Early initiation of breastfeeding reduces neonatal mortality
Summary of published research1
A recently published study assessed the contribution of the timing of initiation of breastfeeding to neonatal death. The study also set out to assess whether the different types of breastfeeding (exclusive, predominant, and partial breastfeeding) were associated with substantially different risks of neonatal death.
This study took advantage of the 4-weekly surveillance system from a large ongoing maternal vitamin A supplementation trial (ObaapaVitA) in rural Ghana involving all women of childbearing age and their infants. During the course of routine four-weekly field visits, when a birth was reported, the trained village fieldworkers administered a 'birth' questionnaire, which included birth outcome and birth weight (if taken within 48 hours of birth at a health facility. At the next 4-week visit, an 'infant' questionnaire was administered to obtain additional outcome data (infant morbidity and mortality) and information about infant feeding practices. Infants were followed up at subsequent visits every 4 weeks until they reached 12 months of age.
The analysis is based on 10,947 breastfed singleton infants born between July 2003 and June 2004 who survived to day 2 and whose mothers were visited in the neonatal period.
The primary comparisons were made between early and late initiation of breastfeeding and between the types of established breastfeeding patterns (exclusive, predominant, and partial). To reduce problems with reverse causality (i.e. the possibility of the breastfeeding pattern being affected by serious illnesses that lead to death), only infants who survived to day 2 and who were breastfed successfully were included in the primary analyses.
The mother's perception of birth size was used in the logistic-regression models as a proxy for birth weight (mothers' perception of an infant as "very tiny" or "smaller than average" gave a sensitivity of 80% and specificity of 95% in detecting a birth weight of 2.0 kg).
Data were captured for 11,316 (82%) of the 13,860 singleton births within 28 days of delivery (median: 14 days postpartum; inter-quartile range: 7-21 days). Excluded from the analysis were 109 (41%) neonatal deaths which occurred within the first day of birth, 106 (0.9%) of the day-2 singleton survivors who did not initiate breastfeeding or started then stopped, plus 154 (1.4%) infants whose mothers moved out of the study area before the second infant interview. The analysis is based on the remaining 10, 947 infants, among whom there were 145 neonatal deaths from days 2 to 28.
Initiation of breastfeeding
Breastfeeding was initiated within one hour in 43% of the infants, between one hour and the end of the first day of birth in 28% of the infants, and by the end of day 3 in all but 1.3% of them. Overall, 70% of the infants were exclusively breastfed, 27% predominately breastfed and 2.1% partially breastfed during the neonatal period (median age 14 days for established breastfeeding pattern).
There was a marked dose response of increasing risk of neonatal mortality with increasing delay in initiation of breastfeeding from 1 hour to day 7. Overall, late initiation (after day 1) was associated with a 2.4-fold increase in the risk of neonatal mortality. The size of this effect was similar (Adjusted Odds Ration (aOR): 2.44; 95% CI:1.60 to 3.74; P <0.0001) when infants at high risk of death or when deaths during the first week (days 2-7) were excluded (aOR: 2.36; 95% CI: 1.44 to 3.87]; P<0.001).
The trend with late initiation was still significant after adjusting for the type of breastfeeding and the increased risk associated with late initiation was similar within each breastfeeding category. Infants who were given prelacteal feeds (any food or fluids before breastfeeding was established) on day 1 also had a high neonatal mortality risk (aOR: 1.63; 95% CI: 1.09 to 2.45; P <0.017).
Type of breastfeeding
The type of breastfeeding was also found to be associated with mortality risk. Both predominantly (aOR: 1.41; 95% CI: 0.97 to 2.03) and partially (aOR, 4.51; 95% CI, 2.38 to 8.55) breastfed infants had higher risks of neonatal death than exclusively breastfed infants, although the risk was much higher and only statistically significant in the partially breastfed group. The pattern was unchanged and the size of the ORs was only slightly reduced after adjustment for timing of initiation of breastfeeding.
Public heath significance
The percentage of neonatal deaths from 2 to 28 days of life that could be prevented if all of the infants in the study population initiated breastfeeding in the first hour of life was 41.3%. This is equivalent to preventing 22.3% of all neonatal deaths if it is assumed that breastfeeding has no impact on deaths during the first day of life. Similarly, initiating breastfeeding on the first day (rather than the first hour) could have saved 30.2% of neonatal deaths from days 2 to 28, or 16.3% of all neonatal deaths.
These findings indicate that both timing of initiation and type of breastfeeding pattern exert independent influences on neonatal mortality.
Interventions to improve early infant feeding practices can result in considerable reductions in neonatal mortality. All-cause neonatal mortality could be reduced by 16.3% if all infants initiated breastfeeding on day 1 of life and by 22.3% if initiation took place within the first hour. The risk of neonatal death is increased approximately fourfold if milk-based fluids or solids are provided to breastfed neonates.
1Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood B (2006). Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality. Pediatrics 2006;117;380-386
More like this
FEX: Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect
Summary of research1 Location: Global What we know: The decision not to breastfeed a child impacts on the health, nutrition and development of a child and on women's...
FEX: Diarrhoea risk associated with not breastfeeding in Botswana
Summary of report and presentation1 Between November 2005 and February 2006, there were unusually heavy rains and flooding in Botswana, and by January 2006, there was an...
FEX: Infant Feeding Patterns and Risk of Death
Summary of published paper1 Current WHO guidelines recommend that HIV positive mothers should avoid breastfeeding only if replacement feeding is acceptable, feasible,...
FEX: Infant feeding strategies and PMTCT - Mashi trial from Botswana
Summary of published research1 Arecently published paper compares the efficacy and safety of two infant feeding strategies for the prevention of postnatal mother-to-child HIV...
FEX: Diluted F100 v infant formula in treatment of severely malnourished infants < 6 months
By Caroline Wilkinson and Sheila Isanaka Caroline Wilkinson was Nutrition Advisor with Action Contre la Faim - France (ACF-F), until November 2008. She spent most of 2007 in...
FEX: Risk factors for acutely malnourished infants aged under six months
Research snapshot 1 Acute malnutrition (wasting) in infants aged under 6 months (< 6m) is often neglected. Worldwide, some 8.5 million infants < 6m are affected, yet...
FEX: Risk factors associated with severe acute malnutrition in infants under six months in India: a cross sectional analysis
By Susan Thurstans Susan is a registered nurse and midwife with over 12 years' experience in maternal and child health and nutrition programmes in both development and...
FEX: Diagnostic criteria for severe acute malnutrition among infants under six months of age
Summary of research1 Location: Kenya What we know: Diagnosis of acute malnutrition in infants under six months old (U6M) is currently based on weight-for-length z score...
Resource: Informing the management of acute malnutrition in infants aged under 6 months (MAMI): risk factor analysis using nationally-representative demographic & health survey secondary data
Background Tackling malnutrition is a global health priority, helping children both survive and thrive. Acute malnutrition (wasting) in infants aged under 6 months (u6m) is...
FEX: Maternal profiles and social determinants of severe acute malnutrition among children under five years of age: A case-control study in Nepal
View this article as a pdf Research snapshot1 Malnutrition remains a major public health issue in Nepal and is estimated to be the underlying cause of 50% of child deaths. An...
FEX: Does nutritional supplementation for two weeks prevent malnutrition in ill children?
Summary of research1 Location: DRC, Uganda and Nigeria What we know: Ill children are at increased risk of malnutrition due to the infection-malnutrition cycle. What this...
Resource: Optimal breastfeeding practices and infant and child mortality
A Systematic Review and Meta-analysis Breastfeeding is one of the few interventions where the survival benefits span the entire continuum of childhood: newborn, infancy and...
FEX: Improving practical skills for breastfeeding vulnerable infants in low-resource settings: training material development and a case study from Rwanda
Read a summary of this field article here. By Himali de Silva and Maya Asir with contributions from Kathryn Beck, Catherine M Kirk, Gato Saidath, Marie Louise Manirakiza and...
FEX: Ten steps to successful breastfeeding programme in DRC: a cluster-randomised controlled trial
Summary of research1 Location: DRC What we know: Whilst most mothers initiate and continue breastfeeding in DRC, exclusive breastfeeding rates remain low. What this article...
FEX: Severe wasting among Indian infants under six months of age
View this article as a pdf Research snapshot1 The burden and risk factors for wasting among infants under six months of age in India are not well documented. Data from...
FEX: Ethiopia: Are children of employed mothers less stunted than those of unemployed mothers?
View this article as a pdf Kedir Mohammed is the Nutrition Cluster Coordinator of the Sub-National Emergency Nutrition Coordination Unit (ENCU), Semera, Afar Region,...
Resource: Breastfeeding and the risk of postneonatal death in the United States
Chen A, Rogan WJ. Breastfeeding and the risk of postneotal death in the United States. Pediatrics 113: 435-439, 2004 A large US based study based on national representative...
FEX: The effect of acute malnutrition on enteric pathogens, moderate-to-severe diarrhoea, and associated mortality
View this article as a pdf Research snapshot1 Children with acute malnutrition are three times more likely to die from diarrhoea than children with better nutritional status,...
FEX: Assessing the intervention on infant feeding in Gaza 2008
By Susan Thurstans and Vicky Sibson Susan Thurstans has been part of the emergency response team for nutrition with Save the Children UK since January 2009 and previously...
FEX: Managing at risk mothers and infants under six months in India – no time to waste
View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Sila Deb, Arjan de Wagt, Piyush Gupta, Nita Bhandari, Neha Sareen and Satinder...
Reference this page
Early initiation of breastfeeding reduces neonatal mortality. Field Exchange 28, July 2006. p5. www.ennonline.net/fex/28/neonatal