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Address correspondence to: Emily Nagel, PhD, RD, School of Public Health, Division of Epidemiology and Community Health, 1300 2nd St S, Ste 300, Minneapolis MN 55455.
Despite recommendations from the World Health Organization and the American Academy of Pediatrics to exclusively breastfeed infants for their first 6 months of life, 75% of women do not meet exclusive breastfeeding guidelines, and 60% do not meet their own breastfeeding goals. Numerous observational studies have linked maternal psychological distress (eg, perceived stress, anxiety, and depression) with nonoptimal breastfeeding outcomes, such as decreased proportion and duration of exclusive breastfeeding. The physiological mechanisms underlying these associations, however, remain unclear.
Methods
For this narrative review, we evaluated the evidence of relationships between maternal psychological distress and lactation and breastfeeding outcomes in pregnancy and post partum and the possible physiological mechanisms that facilitate these relationships. We searched PubMed using the following terms: stress, anxiety, depression, breastfeeding, and lactation. Additional search by hand was conducted to ensure a thorough review of the literature.
Findings
Among the studies examined, methods used to assess maternal psychological distress were not uniform, with some studies examining perceived distress via a variety of validated tools and others measuring biological measures of distress, such as cortisol. Evidence supports a role for psychological distress in multiple breastfeeding outcomes, including delayed secretory activation and decreased duration of exclusive breastfeeding. One physiological mechanism proposed to explain these relationships is that psychological distress may impair the release of oxytocin, a hormone that plays a critical role in milk ejection during lactation. Continued impairment of milk ejection may lead to decreased milk production because of incomplete emptying of the breast during each feed. Maternal distress may also yield elevated levels of serum cortisol and decreased insulin sensitivity, which are associated with decreased milk production. The relationship between psychological distress and breastfeeding is likely to be bidirectional, however, in that breastfeeding appears to reduce maternal distress, again possibly via effects on the pleasure or reward pathway and calming effects of oxytocin on the mother. This finding suggests that interventions to support lactation and breastfeeding goals in women who score high on measures of psychological distress would be beneficial for both maternal and infant well-being.
Implications
Evidence to date suggests that maternal psychological distress may impair lactation and breastfeeding outcomes, but stronger study designs and rigorous assessment methods are needed. A better understanding of the physiological mechanisms leading to impaired lactation may assist in the development of early interventions for mothers experiencing distress. In addition, stress-reducing programs and policies should be investigated for their potential to improve breastfeeding outcomes.
Danforth KN, Tworoger SS, Hecht JL, Rosner BA, Colditz GA, Hankinson SE. Breastfeeding and risk of ovarian cancer in two prospective cohorts. Cancer Causes Control. 2007;18:517–523. doi:10.1007/s10552-007-0130-2
for the mother. Despite the known benefits of human milk for infants, only 25% of infants are exclusively breastfed at 6 months of age, and 60% of women do not meet their own breastfeeding goals.
US breastfeeding data for infants born in 2017 reveal that 85% of mothers initiated breastfeeding, but nearly 20% provided formula before their infants were 2 days of age, and <50% were exclusively breastfeeding when their infants were 3 months of age.
Several studies have examined reasons for nonoptimal breastfeeding outcomes (nonexclusive breastfeeding and/or breastfeeding cessation), which include barriers such as unsupportive employment and hospital policies, lactation difficulties, and maternal or health care worker concerns about infant growth and nutrition.
In addition, large disparities in breastfeeding rates exist across racial and ethnic groups, with non-Hispanic black mothers and Native American/American Indian mothers less likely to ever breastfeed compared with other groups.
Maternal psychological distress (eg, perceived stress, anxiety, and depression) has also been linked to lactation difficulty and breastfeeding cessation.
Despite being potentially modifiable, the associations between maternal distress and breastfeeding outcomes are unclear. Thus, in this narrative review we focus our attention on these relationships and the potential physiological processes that drive them.
Lactation and the Mother-Infant Dyad
Successful lactation begins long before the infant is born. The first stage is controlled primarily via increases in estrogen and progesterone secreted from the placenta
and involves rapid differentiation of the mammary epithelium within the highly branched lobular and ductal network of the developing mammary gland. The basal layer of the ductal epithelium becomes the myoepithelium, responsible for milk ejection. The luminal layer of the mammary epithelium is composed of epithelial secretory cells called lactocytes, which synthesize and secrete milk components into the lumen of the alveoli.
High progesterone concentrations during pregnancy inhibit milk secretion, leading to accumulation of small amounts of colostrum and no milk production.
Within 48 to 72 hours after parturition, maternal progesterone levels decrease 10-fold, initiating secretory activation in the mammary gland, with copious production of milk.
Prolactin facilitates sustained lactation as progesterone levels decrease and can regulate many aspects of milk synthesis and secretion, although its primacy as a driver of lactation has come under scrutiny of late.
During early lactation, glucocorticoids assist in the closure of tight junctions between lactocytes, which prevents the leakage of milk components, whereas insulin is observed to facilitate the expression of genes involved in milk protein synthesis.
Sustained adequate milk production depends first on efficient nutrient partitioning and uptake by the mammary gland and second on frequent and complete emptying of milk from the breast and thus rests on the biobehavioral interaction within the mother-infant dyad.
in: Landon M Galan H Jauniaux E Driscoll D Berghella V Grobman W Kilpatrick S Cahill A Cahill A Gabbe's Obstetrics: Normal and Problem Pregnancies. Saunders,
2020: 475-502
Infant suckling stimulates neurons in the areola to trigger the release of oxytocin from maternal hypothalamic neurons in the pleasure or reward pathway, leading to calming effects for the nursing mother.
Infant suckling also prompts oxytocin release from the posterior pituitary into maternal circulation, which causes contraction of the myoepithelial cells surrounding the alveoli to allow milk to be ejected into the ducts for passage to the infant.
If emptying of the breast is partial or infrequent, milk accumulates in the ducts, distending them and exposing the mammary gland to increased concentrations of a small whey protein called feedback inhibition of lactation. Feedback inhibition of lactation provides autocrine feedback control on milk production to match maternal milk supply with infant milk demand.
Successful establishment and continuation of lactation therefore rely on a complex hormonally driven orchestration of glandular development during pregnancy and then secretory activation in the early postpartum period, which must be accompanied by prompt initiation of breastfeeding after delivery, proper infant positioning on the breast and efficient latching to achieve efficient milk removal, positive maternal-infant interaction during feeding, and continued frequent nursing.
Given the deeply biobehavioral and interactive nature of lactation, it is reasonable to consider both maternal and infant psychological health and well-being as potentially important drivers of breastfeeding success.
Maternal Psychological Distress
For this narrative review, we use the term psychological distress to refer to different psychological or physiological responses to stressful challenges, such as cognitive appraisals of stress (ie, perceived stress), symptoms of anxiety or depression, and cortisol levels.
Depression, anxiety, and perceived stress are commonly grouped together to characterize maternal distress in perinatal research, and these symptoms are highly comorbid in the perinatal period.
In response to stress, neurobiological systems activate to protect the body and promote adaptation, facilitated by the sympathetic adrenomedullary system and the hypothalamic-pituitary-adrenocortical (HPA) axis.
Maternal psychological distress during pregnancy has been associated with negative birth outcomes, such as low birth weight, preterm birth, and later risk for neurodevelopmental, psychiatric, cardiovascular, and metabolic disease.
Activation of the HPA axis leading to increased maternal cortisol concentrations is the most commonly studied physiological mechanism for assessing the effects of maternal psychological distress on infant outcomes.
Maternal cortisol can be directly transported across the placenta to enter fetal circulation and has been observed to account for approximately 40% of the variance in fetal cortisol concentrations.
Although most maternal cortisol is metabolized during passage through the placenta, increased maternal cortisol concentrations may still have a significant effect on fetal concentrations.
Furthermore, an increasing body of evidence suggests that maternal HPA axis dysregulation is not the only physiological mechanism responsible for adverse infant outcomes, and indirect mechanisms, such as colonization of the infant gut by maternal microbes, may be affected by maternal distress.
The physiological mechanisms explaining the observed relationships between maternal psychological distress and adverse breastfeeding outcomes remain unclear.
Elucidating these mechanisms may assist in better development of early interventions targeted at improving breastfeeding outcomes among mothers at risk for experiencing psychological distress. Thus, for this narrative review, we aimed to evaluate the evidence of relationships between psychological distress and nonoptimal breastfeeding outcomes in humans and to identify potential physiological mechanisms that could underlie these associations.
Methods
For this narrative review, we evaluated the evidence of relationships between maternal psychological distress and lactation and breastfeeding outcomes (ie, exclusivity and duration) and the possible physiological mechanisms that facilitate these relationships. We reviewed PubMed using the following search terms: stress, anxiety, depression, breastfeeding, and lactation. An additional search by hand was conducted to ensure a thorough review of the literature. Peer-reviewed publications from the United States, Canada, Europe, and Australia were considered for inclusion and selected for their relevance to the review's objectives.
Results
Maternal Psychological Distress and Lactation and Infant Feeding Outcomes
Multiple studies have examined lactation and infant feeding outcomes in relation to maternal psychological distress with varied results, likely because of differences in stress measurement (type and timing of measures), feeding outcomes, and adjustment for confounding factors. In addition, attributing feeding outcomes specifically to maternal psychological distress may be difficult because of the numerous interrelated factors that are potentially associated with lactogenesis (eg, delivery mode, duration of labor, and maternal distress).
Lactogenesis and infant weight change in the first weeks of life.
Integrating Population Outcomes, Biological Mechanisms and Research Methods in the Study of Human Milk and Lactation. Kluwer Academic/Plenum Publishers,
2002: 159-166
Grigoriadis S, Graves L, Peer M, Mamisashvili L, Tomlinson G, Vigod SN, Dennis C-L, Steiner M, Brown C, Cheung A, et al. A systematic review and meta-analysis of the effects of antenatal anxiety on postpartum outcomes. Arch Women's Ment Health. 2018;22:543–556. doi:10.1007/S00737-018-0930-2
The associations between maternal anxiety, depression, or perceived stress and breastfeeding outcomes were inconclusive, with several meta-analyses citing low-quality studies (inadequate adjustment for confounding, lack of uniform definition of breastfeeding, lack of prospective measurements, inadequate statistical power, or insufficient analysis to determine relationship between variables) and heterogenous outcomes. The link between maternal depression and breastfeeding outcomes, however, appears to be stronger, with 1 meta-analysis reporting associations between elevated maternal depressive symptoms and nonexclusive breastfeeding or shorter breastfeeding duration for more than half of the 38 studies examined. In our further review of the literature, 15 studies found positive associations between maternal distress (perceived stress, anxiety, and/or depression) and nonoptimal breastfeeding outcomes, whereas 6 studies found no association, and 5 studies found that maternal distress was associated with increased breastfeeding or provided potential evidence for a bidirectional relationship (because most studies assessed multiple types of maternal distress [ie, prenatal and postnatal anxiety and depression]; some overlap exists between the provided numbers).
There are 2 primary time points when maternal stress may reduce breastfeeding: before breastfeeding begins (eg, by delaying initial milk production [ie, lactogenesis]) or after breastfeeding is initiated. The next sections describe each of these time points.
Delayed Onset of Lactogenesis
Delayed onset of lactogenesis is defined as insufficient milk production in the first 2 weeks post partum.
but several studies have noted associations with long duration of labor and urgent caesarean delivery, which are strongly linked with postpartum stress for both mother and infant at birth.
Lactogenesis and infant weight change in the first weeks of life.
Integrating Population Outcomes, Biological Mechanisms and Research Methods in the Study of Human Milk and Lactation. Kluwer Academic/Plenum Publishers,
2002: 159-166
Women who experience delayed onset of lactation may introduce formula to their infants shortly after birth, and supplementation of human milk with infant formula during hospitalization is predictive of breastfeeding cessation in early lactation.
However, it is possible that providing a small amount of formula in the hospital setting could decrease acute maternal psychological distress and/or improve the perception of adequate milk supply, benefiting long-term exclusivity of maternal breastmilk feeding. A randomized controlled trial conducted by Flaherman et al
assigned participants to receive small formula volumes (10 mL after each breastfeeding) or exclusive breastfeeding before the onset of mature milk production. They hypothesized that early provision of formula would reduce the discontinuation of exclusive breastfeeding by alleviating maternal concerns about milk supply and found that 79% of the formula group were breastfeeding exclusively at 6 months post partum compared with 42% of the exclusive breastfeeding group (P = 0.02).
Insufficient Milk Supply and Decreased Duration and Exclusivity of Breastfeeding
Many women discontinue exclusive breastfeeding when infants are between 3 and 6 months of age, and evidence suggests that maternal psychological distress may also affect breastfeeding even after milk production has been fully established (ie, after 1 month post partum).
Maternal anxiety and depressive symptoms during pregnancy are predictive of depressive symptoms in the postpartum period, which are associated with shorter duration of exclusive (and/or any) breastfeeding.
Maternal depressive symptoms at three months postpartum and breastfeeding rates at six months postpartum: Implications for primary care in a prospective cohort study of primiparous women in Australia.
found that every point increase in the State Trait Anxiety Inventory score at 3 months post partum (when lactation had already been established) was associated with decreased odds of any breastfeeding at 12 months post partum. Exposure to stressful life events may negatively affect breastfeeding exclusivity. Data from the Pregnancy Risk Assessment and Monitoring System reveal that among women ≤24 years of age, the odds of exclusive breastfeeding for 3 months were lower for those who experienced ≥2 stressful life events compared with those who experienced no stressful life events.
Another study documented evidence of bidirectional associations between maternal depressive symptoms and breastfeeding duration in a group of 205 women who were followed up prenatally and at 3, 6, 12, and 24 months after birth.
Women with elevated depressive symptoms during pregnancy weaned their infants approximately 2 months earlier than women who did not experience prenatal depression, and in turn, women who breastfed more frequently at 3 months post partum had greater decreases in depressive symptoms up to 2 years after birth. Similarly, mothers who were exclusively breastfeeding at 3 months post partum had significantly lower perceived stress scores compared with those providing mixed feedings (breast milk and formula).
The association between breastfeeding, the stress response, inflammation, and postpartum depression during the postpartum period: Prospective cohort study.
Inadequate milk supply (perceived or actual) is a commonly cited reason for discontinuation of exclusive breastfeeding both early in lactation and after lactation has been established; approximately 35% of women report early perceived insufficient milk supply as the primary reason for cessation of breastfeeding.
By 8 days post partum, the lactating woman produces a mean of 650 mL of breastmilk per 24 hours; from 1 to 6 months of lactation, a woman who is exclusively breastfeeding produces a mean of 750 to 800 mL per 24 hours.
In a sample of 1323 women, the perception that infants were not satisfied by breastmilk alone was among the top 3 reasons provided by mothers for breastfeeding cessation regardless of weaning age (assessed from 2–12 months post partum).
In this study, inadequate milk supply was reported more often by Hispanic mothers and those with a household income of <350% of the federal poverty level compared with white mothers and those with income >350% of the federal poverty level, suggesting that multiple factors (including nonphysiological factors) may influence breastfeeding duration.
Potential Mechanisms by Which Psychological Distress Affects Lactation
Physiological mechanisms by which maternal psychological distress may impair lactation are not fully elucidated, and much of the existing support for the association between these variables arises from animal studies or from observational studies in humans. We discuss the potential impact of distress on hormones implicated in lactation and on HPA axis–related mechanisms (Fig. 1).
Regulation of Hormones Implicated in Lactation
Lactation is dependent on the intricate coordination of hormones, such as progesterone, prolactin, and oxytocin. One hypothesized physiologic mechanism for the relationship between maternal distress and lactation is the impaired release of maternal oxytocin, which impedes the contraction of myoepithelial cells involved in milk ejection.
found that maternal exposure to stress impaired oxytocin release in response to infant suckling. Participants were exposed to stressors via noise or mental calculation (arithmetic problems), and the number of pulsatile releases of oxytocin in maternal blood was measured. Women in the stressor groups had decreased and delayed responses to suckling and decreased number of oxytocin pulsatile releases. Prolactin levels before and during infant suckling were also measured in relationship to milk secretion volume, and no differences were observed among the groups. The authors concluded that, unlike oxytocin, the increase in prolactin level in response to infant suckling was not impaired by maternal psychological distress. These results are confirmed by studies that have found that higher anxiety and depression scores are associated with lower maternal oxytocin levels during breastfeeding
and that significant interactions between early breastfeeding cessation and depression status on maternal oxytocin levels are present at 8 weeks post partum.
found that positive maternal emotions were associated with increased infant feeding frequency and greater milk volume. Because positive emotions are correlated with increased maternal oxytocin,
Thus, mothers who experience positive emotions and less distress may have better lactation outcomes. However, maternal depression and anxiety are not necessarily predictive of maternal oxytocin levels and may be influenced by other factors. At 2 and 6 months post partum, Whitley et al
found no significant differences in oxytocin levels across a feed between women with symptoms of depression or anxiety versus asymptomatic women.
Maternal distress may affect lactation by interfering with insulin sensitivity and secretion. Insulin and its regulation of glucose are important for optimal lactation. Insulin resistance and impaired glucose tolerance, such as that observed in type 2 diabetes mellitus or gestational diabetes, have been associated with delayed onset of lactation, low maternal milk supply, and decreased breastfeeding duration.
hypothesized that the combined effects of insulin resistance and impaired insulin secretion on insulin-sensitive signaling in the lactocyte (rather than circulating levels of insulin or glucose) are responsible for the decreased rate of milk synthesis. This hypothesis is supported by work from Neville et al,
who found that genes involved in mammary differentiation and milk synthesis were significantly down-regulated in an insulin receptor knockout mouse model. Although rarely examined in studies that assess impaired glucose tolerance and lactation, psychological distress is associated with decreased insulin sensitivity. In animal models, early-life stress impairs insulin secretion in response to psychological stress in adulthood.
Animal (mouse) models also reveal that acute psychological stress can alter glucose metabolism by decreasing hepatic sensitivity to insulin, leading to insulin resistance.
In humans, maternal perception of discrimination, an established psychological stressor, is associated with increased odds of developing gestational diabetes mellitus.
Furthermore, patients diagnosed with major depression exhibit insulin resistance after administration of oral glucose tolerance tests compared with healthy patients.
These studies outline a potential physiological mechanism by which stress-induced glucose dysregulation and insulin resistance may lead to lactation difficulty.
Cortisol and HPA Axis–Related Mechanisms
The HPA axis is activated in response to stress and involves a cascade of hormonal events that lead to release of the glucocorticoid steroid hormone cortisol into the bloodstream. The effects of stress-induced alterations in circulating cortisol are numerous because glucocorticoid receptors are widely distributed throughout the body. Pregnancy and the postpartum period involve normative changes in HPA axis function, which plays a role in lactation.
Cortisol is a necessary cofactor for milk production and is involved in the differentiation of mammary gland cells into lactocytes, as well as milk secretion and lactogenesis.
At the same time, lactation results in a reduction in maternal cortisol levels during feeding and an attenuation of maternal HPA axis reactivity to stress,
further highlighting the protective effects of lactation as well as the likelihood that psychological distress and lactation associations are bidirectional. Both maternal psychosocial distress and difficulties with lactation are associated with altered HPA axis functioning, suggesting that maternal HPA axis dysregulation is a pathway by which maternal distress compromises lactation.
potentially because of measurement differences across studies, failure to consider the interacting effects of multiple hormones (eg, cortisol and oxytocin
The lack of uniform study results is likely reflective of varying sample sizes, measures of psychological distress, and breastfeeding outcomes, as well as limited evidence from animal studies and observational studies in humans because of ethicality of assigning participants into nonbreastfeeding groups. Future exploration of maternal distress and lactation and feeding outcomes should use adequate adjustment for potential confounding factors (ie, parity
Milk composition may be altered by maternal psychological distress and have an impact on lactation and breastfeeding success. The macronutrient content, specifically fatty acid concentration, of human milk is negatively associated with stress reactivity (measured via saliva cortisol in response to cold).
Fatty acids comprise most calories in human milk, and decreased concentrations of fatty acids in milk may lead to decreased infant satiation, affecting maternal perception of adequate milk supply.
Recent evidence supports the finding that milk bioactives may serve as biomarkers for lactation difficulty. We found that bioactives present at 1 month post partum in human milk were associated with breastfeeding cessation by 3 months post partum. Specifically, milk glucose and smaller decreases in glucose from 1 to 3 months post partum were associated with increased odds of exclusive breastfeeding, whereas leptin and increases in insulin and leptin were associated with decreased odds of exclusive breastfeeding
Nagel EM, Kummer L, Jacobs DR Jr, Foster L, Duncan K, Johnson K, Harnack L, Haapala J, Kharoud H, Gallagher T, Kharbanda EO, Pierce S, Fields DA, Demerath EW. Human Milk Glucose, Leptin, and Insulin Predict Cessation of Full Breastfeeding and Initiation of Formula Use. Breastfeed Med. 2021 Aug 3. doi:10.1089/bfm.2021.0131. Epub ahead of print. PMID: 34348043.
A longitudinal examination of maternal, family, and area-level experiences of racism on children's socioemotional development: Patterns and possible explanations.
but has not been thoroughly studied in conjunction with breastfeeding outcomes. However, work-related racism has been associated with lower odds of longer breastfeeding duration, whereas police-related racism has been associated with higher odds of longer breastfeeding duration.
The intersection between racism and maternal psychological distress should be examined in conjunction with lactation and breastfeeding outcomes to understand policies and interventions that may improve these outcomes.
Future research should include an exploration of the bidirectional benefits of breastfeeding on maternal psychological distress and overall maternal health.
In addition, breastfeeding may be used as a coping mechanism for some mothers; higher prenatal maternal marital distress has been associated with longer duration of exclusive breastfeeding.
Current evidence suggests a potential role for acute and chronic maternal psychological distress in lactation success and difficulties, including both establishment of lactation and continued duration of breastfeeding. Both physiological and social or behavioral factors may be involved, but additional studies are needed to understand the mechanisms behind these relationships. Comprehensive strategies to decrease maternal psychological distress, as well as policies that focus on dismantling structural barriers to breastfeeding, may improve breastfeeding outcomes (Figure 1).
Figure 1Maternal psychological distress may impair lactation by (1) interfering with oxytocin release, (2) reducing insulin sensitivity and secretion, or (3) causing dysregulation of the hypothalamic-pituitary-adrenocortical (HPA) axis. Figure created with BioRender.com.
Emily M. Nagel is supported by an grant T32DK083250 from the National Institute of Diabetes and Digestive and Kidney Diseases. Mariann A. Howland is supported by a National Science Foundation Graduate Research Fellowship (00074041). Cynthia Pando is supported by grant T32HD095134 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. David A. Fields and Ellen W. Demerath are supported by grant R01HD080444 Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors have indicated that they have no other conflicts of interest regarding the content of this article.
Acknowledgments
Ellen W. Demerath conceptualized the manuscript; Emily M. Nagel, Mariann A. Howland, and Ellen W. Demerath drafted the original manuscript; Cynthia Pando and Emily M. Nagel constructed the figure; Mariann A. Howland, Cynthia Pando, Jamie Stang, Susan M. Mason, David A. Fields, and Ellen W. Demerath critically reviewed the manuscript; Ellen W. Demerath had primary responsibility for final content. All authors read and approved the final manuscript.
Danforth KN, Tworoger SS, Hecht JL, Rosner BA, Colditz GA, Hankinson SE. Breastfeeding and risk of ovarian cancer in two prospective cohorts. Cancer Causes Control. 2007;18:517–523. doi:10.1007/s10552-007-0130-2
in: Landon M Galan H Jauniaux E Driscoll D Berghella V Grobman W Kilpatrick S Cahill A Cahill A Gabbe's Obstetrics: Normal and Problem Pregnancies. Saunders,
2020: 475-502
Lactogenesis and infant weight change in the first weeks of life.
Integrating Population Outcomes, Biological Mechanisms and Research Methods in the Study of Human Milk and Lactation. Kluwer Academic/Plenum Publishers,
2002: 159-166 (Vol 503)
Grigoriadis S, Graves L, Peer M, Mamisashvili L, Tomlinson G, Vigod SN, Dennis C-L, Steiner M, Brown C, Cheung A, et al. A systematic review and meta-analysis of the effects of antenatal anxiety on postpartum outcomes. Arch Women's Ment Health. 2018;22:543–556. doi:10.1007/S00737-018-0930-2
Maternal depressive symptoms at three months postpartum and breastfeeding rates at six months postpartum: Implications for primary care in a prospective cohort study of primiparous women in Australia.
The association between breastfeeding, the stress response, inflammation, and postpartum depression during the postpartum period: Prospective cohort study.
A longitudinal examination of maternal, family, and area-level experiences of racism on children's socioemotional development: Patterns and possible explanations.
Nagel EM, Kummer L, Jacobs DR Jr, Foster L, Duncan K, Johnson K, Harnack L, Haapala J, Kharoud H, Gallagher T, Kharbanda EO, Pierce S, Fields DA, Demerath EW. Human Milk Glucose, Leptin, and Insulin Predict Cessation of Full Breastfeeding and Initiation of Formula Use. Breastfeed Med. 2021 Aug 3. doi:10.1089/bfm.2021.0131. Epub ahead of print. PMID: 34348043.
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