Professionally Mediated Peer Support and Early Breastfeeding Success

Abstract

Social support interventions that incorporate professionally mediated peer support (PMPS) for improved breastfeeding outcomes were compared with no special breastfeeding support. Fifty-five breastfeeding mothers participated. The breastfeeding outcomes of duration, completeness, satisfaction, and exclusive breastfeeding were compared at 6 weeks postpartum among an experimental group that received PMPS, and among younger community (YC) and older community (OC) groups that received no special breastfeeding support. The PMPS group exclusively breastfed for a significantly longer duration than the YC group. At 6 weeks, mothers in both community groups who had weaned were significantly less satisfied with their breastfeeding experiences than the mothers who were still nursing their babies. Professionally mediated peer support can improve the early breastfeeding outcomes of duration of exclusive breastfeeding and satisfaction with breastfeeding.

Breastfeeding is the recommended method of infant feeding because it is associated with health and nutritional benefits (Akre, 1991; Cunningham, Jelliffee, & Jelliffee, 1991). In the United States, exclusive breastfeeding is noted to be ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth, followed by continued breastfeeding with gradual introduction of weaning foods throughout the first year (American Academy of Pediatrics, 1997). Despite this recommendation, breastfeeding rates remain low; about 59.2% of new mothers initiate breastfeeding and only 18% continue for at least 6 months (Mother's Survey, 1996).

Social support from a variety of sources has been recognized as an influential variable in the initiation and successful continuation of breastfeeding (Duckett, Henly, & Garvis, 1993; Matich & Sims, 1992; Raj & Plichta, 1998). Social support constitutes those interpersonal transactions that include expression of positive affect, affirmation or endorsement of behaviors or beliefs, and the giving of symbolic or material aid (Kahn, 1979).

Social support constitutes those interpersonal transactions that include expression of positive affect, affirmation or endorsement of behaviors or beliefs, and the giving of symbolic or material aid.

Theory of Planned Behavior

The Theory of Planned Behavior (TPB) provides a framework for visualizing the process by which social support can affect breastfeeding outcomes (Ajzen & Fishbein, 1980). According to the TPB, behavior is a function of intention to perform the behavior (e.g., planned duration of breastfeeding). In addition to attitude and perceived control, the TPB postulates a link between beliefs of those who provide social support (referents including husband, mother, girlfriend, others) and intention to perform the behavior. A longitudinal, prospective study of 602 breastfeeding first-time mothers (Duckett, et al., 1998) extended earlier findings (Humenick, Hill, Wilhelm, 1997; Manstead, Plevin, & Smart, 1984) verifying the importance of referents to breastfeeding attitudes, intentions, and outcomes using the TPB framework. Duckett et al. refined the TPB into a structural model for explaining variability in breastfeeding intention and duration called “the TPB for Breastfeeding” (TPB-BrF).

Literature Review

Encouragement of breastfeeding, distribution of breastfeeding information, and affirmation of breastfeeding efforts are important social support actions that facilitate the success of breastfeeding. Formal and informal methods may be used to implement these activities. Prenatal and/or postpartum education and support delivered by a lactation consultant, peer counselor, dietitian, or nurse may be used. The mechanism of delivering social support may include groups or individuals. It may be as a one-time support and education session or it may be several sessions continued over varying time intervals and/or critical childbearing events.

The relative effectiveness of variations in provision of social support has not been demonstrated consistently. Three studies that reported conflicting results initiated prenatal interventions in a group format. Kistin, Benton, Rao, and Sullivan (1990) observed that both groups and individualized classes resulted in an increase in breastfeeding rates. Reifsnider and Eckhart (1997) reported a longer duration of breastfeeding in a group that had attended either one or two prenatal breastfeeding classes. On the other hand, Hill (1987) reported no difference in breastfeeding duration in a treatment group that had received prenatal breastfeeding information and support.

The greatest number of intervention studies has focused on postpartum support. Postpartum information and/or support in the hospital increased duration of breastfeeding (Hall, 1978; Cohen, 1980; Princeton, 1986). Studies of postdischarge interventions using hospital visits, phone calls, and group or home visits by a variety of professionals produced data with conflicting results (Saunders & Carroll, 1988; Jones & West, 1986; Grossman, Harter, Sachs, & Kay, 1990; Lynch, Koch, Hislop, & Coldman, 1986). Two studies that utilized prenatal and postpartum social support in a group format and with the sessions extended over time reported increases in duration of breastfeeding (Ladas, 1970; Sciacca, Phipps, Dube, & Ratliff, 1995). A La Leche League leader and childbirth educator implemented the interventions, respectively.

Thus there appears to be no consensus on what type of intervention increases the duration of breastfeeding in the general population or in young, low-income, less educated groups who are at greater risk for early weaning. “Breastfeeding” is not measured using standard procedures in most of the studies, which also makes it difficult to compare findings.

The purpose of this study was to compare the early breastfeeding outcomes of women who received ongoing, professionally mediated peer support designed to encourage breastfeeding initiation and continuation with younger and older mothers in the community who received no designed social support intervention for breastfeeding. Duration of continued breastfeeding, completeness of breastfeeding, duration of exclusive breastfeeding, and satisfaction with breastfeeding were measured at 6 weeks postpartum to evaluate early outcomes.

Methods

Design.

A quasi-experimental design was used to determine if professionally mediated peer support interventions made a difference in early success at breastfeeding. Duration, completeness, exclusive breastfeeding, and satisfaction at 6 weeks postpartum were compared among a treatment group and two control groups. Data were collected from two sites: (a) a Women, Infants, and Children (WIC) clinic at a United States Air Force base for the professionally mediated peer support group (experimental group) and (b) a community hospital for the younger (mothers less than 27 years old) and older (mothers greater than or equal to 27 years) community groups with no special breastfeeding support (control groups).

Subject Selection/Procedure.

The population for the study consisted of adult women breastfeeding their newborn infants. The sample of women in each of the three groups consisted of women who were breastfeeding for the first time (included primiparas and multiparas who had not breastfed previous children), had delivered infants who were receiving normal newborn care, were English speaking, and were at least 18 years of age. The participants were recruited by a convenience sampling method. When subjects agreed to participate in the study, they signed a consent form and provided biographic data, as well as information concerning preparation for breastfeeding. Fifty-five breastfeeding women participated. At 6 weeks postpartum, the mothers were contacted by letter or phone and information about early breastfeeding outcomes was recorded.

Variables and Measurement.

Mothers were asked about 4 breastfeeding outcomes: (a) duration of breastfeeding (age of baby at complete weaning), (b) breastfeeding completeness, (c) duration of exclusive breastfeeding, and (d) breastfeeding satisfaction. All data were collected using questionnaires validated in earlier studies (Duckett et al., 1998).

Duration was measured by adapting and editing some questions from the Weaning Questionnaire (Duckett et al., 1998). The duration item, which gives the age of the baby in weeks when no longer breastfeeding at all, was used in previous studies. As in previous studies, mothers were able and willing to give accurate information about the date on which the baby weaned. Breastfeeding completeness was determined by adapting questions from the Breast and Bottle Feeding Patterns One-Month Interview questionnaire (Duckett et al.). The answers to a series of questions were used to determine how many feedings were from the breast and how many feedings were from the bottle, and the percentage of each was then calculated. Exclusive breastfeeding (Labbok & Krasovec, 1990) was determined by asking the question, “For how many weeks was your infant given only breastmilk to meet her/his nutritional needs?” Satisfaction with breastfeeding was measured by the question, “How are you feeling about how breastfeeding is going?” Response options ranged from unhappy (1) to happy (5). If the baby had already weaned, the question read, “How did you feel when breastfeeding was over?” The possible answers ranged from sad (1) to glad (5).

Description of Intervention and Control Experiences.

The professionally mediated peer support (PMPS) group included a deliberative plan for education and support for the pregnant woman. The environment of the clinic was planned to be conducive for breastfeeding. Appealing pictures of breastfeeding women were posted. A bulletin board in the waiting area displayed pictures of breastfeeding moms and their infants from the clinic. The education room, where classes were held, was furnished with padded rocking chairs, foot stools, and pillows, which helped the pregnant women remain comfortable and modeled how to make preparation for breastfeeding at home. Properly weighted dolls were used to practice techniques for positioning. A library of breastfeeding books was available for individual lending. Breast pumps along with instructions were given to mothers as the need arose.

Before delivery, all pregnant women enrolled in this WIC program were expected to attend 2 to 3 breastfeeding group sessions mediated by an International Board Certified Lactation Consultant (IBCLC). The PMPS subjects in this study were attendees at these group sessions. Information about breastfeeding benefits, breastfeeding role models, differences between breastfeeding and formula feeding, breast changes and individual differences during pregnancy, diet, partner support, and other topics brought up by the group were shared among group members. The IBCLC stressed to the group that they should become knowledgeable about infant feeding practices in order to make an informed decision. A short video was shown depicting breastfeeding babies. Discussion often continued among group members after the session ended, strengthening the belief system of the peer group that breastfeeding was the normal behavior.

The second session focused on information needed in order to successfully initiate and maintain early breastfeeding. Examples of topics discussed included positioning, 3 steps to bring baby to breast, infant hunger signs, preventing nipple soreness, and how to know if baby is getting enough milk. A “helper mom” who brought her breastfeeding baby to the session was a positive role model for breastfeeding and helped to establish breastfeeding as the normal behavior. Each woman practiced positioning techniques with a properly weighted doll. A short video reinforcing the information was shown.

The third and subsequent sessions consisted of pregnant women and women with infants who ranged in age from a few days old to several months old. Because of the various ages, the discussion covered a wide range of topics. Some of the topics discussed were stool characteristics, infant sleep patterns, growth spurts, teething, nipple confusion, introducing foods, and returning to work or school. Once again, the mothers with older babies modeled breastfeeding behavior for the newer mothers.

The mothers were encouraged to call WIC as soon as they delivered so they could be followed with telephone visits to monitor breastfeeding status until they came for their breastfeeding support group appointment. During the support group sessions, the IBCLC identified women who needed additional support and initiated a series of telephone follow-up calls and/or WIC clinic visits until the issue was resolved. All medical problems were referred to the appropriate physician. The mothers were also given names and phone numbers of breastfeeding moms to call when questions arose during the hours that WIC was not open.

Women in the younger community (YC) and older community (OC) groups received no special breastfeeding support. They may have gained breastfeeding knowledge from books, pamphlets, videos, conversations with relatives or friends, or from serendipitously being exposed to a breastfeeding role model. Other breastfeeding information may have been obtained through discussions with physicians and nurses or by attending a single 2-hour breastfeeding class with didactic content presented in a lecture format at the community hospital.

Results

Subject Description.

Fifty-five mothers participated in the study, of which 19 were in the PMPS group. There were 16 women in the YC group and 20 in the OC group. With a mean age of 21.5, the PMPS group was the youngest, on average. The average age was 23.1 for the YC group and 29.9 for the OC group. All participants were first-time breastfeeders and had healthy babies. Most participants were married (87%). Most participants (92%) identified themselves as White/Caucasian. Women of Hispanic and Asian descent were also represented.

Table 1 describes other personal characteristics of participants. Virtually all participants had completed high school; however, the PMPS group completed significantly fewer years of education. Only 38 women reported family income, which ranged from $18,900 for the PMPS group to $43,500 for the OC group. During pregnancy, mothers in the PMPS group worked fewer hours each week than mothers in either of the two community groups. Among the 36 women in all groups who planned to return to work after baby's birth, no difference existed in the average age of baby (about 8 weeks) at the mother's planned time of returning to work. The actual hours worked per week at 6 weeks postpartum were lowest for the PMPS group. Family size (not including the new baby) was about the same (2.1) in all the groups.

Table 1.

Personal Characteristics

Characteristics		All	PMPS	OC	YC	p
Age	mean	25.1	21.5	29.9	23.1	.0001
	SD	4.8	3.17	3.35	2.25
	n	(55)	(19)	(20)	(16)
Income	mean	30.3	18.9	43.5	28.6	.0001
	SD	14.47	6.97	10.36	13.00
	n	(38)	(13)	(13)	(12)
Education	mean	14.1	12.8	15.2	14.1	.0003
	SD	1.13	1.82	1.95	2.07
	n	(55)	(19)	(20)	(16)
Family Size	mean	2.1	2.2	2.1	1.9	.28
	SD	.62	.79	.55	.44
	n	(55)	(19)	(20)	(16)
Hours (per week) Worked During Pregnancy
	mean	20.9	11.5	27.7	23.8	.01
	SD	18.21	15.37	16.77	19.28
	n	(55)	(19)	(20)	(16)
Planned Baby's Age (in weeks) at Return to Work
	mean	8.06	7.55	8.19	8.27	.93
	SD	4.5	2.6	4.97	5.29
	n	(36)	(9)	(16)	(11)
Actual Work Hours (per week) at 6 Weeks Postpartum
	mean	7.59	1.21	11.53	10.5	.04
	SD	1.88	1.21	3.58	4.09
	n	(54)	(19)	(19)	(16)

Note: Income is thousands of dollars. PMPS=Professionally Mediated Peer Support; YC=Younger Community; OC= Older Community. Analysis of variance was used to compare means.

Preparation for Breastfeeding.

On average, participants used a total of 3.3 information sources for breastfeeding preparation. The breastfeeding source most utilized by the YC and OC groups was books/pamphlets. The source used most often by the PMPS group was the WIC clinic, which included the activities and personnel supporting the PMPS breastfeeding intervention at this site. The nurse was an important source of breastfeeding information for the YC and OC groups as indicated by their 68.8% and 60% use, respectively. In contrast, only 3 (15.8%) of the PMPS mothers listed a nurse as a breastfeeding source. One PMPS mother (5.3%), 2 YC mothers (12.5%), and 4 OC mothers (12.7%) used the physician. No participants used the La Leche League as a breastfeeding source.

The number of professionally mediated peer support breastfeeding classes attended by the PMPS mothers ranged from 1 to 4, with 79% attending 2 or more classes. The breastfeeding class provided by a local hospital consisted of 1 class only; 18.8% of the YC group and 31.6% of the OC group attended that class.

Breastfeeding Outcomes.

Tables 2 and 3 describe the breastfeeding outcomes by treatment group. Univariate analysis of variance was used to test for group differences in breastfeeding outcomes. The nominal probability level for Type 1 error was set at 0.05.

Table 2.

Breastfeeding Outcomes by Treatment Group

Outcomes	All	PMPS	OC	YC	F	df	p
Duration
mean	5.51	6.10	5.55	4.75	1.59	2,52	.21
SD	2.27	1.82	2.37	2.52
n	(55)	(19)	(20)	(16)
Completeness
mean	.58	.69	.59	.43	1.3	2,52	.25
SD	.47	.46	.48	.48
n	(55)	(19)	(20)	(16)
Exclusive Breastfeeding
mean	4.51	5.42	4.55	3.38	4.16	2,52	.02
SD	2.21	1.83	2.04	2.42
n	(55)	(19)	(20)	(16)

Table 3.

Satisfaction Outcome by Treatment Groups: Weaned and Still Breastfeeding

Outcome	Total	Weaned			Still Breastfeeding
		PMPS	OC	YC	PMPS	OC	YC	F	df	p
Satisfaction
mean	4.07	3.83	3.13	3.56	4.31	4.59	4.71	3.08	5,49	.02
SD	1.14	1.60	1.25	1.13	1.03	.67	.49
n	55	6	8	9	13	12	7

Duration. Average breastfeeding duration showed a trend toward being higher in the PMPS group. The outcome in the younger, more at-risk PMPS group (6.1 weeks, n=19) was similar to that obtained in the OC groups (5.55 weeks, n=20). The YC group had a mean duration of 4.75 weeks (n=16). None of the differences between the means was significantly different.

Completeness. Average scores for completeness (percentage of feedings that were breast milk) of breastfeeding at 6 weeks ranged from .43 (n=16) for the YC group to .69 (n=19) for the PMPS group, while the OC group scored a mean of .59 (n=20). Again, the PMPS outcome showed a higher trend and was more comparable to the OC performance, but none of the differences between the means was statistically significant.

Exclusive Breastfeeding. The PMPS group had a significantly higher mean at 5.42 (n=19) weeks of exclusive breastfeeding than the YC group, which had a mean of 3.38 weeks (n=16) of exclusive breastfeeding. The OC group had a mean of 4.55 (n=20) weeks of exclusive breastfeeding. The average duration of exclusive breastfeeding was highest in the PMPS group (5.42 weeks). The lower risk OC group continued exclusive breastfeeding for an average of 4.55 weeks, whereas the mothers in the YC group reported shorter average duration of exclusive breastfeeding (3.38). The means were significantly different using the preset p<.05 criterion for Type 1 error rate.

The PMPS group had a significantly higher mean at 5.42 (n=19) weeks of exclusive breastfeeding …

Satisfaction. In order to provide a more accurate description of the breastfeeding outcome of satisfaction, each of the three groups was divided into those women who had weaned and those who were still breastfeeding. Those who weaned and reported being sad, were classified as satisfied (they were sad because they were no longer breastfeeding, meaning the experience had been a satisfying one). Those who weaned and reported being glad were classified as being dissatisfied (they were glad to have weaned, meaning the experience had not been a satisfying one). Those who were still breastfeeding and reported being happy were classified as satisfied. Those who were still breastfeeding and reported being unhappy were classified as dissatisfied. High scores reflected satisfaction.

Table 3 lists satisfaction outcomes for women who had weaned and those still breastfeeding in each of the three groups. Based on results of the omnibus F test for significance and follow-up LSD tests, the PMPS, YC, and OC mothers who were still breastfeeding were significantly more satisfied than the respective groups' mothers who had weaned. Thus the YC and the OC mothers who weaned early were less satisfied with their breastfeeding experience. The PMPS mothers who had weaned were not significantly different in their satisfaction level from the mothers in the PMPS, YC, and OC groups who were still breastfeeding.

Discussion

This study provided the opportunity to compare a group of pregnant women who received professionally medicated peer support (PMPS) for breastfeeding in both the prenatal and postpartum periods at a WIC clinic to two groups of women in the community (YC and OC) who received no special social support for breastfeeding. The findings suggest that social support interventions that incorporate prenatal and postpartum contacts over time and are professionally mediated and peer supported can influence the breastfeeding outcomes of duration of exclusive breastfeeding and satisfaction with breastfeeding.

The Theory of Planned Behavior (Ajzen & Fishbein, 1980) and TPB-BrF (Duckett et al., 1998) were used in this study to anticipate the effect of interventions on the behavioral, normative, and control beliefs that might mediate improved outcomes of the breastfeeding behavior. The PMPS breastfeeding sessions were visualized in the TPB and TPB-BrF conceptual framework in different ways: (a) as informational support in the form of breastfeeding material discussed among group members directed by the IBCLC, which would indirectly affect a person's attitude toward the behavior of breastfeeding; (b) as the breastfeeding group and the IBCLC becoming part of the referent belief system of a person, which would directly affect the attitude toward the behavior of breastfeeding; and (c) as the sum of the breastfeeding behaviors and beliefs of the group becoming the subjective norm for a breastfeeding mother. The TPB-BrF proposed that subjective norm and referent beliefs affect attitudes and intentions, with attitudes and intentions both directly affecting the breastfeeding behavior. This study showed that the PMPS intervention positively affected the breastfeeding behaviors of duration of exclusive breastfeeding and satisfaction with breastfeeding. The TPB-BrF suggests that the positive behavioral outcome was mediated by a change in attitudes and intentions through the vehicle of social support. Future research should be planned to include measurement of important mediating variables from the Theory of Planned Behavior so that mechanisms leading to improved outcomes can be pinpointed. Random assignment of the participants to interventions would also strengthen future studies.

Previous findings suggest that young age and low income have a negative impact on the successful outcomes of breastfeeding (Jacobsen, Jacobsen, & Frye, 1991; Martinez & Krieges, 1985). The YC and the PMPS groups were similar in age and significantly younger than the OC group. The PMPS group had significantly lower levels of income and education than the YC and OC groups. These PMPS group demographics placed members in an even more at-risk category than members of the YC group. Yet, members of the PMPS group had significantly greater success in 2 of the 4 early breastfeeding outcomes: duration of exclusive breastfeeding and satisfaction with breastfeeding.

The OC group had several characteristics common to groups of women who usually have greater success at breastfeeding. These characteristics include higher income, more education, and older age (Grossman, Fitzsimmons, Larsen-Alexander, Sach, & Harter, 1990). An important finding of the study is the fact that the PMPS group was not significantly different from the OC group with respect to the breastfeeding outcomes, even though the PMPS group was at a greater risk of having less success at breastfeeding than the OC group. An additional explanation may be provided in the finding that the PMPS group worked fewer hours per week after delivery (at 6 weeks) than the YC or the OC group. This variable could not be controlled. It may be that another effect of the professionally mediated peer support intervention was that mothers decided to postpone returning to work in order to facilitate breastfeeding. Care at a military base by the PMPS was yet another potentially confounding variable of the PMPS group, as was the motivation of that group to join WIC.

Princeton (1986) studied the effect of a “deliberative” nursing care approach in postpartum breastfeeding women and reported that the intervention group had a longer duration of breastfeeding. In this study, postpartum “deliberate” support was a component of the PMPS intervention.

In this study, postpartum “deliberate” support was a component of the PMPS intervention.

The PMPS group reported significantly more weeks of exclusive breastfeeding than the YC group. Exclusive breastfeeding occurs when 100% of the infant's intake is breast milk. It is a component of the breastfeeding outcome of completeness. Exclusive breastfeeding is an important outcome to report because even a minimal intake of supplements can have an effect on the health and nutrition of infants. For example, analysis of data from the Demographic and Health Surveys shows that the addition of water alone increases the risk of diarrhea (Labbock & Krasovec, 1990).

Satisfaction was also found to be significantly different among the groups. In order to clarify the satisfaction outcome, the PMPS, YC, and OC groups were each subdivided into weaned and still-breastfeeding groups. The OC mothers who weaned were significantly less satisfied than the PMPS, YC, and OC mothers who were still breastfeeding. Without any special breastfeeding support, the OC mothers were unable to sustain breastfeeding and felt relatively dissatisfied with their situation. The YC group that weaned also was significantly less satisfied than the YC and the OC groups who were still breastfeeding. Locklin and Naber's (1993, p. 34) qualitative research on breastfeeding among a group of low-income, minority women identified that “personal motivation and perseverance are enhanced when support and accurate information are available and accessible.” The findings from the current study also suggest that support interventions among the high-risk group (young in age, less education, and lower income) and the low-risk group (older, more education, and higher income) could lessen frustrations and improve satisfaction with the breastfeeding experience.

Recommendations

Current breastfeeding support systems should be evaluated in hospitals, health clinics, and WIC clinics. Components that should be addressed as part of the evaluation include the following: (a) Who is providing the support? (b) Does the opportunity exist for peer interaction? (c) Is support begun prenatally and continued through the postpartum period? and (d) Does it extend over time? Because the process of breastfeeding support begins during the prenatal period, remains crucial during the hospital stay, and peaks in the first few weeks at home, the coordination of support services between clinics, hospitals, and the community should also be scrutinized. The similarity between the PMPS intervention and the UNICEF Baby Friendly Initiative should be noted.

The education component of social support interventions for breastfeeding remains the foundation for influencing the behavioral beliefs of women who are making decisions about their infant's feeding behavior and will likely influence subsequent children's experiences as well. The education component may be enhanced when the mode of delivery is within a peer group where breastfeeding behavior is affirmed and when the support is professionally mediated to ensure information is current and based on research. When breastfeeding support is available over a period of time, the concerns expressed by women can be addressed at the point where the information provided is most likely to have an impact. The importance of social support for breastfeeding women is an idea that is endorsed by many health care providers. The challenge remains in identifying those components of support and fitting them together in a way that provides women with the optimum chance to improve the outcomes of their breastfeeding efforts.

The challenge remains in identifying those components of support and fitting them together in a way that provides women with the optimum chance to improve the outcomes of their breastfeeding efforts.

Baby Walkers Delay Motor and Mental Development

Source: Siegel, A. C., & Burton, R. V. (1999). Effects of baby walkers on motor and mental development in human infants. Journal of Developmental and Behavioral Pediatrics, 20, 355–261.

Many parents use baby walkers to provide mobility and exercise for their young, preambualtory infants. Siegel and Burton analyzed motor and mental development in 109 infants with and without walker experience. Walker-experienced infants sat (P < .000), crawled (P = .03), and walked (P = .02) later than no-walker controls, and they scored lower on the Bayley scales of mental and motor development. The results also suggested that restriction in a walker might exert its greatest negative influence on mental development in the 6- to 9-month age period. The effect of walker use on mental development is not short-lived—frequent initial use continued to predict comparatively lower mental scores in some infants for as long as 10 months after initial use (P < .001).

Baby Walkers Cause More Injuries

Source: AAP Committee on Injury and Poison Prevention (1995). Pediatrics, 95, 778–780.

According to a Consumer Products Safety Commission report (June 23, 1994), baby walkers are responsible for more injuries annually than any other type of juvenile product.