Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review

Amanda K Debes, Anjalee Kohli, Neff Walker, Karen Edmond, Luke C Mullany, Amanda K Debes, Anjalee Kohli, Neff Walker, Karen Edmond, Luke C Mullany

Abstract

Background: Early breastfeeding is defined as the initiation of breastfeeding within twenty four hours of birth. While the benefits of breastfeeding have been known for decades, only recently has the role of time to initiation of breastfeeding in neonatal mortality and morbidity been assessed.

Objective: To review the evidence for early breastfeeding initiation practices and to estimate the association between timing and neonatal outcomes.

Methods: We systematically reviewed multiple databases from 1963 to 2011. Standardized abstraction tables were used and quality was assessed for each study utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Three meta-analyses were conducted for mortality among babies surviving to 48 hours.

Results: We identified 18 studies reporting a direct association between early breastfeeding initiation and neonatal mortality and morbidity outcomes. The results of random effects analyses of data from 3 studies (from 5 publications) demonstrated lower risks of all-cause neonatal mortality among all live births (RR = 0.56 [95% CI: 0.40 - 0.79]) and among low birth weight babies (RR=0.58 [95% CI: 0.43 - 0.78]), and infection-related neonatal mortality (RR = 0.55 [95% CI: 0.36 - 0.84]). Among exclusively breastfed infants, all-cause mortality risk did not differ between early and late initiators (RR = 0.69 [95% CI: 0.27 - 1.75]).

Conclusions: This review demonstrates that early breastfeeding initiation is a simple intervention that has the potential to significantly improve neonatal outcomes and should be universally recommended. Significant gaps in knowledge are highlighted, revealing a need to prioritize additional high quality studies that further clarify the specific cause of death, as well as providing improved understanding of the independent or combined effects of early initiation and breastfeeding patterns.

Figures

Figure 1
Figure 1
Flow diagram of systematic review
Figure 2
Figure 2
a: Combined estimates of the association between early breastfeeding and all-cause mortality within 28 days, among live births surviving at least 48 hours. Figure 2b: Combined estimates of the association between early breastfeeding and all-cause mortality within 28 days, among low birth weight babies surviving at least 48 hours. Figure 2c: Combined estimates of the association between early breastfeeding and all-cause mortality within 28 days, among exclusively breastfed babies surviving at least 48 hours
Figure 3
Figure 3
Combined estimates of the association between early breastfeeding and infection-related mortality outcomes within 28 days, among all live births surviving at least 48 hours
Figure 4
Figure 4
a: Combined estimates of the association between early breastfeeding and sepsis-specific mortality outcomes within 28 days, among all live births surviving at least 48 hours. Figure 4b: Combined estimates of the association between early breastfeeding and birth asphyxia-specific mortality within 28 days, among all live births surviving at least 48 hours. Figure 4c: Combined estimates of the association between early breastfeeding and premature-specific mortality within 28 days, among all live births surviving at least 48 hours
Figure 5
Figure 5
Infection-related mortality effect and quality grade of the estimate for the effect of early initiation of breastfeeding

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