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Nutrition During Lactation
Appendix B
Appendix B presents a compilation of abstracts of studies that address relationships of the mode of infant feeding with the infant's subsequent survival in developing countries. Abstracts are presented in either tabular or narrative form and are arranged chronologically.
ABSTRACT B-1A Death Rate and Relative Risk (RR) of Death by Feeding Method from Birth Among Infants Born in 11 Villages of the Ludhiana District, Punjab, India, 1955 to 1959a
Death Rate/1,000 and RR, During First Year of Life
0-28 days
2-11 mo
Feeding Method at Birth
Sample Size
Number of Deaths/1,000
RR
Number of Deaths/1,000
RR
Breast
739
46
1.00
74
1.00
Bottle
20
750
16.30
200
2.70
a From Gordon et al. (1963).
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ABSTRACT B-1B Mortality from Diarrheal Disease Among Children Breastfed at Birtha
Breastfed Only
Weaned During This Period
Previously Weaned
Age, mo
Sample Size
Cases of Diarrhea/ 100/yrb
Diarrheal Deaths/ 1,000/yr
Sample Size
Cases of Diarrhea/ 100/yr
Diarrheal Deaths/ 1,000/yr
Sample Size
Cases of Diarrhea/ 100/yr
Diarrheal Deaths/ 1,000/yr
0–-2
524
136
3
267
NAc
NA
NA
3–5
380
124
4
100
3
267
6–8
196
184
8
350
4
100
9–11
91
128
11
291
7
171
0–11
23.5
0
(˜1,000.0)d
12–14
31
90
3
240
11
218
15–17
17
118
31
168
40
150
18–20
3
133
79
213
61
230
21–23
1
NRe
39
154
138
151
12–23
153.8
0
48
24–26
1
NR
34
165
87
138
27–29
0
NR
21
133
120
87
24–29
NA
0
10
a From Gordon et al. (1963).
b The same child may have diarrhea more than one time during the year.
c NA = Not applicable.
d Four deaths occurred during 3.5 person-years of observation.
e NR = Not reported.
COMMENTS: Deaths for partially breastfed infants were not presented. Diarrhea increased with the initiation of supplemental foods among breastfed infants in 11 villages in Punjab, India, from 1955 to 1959. "No deaths occurred among cases in the immediate weaning period; fatalities occurred in cases of the late post weaning period. … The explanation would appear to be in the nutritional state of the child" (Gordon et al., 1963, p. 368).
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ABSTRACT B-2 Comparison of Feeding Methods Used for Jamaican Children Who Died Between the Ages of 6 and 36 Months, 1962 to 1963a
Feeding Method
Deathsb
Random Controlsc
Number
% of
Total
Number
% of
Total
Never fully
breastfed
4
2.9
7
5.2
Fully breastfed
<3 mo
37
27.0
24
17.9
Fully breastfed
3–6 mo
73
53.3
69
51.5
Fully breastfed
>6 mo
23
16.8
34
25.4
Unknown
11
d
14
d
a From McKenzie et al. (1967).
b Random sample of deaths (N = 285); completed questionnaires concerning infant feeding were available for 72%.
c Random sample of controls (N = 275); completed questionnaires were available for 56%.
d Children whose feeding method was unknown were excluded from the analysis.
COMMENTS: Relative risk of death was 1.42 for infants breastfed less than 3 months compared with those breastfed longer. Relative risk was calculated from authors' data.
ABSTRACT B-3 Ratios of Observed to Expected Deaths Among 8,456 Births in Rural Senegal, 1962 to 1968, by Breastfeeding Status and Agea
Currently Breastfeeding
Weaned
Age, mo
Number of Observed Deaths
Number of Expected Deaths
Ratio
Number of Observed Deaths
Number of Expected Deaths
Ratio
0–11
455
460
0.99
9
4
2.25
12–23
360
351
1.03
36
45
0.80
24–35
64
59
1.08
181
186
0.97
a From Cantrelle and Leridon (1971).
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ABSTRACT B-4 Death Rates and Relative Risk (RR) Among 1,283 Infants in 15 Rural Communities in Chile, by Feeding Methoda
Death Rate/1,000b and RR, by Feeding Method
Bottle
Mixed
Age, mo
Breast, Number of Deaths/1,000
Number of Deaths/1,000
RRc
Number of Deaths/1,000
RR
1
29.2
60.5
2.07
56.0
1.92
3
13.8
38.7
2.80
37.5
2.72
6
10.0
19.9
1.99
14.0
1.40
a From Plank and Milanesi (1973), obtained in a survey of 1,712 women aged 15 to 44 in 1969 and 1970.
b Death rate for infants between specified age and age 1 year.
c Relative risk for breastfeeding = 1.0.
COMMENTS: The increase in mortality associated with bottle feeding was less than when supplemental foods were given (but was not lower when infants were partially breastfed).
ABSTRACT B-5 Percentage of Infants Breastfeeding in Total Study Sample and Among Those Who Died, and the Relative Risk (RR) of Death for Short-Term Breastfeedinga
Percentage of Infants Breastfed, by Study Population and Breastfeeding Duration
All Infants
Infants Who Died
RRb of Death for Breastfeeding for <6 mo
Study Area
<6 mo
≥6 mo
<6 mo
≥6 mo
El Salvador
20
80
78.0
22.0
14.2
Kingston, Jamaica
51
49
87.4
12.6
7.1
Medellin, Colombia
61.8
31.2
91.3
8.8
6.4
Sao Paolo, Brazil
77.2
22.8
95.9
4.1
6.8
a From Wray (1978), who analyzed data for deaths from Puffer and Serrano (1973) and for rate of breastfeeding among survivors in El Salvador (Menchu et al., 1972), Kingston (Grantham-MacGregor and Back, 1970), Medellin (Oberndorfer and Mejia, 1968), and Sao Paolo (Iunes et al., 1975).
b Relative risk for breastfeeding for ≥6 mo = 1.0.
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ABSTRACT B-6 Mortality and Relative Risk (RR) of Death Among Breastfed and Bottle-Fed Infants in One Australian Aboriginal Settlement, 1953 to 1972a
Breastfed Infantsb
Bottle-Fed Infants
Age, mo
Number of Deaths
Sample Size
Mortality Rate/1,000
Number of Deaths
Sample Size
Mortality Rate/1,000
RRc
1–3
3
547
5.5
4
525
7.6
1.38
4–6
0
99
0
11
705
15.6
d
7–12
0
20
0
9
1,588
5.7
d
a From Dugdale (1980).
b It was unclear whether breastfeeding included mixed feeding.
c Relative risk for breastfed infants = 1.0.
d Cannot be estimated.
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ABSTRACT B-7 Case Fatality and Relative Risk (RR) for Death from Measles Among 602 Breastfed and Weaned Children in Guinea-Bissau (West Africa), 1979a
Breastfed Infants
Weaned Infants
Age, mo
Number of Cases
Case Fatality, %
Number of Cases
Case Fatality, %
RRb
0–11
71
28
1
0
c
12–23
43
37
16
25
0.68
24–35
14
14
42
26
1.86
36–71
2
0
112
11
c
a From Aaby et al. (1981). Data on feeding were obtained 2 months before a measles epidemic.
b Relative risk for breastfed infants = 1.0.
c Cannot be estimated.
ABSTRACT B-8 Postneonatal Mortalitya and Relative Risk (RR) Among Breastfed and Never Breastfed Infants in Six Guatemalan Villages, 1960 to 1974b
Postneonatal Mortality Rates/1,000, by Feeding Method
Period of Birth
Sample Size
Never Breastfed Infants, %c
Ever Breastfed Infants
Never Breastfed Infants
RRd
Before 1960
1,128
6.3
75
375
5.0
1960–1968
1,985
6.5
47
193
4.1
1969–1974
1,442
4.9
39
189
4.8
a Postneonatal mortality = number of deaths between ages 28 days and 1 year per 1,000 live births.
b Based on unpublished data from del Pinal (1981).
c The low proportions of infants never breastfed suggest that illness may have prevented breastfeeding.
d Relative risk for ever breastfed infants = 1.0.
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ABSTRACT B-9 Relative Risk (RR) of Survival by Duration of Breastfeeding Among the Last Child Born to Each of 2,907 Women at Three Hospitals in Cairo, Egypt, 1977 to 1978a
Duration of Breastfeeding, mo
RR of Survival (rather than mortality)
>12
1.0
9-12
0.99
6-9
0.87b
3-6
0.85b
1-3
0.71b
0-1
0.71b
a From Janowitz et al. (1981).
b p ≤ .05.
COMMENTS: It is unclear to what age results refer or whether ages of all groups were equivalent. Results were adjusted for maternal education, parity, age, and past infant death (results therefore are probably overcontrolled).
ABSTRACT B-10 Case-Fatality Rates and Relative Risk (RR) Among 2,339 Young Breastfeeding and Weaned Children Hospitalized with Measles, Diarrhea, or Acute Lower Respiratory Disease, by Breastfeeding Status in Kigali, Rwandaa
Case Fatality Rate, %
Age, mo
Breastfed Infants
Weaned Infants
RRb
0-5
11.2
20.7
1.85
6-11
13.5
26.8
1.99c
12-17
17.3
31.5
1.82
18-23
15.1
23.7
1.57d
a Based on data from Lepage et al. (1981).
b Relative risk for breastfed infants = 1.0.
c p < .001 for entire first year.
d p< .001 for entire second year.
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ABSTRACT B-11 Mortality Rates and Relative Risk (RR) of Death Among Very Low and Low Birth Weight Infants in the Special Care Nursery, Bombay, India, by Feeding Method and Birth Weighta,b
Mortality, %
Birth Weight, kg
Breastfed Infants
Bottle-Fed Infantsc
RRd
1.00-1.30
35.0
59.1
1.69
1.31-1.50
30.0e
50.0
1.67
1.51-1.80
20.0e
40.0
2.02
Total
23.0e
47.0
2.04
a From Patel et al. (1981).
b Age of the infants was not provided. There were 100 infants in each feeding group.
c The number of ''breastfed" infants who were fed human milk by tube or bottle was not stated.
d Relative risk for breastfed infants in each weight group = 1.0.
e p < .01.
ABSTRACT B-12 Infant Deaths Resulting from Diarrhea in 12 Villages in Egypt, by Age and Feeding Method, 1979 to 1980a
Percentage of All Deaths Due to Diarrhea
Age, mo
Breastfed Infants (N [deaths] = 150)
Exclusively Bottle-Fed Infants (N [deaths] = 19)
Mixed-Fed Infants (N [deaths] = 33
0-5
28
60
63
6-11
76
86
71
a Based on data from Tekçe (1982).
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ABSTRACT B-13 Reduction of Infant Death Rate in Malaysia Attributed to Breastfeeding (Compared with Never Breastfeeding), by Age, 1976 and 1977a
Adjusted Impact of Breastfeeding Throughout the Preceding Period, Reduction in Deaths/1,000
Ageb
Exclusive Breastfeeding
Mixed Feeding
8–28 days
16.0
5.1
1–5 mo
23.2
10.5
6–12 mo
20.6
10.0
a From Butz et al. (1984), DaVanzo et al. (1983), DaVanzo and Habicht (1986), and Habicht et al. (1986, 1988). Data from the Malaysian Family Life Survey, which included 1,262 households, 5,573 singleton live births, and 270 infant deaths.
b Age period to which the feeding method applies.
COMMENTS: Neither death rates of nonbreastfed infants nor numbers of breastfed infants were presented. Effects were much smaller in households with a toilet and piped water. The authors' conclusion of a declining association of breastfeeding and mortality with age is not obviously supported by the data presented. The same data set was used by Holland (1987) and Millman and Cooksey (1987). The data do not allow estimation of relative risks.
ABSTRACT B-14 Death Rates and Relative Risk (RR) Among Breastfed, Bottle-Fed, and Mixed-Fed Infants Delivered to More Than 15,000 Women in One Hospital in Tehran, Iran, by Feeding Method, 1977 and 1978 a
Feeding Method
Sample Size
Number of Deaths
Death Rate/1,000
RR
Breast or mixed
12,004
307
25.6
1.0
Bottle
2,379
868
364.8
14.3
a From Janowitz and Nichols (1983).
ABSTRACT B-15 Schmidt (1983) reported on a collaborative study among urban poor in eight Latin American countries and Portugal involving 7,659 children in 1981 and 1982. The infant mortality rate for formula-fed infants was 18.6/1,000 live births, but the results were not presented in a form that allows calculation of mortality rates for those infants who were breastfed or mixed fed or for those whose feeding method was unknown. Furthermore, results were not stratified by site or age of child. The group that was breastfed only was probably much younger (and more susceptible to higher death rates) than the weaned group.
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ABSTRACT B-16 Adjusted Relative Risk (RR) of Mortality Among 1to 12-Month-Old Breastfed and Never Breastfed Infants Living in Urban and Rural Areas of Brazil, 1980a
RR
Characteristic of Residence
Breastfed
Never Breastfed (CI)b
Urban
1.0
1.53 (0.97–2.41)c
Rural
1.0
2.31 (1.41–3.78)d
a From Goldberg et al. (1984). Data obtained from a survey in four states in northeastern Brazil, including 7,852 women and 3,457 children.
b CI = 95% confidence interval.
c p = .07.
d p < .01.
COMMENTS: Results were adjusted for mother's education, employment, age at the time of delivery, parity, time since birth, and use of health services. Adjusting for use of health services may not be appropriate in that it might make real differences between the groups less apparent.
ABSTRACT B-17 Adjusted Relative Risk (RR) of Mortality Associated with Bottle Feeding of Infants in the Near Easta
RR of Mortality of Bottle-Fed Infants, by Ageb
Country
Year of Survey
Total Sample Size
1–5 mo
1–11 mo
Jordan
1976
8,458
3.35
2.95
Tunisia
1978
7,060
3.35
2.95
Yemen
1979
3,889
NSc
NRd
Egypt
1980
11,961
8.39
6.38
a From Adlakha and Suchindran (1985). Data were obtained in world fertility surveys.
b Relative risk for infants breastfed during the ages specified = 1.0 for each country.
c NS = Not significantly different.
d NR = Not reported.
COMMENTS: Infants had been breastfed at least until the end of month 1 after delivery. There were very few nonbreastfed infants (4 to 8%) during the first month, suggesting that these infants were aberrant.
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ABSTRACT B-18 Percent Mortality and Relative Risk (RR) of Mortality Associated with Replacement of Formula by Human Milk for Low-Birth-Weight Infants in a Special Care Nursery in Bombay, India, 1978 to 1980a
Mortality,b % (sample size)
Birth Weight, g
Human Milk
Formula
RRc
≤;1,250
77.0 (74)
84.3 (102)
1.09
1,251–1,499
40.2 (102)
59.6 (104)
1.48
≥;1,500
18.5 (157)
34.4 (186)
1.86
Total sample
38.1 (333)
54.1 (392)
1.42
a From Daga and Daga (1985).
b Mortality differences were observed primarily after 72 h of age; diarrhea and sepsis were the principal causes of death.
c Relative risk of death for breastfed infants = 1.0.
ABSTRACT B-19 Barros and colleagues (1982) conducted a study involving all 5,914 births in the hospital in Pelotas, Brazil, in 1982. The children were followed up at age 2 years. Of the infants born weighing less than 2,000 g, 42% were never breastfed (compared with less than 10% of all others). The children who were small at birth were also more likely to be weaned. The authors reported that even if breastfeeding (either partial or exclusive) had no protective effect, nonbreastfed babies appeared to be at 30% increased risk of death. The duration of breastfeeding was unrelated to birth weight in the highest two (of five) socioeconomic groups.
ABSTRACT B-20 Relative Risk (RR) of Mortality Among Breastfed Infants in Peru, 1977 and 1978, Based on the First and Next-to-Last Births of 5,640 Women Aged 15 to 49 Yearsa
Age, mob
RRc of Mortality, Breastfed Compared with Other Infants
p Value
1–2
0.37
<.01
3–5
0.57
<.01
6–11
0.44
<.01
12–23
0.88
NRd
24–59
0.67
NR
a From Palloni and Tienda (1986). Based on data from the World Fertility Survey.
b Period of breastfeeding was up to the lower age bound in each category.
c Relative risk was based on a risk of 1.0 for infants not breastfed, using multivariate analysis.
d NR = Not reported.
COMMENTS: The total number of births included was not reported. Results were controlled for previous birth interval; birth order; gender; mother's age, education, and region; and father's occupation.
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ABSTRACT B-21 Infant Deaths from Diarrhea or Measles by Feeding Method Among Infants Attending a Clinic in Benin, Nigeria, 1981a
Feeding Method
Number of Deaths
Sample Size
Infant Deaths/1,000
Breast
0
65
0
Mixed
20
282
70.9
Bottle
9
67
134.3
Total
29
414
70.0
a From Scott-Emuakpor and Okafor (1986). Relative risks not calculable, given that there were no deaths in the breastfed group.
ABSTRACT B-22 Relative Risk (RR) of Infant Death in Malaysia by Duration of Breastfeeding and Infant Age, 1976a
RRb by Age of Infant, mo
Duration of Breastfeeding, mo
0–1
2–3
4–6
7–12
Never
1.00
1.00
1.00
1.00
Ever
0.82
NAc
NA
NA
<1
NA
0.89
0.61
NA
1
NA
0.41
0.64
2–3
NA
NA
0.14
0.87
4–6
NA
NA
NA
0.54
a From Holland (1987).
b Relative risk was derived from the author's log-linear models based on data from the Malaysian Family Life Survey, which included 1,262 households and 5,593 births. This is the same data set as that used by Butz et al. (1984) and Millman and Cooksey (1987).
c NA = Not applicable.
ABSTRACT B-23 Logit Coefficient and Relative Risk (RR) of Increased Mortality Among Infants in Malaysia, by Feeding Method, 1976a
Period of Measuring Mortality
Feeding Method
Logit Coefficient
RRb
Through 1 mo
All others versus ever breastfed
1.82c–2.06c,d
6.11–7.85
Through 1 yr
Bottle only
1.10c–1.47c,d
3.00–4.35
1–12 mo
Breastfed <1 mo versus longer breastfeeding
0.69–0.85c,d
1.99–2.34
a From Millman and Cooksey (1987). Based on data from the Malaysian Family Life Survey.
b Range of relative risks associated with range of logit coefficients.
c p < .01.
d Range depends on logistic model used.
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ABSTRACT B-24 Relative Risk (RR) of Mortality Among Guatemalan Children by Duration of Breastfeeding and Age, 1974 to 1976a
RRb by Duration of Breastfeeding
Age, mo
0
1–5 mo
6–11
11–23
1–5
6.1c
NAd
NA
NA
6–11
3.7c
2.3e
NA
NA
12–23
0.8
1.3
1.3
NA
24–59
0.4
0.4
0.5
0.6
a From Pebley and Stupp (1987), who obtained data on approximately 2,880 children in four villages that had health and nutrition intervention and from two urban communities.
b Relative risk for exclusively breastfed infants = 1.0.
c p < 0.05.
d NA = Not applicable.
e p < 0.01.
ABSTRACT B-25 Adjusted Relative Risk (RR) of Infant Mortality, by Disease and Method of Feeding, Among Infants in Urban Southern Brazil, 1985a
RR of Death, by Disease
Method of Feeding
Diarrhea
Respiratory Infections
Other Infections
Breast only
1.0
1.0
1.0
Breast plus formula
4.5b
2.1
0.1b
Breast plus cow's milk
3.4b
1.2
1.4
Formula only
16.3b
3.9b
2.3
Cow's milk only
11.6b
3.3b
2.6
a From Victora et al. (1987, 1989).
b Significantly different from the risk for those breastfeeding only.
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ABSTRACT B-26 Infant and Child Mortality/1,000 in Rural Sierra Leone and Beta Coefficients from Regression Analysis, by Duration of Breastfeeding, 1979a,b
Duration of Breastfeeding, mo
Infant and Child Mortality/1,000c
Beta Coefficients from Regression Analysis
<6
356
Reference group
6–12
253
-0.094d
13–24
194
-0.162d
≥25
286
-0.080d
a From Bailey (1988). Based on data obtained from a probability survey of 2,000 women aged 15 to 49.
b In regression analysis "Dependent variable is . . . ratio of infant and child deaths to live births corresponding to each mother in the sample" (Bailey, 1988, p. 165).
c No statistical test presented.
d p < .001.
COMMENTS: Results are open to circularity: death could cause a shorter period of breastfeeding. It is unclear to what age death rates refer and how infants less than age 3 years at the time of the survey were handled in the analysis.
ABSTRACT B-27 Mortality and Relative Risk (RR) of Mortality Within 1 Month of Interview Among Children in Bangladesh, by Breastfeeding Status and Age, 1985 and 1986a
Breastfed Infantsb
Weaned Infants
Age, mo
Number of Deaths
Period, Child-Monthsc
Number of Deaths
Period, Child-Months
RRd
12–17
11
6,622
0
176
e
18–23
8
5,108
3
753
3.39
24–29
7
5,267
12
2,611
3.45
30–36
3
3,035
7
4,103
1.73
Total
29
20,032
22
7,643
2.83
a From Briend et al. (1988).
b Includes infants partially or exclusively breastfed.
c Child-months refers to the number of months of observation summed across all children.
d Relative risk for breastfed infants = 1.0.
e Cannot be estimated.
COMMENTS: An effect was observed only among those with the smallest arm circumferences. Incidence of diarrhea was not affected, but the case fatality rate was higher among weaned children. The possibility of a spurious association of diarrhea causing weaning was ruled out.
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Representative terms from entire chapter:
breastfed infants
