Abstract
Introduction
This study examined postpartum depression (PPD) as a potential risk factor for non-adherence to infant feeding guidelines and subsequent infant weight gain.
Methods
Participants were mother-infant dyads from the Infant Feeding Practices Study II (N = 1447). Main study variables were PPD, breastfeeding intensity, addition of cereal to infant formula, and age of introduction to solid foods.
Results
In logistic models adjusted for sociodemographic factors, mothers with PPD were 1.57 times (95% confidence interval [CI]: 1.16, 2.13) more likely to breastfeed at low intensity and 1.77 times (95% CI: 1.16, 2.68) more likely to add cereal to infant formula. Although PPD was associated with the early introduction to solid foods (odds ratio: 1.42; 95% CI: 1.07, 1.89), this relationship was not significant after adjusting for potential confounders. A small but significantly greater average weight gain at 6 months was observed among infants of mothers with PPD (10.15 lb, SD = 2.32 vs. 9.85 lb, SD = 2.32).
Discussion
Screening for PPD at well-child visits may lead to improved maternal health outcomes and the prevention of early life risk factors for childhood obesity.
Key Words
Approximately 10% of U.S. infants and toddlers have a ≥ 95th percentile weight-for-recumbent length (
Ogden et al., 2012
). This prevalence rate is a significant public health issue because excess weight gain during infancy has been associated with higher body mass index, higher skin fold thickness, and increased odds of obesity at age 3 years (Taveras et al., 2009
). In a recent meta-analysis that included 10 cohort studies and more than 47,000 children from six countries, it was found that greater infant weight gain in the first year of life was consistently associated with risk for later obesity after adjusting for sex, age, and birth weight (Druet et al., 2011
). This observed pattern for increased weight gain fits the Life Course Health Development model perspective that risk factors which begin during critical and sensitive periods of child development, including early infancy, may have an interactive and cumulative effect over time that leads to long-term poor health outcomes (Halfon and Hochstein, 2002
; Halfon et al., 2005
). To interrupt the trajectory toward lifelong excess weight gain and the concomitant risks for chronic illness, greater focus is needed on the predictors of childhood obesity that begin in early infancy. The Early Childhood Obesity Prevention Policies of the Institute of Medicine (Institute of Medicine, 2011
) has affirmed the recommendations of the American Academy of Pediatrics (American Academy of Pediatrics, 2005
) for infant feeding that include exclusive breastfeeding for the first 6 months of life and continued breastfeeding in conjunction with solid foods for 1 year or more. Research is needed that advances our understanding of factors that influence adherence to these recommended infant feeding practices.Toward that end, the present study examined adherence to infant feeding guidelines within the context of postpartum depression (PPD), a disorder that affects between 12% and 20% of mothers in the United States during their first few months after delivery (
Brett, 2008, April 11
). Previous research has found that mothers who experience PPD are more likely to discontinue breastfeeding in the first few months after giving birth (Dennis and McQueen, 2009
; McLearn et al., 2006
; Taveras et al., 2003
). PPD also has been associated with forceful, indulgent, and restrictive infant feeding styles (Hurley et al., 2008
). To our knowledge no previous studies have examined adherence to infant feeding practice recommendations and subsequent infant weight gain within the context of PPD. Understanding these relationships may inform the future design of clinical interventions to reduce the risk of childhood obesity and related lifelong health consequences.The purpose of this study was to examine the effects of PPD on early infant feeding practices, including breastfeeding intensity at 2 months of age, adding baby cereal to formula at 2 months of age, and early introduction of solid foods (before 4 months of age). We also explored the contribution of sociodemographic, health, and behavioral factors on these infant feeding behaviors and examined the relationship between infant feeding practices and weight gain by 6 months of age for mothers with and without PPD.
Methods
Sample
The Infant Feeding Practices Study II (IFPS II; www.cdc.gov/ifps), which is the source of data for the current study, was conducted by the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention. IFPS II data were collected longitudinally between May 2005 and June 2007, using a survey format with one prenatal and 10 postnatal mailings. Questionnaires were mailed to mothers approximately monthly, and mothers were asked to provide information on their infant feeding practices during the first year of the child's life. The sample of IFPS II was based on a nationally distributed consumer opinion panel, and the study included the following population inclusion criteria: mothers were at least 18 years of age; infants were born after 35 weeks gestation, weighed at least 5 lb, were a singleton birth, and did not require hospitalization for more than 3 days after birth; and neither the mother nor the infant could have a medical condition that would affect feeding behavior (
Fein et al., 2008
). The IFPS II included 4902 mother-infant dyads. For the present study, inclusion criteria specified no missing data for the main study variables. Infant weight at 6 months was available for 1902 babies. From this total, cases with missing data in areas that were required to calculate the three infant feeding practice variables (i.e., breastfeeding intensity at 2 months, adding baby cereal in formula at 2 months, and age of introduction of solid foods) or PPD also were excluded, further reducing the sample size to 1447. The present study was approved by the Institutional Review Board at George Mason University.Measurements
Main Exposure
PPD was measured using the 10-item Edinburgh Postnatal Depression Scale (EDPS) that was incorporated into the IFPS II 2-month postpartum survey. Each item of the EDPS describes a depressive symptom. Mothers rated the extent to which the symptom matched their feelings during the past several days. Possible scores range from 0 to 30, with higher scores signifying greater severity. The original authors of the EDPS recommended a cut-off score of ≥ 10 to screen for minor depression in primary care settings (
Cox et al., 1987
). Recent studies have used this cut-off score to identify depression during the postnatal period with community-based populations (Hansua et al., 2008
; Hiscock and Wake, 2001
; Mayberry et al., 2007
). Previous research has associated maternal symptoms of depression with early cessation of breastfeeding and nonresponsive infant feeding styles (Dennis and McQueen, 2009
; Fergerson et al., 2002
; Hurley et al., 2008
).Outcome Measures
Infant feeding practices and infant weight gain by 6 months of age were the outcome variables for the present study. The three feeding practices assessed were breastfeeding intensity at 2 months, adding cereal to infant formula at 2 months, and age of introduction to solid food.
Infant feeding practices
Breastfeeding intensity at 2 months of age was computed as the average proportion of breast milk to the total milk diet (including breast milk, formula, cow's milk, and other milk) that the baby received on a daily basis. This information was generated from mothers' reports in the IFPS II survey. Originally, this variable included three levels: low, defined as < 20% of milk feedings being breast milk; medium, defined as between 20% and 80% of milk feedings being breast milk; and high, defined as > 80% of milk feedings being breast milk. We combined the medium and high categories (medium/high) to increase the cell sample size for the statistical analyses. Breastfeeding intensity was calculated based on previous research using the same IFPS II dataset in which researchers found that breastfeeding at low intensity in the first 6 months was predictive of excess weight in late infancy (
Gaffney et al., 2012
; Li et al., 2008
).The practice of adding cereal to the baby bottle was assessed using the IFPS II survey item at 2 months that asked the mother about adding baby cereal “to your baby's bottle of formula or pumped or expressed breast milk in the past two weeks.” Based on the mother's response, a dichotomous yes/no variable was created. In this investigation, we assessed the practice of adding cereal to the baby bottle separately from the age of introduction to solid foods because in our clinical practice we have observed that parents often do not consider this practice to be introduction of solid foods.
Introduction to solid foods was measured based on the mother's report of the age at which her infant was first served solid foods. Beginning at the 2-month survey, mothers are provided with a list of solid foods and are asked to check off any items they have fed to their infant in the past 7 days. To construct this variable, data from all 10 surveys were used. The age at which infants were first introduced to solid food was constructed as a categorical variable with two levels: before 4 months of age and 4 months or older.
Infant weight gain by six months
During the 7-month IFPS-II survey, mothers were asked, “How much did your baby weigh the last time he or she was weighed at a doctor's visit?” An assumption for this study was that the last clinical encounter for recording infant weight was the regularly scheduled 6-month well-child visit (
Hagan et al., 2008
). Therefore the mother's response for this item was used as the infant's weight at 6 months. This dependent variable, weight gain by 6 months, was calculated by subtracting birth weight from the reported weight at the last doctor's visit. A recent meta-analysis of 10 international studies showed a consistent positive association between infant weight gain and subsequent childhood obesity (Druet et al., 2011
).Other Measures
Several maternal and child variables were used in the analyses to control for potential confounding effects and to explore their contribution to the outcome variables. These variables were selected on the basis of previous research of early childhood and infant feeding practices and obesity (
Baker et al., 2004
; Gaffney et al., 2012
; Kimbro et al., 2007
; Kim & Peterson (2008)
; Salsberry and Reagan, 2005
; Taveras et al., 2010
). Sociodemographic characteristics included maternal race/ethnicity (Black, White, or Hispanic); age at childbirth (18 to ≤ 24, 25 to ≤ 34, and > 34 years); education (high school or less, some college, or 4 years of college or more); and household income (< 185%, 185% to ≤ 349%, and > 349% of the poverty level). The poverty guidelines for 2006 published by the U.S. Census Bureau. (2009)
were used to classify household income. Maternal health characteristics included were pre-pregnancy body mass index (categorized as < 19.8, underweight; 19.8 to ≤ 26, normal; > 26 to ≤ 29, overweight; and > 29, obese) and postpartum smoking status (yes/no). The sex of the infant and the mother's report of whether she perceived infant fussiness to be a problem at 2 months of age (yes/no) also were included.U.S. Census Bureau. (2009). Poverty thresholds. Retrieved from http://www.census.gov/hhres/www/poverty/data/threshld/index.html
Statistical Analysis
Descriptive statistics were computed and reported for all variables. Chi-square analysis and t-tests were conducted to determine any significant associations among PPD, infant feeding practices, weight gain by 6 months, and our other selected maternal and infant characteristics. Logistic regression models estimated the effect of PPD and other maternal and infant characteristics on breastfeeding intensity, adding cereal to baby bottles, and age of introduction to solid foods. Multivariate linear regression was performed to estimate the effect of early infant feeding practices on weight gain at 6 months separately for mothers with and without PPD.
Results
Table 1 presents the overall descriptive statistics for maternal and infant characteristics of our sample and frequencies by PPD designation. In this sample, 349 (24.1%) of the mothers were categorized with depressive symptoms (EPDS score ≥ 10) at 2 months infant age. The sample consisted primarily of White women (90.8%) between the ages of 25 and 34 years of age (64.5%). A large proportion (44.6%) had completed college; 18.7% had a high school education or less. The household income distribution was approximately the same across the three levels, with the highest proportion (39.1%) falling above 349% of the poverty level, indicating a household income of approximately $40,000 or more per year. Postpartum smoking was reported by 13.2% of the mothers, and 29.2% were obese. Most mothers (61.6%) reported that they did not perceive their infants to have a problem with fussiness or irritability. Chi-square analysis revealed that mothers with PPD, when compared to mothers without PPD, were significantly more likely to be obese (34.4% vs. 27.5%), smoke during the postpartum period (20.4% vs. 10.9%), and report infant irritability/fussiness as a problem (47.4% vs. 35.5%).
Table 1Maternal and infant characteristics, overall and by postpartum depression classification with data from the Infant Feeding Practices Study II (N = 1447)
| Characteristic | Overall (N = 1447; %) | PPD (n = 349; %) | No PPD (n = 1098; %) | p value |
|---|---|---|---|---|
| Mother's race/ethnicity | .39 | |||
| White | 90.8 | 90.4 | 91.0 | |
| Black | 3.9 | 3.1 | 4.1 | |
| Hispanic | 5.3 | 6.5 | 4.9 | |
| Mother's age | .17 | |||
| 18-24 years | 17.6 | 20.7 | 16.7 | |
| 25-34 years | 64.5 | 63.5 | 64.8 | |
| More than 34 years | 17.8 | 15.8 | 18.5 | |
| Mother's education | .82 | |||
| High school or less | 18.7 | 18.7 | 18.7 | |
| Some college | 36.7 | 38.0 | 36.2 | |
| 4-year college or more | 44.6 | 43.3 | 45.1 | |
| Household income (% of poverty line) | .07 | |||
| < 185 | 30.3 | 35.2 | 28.8 | |
| 185 to ≤ 349 | 30.5 | 28.1 | 31.3 | |
| > 349 | 39.1 | 36.7 | 39.9 | |
| Mother's prepregnancy BMI | .01 | |||
| Underweight | 9.6 | 5.8 | 10.9 | |
| Normal | 45.5 | 44.5 | 45.9 | |
| Overweight | 15.6 | 15.3 | 15.7 | |
| Obese | 29.2 | 34.4 | 27.5 | |
| Mother's postpartum smoking status | .00 | |||
| Non-smoker | 86.8 | 79.6 | 89.7 | |
| Smoker | 13.2 | 20.4 | 10.9 | |
| Infant sex | .09 | |||
| Female | 50.2 | 47.0 | 51.2 | |
| Male | 49.8 | 53.0 | 48.8 | |
| Infant's fussiness reported at 2 months | .00 | |||
| Fussy | 38.4 | 47.4 | 35.5 | |
| Not fussy | 61.6 | 52.6 | 64.5 |
BMI, Body mass index; PPD, postpartum depression.
∗ p value: comparing frequencies between mothers with and without PPD.
With regard to infant feeding practices, one third of the mothers in the study breastfed at low intensity at 2 months, 11.7% added cereal in their baby's bottle, and 27% introduced solid food to their infants when they were younger than 4 months (Table 2). The average weight gain by 6 months infant age for the overall sample was 9.93 lb (SD = 2.32 lb). As seen in Table 2, significant differences emerged in infant feeding practices between the two groups. Low breastfeeding intensity, adding cereal to the baby bottle, and early introduction of solid foods distinguished mothers with PPD from the comparison group. In addition, the babies of these mothers experienced slightly greater weight gain by 6 months of age.
Table 2Infant feeding practices and weight gain by 6 months infant age, overall and by postpartum depression classification with data from the Infant Feeding Practices Study II (N = 1447)
| Feeding practice/infant weight gain | Overall (N = 1447; %) | PPD (n = 349; %) | No PPD (n = 1098; %) | p value |
|---|---|---|---|---|
| Breastfeeding intensity at 2 months | .00 | |||
| Low | 33.1 | 41.8 | 30.3 | |
| Medium/high | 66.9 | 58.2 | 69.6 | |
| Added cereal in baby bottle at 2 months | .00 | |||
| Yes | 11.7 | 16.6 | 10.1 | |
| No | 88.3 | 83.4 | 89.9 | |
| Age of introduction to solid food | .02 | |||
| Less than 4 months | 27.0 | 31.8 | 25.5 | |
| 4 months or later | 73.0 | 68.2 | 74.5 | |
| Weight gain by 6 months infant age (lb), mean (SD) | 9.93 (2.32) | 10.15 (2.32) | 9.85 (2.32) | .04 |
PPD, Postpartum depression.
∗ p value: comparing frequencies (and means for weight gain) between mothers with and without PPD.
Logistic regression analyses were performed to estimate the effects of PPD on this study's three infant feeding practice variables, adjusting for the maternal and infant characteristics that in previous research were found to be related to childhood obesity (Table 3). Mothers with PPD were found to be 1.57 times (95% confidence interval [CI]: 1.16, 2.13) more likely to breastfeed at low intensity compared with mothers without PPD. Further, mothers with PPD were 1.77 times (95% CI: 1.16, 2.68) more likely to add cereal to their baby's bottle at age 2 months than were mothers without PPD. Although crude analysis demonstrated that PPD was associated significantly with early introduction of solids (odds ratio [OR]: 1.42; 95% CI: 1.07, 1.89), when we adjusted for potential confounders, this association did not remain significant.
Table 3Effects of maternal postpartum depression and other maternal characteristics on early infant feeding practices (odd ratio and 95% confidence interval)
| Characteristics | Low breastfeeding intensity at 2 months OR (95% CI) | Add cereal to baby bottle at 2 months OR (95% CI) | Early introduction to solid food OR (95% CI) |
|---|---|---|---|
| Maternal PPD | |||
| Yes | 1.57 (1.16, 2.13) | 1.77 (1.16, 2.68) | 1.31 (0.95, 1.79) |
| No | Reference | Reference | Reference |
| Mother's race | |||
| White | Reference | Reference | Reference |
| Black | 0.95 (0.50, 1.81) | 4.12 (2.11, 8.04) | 1.66 (0.89, 3.08) |
| Hispanic | 0.67 (0.35, 1.28) | 0.37 (0.11, 1.26) | 0.49 (0.24, 0.98) |
| Mother's age | |||
| 18-24 years | 0.98 (0.67, 1.43) | 1.57 (0.96, 2.57) | 1.56 (1.08, 2.26) |
| 25-34 years | Reference | Reference | Reference |
| More than 34 years | 1.04 (0.74, 1.46) | 1.20 (0.72, 1.99) | 0.89 (0.61, 1.28) |
| Mother's education | |||
| High school or less | 3.21 (2.15, 4.78) | 2.41 (1.35, 4.28) | 2.78 (1.85, 4.17) |
| Some college | 1.74 (1.27, 2.40) | 1.76 (1.08, 2.87) | 1.74 (1.25, 2.42) |
| 4-year college or more | Reference | Reference | Reference |
| Household income (% of poverty level) | |||
| < 185 | Reference | Reference | Reference |
| 185 to ≤ 349 | 0.71 (0.50, 1.00) | 1.31 (0.81, 2.11) | 0.90 (0.64, 1.26) |
| > 349 | 1.01 (0.72, 1.43) | 0.99 (0.59, 1.66) | 0.71 (0.49, 1.02) |
| Mother's pre-pregnancy BMI | |||
| Underweight | 1.17 (0.72, 1.88) | 1.26 (0.64, 2.49) | 0.73 (0.44, 1.22) |
| Normal | Reference | Reference | Reference |
| Overweight | 1.25 (0.84, 1.85) | 1.42 (0.80, 2.50) | 0.93 (0.61, 1.41) |
| Obese | 2.11 (1.55, 2.87) | 1.63 (1.05, 2.55) | 1.61 (1.18, 2.20) |
| Mother's postpartum smoking status | |||
| Non-smoker | Reference | Reference | Reference |
| Smoker | 3.26 (2.22, 4.77) | 2.21 (1.37, 3.56) | 1.53 (1.04, 2.25) |
| Infant sex | |||
| Female | 1.04 (0.80, 1.36) | 0.62 (0.42, 0.91) | 0.75 (0.57, 0.98) |
| Male | Reference | Reference | Reference |
| Infant's fussiness reported to be a problem at 2 months | |||
| Fussy | 0.94 (0.71, 1.23) | 0.98 (0.66, 1.45) | 1.11 (0.84, 1.46) |
| Not fussy | Reference | Reference | Reference |
BMI, Body mass index; CI, confidence interval; OR, odds ratio; PPD, postpartum depression.
Using multivariate regression models, we assessed the impact of these early infant feeding practices on weight gain at 6 months separately for mothers with and without PPD (Table 4). For mothers with PPD, low breastfeeding intensity at 2 months significantly increased weight gain by 6 months (b = .14, p = .02), as did adding cereal to the baby bottle at 2 months (b = .15, p = .03). The contribution of early solid food introduction on weight gain at 6 months among mothers with PPD was not significant. Early introduction to solid food, however, significantly predicted higher average weight gain (b = .09, p = .01) among mothers without PPD. Breastfeeding intensity and adding cereal to the baby's bottle were not factors that significantly influenced weight gain by 6 months in this group of mothers.
Table 4Effects of early infant feeding practices on weight gain at 6 months stratified by postpartum depression
| Multivariate regression models on weight gain | ||||
|---|---|---|---|---|
| PPD | No PPD | |||
| β coefficients | p value | β coefficients | p value | |
| Breastfeeding intensity at 2 months infant age | .02 | .24 | ||
| Low | 0.14 | 0.04 | ||
| Medium/high | Reference | Reference | ||
| Added cereal to baby bottle at 2 months infant age | .03 | .80 | ||
| Yes | 0.15 | 0.02 | ||
| No | Reference | Reference | ||
| Introduction to solid foods | .45 | .01 | ||
| Less than 4 months | 0.05 | 0.09 | ||
| 4 months or later | Reference | Reference | ||
PPD, Postpartum depression.
Discussion
In this study of the effects of PPD on infant feeding practices and subsequent infant weight gain, approximately one quarter of the mothers in the sample had EPDS scores indicative of at least mild depression when their babies were 2 months old. This rate falls within the range of PPD prevalence found in other recent studies using the same EPDS cutoff score (≥ 10). For example, an Australian study reported a rate of 14.5% (N = 1427) at 3 months postpartum, and a U.S. study found a rate of 34.1% (N = 1359) for mothers in the first 6 months postpartum (
Mayberry et al., 2007
; Woolhouse et al., 2009
). Further, three maternal characteristics in the present study were significantly associated with PPD: pre-pregnancy obesity, postpartum smoking, and the perception that infant fussiness/irritability was a problem. These findings also are consistent with previous research that found these maternal characteristics to be associated with PPD (Howell et al., 2009
; LaCoursiere et al., 2010
; Park et al., 2009
).With respect to relationships among the main study variables, we found that mothers with depressive symptoms were at greater risk for both low breastfeeding intensity and adding cereal to infant formula at 2 months of age than were those without PPD. This finding provides initial support for a trajectory of events that may be occurring when mothers experience PPD. First, both research and clinical practice concur with the finding that depressed mothers tend to cease breastfeeding early (
Dennis and McQueen, 2009
). This early termination may be due to the challenges and frustrations often experienced as mothers attempt to establish effective breastfeeding. When dealing with their own feelings of sadness, mothers often experience fatigue. Transitioning to bottle feeding may provide some relief by removing some of the stressors associated with breastfeeding initiation.Further, the transition to bottle feeding may lead to a change in the dynamic of control in feeding behavior. That is, the infant self-regulation of feeding that comes with breastfeeding may be reduced. In its place, greater external control may occur with encouragement of bottle emptying (
Li et al., 2008
). Sometimes mothers may view the encouragement of bottle emptying as a strategy to promote infant quietude and extended sleep. As a next step in this proposed trajectory, mothers may choose to add cereal to their baby's bottle. Although research about adding cereal to infant formula is not available, clinical experience tells us that mothers most often begin this infant feeding practice with the belief that it causes babies to sleep longer at night. Extended infant sleep time can be another welcome relief because it allows mothers to overcome their own sleep deficits and thus cope better with the postpartum stressors and negative emotions.Our findings are consistent with the Life Course Health Development model, which suggests that the cluster of risk factors occurring during the critical time of early infancy has the potential to interact and accumulate over time with long-term health consequences (
Halfon and Hochstein, 2002
; Halfon et al., 2005
). Interrupting this trajectory that begins with maternal depressive feelings and cycles through maternal-infant dyadic responses may be important, not only for advancing maternal health, but also for modifying early life risk factors for childhood obesity. The differential in weight gain by 6 months of infant age that was found in the present study was very small but statistically significant. The potential importance of incremental changes at this early time in the life cycle is underscored by findings of the Project Viva study (N = 559), in which similarly small increments were predictive of increased risk of obesity at 3 years of age (Taveras et al., 2009
).When considering the findings of our study, some important limitations need to be taken into account. Although the IFPS II is a large and valuable source of data about infant feeding practices throughout the United States, minority representation in the sample is low. This consideration is important when studying early life predictors of childhood obesity because the highest rates are found among Hispanic and non-Hispanic Black children (
Ogden et al., 2012
). Further, the survey approach in this study resulted in self-reported data, which may have led to some inaccuracies, especially with respect to maternal and infant weight data. In addition, exclusion criteria included maternal reports of serious, long-term health problems that would affect infant feeding (Fein et al., 2008
). However, the IFPS II data collection survey did not capture the prevalence of less serious but more common infant disorders, such as gastroesophageal reflux, that may have had an influence on findings regarding the practice of adding cereal to infant bottle feedings.Despite these limitations, the present study has some key strengths. To our knowledge, this is the first study of early childhood predictors of childhood obesity that has used a large national data set to examine the links among PPD, common infant feeding practices, and infant weight gain. In addition, the longitudinal design of the IFPS II allowed for examination of these relationships from a prospective, rather than cross-sectional, view. Further research is needed to replicate and extend these findings using population-based samples with greater generalizibility to the full spectrum of maternal-infant dyads in the United States. Next steps in this line of clinical inquiry also should assess other modifiable risk factors for weight gain among infants of depressed mothers in addition to the feeding practices found to be significant in the present study, namely, low breastfeeding intensity and adding cereal to the baby bottle in early infancy.
Findings from the current study add to the body of evidence available to inform practice when caring for mothers and infants in the first few months after delivery. The high rate of depressive symptoms found in this and other current studies supports practice guidelines that call for PPD assessments during early well-child visits. The EPDS is a particularly suitable tool for this task. It is easily incorporated into practice because it takes little time to administer and is widely available without cost in multiple languages, including English and Spanish.
Other implications for primary care practice emerge from the identified risks for low breastfeeding intensity, adding cereal to formula, and infant weight gain in the PPD group. These findings underscore the need for establishing referral systems for appropriate mental health services, as well as individual lactation support. Programs that help families identify infant fullness and hunger cues also may be constructive in reducing the feed-to-soothe responses to infant irritability and eliminate the practice of adding cereal to infant formula to promote infant quietude and sleep states. Such programs are in concert with the recommended action plan for healthy infant feeding practices as presented in Early Childhood Obesity Prevention Policies (
Institute of Medicine, 2011
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Biography
Kathleen F. Gaffney, Professor, School of Nursing, George Mason University, Fairfax, VA.
Panagiota Kitsantas, Associate Professor, Department of Health Administration and Policy, George Mason University, Fairfax, VA.
Albert Brito, Medical Director, InovaCares Clinic for Children, Falls Church, VA, and Assistant Professor, School of Medicine, Virginia Commonwealth University, Richmond, VA.
Carol S.S. Swamidoss, Doctoral Candidate, School of Nursing, George Mason University, Fairfax, VA.
Article info
Publication history
Published online: December 26, 2012
Footnotes
Conflicts of interest: None to report.
Identification
Copyright
© 2014 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
