“Early breastfeeding cessation: validation of Breastfeeding Assessement Score (BAS) on an Italian validation cohort of women”.
ZOBBI VIRNA FRANCA1, MAURI PAOLA AGNESE2
1 University of study of Milan-Bicocca. PhD student.University of study of Milan
2 University of study ofMilan. PhD student.University of study of Milan
1. Introduction
Many Professional and International organisations have recommended breastfeeding as the optimal method of nutrition for infants1-7.Breastfeeding is the best source of nutritionfor the newborn and growing infant7-11. Short and long term benefits of breastfeeding forthe health of theinfant and mother have been extensively estabilished1. Consequently, exclusive breastfeeding is currently recommended up to the sixth month of life and the introduction, from that age on, of solid food, along with breast milk,until at leastthe second year of life12.
WHO and UNICEF13support that the failure to breastfeed increases the risk of infant weakness and mortality. Moreover, many studies confirm that the infants who did not receive maternal breastfeeding have more scholastic difficulties and lower social competency.
Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health7-14, current estimates of the initiation of breastfeeding at the time of hospital discharge in Italy are ~ 80%; 20% of mothers fail to continue breastfeeding afterthe third month15. Breastfeeding prevalence in Lombardy at hospital discharge is 95,6%, but 3 months after birth only 67,5% carry on with exclusive breastfeeding16.The greatest decrease in the breastfeeding rate occurs during the first 4 postpartum weeks 17.
The reasons for failure to continue breastfeeding are numerous and complex. For instance, a lack of support in the first days after delivery is an important risk factor for early weaning and other newborn difficulties18-21.
Breastfeeding assessment score (BAS), as suggested by Hall et al.22, may be a useful tool to identify the mothers that will stop breastfeeding exclusively within the first month of life. Other research indicates that the intrinsic properties of the BAS are robust23 . The Breastfeeding Assessment Score (BAS) included maternal age (in years: <21, 21-24, or >24), previous breastfeeding experience (failure, none, or successful), latching difficulty (every feeding, half the feeding, or <3), breastfeeding interval (in hours: >6, 3-6, or <3) and the number of bottles of formula before enrolment ( 2, 1 or none) (table 1). In accordance with Hall et all., the score was calculated summarizing scores of individual variables, each worth 0 to 2 points.A lower Breastfeeding Assessment Score of 8, identifies the mothers at increased risk of early weaning.
Table 1. Breastfeeding Assessement Score (BAS) 22
ScoreVariable / 0 / 1 / 2
Maternal age (in years) / <21 / 21–24 / >24
Previous breast-feeding experience / Failure / None / Successful
Suckling difficulty / Every feeding / Half the feeding / <3 feeding
Breastfeeding interval (in hours) / >6 / 3–6 / <3
N° of bottles of formula before enrolment / ≥ 2 / 1 / 0
To identify the mothers at increased risk of stopping breastfeeding could be useful to support them and to prevent the weaning22-24.
Data are currently lacking on the accuracy of the BAS for Italian mother-child pairs.
2. Aim of the study
To assess the accuracy of the BAS22, on an Italian validation cohort of women.
The predictive value of the BAS22 is considered adequate, if it identifies the 80% of the women that will stop breastfeeding.
3. Methods
This is a bicentric, prospective study. This study included Italian women who gave birth from 25th June 2008 to 15th January 2009.
The institutional ethics committee approved the study, and mothers gave their verbal consent to participate. The mothers could leave the study at any time and the midwifery care to mothers was that of routine.
The authors have calculated the BAS on cohort of breastfeeding mothers, just before hospital discharge, at least 48 hours post-delivery age, in Mangiagalli and in S. Gerardo hospitals in Milan.
The including criteria on the convenience sample were:
-healthymothers;
-single pregnancy with vaginal or caesarean delivery;
-healthy newbornsfrom 35 to 42inclusive weeks of gestation;
-infants with birth weight inclusive from 2500 g to 4000 g;
-Italian mothers and fathers;
-Mothers practiced 24-hour rooming-in, breast-fed on demand and started breastfeeding within the first hours post delivery;
-Mothers and newborns discharged within five days after birth.
The exclusion criteria on the convenience sample were:
-mothers aged less than 18 years;
-mothers with post-partum haemorrhage ≥ 1000 ml;
-mothers with Hb 7,5 mg/dl in the post partum;
-hypertensive mothers in drug treatment;
-mothers with psychiatric disease;
The cohort consisted of 386 mothers and the researchers whocollected data at discharge used the following data form collection:
Validation of the Breastfeeding Assessment Score (BAS) on Italian women
Data form during the hospitalization post partum (face A)
Hospital
1Policlinico Mangiagalli Regina Elena Foundation
2San Gerardo Hospital
Progressive number of the file cardNumber of the clinical record
Woman
Family name ______Name ______
Date of birth (mm/dd/yyyy)Province of birth
Province of residence
Day of the BAS data gathering (mm/dd/yyyy)
Breastfeeding Assessment Score (BAS)
ScoreVariable / 0 / 1 / 2
Maternal age (in year) / <21 / 21–24 / >24
Previous breast-feeding experience / Failure / None / Successful
Latching difficulty / Every feeding / Half the feeding / <3 feedings
Breast-feeding interval (in hours) / >6 / 3–6 / <3
N° of bottles of formula before enrolment / 2 / 1 / 0
Total score
School
Never / 1Elementary / 2
Intermediate / 3
Higher / 4
Degree / 5
Post graduate / 6
Marital status
Married / 1Unmarried / 2
Single / 3
Other / 4
Profession
Housewife / 1Employee / 2
Self Employed / 3
Freelancer / 4
Did you follow a course to accompany the birth? / No 0 / Yes 1
Height (cm) / Prenatal weight (g)
Delivery / physiological vaginal delivery 1 / Vacuum extractor 2 / Elective caesarean section 3 / Emergency caesarean section 4
Epidural anaesthesia / No 0 / Yes 1
Hour of delivery (h/min)
Childbirth
Surname ______Name ______
Gender / Male 1 / Female 2Date of the birth (mm/dd/yyyy)
Weight of the birth (g)
Weight at discharge (g)
Phototherapy / No 0 / Yes 1
Dummy / No 0 / Yes 1
Phototherapy / No 0 / Yes 1
Glucose / No 0 / Yes 1
At 4 weeks from birth, theresearcherscarried out structured follow-up telephone interviews.The primary outcome measured was how many women stopped breastfeeding during the first month of thelife of the infant. Other data were also collected duringtelephone interviews.The validation cohort was used to estimate the predictive value of the Breastfeeding Assessment Score. Breastfeeding practiced were classified according to the WHO’s definitions25 . The follow-ups were carried out from 25th July 2008 to 15th February 2009.
At follow-up, researchers usedthe followingdata collecting form:
Data form the first month of life of the baby (face B)
Phone number / 2 / 3 / 4 / 5 / 6 / 7 / 9 / 0 / 0 / 0Mobile number
WOMAN
How are you feeding your baby?
Exclusive breastfeeding / 1Predominant breastfeeding (breastfeeding and H2O or tisane) / 2
Mixed breastfeeding (breastfeeding and bottle feeding) / 3
Only bottle feeding / 4
How many times did you breastfeed (exclusive or predominant breastfeeding)?
Why did you interrupt breastfeeding?
The child has not grown/I had no mother’s milk / 1I felt pain / 2
I had breast inflammation / 3
The baby slept / 4
Last month, did you contact a breastfeeding consultant?
No, I didn’t / 1Paediatric nurse / 2
Midwife / 3
Community midwife / 4
Hospital paediatrician / 5
Paediatrician / 6
General practitioner / 7
How many times did you contact the breastfeeding consultant?
BABY
Baby weight (g)Statistical analyses were carried out entering the data into SPSS version 17.0 (SPSS Inc, Chicago, Ill).
1
4. Results
Three-hundred and eighty-six mother and infantpairs were recruited. Figure 1 illustrates the mother’s age, of participating women.
Figure 1: Mothers age
Figure 2 illustrates the educational qualifications of participating women.
Figure 2. Educational qualifications of women
Figure 3 illustrates the marital status of women, in the validation cohort.
Figure 3. Marital status of women
Figure 4 illustrates the profession of women, in the validation cohort.
Figure 4. Profession of women
Figure 5 illustrates type of delivery, in the validation cohort.
Figure 5. Mode of delivery
Among theparticipating women, we had 119 (30,8%) mothers with a BAS < 8 and 267 (69,2%9) mothers with a BAS 8.Six mother infant pairs (1,5%),all included in the 8 group, were eliminated from data analysis because it was impossible to make follow-up contacts. The remaining 380 couples, constitutes the cohort validation population.
Cessation of exclusive breastfeeding (mixed breast-bottle feeding or only bottle feeding) was identified in 127 (33,5%) mothers, while 253 (66,5%) mothers were still carrying out exclusive or predominant breastfeeding. Figure 6 illustrates the type of feeding at four weeks of life.
Figure 6. Mode of feeding at four weeks post-delivery
Couples with BAS 8 (261 of 380) had a cessation rate of 23,5% (61 of 261). Couple with BAS < 8 (119 of 380) had a cessation rate of 55,4% (66 of 119).Sensibility was calculated as relation between the number of women that carry-on mixed breast-bottle feeding/Only bottle feeding with BAS < 8 and all the women that carry-on mixed breast-bottle feeding/Only bottle feeding. The specificity was calculated as relation between the number of women that carry-on exclusive/predominant breastfeeding with BAS 8, and all the women with exclusive/predominant breastfeeding. The BAS had a sensibility of 51,9% and a specificity of 79,5%.
Table 1 Comparing the value of BAS with modality of breastfeed in the time
Exclusive/predominant breastfeeding / Mixed breast-bottle feeding/Only bottle feeding / TotalsBAS 8 / (44,6%)
(20,95%)
53 / (55,4%)
(51,9%)
66 / 100%
119
BAS ≥ 8 / (76,6%)
(79,05%)
200 / (23,4%)
(31.03%)
61 / 100%
261
Totals / 253 (100%) / 127 (100%) / 380
If weanalyze data, considering only the exclusive/predominant breastfeeding versus only bottle feeding (excluded mixed feeding), we had a total of 311 mother infant pairs.
Table1comparing the BAS≥ 8 and < 8 predicting cessation of breastfeeding within 4 weeks of age.
Table 1 Comparing the value of BAS with modality of breastfeed in the time
Exclusive/predominant breastfeeding / Only bottle feeding / TotalsBAS 8 / (56,99%)
(20,93%)
53 / (43.01%)
(68.97%)
40 / 100%
93
BAS ≥ 8 / (91,74%)
(79,05%)
200 / (8,26%)
(31.03%)
18 / 100%
218
Totals / 253 (100%) / 58 (100%) / 311
For a cut point of 8, recommended by the authors of the BAS22, 93 mother-infant pairs (29,9%) were categorized at high risk for early breastfeeding cessation, with a RR 5,24.
In this case the BAS had a sensibility of 0.69 (68,97%) and a specificity of 0.79 (79,05%).
The positive predictive value was calculated as relation between the number of women that stopped breastfeeding with a BAS < 8, and all the women with BAS < 8. The negative predictive value was calculated as relation between the number of women that carry-on exclusive/predominant breastfeeding with a BAS 8, and all the women with BAS 8.
In this study the BAS had a positive predictive value of 43% (43,01%) and a negative predictive value of 91% (91,74%).
5. Discussion
The prevalence of exclusive breastfeeding mothers 4 weeks after delivery fell down from 85% to 62%.The rate of stopping exclusive breastfeeding is comparable to value reported on Lombardy population16. This result confirms that the first postpartum days are crucial to the establishment of breastfeeding (Figure 7).
Figure 7. Prevalence of breastfeeding mothers recorded by the Lombardy Region and the validation study of the BAS.
In our population, the BAS had individuate the 52% of the women had stoppedexclusive breastfeeding and had a specificity of 79%. In according to other study23 24 we found that the prognostic information of BAS was strong, but not so much to validate it. In fact in our primary outcome we asserted that the predictive value of the BAS22 was adequate, if it identified the 80% of the women that stopped breastfeeding.
Italian mothers differed from those of the Hall’s study22 cohort for one of the five risk factors included in the Breastfeeding Assessment Score. In fact only 1% of Italian mothers delivered before 21.Further research is required to evaluate the prognostic performance of BAS, modified for the mother’s age variable.
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