Postpartum Consequences of an Overlap of Breastfeeding and Pregnancy: Reduced Breast Milk Intake and Growth During Early Infancy Grace S. Marquis, PhD*; Mary E. Penny, MBChB, MRCP‡; Judith M. Diaz, BS‡; and R. Margot Marı´n, BS‡ ABSTRACT. Objective. Despite cultural pressure to cultural taboos against continuing to breastfeed.1,2 wean when a new pregnancy occurs, some women choose The practice of continuing to breastfeed during preg- to continue breastfeeding. We determined the effect of an nancy has been reported among US women but overlap of lactation and late pregnancy on breastfeeding might not be discussed with health professionals and growth in early infancy. because of anticipated criticism of the practice.3–5 Methods. We studied 133 Peruvian pregnant women Breastfeeding during pregnancy is more common in who were >18 years of age, had a child <4 years old, and who then had a vaginal birth with a healthy, normal some low-income countries than in the United States weight infant. Of the 133 women, 68 breastfed during the because shorter birth intervals increase the likeli- last trimester of pregnancy (BFP), and 65 had not breast- hood of a pregnancy-lactation overlap. fed during pregnancy (NBFP). On day 2 and at 1-month It has been suggested that an overlap could pro- postpartum, 24-hour intake of breast milk and other liq- duce suboptimal outcomes for both pregnancy and uids was measured. Twice weekly home surveillance subsequent lactation.6–8 Dairy research has demon- documented infant morbidity and dietary intakes. An- strated that a complete overlap of lactation during thropometry was taken at birth and at 1 month. Maternal pregnancy dramatically compromises the total pro- anthropometric, health, and socioeconomic status data duction of mature milk during the next lactation were collected pre- and postpartum. period.9–14 A dry (nonmilking) period of approxi- Results. Pregnant BFP mothers breastfed 5.3 ؎ 4.3 times/day. BFP and NBFP infants did not differ in breast- mately 2 months before calving is usual in the dairy feeding behavior or in colostrum intake on day 2. BFP industry. This is the first human study to provide infants breastfed longer per feed and per 24 hours (35.2 data on the association between the practice of lac- minutes/24 hours) than did NBFP infants; however, tating through late pregnancy and breastfeeding and 1-month intakes per feed tended to be lower among the growth outcomes of young infants. BFP infants. After controlling for confounders, BFP in- fants gained 125 g less than did NBFP infants (about 15% of mean weight gain). A sustained decline would result METHODS in a ؊0.7 z score change in weight-for-age by 6 months. Participants Conclusions. A lactation-pregnancy overlap had a The study was conducted in a poor periurban community of negative effect on early infant outcomes. Additional approximately 800 000 on the outskirts of Lima, Peru. The inclu- studies are needed to determine whether the effect con- sion criteria for mothers were: 1) pregnant; 2) Ն18 years of age; 3) tinues past 1 month of age. Pediatrics 2002;109(4). URL: multiparous and living with her child Ͻ4 years old; 4) without http://www.pediatrics.org/cgi/content/full/109/4/e56; apparent indicators for elective cesarean section; and 5) either breastfeeding, pregnancy, overlap, breast milk volume, continuing to breastfeed into the third trimester or never breastfed weight gain, infant feeding, Peru. during this pregnancy. Routes to identify possible participants were community census, local prenatal health service registers, and referrals. Between July 1998 and January 2000, 3417 pregnant ABBREVIATIONS. BFP, breastfed during pregnancy; NBFP, did women were identified. Of these, 601 women were not located at not breastfeed during pregnancy; BMI, body mass index; SES, home, and 27 women declined to participate in a screening inter- socioeconomic status; CI, confidence interval; OR, odds ratio. view. Field workers screened 2789 pregnant women, and 727 met all of the inclusion criteria: 170 women breastfed their older chil- dren during the third trimester of pregnancy (BFP) and 557 any women throughout the world breast- women had not breastfed at all during the present pregnancy (NBFP). Breastfeeding was confirmed by direct observation; date feed for as long as possible to give their of weaning was obtained from those mothers who had weaned Mchildren the nutritional, immunologic, and during the third trimester and before enrollment. emotional benefits of breastfeeding. When lactation Postpartum follow-up was confined to women who gave birth overlaps a new pregnancy, some women choose not to an infant who was a vaginal delivery, full-term (Ͼ37 weeks’ gestational age), healthy birth weight (Ͼ2500 g), and with no birth to wean their toddlers, although there may be strong defects or complications that would hinder breastfeeding. Of the 170 enrolled BFP women, 70 mother-infant pairs were followed after birth. Reasons for no postpartum follow-up included refusal From the *Department of Food Science and Human Nutrition, Iowa State (N ϭ 40), moved or worked (N ϭ 12), mother not available within University, Ames, Iowa; and ‡Instituto de Investigacio´n Nutricional, Lima, 48 hours of birth (N ϭ 13), birth problems (N ϭ 19), and other (eg, Peru. twins, older child with problems; N ϭ 16). Received for publication Jun 11, 2000; accepted Nov 28, 2000. Of the 557 NBFP women enrolled during pregnancy, 67 were Address correspondence to Grace S. Marquis, PhD, 1127 Human Nutri- followed up. Probable data of delivery was recorded for all NBFP tional Sciences Building, Department of Food Science and Human Nutri- mothers. For each BFP infant born, a NBFP woman was selected at tion, Iowa State University, Ames, IA 50011. E-mail: [email protected] random from the pool of women scheduled to give birth that PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- month. The first selected NBFP woman who met the postpartum emy of Pediatrics. criteria was included. The reasons for no follow-up were refusal http://www.pediatrics.org/cgi/content/full/109/4/Downloaded from www.aappublications.org/newse56 by guestPEDIATRICS on September Vol. 29, 2021 109 No. 4 April 2002 1of8 (N ϭ 174), moved or worked (N ϭ 40), not randomly selected (N ϭ Morbidity N ϭ 71), not available within 48 hours of birth ( 99), birth problems Maternal reports of daily symptoms of infants and any treat- N ϭ N ϭ ( 54), and other ( 52). Of the 137 infants who were studied ment were recorded twice weekly for the first month. Stool char- on day 2 postpartum, 133 infants had a repeated study at 1 month acter and frequency as well as general and respiratory symptoms of age. Two BFP and 2 NBFP infants had no repeat study because were recorded along with maternal illness and treatment. A diar- N ϭ N ϭ of refusal ( 2) and moving ( 2). This analysis is based on rheal day was a day with 3 or more liquid/semiliquid stools in 24 the 133 infants with observations for both days. hours. A dichotomous variable of ever having diarrhea was de- veloped. Prevalence of diarrhea and cough in the infant and any Comparison of Included and Excluded Families maternal illness was calculated. Other symptoms were infrequent The included BFP families had some indicators of a better (Ͻ6% of days observed) and, therefore, not considered here. economic status (eg, housing quality) than the excluded BFP fam- ilies. The included NBFP mothers were significantly more likely to be younger, born in the mountains, and live with fewer adults as Socioeconomic Data compared with excluded NBFP families. Other family demo- Socioeconomic data on the quality of housing, hygiene, posses- graphic, socioeconomic, and obstetric data that were collected sions owned, and education and employment of family members during pregnancy did not differ. were collected at the screening interview and day 2 postpartum. Data Collection Data Analysis Obstetric History and Birth Mean group differences for continuous variables were tested At screening, all pregnant women were interviewed about their with the Student t test and analysis of variance; Kruskal-Wallis obstetric history and previous breastfeeding experience. Morbid- 1-way analysis of variance was used for variables with nonnormal ity data were gathered twice monthly for all enrolled women. distribution. Frequency differences were tested with the ␹2 good- Relevant delivery and birth information was collected from clini- ness-of-fit test. Multiple linear regression models were used to cal records when available and from mothers. For deliveries at estimate the effect of breastfeeding late in pregnancy on day 2 and health facilities, dystocia (abnormal duration of labor) was defined 1-month breast milk intake and 1-month growth. Logistic regres- by practitioners, using the World Health Organization’s parto- sion was used to estimate the effect of an overlap on the risk of graph to monitor cervical dilatation and fetal descent.15 All home very low (Ͻ25th percentile) milk intake and growth. Both models births were assumed to have involved normal labor. controlled for confounding factors including sex, age, first weight, feeding behaviors (duration and frequency of feeds, breastfed by Breastfeeding Behavior another woman, hours postpartum), and maternal characteristics (age, parity, pregnancy complication, anthropometric measure- Once a month during pregnancy, BFP mothers recorded their ments). With birth weight or length in an equation predicting toddlers’ feeding frequency or the date of weaning. After birth at 1-month weight or length, the other coefficients reflected their twice-weekly home visits, mothers recalled their breastfeeding effects on the corresponding increment from birth. Morbidity (eg, practices of the previous days, including whether the infant was prevalence of diarrhea and cough) and socioeconomic status (SES) breastfed by another woman and whether the mother breastfed variables were not significant predictors of the milk and growth another child.