Characteristics and determinants of breastfeeding in mothers of infants who come to healthy child control

Introduction: The current recommendation of the World Health Organization is that babies be fed exclusively with breast milk from the first hour of birth until 6 months of age, when the complementary feeding to breastfeeding begins until approximately 24 months old Children who are not breastfed have six times the risk of dying from infectious diseases during the first two months of life. Materials and methods: Observational, cross-sectional, descriptive and analytical study. Women over 18 years old were biological mothers of children 1 to 24 months of age who attended the control consultation of the healthy child, and the mothers were grouped according to the child’s age group: under 1 month, 1 to 6 months, 7 to 12 months and >12 months. Results: Two hundred mothers were included in total, 50 for each age group of the child, 54.4% between 18 and 25 years. The children were born at term, 52.5% were women. The prevalence of women feeding with breast milk was 94.5%, and the overall prevalence of exclusive breastfeeding was 45.5%. The main reasons associated with the abandonment of exclusive breastfeeding were feelings of lack of satiety of the child (30.3%), poor milk production (23.9%) and occupation or work (14.7%). Conclusion: The knowledge of breastfeeding plays an important role in the population of women in our hospital and it is possible that the quality of the information provided plays a role in the decisions that women would make about feeding their children. *Correspondence to: Javier Eduardo Castañeda-Juárez, Pediatrics Department, University Hospital “Dr. José Eleuterio González”, Universidad Autonoma de Nuevo Leon (U.A.N.L.), Monterrey, Nuevo Leon, Mexico, Tel: (+52) 8116543224; E-mail: rmoralav91@alumnes.ub.edu


Introduction
The feeding of the human being with breastfeeding is a natural biological phenomenon that has been present since the origins of humanity [1]. The current recommendation of the World Health Organization is that the baby be fed exclusively with breast milk from the first hour of birth until 6 months of life, at which time the complementary feeding begins with others Micronutrient-dense liquids and foods suitable for age and culturally acceptable, continuing to breastfeed until 24 months of age, or longer if both the mother and the child so desire [2]. Breastfeeding protects children in their first year of life against the main causes of infant morbidity and mortality such as sudden death, necrotizing enterocolitis, diarrhea, upper and lower respiratory tract infections and otitis media [2][3][4].
According to a meta-analysis published by the WHO on data from middle and low-income countries, children who are not breastfed have six times the risk of dying from infectious diseases during the first 2 months of life than those who are breastfed [4].
The National Survey of Health and Nutrition (ENSANUT) of 2012 showed the deterioration of the practice of breastfeeding in the country, in the analysis of infant feeding in children under two years showed that 38.3% of girls and boys Newborn children are placed in the mother's womb in the first hour of life, exclusive breastfeeding decreased from 22.3% to 14.5% according to the 2006 and 2012 surveys and in rural areas from 36.9% to 18.5% in the same period. Only one third of girls and boys receive breastfeeding every year, and only two seventh after two years [5].
The reduction of exclusive breastfeeding at the national level was 7.9 percentage points from 2006 to 2012, while in rural areas the difference was 18.4 points. Mothers who never breastfed their daughters and sons present reasons that suggest ignorance or little support before and around childbirth to start and establish breastfeeding, such as: I had no milk 37.4% sick mother 13.7% baby did not want 11.4% baby sick 5.3% premature 3.1%.
According to the same survey, 25% of newborn girls and boys are predominantly breastfeeding, so in conjunction with exclusive breastfeeding and other modalities, 55% of newborn girls and boys would be receiving any type of breastfeeding until six months old. The objective of this study was to report the prevalence of infants fed with breastfeeding, as well as describe the characteristics of breastfeeding provided by mothers of infants who attend the consultation of a healthy child at a University Hospital in Northeast Mexico.

Materials and methods
It is an observational, cross-sectional, descriptive, analytical study. It was carried out in women over 18 years of age who are biological mothers of children from 1 month to 24 months of age who attended the external consultation of the Pediatrics service to control a healthy child of the Hospital Universitario "Dr. José Eleuterio González"of the City of Monterrey, Nuevo Leon, México.
The inclusion criteria were: Women over 18 years of age who are direct providers of breastfeeding, who is the biological mother of the infant who comes to the control of a healthy child, children of the mothers to be surveyed who are female and male infants from 0 months to 24 months of life, who attend a follow-up consultation of a healthy child at the Hospital Universitario "Dr. José Eluterio González "of the city of Monterrey, Nuevo León, Mexico, the nursing children must have a clinical record in the intervention hospital, the nursing children must have been born term, the nursing children must having had a joint discharge with his mother after birth. The exclusion criteria were: Infant children with ambiguous genitalia or undefined sex, infants who were born with conditions of prematurity or pathology that conditioned surgical intervention at birth, infants with inborn errors of metabolism, diseases of the digestive system, diseases of the nervous system or any degree of malnutrition. And the elimination criteria included were: Mothers who did not complete the questionnaire or leave questions unanswered, mothers who did not sign informed consent. The patients of each age group of children under 1 month, from 1 -6 months, from 7 -12 months and over 12 months up to 2 years of age who attended the consultation of a healthy child of the consultation were identified No 14 of the Department of Pediatrics of the Hospital Universitario "Dr. José Eleuterio González", for a total of 200 surveys to be collected. The questionnaires of the cases that met the inclusion criteria entered the study, in addition those cases that have some exclusion and elimination criteria were identified so as not to carry out the questionnaire or eliminate it from the total questionnaires to be carried out. The questionnaire consisted of 26 multiple-choice, simple and practical questions to answer a mother of any level of education and socioeconomic status, with direct and understandable questions, so that there is no confusion in the answers (Supplementary file 1).

Ethical considerations
This protocol was approved by the ethics committee of the medical faculty of the Autonomous University of Nuevo León with the approval code PE19-00018. Written informed consent was applied from the patients included in the study.

Statistical analysis
In the descriptive statistics, frequencies and percentages for qualitative variables were reported. In the quantitative variables, measures of central tendency (mean/median) and measures of dispersion (standard deviation / interquartile range) were reported. The Kolmogorov-Smirnov test will be used for normality of the sample. In the inferential statistics, the Chi-square test was used for qualitative variables. A value of P ≤ 0.05 will be taken as significant. The IBM Corp. Released 2011 statistical package will be used. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.

Results
200 mothers of children who were patients under one month, from 1 to 6 months, from 6 to 12 months and from 12 to 24 months of age, 50 respondents per group were included. The majority of respondents were young adults (between 18 and 25 years old, 54.5%), and whose children were 52.5% women and 47.5% men. More than three quarters of the patients were treated at the University Hospital, followed by the IMSS, and almost all of the patients (99%) were residents of the state of Nuevo León ( Table 1). The median week of gestation at which her pregnancy ended was 39 (38-40) weeks, and all patients were pregnant at term ( Table 1).
The type of feeding in the majority of patients was breastfeeding (94.5%), and in 98 of these cases (51.8%) it was combined with formula. The prevalence of exclusive breastfeeding was 45.5% in 91 mothers. 11 (5.5%) of the patients reported feeding their children only with formula. None of the children under one month received formula. The group of children between 1-6 months showed the highest number of mothers who feed only with formula (10% of those corresponding to that age group) ( Table 2).

Table 2. Questions associated with the use of breastfeeding in mothers
In case they have to carry out activities outside the home, 78.5% know how to express milk, however, where there is a high percentage of women who do not know how to express breast milk is in mothers of children under 1 month (40% of respondents for that age group). Half of the women have used tools for milk extraction, and a minority (17%) once used medications to increase milk production. 56% of women know about the existence of milk banks and 90.5% report that they would donate their own breast milk to these human milk banks, and 74.5% report that they would let their son or daughter consume donated breast milk if they were necessary. In case of having a new child, 98% of women would breastfeed again.
We identify some possible risk factors associated with the onset of formula and suspension or abandonment of exclusive breastfeeding (Table 4). We found that women with knowledge about the benefits of breastfeeding is a protective factor (OR, 0.50, 95% CI, 0.27-0.90), however, guidance on breastfeeding during pregnancy (OR, 1.80, 95% CI, 1,001-3.25) and have knowledge about the extraction of milk itself (OR, 2.16, 95% CI, 1.08-4.31) were found as risk factors associated with the start of feeding with formula and abandonment of exclusive breastfeeding, which leads to the recognition of the type of information provided in the orientation for a better education in the family and in the patient, which may be an area of opportunity in favor of the promotion of breastfeeding in the External Consultation of Pediatrics of the University Hospital.

Discussion
The benefits offered by breastfeeding at biological, psychological, socioeconomic, environmental and family levels are well known.
Eleven of the women (17.2%) have never breastfed and 21.9% stopped breastfeeding before the first month. In people who made the decision to give up breastfeeding, the main influencers in making the decision were themselves by their own decision (56 patients, 87.5%) ( Table 2). Table 3 describes the responses related to the characteristics and determinants of breastfeeding in our population of women. We found that a minority reported receiving information through the media or social networks to initiate formula (28%), and was more frequent in mothers of children between 12 and 24 months (42%); In addition, a small percentage of women (16%) report having used mobile applications that promote the benefit of breastfeeding.
Of the women who have stopped breastfeeding, 50% regret doing so, and it is about half of the women in each age group of the child. Most women report having received breastfeeding when they were infants (72%). Most often, mothers breastfeed every 1 to 3 hours (55.5%), with almost a majority in the <1-month (70%) and 1 to 6 months (74%) groups.
In the majority it was reported that they have received an explanation of the correct breastfeeding technique by a health professional and 65.5% report having received guidance about breastfeeding, however, it is rare that they have attended a clinic breastfeeding (19.5%).
Most women know the health benefits of the child (82%) and for themselves (64%) of breastfeeding, and the vast majority (94.5%) would promote breastfeeding feeding. Almost two fifths of women believe it is important to breastfeed up to 2 years, however, 54.5% believe that the optimal time is between 6 and 12 months. In addition, two fifths of women plan to breastfeed until after the year.  However, despite the knowledge of these benefits, there has been an increase in the tendency to stop using this as a habitual way of feeding infants and young children [6,7]. Breastfeeding is a practice promoted, supported and defended by different public and private organizations, both nationally and internationally. However, progress in some cases has become insufficient, and other factors associated with changes in mothers' lifestyles and their active role in society are added.
In our study we study some characteristics and determinants of breastfeeding in mothers of full-term children who received clinical care for their children in a hospital in northeastern Mexico. The majority were young mothers, between 18 and 25 years old. We found a prevalence of exclusive breastfeeding of 45.5%, being higher prevalent in mothers of infants under one year (64%). From this population group we detected mothers who reported supplementing breastfeeding with formula milk, and that there were mothers who began using formula milk exclusively for any reason, being a minority that covers about 5.5%. Most of the reasons why they decided to support infant feeding with formula milk were associated with a feeling of lack of satiety of the child, as well as poor milk production and occupation or work, and were themselves the main influencers in taking the decision to stop exclusive breastfeeding. In other populations it has been found that the family plays an important role in the reason for abandoning breastfeeding, where up to 13.3% have indicated inadequate family support in adolescent mothers [8].
They have come to study reasons why not start breastfeeding, which lists the risk factors of mothers with any disease during pregnancy, having children with low birth weight, being primiparous and a medium and high income level, for This indicates that said population of women requires priority programs to promote breastfeeding [9]. Figuera et al. [9] found that other risk factors for abandonment of breastfeeding are a low socioeconomic stratum, lower schooling, a prolonged hospital duration, not having received information, having received a bottle during the hospital stay or during the first six months of the infant's life [10]. These results are opposite to those reported in our study, however, we do not thoroughly study other important sociodemographic variables of the mothers that could have been intentionally looking for some association factor with these risk factors. Avila, et al since 1978 had described something different, where they related a high socioeconomic level, associated with what they mention as a process of modernization [11]. This could be another reason why in our population the trend in this way, because the region of northeastern Mexico is characterized by high levels of modernization and industrial economic activity.

Conclusion
The prevalence of exclusive breastfeeding is around 45.5% in our population. In addition, we find that the population of women studied mostly refers to a sufficient degree of knowledge about breastfeeding, and that there have been efforts by our institution to instill and promote the practice of breastfeeding.
The knowledge of breastfeeding plays an important role in the population of women in our hospital, since we detect that breastfeeding promotion measures have been promoted and that they may be reflected in the results of our study. It is possible that the quality of the information provided plays a role in the decisions that women would make about feeding their children.
It is important to recognize the main reasons that have led to the abandonment of breastfeeding by mothers, in which interventions could be developed that improve the quality of milk production, or that allow the mother to identify the level and feeling of satiety on the part of his children. On the other hand, given that a large percentage of mothers know about breastfeeding, milk banks and extraction methods and tools, the occupation or work of women remains one of the three major limitations associated with the abandonment of breastfeeding. This could also guide different public health strategies to improve conditions and access to the right of women to breastfeed and the need for children to receive this type of food, for their recognized physiological and public health benefits.