Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Mary Barger, PhD, MPH, CNM, FACNM-Chairperson; Cynthia D. Connelly, PhD, RN, FAAN; Debra Poeltler, PhD, MPH, RN


breastfeeding, exclusive breastfeeding, hospital factors, nursing factors, risk, supplementation


Background: Formula supplementation of healthy, term, breastfed infants born to mothers who plan to exclusively breastfeed persists at high rates, in spite of global reduction efforts. The identification of modifiable risk factors for supplementation and effective nursing care for successful breastfeeding is understudied.

Purpose: This study aimed to better understand the obstetrical, hospital, and nursing factors associated with supplementation during the hospital stay. The aims were: (1) examine the relationships between aspects of hospital care of infants who are supplemented compared to infants exclusively breastfed and (2) determine what in-hospital risk factors increase the odds of formula supplementation among a sample of breastfeeding infants.

Methods: This was a retrospective analysis of prospectively collected data from the electronic medical record. The cohort was a 25% random sampling of term, healthy, singleton infants born to mothers planning exclusive breastfeeding at a large tertiary hospital between January and June 2015. Adjusted odds ratios and 95% confidence intervals was calculated using logistic regression.

Results: Total sample was 1,023 with 222 (22%) supplemented. Most of the women were primiparous (88%) and 69% experienced a vaginal birth. Less than 50% of infants, reportedly initiated breastfeeding in the first hour after birth. If first breastfeed was after one hour, odds of supplementation increased to 1.42 (1.02, 1.96) Infants born to multiparous mothers had an OR 3.01 (1.95, 4.64) and similar odds were observed for women with a cesarean. Infants born during the evening hours had twice the odds of being supplemented compared to those born 6 am to noon (OR 2.10; 95% CI 1.30, 3.09). No other birth time periods showed a statistically significant increase. Mother-infant dyads who experienced a lactation consultation were more than three times as likely to be supplemented (OR 3.08 [1.88, 5.03]).

Conclusions: Hospital policy to support attempts or initiation of breastfeeding in the first hour of life may help to reduce the odds for formula supplementation. Reducing the percentage of cesareans among healthy, women with uncomplicated pregnancies, may decrease odds for formula supplementation. The effect of the breastfeeding experience with the first birth on subsequent births needs more study.

Document Type

Dissertation: Open Access