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Effect of Early Limited Formula on Breastfeeding Duration in the First Year of LifeA Randomized Clinical Trial

Educational Objective
To determine whether structured, short-term formula supplementation for at-risk neonates affects the proportion still breastfeeding at 6 and 12 months.
1 Credit CME
Key Points

Question  Does structured, short-term formula supplementation for at-risk term neonates affect the proportion still breastfeeding at 6 and 12 months?

Findings  In this randomized clinical trial that enrolled 164 mother-newborn dyads with newborn weight loss at or above the 75th percentile for hour of age, structured, short-term neonatal formula supplementation did not affect breastfeeding prevalence at 6 months.

Meaning  Using neonatal formula supplementation in a structured, short-term manner did not affect breastfeeding through 6 months; further research is needed to determine its effect on breastfeeding through the recommended duration of 12 months.

Abstract

Importance  Breastfeeding through 6 and 12 months are 2 goals of the Centers for Disease Control and Prevention Healthy People 2020 initiative, but the 6-month goal is met for only 52% of US infants and the 12-month goal for 30% of US infants.

Objective  To determine whether structured, short-term formula supplementation for at-risk neonates affects the proportion still breastfeeding at 6 and 12 months.

Design, Setting, and Participants  This randomized clinical trial conducted at 2 US academic medical centers enrolled 164 exclusively breastfeeding mother-infant dyads of mothers who were not yet producing copious milk and infants who were 24 to 72 hours old with newborn weight loss at or above the 75th percentile for age. Participants were enrolled from January 2015 through September 2016.

Interventions  Early Limited Formula (ELF), a structured formula supplementation protocol (10 mL formula fed after each breastfeeding until mothers produced copious milk), compared with control dyads, who continued exclusive breastfeeding and received a safety teaching intervention.

Main Outcomes and Measures  The study’s primary outcome was any breastfeeding at 6 months. Secondary outcomes included age at breastfeeding cessation and any breastfeeding at 12 months. All outcomes were assessed by maternal phone survey.

Results  Eighty-two newborns were randomized to ELF and 82 to the control group. Mean (SD) maternal age was 31.4 (5.9) years, and 114 (69.5%) self-identified as non-Hispanic white; 20 (12.2%), Hispanic; 17 (10.4%), Asian; 5 (3.0%), non-Hispanic black; and 7 (4.3%), other. Compared with controls, mothers randomized to ELF were less likely to be married (n = 53 [64.6%] vs n = 66 [80.5%]; P = .03) and had shorter mean (SD) intended duration of breastfeeding (8.6 [3.4] vs 9.9 [4.4] months; P = .049). Median (interquartile range) duration of breastfeeding in the cohort was 9 (6-12) months. At 6 months, 47 (65%) infants randomized to ELF were breastfeeding, compared with 60 (77%) of the control infants (absolute difference, –12%; 95% CI, –26% to 3%; P = .12). At 12 months, 21 of the 71 ELF infants available for analysis (29.6%) were breastfeeding, compared with 37 of the available 77 (48.1%) control infants (risk difference, –18%; 95% CI, –34% to –3%). Marital status and intended breastfeeding duration were both associated with breastfeeding duration; models adjusting for these found a hazard ratio for time-to-event of breastfeeding cessation through 12 months of 0.74 (95% CI, 0.48-1.14) for ELF infants compared with infants in the control group.

Conclusions and Relevance  In this cohort with high breastfeeding prevalence, ELF was not associated with any improvement in breastfeeding duration. Future research should examine the effect of ELF in populations at higher risk of early cessation.

Trial Registration  ClinicalTrials.gov identifier: NCT02313181

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Article Information

Accepted for Publication: February 14, 2019.

Published Online: June 3, 2019. doi:10.1001/jamapediatrics.2019.1424

Correction: This article was corrected August 5, 2019, to correct a typographical error in Table 2.

Corresponding Author: Valerie J. Flaherman, MD, MPH, Department of Pediatrics, University of California San Francisco, 3333 California St, PO Box 0503, San Francisco, CA 94118 (valerie.flaherman@ucsf.edu).

Author Contributions: Dr Flaherman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Flaherman, Cabana, Paul.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Flaherman, Cabana.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Flaherman, McCulloch.

Obtained funding: Flaherman, Cabana, Paul.

Administrative, technical, or material support: Cabana, Paul.

Supervision: Paul.

Conflict of Interest Disclosures: Dr Flaherman reported receiving grants from Healthcare Resources and Services Administration during the conduct of the study and research grants from the Bill and Melinda Gates Foundation. Dr Cabana reported serving as a paid consultant for Nestle outside the submitted work. Dr McCulloch reported grants from the National Institutes of Health during the conduct of the study. Dr Paul reported serving as a paid consultant for Johnson & Johnson and the Consumer Healthcare Products Association.

Funding/Support: This study was funded by grant R40MC26820 from the Healthcare Resources and Services Administration/Maternal Child Health Bureau.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

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