Transitions in Breastfeeding

Journal of Human Lactation
http://jhl.sagepub.com
Transitions in Breastfeeding: Daily Parent Diaries Provide Evidence of Behavior Over Time
Jennifer L. Bodnarchuk, Warren O. Eaton and Patricia J. Martens
J Hum Lact 2006; 22; 166
DOI: 10.1177/0890334406286992
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Original Research
Transitions in Breastfeeding: Daily Parent Diaries
Provide Evidence of Behavior Over Time
Jennifer L. Bodnarchuk, PhD, Warren O. Eaton, PhD,
and Patricia J. Martens, IBCLC, PhD
Abstract
This study addressed a key question for assessing breastfeeding duration: at what point is an
infant considered no longer exclusively breastfed or no longer breastfed at all? Mothers provided longitudinal infant feeding data via daily checklists. Transitions between exclusive to
partial breastfeeding and partial to no breastfeeding were compared across 11 time periods for
10 age groups of infants. Daily transitions between exclusive and partial breastfeeding were
common, especially for infants 6 months of age and younger, and transitions from partial to
no breastfeeding occurred much more quickly than transitions from exclusive to partial breastfeeding. Ages at supplementation and weaning calculated in 1-day or 7-day spans correlated
highly (intraclass correlation = .99). These results support the Breastfeeding Definitions and
Data Collection Periods guideline recently developed by the Breastfeeding Committee for
Canada and may bring the breastfeeding research and clinical communities closer to a consensus on the definition of breastfeeding over time. J Hum Lact. 22(2):166-174
Keywords: exclusive breastfeeding, partial breastfeeding, longitudinal study, infant feeding
transitions, diary method
Breast milk can quite readily be described as broadspectrum medicine as well as nutrition,1(p 411) and it and
Received for review June 28, 2005; revised manuscript accepted for publication October 2, 2005.
This research was funded by the Social Sciences and Humanities Research
Council of Canada Research Grant 410-2001-0467 to Warren O. Eaton.
No reported competing interests.
Jennifer L. Bodnarchuk recently completed her PhD in Developmental
Psychology at the University of Manitoba, Winnipeg, Canada. Warren O.
Eaton is a professor of Developmental Psychology at the University of
Manitoba and directed the 3-year longitudinal Milestones study on which this
research is based. Patricia J. Martens is the director and a senior researcher
at the Manitoba Centre for Health Policy as well as an associate professor
in the Department of Community Health Sciences, University of Manitoba.
The authors thank Linda Romphf, IBCLC, for her valuable help during
analysis interpretation and manuscript preparation; Wendy Guenette, Dene
Ryz, Amy De Jaeger, and Carolyn Barg for their vital assistance with the
project; and the families for their enthusiastic participation. Address correspondence and requests for reprints to Jennifer L. Bodnarchuk, PhD, e-mail:
jbodnarchuk@mts.net.
J Hum Lact 22(2), 2006
DOI: 10.1177/0890334406286992
Copyright 2006 International Lactation Consultant Association
166
the act of breastfeeding have been designed through

evolutionary history to provide optimal outcomes for
the developing infant as well as for the mother.2 Modern
science has not yet designed an infant formula that can
rival this system, and infants who do not receive breast
milk or experience breastfeeding have, in general, worse
outcomes than infants who do. Thus, several countries
and the World Health Organization have policies in
place that support and recommend breastfeeding.3-5
However, no international accord exists for researchers
and clinicians regarding the best operational definition
of breastfeeding.6-8 This shortcoming is not because of
lack of interest. Labbok and colleagues6,9-10 have made
calls to researchers to define breastfeeding in uniform
terms, and more recently, the Breastfeeding Committee
for Canada (BCC)11 developed a Breastfeeding Definitions and Data Collection Periods guideline for use in
Canada. This guideline defined 5 breastfeeding categories, including exclusive breast milk and total breast
milk. Exclusive breast milk describes infants who have
been fed no other foods or liquids besides breast milk
since birth, and total breast milk describes infants who
J Hum Lact 22(2), 2006
have been fed only breast milk in the past 7 days but
who received a temporary supplementation sometime
since birth.
Both the BCCs guideline and the classification scheme
developed by Labbok and Krasovec6 are straightforward,
yet Labbok and Krasovecs original plea has not
received widespread application,9-10 and it is too early to
know whether the BCC guidelines are useful. Part
of the difficulty in using these schemes may be that they
are designed for use at 1 point in time (eg, the infant
was exclusively breastfed at 3 months of age).7 Use of
these schemes over time is not appropriate because we
cannot label a 2-year-old toddler as exclusively breastfed when he or she was exclusively breastfed up to 4
months of age. For the community of breastfeeding
researchers and clinicians to move closer to an agreedon operational definition of breastfeeding duration,
more information is needed. The purpose of the current
study was to address 1 key question for such a definition: at what point can we say that an infant is no longer
exclusively breastfed or no longer breastfed at all?
At first, the answer may seem to be, for example, to
ask mothers to retrospectively provide the age at which
their infants were no longer breastfed or exclusively
breastfed.12 Although this seems simple enough at the
outset, once researchers consider that breastfeeding
does not always follow a uniform progression from
exclusive to partial to none,7,13-15 the picture becomes
more complicated. The reversible nature of feeding
patterns makes it difficult to define 1 point in time
when exclusive or partial breastfeeding has ended.
If the strictest definition of the duration of exclusive
breastfeeding were used, that is, exclusive breastfeeding ends the day any other liquid or solid is given, then
most infants would not be exclusively breastfed beyond
their hospital stay after delivery.16-18 While such supplementation in the hospital may affect later breastfeeding and health and developmental outcomes,16,18-21
a different definition that accounts for resumed exclusive breastfeeding would be useful for most researchers.
If mother-infant pairs can resume exclusive breastfeeding after partial breastfeeding for a given length of
time, then how do we assign an end point to exclusive
breastfeeding? Perhaps after a certain duration of partial breastfeeding, the majority of mother-infant pairs
will not return to exclusive breastfeeding, and there
may be a similar period for the transition from partial
to no breastfeeding. It would be useful for breastfeeding researchers and clinicians to know whether such a
transitional period is closer to a week or a month in
167
time. However, what that time span is, and how reliable it may be, has not been addressed to our knowledge until now.
Methods
Participants and Procedure
Mothers with young infants living in the city of

Winnipeg and surrounding rural areas in Manitoba,
Canada, were recruited from October 2001 to April
2004 for a longitudinal study of infant gross motor
milestone attainment. Recruitment efforts were targeted
at mothers with infants younger than 8 months of age,
and recruitment methods included brochures delivered
to mothers leaving a large maternity hospital with a
healthy newborn, an invited article in the community
section of the city newspaper, Baby Welcome Wagon
visits to new mothers, and word-of-mouth solicitations from friends and relatives. Each participant
voluntarily telephoned the project coordinator, and if
the infant had not yet begun to walk (which was the
final milestone of interest in the study), the coordinator
mailed a package to the parent once the infant reached
a minimum age of 1 month. The package contained
2 copies of a consent form, age-appropriate versions
of a daily checklist with corresponding instructions,
a health and demographics questionnaire, and postagepaid envelopes. The daily checklists were designed
primarily to obtain information on motor milestones,22
but 4 of 36 checklist items were related to infant feeding: each day, the parent was asked to report whether
the infant received any amount of breast milk, formula,
cow milk, or other solids or liquids, including water.
Parents returned completed checklists monthly.
All study procedures were performed in accord with
the Canadian Tri-Council Policy Statement on Ethical
Conduct for Research Involving Humans, which governs research funded by the 3 major federal funding
agencies in Canada. The Research Ethics Board of the
University of Manitoba approved this study, and the
parents gave written, informed consent.
Data Analysis
The checklists provided continuous daily information

on infant feeding, and although we had information
regarding formula, cow milk, and other solids and liquids, including water, we simply created 2 dichotomous
variables for each day: 1 for breastfeeds and 1 for all
other feeds. Using these 2 variables, each day could be
classified as exclusive breastfeeding (breastfeeds but no
168
Bodnarchuk et al
other feeds), partial breastfeeding (both breastfeeds

and other feeds), or no breastfeeding (other feeds but
no breastfeeds). However, we did not stop at 1 day;
instead, we considered consecutive days simultaneously. For example, we looked at a window of 3 days
and asked whether the infant could be deemed breastfed for that 3-day span. We used window sizes from 1
to 11 days to consider feeding patterns that lasted from
1 day to more than one third of a month.23 For window
size 1, each day was a window. For window size 2,
each window spanned 2 days, and the first window was
checklist days 1 and 2, the second window was days 3
and 4, and so on. The same strategy was used for all
other window sizes up to 11 days, in which the first
window was days 1 to 11, the second window was days
12 to 22, and so forth. Windows were always assigned
starting with the first day of checklist completion, even
though checklist completion started at different ages
and continued for different lengths of time for different
infants.
The categories of exclusive, partial, and no breastfeeding were applied to the various window sizes such
that if any days within the window had breastfeeds and
other feeds, the window was deemed partial. For
example, if an infant were exclusively breastfed on
days 1, 2, and 3 and partially breastfed on day 4, then
the corresponding 4-day window would be classified
as partial. Thus, only 1 day with other feeds among
exclusively breastfed days led to a classification of
partial; likewise, only 1 day with breastfeeds among a
majority of other feeds was also classified as partial.
The category of partial breastfeeding contained a range
of feeding patterns, but exclusive breastfeeding always
meant all days within the window had breastfeeds and
no days had other feeds, and no breastfeeding always
meant no days with breastfeeds and all days with other
feeds, no matter what the window size.
The variation in partial breastfeeding was not a problem in this study because our interest was to determine
when mothers and infants transitioned between exclusive and partial or between partial and no breastfeeding.
We expected some mother-infant pairs to go through
only 1 transition in each category but other pairs to go
through several transitions, for example, from exclusive
to partial, back to exclusive, and then back to partial.
Our strategy of using differently sized windows
allowed us to see the variation in these kinds of flipflopping transitions and whether, once the window size
was large enough, the proportion of infants going
through such transitions approached zero.
J Hum Lact 22(2), 2006
To analyze the transitions, we counted 1 transition

for every time a window was classified differently than
the previous window. For example, a 3-window sequence
of exclusive-partial-exclusive feedings would be counted
as 2 transitions because the exclusive-to-partial shift
would be 1 transition and the partial-to-exclusive shift
would be a second transition. Because we did not
expect transitions to occur between exclusive and no
breastfeeding, we counted transitions during the start
of supplementation (ie, exclusive to partial) separately
from transitions during weaning (ie, partial to none).
Furthermore, because infants at certain ages are more
likely than those at other ages to go through supplementing and weaning transitions, we analyzed the data
by age of infantspecifically, by counting transitions
in 1-month intervals. For example, for all infants in the
sample who had data between the end of their second
month of life and the end of their third month of life
(ie, aged 2-3 months), we summed the number of transitions occurring in that time span for each window
size for each infant. This process was repeated for each
month of age. Because our data had been collected
across different age spans for different infants, we used
data for a given month only when the infant had more
than 90% complete data for that month, and we allowed
each infant to be counted in as many age categories for
which he or she had adequate data. Thus, sample sizes
varied by age of infant.
Because we expected that all exclusively breastfed
infants would transition from exclusive to partial and
from partial to no breastfeeding at least once during
development and that partially breastfed infants would
also go through the latter transition at least once, we
were most interested in the percentage of infants who
transitioned 2 or more times during the start of supplementation and weaning. That is, we were interested
in the cases where the transition from 1 breastfeeding
status to another was reversed.
After calculating the percentages of infants going
through transitions at different ages using different
window sizes, we chose 2 sizes (1-day and 7-day
windows) to compare the durations of breastfeeding
assigned using each window size. For both sizes, the
date assigned for the duration of exclusive breastfeeding was the first day of the first window in which
partial breastfeeding occurred. Duration of exclusive
breastfeeding was defined only for infants whose checklists started with exclusive breastfeeding. The date for
duration of any breastfeeding was assigned to the first
day of the first window in which no breastfeeding
J Hum Lact 22(2), 2006
169
Table 1. Distribution of Mothers Education and Household Income Levels

Current Sample
Comparison Samples
n (%)
City of Winnipeg, %
Province of Manitoba, %
Mothers highest education level

Less than high school
High school and/or some postsecondary
Trade certificate or diploma
College certificate or diploma
University certificate, diploma, or degree
0 (0.0)
104 (28.5)
29 (8.0)
56 (15.3)
176 (48.2)
16.7
29.3
9.0
20.1
25.0
21.4
28.8
9.5
19.8
20.6
Annual household income

<$20 000
$20 000-$40 000
$40 000-$60 000
$60 000-$80 000
>$80 000
Not stated
25 (6.9)
46 (12.6)
71 (19.5)
97 (26.6)
102 (28.0)
24 (6.6)
Table 2. Characteristics of Infants
Birth weight, g
Birth length, cm
Gestational age, wk
No. of monthly checklists
returned
Percentage of days
completed
Age at start of checklist
completion, mo
Age at end of checklist
completion, mo
x- SD
Range
3510 520
52 3
39.8 1.5
8.0 3.4
1640 5130
43 61
33.9 44.3
1 15
96.0 8.9
49.7 100
3.6 2.3
1.0 12.3
9.9 3.4
2.5 17.8
occurred, and duration of any breastfeeding was only

defined for infants who were breastfed at the start of
their checklists. The infants birth date was subtracted
from these dates of duration to produce the infants age
of duration for exclusive and any breastfeeding. For
example, if an infant who was born March 16, 2003,
was first partially breastfed according to the checklists
on July 28, 2003, then the age of exclusive breastfeeding duration would be 4.4 months.
All analyses were performed using SAS version 9.1
(SAS Institute, Cary, NC). The values for the moving
windows were calculated using PROC EXPAND and
other analyses used data set manipulations, PROC
MEANS and PROC FREQ. For the transitions analyses,
95% confidence intervals (95% CIs) were calculated
using PROC MEANS, and for the duration analyses,
intraclass correlations24 were calculated using a
macro by Dr Robert Hamer (http://www.psych.yorku
.ca/lab/sas/intracc.htm). Intraclass correlations assess
the agreement between 2 measurements of the same

outcome, and, unlike Pearson correlations, are lowered
by mean-level differences; therefore, we used the intraclass correlations to determine the level of agreement
between the 2 window sizes in assigning duration-ofbreastfeeding values.
Results
In total, 603 mother-infant pairs enrolled during the

study period. Of these, 427 (71%) submitted at least
1 checklist, but 62 infants records were omitted because
they had fewer than 30 continuous days of checklist data,
leaving 365 (61%) infants with adequate data to conduct
the analyses. Mothers ranged in age from 18 to 44 years
(x- SD = 31 5 years), and their education levels were
similar to those of women aged 20 to 44 years in the city
of Winnipeg and the province of Manitoba (Table 1).25
However, our sample had no mothers with less than a
high school education and roughly twice as many mothers with a university education compared to the general
population. Table 1 also shows that the sample families
had a range of household incomes with a median that fell
between Can$60 000 to Can$80 000, which was higher
than the Winnipeg median of Can$43 385 and the
Manitoba median of Can$41 661.25 Male (n = 183; 50%)
and female (n = 182; 50%) infants had similar birth and
checklist characteristics, and their data were analyzed
together (Table 2).
Table 3 shows the percentage of infants whose transition between exclusive and partial breastfeeding was
reversed. This matrix of percentages by infant age and
window size shows that younger infants transitioned
170
Bodnarchuk et al
J Hum Lact 22(2), 2006
Table 3. Supplementation: Percentage of Infants for Whom the Transition From Exclusive to Partial Breastfeeding Was Reversed, by Age
of Infant and Size of Moving Window
Window Size, d
Age of Infants, mo
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
11-12
10
11
119
198
219
203
189
198
174
160
146
111
26.1
23.2
28.8
24.1
11.6
5.0
6.3
2.5
2.7
3.6
19.3
18.2
16.0
11.3
4.8
1.5
2.3
1.9
2.1
0.9
19.3
14.1
12.3
6.4
2.6
1.0
1.7
1.9
1.4
0.9
16.8
9.6
10.0
3.0
1.6
0.0
1.1
1.9
0.7
0.9
15.1
9.1
8.7
2.0
1.1
1.0
0.6
0.0
0.0
0.0
12.6
6.6
6.4
2.0
1.1
0.5
0.0
0.0
0.0
0.0
8.4
5.1
4.1
2.0
0.5
0.0
0.0
0.0
0.0
0.0
1.7
2.0
1.8
1.5
0.0
0.0
0.0
0.0
0.0
0.0
4.2
3.0
2.3
0.5
0.0
0.0
0.0
0.0
0.0
0.0
5.9
2.5
2.3
0.5
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Table 4. Weaning: Percentage of Infants for Whom the Transition From Partial to No Breastfeeding Was Reversed, by Age of Infant and
Size of Moving Window
Window Size, d
Age of Infants, mo
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
11-12
10
11
119
198
219
203
189
198
174
160
146
111
0.0
1.0
0.5
3.0
2.6
1.0
2.9
3.8
3.4
4.5
0.0
0.0
0.5
1.0
1.6
0.5
1.7
1.9
2.1
2.7
0.0
0.0
0.5
0.5
0.5
0.5
0.6
1.9
1.4
0.0
0.0
0.0
0.5
0.5
0.5
0.5
0.6
1.3
1.4
0.0
0.0
0.0
0.0
0.0
0.5
0.0
0.6
0.6
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.6
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.6
0.6
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
more often than did older infants and that more transitions occurred during shorter windows: the highest
percentages appear in the upper left of the matrix, and
a block of zeros occupies the lower right. In general,
day-to-day (ie, a 1-day window) patterns were the
most variable: 28.8% (95% CI, 22.7%-34.8%) of 4- to
5-month-old infants transitioned back and forth between
exclusive and partial breastfeeding 2 or more times
when considered with 1-day windows, and 26.1%
(95% CI, 18.0%-34.1%) of 2- to 3-month-old infants
did so. That is, for example, after exclusive breastfeeding,
they were partially breastfed for a day or more, and on
a subsequent day, they returned to exclusive breastfeeding. After 4 continuous days (ie, window sizes 4-11)
of partial breastfeeding, we know with 95% confidence that less than 5% of infants older than 5 months
(ie, 5-6 to 11-12 months of age) transitioned back
to exclusive breastfeeding. Conversely, Table 3 shows
that 16.8% (95% CI, 10.0%-23.6%) of 2- to 3-monthold infants continued to transition in spans of 4 days
(ie, a 4-day window) and that only after 8 or more days

(ie, window sizes 8-11) did consistent adherence to
partial breastfeeding approach 95% for the 2- to 3-month
age category.
Detailed exploration of data for the 2- to 3-month-old
infants still transitioning after 8 or more days showed,
for example, 1 mother who reported feeding her exclusively breastfed infant other foods, followed by 10 days
of exclusive breastfeeding, and after another short bout
of feeding other foods, a return to exclusive breastfeeding for an additional 27 days. Other mothers showed
similar patterns, with 18 and 23, 24 and 18, or 17 and
15 days of exclusive breastfeeding during a transitional
period to partial breastfeeding. Of note is that the longer
segments during these transitions were always of exclusive breastfeeding.
Transitions occurred much more quickly during weaning, as evidenced by the lower percentages in Table 4
compared to Table 3. The low percentages mean that
most infants went from partial to no breastfeeding and
J Hum Lact 22(2), 2006
171
100
90
Percent of Infants Breastfed
80
70
Weaning
60
50
40
30
Supplementation
20
10
0
2
10
11
12
13
14
15
Age of Infant in Months
Figure 1. Supplementation and weaning using a 1-day and 7-day moving window: percentage of infants breastfed by age of infant in
months. Black line = 1-day window; gray line = 7-day window.
did not reverse the transition. For example, only 4.5%

(95% CI, 0.6%-8.4%) of infants aged 11 to 12 months
and 3.8% (95% CI, 0.8%-6.7%) of infants aged 9 to
10 months transitioned back and forth between partial
and no breastfeeding 2 or more times when considered
with 1-day windows. After 5 days (ie, window sizes 5-11),
hardly any infants in the current sample transitioned
between partial and no breastfeeding in any age group.
We compared the ages at which first transitions
occurred for infants who had adequate checklist data
using both 1- and 7-day windows. The black lines in
Figure 1 show the percentage of infants in our subsamples (n = 145 for age at supplementation, n = 113 for age
at weaning) who were exclusively or partially breastfed
to each age according to the 1-day window definition.
The horizontal axis in the figure begins at 2 months
because that was the youngest age for which data
existed. The gray lines show the values for durations
calculated using the 7-day definition for the infants in
the same order that the infants were placed according to
the 1-day window definition. This allows a visual comparison of the differences, by infant, between the durations calculated using the 1-day and 7-day windows.
For the supplementation lines in Figure 1, the duration
calculated using the 7-day criterion was always within
1 week of, and equal to or earlier than, the 1-day criterion.
This occurred because in all cases, the day of partial
breastfeeding that counted for the exclusive-to-partial
breastfeeding transition using a 1-day window also

counted for the exclusive-to-partial transition using the
7-day window that contained that 1-day partial breastfeeding window. For example, if August 7 was the first
partial breastfeeding day, then the 1-day window of
August 7 marked the duration of exclusive breastfeeding,
and the 7-day window starting as early as August 1
(August 1-7) and as late as August 7 (August 7-13)
also marked the duration of exclusive breastfeeding.
Because we assigned duration to the first day of the
window, the 7-day duration date would be between
August 1 and August 7. The variation in the placement
of the 7-day window around the corresponding 1-day
window occurred because of the random nature of both
the starting date of checklist completion and the day of
partial breastfeeding.
For the weaning lines in Figure 1, the duration calculated using the 7-day window was always equal to or
later than the 1-day criterion. This occurred because in
all cases, the day of no breastfeeding that counted for
the partial-to-no breastfeeding transition using a 1-day
window did not automatically count for the partialto-no breastfeeding transition using the corresponding
7-day window. The 7-day window required 7 days in
a row of no breastfeeding. Thus, the durations using
each window size were equal only when the 7-day
window began on the day of the 1-day window and the
next 6 days had no breastfeeding. If the 7-day window
172
Bodnarchuk et al
started earlier than the day of the 1-day window, then

the 7-day window would have been a partial breastfeeding window and the transition would be counted as
early as the next 7-day window. In some cases (ie, the
horizontal spikes in the figure), 7 days in a row of no
breastfeeding did not occur until months after the first
no-breastfeeding day.
When we compared the age assigned by a 1-day
window to that assigned by a 7-day window using an
intraclass correlation, we found that the 2 values were
considerably correlated for both supplementation and
weaning: the proportion of variance shared by the 2
measurements was .99 for supplementation (n = 145)
and .98 for weaning (n = 113).
Discussion
A proper research definition of breastfeeding over

time has been sought for several years6-8; however, little
research has been done to show how various definitions
may be useful in the context of real breastfeeding. This
article begins to fill that gap by showing the variation in
breastfeeding transitions over time. By borrowing the
idea of windows used in other research,23 we were able
to investigate the limits of the time span over which
transitions in breastfeeding usually occur. We concluded
that the time span varies by the age of the infant and the
type of transition (ie, exclusive to partial or partial to no
breastfeeding): infants younger than 5 months of age
have longer periods of transition between exclusive and
partial breastfeeding, with 16.8% of 2- to 3-month-old
infants reversing breastfeeding patterns after 4 days or
more. In contrast to the variability seen between exclusive and partial breastfeeding, all infants transitioned
rather quickly from partial to no breastfeeding.
Our results substantiate earlier suggestions that the
onset of supplementation is harder to clearly define
than is weaning: Martens7,26 reported that women faced
difficulty recalling when supplementation began, and
Quandt27 showed that fewer recall errors were made
for weaning than for supplementation. We found that
mothers indeed take longer to make a definite transition
between exclusive and partial breastfeeding compared
to the transition between partial and no breastfeeding.
Thus, our data buttress Martens7 earlier conclusion:
when asked to recall when supplementation began,
mothers may not struggle with faulty memory but
rather with the problem of assigning 1 value to a process
that spans time. Further, mothers varied breastfeeding
patterns make it difficult to ensure that 2 methods for
J Hum Lact 22(2), 2006
determining the onset of supplementation or weaning

will lead to the same result or be interpretable in the
same way. Thus, researchers need to be especially
clear in their definitions of infant feeding practices.
For the purposes of comparing 1-day and 7-day
window definitions, we defined the duration of exclusive
breastfeeding as the time until the first day of the first
window where partial breastfeeding occurred and the
duration of any breastfeeding as the time until the first
day of the first window where no breastfeeding occurred.
However, there were certain limitations within this study
using those definitions. A duration value could only be
assigned for infants with data that included at least 1 relevant transition (eg, some infants were still breastfed at
the end of their final checklist). Further, we could not
guarantee that the ages of duration that we assigned used
the true first windows because we did not have checklist data since birth for any infants. It was possible and
even likely that the infants who were exclusively breastfed at the start of their checklist completion had not been
exclusively breastfed since birth. As well, it was possible
that infants who were partially breastfed at the start of
their checklist completion had not been breastfed every
day since birth. Thus, we could not be certain that our
data produced accurate estimates of breastfeeding duration. Furthermore, because not all infants in our sample
started checklist completion at the same age or continued
for the same number of months, and because using the
windows approach with our data did not provide duration estimates for all infants, we could not determine
the overall percentage of infants who were breastfed
each month. Nonetheless, our available data did provide
a means of comparing the durations calculated using
a 1- or 7-day window.
Given the similarity between durations calculated using
1-day and 7-day windows and the length of transitional
periods, the 7-day approach used in the Canadian guideline11 may better distinguish patterns of breastfeeding for
a majority of infants compared to a single-day approach.
For example, if a mother were asked whether she had
exclusively breastfed her infant on the previous day, a
negative answer would not necessarily suggest that she
had completed the transition to partial breastfeeding.
Indeed, a study of the effect of lactation counseling in
Ghana showed that the percentage of mothers who
reported exclusive breastfeeding in the past 24 hours
increased for the intervention groups during the first
6 months of their infants lives.28 Our results support these
changing feeding patterns: more than 20% of infants
younger than 6 months of age transitioned between
J Hum Lact 22(2), 2006
exclusive and partial breastfeeding in 1-day spans.

Conversely, if a mother were asked whether she had
exclusively breastfed her infant during the previous
week, a negative answer would provide more certainty,
but no guarantee, that she had transitioned to partial
breastfeeding. One caveat, as shown in the current study,
is that for infants 5 months of age and younger, even a
7-day span may not provide a high level of certainty
because approximately 5% to 10% of infants at these
ages continue to transition after 7 days. In addition, the
Ghana study of lactation counseling showed that the
percentage of mothers reporting exclusive breastfeeding
increased for the intervention groups during the first
6 months of life, using intervals as long as 1 month.
However, the increase must be interpreted within the
context of the intervention, which was specifically
designed to increase exclusive breastfeeding rates.
Notably, the control group mothers exclusive breastfeeding rates measured in 1-month intervals did not
increase after 2 months of infant age.28
Seven days may be a conservative time span based
on the results for infants at all ages, but it has the
advantage of being an easy concept for people to grasp:
our lives are structured around weeks of time, and young
infants ages are often described with this metric. Thus,
asking mothers to recall, for example, how old their
infants were when they were first fed other foods at
least 1 day a week may be a successful strategy for
assigning an appropriate value to the duration of exclusive breastfeeding. In the case of weaning, 7 days may
be highly conservative. However, as Figure 1 shows,
durations measured by 1 day or by 7 days are relatively
close for most infants, and either window size may be
appropriate; that is, the precision of daily data collection is not needed because weekly collection provides
essentially the same information.
The substantial level of agreement between the
2 window sizes does not preclude the existence of some
systematic bias. In fact, Figure 1 shows that for supplementation, the 7-day window consistently produced a
younger age than did the 1-day window, and for weaning, the 7-day window calculated a consistently older
estimate of the age of duration. However, this is partially
because of the specific calculations used in the present
study (eg, assigning the 7-day window date of duration
to the first day of the window rather than the middle or
last day). Other strategies may have led to other calculations and potentially other biases. For example, if we had
used the last day of the window, a bias in the opposite
direction would have occurred for supplementation.
173
In addition to the specific calculations in this study,

other cautions for interpretation must be acknowledged.
First, the study was based on a volunteer sample of
Manitoba mothers, and although it is noteworthy that
the participants came from a range of socioeconomic
backgrounds, the median education and household
income levels were higher than provincial averages.
Second, completion of the daily checklists depended
on the mothers motivation to continue completing and
returning the checklists. However, once mothers began
to complete the checklists, they found the task engaging and usually continued for several months. Third,
because the checklists were focused on other aspects
of infant development, the items related to feeding
needed to be very brief; we did not collect information
on the amounts of various foods that the infant was
fed. Nonetheless, such additional information was not
required for looking at transitions from exclusive to
partial and partial to no breastfeeding because exclusive and no breastfeeding were defined in an all-ornone fashion. Fourth, because infants started checklist
completion at different ages, we decided that the best
approach was to analyze the results in 1-month age
groups. This notably limited the window size we could
use. That is, as shown in Tables 3 and 4, no infants
transitioned 2 or more times using an 11-day window.
This is an artifact of the 1-month span because only
two 11-day windows could be counted in a month,
allowing for a maximum of 1 transition. Thus, wider age
spans would have allowed longer transitional periods
to be assessed. Nonetheless, as the windows grew larger,
fewer infants transitioned at these ranges. Finally, the
sample size may be too small to draw general conclusions, but it does provide a step toward a better
understanding of transitions in breastfeeding. Further
research should use larger samples and investigate
infants younger than 2 months and older than 1 year of
age as well as infants from a wider range of demographic
backgrounds.
In conclusion, this study is not a solution to the
problem of defining breastfeeding over time, but it
may provide a step in the right direction. The study
does provide evidence that the Canadian11 guideline
will be a useful way to classify infants at 1 point in
time. That is, defining categories of breastfeeding
using 7 days of information will likely correctly classify more infants than will definitions considering only
1 day. We hope that this study provides the impetus for
future research to move closer to a consensus on the
definition of breastfeeding over time.
174
Bodnarchuk et al
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Resumen
Este estudio considera una pregunta clave de evaluacin de la lactancia materna: hasta que punto se considera que el bebe no recibe lactancia materna exclusiva
o no amamanta? Las madres dieron datos longitudinales
de la alimentacin de sus hijos por medio de un diario
de actividades. Se compararon transiciones de lactancia
exclusiva a parcial y de parcial a no lactancia en 11
perodos en 10 grupos etarios de bebes. Las transiciones
diarias de lactancia exclusiva a parcial fueron muy
comunes, especialmente en los bebes de 6 meses o
menores, y las transiciones de parcial a no lactancia
ocurrieron mucho mas rpido que las transiciones de
lactancia exclusiva a parcial. Se correlacionaron fuertemente (correlacin entre clases = .99) las edades de
suplementacin y cesacin de la lactancia materna que
se calcularon en perodos de 1 da y 7 das. Estos resultados apoyan las Definiciones de Lactancia Materna y la
Gua de Perodos de Recoleccin de Datos desarrollada
recientemente por el Comit de Lactancia Materna de
Canad y puede acercar ms las comunidades de investigacin de lactancia y clnicas para llegar con el tiempo
a un consenso en la definicin de lactancia materna.

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Journal of Human Lactation

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the act of breastfeeding have been designed through

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J Hum Lact 22(2), 2006