EINC Do’s and Don’ts:

Unnecessary Intervention: Giving Pre-lacteals or Artificial Milk Substitutes

It is a common practice in Philippine hospitals to give pre-lacteals like glucose water as a trial of feeding to newborns, or to give artificial milk substitutes to babies while the mother’s milk flow is not yet established.  This delays the mother’s breastmilk letdown, and the ease of feeding from the bottle decreases the newborn’s urge to suckle, two factors that will create a vicious cycle that causes caregivers to continue pre-lacteal feeding, thus undermining the success of breastfeeding. This practice also exposes the newborn to different types of infectious agents and challenges an already weak premature or immature gastrointestinal system.  These were clearly evident in a study by Rashid done in rural Bangladesh, where 94.7 % of newborns were fed either honey, animal milk and sugar (non-exclusively).  In these newborns, the overall mean time of initiating breastfeeding was 35.9 hours (SD ± 28.4). Pre-lacteal feeding delayed breastfeeding by 32.1 hours (p<0.0001), and more newborns fed honey (17.2%) experienced episodes of diarrhea in the first 3 months compared to those who were not fed pre-lacteals (13.77%) (RR 1.25, p<0.01).  Giving artificial milk substitutes is a practice that has serious consequences on the baby’s health and wellbeing. 

Recommended Practice: Initiation of Breastfeeding

The benefits of breastfeeding for the health and wellbeing of the mother and baby are well documented.  WHO recommends initiation of breastfeeding within an hour after birth but in many countries, the rates of early initiation of breastfeeding remain low.  In the Philippines, breastfeeding is initiated within the first hour of life in only 54% of deliveries.

A recent trial by Edmond has shown that early initiation of breastfeeding could reduce neonatal mortality by 22%.  In developing countries, early initiation of breastfeeding can reduce deaths due mainly to diarrhea and lower respiratory tract infections in children. 

Dr. Natividad R. Clavano in a 1982 landmark study, followed a cohort of 9886 infants born at the Baguio General Hospital to assess the relationship of neonatal deaths and diarrhea with feeding patterns. Ninety per cent of the 138 infants with diarrhea were formula fed, 6% were on mixed and 4% on exclusively breastfeeding.  Ninety six per cent of the 67 infant deaths were formula fed, 1% were mixed- and 3% were exclusively breastfed.  After formal breastfeeding policies and rooming in practices were implemented, exclusive breastfeeding increased and deaths among clinically infected newborns dropped by 95.3%.  In another prospective cohort study by Yoon et al, 9942 children in Cebu were followed using longitudinal data from 1988-1991. In the first six months of life, failing to initiate breastfeeding (or ceasing to breastfeed) resulted in an 8-10 fold increase in the rate of diarrheal death.

In the 51-hospital observational study, newborns were washed at a median of 8 minutes, put to the breast at a median of 10 minutes of life but removed at 12 minutes.  Thus only 2 minutes were allowed for their first colostrum feed. 272 (56.5%) were transferred to a nursery. They were weighed at a median of 13 minutes, examined at 17 minutes, taken to the nursery at 20 minutes, given eye prophylaxis at 20 minutes and Hepatitis B and vitamin K injections, the first of which at 22 minutes. They were reunited with their mothers at a median of 2 hours 35 minutes. 47 (9.8%) initiated breastfeeding after 2 hours but prior to discharge.  From these studies, it is evident that institutional routines are depriving our newborns of the benefits of early breastfeeding. 

Early initiation of breastfeeding may reduce neonatal mortality by decreasing the ingestion of infectious pathogens. Early breast milk also provides many immunocompetent factors, including immunoglobulins and lymphocytes that may stimulate humoral or cell-mediated immune systems), and it may also prime the gastrointestinal tract and decrease intestinal permeability and translocation of infectious pathogens, including HIV. 

Edmond et al conducted an observational cohort study of 10,942 breastfed singleton neonates (born between 1 Jul 2003 and 30 Jun 2004 in rural Ghana), who survived to day 2, and whose mothers were visited in the neonatal period.  Verbal autopsies were used to ascertain the cause of death in 130 neonates who died from day 2 to day 28. Ninety three died of infection and 47 of non-infectious causes.  The risk of death as a result of infection increased with increasing delay in initiation of breastfeeding from 1 hr to day 7; overall late initiation (after day 1) was associated with a 2.6-fold risk (adjusted OR 2.61 95% CI 1.68, 4.04).  Partial breastfeeding was associated with a 5.7-fold adjusted risk of death as a result of infectious disease (adj OR 5.73 95% CI 2.75, 11.91).  

Such is the impact of early initiation of breastfeeding and healthcare providers and policy makers need to prioritize this simple preventive strategy. Factors that will promote breastfeeding initiation include: implementation of the Baby Friendly Hospital Initiative Ten Steps to Successful Breastfeeding; avoidance of the use of intramuscular narcotic analgesia, particularly near the end of the first stage of labor; not separating mothers and babies after birth for routine procedures; and routinely placing healthy newborns on their mothers’ chest/abdomen on skin-to-skin contact.

Sources:

Lauer JA et al, Deaths and years of life lost due to suboptimal breastfeeding among children in the developing world: a global ecological risk assessment. Public Health Nutrition 2006; 9: 673-685.

The state of the world’s breastfeeding: report card. Initiation of breastfeeding within one hour. New Delhi: International Baby Food Action Network Asia. www.world breastfeedingtrends.org/reportcard/RC-IB.pdf/

Clavano N. Mode of feeding and its effect on infant mortality and morbidity. J Trop Pediatr. 1982;28 :287 –293.

Yoon PW, Black RE, Moulton LH, Becker S.  Effect of not breastfeeding on the risk of diarrheal and respiratory mortality un children under two years of age in Metro Cebu, the Philippines.  Am J Epidemiol.1996. 143:1142-1148.

Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS.  Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana.  Am J Clin Nutr.  2007; 86:1126-31.

Brandtzaeg P. Mucosal immunity: integration between the mother and the breast fed infant. Vaccine 2003;21:3382–6.

Goldman AS. The immune system of human milk: antimicrobial, antiinflammatory and immunomodulating properties. Pediatr Infect Dis J 1993;12:664–71.

Goldman AS, Garza C, Nichols BL, Goldblum RM. Immunologic factors in human milk during the first year of lactation. J Pediatr 1982;100: 563–

Goldman AS. Modulation of the gastrointestinal tract of infants by human milk. Interfaces and interactions. An evolutionary perspective in symposium: bioactivity in milk and bacterial interactions in the developing immature intestine. J Nutr 2000;130(suppl);426S–31S.

Rollins NC, Filteau SM, Coutsoudis A, Tomkins AM. Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women. J Acquir Immune Defic Syndr 2001;28:132–9.
Rashid M et al. Prelacteal feeding delays breastfeeding initiation in rural Bangladesh, ICDDR,B Periodical