV status, poor health and insufficient milk production. Forty-one % (n=239) of the mothers believed that breastfeeding contains adequate nutrients for the child and 5.7% (33) did not know why breastfeeding is important. Nearly half (49%) were giving infant feeding formula. Seventy % (n=220) of the women were giving either infant feeding formula or other liquids in addition to breast milk. The most stated reason for giving other liquids or foods was the belief that breast milk was not enough for the infant. Almost two thirds (56%) of the mothers gave their infants fortified infant feeding formula. Only one infant (0.2%) met the minimum standard of dietary diversity. Complementary food was introduced from as early as one month, and 73% of the women reported that their infants were receiving dietary supplements. Conclusion: Breastfeeding still remains a universal practice in the country. Sustained exclusive breastfeeding is still a cause of concern and 6 month EBF rates remain very low. Both mothers and caregivers had sound understanding of the importance of breastfeeding. Early initiation of complementary foods is still a norm and wide problem in the country. The dietary diversity of complementary diets given to babies was nutritionally inadequate. / MSc (Nutrition), North-West University, Potchefstroom Campus, 2015

Background: Breastfeeding is widely recognised as the ideal approach for improving child survival and feeding new-born babies and young infants. The World Health Organisation (WHO) recommends exclusive breastfeeding (EBF) for the first 6 months of life with timely introduction of complementary foods at 6 months and continued breastfeeding for up to two years and beyond. The feeding practices of mothers are widely influenced by different factors which may be embedded within different contexts of life. Aim: This study explored the infant feeding practices of mothers and/or caregivers of infants below the age of 6 months. Method: This cross sectional study was conducted in four provinces in South Africa. In total, 40 health facilities were randomly selected in the four provinces and visited including metropolitan and non-metropolitan health facilities over the geographical area of the provinces. Fixed structured interviews were conducted and data on the feeding practices of mothers were collected using a questionnaire which had both open and closed-ended questions. Qualitative data were coded under different themes. The sample size comprised of mothers and/or caregivers of babies aged 6 months and below. A 24-hour recall was completed for all infants. Dietary intake and diversity were assessed using the FAO dietary diversity list consisting of 12 different food groups. Descriptive statistics, crosstabs and Pearson chi-square tests were used. Results: A total of 580 mothers/caregivers of infants below the age of 6 months were interviewed. Ninety-five % (n=551) were biological mothers. A total of 490 (85%) were breastfeeding at the time of the interviews. Ninety % had initiated breastfeeding during the first hour after delivery. At the time of the study, 12% (n=4) of the women were practising exclusive breastfeeding (EBF) for the recommended 6 months. Sixteen % (n=90) were not breastfeeding at the time the interviews were conducted. More than two thirds (64%) had exclusively breastfed their infants but stopped at the time of the interviews and 36% (n=32) did not breastfeed their babies at all. Twelve % (n=4) of the mothers stopped breastfeeding from as early as one month. The most cited reasons by the participants for breastfeeding cessation were the need to return to work or school. Reasons for not breastfeeding at all included the mothers HIV status, poor health and insufficient milk production. Forty-one % (n=239) of the mothers believed that breastfeeding contains adequate nutrients for the child and 5.7% (33) did not know why breastfeeding is important. Nearly half (49%) were giving infant feeding formula. Seventy % (n=220) of the women were giving either infant feeding formula or other liquids in addition to breast milk. The most stated reason for giving other liquids or foods was the belief that breast milk was not enough for the infant. Almost two thirds (56%) of the mothers gave their infants fortified infant feeding formula. Only one infant (0.2%) met the minimum standard of dietary diversity. Complementary food was introduced from as early as one month, and 73% of the women reported that their infants were receiving dietary supplements. Conclusion: Breastfeeding still remains a universal practice in the country. Sustained exclusive breastfeeding is still a cause of concern and 6 month EBF rates remain very low. Both mothers and caregivers had sound understanding of the importance of breastfeeding. Early initiation of complementary foods is still a norm and wide problem in the country. The dietary diversity of complementary diets given to babies was nutritionally inadequate. / MSc (Nutrition), North-West University, Potchefstroom Campus, 2015

abstract: Late preterm infants (LPIs), born between 34 and 37 weeks gestation, are at risk for a myriad of health conditions related to neuro-muscular and physiologic immaturity. However, relative stability allow many of these infants to avoid care in specialty nurseries and discharge home with their mothers after birth. Due to underlying immaturity, feeding difficulty is the most common issue LPIs experience, resulting in early breastfeeding cessation, increased risk for secondary diagnoses, and hospital readmission. The purpose of this study was to assess early breastfeeding behavior of LPIs, including testing inter-rater reliability of an assessment tool and the feeding patterns of infants over time. An extensive review of breastfeeding assessment tools resulted in the selection of the Premature Infant Breastfeeding Behavior Scale (PIBBS) based on its reliability and validity in the preterm infant population. A convenience sample of LPI dyads was recruited and used to conduct inter-rater reliability testing of PIBBS. A longitudinal one-group non-experimental study was used for observational follow-up. A strong statistical agreement of PIBBS scores occurred between mothers and a healthcare professional (Cohen’s kappa values of items ranged from .776 to 1.000, p = <.001). Participants continued using the PIBBS tool after hospital discharge until their infants expected due dates (40 weeks adjusted age). T-test analyses were conducted to examine changes in scores over time indicating increase in item scores (p = .003 - .193). PIBBS appears to be a valid and reliable tool to assess breastfeeding among LPI dyads. Incorporation of PIBBS into a comprehensive plan of care could better support and protect breastfeeding among the LPI population. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2018

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Background: Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide quality improvement collaborative that elected to design and develop a project to address Tennessee's low breastfeeding rates. Purpose: To improve the health of Tennessee infants and mothers by increasing initiation and duration of breastfeeding through systematic implementation of processes with high reliability (> 90%) that promote and support breastfeeding in the delivery setting. Methods: A toolkit was created using the evidence-based practices of the Ten Steps to Successful Breastfeeding and the USBC Toolkit, “Implementing the Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding.” Eleven hospitals across the state of Tennessee are currently participating in the project since the state-wide kick-off in July 2012. Participating hospitals established improvement teams of stakeholders, and began collecting exclusive breastfeeding rates at hospital discharge, according to the Joint Commission Perinatal Core Measure 5 guidelines. After baseline data collection, the centers are implementing one or more of the 10 Steps to Successful Breastfeeding by using rapid Plan-Do-Study-Act (PDSA) cycles. Reliability of implementation is monitored by process measure audits. Web-based data-entry through REDCap provides on-demand run-charts to each individual center. Monthly webinars facilitate sharing of best practices between geographically distant centers, as well as sharing of the state-wide data in aggregate. Each participating center creates a Leadership Report highlighting its recent data on exclusive breastfeeding as well as selected PDSA cycles. Centers also share lessons learned and query participating centers on specific challenges. Additionally centers are invited to attend a face-to-face annual state-wide meeting with nationally recognized experts, as well as two regional workshops per year to share challenges and successes, and to learn quality improvement strategies from the TIPQC Quality Improvement team. Results: Baseline exclusive breastfeeding at discharge according to the Joint Commission criteria was 35% in aggregate. Initial data demonstrate that centers have noted some success in implementing changes in all of the Ten Steps to Successful Breastfeeding. Skin-to-skin care has been markedly increased in several centers, with some centers specifically targeting skin-to-skin care after C-Sections. Centers have also seen increases in rooming-in, staff training, and adoption of a breastfeeding policy. Upstream opportunities have been identified for prenatal education with providers of prenatal care (Step 3). Downstream opportunities have been identified for community support at discharge from the center (Step 10). Baseline data in the first 5 months of the project from over 7000 maternal-infant dyads (approximately 25% of Tennessee births) highlight improvement opportunities on all of the Ten Steps. Conclusions: This project serves as a model for how quality improvement methodologies may be combined with use of distance-learning and web-based data entry and reporting to facilitate implementation of evidenced based practices to increase breastfeeding rates.

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