The longer the delay between birth and the start of breast-feeding, the greater the likelihood that infants will die before they are four weeks old, according to an observational study conducted in rural Ghana.1 Breast-feeding was initiated after the first day of life for 29% of infants. After other factors were taken into account, the odds of dying before four weeks of age was more than twice as high among these infants as it was among infants who began breast-feeding within 24 hours of birth. An estimated 16% of all neonatal deaths that occurred among the infants in the study could have been prevented if all infants had begun breast-feeding on their first day of life.
Researchers analyzed surveillance data from a trial of vitamin A supplementation conducted among women of childbearing age in four rural districts of Ghana (Kintampo, Wenchi, Techiman and Nkoranza). Among singleton infants born to mothers in the trial between July 2003 and June 2004, those who started breast-feeding, who survived for at least one day and whose mothers received a home visit by a fieldworker during the neonatal period were included in the analysis. During the home visits, made every four weeks, fieldworkers collected information about pregnancies and births, maternal and infant health and mortality, socioeconomic and household characteristics, and home-based neonatal care practices, including breast-feeding. The timing of initiation of breast-feeding was categorized as early (starting on the first day of life) or late (starting after the first day). Breast-feeding was classified as exclusive (feeding with breast milk only), predominant (feeding with breast milk along with nonmilk fluids) or partial (feeding with breast milk along with animal milk, infant formula or solids).
Analyses were based on 10,947 infants, of whom about 1% died in the neonatal period (days 2–28 of life). During the neonatal period, 70% of infants were exclusively breast-fed, 27% were predominantly breast-fed and 2% were partially breast-fed. After factors potentially affecting neonatal mortality and breast-feeding practices were taken into account, the odds of neonatal death rose with the level of supplementary feeding; this association persisted after accounting for the timing of initiation of breast-feeding. Compared with exclusively breast-fed infants, partially breastfed infants had almost four times the odds of dying during the neonatal period (adjusted odds ratio, 3.8).
Some 71% of infants began breast-feeding by the end of their first day of life (including 43% who began within one hour of birth), and 99% did so by the end of their third day. After factors potentially affecting neonatal mortality and breast-feeding practices were taken into account, the odds of neonatal death rose with time to initiation of breast-feeding; this association persisted when the type of breast-feeding was taken into account. Infants' odds of dying were more than doubled if they began breast-feeding on their second day or their third day (adjusted odds ratios, 2.5 and 2.8, respectively), and were more than tripled if they began after their third day (3.6), as compared with their first hour of life.
Overall, infants were more than twice as likely to die during the neonatal period if breast-feeding was initiated late instead of early (adjusted odds ratio, 2.4). In addition, the odds of neonatal death for infants who began late remained elevated after the exclusion of those who had a high risk of dying because of factors such as prematurity, congenital abnormalities or illness (2.4) and those who died during days 2–7 (2.4). The odds associated with starting late were also elevated among infants who were exclusively breast-fed (2.2) and those who were predominantly breast-fed (2.6), but not among those who were partially breast-fed.
Final analyses indicated that 41% of neonatal deaths occurring during days 2–28 (22% of all neonatal deaths) could have been prevented if all infants had begun breast-feeding in their first hour of life. Similarly, 30% of neonatal deaths occurring during days 2–28 (16% of all neonatal deaths) could have been averted if all infants had begun breast-feeding during their first day of life.
According to the researchers, early initiation of breast-feeding may protect against neonatal mortality in four ways. First, suckling shortly after birth may help establish breast-feeding and ensure that it continues. Second, early breast-feeding may prevent exposure to substances in other foods that disrupt normal priming of the digestive tract. Third, components of early milk may promote maturation of the digestive tract and protect against infection. And fourth, the bodily warmth associated with breast-feeding may avert infant death from hypothermia. Taken together, the researchers assert, the results suggest that programs to promote breast-feeding in less developed settings should emphasize early initiation, as well as exclusive breast-feeding. "This is particularly relevant for Sub-Saharan Africa," the researchers note, "where neonatal and infant mortality rates are high, most women already exclusively or predominantly breast-feed their infants, and delay of initiation of breast-feeding beyond the first day of life is common."—S. London
1. Edmond KM et al., Delayed breastfeeding initiation increases risk of neonatal mortality, Pediatrics, 2006, 117(3):e380–e386.