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.

Method

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.

Analysis

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).

Results

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.

Conclusions

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