Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials

Background Although the benefi ts of exclusive breastfeeding for child health and survival, particularly in the post-neonatal period, are established, the independent benefi cial eff ect of early breastfeeding initiation remains unclear. We studied the association between timing of breastfeeding initiation and post-enrolment neonatal and postneonatal mortality up to 6 months of age, as well as the associations between breastfeeding pattern and mortality. Methods We examined associations between timing of breastfeeding initiation, post-enrolment neonatal mortality (enrolment 28 days), and post-neonatal mortality up to 6 months of age (29–180 days) in a large cohort from three neonatal vitamin A trials in Ghana, India, and Tanzania. Newborn babies were eligible for these trials if their mother reported that they were likely to stay in the study area for the next 6 months, they could feed orally, were aged less than 3 days, and the primary caregiver gave informed consent. We excluded infants who initiated breastfeeding after 96 h, did not initiate, or had missing initiation status. We pooled the data from both randomised groups of the three trials and then categorised time of breastfeeding initiation as: at ≤1 h, 2–23 h, and 24–96 h. We defi ned breastfeeding patterns as exclusive, predominant, or partial breastfeeding at 4 days, 1 month, and 3 months of age. We estimated relative risks using log binomial regression and Poisson regression with robust variances. Multivariate models controlled for site and potential confounders. Findings Of 99 938 enrolled infants, 99 632 babies initiated breastfeeding by 96 h of age and were included in our prospective cohort. 56 981 (57·2%) initiated breastfeeding at ≤1 h, 38 043 (38·2%) at 2–23 h, and 4608 (4·6%) at 24–96 h. Compared with infants initiating breastfeeding within the fi rst hour of life, neonatal mortality between enrolment and 28 days was higher in infants initiating at 2–23 h (adjusted relative risk 1·41 [95% CI 1·24–1·62], p<0·0001), and in those initiating at 24–96 h (1·79 [1·39–2·30], p<0·0001). These associations were similar when deaths in the fi rst 4 days of life were excluded (1·32 [1·10–1·58], p=0·003, for breastfeeding initiation at 2–23 h, and 1·90 [1·38–2·62], p=0·0001, for initiation at 24–96 h). When data were stratifi ed by exclusive breastfeeding status at 4 days of age (p value for interaction=0·690), these associations were also similar in magnitude but with wider confi dence intervals for initiation at 2–23 h (1·41 [1·12–1·77], p=0·003) and for initiation at 24–96 h (1·51 [0·63–3·65], p=0·357). Exclusive breastfeeding was also associated with the lower mortality during the fi rst 6 months of life (1–3 months mortality: exclusive vs partial breastfeeding at 1 month 1·83 [1·45–2·32], p<0·0001, and exclusive breastfeeding vs no breastfeeding at 1 month 10·88 [8·27–14·31], p<0·0001). Interpretation Our fi ndings suggest that early initiation of breastfeeding reduces neonatal and early infant mortality both through increasing rates of exclusive breastfeeding and by additional mechanisms. Both practices should be promoted by public health programmes and should be used in models to estimate lives saved

Interventions for promoting the initiation of breastfeeding

Background: Despite the widely documented risks of not breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower-income groups. In low- and middle-income countries, many women do not follow World Health Organization (WHO) recommendations to initiate breastfeeding within the first hour after birth. This is an update of a Cochrane Review, first published in 2005.Objectives: To identify and describe health promotion activities intended to increase the initiation rate of breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding early (within one hour after birth).Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and scanned reference lists of all articles obtained.Selection criteria: Randomised controlled trials (RCTs), with or without blinding, of any breastfeeding promotion intervention in any population group, except women and infants with a specific health problem.DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial reports for inclusion, extracted data and assessed trial quality. Discrepancies were resolved through discussion and a third review author was involved when necessary. We contacted investigators to obtain missing information.Main results: Twenty-eight trials involving 107,362 women in seven countries are included in this updated review. Five studies involving 3,124 women did not contribute outcome data and we excluded them from the analyses. The methodological quality of the included trials was mixed, with significant numbers of studies at high or unclear risk of bias due to: inadequate allocation concealment (N = 20); lack of blinding of outcome assessment (N = 20); incomplete outcome data (N = 19); selective reporting (N = 22) and bias from other potential sources (N = 17).Healthcare professional-led breastfeeding education and support versus standard careThe studies pooled here compare professional health workers delivering breastfeeding education and support during the prenatal and postpartum periods with standard care. Interventions included promotion campaigns and counselling, and all took place in a formal setting. There was evidence from five trials involving 564 women for improved rates of breastfeeding initiation among women who received healthcare professional-led breastfeeding education and support (average risk ratio (RR) 1.43, 95% confidence interval (CI) 1.07 to 1.92; Tau² = 0.07, I² = 62%, low-quality evidence) compared to those women who received standard care. We downgraded evidence due to design limitations and heterogeneity. The outcome of early initiation of breastfeeding was not reported in the studies under this comparison.Non-healthcare professional-led breastfeeding education and support versus standard careThere was evidence from eight trials of 5712 women for improved rates of breastfeeding initiation among women who received interventions from non-healthcare professional counsellors and support groups (average RR 1.22, 95% CI 1.06 to 1.40; Tau² = 0.02, I² = 86%, low-quality evidence) compared to women who received standard care. In three trials of 76,373 women, there was no clear difference between groups in terms of the number of women practicing early initiation of breastfeeding (average RR 1.70, 95% CI 0.98 to 2.95; Tau² = 0.18, I² = 78%, very low-quality evidence). We downgraded the evidence for a combination of design limitations, heterogeneity and imprecision (wide confidence intervals crossing the line of no effect).Other comparisonsOther comparisons in this review also looked at the rates of initiation of breastfeeding and there were no clear differences between groups for the following comparisons of combined healthcare professional-led education with peer support or community educator versus standard care (2 studies, 1371 women) or attention control (1 study, 237 women), breastfeeding education using multimedia (a self-help manual or a video) versus routine care (2 studies, 497 women); early mother-infant contact versus standard care (2 studies, 309 women); and community-based breastfeeding groups versus no breastfeeding groups (1 study, 18,603 women). None of these comparisons reported data on early initiation of breastfeeding.Authors' conclusions: This review found low-quality evidence that healthcare professional-led breastfeeding education and non-healthcare professional-led counselling and peer support interventions can result in some improvements in the number of women beginning to breastfeed. The majority of the trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention, thus limiting the generalisability of these results to other settings.Future studies would ideally be conducted in a range of low- and high-income settings, with data on breastfeeding rates over various timeframes, and explore the effectiveness of interventions that are initiated prior to conception or during pregnancy. These might include well-described interventions, including health education, early and continuing mother-infant contact, and initiatives to help mothers overcome societal barriers to breastfeeding, all with clearly defined outcome measures.</p

Early Initiation and Exclusivity of Breastfeeding in Rural Zimbabwe: Impact of a Breastfeeding Intervention Delivered by Village Health Workers.

Background: Suboptimal breastfeeding contributes to >800,000 global child deaths annually. Optimal breastfeeding includes early initiation (EI) and exclusive breastfeeding (EBF) for the first 6 mo. Objectives: We tested the hypothesis that an intervention targeting context and infant age-specific barriers to EI and EBF will achieve a higher EI and EBF prevalence than those of women participating in the concurrently conducted 2015 Zimbabwe Demographic Health Survey (Z-DHS). Methods: We designed an intervention to promote EI and EBF, and implemented it within the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. Intervention modules were delivered at 4 perinatal time points by government-employed village health workers. We compared EI and EBF prevalence among SHINE women who provided outcomes at 1 mo (n = 2442) and 3 mo (n = 2728), with women in the 2015 Z-DHS. Results: In cross-sectional analyses EI prevalence was 86.6% and 64.3% in the SHINE and Z-DHS samples, respectively; absolute difference (95% CI) = 22.4% (17.5%, 27.3%). EBF prevalence was similarly high (>80%) in both surveys during the first month of life; during 1 to <2 mo, 2 to <3 mo, 3 to <4 mo, 4 to <5 mo, and 5 to <6 mo, EBF prevalence was, respectively, 85%, 90%, 90%, 84%, and 75% in SHINE, and 71%, 65%, 35%, 26%, and 25% in Z-DHS; absolute difference (95% CI) = 50.2% (34.7%, 65.7%) at 5 to <6 mo. Cesarean delivery, mother's belief that intimate partner violence was sometimes justifiable, and having a male infant negatively modified the effects of the intervention. Conclusions: The SHINE intervention achieved a high prevalence of EI and EBF. Concurrently addressing gender norms will be critical to make further progress. Formative studies to identify context- and infant age-specific barriers to EI and EBF may inform improvement of breastfeeding practices elsewhere. Important work remains to scale up this intervention beyond a research setting. SHINE was registered at www.clinicaltrials.gov as NCT01824940.Bill and Melinda Gates Foundation (OPP1021542 and OPP1143707)United Kingdom Department for International Development (DFID/UKAID)Wellcome Trust (093768/Z/10/Z and 108065/Z/15/ZSwiss Agency for Development and Cooperatio