Sequential Mediation Effects of First Feeding Practices and Early Breastfeeding Initiation on the Relationship between Prenatal Exclusive Breastfeeding (EBF) Intentions and EBF at 5 Months: A Prospective Special Supplemental Nutrition Program for Women, Infants, and Children Program Infant and Toddler Feeding Practices Study-2

Background Prenatal exclusive breastfeeding (EBF) intentions are consistently associated with EBF, the best and recommended feeding practice for infants under 6 months, yet suboptimal EBF rates remain. Further, evidence on the behavioral pathways underlying this association remains limited, which is crucial for designing and implementing effective child nutrition programs. Objective This study examined the sequential mediation effects of first feeding practices and early breastfeeding initiation on the relationship between prenatal EBF intentions and EBF. Methods A prospective WIC ITFPS-2 cohort of 4,367 infant-caregiver dyads was analyzed using sequential mediation analysis. Prenatal EBF intention was measured using the Infant Feeding Intention Scale. First feeding practices were assessed using the very first food/drink the infant was fed after birth. Early breastfeeding initiation and EBF were defined as when the infant started breastfeeding in the first hour after birth, and fed only breastmilk from birth to 5 months, respectively. Adjusted path coefficients ( β ) of first feeding practices and early breastfeeding initiation on the relationship between prenatal EBF intentions and EBF were reported based on an analytical sample of 2,617 observations with complete EBF data. Robustness was assessed through sensitivity and subgroup analyses. Results Among 2,617 mothers, 48.0% were aged ≥26 years, 61.2% White, and 22.8% African-American. The sequential indirect effect of prenatal EBF intention on EBF via first feeding practices and early breastfeeding initiation was significant (β=−0.062, p =0.009). Indirect effects were observed through first feeding practices (β=0.252, p <0.001) and early breastfeeding initiation (β=0.036, p =0.017), with a significant total indirect effect (β=0.226, p <0.001). The direct (β=0.292, p <0.001) and total effects (β=0.518, p <0.001) were significant, indicating partial mediation. Sensitivity and subgroup analyses yielded consistent findings with the primary model. Conclusions Incorporating strategies that promote prenatal EBF intention, early breastfeeding initiation, and discourage pre-lacteal feeding into child nutrition programs could improve EBF.