Date Published: August 30, 2019
Publisher: Public Library of Science
Author(s): Shahreen Raihana, Michael J. Dibley, Mohammad Masudur Rahman, Tazeen Tahsina, Md. Abu Bakkar Siddique, Qazi Sadequr Rahman, Sajia Islam, Ashraful Alam, Patrick J. Kelly, Shams El Arifeen, Tanvir M Huda, Kathleen Rasmussen
Abstract: BackgroundIn Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0–6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness.Methods and findingsWe used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2–25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48–4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52–6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers’ report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive.ConclusionsBreastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited.Trial registrationTrial Registration number: anzctr.org.au ID ACTRN12612000588897.
Partial Text: Globally 2.7 million newborns died during the first 28 days of life (0–27 days) in 2015 . More than a third of these neonatal deaths occurred on the first day, and three-quarters in the early neonatal period, i.e., 0 to 6 days [2,3]. In Bangladesh, overall neonatal mortality has decreased from 55 per 1,000 live births in 1990  to 23 per 1,000 live births in 2015 , with an average yearly reduction of 1 death per 1,000. However, this reduction is 3 times slower than the reduction of under-5 mortality over the same period, and neonatal deaths now account for 62% of all under-5 deaths , whereas early-neonatal deaths (19.3/1,000) contribute to over 65% of all neonatal deaths.
There were 30,646 live-born infants during the study period, and time to initiation of breastfeeding was known for 29,873 (97.5%) infants. The remaining 773 women had no information on their breastfeeding status, and we excluded them from the analysis. Two-thirds of the newborns (66.7%) with known breastfeeding initiation status had initiated breastfeeding within 1 hour of birth. The mean time to initiate breastfeeding, among children with a record of their breastfeeding initiation time was, 3.8 hours (SD 16.6 hours). By the end of 48 hours, all but 5.7% of infants were breastfed. Severe illness in the neonatal period early (0–6 days) was reported for 4,437 (14.9%; Fig 1) infants of whom 338 (7.6%) subsequently died within the first 7 days. Among the severe illness cases, hyperthermia was the most common danger sign reported by 36.6% mothers, followed by respiratory distress reported by 37.4% mothers. Convulsion was the least reported danger sign and was reported by 7.8% mothers. Fig 2 shows the percentages of newborns who had any of the danger signs in the first 7 days after birth. Table 1 summarizes some infant, maternal, and household characteristics of the newborns by their time of breastfeeding initiation.
We found that early initiation of breastfeeding within an hour of birth was significantly associated with a reduced risk of early newborn (0–6 days) danger signs and severe illnesses in rural Bangladesh. We detected a dose-response relationship of increasing odds of severe illnesses in the early newborn stage with greater delay in initiation of breastfeeding after adjusting for confounders. Our findings indicate that the highest risk of presenting with early newborn danger signs following delayed initiation of breastfeeding beyond the first hour was with newborns who were first born, had very LBW (<2,000 g), did not receive appropriate cord and thermal care, were born through NVD at home with unskilled attendance, had a history of stillbirth/miscarriage of a previous sibling, or whose mother had prolonged labor during childbirth. We also found that one-sixth of the reported danger signs in the early neonatal period could be reduced if children who initiated beyond the first hour could initiate within the recommended time. Excluding children whose mother had maternal complications and those who died within 48 hours had a minimum to no effect on the fraction of severe illness cases that could be prevented. The findings from this study highlight the need to encourage women and caregivers to facilitate early initiation of breastfeeding to reduce early newborn danger signs and severe illnesses, especially among high-risk newborns. Source: http://doi.org/10.1371/journal.pmed.1002904