BREASTFEEDING MEDICINE

Volume XX, Number XX, 2016 Clinical Research

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2016.0134

Association Between Gestational Weight

Gain and Delayed Onset of Lactation:
The Moderating Effects of Race/Ethnicity

Zelalem T. Haile,1 Bhakti Bhaoo Chavan,1 Asli Teweldeberhan,2 and Ilana R. Chertok3
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.

Abstract

Background: In the United States, a high percentage of pregnant women gain weight outside of the current
Institute of Medicine’s (IOM) gestational weight gain (GWG) recommendations. There is limited research
examining the relationship between GWG and onset of lactation. Delayed onset of lactation (DOL) can
negatively affect breastfeeding outcomes.
Methods: Secondary data analysis was conducted using data from 2,053 women who participated in the
population-based Infant Feeding Practices Study II between 2005 and 2007. The main outcome of interest was
maternal perception of DOL, defined as milk coming in >3 days postpartum. Three categories of GWG were
Breastfeeding Medicine

created based on the IOM’s revised cutoff: inadequate, adequate, and excessive. Descriptive statistics and
multivariable logistic regression modeling were performed. Interactions between GWG and race/ethnicity on
DOL were examined to test whether the relationship between GWG and DOL differs by race/ethnicity.
Results: Overall, 23.7% of the study sample reported DOL. Of these, 49.5% and 19.5% of women had
excessive GWG and inadequate GWG, respectively. After adjusting for potential confounders, there was a
significant interaction between GWG and race/ethnicity on DOL. Among non-Hispanic white women, the odds
of DOL were higher in women with excessive GWG compared to those who had the recommended GWG (OR
1.47, 95% CI 1.14–1.90, p = 0.003). For other race/ethnicity groups, no significant relationships between GWG
and DOL were detected.
Conclusions: With the increasing rates of excessive GWG, it is critical to identify populations at increased risk
of DOL and provide targeted breastfeeding support, especially in the early postpartum period.

Keywords: breastfeeding, onset of lactation, Infant Feeding Practices Study II, gestational weight gain

Background Previous studies have found that maternal obesity, pre-

B reast milk is the ideal nutrition for nearly all infants
and is recommended to be the exclusive nutrition pro-
vided to infants in the first 6 months of life.1–4 Breastfeeding
and provision of expressed breast milk (included from herein
as breastfeeding) promote infant development, growth, and
health, as well as afford maternal health benefits.5 While
breastfeeding rates in the United States have been steadily
increasing over the past couple of decades,6 exclusive
breastfeeding rates are lagging behind recommendations. In
addition, there are maternal subpopulations who have char-
acteristically had lower breastfeeding rates than the general
population.
pregnancy, and/or postpartum are associated with lower rates
of exclusive breastfeeding7 and shorter duration of breast-
feeding.8,9 A population-based study conducted in Florida
found that women who were underweight or obese before
pregnancy had lower breastfeeding initiation rates than normal
weight women.10 Similarly, a hospital-based cohort study also
found lower breastfeeding initiation rates among women who
were overweight or obese before pregnancy compared to
women who were normal weight or underweight.11 Maternal
obesity has also been associated with delayed onset of lactation
(DOL),12–14 defined as maternal report of onset of lactation
beyond 72 hours postpartum.15 Researchers also found that
overweight/obese women had a lower prolactin response to

1
Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Dublin, Ohio.
2
Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio.
3
Department of Nursing, Ohio University, Athens, Ohio.

1
 2 HAILE ET AL.
infant suckling at 48 hours compared to normal weight
women,16 which suggests a possible biological mechanism of
action. DOL negatively affects breastfeeding outcomes, es-
pecially exclusive breastfeeding.12
Prepregnancy overweight and obesity rates among women
of childbearing age in the United States are increasing.17
Excessive or inadequate prepregnancy body mass index
(BMI) is associated with excessive or insufficient gestational
weight gain (GWG).18 Over half of pregnant women in the
United States fail to achieve the recommended amount of
GWG during pregnancy with a majority of those pregnant
women gaining excessive weight and a smaller proportion
gaining insufficient weight.19,20
Few studies have been published examining the associa-
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.
tion between GWG and breastfeeding outcomes. Among
white women in New York and women in Brazil who had
abnormal prepregnancy BMI levels and experienced exces-
sive GWG, exclusive breastfeeding duration was shorter
compared to women with a normal BMI and adequate
GWG.18,19 Among women in a cohort study in Pennsylvania
who were overweight or obese and/or had excessive GWG,
breastfeeding duration was not significantly different from
women who had a normal BMI and adequate GWG, although
obese women with excessive GWG experienced DOL.21
However, there is limited research examining the relationship
between GWG and onset of lactation. This study utilizes
population-based approaches to examine the association be-
Breastfeeding Medicine
tween GWG in women and their perceived onset of lactation
after adjusting for potential confounders.
Methods
Secondary data analysis was conducted using data from
2,053 women who participated in the population-based Infant
Feeding Practices Study II (IFPS-II) between 2005 and 2007.
Conducted by the U.S. Food and Drug Administration (FDA)
and the Centers of Disease Control and Prevention (CDC),
IFPS-II is a longitudinal study of women and their children,
following women from their late pregnancy until first 12
months postpartum to better understand the changes in the
infant feeding practices among women in the United States.22
Detailed IFPS study methods are reported elsewhere.22 In
brief, women eligible for IFPS were 18 years of age or older,
delivered a singleton weighing at least 5 pounds, born after at
least 35 weeks of gestation, not have stayed in intensive care
for more than 3 days, and both mother and the baby are free
from medical condition impeding breastfeeding. Data were
collected longitudinally by a prenatal questionnaire, a short
telephone interview near infant’s birth, and a neonatal
questionnaire that was sent to the mother when her infant was
*3 weeks old followed by nine questionnaires sent monthly
from 2 to 7 months and every 7 weeks until 12 months
postpartum. However, our analysis utilized data only from
the prenatal and neonatal questionnaires. The study sample
included women who reported the time of onset of lactation
(n = 2,555). Women with missing data on any of the study
variables were excluded from the analysis (n = 502). Thus the
final analysis included 2,053 women.
Outcome of interest: DOL
The main outcome of interest for our study was DOL.
Onset of lactation is the period of transition from colostrum
(early milk) to copious breast milk production, which usually
occurs between 2 and 3 days postpartum.23 The neonatal
questionnaire included a question wherein women were asked,
‘‘How long did it take for your milk to come in?’’ (1 day or
less, 2 days, 3 days, 4 days, more than 4 days). For the pur-
pose of analysis, we dichotomized it into ‘‘£3 days’’ and
‘‘>3 days.’’ Thus our outcome variable was classified as DOL
if women reported their milk coming in ‘‘>3 days’’ after
delivery and not having DOL if women reported their milk
coming in ‘‘£3’’ after delivery.
Exposure measurement
Prepregnancy BMI and weight gain during pregnancy were
used to determine GWG. We used the Institute of Medicine
(IOM) guidelines for GWG namely ‘‘underweight’’ (BMI <18.5;
recommended weight gain 12.5–18 kg), ‘‘normal weight’’
(BMI 18.5–24.9; recommended weight gain 11.5–16 kg),
‘‘overweight’’ (BMI 25.0–29.9; recommended weight gain
7–11.5 kg), and ‘‘obese’’ (BMI ‡30; recommended weight
gain 5–9 kg). Based on this guideline GWG was classified as
‘‘inadequate,’’ ‘‘adequate,’’ and ‘‘excessive.’’
Covariates
The following covariates were included in our analysis:
maternal age (18–24, 25–34, ‡35), race/ethnicity (non-
Hispanic white, non-Hispanic black, Hispanic, other), ma-
ternal education (high school or less, some college, college
graduate), marital status (never married, married, other),
prepregnancy BMI (<18.5, 18.5–25, 25–30, ‡30), poverty-
to-income ratio (PIR) (<185%, 185–349%, ‡350%), gesta-
tional diabetes mellitus (yes, no), prenatal breastfeeding in-
tention (yes, no), prenatal smoking (yes, no), method of
delivery (vaginal, caesarean), labor pain medications or an-
esthesia (yes, no), and the number of Baby Friendly Hospital
Initiative (BFHI) hospital practices experienced (0–2, 3–4,
5–6). Based on the evidence, the BFHI program identifies 10
baby friendly hospital practices that support early breast-
feeding.24 Six of these practices (breastfeeding within 1 hour
of birth, giving only breast milk, rooming in, breastfeeding
on demand, not giving pacifiers, and providing information
on postdischarge support) were measured in IFPS-II and
were used to determine number of practices the mother ex-
perienced during her hospital stay.
Statistical analysis
Descriptive statistics were used to summarize and de-
scribe the distribution of different variables. Using chi-
square (w2) test statistic, bivariate analyses were per-
formed to compare women with and without DOL by
GWG, race, and all the potential covariates. Variables
significant at 0.2 level in w2 test were retained in the mul-
tivariable modeling analysis. Logistic regression analysis
was used to determine association between GWG and
DOL. Pairwise interactions between GWG and race/eth-
nicity were examined to test whether the relationship be-
tween GWG and DOL differs by race/ethnicity. All other
interaction terms between GWG and each covariate ad-
justed in the multivariable model were not significant,
and the model with interaction term between GWG and
 GESTATIONAL WEIGHT GAIN AND LACTATION 3

race/ethnicity was fitted. Odds ratio (OR), 95% confidence
interval (95% CI), and p-value were determined for each
of the independent variables and interaction terms. We
assessed potential multicollinearity using variance infla-
tion factor. Results revealed that our regression analysis is
not prone to multicollinearity. We evaluated model fit
through inspection of Hosmer and Lemeshow Goodness-
of-Fit Test ( p = 0.415), implying that the model’s estima-
tes fit the data at an acceptable level. All analyses were
conducted using SAS 9.4 (SAS Institute, Inc., Cary, NC).

Table 1. Characteristics of the Study Sample by Onset of Lactation

Delayed onset of lactation
Overall, n (%) No, n (%) Yes, n (%) p
Age, years 0.217
18–24 397 (19.3) 308 (77.6) 89 (22.4)
25–34 1,318 (64.2) 990 (75.1) 328 (24.9)
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.

‡35 338 (16.5) 268 (79.3) 70 (20.7)

Marital 0.837
Never married 300 (14.6) 228 (76.0) 72 (24.0)
Married 1,672 (81.4) 1,274 (76.2) 398 (23.8)
Other 81 (4.0) 64 (79.0) 17 (21.0)
Race/ethnicity 0.070
Non-Hispanic white 1,731 (84.3) 1,321 (76.3) 410 (23.7)
Non-Hispanic black 89 (4.3) 76 (85.4) 13 (14.6)
Hispanic 133 (6.5) 93 (69.9) 40 (30.1)
Other 100 (4.9) 76 (76.0) 24 (24.0)
Education 0.967
High school or less 363 (17.7) 275 (75.8) 88 (24.2)
Some college 838 (40.8) 640 (76.4) 198 (23.6)
Breastfeeding Medicine

College graduate 852 (41.5) 651 (76.4) 201 (23.6)

Poverty-to-income ratio, % 0.061
<185 806 (39.3) 631 (78.3) 175 (21.7)
185–349 751 (36.6) 575 (76.6) 176 (23.4)
‡350 496 (24.2) 360 (72.6) 136 (27.4)
Prepregnancy body mass index 0.019
Underweight 111 (5.4) 93 (83.8) 18 (16.2)
Normal 957 (46.6) 749 (78.3) 208 (21.7)
Overweight 524 (25.5) 388 (74.0) 136 (26.0)
Obese 461 (22.5) 336 (72.9) 125 (27.1)
Gestational diabetes mellitus 0.404
No 1,926 (93.8) 1,473 (76.5) 453 (23.5)
Yes 127 (6.2) 93 (73.2) 34 (26.8)
Breastfeeding intention 0.048
No 573 (27.9) 420 (73.3) 153 (26.7)
Yes 1,480 (72.1) 1,146 (77.4) 334 (22.6)
Prenatal smoking 0.861
No 1,906 (92.8) 1,453 (76.2) 453 (23.8)
Yes 147 (7.2) 113 (76.9) 34 (23.1)
Delivery <0.001
Vaginal 1,498 (73.0) 1,179 (78.7) 319 (21.3)
Caesarean 555 (27.0) 387 (69.7) 168 (30.3)
Pain medication/anesthesia <0.001
No 336 (16.4) 295 (87.8) 41 (12.2)
Yes 1,717 (83.6) 1,271 (74.0) 446 (26.0)
Baby Friendly Hospital Initiative Practices 0.008
Meet 0–2 criteria 836 (40.7) 612 (73.2) 224 (26.8)
Meet 3–4 criteria 1,130 (55.0) 880 (77.9) 250 (22.1)
Meet 5–6 criteria 87 (4.2) 74 (85.1) 13 (14.9)
Gestational weight gain 0.004
Inadequate 401 (19.5) 311 (77.6) 90 (22.4)
Adequate 636 (31.0) 510 (80.2) 126 (19.8)
Excessive 1,016 (49.5) 745 (73.3) 271 (26.7)
Onset of lactation
Delayed 487 (24.0)
Not delayed 1,566 (76.0)
 4 HAILE ET AL.

All p-values were two sided, and statistical significance
was set as p < 0.05.
Results
Among the sample of 2,053 women, 24.0% (n = 487) re-
ported DOL and 49.5% (n = 1,016) had GWG above the re-
commended guidelines. Table 1 contains the descriptive
analysis results. Having DOL significantly differed by pre-
pregnancy BMI, breastfeeding intention, method of delivery,
use of pain medication/anesthesia during delivery, number of
baby friendly hospital practices, and GWG. Significantly
higher proportion of obese women had DOL followed by
women who were overweight, normal, and underweight
prepregnancy BMI. GWG significantly differed by age, mar-
ital status, race/ethnicity, education, PIR, prepregnancy BMI,

Table 2. Characteristics of Study Sample by Categories of Gestational Weight Gain

Gestational weight gain
Inadequate, n (%) Adequate, n (%) Excessive, n (%) p
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.

Age, years 0.038

18–24 70 (17.6) 110 (27.7) 217 (54.7)
25–34 263 (20.0) 403 (30.6) 652 (49.4)
‡35 68 (20.1) 123 (36.4) 147 (43.5)
Marital status <0.001
Never married 48 (16.0) 74 (24.7) 178 (59.3)
Married 331 (19.8) 545 (32.6) 796 (47.6)
Other 22 (27.2) 17 (21.0) 42 (51.8)
Race/ethnicity 0.007
Non-Hispanic white 319 (18.4) 534 (30.9) 878 (50.7)
Non-Hispanic black 26 (29.2) 20 (22.5) 43 (48.3)
Hispanic 30 (22.6) 43 (32.3) 60 (45.1)
Other 26 (26.0) 39 (39.0) 35 (35.0)
Breastfeeding Medicine

Education 0.004
High school or less 74 (20.4) 99 (27.3) 190 (52.3)
Some college 182 (21.7) 236 (28.2) 420 (50.1)
College graduate 145 (17.0) 301 (35.3) 406 (47.7)
Poverty-to-income ratio, % 0.002
<185 188 (23.3) 220 (27.3) 398 (49.4)
185–349 136 (18.1) 246 (32.8) 369 (49.1)
‡350 77 (15.5) 170 (34.3) 249 (50.2)
Prepregnancy body mass index <0.001
Underweight 28 (25.3) 48 (43.2) 35 (31.5)
Normal 207 (21.6) 381 (39.8) 369 (38.6)
Overweight 59 (11.3) 126 (24.0) 339 (64.7)
Obese 107 (23.2) 81 (17.6) 273 (59.2)
Gestational diabetes mellitus <0.001
No 354 (18.4) 596 (30.9) 976 (50.7)
Yes 47 (37.0) 40 (31.5) 40 (31.5)
Breastfeeding intention 0.123
No 127 (22.2) 179 (31.2) 267 (46.6)
Yes 274 (18.5) 457 (30.9) 749 (50.6)
Prenatal smoking 0.037
No 364 (19.1) 603 (31.6) 939 (49.3)
Yes 37 (25.2) 33 (22.4) 77 (52.4)
Delivery <0.001
Vaginal 308 (20.6) 493 (32.9) 697 (46.5)
Caesarean 93 (16.8) 143 (25.8) 319 (57.4)
Pain medication/anesthesia 0.278
No 75 (22.3) 106 (31.6) 155 (46.1)
Yes 326 (19.0) 530 (30.9) 861 (50.1)
Baby Friendly Hospital Initiative Practices 0.047
Meet 0–2 criteria 174 (20.8) 252 (30.2) 410 (49.0)
Meet 3–4 criteria 218 (19.3) 346 (30.6) 566 (50.1)
Meet 5–6 criteria 9 (10.3) 38 (43.7) 40 (46.0)
Onset of lactation 0.004
Delayed 90 (18.5) 126 (25.9) 271 (55.6)
Not delayed 311 (19.9) 510 (32.6) 745 (47.5)
 GESTATIONAL WEIGHT GAIN AND LACTATION 5

gestational diabetes, prenatal smoking method of delivery,
number of BFHI practices, and DOL (Table 2).
The unadjusted multivariable analysis showed a significant
interaction between GWG and race/ethnicity on DOL. Even
after adjusting for potential confounders, there was a significant
interaction between GWG and race/ethnicity on DOL. Among
non-Hispanic white women, those who had GWG above the
recommended guidelines had higher odds of DOL compared to
women with GWG within the recommended guidelines (OR
1.47, 95% CI 1.14–1.90, p = 0.003). For other race/ethnicity
groups, there was no significant association between GWG and
DOL. In addition, in the multivariable model, women with the
highest poverty ratio of PIR ‡350% had higher odds of DOL
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.
compared to women with PIR <185% (OR 1.39, 95% CI 1.07–
1.80, p < 0.013). Women who delivered by caesarean section
had higher odds of DOL compared to women who delivered
vaginally (OR 1.27, 95% CI 1.02–1.58, p < 0.035), and women
who received pain medication or anesthesia at the time of de-
livery had higher odds of DOL compared to women who did not
receive any pain medication or anesthesia (OR 2.37, 95% CI
1.68–3.35, p < 0.001) (Table 3).
Discussion
The main finding of the current study is that non-Hispanic
white women with excessive GWG had DOL compared to

Table 3. Crude and Multivariable Adjusted Association Between Gestational

Weight Gain and Delayed Onset of Lactation
Crude OR (95% CI) p Adjusted OR (95% CI) p
Age, years
18–24 Ref. Ref.
25–34 1.19 (0.93–1.51) 0.118 1.16 (0.90–1.51) 0.245
‡35 1.03 (0.75–1.42) 0.703 0.94 (0.67–1.34) 0.754
Prepregnancy body mass index
Underweight Ref. Ref.
Normal 0.71 (0.44–1.15) 0.033 1.38 (0.84–2.25) 0.195
Overweight 1.30 (1.03–1.64) 0.022 1.67 (1.01–2.78) 0.046
Breastfeeding Medicine

Obese 1.29 (1.02–1.64) 0.031 1.57 (0.94–2.62) 0.082

Poverty income ratio, %
<185 Ref. Ref.
185–349 1.09 (0.87–1.36) 0.353 1.07 (0.84–1.35) 0.569
‡350 1.43 (1.13–1.82) 0.003 1.38 (1.07–1.80) 0.012
Breastfeeding intention
No Ref. Ref.
Yes 0.81 (0.66–1.00) 0.051 0.83 (0.66–1.03) 0.091
Delivery
Vaginal Ref. Ref.
Caesarean 1.59 (1.30–1.95) <0.001 1.26 (1.01–1.58) 0.034
Pain medication/anesthesia
No Ref. Ref.
Yes 2.72 (1.95–3.79) <0.001 2.37 (1.68–3.35) <0.000
Baby Friendly Hospital Initiative Practices
Meet 0–2 criteria Ref. Ref.
Meet 3–4 criteria 0.82 (0.67–0.99) 0.868 0.86 (0.70–1.06) 0.166
Meet 5–6 criteria 0.63 (0.37–1.08) 0.188 0.73 (0.42–1.25) 0.258
Race/ethnicity
Non-Hispanic white
Adequate Ref. Ref.
Inadequate 1.17 (0.83–1.64) 0.367 1.16 (0.83–1.61) 0.377
Excessive 1.64 (1.26–2.13) <0.001 1.47 (1.13–1.90) 0.003
Non-Hispanic black
Adequate Ref. Ref.
Inadequate 1.14 (0.80–1.63) 0.446 0.24 (0.02–2.57) 0.243
Excessive 1.17 (0.86–1.60) 0.303 1.55 (0.39–6.15) 0.527
Hispanic
Adequate Ref. Ref.
Inadequate 1.12 (0.62–2.01) 0.695 0.97 (0.36–2.58) 0.954
Excessive 0.84 (0.48–1.45) 0.542 0.71 (0.31–1.61) 0.414
Other
Adequate Ref. Ref.
Inadequate 1.10 (0.45–2.64) 0.828 1.54 (0.54–4.39) 0.412
Excessive 0.60 (0.26–1.37) 0.229 0.55 (0.19–1.58) 0.274
CI, confidence interval; OR, odds ratio.
 6 HAILE ET AL.
non-Hispanic white women with adequate GWG. This as-
sociation remained significant after adjusting for potential
confounders. The study did not detect significant associations
between race/ethnicity and GWG on DOL for other racial/
ethnic groups. The clinical implication of DOL is that women
may feel that their milk production is inadequate in the early
postpartum period, which is associated with poor breast-
feeding outcomes.25 Women who perceive insufficient milk
production are at risk for using formula, decreasing milk
production, and terminating breastfeeding, especially among
those from lower socioeconomic backgrounds.25–27
In the current study, excessive GWG was highest among
non-Hispanic white women compared to women from other
racial/ethnic groups. This finding may explain the association
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.
between excessive weight gain and DOL among non-
Hispanic white women observed in the current study. The
biological mechanism for the negative association between
excessive GWG and DOL could be similar to the biological
mechanisms of the negative influence of obesity on delayed
lactogenesis II.28,29 Animal studies have found an association
between obesity and impaired lactation failure.30–32 Re-
searchers found that overweight and obese women do not
produce as much prolactin in response to suckling in the first
week postpartum as normal weight women.16 Progesterone
withdrawal that prepares mammary glands in the immediate
postpartum period coupled with prolactin and cortisol se-
cretion results in copious milk secretion thus marking the
Breastfeeding Medicine
onset of lactation. Prolactin secretion is lower among obese
women compared to women with normal weight. Further-
more, increased levels of progesterone concentration stored
in adipose tissue as observed among obese women along with
decreased prolactin secretion are associated with DOL.16,33
Increased adipose tissue between ducts as commonly ob-
served in obese women may also prevent proper milk flow
resulting in a perceived delay in lactogenesis. Another pos-
sible reason would be mechanical difficulty impeding proper
positioning of the baby among women with excessive GWG,
thus affecting suckling.10,34 In addition, women with exces-
sive GWG may have lower perceived self-efficacy with re-
gard to lactation compared to women with normal GWG, thus
negatively affecting breastfeeding.13
The study findings are supported by a previous study
conducted among non-Hispanic white women in the United
States that showed excessive GWG to be associated with
DOL and early termination of breastfeeding.13,33 In a small
longitudinal study in Connecticut, white and Hispanic wo-
men had higher odds of DOL compared to black women after
adjusting for potential confounders.23 However, due to small
sample size, this study combined white and Hispanic women
into one group. Another population-based study found that
women who were obese before pregnancy or who had exces-
sive GWG were less likely to initiate and maintain breast-
feeding compared to women who had normal prepregnancy
BMI or GWG.35
The current findings of the association between PIR, mode
of delivery, receipt of pain medication or anesthesia, and
DOL are consistent with previous findings. Previous studies
in the United States reported DOL among women who de-
livered by caesarean section and those who received pain
medication and anesthesia during delivery.12,25 Similarly,
studies in urban Guatemala and Australia reported DOL
among women who underwent caesarean section.36,37
The major limitation of the study is that the study partic-
ipants were not randomly selected, and the study sample is
not representative of the U.S. population. To ensure a high
response rate for the series of mailed questionnaires, the
study participants were selected from a consumer panel.
Thus, non-Hispanic white women, households with higher
socioeconomic status, women who could read English, and
households with stable mailing address were overrepresented
in the study population, and hence, the results cannot be
generalized to the overall U.S. population.22 In addition, the
data were based on self-report, which are susceptible to recall
bias. Furthermore, the cross-sectional study design precludes
the determination of a causal link. Despite these limitations,
the study has numerous strengths. The study had a large
sample size with a high response rate. The survey questions
were extensively tested thus increasing their validity. Finally,
the availability of several covariates for adjustment was an-
other strength of the study.
To conclude, the present study findings support findings
from previous studies and effectively adds to the scant lit-
erature on the combined influence of GWG and race/ethnicity
on DOL. Both race and GWG are associated with DOL and
understanding these factors is essential for informing public
health policy and actions. It is critical to identify populations
at increased risk of DOL and to provide targeted breast-
feeding support, especially in early postpartum period. Fur-
ther research should be conducted in a more diverse and
representative population.
Acknowledgment
The authors thank the Centers for Disease Control and
Prevention for providing access to data from the Infant
Feeding Practices Study II.
Disclosure Statement
No competing financial interests exist.
References
1. Chantry CJ, Howard CR, Auinger P. Full breastfeeding
duration and associated decrease in respiratory tract infec-
tion in US children. Pediatrics 2006;117:425–432.
2. U.S. Department of Health and Human Services. The
Surgeon General’s Call to Action to Support Breastfeeding.
Washington, DC: U.S. Department of Health and Human
Services, Office of the Surgeon General, 2011.
3. American Academy of Pediatrics. Breastfeeding and the
use of human milk. Pediatrics 2012;129:e827–e841.
4. World Health Organization. The World Health Organiza-
tion’s infant feeding recommendation. World Health Or-
ganization. Published 2001. Available at www.who.int/
nutrition/topics/infantfeeding_recommendation/en (accessed
October 10, 2016).
5. Chung M, Raman G, Chew P, et al. Breastfeeding and
maternal and infant health outcomes in developed coun-
tries. Evid Rep Technol Assess (Full Rep) 2007;153:1–186.
6. Ryan AS. The resurgence of breastfeeding in the United
States. Pediatrics 1997;99:e12–e12.
7. Martinez JL, Chapman DJ, Pérez-Escamilla R. Pre-
pregnancy obesity class is a risk factor for failure to ex-
 GESTATIONAL WEIGHT GAIN AND LACTATION
clusively breastfeed at hospital discharge among Latinas.
J Hum Lact 2016;32:258–268.
8. Amir LH, Donath S. A systematic review of maternal
obesity and breastfeeding intention, initiation and duration.
BMC Pregnancy Childbirth 2007;7:9.
9. Turcksin R, Bel S, Galjaard S, et al. Maternal obesity and
breastfeeding intention, initiation, intensity and duration: A
systematic review. Matern Child Nutr 2014;10:166–183.
10. Thompson LA, Zhang S, Black E, et al. The association of
maternal pre-pregnancy body mass index with breastfeed-
ing initiation. Matern Child Health J 2012;17:1842–1851.
11. Mehta UJ, Siega-Riz AM, Herring AH, et al. Maternal
obesity, psychological factors, and breastfeeding initiation.
Breastfeed Med 2011;6:369–376.
12. Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk
Downloaded from online.liebertpub.com by 200.54.130.5 on 02/20/17. For personal use only.
factors for suboptimal infant breastfeeding behavior, de-
layed onset of lactation, and excess neonatal weight loss.
Pediatrics 2003;112:607–619.
13. Hilson JA, Rasmussen KM, Kjolhede CL. High pre-
pregnant body mass index is associated with poor lactation
outcomes among white, rural women independent of psy-
chosocial and demographic correlates. J Hum Lact 2004;
20:18–29.
14. Nommsen-Rivers LA, Chantry CJ, Peerson JM, et al.
Delayed onset of lactogenesis among first-time mothers is
related to maternal obesity and factors associated with
ineffective breastfeeding. Am J Clin Nutr 2010;92:574–
584.
Breastfeeding Medicine
15. Perez-Escamilla R, Chapman DJ. Validity and public
health implications of maternal perception of the onset of
lactation: An international analytical overview. (Sympo-
sium: Human Lactogenesis II: Mechanisms, Determinants
and Consequences.) J Nutr 2001;131:3021S–3024S.
16. Rasmussen KM, Kjolhede CL. Prepregnant overweight and
obesity diminish the prolactin response to suckling in the
first week postpartum. Pediatrics 2004;113:E465–E471.
17. Fisher SC, Kim SY, Sharma AJ, et al. Is obesity still in-
creasing among pregnant women? Prepregnancy obesity
trends in 20 states, 2003–2009. Prev Med 2013;56:372–
378.
18. Chu SY, Callaghan WM, Bish CL, et al. Gestational weight
gain by body mass index among US women delivering live
births, 2004–2005: Fueling future obesity. Am J Obstet
Gynecol 2009;200:271.e1–271.e7.
19. Baskin ML, Ard J, Franklin F, et al. Prevalence of obesity
in the United States. Obes Rev 2005;6:5–7.
20. Kiel DW, Dodson EA, Artal R, et al. Gestational weight
gain and pregnancy outcomes in obese women: How much
is enough? Obstet Gynecol 2007;110:752–758.
21. Bartok CJ, Schaefer EW, Beiler JS, et al. Role of body
mass index and gestational weight gain in breastfeeding
outcomes. Breastfeed Med 2012;7:448–456.
22. Fein SB, Labiner-Wolfe J, Shealy KR, et al. Infant Feeding
Practices Study II: Study Methods. Pediatrics 2008;122
(Suppl 2):S28–S35.
7
23. Chapman DJ, Pérez-Escamilla R. Identification of risk
factors for delayed onset of lactation. J Am Diet Assoc
1999;99:450–454.
24. Saadeh R, Akré J. Ten steps to successful breastfeeding: A
summary of the rationale and scientific evidence. Birth
1996;23:154–160.
25. Brownell E, Howard CR, Lawrence RA, et al. Delayed
onset lactogenesis II predicts the cessation of any or ex-
clusive breastfeeding. J Pediatr 2012;161:608–614.
26. Lewis JA. Maternal perceptions of insufficient milk supply
in breastfeeding. MCN Am J Matern Nurs 2009;34:264.
27. DaMota K, Bañuelos J, Goldbronn J, et al. Maternal request
for in-hospital supplementation of healthy breastfed infants
among low-income women. J Hum Lact 2012;28:476–482.
28. Lepe M, Gascon MB, Castaneda-Gonzalez LM, et al. Ef-
fect of maternal obesity on lactation; systematic review.
Nutr Hosp 2011;26:1266–1269.
29. Jevitt C, Hernandez I, Groër M. Lactation complicated by
overweight and obesity: Supporting the mother and new-
born. J Midwifery Womens Health 2007;52:606–613.
30. Flint DJ, Travers MT, Barber MC, et al. Diet-induced
obesity impairs mammary development and lactogenesis in
murine mammary gland. Am J Physiol Endocrinol Metab
2005;288:E1179–E1187.
31. Shaw MA, Rasmussen KM, Myers TR. Consumption of a
high fat diet impairs reproductive performance in Sprague-
Dawley rats. J Nutr 1997;127:64–69.
32. Rasmussen KM. Effects of under-and overnutrition on
lactation in laboratory rats. J Nutr 1998;128:390S–393S.
33. Hilson JA, Rasmussen KM, Kjolhede CL. Excessive weight
gain during pregnancy is associated with earlier termination
of breast-feeding among white women. J Nutr 2006;136:
140–146.
34. Fernandes TA, Werneck GL, Hasselmann MH. Pre-
pregnancy weight, weight gain during pregnancy, and ex-
clusive breastfeeding in the first month of life in Rio de
Janeiro, Brazil. J Hum Lact 2012;28:55–61.
35. Li R, Jewell S, Grummer-Strawn L. Maternal obesity and
breast-feeding practices. Am J Clin Nutr 2003;77:931–936.
36. Grajeda R, Pérez-Escamilla R. Stress during labor and
delivery is associated with delayed onset of lactation
among urban Guatemalan women. J Nutr 2002;132:3055–
3060.
37. Scott JA, Binns CW, Oddy WH. Predictors of delayed
onset of lactation. Matern Child Nutr 2007;3:186–193.
Address correspondence to:
Zelalem T. Haile, PhD., MPH
Department of Social Medicine
Heritage College of Osteopathic Medicine
Ohio University
6775 Bobcat Way
Dublin, OH 43016
E-mail: haile@ohio.edu