Community and International Nutrition

Maternal Perception of the Onset of Lactation Is a Valid, Public Health

Indicator of Lactogenesis Stage II1
2 3
Donna J. Chapman and Rafael Perez-Escamilla
Department of Nutritional Science, University of Connecticut, Storrs, CT 06269

ABSTRACT Test weighing is the gold standard for documenting lactogenesis stage II. However, this method is
impractical for use in population studies. Maternal perception of the timing of the onset of lactation may be a useful
proxy for lactogenesis stage II. This study seeks to validate maternal perception of the onset of lactation as a
marker of lactogenesis stage II. Women (n 5 60) were recruited after cesarean delivery. Beginning at 24 h
postpartum (pp), the onset of lactation was assessed 3 times daily by both test weighing and maternal perception.
Delayed onset of lactation was dened as follows: 1) milk transfer , 9.2 g/feeding at 60 h pp and 2) maternal
perception _ 72 h pp. Misclassication analyses were conducted. Multivariate logistic regression, bivariate
analyses and Cox survival analyses were used to evaluate the determinants and consequences of delayed onset of
lactation, using both denitions. The sensitivity and specicity of delayed maternal perception as an indicator of
delayed lactogenesis were 71.4 and 79.3%, respectively. Four risk factors for low milk transfer were signicant (P ,
0.05) or nearly signicant (P _ 0.08) predictors of delayed perception of the onset of lactation. The effects of low
milk transfer and delayed maternal perception on breast-feeding duration were similarly modied by intended
breast-feeding duration. The magnitude and directionality of the _ coefcients for the milk transfer and perception
variables were consistent. On the basis of these results, we conclude that maternal perception of the onset of
lactation is a valid public health indicator of lactogenesis stage II. J. Nutr. 130: 29722980, 2000.
KEY WORDS: c breast-feeding c lactogenesis stage II c test weighing c cesarean delivery c lactation jn.nutrition

The measurement of milk transfer by test weighing is con-

sidered to be the gold standard for documenting lactogenesis
stage II (i.e., the initiation of copious secretion of breast milk
after delivery) (Daly and Hartmann 1995). Unfortunately, test
weighing is costly, invasive and impractical to use in popula-tion
studies. Biochemical indices of lactogenesis stage II have been
developed (Arthur et al. 1989, Kulski and Hartmann 1981,
Neubauer et al. 1993, Neville 1995). However, these methods
require milk sampling and laboratory analyses, ren-dering them
impractical for routine clinical assessment or use in large-scale
studies. Reliable, inexpensive and noninvasive alternatives to test
weighing or biochemical analyses have not been developed. From
a public health perspective, maternal perception of the timing of
the onset of lactation may be a useful proxy for lactogenesis stage
II because it describes when women actually feel their breast milk
came in. The symp-toms commonly reported to conrm the
onset of lactation (Chapman and Perez-Escamilla 1999b) (i.e.,
breast fullness, engorgement, leaking) are consistent with the
physiology of lactogenesis stage II and may indicate a milk
supply that is
1 Funded by the University of Connecticut Research Foundation, the Con-
necticut Family Nutrition Program for Infants, Toddlers and Children and Hartford
Hospital Research Administration. We are grateful to Medela, Incorporated for in
kind support. This article is scientic contribution number 1978, Storrs Agricul-
tural Experiment Station, University of Connecticut, Storrs, CT.
2 To whom correspondence should be addressed.
E-mail: djc@discovernet. net
3
To whom reprint requests should be addressed.
E-mail: rperez@canr.cag. uconn.edu.
0022-3166/00 $3.00 2000 American Society for Nutritional Sciences.
more than adequate (Chen et al. 1998, Hartmann et al. 1996). .org
Maternal perception is admittedly subjective, however, and by
has not been established as a valid marker of lactogenesis
stage II.
Few researchers have investigated the onset of lactation by
collecting data on both maternal perception and milk transfer.
Arthur et al. (1989) studied indicators of lactogenesis inFebruary
Australian women after vaginal delivery and observed signif-
icant increases in milk transfer between 24 and 48 h postpar-3,
tum (pp), signaling lactogenesis stage II. These changes in milk
transfer coincided with increases in breast milk lactose2017 and
citrate concentrations. The biochemical and milk transfer
indicators of lactogenesis preceded maternal report that milk
had come in by at least 11 h. Because maternal perception of
the onset of lactation occurred later than the phenomenon was
documented by test weighing, Arthur and colleagues con-cluded
that maternal perception of milk arrival is not a viable marker
of lactogenesis stage II.
We postulate, however, that although women perceive the
onset of lactation later than its occurrence is indicated by
biochemical or test weighing analyses, this may be a systematic
phenomenon. Thus, maternal perception may be a useful indicator
of lactogenesis stage II. Maternal perception cannot be used with
to the minute accuracy, but it can be used to differentiate women
who perceive the onset of lactation to be early (i.e., ,72 h pp) vs.
late (i.e., _72 h pp). We hypothe-sized that perception of the onset
of lactation (early vs. late) is likely to correspond with the level of
milk transfer (high vs.
Manuscript received 6 June 2000. Initial review completed 26 July 2000. Revision accepted 6 September 2000.

2972
MATERNAL PERCEPTION OF LACTOGENESIS STAGE II 2973

TABLE 1

Charact
eristics
low). Thus, maternal perception may be used as a valid indi-
cator to examine the determinants and infant feeding conse-
quences of the timing of lactogenesis.
The objective of this study is to substantiate the use of
maternal perception of the onset of lactation as a marker of
lactogenesis stage II. Specically, this study compares the
determinants and consequences of delayed onset of lactation
after cesarean delivery, as measured by both test weighing and
maternal perception.
SUBJECTS AND METHODS
Subjects
Healthy breast-feeding women (n 5 60) who gave birth by cesar-
ean delivery at Hartford Hospital, Hartford, CT were recruited to
participate in this study between June 1997 and November 1998 as
described previously (Chapman 1999). Subjects were primarily re-
cruited 8 to 24 h after delivery of a healthy singleton; however, three
were recruited prenatally. Final analyses include 57 women because
two subjects were dropped due to ineffective infant suckling and one
was dropped due to poor compliance with study protocol. Baseline
data were collected on nonparticipants. Between-group baseline char-
acteristics (participants vs. nonparticipants) were compared using
Student's t test and _2 analyses. Subjects were primarily Caucasian,
married and ;31 y old, with some college education. Overall, sub-
jects had baseline characteristics similar to the 111 women who
declined to participate in the study (Table 1). The only signicant
difference between participants and nonparticipants was that partic-
ipants intended to breast-feed for 1.5 mo longer than those who
declined. This study was approved by the Institutional Review
Boards at the University of Connecticut and Hartford Hospital,
Hartford, CT.
Study design
Data used in this methodologic evaluation of the perceived onset of
lactation were obtained from a randomized clinical trial, designed to evaluate
the effect of breast pumping on the onset of lactation (Chapman 1999). In that
study, 57 subjects were randomly assigned to either a breast pumping group or
a control group. Beginning at 24 h pp, subjects in the pumping group used a
double electric breast pump
(Lactina Select, Double Pumping Kit, Medela, McHenry, IL) for 10
15 min, three times daily after breast-feeding. Using this same time
frame, those in the control group held the breast shields of the electric
pump to their breasts, but did not turn on the pump. The onset of
lactation was assessed three times daily by test weighing and
maternal perception. In this analysis, the determinants and conse-
quences of delayed onset of lactation, as dened by these two indi-
cators, are evaluated.
Test weighing
Procedure. Beginning at ;24 h pp, infants were weighed before and
after three breast-feeding sessions per day to determine milk
transfer/feeding. The times of these feedings were 0842 6 0102, 1321 6
0155 and 1846 6 0102 h. Test weights were obtained in triplicate by
research staff using an electronic integrated scale tted with an infant
seat and a recording printer (model BP34; Sartorius, Goettin-gen,
Germany). The manufacturer's stated accuracy for the scale is 60.05 g.
Each printed weight was the average of 20 consecutive measurements.
Women were not provided with the results of the test weighing.
Insensible water loss was measured over one 15-min period. Test
weighing continued until the onset of lactation was veried by both test
weights (i.e., sharp increase in milk transfer curve, typically
associated with milk transfer _ 15 g/feeding) and maternal percep-
tion of the onset of lactation.
If subjects were discharged from the hospital before the onset of
lactation, test weights were obtained by the subject at home, as
described previously (Dewey et al. 1991, Ferris et al. 1993, Neville et
al. 1988, Neubauer et al. 1993). Research staff delivered the same from
model of electronic balance to the subject's home on the date of
quired to demonstrate their ability to use the balance before collect-
discharge. The subject and interested family members received verbal jn.
and written instructions on test weighing procedures and were re-nutrition
ing data. Subjects were requested to weigh their newborns before and .
after three feeding sessions per day until advised to stop by research org
staff. Researchers were available by pager and remained in telephone
contact with the subjects to ensure compliance with the test weighing
protocol.
Milk transfer curves. Milk transfer data were adjusted for insen-
sible water loss, which was measured individually. For the 12 infants
with missing data for insensible water loss, the mean [1.29 g/(kg z h)]
was used. Milk transfer was then plotted over time to generate
 1
n Participants n Nonparticipants P
2
Maternal age, y 60 31.3 6 4.3 111 31.7 6 4.5 0.52
Maternal education level, y 60 15.2 6 2.0 97 15.3 6 2.2 0.73
Primiparous, % 60 42.1 112 44.6 0.48
Ethnicity, %
African American 7 11.7 8 8.5 0.34
Caucasian 44 73.3 80 85.1
Hispanic 4 6.7 5 5.3
Asian 2 3.3 1 1.1
Other 3 4.1 0 0
3
Intended BF duration, mo 60 7.3 6 4.0 82 5.8 6 3.2 0.02
Scheduled deliveries, % 60 56.7 111 62.2 0.48
Anesthesia type
Epidural, % 23 38.3 40 36.4 0.80
Spinal, % 37 61.7 70 63.6
Infant sex, % male 60 56.7 81 55.6 0.90
1-min Apgar score 60 8.1 6 1.1 111 8.3 6 0.9 0.41
5-min Apgar score 60 9.0 6 0.3 111 9.0 6 0.3 0.81
Infant birth weight, kg 60 3.6 6 0.4 111 3.6 6 0.5 0.27
Gestational age, wk 60 39.4 6 1.0 108 39.6 6 1.0 0.13
1 Nonparticipants (n) vary due to missing data.
2 Values are means 6 SD.
3 Breast-feeding.
2974 CHAPMAN AND PEREZ-ESCAMILLA

individual milk transfer
curves. These curves were
tted to the quadratic equation
to generate predicted milk
transfer curves for each
mother-infant pair. The
coefcients of each individual
predictive curve were then
used to predict milk transfer
for 24, 30, 36, 48, 60 and 72 h
pp.
Maternal perception
Assessment of maternal
perception of the onset of
lactation began at 24 h pp. To
evaluate the clinical symptoms
of lactogenesis, subjects were
interviewed regarding breast
symptoms (i.e., breast fullness,
swelling, leakage) three times
daily, immediately after the
test weights were completed.
Subjects were then asked Has
your milk come in yet? If the
response was positive, the
subject was then asked, When
did your milk come in?; the
response to this question was
recorded to the nearest hour.
Subjects routinely reported
breast symptom changes
before reporting that the onset
of lactation had occurred. No
attempt was made to coach
subjects on the clinical
indicators of lactogenesis.
Subjects who were discharged
before the onset of lactation (n
5 11) were contacted at least
daily by research staff to
determine the timing of
maternal perception of the
onset of lactation.
Follow-up data collection
Follow-up telephone
interviews were conducted to
assess the relationship between
the timing of the onset of
lactation and breast-feeding
duration. Researchers
contacted subjects ;6 mo pp to
deter-mine the duration of both
exclusive and any breast-
feeding. If sub-jects were still
breast-feeding, additional
follow-up calls were made at
4-mo intervals. Data analysis
was conducted 6 mo after the
last subject was enrolled into
the study. At the time of data
analysis, 30% of subjects were
still breast-feeding, and the
average breast-feeding
duration was 6.3 6 4.8 mo.
Model
specication:
determinants of
delayed onset of
lactation
Multivariate logistic
regression analyses were used
to identify the independent
effects of the determinants of
delayed onset of lactation. All
statistical analyses were
conducted using SPSS for
Windows, Version 8.0 (Norusis
1992), and were interpreted
using P _ 0.05 (two-tailed) as
level of signicance.
Dependent variables. Two
multivariate logistic regression
mod-els were developed,
differing only in the denition
of the dependent variable, i.e.,
the timing of the onset of
lactation. In the maternal
perception model, the
perceived timing of the onset of
lactation was characterized as
early or late (,72 h pp vs. _72 h
pp), as described previously
(Chapman and Perez-
Escamilla 1999b).
For the milk transfer
model, predicted milk transfer
at 60 h pp was dened as high
or low, using the sample mean
(n 5 57) as a cut-off value (_9.2
g/feeding vs. ,9.2 g/feeding), as
described previ-ously
(Chapman 1999). The time
frame of 60 h pp was chosen
because 55.4% of subjects had
perceived milk arrival by 72 h
pp, and test weighing had
frequently been discontinued.
Rather than estab-lishing a milk
transfer denition based on
predicted curves extending
beyond the limits of our raw
data (i.e., at 72 h pp), we chose
to use 60 h pp, the point at
which 98% of subjects had
milk transfer data. The
predicted milk transfer curves
provided a useful estimate of
actual milk transfer values. The
overall correlation coefcient
for the actual vs. predicted
curves was 0.84. The average
predicted value for milk
transfer at 60 h pp was 94% of
the corresponding value
derived by averaging raw data.
Because of these close
correlations with actual milk
transfer data, using predictive
milk transfer curves was
deemed more objective than
determining the inection point
for each indi-vidual curve.
Independent variables. The
multivariate logistic regression
models included 10 main
effects and two two-way
interactions.
Maternal factors. Maternal
obesity has been associated
with de-layed perception of the
onset of lactation (Chapman
and Perez-Escamilla 1999b).
Because of uid retention in the
immediate post-partum period,
the assessment of maternal delivery is challenging. Our
obesity at the time of approach was to assess three
indicators of maternal obesity.
Women were classied as
obese if at least two of these
three indicators were positive:
body mass index at 72 h pp _
30 kg/m2, subscapular skinfold
thickness at 72 h pp more than
the 85th percentile of our
study data (i.e., .33.7 mm) and
heavy/obese body build on d 1
pp (vs. slim/average body
build). Tricep skinfold mea-
surements were not used
because previous research
demonstrated that these
measurements are unreliable
markers of body fat during
lacta-tion (Brewer et al. 1989).
Ethnicity was categorized
as African American vs. all
other ethnic groups on the
basis of the previous
identication of non-African
American ethnicity as a risk
factor for delayed onset of
lactation (Chapman and
Perez-Escamilla 1999b).
Parity was categorized as
primiparous vs. multiparous
and was included in the model
due to documented differences
in milk transfer (Chapman
1999) and per-ception of the
onset of lactation among
primiparae vs. multiparae
(Chapman and Perez-
Escamilla 1999b). Because of
the potential for maternal age
to affect the timing of the
onset of lactation, age was
entered as a continuous
variable.
Early breast-feeding
factors. Previous research
suggests that early breast-
feeding initiation (Sozmen
1992) and frequent breast-
feeding (Salariya et al. 1978,
Sozmen 1992) may hasten the
onset of lacta-tion. The time of
breast-feeding initiation was
categorized as early vs.
(_7 feedings) vs. low (,7
feedings) on the basis of the
mean. These
late, using the median as a cut-off
value (i.e., _105 vs. .105 min pp).
Breast-feeding frequency during the
rst 24 h pp was classied as
highDownloaded
data were derived by maternal
recall, obtained between 24 and
36 h
pp. For the seven subjects with
missing data, breast-feeding
frequency
during the rst 24 h was
obtained from the medical
record. Predicted milk transfer
at 30 h pp was expressed as a Maternal factors. Maternal
continuous variable. from obesity (Hilson et al. 1997, Rut-
Infant/delivery factors. ishauser and Carlin 1992),
education level (Ford and
Birth weight , 3.5 kg has Labbok 1990, Michaelsen et al.
been identied jn 1994, Quarles et al. 1994),
parity (Chapman and Perez-
Escamilla 1999a, Ford and
above the mean (,3.5 kg vs. Labbok 1990), employment
_3.5 kg). Due to the previous status (Chapman and Perez-
identi- Escamilla 1999a, Perez-
. Escamilla et al. 1993), age
as a risk factor for delayed onset (Ford and Labbok 1990,
of lactation (Chapman and Michaelsen et al. 1994,
Perez-Escamilla 1999b). Thus Samuels et al. 1985) and group
birth weight was categorized as assignment (Chapman 1999),
below ornutrition . have all been shown to affect
cation of unscheduled cesarean delivery as a risk of
the duration factor for delayed
breast-feeding.
Maternal obesity, education
onset of lactation (Chapman and Perez-Escamilla 1999b), delivery

type was expressed as scheduled vs. unscheduled.

Study group. Because of the potential for group assignment to
affect the timing of the onset of lactation, study group was classied
as pumping vs. control.
Interaction terms. Parity z study
group was included in the model to test the
hypothesis that the effect of breast
pumping on the onsetFebruary esis that the
onset of lactation occurs later in obese
women as a result
of lactation was modied by
parity. To evaluate our post-hoc
hypoth-of less frequent nursing,
we included the breast-feeding
frequency3,
z maternal obesity interaction term.

Model specication:
determinants of the
duration of any
breast-feeding
Multivariate survival
analyses (Cox model) were
used to identify the
determinants of the duration
of any breast-feeding, after
control-ling for potential
confounders.
Dependent variable. The
duration of any breast-
feeding was assessed during
follow-up telephone
interviews made to subjects
be-tween 2 and 19 mo pp.
One subject was lost to
follow-up; thus the breast-
feeding duration models
include 56 subjects. In total,
four models were evaluated.
For women who were still
breast-feeding when the last
contact was made, the
duration of any breast-
feeding was identied as
right censored in the Cox
regression model.
Independent variables.
Series 1. The rst series
included two models, each
consisting of 10 main effects.
Each model included one
indicator of lactogenesis
stage II, based on either milk
transfer or maternal
perception.
MATERNAL PERCEPTION OF LACTOGENESIS STAGE II 2975

Consequences of delayed onset of lactation

Determinants of the duration of any breast-feeding.


level and parity were
expressed categorically, as
described in the determinants
of delayed onset of lactation
model specications. Maternal
employment status at the time
of the last follow-up call was
entered as a three-category
(full-time, part-time, not
employed out-side of the
home) dummy variable.
Maternal age was expressed as
a continuous variable.
Early infant feeding
practices. Early infant feeding
practices, in-cluding the
frequency of breast-feeding in
the rst 24 h after delivery
(Salariya et al. 1978, Sozmen
1992), the timing of the onset of
lactation (Chapman and Perez-
Escamilla 1999a, Ferris et al.
1987, McCabe 1982, Perez-
Escamilla et al. 1993 and 1996,
Segura-Millan et al. 1994) and
the use of prelacteal feedings
(Perez-Escamilla et al. 1996,
Samuels et al. 1985), can affect
breast-feeding duration.
Breast-feeding frequency
during the rst 24 h pp, milk
transfer at 60 h pp and
maternal perception of the
onset of lactation at 72 h were
categorized as described in the
determinants of delayed onset
of lactation model. (Only one
term describing the timing of
the onset of lactation was
included per model.) Data on
the use of prelacteal feedings
(yes/no) were obtained from
daily interviews and
conrmed by medical record
review.
Intended breast-feeding
duration. Women planning to
breast-feed for ,6 mo are at
risk for early breast-feeding
termination (Chapman and
Perez-Escamilla 1999a,
Loughlin et al. 1985). On d 1
pp, subjects were asked for
how long they planned to
breast-feed, using an open-
ended question. Intended
breast-feeding duration was
entered as a dichotomous
variable (,6 mo vs. _6 mo).
Series 2. Intended breast-
feeding duration modies the
associa-tion between the onset
of lactation and actual breast-
feeding duration (Chapman
and Perez-Escamilla 1999a).
In the second series of mod-
els, we attempted to evaluate
this relationship. The two
models in series 2 each
contained nine main effects.
Eight of the main effects were
identical to those of series 1
(maternal obesity, education
level, parity, group
assignment, employment
status, age, breast-feeding fre-
quency in rst 24 h pp and use
of prelacteal feedings). In
addition, a new three-term
variable was developed to
combine intended breast-
feeding duration and the onset
of lactation. For this variable,
the subgroups planning to
breast-feed ,6 mo were
combined. This was done for
the following reasons: 1) the
strong similarities in breast-
feeding duration and small
sample size (n 5 7) of these
subgroups in the current study;
and 2) previous research
indicating that the onset of
lactation does not affect breast-
feeding duration among women
planning to breast-feed for ,6
mo (Chapman and Perez-
Escamilla 1999a). Thus, the
milk transfer and maternal
perception model each contain
one three-term variable, based
on their respective denitions
of delayed onset of lactation
(i.e., intended breast-feeding
duration , 6 mo vs. early onset
of lactation and planning to
breast-feed _6 mo vs. late onset
of lactation and planning to
breast-feed _6 mo).
Model
specication:
determinants of the
duration of
exclusive breast-
feeding
Dependent variable. The
duration of exclusive breast-
feeding was assessed through
follow-up telephone interviews.
At the time of nal data
analyses, all subjects had
discontinued exclusive breast-
feeding. The duration of
exclusive breast-feeding ranged
from 0.1 to 6.0 mo, with a
mean of 3.0 6 1.7 mo.
Independent variables. The
determinants of the duration of
exclusive breast-feeding in the
United States have not been
well characterized. Therefore,
the independent variables used
to model the determinants of
the duration of any breast-
feeding were also utilized to
model the duration of exclusive
breast-feeding in our
population. As in the previous
series of models, a total of four
multivariate survival analyses
models were evaluated.
R obese women. from
ES
UL
TS
The sensitivity and
specicity of delayed
(11/14) and 71.4% (10/14),
maternal percep-tion of the respectively. For subjects in
onset of lactation as an the control group, the
indicator of delayed
sensitivity and specicity
lactogenesis stage II were of maternal per-ception
71.4% (20/28) and 79.4%
were 64.4% (9/14) and
(23/29), respectively. The 86.7% (13/15),
positive and negative
respectively.
predictive values were 76.9 Determinants of
and 74.2%, respectively.
delayed onset of lactation.
Within the pumping group, Five variables were
the sensitivity and identied as signicant
specicity of delayed risk factors for delayed
perception were 78.6%
onset of lactation (Table 2).
Two of these terms (breast-
feeding initi-ation later than
105 min pp and parity z
study group inter-action)
were signicant in both the
milk transfer and maternal
perception models. Two
terms (lower milk transfer
at 30 h and the obesity z
breast-feeding frequency
interaction during the rst
24 h pp) were signicant in
the milk transfer model and
approached signicance in
the maternal perception
model. Unscheduled
cesarean delivery was a
signicant risk factor
unique to the maternal
perception model.
In both models, the
effect of study group on the
onset of lactation was
modied by parity. Low
milk transfer (Fig. 1A) and
delayed perception of the
onset of lactation (Fig. 1B)
were more likely to occur
among primiparae who
pumped than among control
primiparae. This
relationship did not occur
among multiparae.
Similarly, the effect of
breast-feeding fre-quency
during the rst 24 h pp on
the onset of lactation was
modied by maternal
nutritional status. Among
nonobese women, those who
breast-fed more frequently had
higher milkDownloaded transfer
values (Fig. 2A) and tended to
perceive the onset of
lactation sooner (Fig. 2B) than
their counterparts who breast-fed
less frequently. This relationship,
however, was not ob-served for
As jn.nutrition
main effects, neither low
milk transfer nor delayed
perception .org
of the onset of lactation
were identied as risk
factors for by
discontinuing breast-
feeding. Planning to breast-
feed for ,6 mo (P , 0.05)
and full-time employment
(P , 0.05) wereguest
identied as signicant
risk factors for early
termination of
breast-feeding in both series
1 models. Breast-feeding ,
7on times in the rst 24 h pp
signicantly increased the
risk ofFebruary discontinuing
breast-feeding in the milk
transfer model (P
, 0.05) and approached
signicance (P , 0.08) in
the per-ception model. In
both models, maternal
obesity tended to3,
5 0.06 0.10). 2017 The three-
obesity was associated
with signi-cantly longer
breast-feeding duration in
the milk transfer model
and approached
signicance in the
maternal perception model
(P , 0.08). Among women
planning to breast-feed for
_6 mo, those with early
perception of the onset of
lactation breast-fed
signicantly longer than
their counterparts with a
delayed onset of lactation.

term variables used in series 2

(combining

onsethaveapositiveeffectonthe
durationofanybreast-feeding(P
of lactation with intended
breast-feeding duration)
were rst evaluated in a
bivariate model. The
unadjusted breast-feeding
duration values associated
with the three-term
variables dis-played a
signicant dose-response
relationship. Breast-
feeding duration was
longest for those planning
to breast-feed for at least
6 mo and experiencing an
early onset of lactation. It
decreased for their
counterparts experiencing
a delayed onset of
lactation, and was shortest
for those planning to
breast-feed for ,6 mo.
This dose-response effect
was evident when the
onset of lactation was
dened by milk transfer
(P , 0.0001) and by
maternal perception (P ,
0.0001).
In the series 2
multivariate model, three
terms were iden-tied as
signicant risk factors for
early termination of
breast-feeding in both
models (low breast-
feeding frequency on day
1 pp, full time
employment and planning
to breast-feed for ,6 mo)
(Table 3). Maternal
2976 CHAPMAN AND PEREZ-ESCAMILLA

TABLE 2
Multiple logistic regression of the determinants of delayed onset of lactation as dened by milk transfer vs. maternal perception

Milk transfer at 60 h pp
(, vs. _ 9.2 g/feeding) Maternal perception (_ vs. , 72 h pp)
1 2 3
Independent variable (n ) OR (95% CI ) P OR (95% CI) P
Obese (22) 6.14 (1.0137.41) 0.05 1.97 (0.2913.41) 0.49
Nonobese (35) 1.0 1.0
4
First BF _ 105 min pp (28) 7.53 (1.2445.68) 0.03 9.45 (1.1280.01) 0.04
First BF , 105 min pp (29) 1.0 1.0
BF frequency in rst 24 h , 7 (28) 0.31 (0.051.91) 0.21 0.80 (0.134.80) 0.81
BF frequency in rst 24 h _ 7 (29) 1.0 1.0
Wt , 3.5 kg (17) 0.48 (0.102.30) 0.36 6.01 (0.8243.82) 0.08
Wt _ 3.5 kg (40) 1.0 1.0
Caucasian/Hispanic (50) 1.99 (0.2416.44) 0.53 1.20 (0.1014.53) 0.89
African American (7) 1.0 1.0
Unscheduled cesarean (26) 1.12 (0.245.38) 0.88 6.23 (1.0437.28) 0.05
Scheduled cesarean (31) 1.0 1.0
Age in years (57) 0.95 (0.771.16) 0.59 1.25 (0.981.59) 0.08
Primiparous (24) 1.09 (0.177.02) 0.93 5.68 (0.6450.05) 0.12
Multiparous (33) 1.0 1.0
Pumping (28) 0.68 (0.162.94) 0.60 1.80 (0.3110.54) 0.52
Control (29) 1.0 1.0

Downloaded from .jn

Volume at 30 h pp (57) 0.81 (0.680.97) 0.02 0.83 (0.671.02) 0.08
Parity z pumping (57) 35.74 (0.981.3 3 103)5 0.05 1015.21 (4.87211 3 103)5 0.01
5 5
Obese z BF frequency in rst 24 h pp (57) 0.02 (0.000.64) 0.03 0.02 (0.001.22) 0.06
1
n 5 number of subjects.
2
OR, odds ratio for delayed onset of lactation, as dened by low milk transfer and delayed maternal perception, respectively.
3
95% CI, 95% condence interval.
4 BF, breast-feeding; pp, postpartum. nutrition replaced with their respective four-term variables, whereas all other variables were unchanged,
resulting in the identication of the same signicant.
5
The wide condence intervals persisted with the removal of the continuous variables from the model. The interactions were then individually
risk factors as those previously identied in the interactive model. Using the respective four term variables in the multivariate logistic regression org
models, the wide condence intervals were explained by the comparisons between subgroups of primiparae in the parity z pumping interaction and
between obese vs. nonobese women with a high breast-feeding frequency in the obesity z breast-feeding frequency interaction.

gu
on
es
Determinants of the duration of exclusive breast-feeding. magnitude and directionality (_ 5

t
0.66 in the milk transfer
As main effects, neither denition of delayed onset of lacta- model and 0.47 in the maternal perception model). Maternal
tion was a signicant risk factor for shorter duration of exclu- education level , 16 y approached signicance as a risk factor
sive breast-feeding; however, their _ coefcients were nearly for early termination of exclusive breast-feeding in both mod-
identical (0.41 for the milk transfer model, and 0.40 for the els (P 5 0.07).
maternal perception model). Maternal education level , 16 y

was identied as the only signicant risk factor (P , 0.05) for
early termination of exclusive breast-feeding in the series 1
maternal perception model, and this was the only term to
approach signicance in the milk transfer model (P 5 0.10).
In the bivariate model, the three-term variable combining
the timing of the onset of lactation with intended breast-
feeding duration yielded a dose-response relationship for the
duration of exclusive breast-feeding. As was observed for the
duration of any breast-feeding, women experiencing early on-
set of lactation and intending to breast-feed for at least 6 mo
had the longest duration of exclusive breast-feeding, followed
by those with late onset of lactation and plans to breast-feed
for at least 6 mo, and those intending to breast-feed for ,6 mo,
respectively. This relationship was signicant in the milk
transfer model (P 5 0.02) and approached signicance in the
maternal perception model (P 5 0.06).
In the series 2 multivariate model, the three-term variable
approached signicance in the milk transfer model (P 5 0.13)
(Table 4). Among women planning to breast-feed for at least
6 mo, those with higher milk transfer values at 60 h pp tended
to breast-feed exclusively for longer than their counterparts
with lower milk transfer values. The _ coefcients for the
comparisons of early vs. late onset of lactation among women
who intended to breast-feed for at least 6 mo were of similar
MATERNAL PERCEPTION OF LACTOGENESIS STAGE II
17
20
DISCUSSION
To our knowledge, this study is unique in its attempt to
validate maternal perception as a marker of lactogenesis stage
II after cesarean delivery. Our ndings strongly suggest that
maternal perception of the onset of lactation is a valid, public
health indicator of lactogenesis stage II. The determinants of
low milk transfer at 60 h pp and delayed perception of the
onset of lactation are almost identical. Despite the sample size
limitations of this study, all four variables identied as signif-
icant risk factors for low milk transfer were signicant or nearly
signicant risk factors for delayed maternal perception. The
effects of low milk transfer and delayed maternal perception on
breast-feeding duration were similarly modied by intended
breast-feeding duration. Thus, regardless of whether delayed
onset of lactation is dened by milk transfer or maternal
perception, the conclusions reached are consistent.
Our ndings coincide with previous studies assessing ma-
ternal perception of the onset of lactation, in combination
with other indicators of lactogenesis. Using biochemical mark-
ers, Arthur et al. (1989) demonstrated delayed lactogenesis
among diabetic vs. control subjects. This was supported by a
nearly signicant delay in maternal perception (P , 0.06)
among the four diabetic women who perceived the onset of
2977

FIGURE 1 Effect of
pumping on the probability of
delayed onset of lactation
modied by parity [delayed
onset of lactation dened as
low milk transfer (A) and
delayed maternal perception
(B)].
lactation. In a similar series
of studies (Ferris et al. 1993,
Neubauer et al. 1993),
maternal perception, breast
milk intake on d 7 pp and
biochemical markers of
lactogenesis consistently
indicated delayed
lactogenesis among control
subjects and those with
insulin-dependent diabetes
mellitus, compared with their
reference group. Chen et al.
(1998) evaluated four
indicators of lactogenesis,
including maternal
perception of the onset of
breast fullness. Although this
term differs from our
denition of maternal
perception, maternal/fetal
stress markers were
associated with delays in
both breast fullness and
casein appearance. The
timing of the onset of breast
fullness was highly
correlated with milk volume
on d 5 pp and with casein
appearance. Delayed
lactogenesis was
demonstrated among
primiparae (vs. multiparae)
by both delayed breast
fullness and decreased milk
volume on d 5. Chen and
colleagues (1998) caution that
maternal perception of breast
fullness may not always be a
useful indicator of
lactogenesis, especially in
situ-ations in which decreased
breast-feeding frequency may
result in engorgement.
The determinants of
delayed onset of lactation
that we have identied
either conrm previous
ndings or provide new
insights. The identication
of delayed breast-feeding
initiation as a risk factor for
delayed onset of lactation
supports the ndings of
Sozmen (1992) and Salariya
et al. (1978). The
consistently signicant
interaction between parity
and study group
demonstrates that breast
pumping between 24 and 72
h after cesarean delivery
delays the onset of lactation
among primiparae and
therefore should be avoided.
As expected, low milk
transfer at 30 h pp predicts
low milk transfer at 60 h pp
and tends to predict delayed
maternal perception. The
absence of a stimulatory
effect of early, frequent
breast-feeding in the rst 24
h pp on the onset of
lactation among obese
women has not been
described previously. This
nding may explain in
perceived it earlier. In the
part why obese women bivariate analyses, the duration
perceive the onset of ofjn
.
lactation later than slim or any breast-feeding decreased
average women (Chapman signicantly in a dose-response
and Perez-Escamilla fashion when comparing
subgroups of the intended
1999b) and are less breast-nutrition feeding
successful initiating duration/onset of lactation three-
.org by
breast-feeding (Hilson et term variable. This
onguest
al. 1997). Possible
explanations include
February 3, 2017
decreased ability to
perceive breast fullness or
elevated levels of steroid
hormones/ leptin among
obese women in the early
post-partum period
(Chapman and Perez-
Escamilla 1999b). This
area requires further
investigation.
The identication of
unscheduled cesarean
delivery as a signicant
risk factor for delayed
perception of the onset of
lactation supports our
previous ndings
(Chapman and Perez-
Escamilla 1999b) and the
conclusions of Chen et al.
(1998) that delivery-
related stress has a
negative effect on the
onset of lactation. The type
of cesarean delivery
(scheduled vs. un-
scheduled), however, did
not signicantly affect
milk transfer. This delay in
perception, despite similar FIGURE 2 Effect of breast-
feeding frequency during the
milk transfer values, may
rst 24 h postpartum on the
be related to maternal
exhaustion or the use of
probability of delayed onset of
lactation modied by maternal
anesthesia. In this study, obesity [delayed onset of
delivery type and lactation dened as low milk
anesthesia type (spinal vs. transfer (A) and as delayed
epidural) were collinear perception (B)].
variables; thus the effect of
these terms could not be
disentangled.
The consequences of late
onset of lactation on
breast-
feeding duration were similar,
regardless of how the
indepen-dent variable was
dened. Our data replicate
our previousDownloaded
nding (Chapman and
Perez-Escamilla 1999a) that
among
women planning to breast-
feed for at least 6 mo, those
with delayed perception of
the onset of lactation are
more likely to discontinue
breast-feeding sooner than
their counterparts whofrom
2978 CHAPMAN AND PEREZ-ESCAMILLA

TABLE 3
Multivariate survival analyses (series 2) of the determinants of the duration of any breastfeeding (BF), using a three-term
independent variable combining breastfeeding intentions with markers of the onset of lactation

Model 1 Likelihood of not BF Model 2 Likelihood of not BF

1 2 3
Independent variable (n) OR (95% CI) P OR (95% CI) P
Age , 32 y (27) 1.43 (0.683.01) 0.34 1.46 (0.713.00) 0.31
Age _ 32 y (29) 1.0 1.0
Pumping (28) 1.57 (0.733.42) 0.25 1.46 (0.683.17) 0.34
Control (28) 1.0 1.0
Maternal education _ 16 y (30) 1.09 (0.502.38) 0.83 1.15 (0.532.46) 0.72
Maternal education , 16 y (26) 1.0 1.0
Employment status 0.07 0.03
Full time (29) 2.81 (1.077.42) 0.04 3.28 (1.248.72) 0.02
Part time (11) 1.14 (0.353.79) 0.83 1.04 (0.303.57) 0.95
Not employed (16) 1.0 1.0
Nonobese (35) 2.28 (1.025.11) 0.05 2.00 (0.914.41) 0.08
Obese (21) 1.0 1.0
Multiparous (32) 1.12 (0.552.29) 0.76 1.26 (0.612.60) 0.53

Downloaded
Primiparous (24) 1.0 1.0
Prelacteals given: yes (8) 1.23 (0.374.10) 0.73 1.24 (0.384.02) 0.72
Prelacteals given: no (48) 1.0 1.0
4
BF frequency in rst 24 h pp , 7 (27) 2.23 (1.005.00) 0.05 2.20 (1.014.80) 0.05
BF frequency in rst 24 h pp _ 7 (29) 1.0 1.0
Intended BF duration and milk transfer 60 h pp 0.03
, 6 mo, _ or , 9.2 g (14) 4.11 (1.3712.31) 0.01
_ 6 mo, , 9.2 g (20) 1.57 (0.594.18) 0.36

jnfrom .
_ 6 mo, _ 9.2 g (22) 1.0
0.01
Intended BF duration and maternal perception
, 6 mo, _ or , 72 h (14) 4.96 (1.7314.21) 0.003

nut
riti

.
_ 6 mo, _ 72 h pp (20) 2.46 (1.035.86) 0.04
_ 6 mo, , 72 h pp (22) 1.0
1 n, number of subjects.

guestbyorg
2 OR, odds ratio for delayed onset of lactation, as dened by low milk transfer and delayed maternal perception, respectively.
3 95% CI, 95% condence interval.
4 pp, postpartum.

signicant bivariate dose-
response relationship was
replicated for the duration
of exclusive breast-feeding
when milk transfer was a
component of the three-
term variable, and
approached signicance
with maternal perception in
the three-term vari-able.
With a larger sample size, it
is likely that the latter
would have been
signicant.
Five main effects were
consistently signicant or
nearly signicant risk
factors for short breast-
feeding duration. Our data
support previous research
documenting the negative
ef-fects of the following: 1)
planning to breast-feed for ,
6 mo (Loughlin et al. 1985,
McCabe 1982, Perez-
Escamilla et al. 1993 and
1997, Quarles et al. 1994);
2) low breast-feeding
frequency in the early pp
period (Salariya et al.
1978); 3) full-time
employment (Samuels et al.
1985); and 4) the inter-
action between the onset of
lactation and intended
breast-feeding duration
(Chapman and Perez-
Escamilla 1999a) on the
duration of any breast-
feeding. Our nding that
obese women were more
likely to breast-feed longer
(P 5 0.05 0.10) than their
nonobese counterparts is in
contrast to previous
research (Hilson et al.
1997, Rasmussen 1998,
Rutishauser and Carlin
1992). This association
persisted, even after
removal of the milk transfer
and maternal perception
variables from the model.
Our ndings suggest that
maternal obesity may not
necessarily interfere with
breast-feeding success, if
in-depth breast-feeding
support is provided through
the onset of lacta-tion.
Because our data were
obtained from women who
gave birth via cesarean
delivery and were enrolled
in a breast pumping study,
the external validity of our
ndings may be
ease of use and high
limited. Women undergoing
degree of correlation with
cesarean delivery may not the expen-sive and
invasive standard of test
beonFebruary representative of weighing. Women who are
MATERNAL PERCEPTION OF LACTOGENESIS STAGE
the general population. We
have shown TABLE 4
previously that womenMultivariate survival analyses (series 2) of the determinants of the duration of
delivering by unscheduled exclusive breastfeeding (BF), using a three-term independent
cesarean delivery (43% of
variable combining breastfeeding intentions with markers of
the subjects in this study) the onset of lactation
are more likely to3, have a
delayed perception of the
onset of lactation than
those2017 delivering
vaginally with a short stage
II labor (Chapman and
Perez-Escamilla 1999b).
Subjects in the pumping
group visu-alized the
residual milk after a feeding,
potentially becoming more
aware of milk production
levels than the average post-
partum woman. This could
have exaggerated the
predictive ability of
maternal perception. This
does not appear to be the
case because the sensitivity
of maternal perception as an
indicator of delayed
lactogenesis was better
among the pump-ing
subjects, whereas the
specicity of maternal
perception was better among
controls.
In conclusion, our
ndings strongly suggest
that maternal perception of
the onset of lactation is a
useful public health
indicator of lactogenesis
stage II. This conclusion is
based on the
misclassication analyses
and the similarities in the
deter-minants and
consequences of low milk
transfer and delayed
maternal perception of the
onset of lactation in our
popula-tion. When posing
questions on the
determinants and conse-
quences of delayed
lactogenesis, essentially
the same conclu-sions
would be reached
regardless of the denition
of lactogenesis II.
Our ndings suggest
that it is worthwhile for
clinicians to evaluate
maternal perception of the
onset of lactation, given its
Model 1 Likelihood of not Model 2 Likelihood of not
exclusively breastfeeding exclusively breastfeeding
 1 2 3
Category (n) OR (95% CI) P OR (95% CI) P
Age , 32 y (27) 0.87 (0.451.68) 0.68 0.95 (0.501.80) 0.87
Age _ 32 y (29) 1.0 1.0
Pumping (28) 0.96 (0.521.75) 0.89 0.89 (0.481.65) 0.70
Control (28) 1.0 1.0
Maternal education _ 16 y (30) 0.53 (0.271.05) 0.07 0.53 (0.271.04) 0.07
Maternal education , 16 y (26) 1.0 1.0
Employment status 0.26 0.15
Full time (29) 1.70 (0.823.55) 0.16 1.86 (0.873.94) 0.11
Part time (11) 1.00 (0.382.66) 0.99 0.95 (0.362.50) 0.91
Not employed (16) 1.0 1.0
Nonobese (35) 1.23 (0.672.27) 0.51 1.11 (0.602.04) 0.74
Obese (21) 1.0 1.0
Multiparous (32) 0.82 (0.411.61) 0.56 0.93 (0.471.84) 0.84
Primiparous (24) 1.0 1.0 jn fromDownloaded

Prelacteals given: yes (8) 0.56 (0.201.58) 0.27 0.66 (0.241.78) 0.41
Prelacteals given: no (48) 1.0 1.0
4
BF frequency in rst 24 h pp 0.77 (0.391.49) 0.43 0.83 (0.431.60) 0.58
,7 (27)
BF frequency in rst 24 h pp 1.0 1.0
_7 (29)
Intended BF duration and milk transfer 60 h pp 0.13
, 6 mo, _ or , 9.2 g (14) 2.07 (0.934.61) 0.08
_ 6 mo, , 9.2 g (20)

..nutrition
1.94 (0.904.19) 0.09
_ 6 mo, _ 9.2 g (22) 1.0
Intended BF duration and maternal perception 0.24
, 6 mo, _ or , 72 h (14) 1.77 (0.833.79) 0.14
_ 6 mo, _ 72 h pp (20) 1.60 (0.783.28) 0.20org
_ 6 mo, , 72 h pp (22) 1.0

by
1
n, number of subjects.

guest
2
OR, odds ratio for delayed onset of lactation, as dened by low milk transfer and delayed maternal perception, respectively.

on
3
95% CI, 95% condence interval.
4
pp, postpartum.

February
attempting to breast-feed do not routinely have access to Aleja Rosario, Jocelyn Cruz, Paula McKernan, Ann-Marie Nocton

3,
and Melissa Wills for their expert assistance with data collection. We
biochemical markers of lactogenesis. Thus, they are likely to thank the staff of Hartford Hospital Women's Health Services for
base their infant feeding decisions on their perception of the

2017
adequacy of their breast milk supply. By asking women when their support of this project.
they perceived the onset of lactation, health care providers
can identify women at risk for poor breast-feeding outcomes in LITERATURE CITED
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