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Factors Associated with Supplemental Formula Feeding
of Breastfeeding Infants During Postpartum Hospital Stay
Joanna Pierro, Bdair Abulaimoun, Philip Roth, and Jonathan Blau
Abstract
Objective: To determine reasons potentially amenable to interventions that mothers choose to supplement
breastfeeding with formula in the immediate postpartum period.
Study Design: We distributed surveys to all mothers in the postpartum unit who delivered a live newborn on
day of maternal discharge to assess feeding behaviors during their inpatient admission. We evaluated, when
applicable, their reasons for supplementation and examined cultural and demographic information to uncover
trends for formula use and potential areas for provider intervention.
Results: Seven hundred twelve of 1,400 mothers responded, of which 478 (65%) reported supplementing
breastfeeding with formula (BF+F). The most common reasons for formula supplementation were perception of
inadequate milk supply (36.4%), desire for sleep (35.4%), and a plan to breast and bottle feed (35.2%).
Exclusive breastfeeding (EBF) was associated with primiparous status (OR 1.95; 95% CI 1.3–3.0), higher
education level (OR 2.6; 95% CI 1.7–3.9), and having been breastfed as an infant (OR 1.54; 95% CI 1–2.37).
Mothers who experienced skin-to-skin contact also had higher rates of EBF (29.5% versus 19.9%). Factors
associated with exclusive formula feeding included single marital status, birth of mother in the United States,
Catholic religion, multiparity, and cesarean delivery. Religious and cultural factors also played important roles
in maternal feeding behaviors.
Conclusion: Clinicians can anticipate risk factors for formula use in mothers who plan to breastfeed and tailor
counseling appropriately to increase EBF rates.
Introduction
The benefits of breastfeeding are well established, and
multiple public health measures to promote these benefits
and provide breastfeeding support are underway.
1–3
The
American Academy of Pediatrics (AAP) and the World Health
Organization (WHO) recommend exclusive breastfeeding
(EBF) for the first 6 months of life with continued breast-
feeding as long as mutually desired.
1,2
Despite significant efforts nationwide and in our own
institution, breastfeeding with formula supplementation
(BF+F) and exclusive formula feeding (EFF) persist as
common feeding practices in the inpatient postpartum set-
ting.
4
Supplementation with formula during inpatient hos-
pitalization has been shown to decrease breastfeeding
duration two- to threefold, 30 and 60 days postdischarge,
respectively.
5,6
An established maternal plan to supplement
is also detrimental to the duration of breastfeeding. Of the
one third of mothers who intended to supplement, 69% used
formula within the first 12 months and breastfed for shorter
durations than their nonsupplementing counterparts.
7
These
effects are possibly due to decreasing the infant’s drive to
feed frequently, leading to decreased maternal supply.
5
Preexisting personal preferences of formula usage, com-
fort with formula feeding, and discomfort with breastfeeding
have been associated with lack of EBF.
8
Prior research
consistently reveals higher rates of formula use among
mothers with low income, African American race, young
maternal age, low educational level, and reliance on public
assistance programs, such as WIC.
5,9–11
Despite the adverse
impact of supplementation, few studies have investigated the
basis for this feeding practice.
Prior abstract publications:
Pierro J, Abulaimoun B, Roth P, and Blau J. Formula Supplementation in Breastfeeding Mothers and Suggestions for Intervention by the
Pediatric Community. 2013. Presented at the Eastern Society for Pediatric Research Annual Meeting, PA.
Pierro J, Abulaimoun B, Roth P, and Blau J. Reasons for Formula Supplementation in Breastfeeding Mothers in the Inpatient Setting.
2013. Presented at the American Academy of Pediatrics National Conference and Exhibition, FL.
Pierro J, Abulaimoun B, Roth P, and Blau J. Reasons for Formula Supplementation in Breastfeeding Mothers in the Inpatient Setting.
2013. Presented at the Academy of Breastfeeding Medicine Annual Meeting, PA.
Division of Neonatology, Department of Pediatrics, Staten Island University Hospital, Staten Island, New York.
BREASTFEEDING MEDICINE
Volume 11, Number 4, 2016
ªMary Ann Liebert, Inc.
DOI: 10.1089/bfm.2015.0091
196
We hypothesize that parental formula use in the immediate
postpartum period is most likely related to perception of low
milk supply and other factors that are likely amenable to
education. We aim to determine these factors to provide
targeted education to our patient population and decrease
BF +F rates while simultaneously increasing EBF. Since
cultural factors also likely play a role in feeding behavior, we
hope to identify cultural differences to help guide future
educational efforts in our institution.
Materials and Methods
Our analysis was based on a sample of mothers from the
postpartum unit of our urban community teaching hospital. All
1,400 mothers who delivered a live newborn in our institution
from October 2012 to April 2013 were eligible to participate.
The sample size in the study was one of convenience and not
based on any formal statistical power calculation. Surveys
were distributed 7 days a week by house staff, NPs, and PAs
covering the Well Baby Nursery to all mothers on day of
maternal discharge regardless of disposition of their newborn:
Well Baby Nursery or Level IIIB NICU. Two surveys were
created by the researchers—one for EFF mothers and one for
BF mothers, whether exclusive or BF+F—both of which were
available in English and Spanish. An institutionally certified
Spanish translator translated the survey. All surveys were
completed by the mother except in the rare instance in which
the mother did not speak English or Spanish, and the survey
was administered using a certified translator service.
Participants were asked to provide demographic informa-
tion, including age, ethnicity, religion, marital status, and
educational background. Mothers also provided the birth
method, birth weight, gestational age, and disposition of their
newborn. They were then asked to answer questions related
to how they had fed their newborn over the course of their
inpatient postpartum admission, and if formula was used,
they were asked to choose the reason why. An option for
‘‘other’’ was included in this list. Finally, questions were
asked regarding breastfeeding education and support to at-
tempt to correlate supplementation with either of those fac-
tors. All patients were included; participation was voluntary,
and responses were anonymous. The Staten Island University
Hospital Institutional Review Board approved this study, and
informed consent was waived.
Statistical analysis was performed using Statistical Analysis
Software (SAS), Version 9.3. All continuous variables were
summarized using descriptive statistics, including mean,
standard deviation (SD), and median. All categorical variable
characteristics were summarized using frequencies and pro-
portions. Comparisons of continuous variables between groups
were carried out using either the t-test or Mann–Whitney test
for two-group comparisons or ANOVA or Kruskal–Wallis test
for three-group comparisons, as appropriate. The chi-square
test or Fisher’s exact test was used for categorical variables.
Upon finding significant differences, Bonferroni-like adjusted
pairwise comparisons ( p<0.02) were conducted. As a sec-
ondary analysis, we collapsed EFF and BF+F into one group
(‘‘any formula use’’) and compared it with EBF to determine
which factors may be associated with increased formula use.
Factors, which were significantly different between groups,
were then entered into a logistic regression model with ‘‘any
formula use’’ as the outcome of interest.
Results
One thousand four hundred mothers were approached, and
741 (52.9%) agreed to participate. Of the respondents, the
feeding behavior was 84 (11.3%) EFF, 179 (24%) EBF, and
478 (65%) BF+F. While maternal age and race did not play a
factor in influencing feeding behavior during univariate
analysis, maternal education, marital status, and religion did
play a role across all groups (Table 1). Mothers with higher
levels of education (some college or more) were 2.6 times
more likely to EBF than those with a high school diploma or
less (95% CI 1.74–3.78). Married women were more likely to
EBF compared to their unmarried counterparts (74.2 versus
51.7%, p<0.002), whereas single mothers were more likely
to EFF (48.3 versus 25.8%, p<0.009).
Mothers, who EBF, were more likely to have delivered
vaginally than surgically (71.8% versus 52.9%, p<0.012).
Furthermore, in accordance with prior data, cesarean delivery
was associated with increased rates of EFF compared to
vaginal deliveries (Table 1).
12
When adjusting for con-
founding factors by logistic regression, EBF mothers were
more likely to have had skin-to-skin contact in the delivery
room compared to their EFF counterparts (72.1% versus
55.3%, p<0.035). When looking specifically at only BF
mothers (EBF and BF+F), skin-to-skin contact continued to be
associated with EBF (72.1 versus 55.3%, p<0.035). Contrary
to prior studies, NICU stay did not negatively impact BF
rates
13,14
as there was no significant difference in feeding
behavior between groups (Table 1).
Among postpartum mothers, Jewish and Catholic mothers
comprised the two largest religious groups. Across all religious
groups, Jewish mothers were more likely to EBF or BF+F,
whereas Catholic mothers were more likely to EFF (18.9%,
p<0.01) (Table 1). Furthermore, Jewish mothers were less
likely to EFF (OR=0.34, 95% CI 0.19–0.60) or plan to use
formula upon discharge (11.9% versus 25%, p<0.05). In ad-
dition, while they were less likely to undergo cesarean section
and, independent of that, more likely to experience skin-to-
skin contact compared to non-Jewish mothers, Jewish women
were independently more likely to breastfeed and use formula
as mentioned above (77% versus 70%, p<0.04). Also, despite
higher rates of BF +F in the hospital, Jewish mothers were less
likely to plan to use formula upon discharge (11.9% versus
25%, p<0.05) and reported breastfeeding prior children for
longer periods compared to other religious groups (Table 2).
With respect to other cultural influences, Hispanic back-
ground influenced formula use (Table 2). While we did not
find increased rates of supplementation among Hispanic
mothers as found in prior studies, these mothers were sig-
nificantly more likely to cite perception of low milk supply as
their reason for supplementation (47.4% versus 33.9%,
p<0.02)
15
and planned to use formula upon discharge (Ta-
ble 2) for the same reason (71.4% versus 52.9%, p<0.0002).
Having been breastfed in one’s own infancy was also asso-
ciated with EBF relative to those who were not (Table 1).
Furthermore, they were less likely to plan to use formula upon
discharge compared to the BF +F feeding mothers. Similarly,
when looking at all three feeding groups, mothers born in the
United States were more likely to EFF, while those born outside
the United States were more likely to EBF (Table 1). Supple-
mentation rates, however, did not differ between the two groups.
Primiparous state was also associated with higher rates of EBF,
REASONS FOR POSTPARTUM FORMULA SUPPLEMENTATION 197
while multiparous mothers were more likely to BF +F
(Table 3). There was no correlation between length of prior
breastfeeding experience among multiparous mothers with
respect to feeding behavior. However, prior BF experience
increased the likelihood of supplementation in mothers who
chose to BF (Table 3). Furthermore, the number of previous
children breastfed did not play a role in feeding behavior.
When examining length of prior BF experience, Jewish wo-
men who EBF or BF +F did so for significantly longer periods
than non-Jewish women (Table 2).
With regard to inpatient breastfeeding support, the vast
majority of both the EBF and BF +F groups reported receiving
adequate support from staff (Table 4). Of concern, mothers in
both the EBF and BF +F groups frequently reported being
offered formula without having requested it. This offers an
opportunity for self-improvement for providers in a hospital
looking to enhance breastfeeding success. While not statisti-
cally significant, there was a trend toward increased supple-
mentation in mothers who were offered formula without
asking (Table 4). Furthermore, there was a significant differ-
ence in supplementation rates in groups who received educa-
tion on the adverse effects of formula on breastfeeding duration
relative to those who did not. Education was provided in the
form of clinical instruction by the physicians, nurses, and staff
Table 1. Maternal Characteristics
Maternal characteristics
EFF EBF BF +F
p*n=84 n=179 n=478
Gestational age (weeks), mean –SD 38.8 –2.0 39.2 –1.2 39.0 –1.6 0.55
Birth weight (g), mean –SD 3370 –502 3329 –411 3388 –499 0.19
Delivery method, %
Vaginal 10.3 26.1 63.6 0.04*
C-section 16.1 18.1 65.8
NICU admission, %
Yes 7.70 20.0 72.3 0.43
No 11.4 24.9 63.7
Maternal age (years)
£17 0.00 40.0 60.0 0.41
18–24 9.20 22.7 68.1
25–30 13.4 27.3 59.3
31–35 9.40 24.7 65.9
36–40 12.4 17.5 70.1
>40 5.30 15.8 78.9
Race, %
Caucasian 12.4 25.6 62.0 0.46
African American 11.6 18.8 69.6
Hispanic 9.90 21.3 68.8
Asian 10.3 24.1 65.5
Others 0.00 36.0 64.0
Religion, %
Jewish 5.50 21.7 72.8 0.001*
Catholic 18.9 24.1 57.0
Muslim 7.40 29.6 63.0
Christian/Protestant 7.04 32.4 60.6
None 19.4 8.3 72.2
Others 4.40 43.5 52.2
Marital status, %
Single/divorced 18.1 20.5 61.4 0.005*
Married 8.90 25.6 65.5
Education, %
No high school diploma 11.6 14.7 73.7 <0.0001*
‡High school diploma 10.7 33.2 56.1
Birth place, %
U.S. born 14.3 22.4 63.3 <0.0001*
Non-U.S. born 5.00 27.3 67.8
Mother breastfed as infant, %
Yes 4.60 28.6 66.8 <0.001*
No 22.9 22.4 54.6
Do not know 14.3 6.5 79.2
Skin-to-skin contact, %
Yes 10.3 26.4 63.3 0.04*
No 13.8 17.1 69.1
*Statistical significance was defined as p<0.05, which signifies that a difference exists across all three groups. Further analysis was
performed to identify those differences.
BF+F, breastfeeding with formula; EBF, exclusive breastfeeding; EFF, exclusive formula feeding; SD, standard deviation.
198 PIERRO ET AL.
of the postpartum unit and was not standardized across groups.
Ironically, mothers who were educated were more likely to
supplement than those who were not (Table 4), raising the con-
cern that education is only provided when the request for formula
is made. Furthermore, regarding BF education, when looking
specifically at EFF mothers, most mothers reported knowing
many benefits of BF and that even had they known more, only
12.5% said they would consider BF—a relatively small but
significant number. In addition, of the EFF mothers, only 3.2%
expressed interest in receiving more information about BF de-
spite only 82.5% reporting receiving any education at all.
Finally, when asked to select the reasons they chose to sup-
plement their breastfed newborns with formula, BF +Ffeeding
mothers cited low milk supply (36.4%), the desire to rest
(35.4%), or the plan to BF +F (35.2%) as the three most com-
mon reasons (Table 5). When asked reasons for supplementa-
tion upon discharge, perception of low milk supply remained the
commonest reason cited for formula use (Table 5). Interestingly,
not all mothers who BF +F in the immediate postpartum period
planned to use formula upon discharge, highlighting the in-
creased risk of formula supplementation during this time.
5
Furthermore, the percentage of mothers who planned to use
formula after discharge was significantly higher in the BF +F
feeding group (90.1%) compared to the EBF group (9.4%),
which suggests planning to supplement is a risk factor for in-
hospital formula use. Although interesting, this small subset of
mothers who EBF despite planning to use formula was too small
to perform further analysis.
Table 2. Religious and Ethnic Influences on Breastfeeding (Excluding EFF)
Jewish mothers Non-Jewish mothers
pEBF and BF +F EBF and BF +F
Feeding behavior, %
EBF 23.0 30.4 0.045*
BF+F 77.0 69.6
Prior BF duration, %
Among those who BF in the past (months) <0.0001*
0–3 3.43 30.2
3–6 4.90 23.1
6–9 10.8 13.2
9–12 25.5 11.5
12–18 42.7 13.7
18–24 12.3 7.14
>24 0.50 1.10
Hispanic mothers Non-Hispanic mothers
pEBF and BF +F EBF and BF +F
Used formula in hospital, % yes 76.4 71.4 0.31
Cited perception of low milk supply as reason, % yes 47.4** 33.9 0.02*
Plan to use formula upon discharge, % yes 71.4 52.9 0.0002*
*Statistical significance was defined as p<0.05.
**Excluding EBF.
Table 3. Maternal Experience
EFF EBF BF +Fp
Parity, %
First-time mother 11.0 35.0 54.1 <0.0001*
Experienced mother 11.1 20.0 68.9
Previous breastfeeding, %
Excluding EFF 0.03*
Yes — 23.4 76.6
No — 31.6 68.4
Parity, %
Excluding EFF <0.0001*
First-time mother — 39.3 60.8
Experienced mother — 22.5 77.5
Previous average breastfeeding duration in each feeding
group (months), %
0–3 42.1 13.8 18.7 0.38
3–6 5.26 12.8 13.9
6–9 10.5 8.51 12.6
9–12 5.26 22.3 17.1
12–18 31.6 30.9 28.1
18–24 5.26 10.6 9.03
>24 0.00 1.06 0.65
*Statistical significance was defined as p<0.05.
Table 4. Inpatient Breastfeeding Support
Inpatient BF support EBF BF +Fp
Offered formula without
asking, % yes 18.1 25.5 0.06
Received adequate support, % yes 88.2 88.9 0.54
Educated on consequences
of formula supplementation
on breastfeeding, % yes 36.1 46.1 0.03*
*Statistical significance was defined as p<0.05.
REASONS FOR POSTPARTUM FORMULA SUPPLEMENTATION 199
Discussion
While many studies have highlighted the negative effects
of formula supplementation on the BF relationship,
16
few
have highlighted the reasons that women choose to formula
feed their infants. The results of our study are unique as they
represent a large sample of diverse women in an urban com-
munity teaching hospital in New York City and are easily
translatable to other centers. In addition, unlike prior studies
investigating maternal reasons for formula supplementation,
our study occurred in real time and directly asked the mothers to
report their reasoning and was done on day of discharge,
hopefully eliminating recall bias. Despite local efforts, such as
the pathway to Baby-Friendly designation and discontinuation
of free formula samples at discharge, formula use was wide-
spread (76.3%) in our population.
17
The most commonly cited
reasons—perceived low milk supply, the need to rest, and the
plan to BF+F—are all potentially amenable to provider inter-
vention and will be the focus of the remainder of this discussion.
Notably, only 53% of women who delivered newborns at
our institution completed the study. Therefore, we do not
have data on mothers who elected not to complete the survey.
We believe the distribution of the surveys combined with the
method by which they were distributed accounts for this
lower than desired response rate. As mentioned above, the
surveys were distributed and completed by mothers rather
than administered by staff. In addition, they were distributed
by the house staff, NP, or PA provider covering the Well
Baby Nursery. Clinical duties sometimes limited their ability
to follow up and collect surveys or remind mothers to com-
plete the survey. However, despite this lower than desired
participation rate, compared to hospital data of the overall
patient population from the same 6-month period, our study
population was relatively similar with respect to feeding
practices. While EFF rates were almost identical between our
study participants and our patient population (11.3% versus
12.9%, respectively), there were differences in the rates of
EBF and BF+F. Our respondents had a lower rate of EBF
(24% versus 35.4%) and a higher rate of BF +F (65% versus
45%) than our patient population.
The focus of our study was to determine reasons mothers
supplement with formula to identify potential educational ef-
forts to combat these reasons. Of the reasons cited for formula
use, perception of low milk supply was the most common, a
well-established theme in the current literature.
18–20
In-
adequate milk production is most often related to infrequent
breast stimulation and emptying, commonly due to formula
supplementation, rather than organic causes.
21
This highlights
the importance of educating mothers on milk production, milk
supply, and infant needs in the first weeks of life. In particular,
mothers must understand that infants’ nutritional needs are
adequately met by the small volumes of colostrum initially
produced.
22
Mothers should also be educated on the demand
and supply nature of breast milk production and the adverse
effects of long intervals between nursing sessions on milk
supply.
21
Mothers should also understand the normal breast-
feeding frequencies early in life and the use of objective tools,
such as weight gain and stool output, to ensure adequate intake.
Furthermore, use of tools, such as a recently established weight
loss nomogram, can reassure mothers of adequate intake.
23
Maternal desire to rest was also frequently cited by our
study participants as a reason for formula use. This was not
surprising as a recent study found that maternal fatigue
was a risk factor for formula supplementation of breastfed
infants.
24
Despite efforts of the Baby-Friendly Hospital In-
itiative to promote rooming-in, the practice of mother and
infant sharing the same hospital room, rates in our institution
remain relatively low.
3
While counterintuitive, it is important
to emphasize to mothers that mother–infant separation
overnight has not been shown to increase maternal restful-
ness. A prior study found that women who breastfed exclu-
sively averaged 30 minutes more nocturnal sleep than women
who used formula.
25
A similar study showed that although
breastfeeding mothers spent more time awake at night than
their formula feeding counterparts, they had no difference in
total daily sleep time and no statistically significant differ-
ence in restfulness and daytime function.
26,27
One of the most concerning revelations of this study was
the high percentage of women reportedly being offered for-
mula without asking. Along with discontinuing free formula
samples in our institution, nursing staff was also educated to
only provide formula upon maternal request. In addition, that
request should prompt assessment of breastfeeding as well as
education on the effects of BF+F. If the mother still wishes to
use formula after these efforts, only then should it be pro-
vided. While not statistically significant, there was a trend
toward offering formula, leading to increased use ( p=0.06)
(Table 4). As mentioned above, our data also revealed higher
rates of supplementation in women who received education
about the effects of formula use. We do not believe this is a
cause and effect relationship but rather due to education only
being offered upon maternal formula request, when any ed-
ucational efforts may no longer be successful. Similar to the
need for breastfeeding education to occur prenatally, the
discussion about the negative effects of formula use on
Table 5. Maternal Reasons for Formula
Supplementation
Maternal reason, %
BF +F in the
immediate
postpartum
period
Plan to use
formula
after
discharge
BF +F
BF +F
and EBF
n=478 n=371
Not enough milk 36.4 23.5
Need to rest postpartum 35.4 —
Desire for partner to feed — 23.2
Plan to breast and bottle feed 35.2 —
Returning to work — 18.1
Separated from baby 6.07 —
Desire to quantify feeds 4.60 —
Medical necessity 3.14 —
MD recommends 2.51 —
Plan for short breastfeeding
duration
1.68 —
Other children to care for — 22.4
Formula equivalent to BM — 9.70
Formula superior to BM — 0.30
Mothers were allowed to select more than one reason. Fields
without data represent questions that were not applicable for that
period (immediate postpartum, after discharge).
200 PIERRO ET AL.
breastfeeding should be done before maternal request to use
formula.
While Hispanic mothers were not more likely to BF+F
compared to their non-Hispanic counterparts, our study re-
vealed that they were significantly more likely to cite percep-
tion of low milk supply as their reason for supplementation,
consistent with prior studies.
15
In addition, compared to other
breastfeeding mothers, they were also more likely to plan to use
formula upon discharge, another common theme in the litera-
ture.
28
The practice of ‘‘los dos’’—or BF+F as referred to by
Hispanic mothers—is widespread, and providers should be
aware of this cultural practice. The need to return to work and
common cultural beliefs, such as a fear that the baby is not
taking enough as well as the desire for the baby to be ‘‘gordito’’
(chubby)—a sign of a healthy child—may account for this
finding.
28
Childhood obesity rates in Hispanic children have
been increasing,
29
and the trend appears to begin in infancy.
Efforts to decrease supplementation will not only decrease
early overfeeding, but it will also impart the decreased obesity
risk associated with EBF.
Jewish mothers in our cohort, who are largely Hasidic Or-
thodox practitioners and grand multiparouswomen, were more
likely to BF+F, less likely to plan to use formula upon dis-
charge, and more likely to report longer prior breastfeeding
durations compared to other groups (Table 2). These data im-
ply that their use of formula does not negatively impact their
breastfeeding duration. Jewish mothers reported the need to
rest as the most commonreason for formula supplementationin
the hospital. Strong family and community support of EBF
may in part immunize them from the adverse effects of early
formula use. In addition, use of breastfeeding as a means of
birth control
30
may provide additional motivation for pro-
longed BF. Aside from sociocultural factors, EBF was more
likely in mothers who had been breastfed in their own infancy.
This implies that having a grandmother who values breast-
feeding and has breastfed herself is more likely to support the
mother and lower her risk of early weaning.
31
In our cohort,
there was a significantly higher proportion of Jewish women
than non-Jewish women who were breastfed themselves in
infancy (84% versus 57%, p<0.0001).
In the case of infants admitted to the NICU, while data
generally support increased rates of formula supplementation,
which is well established to lead to a shorter duration of
breastfeeding,
14
more recent data revealed increased BF du-
ration in special care nurseries.
13
An increase of 10% in overall
likelihoodto breastfeed was attributed to increased exposure to
positive messages and educational efforts promoting breast-
feeding. While this study did not directly address formula
supplementation rates, it is consistent with our findings that
NICU admission did not lead to increased formula use and may
explain the finding in our cohort. Similarly, other factors that
were associated with exclusive breastfeeding such as higher
maternal education and the plan to EBF, have also been shown
to be associated with EBF in other recent studies.
24
Interestingly, the highest rates of EBF were among
breastfeeding-inexperienced primiparous women. We suspect
that current educational efforts focus on first-time mothers
with the assumption that experienced mothers do not require as
much education. Providers should make a conscious effort not
to overlook these experienced mothers who have misconcep-
tions and/or prior experiences that may prevent EBF in sub-
sequent children.
Conclusions
Providers can predict risk of formula use by identifying
maternal characteristics, such as single marital status, lower
educational achievement, cesarean deliveries, and increased
parity. The practice of skin-to-skin contact should continue to
be promoted in an effort to increase EBF rates. Mothers of all
breastfeeding experience levels should receive equal time
and effort when it comes to breastfeeding support.
Acknowledgments
The authors gratefully acknowledge the nurses, NPs/PAs,
residents, and other staff of the postpartum unit at the Staten
Island University Hospital for their assistance in collecting
data for this study. We would also like to acknowledge our
Spanish interpreter, Vivian Alestra, for her assistance in
translating our survey into Spanish.
Disclosure Statement
No financial interests exist.
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Address correspondence to:
Jonathan Blau, MD
Department of Pediatrics
Staten Island University Hospital
475 Seaview Avenue
Staten Island, NY 10305
E-mail: jblau@northwell.edu
202 PIERRO ET AL.
