Description of the condition

Breastfeeding is the optimal method of infant feeding with numerous benefits for mother and baby (Victoria 2016). Early initiation of breastfeeding is important in reducing neonatal and early infant mortality (Neovita Study Group 2016). It is recommended that infants are breastfed, exclusively, for the first six months of life (WHO 2001), followed by continued breastfeeding for up to two years or beyond, with appropriate complementary foods (WHO 2002). The World Health Organization (WHO) has set a target of increasing exclusive breastfeeding rates at six months to 50% (WHO 2014). Successful breastfeeding can be considered to have occurred when these targets have been met, but the individual woman’s experience also contributes to her sense of breastfeeding success.

Exclusive breastfeeding requires that the breastfed infant takes no other food or drink for the first six months of life (WHO 2008). Specific benefits of exclusive breastfeeding for six months have been identified (Kramer 2012), but achieving this target has proved difficult. Some increases in exclusive breastfeeding for six months have been reported (CDC 2013), although there are variations between countries and continents in rates of exclusive breastfeeding at six months (Callen 2004). In England, 81% of women initiated breastfeeding while 1% exclusively breastfed at six months (McAndrew 2012). In Norway, where 98% of women initiated breastfeeding, 80% continued at six months with 2.1% breastfeeding exclusively (Häggkvist 2010). In Canada, 89% of women initiated breastfeeding, with 26% exclusively breastfeeding at six months (Gionet 2013). In the USA, 80% of women initiated breastfeeding with 21.9% breastfeeding exclusively at six months (CDC 2016). In Asian and Pacific countries, exclusive breastfeeding at six months was achieved to a greater extent and varied from 7% in Hong Kong to 89% in Korea (OECD/WHO 2014).

While many studies report on exclusive breastfeeding rates at six months, few report data at 24 months, but those that do, report rates higher than exclusive breastfeeding rates at six months in most cases. For example, in Northeast Italy, 98% of women initiated breastfeeding, with 6% exclusively breastfeeding at six months and 12% continuing to breastfeed at 24 months (Carletti 2011). A study from Lao People's Democratic Republic reports that 98.8% of women initiated breastfeeding, with 19.4% exclusively breastfeeding at six months and 18.6% continuing to breastfeed at 24 months (Putthakeo 2009), and in Central and Western China, 98.3% of infants were breastfed, 28.7% were exclusively breastfed under six months and 9.4% continued breastfeeding for two years (Guo 2013). While in Mauritius, 93.4% of women initiated breastfeeding, with 17.9% exclusively breastfeeding at six months and 26.1% continuing to breastfeed for up to two years (Motee 2013).

Description of the intervention

How the intervention might work

There are many ways in which the frequency and duration of a breastfeed might work and contribute to successful breastfeeding. Emotional, informational and practical aspects of the intervention might have an effect. The frequency with which a baby breastfeeds may be a source of reassurance or cause difficulty for women in the early days, especially if the baby is perceived to be feeding frequently. This can be misinterpreted as insufficient milk; and has been cited by women as one of the main reasons for supplementing with formula (Pierro 2016) and discontinuing breastfeeding (Marshall 2007; Hinsliff‐Smith 2014; Teich 2014). Frequent feeding can also lead the health professional or family to recommend a bottle feed (Marshall 2007), and complementary bottle feeds have been identified as posing a risk to successful breastfeeding (Howel 2013; Parry 2013).

The informational aspect of the frequency and duration of a breastfeed is crucial to successful breastfeeding. Frequent feeding can undermine a woman's confidence with breastfeeding but women are reassured when they know the reason for frequent feeding (Marshall 2007). Baby‐led breastfeeding encourages the supply feedback mechanism that underpins the physiology of lactation. Baby‐led breastfeeding allows the milk supply to meet the demand set by the baby (Kent 2006; Kent 2012; Jonas 2016), thereby sustaining lactation, encouraging exclusive breastfeeding. However, antenatal expectations of breastfeeding do not always match the woman's reality postnatally (Hoddinott 2012; Hinsliff‐Smith 2014).

Practical (technical) aspects of the frequency and duration of a breastfeed might contribute to successful breastfeeding. It is important especially in the early days that someone sits with the mother for the duration of a breastfeed (Hoddinott 2012) and provides guidance on practical aspects such as; recognising infant feeding cues, milk production and transfer, responsive breastfeeding (Entwistle 2013), attachment and positioning. Some women can find breastfeeding demanding (Hinsliff‐Smith 2014), while others will not find it so (Hoddinott 2012). Scheduled breastfeeding provides a structured and predictable pattern to the frequency and duration of a breastfeed, which would allow the mother to deal with competing demands on her time (Diaz 1995; Leonard 2000; Ghosh 2006) and establish a pattern that would allow her exclusively to breastfeed. However, flexible working hours can also help the working mother continue breastfeeding (Skafida 2012). Mixed patterns of breastfeeding could facilitate baby‐led breastfeeding, and at other times accommodate a schedule.

Why it is important to do this review

Current guidelines issued by the WHO and the United Nations Children’s Fund (WHO 2009), through the Baby Friendly Hospital initiative, encourage baby‐led breastfeeding. It is important to systematically review the evidence of the effectiveness of baby‐led and scheduled breastfeeding, to provide high‐quality evidence to inform women's decisions on the relative effectiveness of each method. It may seem counter‐intuitive to undertake this review and question an aspect of breastfeeding practice that has become so accepted, but it is important to not only base practice on evidence, but also to question and assess such evidence. A review of practice bulletins from the American College of Obstetricians revealed that just one third were based on "good and consistent scientific evidence"'' (Wright 2011, p. 505) and a review of the 'Green Top Guidelines' from the Royal College of Obstetricians and Gynaecologists revealed that overall, less than one fifth were based on high‐quality evidence (Prusova 2014). When questioning an engrained practice such as baby‐led breastfeeding, there is an obligation to undertake research that is robust (Woolridge 2008). Therefore a review of existing trials is an appropriate starting point.

This review is also important as baby‐led breastfeeding despite being considered "an entrenched piece of evidenced based practice" (Woolridge 2008 p. 353), is not always followed, as many women and caregivers seem uncomfortable with baby‐led feeding patterns that deviate from scheduled feeding patterns (Renfrew 2005). This review is necessary to initiate dialogue, as history tells us that the frequency and duration of a breastfeed are very susceptible to changing fashion and trends (Fildes 1986), and the impact of scheduling breastfeeds in the 20th century continues to exert an influence (Manz 1999). Current popular media bears testament to this, where it is evident that guidance is frequently provided to mothers that is not consistent with practice guidelines, as various schedules and restrictions are recommended. Mothers require information on the frequency and duration of breastfeeds (Leurer 2015), but receive conflicting advice (Graffy 2005). Health professionals also require up‐to‐date information (Ogburn 2011), based on the best available evidence.