Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE Promotion of exclusive is not likely to be cost effective in West Africa. A randomized intervention study from Guinea-Bissau Marianne S. Jakobsen ([email protected]), Morten Sodemann, Sidu Biai, Jens Nielsen, Peter Aaby Bandim Health Project, Indepth Network, Danish Epidemiology Science Centre, Apartado 861, Bissau, Guinea-Bissau; and , 2300 Copenhagen S, Denmark

Keywords Abstract Anthropometry, Epidemiological study, Exclusive Aim: To evaluate the impact of promotion of exclusive breastfeeding on infant health in Guinea- breastfeeding, Guinea-Bissau, Infant mortality and morbidity, Randomized intervention study Bissau, West Africa, where mortality rates are high, breastfeeding is widely practiced but exclusive Correspondence breastfeeding is rare. Marianne Skytte Jakobsen, Bandim Health Project, Method: At the Bandim Health Project in Guinea Bissau, West Africa, a birth cohort of 1721 infants Danish Epidemiology Science Centre, Statens were randomized to receive health education: promotion of exclusive breastfeeding for the first Serum Institut 2300, Copenhagen S, Denmark. Email: [email protected] 4–6 months of life according to WHO recommendations at the time of the study. All children were followed from birth to 6 months of age. Received 2 April 2007; revised 2 June 2007; Results: Introduction of both water and weaning food was significantly delayed in the intervention accepted 23 August 2007 group. However we found no beneficial health effects of the intervention; there was no reduction in DOI:10.1111/j.1651-2227.2007.00532.x mortality in the intervention group compared with the control group (mortality rate ratio: 1.86 (0.79–4.39)), weight at 4–6 months of age was significantly lower in the intervention group (7.10 kg vs. 7.25 kg; Wilcoxon two-sample test: p = 0.03). There was no difference in diarrhoea morbidity and hospitalization rates. Conclusion: Although mothers were sensitive to follow new breastfeeding recommendations, it had no beneficial impact on infant health in this society with traditional, intensive breastfeeding. There seems to be little reason to discourage local practices as long as there are no strong data justifying such a change.

In most low-income countries, health situation of infants INTRODUCTION is poor and there is a need for effective interventions that are There is no doubt that breastfeeding is the ideal food for in- carefully evaluated in order to achieve improvements in in- fants and it has been documented that an infant needs no fant health. Very few settings in low-income countries have supplement and does well easily on breast milk alone up to the possibility of evaluating the impact of health interven- the age of 6 months (1,2). Therefore exclusive breastfeeding tions on mortality. However, in Guinea Bissau, West Africa, is promoted worldwide by WHO to improve infant and child the Bandim Health Project maintains a demographic health health (3,4). However, evidence obtained from randomized surveillance system making longitudinal follow-up possible. studies showing that exclusive breastfeeding is beneficial to As in most Sub-Saharan countries the population in child health is limited. Only two randomized study, in which Guinea Bissau is characterized by high infant mortality and mothers were randomized to receive counselling about the high prevalence of infectious diseases. Almost 100% of the benefits of exclusive breastfeeding, have been conducted to mothers start breastfeeding but only few percent are breast- evaluate the direct effect of promotion of exclusive breast- feeding exclusively. Nonetheless, the tradition is prolonged feeding on infant morbidity and growth, one from Belarus breastfeeding with a median length of more than 22 months (5) and one from India (6). A study from Mexico examined, (9). The present randomized study with longitudinal follow- as a secondary outcome, the effect of exclusive breastfeeding up was designed to examine whether promotion of exclusive promotion on diarrhoea morbidity (7). breastfeeding is effective in reducing infant morbidity and The ultimate decision of how to feed an infant is taken mortality in Guinea-Bissau. by its mother or its family and is a product of culture and traditions as well as socioeconomic conditions and well- being of mother and child. It is therefore always a question SUBJECTS AND METHOD whether the observed impact of exclusive breastfeeding on Study area child health is due to reverse causality, selection bias, con- The Bandim health project founding or a causal effect. Several randomized studies have The study was conducted at the Bandim Health Project in demonstrated that the proportion of exclusive breastfeed- Guinea-Bissau, West Africa, one of the poorest countries in ing mothers and children can be increased by counselling the world (17). The infant mortality rate is 100/1000 (18) and (7–9). However the knowledge of the impact of exclusive the case fatality rate among children admitted to the only breastfeeding on child health is based mainly on observa- paediatric ward in the country is almost 15% for children tional studies (10–16). under 5 years of age (19). In the study area, suburban districts

68 C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 Jakobsen et al. Exclusive breastfeeding and infant health in the capital, people are living mainly in clay houses. Most and at the same intervals as in the intervention group. Only houses have no access to electricity, and water is collected during these visits no health education was given and only at public standpipes or wells. the information on introduction of water and weaning food Since 1978, the Bandim Health Project has maintained was obtained. These biweekly visits were conducted from a demographic health surveillance system, at the time of birth to 6 months of age or until the infant was reported to the study covering around 46 000 people in four suburban have started both water and weaning food. districts. All houses in the study area are visited monthly to record new pregnancies and new births. Children under Background information 3 years of age are followed with three-monthly home visits at Apart from the visits in which the intervention was deliv- which breastfeeding status, arm-circumference, sta- ered and information on feeding practices was obtained all tus, residence and survival are ascertained. Measurements of enrolled infants were followed with weekly morbidity inter- weight and height are collected by specific teams visiting ev- view and monthly monitoring of anthropometric data. All ery month for children less than 6 months of age. The project study children were further followed from birth to 6 months also registers all admissions at the paediatric ward of the na- of age, , migration or weaning whichever came first tional hospital. The study was registered as a clinical trial through the routine registration system. Further the infor- and ethically approved by the Ministry of Health in Guinea mation included birth dates as well as background informa- Bissau and by the Danish Central Ethical Committee. tion such as residence, mother’s age, schooling, ethnic group and vaccination status. Information on hospitalization was Intervention design obtained from the Bandim Health Project’s routine registra- Study population. A cohort of infants born between 1 March tion system. HIV status was not available but the 2000 and 28 February 2001 were eligible for the study. In- prevalence of HIV-1 in the country was low at the time of the fants were enrolled in the study if the mother was recorded as study. All information from these different routines was col- living in the area during pregnancy and present when mother lected by field assistants unrelated to the intervention part and child were visited by the field assistant during the study of the study. period. Further in order to avoid birth-related only Cluster versus individual randomization. With informa- children who were alive at 7 days of age were included; for tion interventions there is always a problem of communica- the majority of children dying within the first few hours of life tion between members of control and intervention groups we do not have any information on whether they were fed and therefore ‘contamination’ of the control group. To anything before dying. Exclusive breastfeeding for the first address the question of contamination of the intervention 4–6 months is the official policy in Guinean Bissau. Hence, message, we previously conducted a study in the same pop- we did not obtain informed consent at enrolment for the ulation randomizing mothers and children into clusters. In information campaign. that study we found that the variation in how intervention mothers changed feeding habits was the same within the Follow-up of enrolled infants clusters as between the clusters. We therefore concluded that Infants and mothers in both the intervention group and the contamination of that type of intervention message in the control group were visited every two weeks. During these population was not a major problem (9). In order to increase visits, health information was given to mothers in the inter- the power of the present study, we choose to randomize at vention group. The health information was provided indi- the individual level. vidually to the mother. As many mothers are illiterate it was Randomization procedure. All pregnancies detected by given orally in the local language Criolo by a local female the demographic surveillance system at Bandim Health health worker. We have previously performed focus group Project are allocated an ID number at the time the mother discussions with different groups of mothers. The local be- is recorded as pregnant. ID numbers are allocated sequen- liefs about why and when to introduce water and weaning tially within each subdistrict by an independent assistant food were used as basis for the intervention message, i.e. an who was blind to the enrolment criteria for the present trial. infant can satisfy its thirst by breast milk and sexual activity All recorded pregnancies were randomized according to the does not harm the breast milk. The health education focused last two digits of their ID. On a list with numbers from 00 to on encouraging the mothers to postpone introduction of wa- 99, 50 numbers were randomly allocated to the intervention ter and weaning food until the age of 4–6 months according group and 50 to the control group. to the WHO recommendation at the time the study was con- Non-enrolled children. Stillborn children and children ducted. As breastfeeding is rarely stopped before 12 months who died during the first 7 days after birth were not enrolled of age, the intervention focused on avoiding early introduc- in the study. tion of water and weaning food. Furthermore, it was part Among the enrolled infants born in the study area in the of the intervention to explain that breast milk is sufficient study period, a group of 425 mother and child pairs were as the only nutrient up to 6 months of age and that breast never present in the study area during the study (Fig. 1). milk has protective effect against illnesses. At the visits it This was mainly due to the mother giving birth outside the was monitored whether the infant had received any water study area, the infant moving or dying shortly after birth or weaning food during the preceding two weeks. Children or being hospitalized shortly after delivery. We were there- in the control group were visited by the same health worker fore not able to provide intervention to this group and

C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 69 Exclusive breastfeeding and infant health Jakobsen et al.

Intervention Control at inclusion at inclusion Randomisation

Study population 1,721

Died Moved Died Moved 18 36 20 40

857 864 Missing information on Missing information on water and weaning food water and weaning food 197 (23.0 %) 228 (26.4 %)

Censored at 660 636 Censored at last known last known Moved Moved date still date still 0-6 months 0-6 months breastfeeding 15 10 breastfeeding Follow-up 1 2 Died during Died during 1 Censored at follow-up 15 follow-up 8 weaning

Censored due to stop of Censored due to stop of breastfeeding. 5 breastfeeding. 5

ofmonths age End of follow-up 6at

629 618

Figure 1 Flowchart of the intervention. enrol them in the study. However, due to the demographic for equality of survivor functions was used. Testing pro- health surveillance system, we know whether these chil- portional hazard assumptions was based on Schoenfeld’s dren were alive, had moved or died during the study pe- assumptions. Mortality ratios were compared using Cox pro- riod. The overall mortality in the group of 425 noneligible portional hazard regression model with age as underlying children was considerably higher compared with enrolled scale. If weaned before 6 months of age the children were infants (38/425 (8.94%) vs. 23/1296 (1.77%)) (log rank test censored at the time of weaning. Weight-for-age was com- for equality of survivor functions 2 = 7.19, p = 0.007). There puted using the NCHS/WHO growth reference and Anthro was no difference in total number (197 interventions and 228 software. Weight-for-age z-scores above +3 or below 6 were controls [risk ratio: 0.91; 95% CI: 0.81–1.02]), and no differ- considered unreliable and included as unknown. If a child ence in mortality between the intervention group and con- had more than one measurement in each age group only the trol group (HR 0.97 [0.51–1.86]). Significantly more mothers first measurement has been counted (Table 3). of not enrolled infants had low educational level (data not A child was defined as having diarrhoea if the mother re- shown). ported the child to suffer from diarrhoea independently of the frequency and consistency of the stool. The incidence of Statistical methods diarrhoea was estimated as number of initiated episodes per Time to introduction of water and weaning food, hospital- 100 days at risk. To be counted as independent the episodes ization and death were calculated using a hazard regression should be separated by at least two diarrhoea free days. Diar- model with age as underlying time scale. If the propor- rhoea incidence rates were compared in a Poisson regression tional hazard assumption was not fulfilled, log-rank test model adjusting for age.

70 C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 Jakobsen et al. Exclusive breastfeeding and infant health

Table 1 Time to introduction of water and weaning food for different age groups comparing intervention and control groups

Water Weaning food

Beginning of period. Total number not Time to introduction Beginning of period. Total number not Time to introduction of introduced/total number at risk (%) of water I vs. C introduced/total number at risk (%) weaning food I vs. C

Intervention Control Hazard ratio (95% CI) Intervention Control Hazard ratio (95% CI)

0–30 days 660/660 636/636 0.96 (0.83–1.11) 660/660 636/636 0.73 (0.53–1.01) 31–60 days 213/623 (34.2) 178/592 (30.1) 0.65 (0.48–0.87) 564/640 (88.1) 522/615 (84.9) 0.91 (0.64–1.30) 61–120 days 121/610 (19.8) 77/585 (13.2) 0.62 (0.44–0.87) 482/638 (75.6) 434/615 (70.6) 0.78 (0.64–0.95) 120–187 days 9/569 (1.58) 5/566 (0.88) 0.18 (0.06–0.49) 226/628 (36.0) 167/607 (27.5) 0.81 (0.61–1.06) Overall 2 = 8.99, p = 0.003∗∗ 0.79 (0.70–0.91)

∗∗Log-rank test for equality of survivor functions (Test for proportional hazard assumption 2 = 15.12, p = 0.0001).

Weight was measured to the nearest 100 g using a Salter of life and at the age of 4 months only 1.2% had not started scale. Length was measured to the nearest millimetres using receiving water (Table 1). Overall water was introduced sig- a locally manufactured measure board of wood. nificantly later in the intervention group compared with the The original sample was based on the calculation that it control group (log-rank test for equality of survivor func- would require a population of 2000 infants to detect a 50% tions: p = 0.003). At 2 months of age 19.8% versus 13.2% reduction in mortality with 95% confidence limits and 80% from the intervention and control group, respectively were power given that the expected mortality rate was 6% for chil- not yet introduced to water. dren between 2 and 12 months of age. However, the study For weaning food, 393 children (31.8%) were not yet in- took place during a postwar period with political and so- troduced at the age of 4 months and at 6 months of age the cial turmoil and many labour conflicts. The population was number was 48 children (4.0%). Overall, weaning food was even more mobile than usual, many people staying out of the significantly delayed in the intervention group compared city that had been hit by the war one year earlier. We there- with the control group (Hazard ratio [HR]: 0.79; 95% CI: fore enrolled fewer children than originally planned making 0.70–0.91) (Table 1). it unlikely that we would be able to measure any effect on mortality. Hence, we have emphasized the result for mor- Morbidity bidity, hospitalizations and growth in the first 6 months of A total of 588 episodes of diarrhoea were observed follow- life which would require much fewer children. ing 58 001 diarrhoea free days (1.01 episodes per 100 days). In the intervention group the incidence was 1.00 per 100 RESULTS diarrhoea free days and in the control group the incidence Study population was 1.01 per 100 (Poisson regression rate ratio: 0.99 [95% CI: 0.84–1.17]) (Table 2). A total of 1721 infants were born in the study period and fulfilled the criteria for inclusion in the study; 857 (49.8%) belonging to the intervention group and 864 (50.2%) to the Hospitalization control group. A total of 1296 infants provided informa- During the first 6 months of life, a total of 20 (2.9%) children tion on either introduction of water and weaning food and from the intervention group and 18 (2.7%) from the control were enrolled in the intervention study (Fig. 1). As described group were hospitalized at least once. No difference in time above the remaining 425 children were not seen in the area to hospitalization was revealed between the two groups; me- at the time of enrolment and were not eligible for the inter- dian time to first hospitalization was 119 days for the inter- vention. vention group and 123 days for the control group (Log-rank = Except for maternal education and birth order, the dis- test for equality of survivor functions: p 0.79). Four chil- tribution of different socioeconomic indicators was similar dren were hospitalized twice; 1 from the intervention group for the intervention group and the control groups (Table S1). and 3 from the control group. The present study is randomized and all results are therefore presented uncontrolled. However, in analyses adjusting all Anthropometry results for maternal education and birth order, we found no A total of 763 infants (386 intervention and 377 control effect of these imbalances (data not shown). infants) had their weight measured at least once during the study period. There was no difference in median time Introduction of water and weaning food to first measurement between the two groups (64 days vs. As a process indicator for the intervention, we analyzed the 70 days HR: 0.95; 95% CI: 0.83–1.10). Median number of time to introduction of water and weaning food. More than measurements per child was 7 in both the intervention group 70% of the children received water during the first month and the control group. Among children 4–6 months of age,

C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 71 Exclusive breastfeeding and infant health Jakobsen et al.

Table 2 Mortality and morbidity. Comparing intervention with control groups. Follow-up from 7 days to 5 months (diarrhoea) and 7 days to 12 months (mortality)

Mortality Diarrhoea morbidity

Mortality rate per 100 person-years Hazard ratio Comparing Number of episodes per Poisson regression (number of deaths) I and C (95% CI) 100 days of observation Comparing I and C

Age group I C I C

7–30 days 0 (0) 0 (0) 0.38 0.33 1.23 (0.53–2.84) 31–60 3.7 (2) 1.9 (1) 1.43 (0.30–6.77) 0.66 0.43 1.32 (0.75–2.34) 61–120 days 5.7 (6) 3.9 (4) 2.11 (0.73–6.15) 0.98 1.18 0.84 (0.64–1.10) 121–180 days 6.5 (7) 2.8 (3) 2.62 (0.93–7.39) 1.47 1.45 1.03 (0.80–1.32) Overall (7–180 days) 4.7 (15) 2.6 (8) 1.86 (0.79- 4.39) 1.00 1.01 0.98 (0.83–1.17) 181–274 days 2.4 (7) 1.4 (4) 1.49 (0.60–3.65) 275–365 days 2.8 (4) 2.8 (4) 1.05 (0.34–3.29)

Table 3 Median weight for age and median z-score. Comparison between intervention and control groups for different age groups Median weight (kg) Weight for age (median z-scores)

Age group Total number of I C Wilcoxon two-sample I C Wilcoxon two-sample (in days) measurements (I/C) test (p-value) test (p-value)

7–60 176/151 4.7 4.8 0.58 0.44 0.42 0.85 61–120 254/260 6.0 6.0 0.23 0.45 0.59 0.24 121–150 210/202 6.8 7.0 0.01 0.19 0.47 0.02 151–180 350/349 7.5 7.8 0.04 −0.16 0.08 0.05

those in the intervention group had a significantly lower fects of promoting late introduction of water and weaning weight compared with the control group (Table 3). food in the intervention group. There was no difference in di- arrhoea morbidity and hospitalization rates, the nutritional Mortality status was lower in the intervention group between 4 and Among the 1296 children enrolled in the intervention study, 6 months of age. Although the sample was smaller than orig- 1.7% (23/1296) died between 7 days and before 6 months of inally planned, there was no tendency towards reduction in age; 2.3% (15/660) died in the intervention group and 1.3% mortality – if anything mortality tended to be higher in the (8/636) in the control group. Mortality was slightly, though intervention group. The intervention was designed to reflect not significantly higher in the intervention group, the HR a realistic community situation and our results demonstrate being 1.86 (95% CI: 0.79–4.39) (Table 2). that the benefits of such an intervention are likely to be of Using the demographic surveillance of the Bandim Health limited impact and probably not cost effective. Project, we followed the study population to the age of When investigating the impact of promotion of exclusive 12 months (Table 2). There might still have been some differ- breastfeeding on child health, maternal change of behaviour ence at 6–9 months but after 9 months there was no longer becomes an important process indicator. The intervention any difference between the two groups. In the age group 2– appeared to be a success in the sense that the introduction 12 months of age specified in the protocol, the HR between of water and weaning food was significantly postponed in the intervention and control group was 1.58 (95% CI 0.85– the intervention group compared with the control group. 2.95). As the study was randomized, the reported delay is un- likely to be a result of socioeconomic bias. Some socioe- DISCUSSION conomic indicators were not equally distributed between In the present study, we randomly allocated the infants to the two groups, but control for these indicators did not in- promotion of intensive information on the benefits of exclu- fluence the estimated difference between the two groups. sive breastfeeding according to WHO recommendation. To In this kind of study, change of behaviour is not objective our knowledge only two randomized studies undertaken in but we have to rely on what the mother reports. The risk a low-income countries (India and Mexico) (6,7) have exam- of reporting bias must therefore be considered. Collection ined the impact of promoting delayed introduction of water of information on introduction of water and weaning food and weaning food on morbidity. No studies have been con- was performed by the same health worker and at the same ducted in Africa where breastfeeding is often more intensive time as the intervention was given, which potentially could and no studies have evaluated the effect on overall mortality. give rise to reporting bias as mothers may not want to ad- In the present randomized intervention study with longi- mit starting water and weaning food. However, the reported tudinal follow-up we did not find any beneficial health ef- change was far from being fully compliant with the WHO

72 C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 Jakobsen et al. Exclusive breastfeeding and infant health recommendations. It is therefore reasonable to believe that episode per 100 days of observation. This is in line with a the delay in introduction of water and weaning food was due previous study from Guinea-Bissau (21). This observational to a partial acceptance of the intervention message. Contam- study did not find any difference in diarrhoea morbidity be- ination of the control group with the intervention message tween exclusively breastfed infants and infants introduced could be a possible source of bias as intervention and con- to weaning food. trol mother might meet and communicate about the inter- In one randomized study from Mexico diarrhoea morbid- vention. However, we consider it unlikely as data from a ity was found to be significantly lower in the intervention previous study with a similar intervention message showed group from 0 to 3 months (7). However, 15% of the chil- that such a contamination did not take place. dren in the control group in this study were weaned before The fact that the mothers only seemed to postpone the 3 months of age, and it is not possible from the numbers to introduction rather than to follow the advice and avoid in- see whether it is exclusive breastfeeding or any breastfeed- troduction of water and weaning food until the age of 4– ing that accounts for the lower diarrhoea morbidity in the 6 months might lead to speculations whether the interven- intervention group. tion was too weak. In Guinea-Bissau, the introduction of, The beneficial effect of breast milk is often considered to especially, water is associated with supernatural beliefs. It is be dose–response related (12,16,21). It could be that early in- even believed that late introduction of water may harm the troduction of water and weaning foods is less dangerous in child. It is understandable that a mother in a society with an a society with intensive breastfeeding, while the children are infant mortality of 100 per 1000 and poor public health care still protected by a very high content of immune competent might not be willing to take the chance of potentially harm- factors in the milk and by maternal antibodies. Alternatively, ing her child by delaying introduction of water. Even if the other factors could be more important than the time of in- difference in time to introduction of water and weaning food troduction of weaning food e.g. provision of primary health was significant later in the intervention group the difference care and the quality of hospital treatment and medication. was small. Health resources in most low-income countries A recent observational multicentre study from Ghana, Peru are limited. It must be taken into consideration whether it and India (22) supports this hypothesis. They found a sig- is sensible to use the limited financial resources to change nificant higher morbidity and mortality comparing breast- the mother’s behaviour towards exclusive breastfeeding if it fed infants with no breastfeeding. However there were no is not improving mortality and morbidity rates considerably. significant difference in mortality and morbidity comparing Exclusive breastfeeding is promoted world wide with the infants who were exclusively breastfed with predominantly purpose of improving infant health (4,20). However, the im- breastfed children. pact on infant health has to our knowledge only been docu- Anthropometric measurements took place in the after- mented in three randomized studies. All three studies report noon when mother and child were often away from the a significant positive impact on infant health. In the study house for visits and we therefore had a relatively large group from Belarus (5) exclusive breastfeeding was promoted at of children who were not examined anthropometrically. hospital level. At 3 months of age 43.3% of the children However, missing measurements were equally common in in the intervention group were exclusively breastfed versus the intervention group and control group. It is unlikely that 6.4% in the control group; at 6 months of age, the numbers the children not seen in the control group were more ill than were 7.9% in the intervention group and 0.6% in the control the children not seen in the intervention group. In our study group. Any breastfeeding at 12 months of age was 19.7% in infants from 4 to 6 months of age in the intervention group the intervention group versus 11.4% in the control group. had a significantly lower weight. None of the study chil- A significant decrease in gastrointestinal disease and atopic dren were malnourished and median z-score were mainly eczema was observed in the intervention group. However, above 0. It is well described that breastfed infants have a in the Belarus study, only around 50% of the children were lower nutritional status compared with formula fed children breastfed at 6 months thus the beneficial effect of the inter- (23,24). Our findings are therefore not likely to be an indica- vention is not solely the effect of exclusive breastfeeding but tion of poor growth or health among the breastfed children also the effect of breastfeeding versus no breastfeeding. In but merely a result of different growth patterns for breastfed Guinea-Bissau, weaning before the age of 12 months is an and formula-fed children. unusual event and often associated with serious events as In Guinea Bissau it is local practice to introduce, espe- death or severe illness of the mother. In our analysis we are cially, water very early although the amounts given usually therefore only comparing children who are breastfed. are small. There is evidence that exclusive breastfeeding may In the study from India, exclusive breastfeeding was pro- be especially important for the first few weeks of life (25). moted in the community (6). At 3 months of age, 79% of the This important aspect is not covered by the present study infants in the intervention group were exclusively breast- as we do not have information on both breastfeeding and fed compared with 48% in the control group. At 6 months morbidity and mortality in the first 7 days of life. of age, the numbers were 42% versus 4%, respectively. The Mothers and children were followed as soon as possible 7-day diarrhoea prevalence was significantly lower in the after the birth. However, the study was community based, intervention communities compared with controls at both 3 leading to a delay in the identification of new deliveries. The and 6 months of age. No difference was seen in anthropo- fact that infant mortality is very high in first 7 days of life metric status. In our study, the diarrhoea incidence was 1 makes it an important issue to investigate. There seems to

C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 73 Exclusive breastfeeding and infant health Jakobsen et al. be no major advantages on the health of infants more than 8. Haider R, Ashworth A, Kabir I, Huttly SR. Effect of 7-day old when combining the efforts to change mother’s community-based peer counsellors on exclusive breastfeeding behaviour towards exclusive breastfeeding and the effect on practices in Dhaka, Bangladesh: a randomised controlled trial infant health. [see comments]. Lancet 2000; 356: 1643–7. 9. Jakobsen MS, Sodemann M, Molbak K, Alvarenga I, Aaby P. International recommendations are generally believed to Promoting breastfeeding through health education at the time be beneficial for all infants with the expectation of equal ac- of immunizations: a randomized trial from Guinea Bissau. cess to the intervention for all groups. It is worth noting that Acta Paediatr 1999; 88: 741–7. mortality was highest in the group of children who were not 10. Arifeen SE, Black RE, Caulfield LE, Antelman G, Baqui AH. even reached by the intervention program. We do not know Determinants of infant growth in the slums of Dhaka: size and if promotion of exclusive breastfeeding would decrease mor- maturity at birth, breastfeeding and morbidity. Eur J Clin Nutr 2001; 55: 167–78. tality in this subgroup, but it would demand considerable and 11. Habicht JP, DaVanzo J, Butz WP. Does breastfeeding really more specific efforts to reach this vulnerable group. save lives, or are apparent benefits due to biases? Am J Hence, it is questionable whether large-scale promotion Epidemiol 1986; 123: 279–90. of exclusive breastfeeding will lead to any improvement in 12. Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, infant health in countries with strong breastfeeding prac- Teixeira AM et al. 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74 C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 Jakobsen et al. Exclusive breastfeeding and infant health

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C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 68–75 75