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.
OBJECTIVES. We sought to assess the contribution of the timing of initiation of breastfeeding to any impact.
METHODS. This study took advantage of the 4-weekly surveillance system from a large ongoing maternal vitamin A supplementation trial in rural Ghana involving all women of childbearing age and their infants. It was designed to evaluate whether timing of initiation of breastfeeding and type (exclusive, predominant, or partial) are associated with risk of neonatal mortality. The analysis is based on 10947 breastfed singleton infants born between July 2003 and June 2004 who survived to day 2 and whose mothers were visited in the neonatal period.
RESULTS. Breastfeeding was initiated within the first day of birth in 71% of infants and by the end of day 3 in all but 1.3% of them; 70% were exclusively breastfed during the neonatal period. The risk of neonatal death was fourfold higher in children given milk-based fluids or solids in addition to breast milk. 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 risk. The size of this effect was similar when the model was refitted excluding infants at high risk of death (unwell on the day of birth, congenital abnormalities, premature, unwell at the time of interview) or when deaths during the first week (days 2–7) were excluded.
CONCLUSIONS. Promotion of early initiation of breastfeeding has the potential to make a major contribution to the achievement of the child survival millennium development goal; 16% of neonatal deaths could be saved if all infants were breastfed from day 1 and 22% if breastfeeding started within the first hour. Breastfeeding-promotion programs should emphasize early initiation as well as exclusive breastfeeding. This has particular relevance for sub-Saharan Africa, where neonatal and infant mortality rates are high but most women already exclusively or predominantly breastfeed their infants.
Comments
Should breastfeeding be initiated within the first 10 minutes after birth?
Edmond et al1 have shown in a study in rural Ghana, a 22% reduction in neonatal mortality if breastfeeding is started within the first hour after birth. 43 % of infants in the study initiated breastfeeding within this time. The authors stated “The mother was asked when she initiated breastfeeding and was prompted for the exact timing (within 1 hour…” More precise timing of the first feed may however be important. Previous studies have examined breastfeeds within the first hour. Righard et al2 studied babies allowed uninterrupted skin-to-skin contact for at least 1 hour after birth. At an average of 50 minutes after birth only 63% of babies were sucking correctly at the breast. Babies of mothers receiving pethidine during labour were more likely to suck incorrectly or not at all. In a study assessing early initiation and frequency of breastfeeding Salariya et al3 observed that babies put to the breast within the first 10 minutes of life had no fixing or sucking difficulties even though 75% of the mothers of these babies had received pethidine during labour.
In order to obtain the benefits of an early feed, it may be that this should be initiated within the first 10 minutes after birth as waiting until later in the first hour may be too late for some babies, particularly those whose mothers received sedation during labour.
Recent advice is that the baby should have skin-to-skin contact with the mother after birth, thereby having free access to the breast so that the baby will be able to feed when he or she is ready.4 In light of the evidence in Edmond’s study, perhaps mothers should be advised that an early feed is important, and they should initiate this within the first hour and possibly within the first 10 minutes, rather than wait until the baby is ready, since the opportunity for an early feed may then have been lost.
1 Edmond K.M. Zandoh C. Amengo-Etego S. Kirkwood B R. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics Vol 117 No. 3 March 2006 ppe380-e386
2 Righard L. Alade M.O. Effect of delivery room routines on success of first breast-feed. Lancet Vol 336. Nov 3 1990. pp1105-1107
3 Salariya E.M. Cater J.I. Easton P.M. Duration of breast-feeding after early initiation and frequent feeding. Lancet Nov 25, 1978 pp1141- 1143
4 Renfrew M. J. Woolridge M. W. McGill H. R. Enabling women to breastfeed. The Stationery Office. ISBN 0 11 321873 7
Conflict of Interest:
None declared
Should breastfeeding be initiated within the first 10 minutes after birth?
Edmond et al1 have shown in a study in rural Ghana, a 22% reduction in neonatal mortality if breastfeeding is started within the first hour after birth. 43 % of infants in the study initiated breastfeeding at this time. The authors stated “The mother was asked when she initiated breastfeeding and was prompted for the exact timing (within 1 hour…”
More precise timing of the first feed may however be important. Previous studies have examined breastfeeds within the first hour. Righard et al2 studied babies allowed uninterrupted skin-to-skin contact for at least 1 hour after birth. At an average of 50 minutes after birth only 63% of babies were sucking correctly at the breast. Babies of mothers receiving pethidine during labour were more likely to suck incorrectly or not at all. In a study assessing early initiation and frequency of breastfeeding Salariya et al3 observed that babies put to the breast within the first 10 minutes of life had no fixing or sucking difficulties even though 75% of the mothers of these babies had received pethidine during labour.
In order to obtain the benefits of an early feed, it may be that this should be initiated within the first 10 minutes after birth as waiting until later in the first hour may be too late for some babies, particularly those whose mothers received sedation during labour.
Recent advice is that the baby should have skin-to-skin contact with the mother after birth, thereby having free access to the breast so that the baby will be able to feed when he or she is ready.4 In light of the evidence in Edmond’s study, perhaps mothers should be advised that an early feed is important, and they should initiate this within the first hour and possibly within the first 10 minutes, rather than wait until the baby is ready, since the opportunity for an early feed may then have been lost.
1 Edmond K.M. Zandoh C. Amengo-Etego S. Kirkwood B R. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics Vol 117 No. 3 March 2006 ppe380-e386
2 Righard L. Alade M.O. Effect of delivery room routines on success of first breast-feed. Lancet Vol 336. Nov 3 1990. pp1105-1107
3 Salariya E.M. Cater J.I. Easton P.M. Duration of breast-feeding after early initiation and frequent feeding. Lancet Nov 25, 1978 pp1141- 1143
4 Renfrew M. J. Woolridge M. W. McGill H. R. Enabling women to breastfeed. The Staionery Office. ISBN 0 11 321873 7
Conflict of Interest:
Researching into infant growth and breastfeeding