copyright by tyra martin carter 1978
TRANSCRIPT
Copyright by TYRA MARTIN CARTER 1978
FACTORS AFFECTING THE DECISION OF LOW SOCIOECONOMIC
WOMEN NOT TO BREAST FEED
by
TYRA MARTIN CARTER, B.S. in H.E.
A THESIS
IN
FOOD AND NUTRITION
Submitted to the Graduate Faculty of Texas Tech University in
Partial Fulfillment of the Requirements for
the Degree of
MASTER OF SCIENCE
IN
HOME ECONOMICS
Approved
c n a i r m a n / o r r n e uommi-cree y
A c c e p t e d
May, 1978
ACKNOWLEDGMENTS
I would like to express my appreciation to Mrs. Clara
M. Mcpherson for her direction in preparation of this thesis
and to other members of my committee. Dr. Joe D. Cornett and
Dr. Charles V. Morr for their continued encouragement, help
ful suggestions, and criticism. Special gratitude is ex
tended to Miss Linda Affleck for her guidance in analysis of
statistical data.
Special acknowledgments are extended to the Lubbock
City Health Department Maternity Division for making this
research possible and to all the respondents for their will
ingness to participate in this research project.
Special thanks are accorded to my husband for his
understanding and support throughout my graduate studies.
11
TABLE OF CONTENTS
ACKNOWLEDGMENTS ii
LIST OF TABLES v
Chapter
I. INTRODUCTION 1
Statement of the Problem 2
Hypothesis 3
Limitations of Study 4
II. REVIEW OF LITERATURE 5
History of Infant Feeding Practices . . . . 5 ^ I
Advantages of Human Milk for the Infant 6
Maternal Advantages of Nursing 12
Contra-indications of Breast Feeding . . . 17
Economics of Breast Feeding 21
Factors Which Negatively Affect Breast Feeding 24
Mothers' Decisions Regarding Infant Feeding 3 2
Role of Education in Increasing Breast Feeding 33
III. METHODOLOGY 36
Selection of Subjects 36
Development of Instrument 36
Collection of Data 37
Treatment of Data 38
111
IV
IV. RESULTS AND DISCUSSION 39
Part I. Demographic Data 39
Part II. Survey Results 40
V. SUMMARY AND CONCLUSIONS 53
REFERENCES 57
APPENDIX 63
LIST OF TABLES
Table Page
1. Age and Race Distribution of Subjects 39
2. Educational Background of Subjects by Race 40
3. Physician's Communication with Patient Concerning Method of Infant Feeding 41
4. Relationship of Physician's Attitude to Patient's Decision to Breast Feed . . . . 42
5. Convenience Factors Associated with Breast Feeding 43
6. Relationship of Breast Feeding to Social Attitudes 45
7. Relationship of Husband's Attitude to Breast Feeding 46
8. Relationship of Husband's Attitude to Breast Feeding If a Positive Choice Was Made 47
9. Factors Contributing to Success or Failure in Breast Feeding 48
10. Mothers' General Knowledge Concerning Breast Feeding 50
11. Product Distribution As an Influence on Decision to Breast Feed 52
V
CHAPTER I
INTRODUCTION
Methods of infant feeding consist of a blend of
biological constants modified by cultural factors, both
ancient and modern, which are strongly influenced by local
food availability (1). Following the scientific medical
revolution of 100 years ago, infant feeding in Euro-America
(and increasingly in urban areas elsewhere) became mainly
influenced by the Western world. Biological considerations
and traditional practices were regarded as old-fashioned,
outdated, and out-of-phase with present day urban life styles
Infant feeding came to be considered by some as an engineer
ing exercise, with the child being "refueled" with specific
nutrients by mechanical means, e.g., from a feeding bottle
(1. 2) .
It is estimated that two-thirds of all mothers in
the world currently nurse their infants for at least the
first three months. The average incidence of breast feeding
ranges from a low of about 25 per cent in the United States
to nearly 100 per cent in rural areas of developing countries
(3). Moreover, rural women in developing countries often
breast feed for two years or longer compared with the average
of two to six months for women in developed countries. I In
the last decade, however, breast feeding declined sharply in
urban areas of many developing countries (2, 4). This has
been caused by vigorous commercial promotion of milk for
mulas and supplemental foods for infants, by lack of strong
medical support for breast feeding, by a changed perception
of the acceptability and social status of breast feeding,
and, to a lesser degree, by increased employment of women
in places outside the home where little provision is made
for breast feeding (3)(
The unique value of human milk for the infant and
the value of breast feeding for the mother has become in- •
creasingly clear in all parts of the world with respect to
economics, health, nutrition, and even fertility. The basic
issue is to use an educational approach to improve the pat
tern of breast feeding by decelerating the present rate of
decline. As of yet, no wi'de-spectrum efforts have been at
tempted to counter the current trend (1).
Statement of the Problem
^ Despite significant benefits for both mother and
child, the rates for breast feeding in the United States
are the lowest in the world.( Although breast feeding rates
are presently rising among educated and middle-class women,
it remains lowest among the poor—those populations with
the highest infant and maternal mortality rates which have
the greatest need for better nutrition (5). The reasons
for decreased breast feeding rates among the poor are com-\
plex and vary according to the specific area.\ Therefore,
jiield research is needed to make detailed community diag
nosis of the factors affecting the decision of low socio
economic women not to breast feed. It is for this purpose
that the present study was undertaken.
The questionnaire is useful for obtaining personal
facts, beliefs, and attitudes to allow one to solve problems
within the sample group. It is known that a survey produces
reliable results, particularly when subjects are asked to
respond to an area of personal concern. Because of the
information the survey reveals, it prepares the way for
future experimental studies from which inferences can be
drawn.
Hypothesis
This research was designed to test the hypothesis
that the various independent variables to be studied af
fect the choice of low socioeconomic women not to breast
feed. The independent variables include: professional
influence, urbanization and modernization, inconvenience,
negative social attitudes, previous exposure and experiences,
physical complications, the early introduction of semisolids
to infants, knowledge of the advantages of breast feeding,
advertising of infant formulas, number of children in the
family, and age, education, and marital status of the woman.
Limitations of Study
The following are limitations of the study:
1. Survey research may not produce responses which
are indicative of true behavior. Subjects may respond in a
way that they feel will be pleasing to the interviewer.
2. Survey information may not reveal in-depth
feelings of the respondents.
3. Descriptive research, by the survey method,
does not necessarily provide inferential sample information
which can be applied to the general population.
CHAPTER II
REVIEW OF LITERATURE
History of Infant Feeding Practices
Lactation is a most ancient physiological process
dating back millions of years. It antecedes placental ges
tation, as earlier mammals were egg-laying marsupials (6).
During these vast periods of time, adaptation of milks has
occurred to meet the different needs of the many species
of mammals.
This principle can be observed with the whale and
other cold water mammals, in whose milks there is a very
high percentage of fat. This matches high caloric require
ments of their offspring and the need to put on a thick
layer of blubber rapidly. Similarly, species such as the
rabbit, whose newborn grow extremely fast, have a very high
protein content in their milk (6).
Historically, human milk has been universally rec
ognized and revered as the only means of infant feeding.\
Frequent references to it are found in religion, folklore,
and value systems. In ancient Egypt, nursing was commonly
continued for three years, and in biblical Israel for two
years. In Babylonia, the mother goddess Ishtar was often
depicted nursing her baby,—A Spartan royal law of the
fourth century B.C. required mothers to breast feed their
babies, and Caesar ridiculed Roman mothers who retained
nurses for their children (4).
When observing recent changes in patterns of infant
feeding, it becomes apparent that cow milk has been the
food of man for only the last ten or twenty thousand years.
The major part of the human race does not use animal milk
at all. More relevantly, the widespread use of cow milk
for feeding young infants has occurred in the last fifty
years, and was made possible by spectacular advances in
scientific dairy farming and in food technology (7). Even
so, this extraordinary, anti-mammalian situation spread
widely throughout the Western world and is now regarded as
the norm, fin terms of man's history, use of cow milk for
infant feeding is highly experimental. Unexpected nutri
tional and related problems are coming to the forefront as
modern knowledge unfolds.
Advantages of Human Milk for the Infant
As pointed out by Kon (8),("It stands to reason that
milk, which only for a limited time and with certain reser
vations is the ideal food for the young of any one species,
is further restricted in value when used by another species,
and the limitations of milks of domesticated animals in
human nutrition must be frankly accepted and understood^. "1
Basic to the whole issue is the question of the existence
of specific and unique ingredients in human breast milk,
as opposed to the milk of other mammals. Numerous studies
P^
on the biochemical and nutritional properties of different
types of mammalian milk have been conducted in the past
decade. Essentially, these have shown that each milk source
is a highly complex system differing greatly from one
another (9).
Human- milk contains over a hundred constituents.
This is not to say that milk of other species is not equally
complicated, but they are totally different (6). It is
worth noting that the growth rates of the human infant and
the calf are quite different, the human infant requiring
about twice as long as the calf to double its birth weight
(100 versus 50 days). Thus, the ratio of nutrient require
ment for growth to that for maintenance is greater for the
calf than for the human infant. Furthermore, protein and
minerals account for a smaller percentage of weight gain in
the human infant than in the calf (10, 11). f
Proteins
\ Both human and cow milk contain approximately 67
kcal. per 100 ml. Seven per cent of the calories of human
milk come from protein, 30-55 per cent from fat, and 40 per
cent from sugar (1^) . Human milk contains approximately
1.1 per cent protein compared to_^.3 per cent protein in j
cow milk. The protein in human milk is mainly lactalbumin
rather than casein; the reverse is the case in cow milk
(11) .7 Both are complete proteins, but the increased casein
8
in cow milk leads to higher curd tension and poorer absorp
tion. Lower protein levels in human milk decrease BUN and
thus, also decrease the solute mineral load in breast fed
infants. This makes it unnecessary to give extra water to
breast fed infants, except in unusual circumstances that
cause excessive water loss.
Lipids
j The fatty acid composition of human milk differs
from cow milk in that it has a much higher percentage of
linoleic acid (9). Medium-chain triglycerides, also well
absorbed, are present in human milk (11). The enzyme lipase
is one of the most important constituents of human milk.
It has been recently confirmed how effective this is in
producing lipolysis and initiating the digestion of milk
fat (12). This means that the main source of calories in
human milk is already undergoing digestion while in the
mouth, esophagus, and stomach.
The amount of cholesterol in human milk is higher
than in cow milk and even higher than most commercial infant
formulas, which are often made with various vegetable oils
containing no cholesterol (9, 10, 11, 13) J Results of
animal experiments have shown that relatively high intakes
of cholesterol are needed in early life to insure the de
velopment of appropriate enzyme systems needed in later
life to control the level of cholesterol in the blood (14).
An exogenous source may be desirable to prevent excessive
cholesterol blood levels later in childhood or adulthood
(10) .
Lactose
1^ Lactose, a disaccharide of glucose and galactose,
is present in greater amounts in human milk than in cow
milk (7 per cent compared to 5 per cent) (7, 11) . This is
a readily available source of galactose which is needed for
the formation of galactolipids, one of the main constituents
of the brain (6, 7)
Vitamins and Minerals
r̂^ E[uman milk from a well nourished woman, if taken in
adequate quantity by the infant, may be expected to satisfy
advisable intakes for vitamin A, thiamin, riboflavin, niacin,
vitamin B^/ vitamin B-|2' folacin, vitamin C, and vitamin E
(10). Although human milk is not a particularly rich source
of preformed niacin, it is a good source of tryptophan,a
niacin precursor, so the total intake of niacin is more than
adequate. Human milk provides little vitamin D thus sup
plementation of the infant's diet with a daily dosage of
400 I.U. is recommended (10, ll)~v
[ Concentrations of phosphorus, sodium, potassium,
and zinc have been noted to decrease as duration of lacta
tion increases (10). Flouride, even when present in optimal
amounts in water, is not contained in human milk in
10
sufficient amount. Flouride supplementation of 0.5 mg.
should be given daily (10, 11). some research indicates
that full-term infants who receive only human milk do not
need iron supplementation for the first four to six months
of life (15, 16, 17, 18). Fomon and Filer (10), however,
strongly recommend iron supplementation for all infants.
They believe a daily intake of 7 mg. (as ferrous sulfate),
beginning no later than age four weeks, is adequate to
prevent development of iron-deficiency anemia.(
Anti-infection Agents
\ It has long been recognized that breast fed infants
seem to be protected against many infections, especially in
surroundings of poor hygiene. Until recently, this protec
tion was thought to be associated with the fact that human
milk is sanitary and has no opportunity for contamination
(7). It is now apparent that human milk contains positive
and active host-resistant factors, both cellular and humoral
(1).
The cellular content of human milk is almost as
great as in blood, with a hierarchy of cells, ranging from
mobile, ameboid macrophages, to interferon-producing lym
phocytes (19). These are present in colostrum and have a
protective function in the mammary lacteals as well as
within the infant. Humoral constituents are numerous and
include secretory immunoglobulin A (IgA), lactoferrin.
11
lysozymes, and the bifidus factor (1, 10, 11). These sub
stance.̂ , 'p.rp'o a bactericidal effect and also protect the
newborn's gastrointestinal tract from foreign protein al
lergens. The bifidus factor, not present in appreciable
concentrations in cow milk, is responsible for the dominance
of Lactobacillus bifidus in the infant's intestinal flora;
the acid environment inhibits _in, vitro growth of Escherichia
coli and the enteroviruses (20).
Allergenic Factors
Covy^milk is the most common foo.d responsible for
allergy in bottle-fed infants (1). Up to 7 per cent of all
infants may be sensitive to cow milk (11). Among carefully
proven cases, almost 60 per cent occur in the first month
and 80 per cent in the first three months of life. Detailed
studies show the most frequent al^lergens to be beta-
lactoglobulin and serum bovine albumin,_neither of which
are found in breast milk (2ixj Gerrard (22) recommends.
that human milk, with^its low allergenicity and its supply
of IgA, should be used for at least the first six months of
infancy, especially in infants with allergic heritage
Obesity
There is a rising incidence of infantile obesity in
the United States and other industrialized countries, which
seems to be related to the pattern^f infant feeding (6) .
The volume and concentration of milk consumed are controlled
12
by the mother (or other person) but, in the breast fed
infant, they are biologically controlled (1). Because the
composition of human milk from a well nourished woman changes
daily, the P^eve_ntion of obesity is aided. The fat content
of breast milk increases during nursing and the baby auto
matically develops an appetite control mechanism to decrease
consumption (13). Breast feeding is also associated with a
delay in earli^r^jLntroduction of semi-solid foods, whi_ch
influences the onset of obesity (1, 6).
Maternal Advantages of Nursing
The child spacing effect of breast feeding, well
recognized in many cultures, has been long regarded as an
old wives' tale (1). Recent endocrinological investigations
have demonstrated that prolactin, a pituitary hormone, sup
presses ovulation (23, 24). Postpartum plasma prolactin
levels differ greatly in nursing and non-nursing mothers
(25, 26). The secretion of prolactin has been shown to vary
quantitatively with the sucking stimulus to the breast (3).
The success of lactation in suppressing ovulation
occurs when the baby suckles frequently and at short inter
vals during both day and night. The contraceptive effect
of_lactation is greatly reduced if breast feeding is par
tially replaced with even occasional formula feedings or
with early introduction of semi-solids (13). The effect of
lactation on postpartum amenorrhea therefore, varies with
13
custom in relation to surVi-in . . . ^ sucKimg practices, with the addition
of other foods, and thus tn a ' ^^^^ ^° ^ ma:or extent to maternal
understanding and motivation.
in the lactating mother, ̂ ^n^ruation and ovulation
aj_e_commo^^ delayed from ten ^eeks to as long as twenty-
six months (27, 28, 29) I The ^ *. x. • i JT n a.
.̂ ^ ' ' ^^>- \ ^^^\ contraceptive value of lacta-
^!flJf """̂ ^ effective if, in_the first four to six months,
the infant receives only huma^ milk. Evidence concerning
the suppression of ovulation and prolongation of postpartum
amenorrhea resulting from lactation is available from basal
temperature recordings, by histological examination of endo
metrial biopsies, and from fi^id observations in developing
countries (29, 30).
A study in the Philippines demonstrated that a
twenty-four to thirty-five mo^th birth-spacing interval was
achieved in 51.2 per cent of hiothers who breast fed their
infants for seven to twelve muj^ths, as opposed to only 30
per cent in mothers whose infants were artificially fed (31).
In Taiwan it is estimated that lactation prevents as many as
20 per cent of the births that would otherwise occur. In
India the same ratio would mean a prevention of approxi
mately five million births eatih year (4) .
Q j f breast feeding decunes and other fertility con
trol measures are not introdut:ed, birth rates can be expected
to increase (3).' Studies in the Eskimo culture of Canada and
Alaska substantiate this. As bottle feeding in Canadian
14
Eskimo villages increased from 5 per cent to 30 per cent
between 1940 and 1960, the mean duration of lactation de
creased from fifteen to five months (32). Schaefer (33)
reported that the difference in birth rates in Alaskan
Eskimo villages, which ranged between 40 and 64 per 1,000,
was directly related to the proximity of the nearest trad
ing center providing canned milk.
In some areas of the world where breast feeding is
regarded as essential to a baby's survival, social custom
limits sexual intercourse for lactating women, thus rein
forcing the link between breast feeding and contraception.
Intercourse is avoided as long as one year after giving
birth in parts of India, for two years in New Guinea, and
twenty-seven months in Nigeria. In some societies the taboo
reflects the belief that intercourse will dry up the milk
flow and in others that it will poison the milk. In parts
of South Africa, if a baby dies, it is assumed that the
mother has ignored the taboo, thus killing her baby with
"bad milk" (4). However, the strength of this taboo in
reducing births should be viewed with caution since the
traditional culture of many societies is changing rapidly
and these strictures on sexual behavior are being modified
(3). ^
( Delay in onset of menstruation has another benefi
cial effect on maternal_nutrition. The nursing woman is
allowed to replenish and conserve her iron stores, which
15
is a very important consideration in poorer communities
where^many women are anemic (4, 34, 35)7] Up to 40 per cent
of the reproductive lives of Indian women of ages twelve to
forty years can be in an anovulatory phase because of either
pregnancy or lactation (36).
There are significant differences in the incidence
rates of carcinoma of the breast not only from country to
country, but even within the same country. For example,
Puerto Rico and Japan show a much lower breast carcinoma
rate than that in the United States and some European coun
tries (37). Moreover, data obtained in the national cancer
survey have shown that the incidence of breast cancer in
Japanese women in the San Francisco Bay area is about five
times as high as in Japanese in their homeland (38). Such
significant differences between migrants and their com
patriots in their original homeland suggest that environ
mental factors play a large part in maintaining the, low
incidence of breast cancer in Oriental women.
Mammary function is one environmental factor which
has recently been shown to be strongly associated with the
development of mammary carcinoma (39). Malhotra (40) com
pared twenty-four patients with carcinoma of the breast,
twenty-four healthy controls, and forty-eight patients suf
fering from other diseases. He found that breast cancer
patients married later, had shorter lactational histories,
and had fewer children as compared with controls. It is
16
suggested that one carcinogenic factor may be an alkaline
milieu produced by the stasis of milk in the breast. An
alkaline milieu surrounding epithelial surfaces produces
cell proliferation leading to a 40-fold increase in mitotic
activity; this may eventually lead to hyperplasia, meta
plasia, and chronic inflammatory changes. /
\ A lower incidence of breast cancer has been observed
in communities of less technically developed countries in
which breast feeding is widespread and prolonged. In the
United States, as breast feeding has declined in frequency,
the incidence of breast cancer has increased (13jV "^Avail
able human data support the claim that breast feeding pro
tects against breast^caricer (33, 34, 40, 41, 42) . I However,
further research is needed to explain specific relationships
affecting carcinogenesis.
'One of the most important benefits of breast feeding
may be its effect on psychological development. Although
evidence linking breast feeding with later emotional adjust
ment is inconsistent, the quality of mother-infant inter
action seems_J:^i_be_eiih^ncsd--whsn a good breast feeding
relationship is established (43). Research on nursing women
shows that they are more likely than bottle-feeders to touch
their babies, to keep nipples in the infants' mouths longer,
to rock them, and to sleep or rest with them (1, 44). The
timing and coming together in meeting each other's needs are
well demonstrated when the "milk-ejection reflex" effects a
17
generalized warm and pleasurable sensation in the mother
(11) . Breast feeding provides the infant with maximum
sensory stimulation which cannot be equivocated from bottle — - ^ ^
feeding (1)./
During established successful lactation, a mother
will experience painless uterine contractions throughout
nursing and up to twenty minutes following a feeding (34).
This process of lactation causes the uterus to shrink more
quickly to its prepregnancy size (43) .\ The breast feeding
mother also does not face the slightly increased risk of
blood clots associated with the use of estrogens to sup
press lactation (43).1
The convenience aspect of human milk is often under
appreciated. An increasing number of mothers in the Western
world are conveniently and quietly breast feeding their chil
dren in public without any particular bother or danger of
arrest for indecent exposure. It is largely a question of
attitude (of both the mother and the public) and of having
clothes which are both fashionable and suited to breast
feeding in the Western culture (6).
Contra-indications of Breast Feeding
For a small proportion of women, there are some valid
medical reasons for not breast feeding. Women with active
tuberculosis, debilitating disease, or severe malnutrition
should not nurse./ Also continued maternal ingestion of
18
medications deleterious to the infant, or high levels of
maternal pollutants, such as mercury or fungicides, would
contraindicate breast feeding (11, 43).
Considerable information has been gathered on the
interrelationships of poor maternal nutrition and lactation
in developing countries. Gopolan and Belavady (45) show
some variation in composition of the breast milk of malnour
ished mothers in different parts of the world. As a gener
alization, lactose is unchanged; the pattern of fatty acids
varies considerably with the mother's past and present diet;
the water soluble vitamins and also vitamin A are decreased
with inadequate maternal intakes; the protein was often
found to be within lower limits of normal values. Lindblad
and Rahimtoola (46) found low levels of lysine and methionine
in a group of poor, urban Pakistan women. The diets of these
mothers consisted mainly of rice or wheat, which suggests
that a dietary deficiency of these amino acids is reflected
in milk production. The milk volume, which is the most im
portant variable contributing to failures in breast milk
feeding, is decreased in poorly nourished women (35, 46, 47).
Almost all compounds ingested by the lactating mother
are excreted in her milk, though in most instances in such
small amounts as to be barely detectable and insignificantly
hazardous (48). Arena (48), however, advises against the
use of the following drugs while^reast_feeding: any drug
or chemical in excessive amounts, diuretics, oral
19
contraceptives, atropine, reserpine, steroids, radioactive
preparations, morphine and its derivatives, hallucinogens,
anticoagulants, bromides, antithyroid drugs, anthraquinones,
dihydrotachysterol, and antimetabolites. These limitations
should in no way discourage the majority of mothers requir
ing medication who want to breast feed. When the possibility
of potential harm for the nursing infant exists, the offend
ing drug can usually be discontinued, or the chemical removed
from the mother's immediate environment.
In some instances, it is the infant who cannot or
should not be nursed. An infant born with a blockage of the
nasal passage, oral defects, gastrointestinal anomalies and
diseases, or congenital__heart disease may require an artifi-
cial feeding mechanism (11). Certain genetic disorders,
such as inborn errors of metabolism, will make an infant
intolerant to human milk (43).f Very small, premature in
fants may not be able to suck vigorously enough to nurse,
although they still might be fed with human milk (11,^43) .
Promotion of feeding prematures human milk is supported by
past clinical studies and current experimental data (7, 11);
however, Fomon and Filer (10), feel that protein intake is
inadequate for low-birth-weight infants fed only human milk.
They recommend that one or two bottle feedings be given each
day to supplement the intake of protein and minerals found
in human milk.
20
It has been observed that breast feeding may in
crease the risk of future breast cancer in female infants.
An RNA tumor virus is known to be present in certain human
milks and in human mammary carcinomas (49, 50) . Such par
ticles were detected in milk of 60 per cent of American
women with a familial history of breast cancer and in only
5 per cent of those with no familial history of breast
cancer (50). The significance of these viruses is not yet
known. Although there is the implication that RNA mole
cules appear in cancer cells because human milk virus is
replicating in these cells, the findings by no means prove
that human breast cancer virus causes breast cancer (10).
Epidemiologic data generally fail to support the
hypothesis that breast feeding is the major mode of trans
mitting breast cancer in the human (51). If breast feeding
were a major factory in transmission of breast cancer, the
decreasing frequency of breast feeding between 1900 and 1950
should have been associated with decreasing rates of breast
cancer in the 1950s and 1960s. However, breast cancer rates
actively increased during that period of time (52) . In
countries where breast feeding is common, rates of breast
cancer are generally low (53).
Thus, there is at present time some basis for concern
that human breast cancer virus may be transmitted from mother
to infant by breast feeding. However, from the evidence
currently available it seems unlikely that total elimination
21
of all breast feeding in the United States would substan
tially alter breast cancer rates (10). Additional studies
of mother-daughter occurrences of breast cancer in relation
to infant feeding are urgently needed.
A[<- Economics of Breast Feeding
Breast feeding is the traditional and ideal form of
infant nutrition, usually capable of meeting a child's nu
tritional needs for his first four to six months of life.
Even after the essential introduction of supplemental foods,
human milk can serve as an important continuing source of a
child's nutritional well-being. \^t can supply up to three-
quarters of a child's protein needs from their sixth to
twelfth month.
The differences in financial cost of breast feeding
and bottle feeding are significant. On an individual family
basis, the cost of formula can be compared with the extra
nutrients needed by a lactating woman (500 kcal. and 20 gm.
protein). A 1974 Los Angeles study showed that bottle feed
ing a three-month-old infant would cost 50 to 75 cents per
day compared to 17 to 21 cents for extra amounts of every
day foods for the mother (in the United States, a peanut
^oTtter sandwich and a glass of milk) (54). Lann, et al.
(55) report that breast feeding costs 50 to 60 per cen^_of
that of formula feeding.
22
In developing countries, the economic significance
is much more serious. Comparison of the cost of cow milk
formulas and basic wages in poorer areas shows that the
purchasing of adequate quantities would take from 25 to 50
per cent of the family's earnings (1). These costs for
commercial milk do not take into consideration any waste or
diversion to other members of the family. Nor do they re
flect the cost of bottles, nipples, cooking utensils, refrig
eration of fresh milk, fuel, and perhaps most important,
medical care, which is frequently ten times greater than
for breast fed babies (4).
j Bottle feeding will inevitably be attempted by lower
socioeconomic populations with increased incidence of maras
mus and diarrheal disease as a result of giving dilute feed
ings in unsanitized bottles (56)^VThe parents' lack of
education prevents them from reading or understanding in
structions for preparation and, together with ignorance of
sanitary requirements, fosters a high incidence of illness.
Even mothers aware of hygienic needs often find it difficult
to meet sanitary requirements, due to limited and unclean
water, inadequate fuel, poor storage, and use of a single
bottle and nipple (4). Cunningham (57) found that respira
tory and gastrointestinal illness occurred___two to three
times as frequently in bottle fed babies as with breast fed
babies at a New York outpatient clinic. He observed that
the health advantages were most evident in babies who were
23
breast fed^in excess of four to five months. Medical treat
ment for malnutrition, largely related to inadequate lacta
tion, was calculated over a recent decade to be the equiva
lent of 10 million dollars in the English-speaking Caribbean
(56) .
As breast feeding has decreased over the past two
decades, the average age of youngsters suffering from severe
forms of malnutrition has also dropped—from eighteen to
eight months (4). ̂ Generally in India, severe protein-
calorie malnutrition is found less frequently among those
under one year than those between one and two. However,
among Indian immigrants in south Trinidad, protein-calorie
malnutrition is much higher in the first year than in the
second, and the decline in breast feeding of infants in this
age group is believed to be responsible (56). Since malnu
trition in the early months of life is most critical to
brain development, this lowering of the average age of inci
dence of severe nutritional deficiencies takes on special
significance.
CHuman milk should also be recognized as a national
resour'ce in agronomic planning and energy conservation (56) . ,
For example, the recorded decline in breast feeding in
Singapore between the 1950s and 1960s required an approxi
mate expenditure by families or agencies equivalent to 1.8
million dollars to purchase substitute formulas; in 1968 in
the Philippines, the expense was about 33 million dollars (4)
24
Declining lactation can also be visualized in terms of
appropriate food production to make good these losses.
Thus, if all women in India ceased to breast feed and used
cow milk formulas as replacement, an additional 114 million
lactating cattle would be needed (56).
In addition, the energy cost and loss of raw mate
rials in processing, packing, and distributing cow milk
formulas should be considered. An infant reared on ready-
to-feed formula based on cow milk will use approximately
150 cans in six months of bottle feeding. With three mil
lion births in the United States in 1974, an overall annual
consumption of 450 million nonrecycleable cans will result,
with a waste of 70,000 tons of tinplate each year (56)
Factors Which Negatively Affect Breast Feeding
The current trend away from extended nursing among
lower income families has been strongly influenced by upper
income families. A continuing nationwide study of 2.5 mil
lion babies in the United States found that the number of
mothers who were breast feeding at the time they left.the
maternity hospital has declined by nearly half in only ten
years; the national average, which had dropped from 38 per
cent to 21 per cent from 1946 to 1956, decreased again to
18 per cent in the following decade. The decline is most
pronounced in the poorest states. In Arkansas, 84 per cent
of infants were totally or partially breast fed in 1946;
25
by 1966, only 22 per cent. The analogous figures for
California were 60 per cent and 38 per cent (58).
Encroaching urbanization and modernization are
significant influences resulting in the dramatic decline
in breast feeding. Breast feeding is often viewed as an
old-fashioned or backward custom and, by some, as a vulgar
peasant practice (4). Bottle feeding seems to be one
sophistication of city life the urban migrant adopts, often
referred to as "the urban avalanche" (2). In most coun
tries, the greater the sophistication, the worse the lacta
tion; the bottle has become a status symbol (4, 56).
Fear of failure, exhaustion, frustration, or any
stress-producing situation associated with the modern life
styles of many American women may hinder lactation (5).
Failure to initiate or continue breast feeding is rarely
traced to a physical cause but often to psychophysiological
causes that interfere with the key "let-down reflex" (4).
The "let-down reflex" is a psychobiological mechanism by
which sphincter muscles are relaxed to allow the milk to
flow (5). If this mechanism does not take place, the infant
obtains only a small portion of the milk contained in the
breast; inadequate emptying of the breast, on the other
hand, is likely to cause inadequate milk production (3).
For many women, improved communication has brought
knowledge of the alternatives to breast feeding. Aggres
sive sales promotion tactics often persu_ade the new mother
26
to succumb to the blandishments of the processed food and
^£^.^^^Ju_^ompanies. Complimentary samples oj formula are
also made available to mothers at many maternity clinics
and hospitals. The easy availability of free formula being
distributed by various government assistance programs has
also been blamed for defections from breast feeding (4).
Emphasis should be given to providing food for lactating
mothers whenever possible, rather than to distributing
formula. This position has been recently endorsed by the
World Health Organization, the Food and Agriculture Orga
nization, and the Protein Advisory Group of the United
Nations (56).
Changing social attitudes regarding the body rein
force the downward trend. Weichert (34) believes that a
"functional castration of women has occurred." There is
presently an overemphasis of the breast as a primary sex
symbol and as a result feminine desirability has been
divorced from its nurturing role (34, 56). Given the iden
tification of the breast with feminine desirability, one of
the major anxieties women experience in relation to breast
feeding is that they fear lactation will change the shape
of their breasts, and hence it is threatening to their
notions of continued attractiveness (4, 34).
Confusions and anxiety over breast size and adequacy
to nurse also exist. Some women assume that the larger the
breasts, the more glandular tissue (34). Engel's (59)
27
study of twenty-six breasts removed from women who had died
during or shortly after delivery, points out that there was
no correlation between breast size and amount of glandular
tissue. The larger breasts were often found to contain
much fibrous tissue and fat and relatively little glandular
tissue.
Low breast feeding rates are also consequences of
cultural forces. in cultures where it is accepted that
women breast feed their babies, the rates are high (4, 5).
This is true of the majority of preliterate and traditional
societies, where there was, or is, no such thing as a mother
who is unable to nurse her child. It is in cultures that
have socially accepted alternatives to breast feeding that
the rates drop and some mothers "cannot" nurse (5, 60).
Negative feelings concerning public breast feeding cause
many women to feel too embarrased to discuss the subject
(5, 61)7' Brack (5) speculates that most women in the United
States have not seen another woman nursing a baby, which
probably internalizes negative feelings towards breast
feeding.___,.
Conflicts may also arise from objections on the part
of the father to the mother's breast feeding. At stake here
are anxieties concerning how the new infant will affect the
marital relationship and incipient feelings of displacement
and/or jealousy on the part of the father for the new
mother's attention (59). The father may also desire to
28
assist in feeding the infant after delivery. In Masters
and Johnson's (62) study 64 per cent of the women rejected
nursing post partum for this reason. Other studies also
confirm that the husband influences the mother's decision
regarding breast feeding (61, 63, 64, 65).
A mother with other young children in the family
may find that breast feeding, rather than promoting a psy
chological bond between herself and the new addition, actu
ally causes a feeling of antagonism or resentment because
it may be very difficult to adequately care for her other
young children during the nursing period. The anxiety the
mother may feel while other children are relatively unat
tended would certainly communicate itself to the newborn
(66).
Convenience also is a factor in the abandonment of
breast feeding. Women no longer bound by tradition and now
enabled by the changing pattern of home life to take advan
tage of an increasing number of diversions, have turned to
artificial feeding to free themselves from the constraints
of motherhood (4, 5). Although this is especially true of
those who wish to join the organized work force, they are
only a small part of the women who have abandoned breast
feeding (4, 13, 65).
It is acknowledged that physicians and nursing per
sonnel have control over the situation in which breast feed
ing is initiated; but as a rule they do not understand the
29
psychobiological processes involved, seldom know how to
help a mother who has problems nursing, and often do not
want to take the time and patience necessary to solve the
problem (34, 61). When mothers report difficulties with
breast feeding such as an inadequate milk supply (the most
frequent reason given for weaning), many pediatricians
respond by suggesting solids or perhaps supplemental formula
or even weaning, rather than encouraging the women to build
up their milk supply through more frequent nursing sessions
and greater intake, of fluids (61) .
In a study of 301 primiparas by Sacks, et al. (63)
during 1974, most doctors were reported by mothers as being
uninformative even though they had been seen by 9 5 per cent
of the mothers. Halpern, et al. (67) found that among 1,700
infants seen by eleven pediatricians in the Dallas, Texas,
area, a significantly greater number of mothers did breast
feed when their pediatricians felt positively about the
subject. Jelliffe and Jelliffe (68), Scott (69), Washburn
(70), Leeson (71), and Winter (72) have all editorialized
recently on the critical role of their profession in either
encouraging or discouraging breast feeding- However, to
attribute the decline in the popularity of breast feeding
to the medical profession is much too simplistic; they are
components of the larger culture that has put little value
on breast feeding in recent years (61).
30
Another problem is that the mother and infant are
sepaxated by hospital routine, and in most instances they
do not have the same personnel for medical care (5). This
may mean that the nursing care is not ideally coordinated
between the nursery and the mother. Cole (61) reports that
mothers who had the experience of "rooming-in" in the hos
pital, as opposed to a central nursery with scheduled feed
ing, were more successful in establishing lactation and
breast fed longer. In this same study, only one-third of
the new mothers indicated that hospital nurses had supplied
helpful information. In our modern culture, many hospitals
lack a relaxed, supporting atmosphere in which a mother can
learn and practice the art of breast feeding (5).
Early introduction of solid foods is thought to
reduce the mother's milk supply_since the baby nurses less
often (6). In developed countries solid foods are presently
being given in excessive amounts to infants at the age of
four weeks or under as a result of cultural pressure. This
is often practiced by parents who wish to decrease the fre
quency of feeding, especially at night (13). Advocates of
breast feeding generally recommend delaying the introduction
of solid foods (pureed baby foods) until the infant is three
to four months old. Cole (61) found that early introduction
of solids and early weaning from the breast were signifi
cantly associated with each other.
31
Lack of milk, and/or the fear of lack of milk, seem
to be the most common reasons for weaning in early months
(61, 63, 65). This could be due to a genetically poor milk-
producing capacity, but it is more likely to be related to
a widespread lack of support of breast feeding in the United
States (61). Failure of the "let-down reflex", nipple ab
normalities, mastitis, and breast engorgement hinder breast
feeding and milk removal (3, 61). These physiological com
plications could be eliminated with the proper information
being related to mothers before lactation begins (73).
However, with appropriate attention, any of these problems
can be corrected so that lactation may be continued (3).
Eastham, et al. (64) found no significant differ
ences between breast and bottle feeding with respect to the
numbers, age, or sex of other children in the household.
However, the mothers' knowledge of how they had been fed
as infants showed a similar positive relationship with their
own choice in this study. There is a greater chance of
successful lactation if the mother was herself breast fed
as an infant (74). This is related to the fact that mothers
often seek advice from family members concerning infant
feeding (63).
Although there has been a resurgence of interest
in breast feeding in the United States, it has been concen
trated among the college-trained and well-to-do. Nation
wide surveys in 1971 showed that 32 per cent of college-
32
educated mothers breast fed_compared__with 8 per cent of
grade-school educated mothers (4). in the Boston area,
breast feeding was found to be nearly twice as prevalent
among upper income as among lower income families (75).
Middle income mothers in New York and San Francisco were
six times more likely to breast feed their babies than
lower income mothers (58). Sacks, et al. (63) found breast
feeding to be more common in families of nonmanual workers
as compared to manual workers. There was also a tendency
for mothers who breast fed to be older, better educated,
and married. Cunningham (57) also observed that breast
feeding was significantly associated with educational ad
vancement in both parents and with increased maternal age.
Mothers' Decisions Regarding Infant Feeding
Most mothers decide on a method of feeding before
they become pregnant (61, 64). Those who bottle feed tend
to decide later than those who breast feed, but only a few
women leave the choice until after delivery (61). A mother
most often seeks advice about infant feeding from her
family and friends; professional help was reported by Sacks,
et al. as being important in only 9 per cent of cases (61,
63). Eastham, et al. (64) reported that the source of lay
advice with which a breast feeding mother's decision most
frequently agreed was that of her husband.
33
The results of the study by Sacks, et al. (61)
showed that the discontinuation rate was highest during
the first week post partum and declined thereafter. At
the end of two weeks one-third of the mothers who breast
fed had discontinued, and by one month only one-half were
still breast feeding. Cole (61) failed to find a positive
correlation between the length of time a woman expected to
breast feed, and the actual length of breast feeding. In
her study, only one mother had intended to breast feed for
less than one month, yet nineteen ended up by doing so.
One might conclude that complications arising during initial
stages of the lactation period account for a high drop-out
rate among mothers who breast feed. The primary difference
in experience between those who continue breast feeding and
those who stop seems to lie in the availability of support
and other resources to which one can turn when problems
arise, rather than to the presence or absence of problems,
since both groups reported difficulties (61).
Role of Education in Increasing Breast Feeding
The most essential objective to reverse the current
downward trend in breast feeding is improved understanding
of its benefits and of the dangers associated in foregoing
it (4). Obstetricians, pediatricians, general practition
ers, nurses, dietitians, and other health workers should
be indoctrinated in the importance of breast feeding and
34
breast feeding methods (1, 4, 5, 13). Medical education
generally gives little attention to nursing and often em
phasizes the importance of artificial feeding (4, 13). Con
sequently, those who should be most knowledgeable about the
subject are ill prepared by education or experience to ad
vise and educate parents in this area.
Educating the lay public concerning the benefits of
breast feeding should be done at an early age. Most mothers
who bottle feed do not consider that breast feeding offers
advantages over bottle feeding; in fact, many consider breast
feeding as having disadvantages (63, 65). Education on this
subject should be encouraged for both boys and girls (63,
64) . This is evidenced by the fact that most women decide
on_a method of infant feeding before becoming pregnant and
that fathers often influence their choice, as discussed
previously.
Finally, efforts must be undertaken to prevent com
plications and failure in lactation, which has become in
creasingly important under stress of modernization. A
program should include information not only on the "why" of
breast feeding, but also on its "how" (4). A new mother who
is overly fearful about being able to breast feed seems more
likely to have difficulty in breast feeding, particularly
when her environment fails to provide information and emo
tional support (9, 73, 76, 77). Breast feeding should be
a natural sequel to pregnancy and childbirth (9, 61, 76).
35
For the vulnerable infant and young child, an effective
public effort to counter the current trend may be of greater
significance than any other form of nutrition intervention
(4).
CHAPTER III
METHODOLOGY
Selection of Subjects
Subjects for this research were selected from a
group of low socioeconomic, pregnant women attending a
Maternity Clinic at the Lubbock City Health Department.
A total of sixty-three subjects was selected including
sixteen Anglo, thirteen Black, and thirty-four Mexican-
American women. Each subject was informed of the purpose
of the study and was asked to participate on a voluntary
basis.
Development of Instrument
A Likert-type questionnaire was developed to measure
the influence of the independent variables on the single
dependent variable. The evaluation instrument included
twenty-eight questions to which each respondent replied in
one of the following ways: yes, undecided, unfamiliar with
the subject, no, or non-applicable. A copy of the question
naire used appears in the Appendix.
A pilot testing of the questionnaire was performed
to establish reliability and validity. A group of seventeen
pregnant women attending a La Maze natural childbirth class
were asked to complete and evaluate the instrument follow
ing an explanation of its intended purpose. These subjects
36
37
were given freedom to make written or verbal comments con
cerning the effectiveness of the questionnaire in measuring
attitudes toward breast feeding. They also were asked to
give suggestions for improvement of the instrument. After
reviewing all questionnaires from the pilot subject group,
revisions were made to facilitate the collection of perti
nent data.
The questionnaire also provided for collection of
data such as age of the mother, highest grade completed in
school, number of children in the family, marital status,
and ethnic origin of each subject.
Collection of Data
The questionnaire was administered to each subject
individually through a personal structured interview by the
researcher. The interview method was considered to be the
best procedure for collecting data from these subjects so
that further explanation or restatement of questions for
simplification could be done when necessary. The inter
view also allowed one to determine the motivation behind
answers given by individuals, thus facilitating a more
thorough understanding of the problem under study.
Each subject was given a printed card supplying all
answers for each question. They were verbally instructed
to give honest answers since no question had a "right" or
"wrong" answer. They were also informed that the
38
information obtained would be held in confidence and would
remain anonymous. Approximately ten minutes was necessary
for completing each interview.
Treatment of Data
The statistical method employed for analysis of
data was the chi-square technique. This technique allowed
testing for independence between responses of women from
the questionnaire and the independent variables. A fre
quency distribution was also used to organize data and
indicate percentages of various levels of responses for
each question.
CHAPTER IV
RESULTS AND DISCUSSION
Part I. Demographic Data
The total sample for this study consisted of sixty-
three pregnant females, of which 25 per cent (16) were
Anglo, 21 per cent (13) were Black, and 54 per cent (34)
were Mexican-American. Ages ranged from fourteen to thirty-
eight with the mean age being twenty-two years. Table 1
shows the age and race distribution of the subjects.
TABLE 1
AGE AND RACE DISTRIBUTION OF SUBJECTS
Age Total Ethnic Group
Anglo Black Mexican-American
N N
6 16
17 33
11 14
14-17
18-25
26-38
Total
N
6
9
1
16
N 4
7
2
13 34 63
For the total sample, 20.6 per cent (13) were single,
69.8 per cent (44) were married, 4.8 per cent (3) were di
vorced, and 4.8 per cent (3) were separated. Approximately
one-half of the women were primagravidas and the remaining
women had one to eleven other children.
39
40
Table 2 gives the educational background of the
subjects. Thirty-three had only grade school education,
twenty-nine had high school training, and one had attended
college. A greater percentage of Anglos had higher levels
of education than either Blacks or Mexican-Americans.
TABLE 2
EDUCATIONAL BACKGROUND OF SUBJECTS BY RACE
Education Ethnic Group Total
Anglo Black Mexican-American
Grade School 6 5 22 33
N
6
10
0
N
5
8
0
High School 10 8 11 29
College _2. _£ _1 -Jt Total 16 13 34 63
Part II. Survey Results
Professional Influence on Breast Feeding Rates
Table 3 summarizes data obtained from Question 1 on
the survey concerning whether physicians discussed with these
patients a method of feeding their infants following deliv
ery. It should be noted that of the sixty-three women in
terviewed, only fifty-seven had previously visited a doctor
for maternity care and responded to this question. Of the
fifty-seven respondents, 8.5 per cent (5) reported that
their doctor had discussed this topic and 91.2 per cent (52)
41
reported that the topic had not been discussed.
TABLE 3
PHYSICIAN'S COMMUNICATION WITH PATIENT CONCERNING
METHOD OF INFANT FEEDING
Response Anglo Black Mexican-American Total
Yes Number Percentage
No Number Percentage
2 3.5
13 22.8
0 0.0
9 15.8
3 5.2
30 52.6
5 8.7
52 91.2
These results indicate that, in this particular group
of women, there was a lack of communication with their doctor
concerning plans for infant feeding after delivery. This
could be due to lack of interest or motivation by the physi
cian concerning infant feeding. Many physicians may be un
educated with respect to infant nutrition due to lack of
emphasis in this area during their professional training,
as supported in the literature (4, 13). This may lead to
an avoidance of the subject when confronting patients. Most
women (96.5 per cent) were unfamiliar with their doctor's
attitude towards breast feeding, which relates to the sub
ject not being discussed as mentioned above.
From the total number of women interviewed, sixteen
planned to breast feed their infants. In these particular
women, the choice seemed to be independent of their
42
physician's attitude. Table 4 indicated that 93.8 per cent
(15) of the women had not discussed a feeding method with
their doctor and were consequently unfamiliar with the
doctor's attitude towards breast feeding. One person who
planned to breast feed was not able to respond to these
questions because she had not visited a doctor. Even though
a small percentage of women interviewed had plans to breast
feed despite their doctor's attitude, it seems reasonable
to conclude that the number of breast feeding mothers could
be increased if doctors' attitudes were more favorable.
TABLE 4
RELATIONSHIP OF PHYSICIAN'S ATTITUDE TO PATIENT'S DECISION TO BREAST FEED
Survey Question Response Un- Un- Non-
Yes decided familiar No applicable
1. Doctor discussed method of feeding
Number Percentage
2. Doctor in favor of breast feeding
Number Percentage
Modernization and ( Factors
0 0.0
0 0.0
0 0.0
0 0.0
:;:onvenience
0 0.0
15 93.8
15 93.8
0 0.0
1 6.2
1 , 6.2
Table 5 shows that 74.6 per cent (47) of the women
felt that bottle feeding is a more modernized way to feed
43
an infant as compared to breast feeding. The majority of
women (68.3 per cent) said that it would be convenient for
them to breast feed, while 28.6 per cent (18) said that it
would be inconvenient for them to breast feed. Employment
after delivery was one major factor contributing to the in
convenience of breast feeding, as shown in Question 6. How
ever, 52.4 per cent (33) had no plans to be employed follow
ing delivery. These results indicate that many women who
choose not to breast feed are doing so for factors other
than their personal convenience.
TABLE 5
CONVENIENCE FACTORS ASSOCIATED WITH BREAST FEEDING
Survey Question Response Un- Un- Non-
Yes decided familiar No applicable
4. Bottle feeding modern method
5.
6.
Number Percentage
Convenient to breast feed
Number Percentage
Employed after delivery
Number Percentage
47 74.6
43 68,3
23 36.5
4 6.3
2 3.2
7 11.1
1 1.6
0 0.0
0 0.0
11 17.5
18 28.6
33 52.4
0 0.0
0 0.0
0 0.0
44
Social Factors Affecting Breast Feeding
Data concerning the effect of social factors on
breast feeding rates are shown in Table 6. In response to
Question 1, 60.3 per cent (38) had previously been associ
ated with family members or friends who had breast fed their
infants. However, 39.7 per cent (25) had not had this as
sociation. This indirectly may account for the fact that
many young mothers are choosing to bottle feed due to lack
of exposure to the art of breast feeding, as supported in
the literature (5, 61). Approximately one-third of the
women reported that they were unfamiliar with attitudes of
family and friends towards breast feeding, which indicated
that the subject is not being discussed. The majority of
women felt that their family and friends would be in favor
of breast feeding. Embarassment concerning breast feeding
was not a significant factor in determining a feeding
method. During the interview period, many women indicated
that they would not be embarassed to breast feed their
infant in the privacy of their home, but would not breast
feed in public.
45
TABLE 6
RELATIONSHIP OF BREAST FEEDING TO SOCIAL ATTITUDES
Survey Question Response Un- Un- Non-
Yes decided familiar No applicable
7. Associated with family or friends
Number 38 Percentage 60.3
0 0.0
0 0.0
25 39.7
0 0.0
8.
11.
Family and friends in favor
Number Percentage
Embarassed
Number Percentage
24 38.1
10 15.9
12 19.0
2 3.2
22 34.9
0 0.0
5 7.9
51 81.0
0 0.0
0 0.0
Table 7 summarizes the importance of the husband's
opinion in relation to breast feeding; the results include
data from forty-four women who were married. No prevalence
of opinion existed among husbands' opinions, as shown in
the responses to Question 9. It is significant to note
that 27.3 per cent (12) husbands were against their wives'
breast feeding. This becomes important if assessed in
relation to the fact that 75 per cent (33) of the women
felt that their husband's opinion was of major importance
in determining how they would feed their child. This is
in agreement with the literature (64), which stated that
the husband was the person with whom the mother most often
agreed when selecting a feeding method.
46
TABLE 7
RELATIONSHIP OF HUSBAND'S ATTITUDE TO BREAST FEEDING
Survey Question Response Un- Un- Non-
Yes decided familiar No applicable
9. Husband prefer
Number 17 7 Percentage 38.6 15.9
8 12 18.2 27.3
0 0.0
10. Husband important
Number 33 Percentage 75.0
2 4.5
0 9 0.0 20.5
0 0.0
Because of the importance of the husband's opinion,
it is relevant to determine if the women in this study who
chose to breast feed were influenced by their spouse.
Table 8 reveals that 68.8 per cent (11) of the husbands
preferred that their wives breast feed and, again, 75 per
cent (12) of the women felt that the husband's opinion was
of major importance. It is apparent that the husband's
attitude strongly influences the wife's decision in this
regard. Two women who planned to breast feed were not
married
47
TABLE 8
RELATIONSHIP OF HUSBAND'S ATTITUDE TO BREAST FEEDING IF A POSITIVE CHOICE WAS MADE
Survey Question Response ^__ Un- Un- Non-
Yes decided familiar No applicable
9. Husband prefer
Number 11 2 0 1 2 Percentage 68.8 12.5 0.0 6.2 12.5
10. Husband important
Number 12 0 0 2 2 Percentage 75.0 0.0 0.0 12.5 12.5
Various Factors Relating to Success or Failure of Lactation
Of the thirty-two women who had other children, 2 5
per cent (8) indicated they had previously breast fed while
75 per cent (24) had not. Of the eight women who had breast
fed, one-half felt that they had been successful and one-
half considered themselves to have been unsuccessful. The
majority of women interviewed did not experience physical
complications associated with breast feeding. In response
to Question 15 which asked if the hospital nursing staff
was cooperative and helpful in establishing breast feeding,
62.5 per cent (5) answered positively. Data are shown in
Table 9.
48
TABLE 9
FACTORS CONTRIBUTING TO SUCCESS OR FAILURE IN BREAST FEEDING
Survey Question Response Yes No
13. Feel successful Number 4 4 Percentage 50.0 50.0
14. Experience physical complications
Number 2 6 Percentage 25.0 75.0
15. Nursing staff helpful
Number 5 3 Percentage 62.5 37.5
Reasons given for success in breast feeding were
predominantly associated with the well-being of the infant
Mothers felt that their infants were healthier, happier,
and growing satisfactorily on breast milk. Also, mothers
expressed that breast feeding afforded a pleasurable ex
perience which resulted in their spending more time with
their infant.
The most common reason given for failure of lacta
tion was lack of milk production and, consequently, an
unsatisfied baby. This problem frequently results in a
mother ceasing to breast feed, as reported by other re
searchers (61, 63, 65). Out of desperation, the mother
49
turns to bottle feeding not realizing that this problem
could be easily solved with more frequent feedings at the
breasts.
The mean age given for continuing breast feeding
before weaning was two months. Most women (90.6 per cent)
who had other children, had introduced solid foods to their
child before age four months. This is perhaps an important
factor contributing to the relatively short lactation periods
of most of the women interviewed.
-Mothers' Knowledge of Advantages of Breast Feeding
Table 10 summarizes the sixty-three respondents
general knowledge of breast feeding and associated topics.
It is encouraging to note that 93.7 per cent (59) of the
women considered that the mother's diet influenced her suc
cess or failure with lactation. When asked if breast feed
ing offered emotional, physiological, or psychological ad
vantages which could not be obtained from bottle feeding,
55.6 per cent (35) felt positive concerning this subject.
However, 20.6 per cent (13) felt that breast feeding offered
no advantages over bottle feeding. When asked if breast
feeding would delay pregnancy and if breast feeding would
protect against breast cancer, the majority of women were
unfamiliar with either subject. These responses indicate
a lack of education concerning breast feeding and its
advantages among the respondents.
50
TABLE 10
MOTHERS' GENERAL KNOWLEDGE CONCERNING BREAST FEEDING
Sur^
18.
19.
20.
21.
27.
/ey Question
Diet important
Number Percentage
Maternal advantages
Number Percentage
Delay pregnancy
Number Percentage
Breast cancer
Number Percentage
Breast feeding best
Number Percentage
Yes
59 93.7
35 55.6
5 7.9
6 9.5
40 63.5
Response Undecided
0 0.0
12 19.0
2 3.2
0 0.0
11 17.5
Unfamiliar
2 3.2
3 4.8
29 46.0
41 65.1
1 1.6
No
2 3.2
13 20.6
27 42.9
16 25.4
11 17.5
Breast feeding was considered to be best for a baby
by 63.5 per cent (40) of the women. Even though these
women verbalized a positive attitude towards breast feed
ing, they were not generally following through by feeding
their infants in this manner. This is evidenced by the
fact that only 25.4 per cent (16) had planned to breast
feed. Eleven women were undecided concerning whether or
not breast feeding was best for a baby, and the same num
ber felt that bottle feeding was best.
51
Infant Formulas and Breast Feeding
Of the sixty-three women interviewed, 42.9 per cent
(27) said that they had previously been given complimentary
formula packets at a doctor's office, clinic, or hospital.
More women (36) said they had never received any such prod
uct. This is assumed to be due to the fact that formula is
most often distributed to women upon leaving the hospital
after delivery and approximately one-half of the women in
this study were primagravidas. Of the twenty-seven women
who reported to have received complimentary formula, twenty-
five continued to use the same brand of formula for their
child's feedings. One must conclude that the distribution
of complimentary formula packets strongly encourages bottle
feeding.
When asked if bottle feeding would be more expen
sive than breast feeding, 93.7 per cent (59) of the women
agreed that it would be. Even though the subjects were
all of low socioeconomic status, 77-8 per cent (49) indi
cated that a free formula program would not influence their
choice of feeding method in any way. Many women expressed
that they would purchase formula for their infant regard
less of the possibility of receiving free formula at a
health clinic. Data are summarized in Table 11.
52
TABLE 11
PRODUCT DISTRIBUTION AS AN INFLUENCE ON DECISION TO BREAST FEED
Survey Question
22. Complimentary formula given
Number Percentage
23. Continue to use same brand
Number Percentage
Yes
27 42.9
25 39.7
Undecided
0 0.0
0 0.0
Response Unfamiliar
0 0-0
1 1.6
No
36 57.1
1 1.6
Non-app: Licable
0 0.0
36 57.1
24. More expensive to bottle feed
Number Percentage
25. Receive free formula
Number Percentage
Personal Data and Feeding
59 93.7
11 17.5
Breast
2 3.2
3 4.8
0 0.0
0 0.0
2 3.2
49 77.8
0 0.0
0 0.0
The chi-square test indicated that there was no
significant relationship between age, education, or marital
status of the women and their responses to items on the
questionnaire. This is due primarily to the homogeneity
of responses within the subject group. The number of
children within the family similarly did not affect
responses.
CHAPTER V
SUMMARY AND CONCLUSIONS
This study was undertaken to determine factors which
influence the decision of low socioeconomic women not to
breast feed. A survey was conducted to determine attitudes
of pregnant women towards this subject. Sixty-three women
attending a Lubbock City Health Department Maternity Clinic
were interviewed during January 1978.
Of the fifty-seven subjects who had previously
visited a physician, 91.2 per cent (52) indicated that a
method of feeding their infant had not been discussed with
the physician. Only sixteen women from the total inter
viewed had plans to breast feed their infants; all of these
women reported that their doctor had not discussed a feed
ing method with them. Even though a small percentage of
women planned to breast feed, despite their doctor's atti
tude, it seems reasonable to conclude that a positive at
titude by physicians would increase breast feeding rates.
The majority of women felt that bottle feeding is
a more modernized method of feeding an infant, compared to
breast feeding. Lack of convenience does not seem to be a
major factor contributing to low breast feeding rates, as
most women stated that it would be convenient for them to
breast feed. Employment after delivery was planned by
eighteen women.
53
54
Because breast feeding is not the norm in our pres
ent culture, twenty-five women reported that they had never
been associated with family or friends who had breast fed.
Although the majority of women felt that their family and
friends would be in favor of breast feeding, twenty-two
women reported that the topic had not been discussed. Em
barassment concerning breast feeding was not a significant
factor in determining a feeding method.
The husband's opinion concerning breast feeding
seemed to be more important to the woman compared to her
family and friends. Of the forty-four married women inter
viewed, this topic had been discussed with husbands by
thirty-six subjects. Thirty-three women felt that the
husband's opinion was of major importance in determining
how they would feed their child. Fourteen married women
planned to breast feed their infants. Of this number,
eleven felt that their husbands were in favor of breast
feeding.
Eight women in the study had previously experienced
breast feeding; four of these women felt that they had been
successful and four felt that they had been unsuccessful.
The most common reason given for failure of lactation was
lack of milk production. The early introduction of solid
foods was common among mothers with other children, regard
less of method of feeding.
55
Among the total women interviewed, 93.7 per cent
(59) considered that a lactating mother's diet influenced
her success or failure with lactation. Although the ma
jority of women felt that breast feeding offered maternal
advantages, 20.6 per cent (13) felt contrarily. The ma
jority of women were unfamiliar with contraception and
cancer as related to breast feeding. Breast feeding was
considered to be best for a baby by 63.5 per cent (40) of
the women, although only 25.4 per cent (16) of the women
planned to breast feed after delivery.
The majority of women interviewed had never received
complimentary formula in the past. However, of the twenty-
seven women who reportedly received formula packets, twenty-
five continued to use the same brand of formula. When asked
if bottle feeding would be more expensive than breast feed
ing, 93.7 per cent (59) of the women agreed that it would
be. Even so, most women indicated that a free formula
program would not influence their choice of feeding method.
Due to the homogeneity of responses, there was no
significant relationship between age, education, or marital
status of the women and their responses to items on the
questionnaire. The number of children within the family
similarly did not affect responses.
Major factors which seem to affect women's decisions
concerning breast feeding are the attitudes of physicians,
family/ friends, and, most important, the husband. A
56
general lack of education on the part of the women, as well
as the individuals mentioned above, seems to prevail con
cerning all aspects of breast feeding. Because of multiple
health, nutritional, and psychological advantages of breast
feeding for both the mother and infant, it is apparent that
an educational approach is the first logical step in revers
ing the current downward trend in its use frequency. Vari
ous problem areas have been described concerning the lack
of breast feeding among a low socioeconomic sample; an ex
perimental study attempting to reverse negative attitudes
is imperative.
REFERENCES
1. Jelliffe, D. B. World trends in infant feeding. Am. J. Clin. Nutr. 29:1227, 1976.
2. Jelliffe, D. B., and Jelliffe, E. F. The urban avalanche and child nutrition. J. A. Dietet. A. 57:111, 1970.
3. Buchanan, R. Breast-feeding: Aid to infant health and fertility control. Population Reports, Series J, No. 4, 1975.
4. Berg, A. The Nutrition Factor. Washington: The Brookings Institute, 1973.
5. Brack, D. C. Social forces, feminism, and breastfeeding. Nurs. Outlook. 23:556, 1975.
6. Jelliffe, D- B. Unique properties of human milk. J. Reprod. Med. 14:133, 1975.
7. Jelliffe, D. B., and Jelliffe, E. F. Nutrition and human milk. Postgrad. Med. 60:153, 1976.
8. Kon, S. K. Milk and Milk Products in Human Nutrition. FAO Nutritional Studies No. 17, Rome, Food and Agriculture Organization, 1959.
9. Jelliffe, D. B., and Jelliffe, E. F. The uniqueness of human milk. Am. J. Clin. Nutr. 24:968, 1971.
10. Fomon, S. J., and Filer, L. J. Milks and formulas. In Fomon, S. J., eds. Infant Nutrition. Philadelphia: W. B. Saunders Co., 1974.
11. Oseid, B. J. Breast-feeding and infant health. Clin. Obstet. Gynecol. 18:149, 1975.
12. Olivecrona, T.; Billstrom, A.; Fredrikzon, B.; Johnson, O.; and Samuelson, G. Gastric lipolysis of human milk lipids in infants with pyloric stenosis. Acta. Paediatr. Scand. 65:520, 1973.
13. . Jackson, R. L. Long-term consequences of suboptimal nutritional practices in early life. Pediatr. Clin. North Am. 24:63, 1977.
57
58
14. Reiser, R., and Sidelman, Z. Control of serum cholesterol homeostasis by cholesterol in the milk of the suckling rat. J. Nutr. 102:1009, 1972.
15. Tsuchiya, S. Study of infant nutrition: Intestinal digestion and absorption of iron present in milk. Acta. Paediatr. Jap. 76:84, 1972.
16. World Health Organization Technical Report, Series No. 503, Geneva, 1972.
17. Josephs, H. W. Absorption of iron as a problem in human physiology. A critical review. Blood. 13:1, 1958,
18. Coulsen, K. M.; Cohen, R. L.; Coulsen, W. F.; and Jelliffe, D. B. Hematocrit levels in breast-fed American babies. Clin. Pediatr. 16:649, 1977.
19. Smith, C. W. ; GolcMan, A. S.; and Yates, R. D. The interaction of lymphocytes and macrophages from human colostrum. Exp. Cell Res. 69:409, 1971.
20. Gyorgy, P. Biochemical aspects. Am. J. Clin. Nutr. 24:970, 1971.
21. Goldman, A. S. Cow milk sensitivity: A review. Iji Food and Immunology, Swedish Nutrition Foundation Symposium, 1976.
22. Gerrard, J. W. Breast-feeding: Second thoughts. Pediatrics. 54:757, 1974.
23. Jacobs, L. S., and Daughday, W. H. Physiologic regulation of prolactin secretion in man. In Josimovich, J. V.; Reynolds, M.; and Cobo, E., eds. Lactogenic Hormones, Fetal Nutrition and Lactation. New York: John Wiley and Sosn^ 1974.
24. L'Hermite, M.; Vekemans, M.; Deloye, P.; Nokin, J.; and Robyn, C. Prolactine studies in normal subjects. Proc. R. Soc. Med. 66:864, 1973.
25. Bonnar, J.; Franklin, M.; Nott, P. N.; and Macneilly, A. S. Effect of breast feeding on pituitary-ovarian function after childbirth. Br. Med. J.
• 4:82, 1975.
59
26. Turkington, R. W. Pathophysiology of prolactin secretion in man. ni Larson, B. L., and Smith, V. B., eds. A Comprehensive Treatise. Vol. II. New York: Academic Press, 1974.
27. Kippley, S. A. Breast Feeding and Natural Child Spacing. New York: Harper and Row, 1974.
28. El-Minawi, M. F., and Foda, M. S. Postpartum lactation amenorrhea. Am. J. Obstet. Gynecol. 111:19, 1970.
29. Cronin, T. J. Influence of lactation upon ovulation. Lancet. 2:4-22, 1968.
30. Udesdy, I. C. Ovulation in lactating women. Am. J. Obstet. Gynecol. 59:843, 1950.
31. Del Mundo, F., and Adiao, A. Lactation and child spacing as observed among 2,102 rural Filipino mothers. Phillip. J. Pediatr. 19:128, 1970.
32. Romaniuk, A. Modernization and natural fertility: The case of the James Bay native Indians. Iri Natural fertility. Liege Belgium, International Population Conference, 1973.
33. Schaefer, O. When the Eskimo comes to town. Nutr. Today. 6:8, 1971.
34. Weichert, C. Breast-feeding: First thoughts. Pediatrics. 56:987, 1975.
35. Jelliffe, D. B., and Jelliffe, E. F. Lactation, conception, and the nutrition of the nursing mother and child. J. Pediatr. 81:829, 1972.
36. Salber, E. J.; Feinleib, M.; and MacMahon, B. The duration of postpartum amenorrhea. Am. J. Epidemiol. 82:347, 1966.
37. Dorn, H. F., and Culter, S. J- Morbity from cancer in the United States. Public Health monograph No. 29, Washington, U.S. Department of Health Education and Welfare, 1955.
38. Buell, P. Changing incidence of breast cancer in Japanese-American women. J. Natl. Cancer Inst. 51:1479, 1973.
60
39. Haagensen, C. D- Diseases of the Breast. Philadelphia: W. B. Saunders Co., 1971.
40. Malhotra, S. L. A study of cancer of the breast with special reference to its causation and prevention. Med. Hypotheses. 3:21, 1977.
41. Morgan, R. W.; Vakil, D. V.; and Chipman, M. L. Breast feeding, family history, and breast disease. Am. J. Epidemiol. 99:117, 1974.
42. Anderson, J. D. Breast feeding and breast cancer. S. Afr. Med. J. 49:479, 1975.
43. . Is breast-feeding best for babies? Consumer Reports. 42:152, 1977.
44. Klaus, M. H.; Kennall, J. H.; Plumb, N.; and Zuehlke, S, Human maternal behavior at the first contact with the young. Pediatrics. 46:187, 1970.
45. Gopolan, C., and Belavady, B. Nutrition and lactation. Fed. Proc. 20:3, 1961.
46. Lindblad, B. S., and Rahimtoola, R. J. A pilot study of the quality of human milk in a lower socioeconomic group in Kurachi, Pakistan. Acta. Paediatr. Scand. 63:125, 1974.
47. Belavady, B., and Gopolan, C. Effect of diatary supplementation on the composition of breast milk. Indian J. Med. Res. 48:518, 1960.
48. Arena, J. M. Contamination of the ideal food. Nutr. Today. 5:2, 1970.
49. Feller, W. F., and Chopra, M. C. Studies of human milk in relation to the possible viral etiology of breast cancer. Cancer. 24:1250, 1969.
50. Moore, D. H. ; Chareney, J.; Kramarsky, B.; Lasfargues, E. Y.; Sarkar, N. H.; Brennan, M. J.; Burrows, J.; Sirsat, S. M. ; Paymaster, J. C ; and Vaidya, A. B. Search for a human breast cancer virus. Nature. 229:611, 1971.
51. Miller, R. W., and Fraumeni, J- F., Jr. Does breastfeeding increase the child's risk of breast cancer? Pediatrics. 49:645, 1972.
61
52. Feinleib, M., and Garrison, R. J. Interpretation of the vital statistics of breast cancer. Cancer. 24:1109, 1969.
53. MacMahon, B.; Lin, T. M.; Lowe, C. R.; Mirra, A. P.; Ravnihar, B.; Salber, E. J.; Trichopoulos, D.; Valaoras, V. G.; and Yuasa, S. Lactation and cancer of the breast. A summary of an international study. Bull. W.H.O- 42:185, 1970.
54. Jelliffe, D. B., and Jelliffe, E. F. Human Milk in the Modern World. St. Louis: The C. V. Mosby Co., (in press).
55. Lann, E.; Delaney, J.; and Dwyer, J. Economy of feeding infants. Pediatr. Clin. North Am. 24:71, 1977.
56. Jelliffe, D. B., and Jelliffe, E. F. Human milk, nutrition, and the world resource crisis. Science. 188:557, 1975.
57. Cummingham, A. S. Morbidity in breast-fed and artificially fed infants. J. Pediatr. 90:726, 1977.
58. Meyer, H. F. Breast feeding in the United States. Clin. Pediatr. 7:708, 1968.
59. Engel, S. Anatomy of the lactating breast. Br. J. Child. Dis. 38:14, 1941.
60. Newton, N. , and Newton M. Psychologic aspects of lacation. N. Engl. J. Med. 277:1179, 1967.
61. Cole, J. P. Breastfeeding in the Boston suburbs in relation to personal-social factors. Clin. Pediatr. 16:352, 1977.
62. Masters, W., and Johnson, V. Human Sexual Response. Boston: Little Brown & Co., 1966.
63. Sacks, S. H. ; Brada, M.; Hill, A. M.; Barton, P.; and Harland, P. S. To breast feed or not to breast feed. Practitioner. 216:183, 1976.
64. Eastham, E.; Smith, D.; Poole, D.; and Neligan, G. Further decline of breast feeding. Br. Med. J. 1:305, 1976.
62
65. Evans, N.; Walpole, T. R.; Qureshi, M. U.; Memon, M. H.; and Jones, H. W. Lack of breast feeding and early weaning in infants of Asian immigrants to Wolverhampton. Arch. Dis. Child. 51:608, 1976.
66. McWilliams, M. Nutrition for the Growing Years. New York: John Wiley & Sons, inc., 1975.
67. Halpern, S. R.; Sellars, W. A.; Johnson, R. B.; Anderson, D. W. ; Saperstein, S.; and Shannon, S. Factors influencing breast-feeding: Notes on observations in Dallas, Texas. South Med. J. 65:100, 1972.
68. Jelliffe, D. B., and Jelliffe, E. F. Doulas, confidence and science of lactation. J. Pediatr. 84:462, 1974.
69. Scott, R. B. Is breast feeding obsolete? J. Natl. Med. Assoc. 66:446, 1974.
70. Washburn, T. C. Bottle or breast feeding of infants. J.A.M.A. 229:141, 1974.
71. Leeson, R. G. Breast feeding—success or failure. Med. J. Austr. 59:942, 1972.
72. Winter, S. T. Breast feeding and the lying-in ward. Clin. Pediatr. 11:127, 1972.
73. Ladas, A. K. How to help mothers breast feed: Deductions from a survey. Clin. Pediatr. 9:702, 1970.
74. Sloper, K.; McKean, L.; and Baum, J. D. Factors influencing breast feeding- Arch. Dis. Child. 50:165, 1975.
75. Eva, J. S., and Feinleib, M. Breast feeding in Boston-Pediatrics. 37:299, 1966.
76. Applebaum, R. M. TTie modern management of successful breastfeeding. Pediatr. Clin. North Am. 17:203, 1970.
77. Newton, N. Psychological differences between breast and bottle feeding. Am. J. Clin. Nutr. 24:993, 1971.
APPENDIX
ATTITUDE SURVEY QUESTIONNAIRE
63
6 4
ATTITUDE SURVEY QUESTIONNAIRE
Age of Mother M a r i t a l S t a t u s : Sg M D Sp
Highes t g rade completed i n school Ethnic Or ig in : A B C
Number of c h i l d r e n i n fami ly
Yes Y
Undecided Ud
Unfamiliar with subject Uf
No N
Y Ud Uf N NjA 1. Has your doctor discussed with you a method of feeding your baby?
Y Ud Uf N 2. In your opinion, is your doctor in favor of breast feeding?
Y Ud Uf N 3. Has your doctor instructed you in preparing to breast feed?
Y Ud Uf N 4. Is bottle feeding a more modernized way of feeding
an infant as compared to breast feeding?
Y Ud Uf N 3. Would it be convenient for you to breast feed?
Y Ud Uf N 6. Will you be employed after your baby's delivery?
Y Ud Uf N 7. Have you been associated with family members or friends who breast feed?
Y Ud Uf N 8. Would your family and friends be in favor of you' breast feeding?
Y Ud Uf N 9. Does your husband prefer that you breast feed your baby?
Y Ud Uf N 10. Do you consider your husband's opinion to be of major importance in determining the final decision in feeding your infant?
Y Ud Uf N' 11. Would you feel embarassed or ashamed to breast feed your baby?
Y Ud Uf N 12. Have you breast fed a previous baby ?
65
Y Ud Uf N 13. If the answer to #12 was yes, do you feel you were successful in breast feeding?
A. If you feel you were successful, why?
B, If you feel you were unsuccessful, why'
G. How long did you breast feed before weaning?
Y Ud Uf N 1^, If the answer to #12 was yes, did you experience any physical complications?
Y Ud Uf N 15. If the answer to #12 was yes, do you feel that the hospital nursing staff where you delivered was cooperative and helpful in establishing breast feeding?
Y Ud Uf N 16. If the answer to #12 was yes and you feel you were unsuccessful in breast feeding, do you feel you have failed as a mother?
Y Ud Uf N 17. If you have at least one other child, did he/she eat any solid foods before age k months?
Y Ud Uf N 18. Does a lactating mother's diet influence her success or failure with breast feeding?
Y Ud Uf N 19. In your opinion, does breast feeding offer emotional, physiological, or psychological advantages for the nursir.p- mother which cannot be obtained from bottle feediiur'̂
'o
Y Ud Uf N 20. Does breast feeding delay your becoming pregnant?
Y Ud Uf N 21. Does breast feeding lower the incidence of breast cancer?
Y Ud Uf N 22. Have you ever been given complimentary formula packets at a doctor's office, clinic, or hospital?
Y Ud Uf N 23. If so and you have at least one other child, did you continue to use this brand of formula?
Y Ud Uf N 24. Would it be more expensive to bottle feed an infant rather than to breast feed?
Y Ud Uf N 25. If you could receive free formula at this clinic, would this influence your choice of feeding method?
66
Y Ud Uf N 26. Were you breast fed as an infant?
Y Ud Uf N 27. Do you feel that breast feeding is best for a baby?
Y Ud Uf N 28. Do you plan to breast feed your infant?