Maternal and Child Health Journal

, Volume 20, Issue 7, pp 1539–1548 | Cite as

Factors Associated with Age at Breastfeeding Cessation in Amazonian Infants: Applying a Proximal–Distal Framework

  • Annie D. Kearns
  • Marcia C. Castro
  • Bárbara H. Lourenço
  • Rosângela A. Augusto
  • Marly A. Cardoso
  • The ACTION Study Team


Introduction Breastfeeding is an important determinant of child survival and normal growth and development, but breastfeeding prevalence is generally low in Brazil. Factors associated with infant feeding practices there are not well understood. This paper examines factors associated with breastfeeding cessation in a township in the western Brazilian Amazon. Methods A cross-sectional, population-based study was conducted among children younger than 25 months and collected information on maternal and child characteristics. Survival analysis based on a proximal–distal framework examined the association between breastfeeding duration and socioeconomic and maternal/child biological factors. Results The median breastfeeding duration among 101 children who were no longer breastfeeding was 120 days. Almost two-thirds (63 %) of these children stopped breastfeeding before 6 months of age. In the larger sample of 209 children, 74.6 % had previously been bottle-fed. Considering the full proximal–distal model, a child who had ever been bottle-fed was expected to cease breastfeeding about 88 % sooner than one who was never bottle-fed (p < 0.001). Children in the second-poorest wealth quartile stopped breastfeeding sooner than children in the poorest quartile (p < 0.05). Discussion Breastfeeding cessation in the study area occurred much earlier than the recommended 2 years of age. Factors associated with ending breastfeeding early included ever-use of a bottle, having a single mother, and belonging to the second-poorest wealth quartile. Further research is needed to better understand these factors and other barriers women face to continuing breastfeeding.


Breastfeeding Breastfeeding duration Infant health Amazon Brazil 



The authors gratefully acknowledge all families and health professionals in Acrelândia for their collaboration in this study. This study was funded by the Brazilian National Council for Scientific and Technological Development (CNPq; Grant Nos. 551359/2001-3, 502937/2003-3, 307728/2006-4, and 470573/2007-4), the São Paulo Research Foundation (FAPESP; Grant no. 2007/53042-1), and the Coordination for the Improvement of Higher Education Personnel (CAPES, Ministry of Education of Brazil). ADK received funding as part of Award Number R25TW007505 from the Fogarty International Center, National Institutes of Health, USA. The funders had no influence on the study design, data collection, analysis or interpretation, decision to publish, or preparation of the manuscript.

Compliance with ethical standards

Conflicts of interest

The authors declare no conflicts of interest.


  1. 1.
    Bolton, T. A., Chow, T., Benton, P. A., & Olson, B. H. (2009). Characteristics associated with longer breastfeeding duration: An analysis of a peer counseling support program. Journal of Human Lactation, 25(1), 18–27. doi: 10.1177/0890334408325985.CrossRefPubMedGoogle Scholar
  2. 2.
    Bueno-Gutierrez, D., & Chantry, C. (2015). Using the socio-ecological framework to determine breastfeeding obstacles in a low-income population in Tijuana, Mexico: healthcare services. Breastfeed Med, 10(2), 124–131.CrossRefPubMedGoogle Scholar
  3. 3.
    Byers, T., Graham, S., Rzepka, T., & Marshall, J. (1985). Lactation and breast cancer. Evidence for a negative association in premenopausal women. American Journal of Epidemiology, 121(5), 664–674.CrossRefPubMedGoogle Scholar
  4. 4.
    Cardoso, M. A., Scopel, K. K., Muniz, P. T., Villamor, E., & Ferreira, M. U. (2012). Underlying factors associated with anemia in Amazonian children: A population-based, cross-sectional study. PLoS ONE, 7(5), e36341. doi: 10.1371/journal.pone.0036341.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Cobayashi, F., Augusto, R. A., Lourenco, B. H., Muniz, P. T., & Cardoso, M. A. (2013). Factors associated with stunting and overweight in Amazonian children: A population-based, cross-sectional study. Public Health Nutrition. doi: 10.1017/s1368980013000190.PubMedGoogle Scholar
  6. 6.
    DATASUS. (2011). Taxa de mortalidade infantil em menores de 5 anos from
  7. 7.
    Emond, A., Pollock, J., Da Costa, N., Maranhao, T., & Macedo, A. (2002). The effectiveness of community-based interventions to improve maternal and infant health in the Northeast of Brazil. Revista Panamericana de Salud Publica, 12(2), 101–110.CrossRefPubMedGoogle Scholar
  8. 8.
    Feldens, C. A., Vitolo, M. R., Rauber, F., Cruz, L. N., & Hilgert, J. B. (2012). Risk factors for discontinuing breastfeeding in southern Brazil: A survival analysis. Maternal and Child Health Journal, 16(6), 1257–1265. doi: 10.1007/s10995-011-0885-7.CrossRefPubMedGoogle Scholar
  9. 9.
    Filmer, D., & Pritchett, L. H. (2001). Estimating wealth effects without expenditure data–or tears: An application to educational enrollments in states of India. Demography, 38(1), 115–132.PubMedGoogle Scholar
  10. 10.
    Flacking, R., Wallin, L., & Ewald, U. (2007). Perinatal and socioeconomic determinants of breastfeeding duration in very preterm infants. Acta Paediatrica, 96(8), 1126–1130. doi: 10.1111/j.1651-2227.2007.00386.x.CrossRefPubMedGoogle Scholar
  11. 11.
    Gillespie, B., d’Arcy, H., Schwartz, K., Bobo, J. K., & Foxman, B. (2006). Recall of age of weaning and other breastfeeding variables. International Breastfeeding Journal, 1, 4. doi: 10.1186/1746-4358-1-4.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Granado, F. S., Augusto, R. A., Muniz, P. T., & Cardoso, M. A. (2013). Anaemia and iron deficiency between 2003 and 2007 in Amazonian children under 2 years of age: Trends and associated factors. Public Health Nutrition, 16(10), 1751–1759. doi: 10.1017/s1368980012005617.CrossRefPubMedGoogle Scholar
  13. 13.
    Grant, C. C., Emery, D., Milne, T., Coster, G., Forrest, C. B., Wall, C. R., & Robinson, E. M. (2012). Risk factors for community-acquired pneumonia in pre-school-aged children. Journal of Paediatrics and Child Health, 48(5), 402–412. doi: 10.1111/j.1440-1754.2011.02244.x.CrossRefPubMedGoogle Scholar
  14. 14.
    Greiner, T. (2014). Exclusive breastfeeding: Measurement and indicators. International Breastfeeding Journal, 9, 18. doi: 10.1186/1746-4358-9-18.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Grummer-Strawn, L. M. (1996). The effect of changes in population characteristics on breastfeeding trends in fifteen developing countries. International Journal of Epidemiology, 25(1), 94–102.CrossRefPubMedGoogle Scholar
  16. 16.
    Hörnell, A., Hofvander, Y., & Kylberg, E. (2001). Solids and formula: Assocition with pattern and duration of breastfeeding. Pediatrics, 107(3), e38.CrossRefPubMedGoogle Scholar
  17. 17.
    Jurberg, C., & Humphreys, G. (2010). Brazil’s march towards universal coverage. Bulletin of the World Health Organization, 88(9), 646–647.CrossRefPubMedGoogle Scholar
  18. 18.
    Lamberti, L. M., Fischer Walker, C. L., Noiman, A., Victora, C., & Black, R. E. (2011). Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health, 11(Suppl 3), S15. doi: 10.1186/1471-2458-11-s3-s15.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Lares, B., Rebhun, L., & Souza, M. (1996). The cultural context of breast-feeding: Perspectives on the recent decline in breast-feeding in Northeast and Northcentral Brazil. In G. Rl, S. Ma, & N. Mk (Eds.), At the edge of development: Health crises in a transitional society (pp. 335–362). Durham: Carolina Academic Press.Google Scholar
  20. 20.
    Lima, T. M. D., & Osório, M. M. (2003). Perfil e fatores asssociados ao aleitamentamento materno em crianças menores de 25 meses da Região Nordeste do Brasil. Revista Brasileira de Saúde Materno Infantil, 3(3), 305–314.CrossRefGoogle Scholar
  21. 21.
    da Saúde, Ministério. (2005). Pré-natal e puerpério: Atenção qualificada e humanizada Série A. Ministério da Saúde: Normas e Manuais Técnicos. Série Direitos Sexuais e Direitos Reprodutivos. Brasília.Google Scholar
  22. 22.
    Ministério da Saúde. (2009). Saúde da criança: Nutrição infantil. Aleitamento materno e alimentação complementar Série A. Normas e Manuais Técnicos Cadernos de Atenção Básica Brasília: Ministério da Saúde.Google Scholar
  23. 23.
    Moreira, M. A., Cabral, P. C., Ferreira, H. S., & Lira, P. I. (2012). Overweight and associated factors in children from northeastern Brazil. Jornal of Pediatria’s (Rio J), 88(4), 347–352. doi: 10.2223/JPED.2203.CrossRefGoogle Scholar
  24. 24.
    Muniz, P. T., Castro, T. G., Araujo, T. S., Nunes, N. B., da Silva-Nunes, M., Hoffmann, E. H., & Cardoso, M. A. (2007). Child health and nutrition in the Western Brazilian Amazon: Population-based surveys in two counties in Acre State. Cad Saude Publica, 23(6), 1283–1293.CrossRefPubMedGoogle Scholar
  25. 25.
    Neves, A. C. M. D. (2012). Preditores do aleitamento materno exclusivo, Amazônia Legal e Nordeste, Brasil, 2010. (Mestrado), Universidade de Brasília, Brasília. Retrieved from
  26. 26.
    Parizoto, G. M., Parada, C. M., Venancio, S. I., & Carvalhaes, M. A. (2009). Trends and patterns of exclusive breastfeeding for under-6-month-old children. Jornal of Pediatria’s (Rio J), 85(3), 201–208. doi: 10.2223/JPED.1888.Google Scholar
  27. 27.
    Patel, A., Pusdekar, Y., Badhoniya, N., Borkar, J., Agho, K. E., & Dibley, M. J. (2012). Determinants of inappropriate complementary feeding practices in young children in India: Secondary analysis of National Family Health Survey 2005–2006. Maternal and Child Nutrition, 8(Suppl 1), 28–44. doi: 10.1111/j.1740-8709.2011.00385.x.CrossRefPubMedGoogle Scholar
  28. 28.
    Rosenblatt, K. A., & Thomas, D. B. (1995). Prolonged lactation and endometrial cancer. WHO Collaborative Study of Neoplasia and Steroid Contraceptives. International Journal of Epidemiology, 24(3), 499–503.CrossRefPubMedGoogle Scholar
  29. 29.
    Schwarz, E. B., Ray, R. M., Stuebe, A. M., Allison, M. A., Ness, R. B., Freiberg, M. S., & Cauley, J. A. (2009). Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and Gynecology, 113(5), 974–982. doi: 10.1097/ Scholar
  30. 30.
    Segall-Corrêa, A. M., Marín-León, L., Panigassi, G., Rea, M. F., & Pérez-Escamilla, R. (2009). Amamentação e alimentação infantil. In Ministério da Saúde (Ed.), Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher PNDS 2006: Dimensões do Processo Reprodutivo e da Saúde da Criança (pp. 195–212). Brasília: Ministério da Saúde.Google Scholar
  31. 31.
    Victora, C. G., Horta, B. L., Loret de Mola, C., Quevedo, L., Pinheiro, R. T., Gigante, D. P., & Barros, F. C. (2015). Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: A prospective birth cohort study from Brazil. Lancet Global Health, 3(4), e199–e205. doi: 10.1016/s2214-109x(15)70002-1.CrossRefPubMedGoogle Scholar
  32. 32.
    Vogel, A., Hutchison, B. L., & Mitchell, E. A. (1999). Factors associated with the duration of breastfeeding. Acta Paediatrica, 88(12), 1320–1326.CrossRefPubMedGoogle Scholar
  33. 33.
    Volpini, C. C. D. A., & Moura, E. C. (2005). Determinantes do desmame precoce no distrito noroeste de Campinas. Revista de Nutrição, 18(3), 311–319.CrossRefGoogle Scholar
  34. 34.
    Wayland, C. (2004). Breastfeeding patterns in Rio Branco, Acre, Brazil: A survey of reasons for weaning. Cad Saude Publica, 20(6), 1757–1761. doi: 10.1590/S0102-311X2004000600038.CrossRefPubMedGoogle Scholar
  35. 35.
    Wenzel, D., Ocana-Riola, R., Maroto-Navarro, G., & de Souza, S. B. (2010). A multilevel model for the study of breastfeeding determinants in Brazil. Maternal and Child Nutrition, 6(4), 318–327. doi: 10.1111/j.1740-8709.2009.00206.x.CrossRefPubMedGoogle Scholar
  36. 36.
    Whittemore, A. S., Harris, R., & Itnyre, J. (1992). Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. II. Invasive epithelial ovarian cancers in white women. Collaborative Ovarian Cancer Group. American Journal of Epidemiology, 136(10), 1184–1203.PubMedGoogle Scholar
  37. 37.
    WHO. (2012a). 10 Facts on breastfeeding. Retrieved July, 2012, from
  38. 38.
    WHO. (2012b). Nutrition: Infant and young child feeding data by country. Retrieved July, 2012, from
  39. 39.
    Winikoff, B., & Laukaran, V. H. (1989). Breast feeding and bottle feeding controversies in the developing world: Evidence from a study in four countries. Social Science and Medicine, 29(7), 859–868.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Annie D. Kearns
    • 1
  • Marcia C. Castro
    • 1
  • Bárbara H. Lourenço
    • 2
  • Rosângela A. Augusto
    • 2
  • Marly A. Cardoso
    • 2
  • The ACTION Study Team
  1. 1.Department of Global Health and PopulationHarvard T. H. Chan School of Public HealthBostonUSA
  2. 2.Department of Nutrition, School of Public HealthUniversity of São PauloSão PauloBrazil

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