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Timing of Breastfeeding Initiation and Exclusivity of Breastfeeding During the First Month of Life: Effects on Neonatal Mortality and Morbidity—A Systematic Review and Meta-analysis

Abstract

The purpose of this study was to review the evidence on the effect of initiation of breastfeeding early after birth and of exclusive breastfeeding during the first month in reducing neonatal mortality and morbidity. We searched Cochrane and PubMed databases for all available papers addressing our review questions and identified eleven papers. Data were extracted using a standard abstraction form. Evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system. Meta-analysis was done using STATA 11.0. Early initiation of breastfeeding was associated with a reduced risk of neonatal mortality. Initiating breastfeeding after the first hour doubled the risk of neonatal mortality. Exclusively breastfed neonates had a lower risk of mortality and infection-related deaths in the first month than partially breastfed neonates. Exclusively breastfed neonates also had a significantly lower risk of sepsis, diarrhea and respiratory infections compared with those partially breastfed. The pooled evidence indicates that substantial benefits in reducing neonatal mortality and morbidity can be achieved with effective promotion of early initiation of breastfeeding and exclusive breastfeeding during the first month of life.

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Acknowledgments

We are grateful to Dr Karen Edmond, Dr Luke Mullany and Dr Cesar Victora for providing us additional information on the results of their studies. We are also thankful to Tomas Allen, the librarian at the WHO Geneva for his support in developing the search strategy for this review. This work was supported by the Department of Maternal, Newborn, Child and Adolescent Health of the World Health Organization, Geneva, Switzerland.

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Correspondence to Jehangir Khan.

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Appendices

Appendix 1: PubMed Search

Systematic Review PICO Questions

  1. 1.

    In all newborn infants (P), does initiation of breastfeeding within the first hour after birth (I) compared with later initiation of breastfeeding (C) reduce the risk of mortality and morbidity during the neonatal period (O)?

  2. 2.

    In all newborn infants (P), does exclusive breastfeeding during the first month of life (I) compared with predominant (C) or partial breastfeeding (C) reduce the risk of mortality and morbidity during the neonatal period (O)?

Search Criteria

(“breast feeding”[MeSH Terms] OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR “breastfeeding”[All Fields]) OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields]) OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields]) OR breastfed[All Fields] OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR (“breast”[All Fields] AND “fed”[All Fields]) OR “breast fed”[All Fields]) OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR (“breast”[All Fields] AND “fed”[All Fields]) OR “breast fed”[All Fields]) OR “colostrum”[MeSH Terms] OR (“colostrum”[MeSH Terms] OR “colostrum”[All Fields]) OR (“colostrum”[MeSH Terms] OR “colostrum”[All Fields] OR “colostrums”[All Fields])))

AND

((“infant, newborn”[MeSH Terms] OR (“infant”[MeSH Terms] OR “infant”[All Fields]) OR (“infant, newborn”[MeSH Terms] OR (“infant”[All Fields] AND “newborn”[All Fields]) OR “newborn infant”[All Fields] OR “newborn”[All Fields]) OR (“infant, newborn”[MeSH Terms] OR (“infant”[All Fields] AND “newborn”[All Fields]) OR “newborn infant”[All Fields] OR “newborns”[All Fields]) OR (“infant, newborn”[MeSH Terms] OR (“infant”[All Fields] AND “newborn”[All Fields]) OR “newborn infant”[All Fields] OR “neonate”[All Fields]) OR (“infant, newborn”[MeSH Terms] OR (“infant”[All Fields] AND “newborn”[All Fields]) OR “newborn infant”[All Fields] OR “neonates”[All Fields]) OR neonatal[All Fields] OR (“infant, newborn”[MeSH Terms] OR (“infant”[All Fields] AND “newborn”[All Fields]) OR “newborn infant”[All Fields] OR “baby”[All Fields] OR “infant”[MeSH Terms] OR “infant”[All Fields]) OR (“infant”[MeSH Terms] OR “infant”[All Fields] OR “babies”[All Fields]) OR “infant, newborn”[MeSH Terms])

AND

(“breast feeding”[MeSH Terms] OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR (“breast”[All Fields] AND “feeding”[All Fields] AND “exclusive”[All Fields])) OR “breast feeding”[MeSH Terms] OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR (“breastfeeding”[All Fields] AND “exclusive”[All Fields])) OR “breast feeding”[MeSH Terms] OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR (“exclusive”[All Fields] AND “breast”[All Fields] AND “feeding”[All Fields]) OR “exclusive breast feeding”[All Fields]) OR “breast feeding”[MeSH Terms] OR (“breast feeding”[MeSH Terms] OR (“breast”[All Fields] AND “feeding”[All Fields]) OR “breast feeding”[All Fields] OR (“exclusive”[All Fields] AND “breastfeeding”[All Fields]) OR “exclusive breastfeeding”[All Fields]) OR initiate[All Fields] OR initiation[All Fields] OR begin[All Fields] OR beginning[All Fields] OR start[All Fields] OR starting[All Fields] OR started[All Fields] OR initiated[All Fields] OR begun[All Fields] OR initiating[All Fields])

NOT “addresses”[Publication Type] NOT “autobiography”[Publication Type] NOT “bibliography”[Publication Type] NOT “biography”[Publication Type] NOT “case reports”[Publication Type] NOT “clinical conference”[Publication Type] NOT “collected works”[Publication Type] NOT “comment”[Publication Type] NOT “congresses”[Publication Type] NOT “consensus development conference”[Publication Type] NOT “consensus development conference, nih”[Publication Type] NOT “dictionary”[Publication Type] NOT “directory”[Publication Type] NOT “editorial”[Publication Type] NOT “electronic supplementary materials”[Publication Type] NOT “ephemera”[Publication Type] NOT “festschrift”[Publication Type] NOT “guideline”[Publication Type] NOT “historical article”[Publication Type] NOT “in vitro”[Publication Type] NOT “interactive tutorial”[Publication Type] NOT “interview”[Publication Type] NOT “lectures”[Publication Type] NOT “legal cases”[Publication Type] NOT “legislation”[Publication Type] NOT “letter”[Publication Type] NOT “news”[Publication Type] NOT “newspaper article”[Publication Type] NOT “practice guideline”[Publication Type] NOT “review”[Publication Type]

Limits applied: humans, new born: birth-1 month.

Characteristics of the Included Studies

Arifeen 2001

Methods Cohort study
Participants 1,677 singleton births included into the study born to a cohort of mothers resident in 5 sub-districts of Dhaka city, Bangladesh between November 1993 and June 1995
Loss to follow up: <12 %
Intervention Type of breastfeeding: [1] exclusively breastfed, [2] predominantly breastfed and [3] partial or not breastfed
Outcome Neonatal mortality was attributed to all causes, ARI and diarrhea

Risk of bias

Items Author’s judgment Description
Confounding Differences in height and education Controlled

Cushing 1997

Methods Cohort study
Participants 1,202 babies born between January 1, 1988 and June 30, 1990 in Albuquerque, New Mexico, United States
Inclusion criteria: Mother’s age above 18 years, English speaking non-smoker and with access to telephone at home
Exclusion criteria: If parents plan to put the infants in the full time day care and if the family plans to move from Albuquerque within the next 18 months
Loss to follow up: 13 %
Intervention Type of breastfeeding: [1] fully breastfed, [3] partially breastfed and [3] not breastfed
Outcome Lower, upper and all respiratory illness

Risk of Bias

Item Author’s judgment Description
Confounding Differences in income and maternal education Controlled
Misclassification Mild Possible due to recall (telephone interviews) and errors in mother’s filling of the diaries

Clavano 1982

Methods Cohort study
Participants 9,886 charts reviewed from babies delivered between January 1973 and April 1977 in a hospital in the Philippines
Inclusion criteria: Newborns
Exclusion criteria: No feeding record available, newborns deaths due to different causes like those acutely ill at birth, immature and having congenital abnormalities
Loss to follow up: <3 %
Intervention Type of breastfeeding: [1] breastfed, [2] mixed fed and [3] formula fed
Outcomes Neonatal mortality and morbidity attributed to diarrhea, sepsis and oral thrush

Risk of bias

Item Author’s judgment Description
Confounding Groups reported as comparable Data was not provided

Garcia 2011

Methods Cohort study as part of randomized, placebo controlled trial for Vitamin A
Participants 10,464 newborns in a rural village in Tamil Nadu, India
Inclusion criteria: Newborns between 2 and 28 days old and breastfeeding initiation time could be determined
Exclusion criteria: Women delivered 20 km or more outside the study area, first visit >7 days after birth
Loss to follow up: <1 %
Intervention Breastfeeding initiation time: [1] <12 h after birth, [2] 12–24 h after birth and [3] >24 h after birth
Outcome Neonatal mortality

Risk of bias

Item Author’s judgment Description
Reverse causation bias Mild Risk reduced as deaths in the first 48 h excluded
Recall bias Low Only infants with visits done in the first 7 days after birth included
Confounding Birth weight, sex, care at birth, vitamin A status, household head’s occupation Controlled

Edmond 2006

Methods Cohort study as part of a large Vitamin A trial
Participants 10,947 newborns in rural Ghana
Inclusion criteria: Infants surviving to day 2 and who were breastfed successfully
Exclusion criteria: Multiple births, non-initiators and those interviewed outside the neonatal period
Loss to follow up: 4.4 %
Intervention Initiation of breastfeeding: [1] Early versus [2] late
Type of breastfeeding: [1] Exclusive, [2] partial and [3] predominant
Outcome Neonatal mortality

Risk of bias

Item Author’s judgment Description
Reverse causality Mild Risk was reduced as all deaths in the 1st 2 days were excluded
Misclassification Moderate 24 h recall for feeding status at 1 month, but 4 weeks recall for timing of initiation
Confounding Gender, birth size, gestational age, congenital anomaly, health on day of birth, health at time of interview, mother’s health at delivery, mother’s age, parity, education, cash income, household water supply, place of defecation, antenatal visits, place of birth and presence of birth attendant Controlled

Edmond 2007

Methods Cohort study as part of a large Vitamin A trial
Participants 10,942 newborns in rural Ghana
Inclusion criteria: Infants surviving to day 2 and who were breastfed successfully
Exclusion criteria: Multiple births, non-initiators and those interviewed outside the neonatal period
Loss to follow up: <5 %
Intervention Initiation of breastfeeding: [1] Early versus [2] late
Type of breastfeeding: [1] Exclusive, [2] partial and [3] predominant
Outcome All infectious disease related neonatal mortality

Risk of bias

Item Author’s judgment Description
Reverse causality Mild Risk was reduced as all deaths in 1st 2 days were excluded
Misclassification Moderate 24 h recall for feeding status at 1 month, but 4 weeks for timing of initiation
Confounding Gender, birth size, gestational age, congenital anomaly, health on day of birth, health at time of interview, mother’s health at delivery, mother’s age, parity, education, cash income, household water supply, place of defecation, antenatal visits, place of birth and presence of birth attendant Controlled

Kasla 1995

Methods Cohort study
Participants 537 newborns in a hospital in Bombay, India
Inclusion criteria: Newborns
Exclusion criteria: Birth weight <2,000 g, seriously ill in early neonatal period
Loss to follow up: 12 %
Intervention Type of breastfeeding: [1] Exclusive, [2] artificial and [3] mixed
Outcomes Total morbidity and morbidity due to gastrointestinal and respiratory infections

Risk of bias

Item Author’s judgment Description
Misclassification Mild Disease classification based on mother’s recall and classification
Confounding Possible confounding not described Not adjusted in the analysis

Lopez-Alarcon 1997

Methods Cohort study
Participants 216 newborns in a community and a hospital in Mexico City, Mexico
Inclusion criteria: Singleton, full-term, healthy and weighing >2,500 g at birth
Exclusion criteria: Congenital malformations and those who moved out
Loss to follow up: 22 %
Intervention Type of breastfeeding: [1] Exclusively breastfed, [2] partially breastfed and [3] formula fed
Outcomes Diarrhea and acute respiratory infection related morbidity

Risk of bias

Item Author’s judgment Description
Misclassification Mild Babies shifted during the 6 month period in the three feeding groups
Misclassification of outcome unlikely as the diagnosis was clear and the physicians were blinded to the feeding history
Confounding Possible—differences by feeding groups not described Not controlled

Mullany 2008

Methods Cohort study
Participants 23,662 newborns between 2002 and 2006 as part of a randomized control trial in a rural community in Southern Nepal
Inclusion criteria: Newborns
Exclusion criteria: If two or more of the following conditions were present
1. Difficulty breathing
2. Stiffness of the back or convulsions
3. Dysentery
4. Presence of watery stools five or more times within 24 h
5. Severe chest in drawing
6. Axillary temperature >37.8 °C
7. Respiratory rate <70 breath/min
Loss to follow up: 1.4 %
Interventions Initiation on breastfeeding: [1] Early versus [2] late
Outcomes Neonatal mortality and morbidity

Risk of bias

Item Author’s judgment Description
Reverse causation bias Low Early deaths excluded
Recall bias Low Feeding classification based on 24 h recall
Confounding Birth weight, gestation, sex, maternal literacy, chlorhexidine use, maternal hand washing, death of siblings, parity, maternal fever, ethnicity Controlled

Sinha 2003

Methods Case control study
Participants 933 infants born between 1990 and 1998 in a hospital in Boston, Massachusetts, United States
Inclusion criteria: Infants delivered ≥37 weeks gestation with respiratory tract infection (LRTI but not pneumonia) diagnosed after discharge
Exclusion criteria: Pneumonia and delivery <37 weeks
Loss to follow up: 1 %
Intervention Type of breastfeeding: [1] Exclusive breastfed, [2] mixed breastfed and [3] not breastfed
Outcomes Neonatal morbidity

Risk of bias

Item Author’s judgment Description
Selection bias or measurement bias Mild Electronic search of feeding records
Confounding and adjustment Year of birth, season of birth, presence of siblings, and socioeconomic status Controlled

Victora 1987

Methods Case control study
Participants 510 Neonates in urban area in Southern Brazil
Inclusion criteria: Infant deaths 7–364 days of life
Exclusion criteria: Very low birth weight (<1,500 g), multiple births, more than 15 days in hospital immediately before death and congenital malformation or cerebral palsy
Loss to follow up: <2 %
Intervention Cases were deaths due to diarrhea, respiratory and other infections (meningitis, skin infections, measles, whooping cough, neonatal sepsis and tuberculosis
Controls were neighbors aged 7–364 days
Type of feeding: [1] Breastfeeding, [2] mixed and [3] artificial
Outcomes Neonatal deaths

Risk of bias

Item Author’s judgment Description
Interviewer bias Mild Reduced as information on outcome (diarrhea) was collected at the end of interview
Reverse causality Mild Feeding classified as status before illness
Confounding Age, social status, birth weight, type of housing, piped water, birth interval, maternal education, family income Controlled

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Khan, J., Vesel, L., Bahl, R. et al. Timing of Breastfeeding Initiation and Exclusivity of Breastfeeding During the First Month of Life: Effects on Neonatal Mortality and Morbidity—A Systematic Review and Meta-analysis. Matern Child Health J 19, 468–479 (2015). https://doi.org/10.1007/s10995-014-1526-8

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Keywords

  • Breastfeeding
  • Neonates
  • Mortality and morbidity