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      Effect of exclusive breastfeeding cessation time on childhood morbidity and adverse nutritional outcomes in Ethiopia: Analysis of the demographic and health surveys

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          Abstract

          Background

          Though exclusive breastfeeding (EBF) for the first six months is recommended, it remains a debatable issue in both developed and developing countries. Thus, this study investigated the effect of EBF cessation time on childhood morbidity and adverse nutritional outcome in Ethiopia.

          Methods

          We used the 2011 and 2016 Ethiopian Demographic and Health Surveys. The study involved 2,433 children under six months of age. Logistic regression model was applied to determine the effect of EBF cessation time on outcome variables. Population Attributable Fraction was calculated to evaluate the public health impacts of EBF termination in the population.

          Results

          Discontinuing EBF at 0–3 months (adjusted odds ratio (AOR): 1.95, 95% confidence interval (CI): 1.08, 3.53)) and 4–6 months (AOR: 3.57, 95% CI: 2.19, 5.83) increased diarrhea occurrence compared to children who continued EBF up to 6 months. Children who had terminated EBF at 4–6 months had increased odds of fever (AOR: 1.73, 95% CI: 1.11, 2.68) and acute respiratory illnesses (ARIs) (AOR: 2.74, 95% CI: 1.61, 4.65). Cessation of EBF earlier than 4 months or between 4–6 months was associated with increased odds of having at least one childhood morbidity. Termination of EBF at 0–3 months and at 4–6 months were associated with increased occurrence of wasting (AOR: 2.32, 95% CI: 1.45, 3.74) and underweight (AOR: 2.30, 95% CI: 1.36, 3.91), respectively. Exclusive breastfeeding can avert 42% of diarrhea, 27% of ARI, 21% of fever, 26% of wasting and 23% of underweight burden among children under six months of age.

          Conclusions

          Termination of EBF before six months was associated with increased occurrence of diarrhea, fever and ARIs. It was also linked with increased occurrence of childhood wasting and underweight. The finding emphasized EBF for the first six months to reduce childhood morbidity and adverse nutritional outcomes.

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          Most cited references17

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          Infant feeding practices and diarrhoea in sub-Saharan African countries with high diarrhoea mortality

          Background The impacts of optimal infant feeding practices on diarrhoea have been documented in some developing countries, but not in countries with high diarrhoea mortality as reported by the World Health Organisation/United Nations Children’s Fund. We aimed to investigate the association between infant feeding practices and diarrhoea in sub-Saharan African countries with high diarrhoea mortality. Method The study used the most recent Demographic and Health Survey datasets collected in nine sub-Saharan African countries with high diarrhoea mortality, namely: Burkina Faso (2010, N = 9,733); Demographic Republic of Congo (2013; N = 10,458); Ethiopia (2013, N = 7,251); Kenya (2014, N = 14,034); Mali (2013, N = 6,365); Niger (2013, N = 7,235); Nigeria (2013, N = 18,539); Tanzania (2010, N = 5,013); and Uganda (2010, N = 4,472). Multilevel logistic regression models that adjusted for cluster and sampling weights were used to investigate the association between infant feeding practices and diarrhoea in these nine African countries. Results Diarrhoea prevalence was lower among children whose mothers practiced early initiation of breastfeeding, exclusive and predominant breastfeeding. Early initiation of breastfeeding and exclusive breastfeeding were significantly associated with lower risk of diarrhoea (OR = 0.81; 95% confidence interval (CI): 0.77–0.85, P<0.001 and OR = 0.50; 95%CI: 0.43–0.57, respectively). In contrast, introduction of complementary foods (OR = 1.31; 95%CI: 1.14–1.50) and continued breastfeeding at one year (OR = 1.27; 95%CI: 1.05–1.55) were significantly associated with a higher risk of diarrhoea. Conclusion Early initiation of breastfeeding and exclusive breastfeeding are protective of diarrhoea in sub-Saharan African countries with high diarrhoea mortality. To reduce diarrhoea mortality and also achieve the health-related sustainable development goals in sub-Saharan African, an integrated, multi-agency strategic partnership within each country is needed to improve optimal infant feeding practices.
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            Breast and complementary feeding practices in relation to morbidity and growth in Malawian infants.

            The objective of this study was to compare growth, morbidity incidence and risk factors for undernutrition between infants receiving complementary feeding early, before 3 months of age, with those receiving complementary foods after 3 months in a poor rural Malawian community. A cohort of babies was enrolled at birth for follow-up to 12 months of age. Weight, length, morbidity and feeding patterns were recorded at 4 weekly intervals from birth to 52 weeks. Mean age at introduction of water was 2.5 months (range 0-11.8), complementary foods 3.4 months (range, 1.0-10.7) and solids 4.5 months (range 1.2-13.8). Over 40% of infants had received complementary foods by 2 months and 65% by 3 months. The proportion of exclusively breast-fed infants, which included those receiving supplemental water, was 13% at 4 months, 6.3% at 5 months and 1.5% at 6 months. Infants with early complementary feeding had lower weight for age at 3 and 6 months (P<0.05), and at 9 months (P=0.07) and at 2 months they were approximately 200 g lighter. Early complementary feeding was significantly associated with increased risk for respiratory infection (P<0.05), and marginally increased risk for eye infection and episodes of malaria. Maternal illiteracy was associated with early complementary feeding (OR=2.1, 95% CI 1.3, 3.2), while later complementary feeding was associated with reduced infant morbidity and improved growth. Breast-feeding promotion programmes should target illiterate women. Greater emphasis is required to improve complementary feeding practices.
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              Optimal duration of exclusive breastfeeding: what is the evidence to support current recommendations?

              Before 2001, the World Health Organization (WHO) recommended that infants be exclusively breastfed for 4-6 mo with the introduction of complementary foods (any fluid or food other than breast milk) thereafter. In 2001, after a systematic review and expert consultation, this advice was changed, and exclusive breastfeeding is now recommended for the first 6 mo of life. The systematic review commissioned by the WHO compared infant and maternal outcomes for exclusive breastfeeding for 3-4 mo versus 6 mo. That review concluded that infants exclusively breastfed for 6 mo experienced less morbidity from gastrointestinal infection and showed no deficits in growth but that large randomized trials are required to rule out small adverse effects on growth and the development of iron deficiency in susceptible infants. Others have raised concerns that the evidence is insufficient to confidently recommend exclusive breastfeeding for 6 mo for infants in developed countries, that breast milk may not meet the full energy requirements of the average infant at 6 mo of age, and that estimates of the proportion of exclusively breastfed infants at risk of specific nutritional deficiencies are not available. Additionally, virtually no data are available to form evidence-based recommendations for the introduction of solids in formula-fed infants. Given increasing evidence that early nutrition and growth have effects on both short- and longer-term health, it is vital that this issue be investigated in high-quality randomized studies. Meanwhile, the consequences of the WHO recommendation should be monitored in different settings to assess compliance and record and act on adverse events. The policy should then be reviewed in the context of new data to formulate evidence-based recommendations.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                2 October 2019
                2019
                : 14
                : 10
                : e0223379
                Affiliations
                [1 ] Department of Reproductive Health and Population Studies, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
                [2 ] Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
                university of campus biomedico, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-7303-6723
                http://orcid.org/0000-0003-3222-0158
                Article
                PONE-D-19-14831
                10.1371/journal.pone.0223379
                6774524
                31577821
                4d933527-3a8c-43d9-a548-4cb5196a001b
                © 2019 Nigatu et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 14 June 2019
                : 19 September 2019
                Page count
                Figures: 0, Tables: 4, Pages: 12
                Funding
                The author(s) received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Breast Feeding
                Medicine and Health Sciences
                Pediatrics
                Neonatology
                Breast Feeding
                People and Places
                Population Groupings
                Age Groups
                Children
                People and Places
                Population Groupings
                Families
                Children
                Medicine and Health Sciences
                Health Care
                Health Statistics
                Morbidity
                Medicine and Health Sciences
                Gastroenterology and Hepatology
                Diarrhea
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Diarrhea
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Diarrhea
                Medicine and Health Sciences
                Pediatrics
                Child Health
                Medicine and Health Sciences
                Public and Occupational Health
                Child Health
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Fevers
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Fevers
                Biology and Life Sciences
                Nutrition
                Medicine and Health Sciences
                Nutrition
                People and Places
                Population Groupings
                Age Groups
                Children
                Infants
                People and Places
                Population Groupings
                Families
                Children
                Infants
                Custom metadata
                The authors have no mandate to share the data set or make it publicly available because the data were obtained from The DHS Program repository. However, upon fulfilling their criteria, the data can be accessed by requesting from the DHS Program website (Available at: https://www.dhsprogram.com/data/available-datasets.cfm). Upon clicking the web-page, a list of countries name and lists of standard DHS data by year with other details columns would be displayed. When clicking on “Data Available” under the column heading “survey data-sets” with respective survey years (Ethiopia 2011 and Ethiopia 2016), zipped file names under different main recode file names would be displayed. Go to the main recode file name “Children’s Recode” check the box to download “ETKR61DT.ZIP” and “ETKR70DT.ZIP” zipped files. The file names require unzipping to run the analysis. The file names used for this analysis are “ETKR61FL.DTA” and “ETKR70FL.DTA”. The authors had no special access or privileges to the data source used for this analysis. The data-sets are available to all interested researchers upon request by fulfilling the DHS Program criteria to grant access. Their criteria to grant access to the data-sets are to have a project/research idea with a brief statement of the purpose/aim/objectives.

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