December 2009

Determinants of Early Weaning and Use of Unmodified Cow’s Milk in Infants: A Systematic Review.

Katrien Wijindaele, PhD; Rajalakshmi Lakshman, MD; Jill R. Landsbaugh, PhD; Ken K. Ong, PhD; David Ogilvie, PhD

Research indicates that the introduction of complementary foods (weaning) before 4 to 6 months of age and unmodified cow’s milk before age 12 months are associated with several health risks. Despite recommendations from several authorities, including the World Health Organization and the American Academy of Pediatrics, the prevalence of early weaning and early introduction of unmodified cow’s milk remains high. Based on this information, the authors of this study completed a systematic review, focusing on the determinants of infant feeding practices. The authors of this study believe that, in order to develop effective interventions discouraging these feeding practices, potential determinants of the timing of introduction of complementary foods and of unmodified cow’s milk to infants diets must first be identified. Therefore, the purpose of this study was to evaluate the strength of evidence for the entire range of potential determinants of these practices and to identify areas for which future research should be focused.

This systematic review identified documents from seven electronic databases and reference lists, and by contacting authors. Seventy-eight studies that were published between 1976 and 2008 and that quantified the association between either feeding practices or its potential determinants were included. All types of potential determinants (i.e. demographic, biological, behavioral, psychosocial) were eligible for inclusion, irrespective of whether they were considered modifiable or nonmodifiable. Study quality was systematically assessed and the distribution of evidence for each determinant was presented in a harvest plot, showing the strength and direction of associations found and the quality of the studies reviewed.The strength of each determinant was then summarized as strong, moderate, limited, or inconclusive.

Results were reported for 43 potential determinants; however, maternal age, maternal education, socioeconomic status, maternal ethnicity, infant sex, parity and breastfeeding were the determinants in which were most intensively investigated. Ultimately, the authors found a strong level of evidence for six determinants of early weaning (i.e. young maternal age, low maternal education, low SES, absence of short duration of breastfeeding, maternal smoking and lack of information/advice from a health care provider) and for two determinants of early introduction of unmodified cows milk (i.e. low maternal education and low SES).

The authors of this study concluded that of all the determinants for which strong evidence was found, improving the advice given by health care providers would be most effective for short-term intervention. More specific research, examining the influence of psychosocial, community and policy factors on infant feeding practices is recommended.

The supplemental article provided below aimed at identifying predictor variables associated with early weaning. In addition to similar determinants discussed in the above study, such as young maternal age and low maternal education other determinants, including a positive attitude towards bottle feeding and a less positive attitude towards breastfeeding, were found.

Continuing Education Article:

Wijindaele, K., Lakshman, R., Landsbaugh, J.R., Ong, K.K., Ogilvie, D. (2009). Determinants of Early Weaning and Use of Unmodifiable Cow’s Milk in Infants: A Systematic Review. Journal of the American Dietetic Association, 109(12), 2017-28.

http://download.journals.elsevierhealth.com/pdfs/journals/0002-8223/PIIS000282230901551X.pdf

Additional Article:

Avery, M., Duckett, L., Dodgson, J., Savik, K., Henly, S.J. (1998). Factors Associated with Very Early Weaning Among Primiparas Intending to Breastfeed. Maternal and Child Health Journal, 2(3), 167-79.