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Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality
Karen M. Edmond, Charles Zandoh, Maria A. Quigley, Seeba Amenga-Etego, Seth
                    Owusu-Agyei and Betty R. Kirkwood
                       Pediatrics 2006;117;e380-e386
                       DOI: 10.1542/peds.2005-1496



The online version of this article, along with updated information and services, is
                       located on the World Wide Web at:
             http://www.pediatrics.org/cgi/content/full/117/3/e380




PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.




                      Downloaded from www.pediatrics.org by on June 2, 2009
ARTICLE




Delayed Breastfeeding Initiation Increases Risk of
Neonatal Mortality
Karen M. Edmond, MMSc, FRCPCHa,b, Charles Zandoh, MSca, Maria A. Quigley, MSc c, Seeba Amenga-Etego, MSca, Seth Owusu-Agyei, PhDa,
Betty R. Kirkwood, MSc, FMedScib
aKintampo Health Research Centre, Ghana Health Service, Kintampo, Brong Ahafo Region, Ghana; bDepartment of Epidemiology and Population Health, London School
of Hygiene and Tropical Medicine, London, United Kingdom; cNational Perinatal Epidemiology Unit, Oxford University, Oxford, United Kingdom
The authors have indicated that they have no relationships relevant to this article to disclose.




ABSTRACT
BACKGROUND. Breastfeeding promotion is a key child survival strategy. Although
there is an extensive scientific basis for its impact on postneonatal mortality,
evidence is sparse for its impact on neonatal mortality.                                                               www.pediatrics.org/cgi/doi/10.1542/
                                                                                                                       peds.2005-1496
OBJECTIVES. We sought to assess the contribution of the timing of initiation of breast-
                                                                                                                       doi:10.1542/peds.2005-1496
feeding to any impact.
                                                                                                                       Dr Edmond conceived the idea for this study,
METHODS. This study took advantage of the 4-weekly surveillance system from a                                          took the lead role in its design, oversaw its
                                                                                                                       conduct, conducted the statistical analysis,
large ongoing maternal vitamin A supplementation trial in rural Ghana involving                                        and wrote the first draft of the paper. She was
all women of childbearing age and their infants. It was designed to evaluate                                           responsible for the final version, together
                                                                                                                       with Prof Kirkwood, who provided technical
whether timing of initiation of breastfeeding and type (exclusive, predominant, or
                                                                                                                       input to and was substantially involved in all
partial) are associated with risk of neonatal mortality. The analysis is based on                                      aspects of the study. Mr Zandoh was head of
10 947 breastfed singleton infants born between July 2003 and June 2004 who                                            fieldwork; Mr Amenga-Etego was responsible
                                                                                                                       for the design and execution of the data
survived to day 2 and whose mothers were visited in the neonatal period.                                               management system; Dr Owusu-Agyei
                                                                                                                       provided technical input to the design and
RESULTS. Breastfeeding was initiated within the first day of birth in 71% of infants
                                                                                                                       conduct; and Ms Quigley provided technical
and by the end of day 3 in all but 1.3% of them; 70% were exclusively breastfed                                        input and contributed to the statistical
during the neonatal period. The risk of neonatal death was fourfold higher in                                          analysis. All authors provided feedback on
                                                                                                                       drafts of the article and approved the final
children given milk-based fluids or solids in addition to breast milk. There was a                                      version.
marked dose response of increasing risk of neonatal mortality with increasing                                          Key Words
delay in initiation of breastfeeding from 1 hour to day 7; overall late initiation                                     breastfeeding, neonatal care, neonatal
                                                                                                                       survival
(after day 1) was associated with a 2.4-fold increase in risk. The size of this effect
                                                                                                                       Abbreviations
was similar when the model was refitted excluding infants at high risk of death                                         OR— odds ratio
(unwell on the day of birth, congenital abnormalities, premature, unwell at the                                        aOR—adjusted odds ratio
time of interview) or when deaths during the first week (days 2–7) were excluded.                                       PAF—population-attributable fraction
                                                                                                                       CI— confidence interval
CONCLUSIONS. Promotion of early initiation of breastfeeding has the potential to make                                  Accepted for publication Sep 7, 2005
a major contribution to the achievement of the child survival millennium devel-                                        Address correspondence to Karen Edmond,
opment goal; 16% of neonatal deaths could be saved if all infants were breastfed                                       MMSc, FRCPCH, London School of Hygiene and
                                                                                                                       Tropical Medicine, Keppel Street, London WC1E
from day 1 and 22% if breastfeeding started within the first hour. Breastfeeding-                                       7HT, United Kingdom. E-mail: Karen.Edmond@
promotion programs should emphasize early initiation as well as exclusive breast-                                      lshtm.ac.uk
                                                                                                                       PEDIATRICS (ISSN Numbers: Print, 0031-4005;
feeding. This has particular relevance for sub-Saharan Africa, where neonatal and                                      Online, 1098-4275). Copyright © 2006 by the
infant mortality rates are high but most women already exclusively or predomi-                                         American Academy of Pediatrics
nantly breastfeed their infants.


e380         EDMOND, et al
                                                             Downloaded from www.pediatrics.org by on June 2, 2009
A      LTHOUGH THE CHILD survival revolution of the
       1980s led to dramatic reductions in overall child
mortality, it had little impact on neonatal mortality.1,2 In
                                                               trial to assess the impact of weekly vitamin A supple-
                                                               mentation on maternal mortality. It involves all women
                                                               of childbearing age who live in 4 rural contiguous dis-
2002, 4 million infants died during the first month of          tricts (Kintampo, Wenchi, Techiman, and Nkoranza) in
life, and neonatal deaths now account for 36% of deaths        the forest-savanna transitional ecological zone in the
among children 5 years of age.1,2 Tackling neonatal            Brong Ahafo region of central Ghana. It covers 12 000
mortality is essential if the millennium development           km2, and 80% of the study population live in remote
goal for child mortality is to be met.3,4 Sub-Saharan          and rural villages.
Africa contributes a high proportion of neonatal deaths,           All of the singleton infants born to mothers in the
yet its progress has been the slowest of any region in the     ObaapaVitA trial between July 1, 2003, and June 30,
world.2,3,5 Because the majority of neonatal deaths occur      2004, who initiated breastfeeding, survived to day 2, and
at home,1 feasible interventions for home-based imple-         whose mothers were visited in the neonatal period were
mentation are needed urgently.                                 included in the present study. Both the ObaapaVitA trial
    The promotion of breastfeeding is a key component of       and this nested study were approved by the ethics com-
child survival strategies.3 Furthermore, the recent Lancet     mittees of Ghana Health Service and London School of
neonatal survival series included breastfeeding in its rec-    Hygiene and Tropical Medicine.
ommended package of interventions to reduce neonatal
mortality.6 International policy places emphasis on ex-        Data Collection
clusive breastfeeding during the first 6 months of life,        Women were visited once every 4 weeks by a network of
with some groups promoting early initiation of breast-         trained village-based fieldworkers to distribute vitamin
feeding within 1 hour of birth.7,8 Although there is an        A capsules and collect data on morbidity and mortality.
extensive scientific basis for the impact of breastfeeding      When a birth was reported, the fieldworker adminis-
on postneonatal mortality,3,9,10 evidence is sparse for its    tered a “birth” questionnaire, which included birth out-
impact on neonatal mortality1,6 and, to our knowledge,         come, birth weight (if taken within 48 hours of birth at
nonexistent for the contribution of the timing of initia-      a health facility), gestational age, details of the delivery,
tion to any mortality impact.                                  health care during pregnancy, health of the mother,
    Maternal colostrum, produced during the first days          socioeconomic and environmental characteristics, and
after delivery, has long been thought to confer additional     home-based neonatal care practices, including early
protection because of its immune and nonimmune prop-           breastfeeding practices. The mother was asked when she
erties.11 However, epidemiologic data indicate that a          initiated breastfeeding and was prompted for the exact
high proportion of neonatal deaths are a result of ob-         timing (within 1 hour, after 1 hour but first day, day 2,
stetric complications,1,12 and these are unlikely to be        day 3, day 4 –7, or after day 7). She was then asked what
affected by colostrum, transitional breast milk, or mature     she offered her child to eat or drink in the 24 hours
breast milk. Elucidating the role of timing of initiation of   before the interview. After noting the unprompted re-
breastfeeding is particularly relevant for sub-Saharan         sponse, the mother was asked if she offered her own
Africa, where neonatal and infant mortality rates are          breast milk, breast milk from a wet nurse, animal milk,
high but most women already exclusively or predomi-            infant formula, milk-based fluids, water-based fluids, or
nantly breastfeed their infants.2                              solid foods. The mother was also asked about the infant’s
    A surveillance system from a large trial in rural Ghana    health on the day of birth and in the previous 24 hours.
of the impact of weekly vitamin A supplementation to           At the next 4-week visit, an “infant” questionnaire was
women of childbearing age on maternal and infant mor-          administered to obtain additional outcome data (infant
tality (ObaapaVitA trial) afforded the opportunity to          morbidity and mortality) and information about infant
evaluate the association between early breastfeeding           feeding practices. Infants were followed up at subse-
practices and deaths in breastfed neonates. Our primary        quent visits every 4 weeks until they reached 12 months
objective was to evaluate the association between the          of age.
timing of initiation of breastfeeding and neonatal mor-
tality. The secondary objective was to assess whether the      Study Definitions and Statistical Analysis
different types of breastfeeding (exclusive, predominant,      An infant was considered to be breastfed if breast milk
and partial breastfeeding) were associated with substan-       constituted any portion of their diet. Infants were clas-
tially different risks of neonatal death.                      sified according to the timing of breastfeeding initiation
                                                               (first hour, after first hour but day 1, day 2, day 3, and
                                                               after day 3). “Early initiation” of breastfeeding referred
METHODS
                                                               to breastfeeding that started on the first day of life. “Late
Setting and Participants                                       initiation” indicated breastfeeding that began after the
The ObaapaVitA trial is an ongoing community-based,            first day of life. “Established breastfeeding” referred to
cluster-randomized, double-blind, placebo-controlled           the reported breastfeeding pattern in the 24 hours before


                                                                                PEDIATRICS Volume 117, Number 3, March 2006   e381
                                   Downloaded from www.pediatrics.org by on June 2, 2009
the first interview (median: 14 days postpartum; inter-                  as “very tiny” or “smaller than average” gave a sensitiv-
quartile range: 7–21 days). “Exclusive breastfeeding”                   ity of 80% and specificity of 95% in detecting a birth
was defined as feeding of only breast milk and nothing                   weight of 2.0 kg (Table 1). Thus, the mother’s percep-
else, not even water, with the exception of vitamin                     tion of birth size was used in the logistic-regression
supplements and prescribed medicines. “Predominant                      models as a proxy for birth weight.
breastfeeding” was defined as feeding of breast milk                        To further reduce problems with reverse causality,
along with other nonmilk fluids. Infants who were of-                    analyses were repeated excluding infants at high risk of
fered breast milk and animal milk, infant formula, or                   death and ill health (congenital anomalies, premature,
solids were considered to be “partially breastfed.” These               unwell on the day of birth, and unwell at the time of
definitions are consistent with the current World Health                 interview) and early neonatal deaths. All of the analyses
Organization definitions for breastfeeding patterns.8                    were conducted in Stata 8.2 (Stata Corp, College Station,
   The primary comparisons were made between early                      TX). aORs and 95% confidence intervals (CIs) are pre-
and late initiation of breastfeeding and between the                    sented. Because neonatal mortality is a relatively rare
types of established breastfeeding patterns (exclusive,                 event, these ORs closely approximate relative risks and
predominant, and partial). To reduce problems with re-                  are referred to as such in the text. To elucidate the public
verse causality (ie, the possibility of the breastfeeding               health importance of improving early breastfeeding pat-
pattern being affected by serious illnesses that lead to                terns, the proportions of all neonatal deaths that would
death), only infants who survived to day 2 and who                      be avoided if all infants initiated breastfeeding during the
were breastfed successfully were included in the primary                first hour or during the first day of life (the population-
analyses. Multiple births, noninitiators, and those who                 attributable fractions [PAFs]) were calculated also.
were interviewed outside the neonatal period were also
excluded. The primary outcome variable was calculated                   RESULTS
as the number of breastfed singleton infants who died                   There were 14 403 live births in the ObaapaVitA trial
during ages 2 to 28 days per 1000 singleton births sur-                 area from July 1, 2003, to June 30, 2004, and 433
viving to day 2. Early neonatal deaths were infants who                 neonatal deaths, giving a neonatal mortality rate of 30.1
died from days 2 to 7, and late neonatal deaths were                    per 1000 live births. Data were captured for 11 316
infants who died from 8 to 28 days of age.                              (82%) of the 13 860 singleton births within 28 days of
   Logistic regression was used to calculate crude and                  delivery (median: 14 days postpartum; interquartile
adjusted odds ratios (aORs) for mortality associated with               range: 7–21 days). This included 268 neonatal deaths,
the breastfeeding-exposure variables. Potential con-                    109 (41%) of which occurred within the first day of
founders relating to the mother (health, parity, age,                   birth. We excluded 106 (0.9%) of the day-2 singleton
educational level, and cash income), household (water                   survivors who either did not initiate breastfeeding or
supply and place of defecation), health system (number                  started then stopped, plus 154 (1.4%) whose mothers
of antenatal visits, place of birth, and birth attendant),              moved out of the study area before the second infant
and the infant (gender, birth size, gestational age, pres-              interview. This analysis is based on the remaining
ence of a congenital anomaly, health on the day of birth,               10 947 infants, among whom there were 145 neonatal
and health at the time of interview) were included a                    deaths from days 2 to 28.
priori in the models. ObaapaVitA trial group (maternal
vitamin A supplementation or placebo) was not includ-                   Breastfeeding Patterns and All-Cause Neonatal Mortality
ed; it was not a confounder, because it was not associ-                 Breastfeeding was initiated within the first day of birth
ated with infant feeding patterns.                                      in 71% of the infants and by the end of day 3 in all but
   Only 3264 infants had their weight measured within                   1.3% of them (Table 2); 70% of the infants were exclu-
48 hours of birth, but perceived birth size was available               sively breastfed during the neonatal period (Table 3).
from all of the mothers. Mothers’ perception of an infant               There was a marked dose response of increasing risk of



                  TABLE 1 Validation of Mother’s Perception of Birth Size
                       Perception of                     Birth Weight, kga                   Total, N      Mean (SD)
                         Birth Size                                                                     Birthweight, kg
                                            2.00     2.00–2.49      2.50–3.49       3.50
                 Very tiny                 8 (35)      6 (26)          8 (35)      1 (4.4)      23        2.23 (0.70)
                 Smaller than average     10 (6.0)    57 (34)         97 (58)      3 (1.8)     167        2.50 (0.45)
                 Average size              5 (0.3)   134 (7.5)      1389 (78)    261 (15)     1789        2.95 (0.43)
                 Larger than average         0        21 (3.2)       388 (59)    248 (38)      657        3.30 (0.46)
                 Very big baby               0         0             326 (52)    302 (48)      628        3.45 (0.46)
                 Total                    23 (0.7)   218 (6.7)      2208 (68)    815 (25)     3264        3.09 (0.51)
                 a Values   are n (%).



e382   EDMOND, et al
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TABLE 2 Risks of Neonatal Mortality According to Timing of Initiation of Breastfeeding in Singletons
                        Who Initiated Breastfeeding and Survived to Day 2
               Initiation of Breastfeeding            No. (%) of Infants          No. of Deaths (% risk)a            aOR 1 (95% CI)b              aOR 2 (95% CI)c
               Within 1 h                                 4763 (43)                         34 (0.7)                         1                            1
               From 1 h to end of day 1                   3105 (28)                         36 (1.2)                1.45 (0.90 to 2.35)          1.43 (0.88 to 2.31)
               Day 2                                      2138 (20)                         48 (2.3)                2.70 (1.70 to 4.30)          2.52 (1.58 to 4.02)d
               Day 3                                        797 (7.3)                       21 (2.6)                3.01 (1.70 to 5.38)          2.84 (1.59 to 5.06)d
               After day 3                                  144 (1.3)                        6 (4.2)                4.42 (1.76 to 11.09)         3.64 (1.43 to 9.30)d
               Total                                     10 947 (100)                      145 (1.3)
                                                                                                                       P LRT .0001                 P LRT .0001
                                                                                                                      P trend .0001               P trend .0001
               LRT indicates likelihood ratio test.
               a % risk   no. of deaths/no. of infants in exposure category.
               b Adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview,

               mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply,
               place of defecation, number of antenatal visits, place of birth, and birth attendant.
               c Adjusted for all factors mentioned previously plus established breastfeeding pattern.

               d The combined aOR for initiation of breastfeeding after 1 d was 2.88 (95% CI: 1.87 to 4.42).




                TABLE 3 Risks of Neonatal Mortality According to Established Breastfeeding Pattern in Singletons Who
                        Initiated Breastfeeding and Survived to Day 2
                Established Neonatal                   No. (%) of Infants              No. of Deaths               aOR 1 (95% CI)b                aOR 2 (95% CI)c
                Breastfeeding Pattern                                                    (% risk)a
                       Exclusive                           7680 (70)                        84 (1.1)                        1                              1
                       Predominant                         3034 (27)                        48 (1.6)               1.41 (0.97 to 2.03)            1.30 (0.90 to 1.87)
                       Partial                               233 (2.1)                      13 (5.6)               4.51 (2.38 to 8.55)            3.82 (1.99 to 7.34)
                       Total                              10 947 (100)                     145 (1.3)
                                                                                                                     P LRT .0001                    P LRT .0001
                                                                                                                    P trend .0001                  P trend .0001
               Median age of ascertainment of established breastfeeding patterns was 14 days (interquartile age, 7–21 days). LRT indicates likelihood ratio test.
               a % risk   no. of deaths/no. of infants in exposure category.
               b Adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview,

               mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply,
               place of defecation, number of antenatal visits, place of birth, and birth attendant.
               c Adjusted for all factors mentioned previously plus timing of initiation of breastfeeding.




neonatal mortality with increasing delay in initiation of                                     1.44 to 3.87]; P     .001). Furthermore, the trend with
breastfeeding from 1 hour to day 7 (Table 2); overall late                                    late initiation was still significant after adjusting for the
initiation (after day 1) was associated with a 2.4-fold                                       type of breastfeeding (Table 2), and the increased risk
increase in the risk of neonatal mortality (Table 4).                                         associated with late initiation was similar within each
   The size of this effect was similar (aOR: 2.44; 95% CI:                                    breastfeeding category (Table 4). Infants who were given
1.60 to 3.74; P .0001) when the model was refitted to                                          prelacteal feeds (any food or fluids before breastfeeding
exclude infants at high risk of death (unwell on the day                                      was established) on day 1 also had a high neonatal
of birth, congenital abnormalities, premature, and un-                                        mortality risk (aOR: 1.63; 95% CI: 1.09 to 2.45; P
well at the time of interview) or when deaths during the                                      .017).
first week (days 2–7) were excluded (aOR: 2.36; 95% CI:                                           The type of breastfeeding was also found to be asso-


                TABLE 4 Neonatal Mortality Risk by Time of Initiation of Breastfeeding and Established Diet
               Established Neonatal                                 Initiation of Breastfeeding                                      Late vs Early Initiation
               Breastfeeding Pattern
                                                       Early (first day)                      Late (After 1 d)                    aOR (95% CI)b                    P
                                                   No. of Deaths (% risk)a               No. of Deaths (% risk)a
                     Exclusive                            48/5767 (0.8)                        36/1913 (1.9)                  2.19 (1.38 to 3.49)                .001
                     Predominant                          18/1968 (0.9)                        30/1066 (2.8)                  2.55 (1.38 to 4.71)                .003
                     Partial                               4/133 (3.0)                          9/100 (9.0)                   2.63 (0.60 to 11.63)               .202
                     Overall                              70/7868 (0.9)                        75/3079 (2.4)                  2.40 (1.69 to 3.40)                .0001
               a%   risk   no. of deaths/no. of infants in exposure category.
               b Late vs early initiation, adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the

               time of interview, mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income,
               household water supply, place of defecation, number of antenatal visits, place of birth, and birth attendant.



                                                                                                                          PEDIATRICS Volume 117, Number 3, March 2006      e383
                                              Downloaded from www.pediatrics.org by on June 2, 2009
ciated with mortality risk. Both predominantly (aOR:                                         breastfeeding and neonatal mortality risk was demon-
1.41; 95% CI: 0.97 to 2.03) and partially (aOR, 4.51;                                        strated after controlling for factors that are known to be
95% CI, 2.38 to 8.55) breastfed infants had higher risks                                     associated with earlier onset of breastfeeding,13,14 lower
of neonatal death than exclusively breastfed infants, al-                                    rates of perinatal and infant mortality,3,6 and established
though the risk was much higher and only statistically                                       breastfeeding practices.15,16 The prevalence of HIV infec-
significant in the partially breastfed group (Table 3). The                                   tion is relatively low in the Brong Ahafo region of Ghana
pattern was unchanged after adjustment for timing of                                         (4% prevalence in women of reproductive age)17,18 and,
initiation of breastfeeding; the size of the ORs was only                                    thus, is unlikely to have influenced the promotion of
slightly reduced (Table 3).                                                                  breastfeeding by health care providers in the region.
    These findings indicate that both timing of initiation                                       To our knowledge, this is the first study that has
and type of breastfeeding pattern exert independent in-                                      examined the impact of initiation of breastfeeding on
fluences on neonatal mortality. Furthermore, there was                                        mortality during the neonatal period. A Guinea-Bissau
no evidence of any interaction between the sizes of these                                    study found no effect of early initiation (day 1) on
effects and birth weight or gestational age.                                                 postneonatal mortality (in infants aged 29 days to 3
                                                                                             years).19 However, the World Health Organization Col-
PAFs                                                                                         laborative Study Team10 reported a higher protective
The percentage of neonatal deaths from 2 to 28 days of                                       effect against mortality of any breastfeeding in the first 2
life that could be prevented if all of the infants in the                                    months compared with later ages, and 3 studies found
study population initiated breastfeeding in the first hour                                    early initiation of breastfeeding (days 1–3) to be sugges-
of life was 41.3% (Table 5, PAF). This is equivalent to                                      tively20 or significantly13,21 associated with a lower rate of
preventing 22.3% of all neonatal deaths if it is assumed                                     diarrhea during infancy. Two of these studies adjusted
that breastfeeding has no impact on deaths during the                                        for confounding factors,13,20 but only 1 adjusted for later
first day of life. The equivalent PAFs associated with                                        breastfeeding patterns.13
initiating breastfeeding on the first day (rather than the                                       Data showing the impact of postinitiation breastfeed-
first hour) are 30.2% of neonatal deaths saved from days                                      ing patterns on neonatal mortality are also sparse. The
2 to 28 or 16.3% of all neonatal deaths.                                                     only study identified examined infants in Bangladesh
                                                                                             and reported no significant differences between exclu-
DISCUSSION                                                                                   sive and predominant breastfeeding on neonatal or post-
                                                                                             neonatal mortality (excluding infants who died within
Statement of Principal Findings
                                                                                               3 days) after adjusting for confounding factors.15 This
Interventions to improve early infant feeding practices
                                                                                             study grouped together partially breastfed and non-
can result in considerable reductions in neonatal mor-
                                                                                             breastfed neonates and presented a combined hazard
tality. All-cause neonatal mortality could be reduced by
                                                                                             ratio of 1.17 (95% CI: 0.26 to 5.38) for not exclusively
16.3% if all infants initiated breastfeeding on day 1 of
                                                                                             breastfeeding.
life and by 22.3% if initiation took place within the first
hour. The risk of neonatal death is increased approxi-
mately fourfold if milk-based fluids or solids are pro-                                       Potential Limitations
vided to breastfed neonates.                                                                 Observational studies of breastfeeding and infant health
                                                                                             may be affected by a number of methodologic problems
Strengths and Relation to Other Studies                                                      including self-selection, reverse causality, confounding,
This article presents the risks of neonatal mortality that                                   and misclassification.22–24 However, we analyzed data for
are associated with early breastfeeding practices from a                                     the entire study population of singleton births and ad-
large cohort study of 10 000 infants in rural Ghana.                                         dressed reverse causality by excluding all deaths before
The protective relationship between early initiation of                                      day 2, excluding infants who either did not start or


                  TABLE 5 PAFs for Initiation of Breastfeeding in Breastfed Singletons Who Survived to Day 2
                                                              No. (%) of Deaths                        aORa (95% CI)                         PAF,b % (95% CI)
                 Within 1 h                                         34 (23.4)                                 1                                      —
                 After 1 h to end of day 1                          36 (24.8)                        1.45 (0.90 to 2.35)                     7.7 ( 2.8 to 13)
                 Day 2                                              48 (33.1)                        2.70 (1.70 to 4.30)                    20.8 (10 to 19)
                 Day 3                                              21 (14.4)                        3.01 (1.70 to 5.38)                     9.6 (5.9 to 12)
                 After day 3                                         6 (4.1)                         4.42 (1.76 to 11.09)                    3.2 (1.8 to 3.7)
                 Total                                             145 (100)                                                                        41.3
                 a Adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview,

                 mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply,
                 place of defecation, number of antenatal visits, place of birth, and birth attendant.
                 b PAF indicates proportion of deaths exposed (aOR       1)/aOR.



e384   EDMOND, et al
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started and stopped breastfeeding, controlling for high-       ACKNOWLEDGMENTS
risk infants, and repeating analyses excluding all deaths      This work was supported by the United Kingdom De-
before day 8 and high-risk infants (which did not alter        partment for International Development, US Agency for
effect estimates). We also adjusted for many potential         International Development, Ghana Health Service, Lon-
confounding variables, although residual confounding           don School of Hygiene and Tropical Medicine, and the
cannot be discounted. Finally, any differential misclassi-     United Kingdom National Perinatal Epidemiology Unit.
fication of type of breastfeeding would have tended to             We thank the mothers and children who participated
underestimate rather than overestimate effect sizes.           in this study for their cooperation and patience, the field
                                                               and computer center staff at Kintampo Health Research
Potential Mechanisms                                           Centre (KHRC) for their dedication and attention to
Early initiation of breastfeeding could affect neonatal        detail, and the ObaapaVitA trial steering committee for
mortality risk by 4 mechanisms. First, the lower rate of       their support and encouragement. Finally, we dedicate
mortality in early initiators may have occurred because        this article to the late Dr Paul Arthur, the founding
mothers who suckle their offspring shortly after birth         director of the KHRC, whose vision, guidance, and in-
have a greater chance of successfully establishing and         spiration enabled the neonatal program of work at
sustaining breastfeeding throughout infancy25 and be-          KHRC to become a reality.
cause breastfeeding during infancy is related protectively
to mortality.10 However, the effect of early initiation
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breastfeeding patterns and was stronger than the effect            Where? Why? Lancet. 2005;365:891–900
of established exclusive breastfeeding in our multivariate      2. Save the Children. State of the World’s Newborns 2001. A Report
models. Second, prelacteal feeding with nonhuman milk              From Saving Newborn Lives. Washington DC: Save the Children;
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e386      EDMOND, et al
                                         Downloaded from www.pediatrics.org by on June 2, 2009
Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality
Karen M. Edmond, Charles Zandoh, Maria A. Quigley, Seeba Amenga-Etego, Seth
                    Owusu-Agyei and Betty R. Kirkwood
                       Pediatrics 2006;117;e380-e386
                       DOI: 10.1542/peds.2005-1496
Updated Information              including high-resolution figures, can be found at:
& Services                       http://www.pediatrics.org/cgi/content/full/117/3/e380
References                       This article cites 18 articles, 5 of which you can access for free
                                 at:
                                 http://www.pediatrics.org/cgi/content/full/117/3/e380#BIBL
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Delayed Breastfeeding Initiation Increases Risk Of Neonatal Mortality

  • 1. Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality Karen M. Edmond, Charles Zandoh, Maria A. Quigley, Seeba Amenga-Etego, Seth Owusu-Agyei and Betty R. Kirkwood Pediatrics 2006;117;e380-e386 DOI: 10.1542/peds.2005-1496 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/117/3/e380 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on June 2, 2009
  • 2. ARTICLE Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality Karen M. Edmond, MMSc, FRCPCHa,b, Charles Zandoh, MSca, Maria A. Quigley, MSc c, Seeba Amenga-Etego, MSca, Seth Owusu-Agyei, PhDa, Betty R. Kirkwood, MSc, FMedScib aKintampo Health Research Centre, Ghana Health Service, Kintampo, Brong Ahafo Region, Ghana; bDepartment of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; cNational Perinatal Epidemiology Unit, Oxford University, Oxford, United Kingdom The authors have indicated that they have no relationships relevant to this article to disclose. ABSTRACT BACKGROUND. Breastfeeding promotion is a key child survival strategy. Although there is an extensive scientific basis for its impact on postneonatal mortality, evidence is sparse for its impact on neonatal mortality. www.pediatrics.org/cgi/doi/10.1542/ peds.2005-1496 OBJECTIVES. We sought to assess the contribution of the timing of initiation of breast- doi:10.1542/peds.2005-1496 feeding to any impact. Dr Edmond conceived the idea for this study, METHODS. This study took advantage of the 4-weekly surveillance system from a took the lead role in its design, oversaw its conduct, conducted the statistical analysis, large ongoing maternal vitamin A supplementation trial in rural Ghana involving and wrote the first draft of the paper. She was all women of childbearing age and their infants. It was designed to evaluate responsible for the final version, together with Prof Kirkwood, who provided technical whether timing of initiation of breastfeeding and type (exclusive, predominant, or input to and was substantially involved in all partial) are associated with risk of neonatal mortality. The analysis is based on aspects of the study. Mr Zandoh was head of 10 947 breastfed singleton infants born between July 2003 and June 2004 who fieldwork; Mr Amenga-Etego was responsible for the design and execution of the data survived to day 2 and whose mothers were visited in the neonatal period. management system; Dr Owusu-Agyei provided technical input to the design and RESULTS. Breastfeeding was initiated within the first day of birth in 71% of infants conduct; and Ms Quigley provided technical and by the end of day 3 in all but 1.3% of them; 70% were exclusively breastfed input and contributed to the statistical during the neonatal period. The risk of neonatal death was fourfold higher in analysis. All authors provided feedback on drafts of the article and approved the final children given milk-based fluids or solids in addition to breast milk. There was a version. marked dose response of increasing risk of neonatal mortality with increasing Key Words delay in initiation of breastfeeding from 1 hour to day 7; overall late initiation breastfeeding, neonatal care, neonatal survival (after day 1) was associated with a 2.4-fold increase in risk. The size of this effect Abbreviations was similar when the model was refitted excluding infants at high risk of death OR— odds ratio (unwell on the day of birth, congenital abnormalities, premature, unwell at the aOR—adjusted odds ratio time of interview) or when deaths during the first week (days 2–7) were excluded. PAF—population-attributable fraction CI— confidence interval CONCLUSIONS. Promotion of early initiation of breastfeeding has the potential to make Accepted for publication Sep 7, 2005 a major contribution to the achievement of the child survival millennium devel- Address correspondence to Karen Edmond, opment goal; 16% of neonatal deaths could be saved if all infants were breastfed MMSc, FRCPCH, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E from day 1 and 22% if breastfeeding started within the first hour. Breastfeeding- 7HT, United Kingdom. E-mail: Karen.Edmond@ promotion programs should emphasize early initiation as well as exclusive breast- lshtm.ac.uk PEDIATRICS (ISSN Numbers: Print, 0031-4005; feeding. This has particular relevance for sub-Saharan Africa, where neonatal and Online, 1098-4275). Copyright © 2006 by the infant mortality rates are high but most women already exclusively or predomi- American Academy of Pediatrics nantly breastfeed their infants. e380 EDMOND, et al Downloaded from www.pediatrics.org by on June 2, 2009
  • 3. A LTHOUGH THE CHILD survival revolution of the 1980s led to dramatic reductions in overall child mortality, it had little impact on neonatal mortality.1,2 In trial to assess the impact of weekly vitamin A supple- mentation on maternal mortality. It involves all women of childbearing age who live in 4 rural contiguous dis- 2002, 4 million infants died during the first month of tricts (Kintampo, Wenchi, Techiman, and Nkoranza) in life, and neonatal deaths now account for 36% of deaths the forest-savanna transitional ecological zone in the among children 5 years of age.1,2 Tackling neonatal Brong Ahafo region of central Ghana. It covers 12 000 mortality is essential if the millennium development km2, and 80% of the study population live in remote goal for child mortality is to be met.3,4 Sub-Saharan and rural villages. Africa contributes a high proportion of neonatal deaths, All of the singleton infants born to mothers in the yet its progress has been the slowest of any region in the ObaapaVitA trial between July 1, 2003, and June 30, world.2,3,5 Because the majority of neonatal deaths occur 2004, who initiated breastfeeding, survived to day 2, and at home,1 feasible interventions for home-based imple- whose mothers were visited in the neonatal period were mentation are needed urgently. included in the present study. Both the ObaapaVitA trial The promotion of breastfeeding is a key component of and this nested study were approved by the ethics com- child survival strategies.3 Furthermore, the recent Lancet mittees of Ghana Health Service and London School of neonatal survival series included breastfeeding in its rec- Hygiene and Tropical Medicine. ommended package of interventions to reduce neonatal mortality.6 International policy places emphasis on ex- Data Collection clusive breastfeeding during the first 6 months of life, Women were visited once every 4 weeks by a network of with some groups promoting early initiation of breast- trained village-based fieldworkers to distribute vitamin feeding within 1 hour of birth.7,8 Although there is an A capsules and collect data on morbidity and mortality. extensive scientific basis for the impact of breastfeeding When a birth was reported, the fieldworker adminis- on postneonatal mortality,3,9,10 evidence is sparse for its tered a “birth” questionnaire, which included birth out- impact on neonatal mortality1,6 and, to our knowledge, come, birth weight (if taken within 48 hours of birth at nonexistent for the contribution of the timing of initia- a health facility), gestational age, details of the delivery, tion to any mortality impact. health care during pregnancy, health of the mother, Maternal colostrum, produced during the first days socioeconomic and environmental characteristics, and after delivery, has long been thought to confer additional home-based neonatal care practices, including early protection because of its immune and nonimmune prop- breastfeeding practices. The mother was asked when she erties.11 However, epidemiologic data indicate that a initiated breastfeeding and was prompted for the exact high proportion of neonatal deaths are a result of ob- timing (within 1 hour, after 1 hour but first day, day 2, stetric complications,1,12 and these are unlikely to be day 3, day 4 –7, or after day 7). She was then asked what affected by colostrum, transitional breast milk, or mature she offered her child to eat or drink in the 24 hours breast milk. Elucidating the role of timing of initiation of before the interview. After noting the unprompted re- breastfeeding is particularly relevant for sub-Saharan sponse, the mother was asked if she offered her own Africa, where neonatal and infant mortality rates are breast milk, breast milk from a wet nurse, animal milk, high but most women already exclusively or predomi- infant formula, milk-based fluids, water-based fluids, or nantly breastfeed their infants.2 solid foods. The mother was also asked about the infant’s A surveillance system from a large trial in rural Ghana health on the day of birth and in the previous 24 hours. of the impact of weekly vitamin A supplementation to At the next 4-week visit, an “infant” questionnaire was women of childbearing age on maternal and infant mor- administered to obtain additional outcome data (infant tality (ObaapaVitA trial) afforded the opportunity to morbidity and mortality) and information about infant evaluate the association between early breastfeeding feeding practices. Infants were followed up at subse- practices and deaths in breastfed neonates. Our primary quent visits every 4 weeks until they reached 12 months objective was to evaluate the association between the of age. timing of initiation of breastfeeding and neonatal mor- tality. The secondary objective was to assess whether the Study Definitions and Statistical Analysis different types of breastfeeding (exclusive, predominant, An infant was considered to be breastfed if breast milk and partial breastfeeding) were associated with substan- constituted any portion of their diet. Infants were clas- tially different risks of neonatal death. sified according to the timing of breastfeeding initiation (first hour, after first hour but day 1, day 2, day 3, and after day 3). “Early initiation” of breastfeeding referred METHODS to breastfeeding that started on the first day of life. “Late Setting and Participants initiation” indicated breastfeeding that began after the The ObaapaVitA trial is an ongoing community-based, first day of life. “Established breastfeeding” referred to cluster-randomized, double-blind, placebo-controlled the reported breastfeeding pattern in the 24 hours before PEDIATRICS Volume 117, Number 3, March 2006 e381 Downloaded from www.pediatrics.org by on June 2, 2009
  • 4. the first interview (median: 14 days postpartum; inter- as “very tiny” or “smaller than average” gave a sensitiv- quartile range: 7–21 days). “Exclusive breastfeeding” ity of 80% and specificity of 95% in detecting a birth was defined as feeding of only breast milk and nothing weight of 2.0 kg (Table 1). Thus, the mother’s percep- else, not even water, with the exception of vitamin tion of birth size was used in the logistic-regression supplements and prescribed medicines. “Predominant models as a proxy for birth weight. breastfeeding” was defined as feeding of breast milk To further reduce problems with reverse causality, along with other nonmilk fluids. Infants who were of- analyses were repeated excluding infants at high risk of fered breast milk and animal milk, infant formula, or death and ill health (congenital anomalies, premature, solids were considered to be “partially breastfed.” These unwell on the day of birth, and unwell at the time of definitions are consistent with the current World Health interview) and early neonatal deaths. All of the analyses Organization definitions for breastfeeding patterns.8 were conducted in Stata 8.2 (Stata Corp, College Station, The primary comparisons were made between early TX). aORs and 95% confidence intervals (CIs) are pre- and late initiation of breastfeeding and between the sented. Because neonatal mortality is a relatively rare types of established breastfeeding patterns (exclusive, event, these ORs closely approximate relative risks and predominant, and partial). To reduce problems with re- are referred to as such in the text. To elucidate the public verse causality (ie, the possibility of the breastfeeding health importance of improving early breastfeeding pat- pattern being affected by serious illnesses that lead to terns, the proportions of all neonatal deaths that would death), only infants who survived to day 2 and who be avoided if all infants initiated breastfeeding during the were breastfed successfully were included in the primary first hour or during the first day of life (the population- analyses. Multiple births, noninitiators, and those who attributable fractions [PAFs]) were calculated also. were interviewed outside the neonatal period were also excluded. The primary outcome variable was calculated RESULTS as the number of breastfed singleton infants who died There were 14 403 live births in the ObaapaVitA trial during ages 2 to 28 days per 1000 singleton births sur- area from July 1, 2003, to June 30, 2004, and 433 viving to day 2. Early neonatal deaths were infants who neonatal deaths, giving a neonatal mortality rate of 30.1 died from days 2 to 7, and late neonatal deaths were per 1000 live births. Data were captured for 11 316 infants who died from 8 to 28 days of age. (82%) of the 13 860 singleton births within 28 days of Logistic regression was used to calculate crude and delivery (median: 14 days postpartum; interquartile adjusted odds ratios (aORs) for mortality associated with range: 7–21 days). This included 268 neonatal deaths, the breastfeeding-exposure variables. Potential con- 109 (41%) of which occurred within the first day of founders relating to the mother (health, parity, age, birth. We excluded 106 (0.9%) of the day-2 singleton educational level, and cash income), household (water survivors who either did not initiate breastfeeding or supply and place of defecation), health system (number started then stopped, plus 154 (1.4%) whose mothers of antenatal visits, place of birth, and birth attendant), moved out of the study area before the second infant and the infant (gender, birth size, gestational age, pres- interview. This analysis is based on the remaining ence of a congenital anomaly, health on the day of birth, 10 947 infants, among whom there were 145 neonatal and health at the time of interview) were included a deaths from days 2 to 28. priori in the models. ObaapaVitA trial group (maternal vitamin A supplementation or placebo) was not includ- Breastfeeding Patterns and All-Cause Neonatal Mortality ed; it was not a confounder, because it was not associ- Breastfeeding was initiated within the first day of birth ated with infant feeding patterns. in 71% of the infants and by the end of day 3 in all but Only 3264 infants had their weight measured within 1.3% of them (Table 2); 70% of the infants were exclu- 48 hours of birth, but perceived birth size was available sively breastfed during the neonatal period (Table 3). from all of the mothers. Mothers’ perception of an infant There was a marked dose response of increasing risk of TABLE 1 Validation of Mother’s Perception of Birth Size Perception of Birth Weight, kga Total, N Mean (SD) Birth Size Birthweight, kg 2.00 2.00–2.49 2.50–3.49 3.50 Very tiny 8 (35) 6 (26) 8 (35) 1 (4.4) 23 2.23 (0.70) Smaller than average 10 (6.0) 57 (34) 97 (58) 3 (1.8) 167 2.50 (0.45) Average size 5 (0.3) 134 (7.5) 1389 (78) 261 (15) 1789 2.95 (0.43) Larger than average 0 21 (3.2) 388 (59) 248 (38) 657 3.30 (0.46) Very big baby 0 0 326 (52) 302 (48) 628 3.45 (0.46) Total 23 (0.7) 218 (6.7) 2208 (68) 815 (25) 3264 3.09 (0.51) a Values are n (%). e382 EDMOND, et al Downloaded from www.pediatrics.org by on June 2, 2009
  • 5. TABLE 2 Risks of Neonatal Mortality According to Timing of Initiation of Breastfeeding in Singletons Who Initiated Breastfeeding and Survived to Day 2 Initiation of Breastfeeding No. (%) of Infants No. of Deaths (% risk)a aOR 1 (95% CI)b aOR 2 (95% CI)c Within 1 h 4763 (43) 34 (0.7) 1 1 From 1 h to end of day 1 3105 (28) 36 (1.2) 1.45 (0.90 to 2.35) 1.43 (0.88 to 2.31) Day 2 2138 (20) 48 (2.3) 2.70 (1.70 to 4.30) 2.52 (1.58 to 4.02)d Day 3 797 (7.3) 21 (2.6) 3.01 (1.70 to 5.38) 2.84 (1.59 to 5.06)d After day 3 144 (1.3) 6 (4.2) 4.42 (1.76 to 11.09) 3.64 (1.43 to 9.30)d Total 10 947 (100) 145 (1.3) P LRT .0001 P LRT .0001 P trend .0001 P trend .0001 LRT indicates likelihood ratio test. a % risk no. of deaths/no. of infants in exposure category. b Adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview, mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply, place of defecation, number of antenatal visits, place of birth, and birth attendant. c Adjusted for all factors mentioned previously plus established breastfeeding pattern. d The combined aOR for initiation of breastfeeding after 1 d was 2.88 (95% CI: 1.87 to 4.42). TABLE 3 Risks of Neonatal Mortality According to Established Breastfeeding Pattern in Singletons Who Initiated Breastfeeding and Survived to Day 2 Established Neonatal No. (%) of Infants No. of Deaths aOR 1 (95% CI)b aOR 2 (95% CI)c Breastfeeding Pattern (% risk)a Exclusive 7680 (70) 84 (1.1) 1 1 Predominant 3034 (27) 48 (1.6) 1.41 (0.97 to 2.03) 1.30 (0.90 to 1.87) Partial 233 (2.1) 13 (5.6) 4.51 (2.38 to 8.55) 3.82 (1.99 to 7.34) Total 10 947 (100) 145 (1.3) P LRT .0001 P LRT .0001 P trend .0001 P trend .0001 Median age of ascertainment of established breastfeeding patterns was 14 days (interquartile age, 7–21 days). LRT indicates likelihood ratio test. a % risk no. of deaths/no. of infants in exposure category. b Adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview, mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply, place of defecation, number of antenatal visits, place of birth, and birth attendant. c Adjusted for all factors mentioned previously plus timing of initiation of breastfeeding. neonatal mortality with increasing delay in initiation of 1.44 to 3.87]; P .001). Furthermore, the trend with breastfeeding from 1 hour to day 7 (Table 2); overall late late initiation was still significant after adjusting for the initiation (after day 1) was associated with a 2.4-fold type of breastfeeding (Table 2), and the increased risk increase in the risk of neonatal mortality (Table 4). associated with late initiation was similar within each The size of this effect was similar (aOR: 2.44; 95% CI: breastfeeding category (Table 4). Infants who were given 1.60 to 3.74; P .0001) when the model was refitted to prelacteal feeds (any food or fluids before breastfeeding exclude infants at high risk of death (unwell on the day was established) on day 1 also had a high neonatal of birth, congenital abnormalities, premature, and un- mortality risk (aOR: 1.63; 95% CI: 1.09 to 2.45; P well at the time of interview) or when deaths during the .017). first week (days 2–7) were excluded (aOR: 2.36; 95% CI: The type of breastfeeding was also found to be asso- TABLE 4 Neonatal Mortality Risk by Time of Initiation of Breastfeeding and Established Diet Established Neonatal Initiation of Breastfeeding Late vs Early Initiation Breastfeeding Pattern Early (first day) Late (After 1 d) aOR (95% CI)b P No. of Deaths (% risk)a No. of Deaths (% risk)a Exclusive 48/5767 (0.8) 36/1913 (1.9) 2.19 (1.38 to 3.49) .001 Predominant 18/1968 (0.9) 30/1066 (2.8) 2.55 (1.38 to 4.71) .003 Partial 4/133 (3.0) 9/100 (9.0) 2.63 (0.60 to 11.63) .202 Overall 70/7868 (0.9) 75/3079 (2.4) 2.40 (1.69 to 3.40) .0001 a% risk no. of deaths/no. of infants in exposure category. b Late vs early initiation, adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview, mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply, place of defecation, number of antenatal visits, place of birth, and birth attendant. PEDIATRICS Volume 117, Number 3, March 2006 e383 Downloaded from www.pediatrics.org by on June 2, 2009
  • 6. ciated with mortality risk. Both predominantly (aOR: breastfeeding and neonatal mortality risk was demon- 1.41; 95% CI: 0.97 to 2.03) and partially (aOR, 4.51; strated after controlling for factors that are known to be 95% CI, 2.38 to 8.55) breastfed infants had higher risks associated with earlier onset of breastfeeding,13,14 lower of neonatal death than exclusively breastfed infants, al- rates of perinatal and infant mortality,3,6 and established though the risk was much higher and only statistically breastfeeding practices.15,16 The prevalence of HIV infec- significant in the partially breastfed group (Table 3). The tion is relatively low in the Brong Ahafo region of Ghana pattern was unchanged after adjustment for timing of (4% prevalence in women of reproductive age)17,18 and, initiation of breastfeeding; the size of the ORs was only thus, is unlikely to have influenced the promotion of slightly reduced (Table 3). breastfeeding by health care providers in the region. These findings indicate that both timing of initiation To our knowledge, this is the first study that has and type of breastfeeding pattern exert independent in- examined the impact of initiation of breastfeeding on fluences on neonatal mortality. Furthermore, there was mortality during the neonatal period. A Guinea-Bissau no evidence of any interaction between the sizes of these study found no effect of early initiation (day 1) on effects and birth weight or gestational age. postneonatal mortality (in infants aged 29 days to 3 years).19 However, the World Health Organization Col- PAFs laborative Study Team10 reported a higher protective The percentage of neonatal deaths from 2 to 28 days of effect against mortality of any breastfeeding in the first 2 life that could be prevented if all of the infants in the months compared with later ages, and 3 studies found study population initiated breastfeeding in the first hour early initiation of breastfeeding (days 1–3) to be sugges- of life was 41.3% (Table 5, PAF). This is equivalent to tively20 or significantly13,21 associated with a lower rate of preventing 22.3% of all neonatal deaths if it is assumed diarrhea during infancy. Two of these studies adjusted that breastfeeding has no impact on deaths during the for confounding factors,13,20 but only 1 adjusted for later first day of life. The equivalent PAFs associated with breastfeeding patterns.13 initiating breastfeeding on the first day (rather than the Data showing the impact of postinitiation breastfeed- first hour) are 30.2% of neonatal deaths saved from days ing patterns on neonatal mortality are also sparse. The 2 to 28 or 16.3% of all neonatal deaths. only study identified examined infants in Bangladesh and reported no significant differences between exclu- DISCUSSION sive and predominant breastfeeding on neonatal or post- neonatal mortality (excluding infants who died within Statement of Principal Findings 3 days) after adjusting for confounding factors.15 This Interventions to improve early infant feeding practices study grouped together partially breastfed and non- can result in considerable reductions in neonatal mor- breastfed neonates and presented a combined hazard tality. All-cause neonatal mortality could be reduced by ratio of 1.17 (95% CI: 0.26 to 5.38) for not exclusively 16.3% if all infants initiated breastfeeding on day 1 of breastfeeding. life and by 22.3% if initiation took place within the first hour. The risk of neonatal death is increased approxi- mately fourfold if milk-based fluids or solids are pro- Potential Limitations vided to breastfed neonates. Observational studies of breastfeeding and infant health may be affected by a number of methodologic problems Strengths and Relation to Other Studies including self-selection, reverse causality, confounding, This article presents the risks of neonatal mortality that and misclassification.22–24 However, we analyzed data for are associated with early breastfeeding practices from a the entire study population of singleton births and ad- large cohort study of 10 000 infants in rural Ghana. dressed reverse causality by excluding all deaths before The protective relationship between early initiation of day 2, excluding infants who either did not start or TABLE 5 PAFs for Initiation of Breastfeeding in Breastfed Singletons Who Survived to Day 2 No. (%) of Deaths aORa (95% CI) PAF,b % (95% CI) Within 1 h 34 (23.4) 1 — After 1 h to end of day 1 36 (24.8) 1.45 (0.90 to 2.35) 7.7 ( 2.8 to 13) Day 2 48 (33.1) 2.70 (1.70 to 4.30) 20.8 (10 to 19) Day 3 21 (14.4) 3.01 (1.70 to 5.38) 9.6 (5.9 to 12) After day 3 6 (4.1) 4.42 (1.76 to 11.09) 3.2 (1.8 to 3.7) Total 145 (100) 41.3 a Adjusted for gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview, mother’s health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply, place of defecation, number of antenatal visits, place of birth, and birth attendant. b PAF indicates proportion of deaths exposed (aOR 1)/aOR. e384 EDMOND, et al Downloaded from www.pediatrics.org by on June 2, 2009
  • 7. started and stopped breastfeeding, controlling for high- ACKNOWLEDGMENTS risk infants, and repeating analyses excluding all deaths This work was supported by the United Kingdom De- before day 8 and high-risk infants (which did not alter partment for International Development, US Agency for effect estimates). We also adjusted for many potential International Development, Ghana Health Service, Lon- confounding variables, although residual confounding don School of Hygiene and Tropical Medicine, and the cannot be discounted. Finally, any differential misclassi- United Kingdom National Perinatal Epidemiology Unit. fication of type of breastfeeding would have tended to We thank the mothers and children who participated underestimate rather than overestimate effect sizes. in this study for their cooperation and patience, the field and computer center staff at Kintampo Health Research Potential Mechanisms Centre (KHRC) for their dedication and attention to Early initiation of breastfeeding could affect neonatal detail, and the ObaapaVitA trial steering committee for mortality risk by 4 mechanisms. First, the lower rate of their support and encouragement. Finally, we dedicate mortality in early initiators may have occurred because this article to the late Dr Paul Arthur, the founding mothers who suckle their offspring shortly after birth director of the KHRC, whose vision, guidance, and in- have a greater chance of successfully establishing and spiration enabled the neonatal program of work at sustaining breastfeeding throughout infancy25 and be- KHRC to become a reality. cause breastfeeding during infancy is related protectively to mortality.10 However, the effect of early initiation REFERENCES persisted after controlling for established neonatal 1. Lawn J, Cousens S, Zupan J. 4 million neonatal deaths: When? breastfeeding patterns and was stronger than the effect Where? Why? Lancet. 2005;365:891–900 of established exclusive breastfeeding in our multivariate 2. Save the Children. State of the World’s Newborns 2001. A Report models. Second, prelacteal feeding with nonhuman milk From Saving Newborn Lives. 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  • 9. Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality Karen M. Edmond, Charles Zandoh, Maria A. Quigley, Seeba Amenga-Etego, Seth Owusu-Agyei and Betty R. Kirkwood Pediatrics 2006;117;e380-e386 DOI: 10.1542/peds.2005-1496 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/117/3/e380 References This article cites 18 articles, 5 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/117/3/e380#BIBL Citations This article has been cited by 4 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/117/3/e380#otherarticl es Post-Publication 2 P3Rs have been posted to this article: Peer Reviews (P3Rs) http://www.pediatrics.org/cgi/eletters/117/3/e380 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition & Metabolism http://www.pediatrics.org/cgi/collection/nutrition_and_metabolis m Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org by on June 2, 2009