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Wilde VK. Neonatal Jaundice and Autism: Precautionary Principle Invocation Overdue. Cureus 2022; 14:e22512. [PMID: 35228983 PMCID: PMC8873319 DOI: 10.7759/cureus.22512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/05/2022] Open
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Edney JM, Kovats S, Filippi V, Nakstad B. A systematic review of hot weather impacts on infant feeding practices in low-and middle-income countries. Front Pediatr 2022; 10:930348. [PMID: 36147803 PMCID: PMC9485728 DOI: 10.3389/fped.2022.930348] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Increased rates of exclusive breastfeeding could significantly improve infant survival in low- and middle-income countries. There is a concern that increased hot weather due to climate change may increase rates of supplemental feeding due to infants requiring fluids, or the perception that infants are dehydrated. OBJECTIVE To understand how hot weather conditions may impact infant feeding practices by identifying and appraising evidence that exclusively breastfed infants can maintain hydration levels under hot weather conditions, and by examining available literature on infant feeding practices in hot weather. METHODS Systematic review of published studies that met inclusion criteria in MEDLINE, EMBASE, Global Health and Web of Science databases. The quality of included studies was appraised against predetermined criteria and relevant data extracted to produce a narrative synthesis of results. RESULTS Eighteen studies were identified. There is no evidence among studies of infant hydration that infants under the age of 6months require supplementary food or fluids in hot weather conditions. In some settings, healthcare providers and relatives continue to advise water supplementation in hot weather or during the warm seasons. Cultural practices, socio-economic status, and other locally specific factors also affect infant feeding practices and may be affected by weather and seasonal changes themselves. CONCLUSION Interventions to discourage water/other fluid supplementation in breastfeeding infants below 6 months are needed, especially in low-middle income countries. Families and healthcare providers should be advised that exclusive breastfeeding (EBF) is recommended even in hot conditions.
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Affiliation(s)
- Jessica M Edney
- Centre on Climate Change and Planetary Health, Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sari Kovats
- Centre on Climate Change and Planetary Health, Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Britt Nakstad
- Division of Paediatrics and Adolescence Medicine, Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
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Ghosh P, Rohatgi P, Bose K. Determinants of time-trends in exclusivity and continuation of breastfeeding in India: An investigation from the National Family Health Survey. Soc Sci Med 2021; 292:114604. [PMID: 34864276 DOI: 10.1016/j.socscimed.2021.114604] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/06/2021] [Accepted: 11/23/2021] [Indexed: 11/28/2022]
Abstract
Breastfeeding is an essential key factor for reducing child mortality and the risk of disease. Therefore, to ensure health and wellbeing for all (Sustainable Development Goal 03), and to reduce inequalities in child health status (SDG 10), understanding the determinants of breastfeeding is essential. Our research aims to investigate determinants of different breastfeeding practices from 2005-06 (NFHS-3) to 2015-16 (NFHS-4), and changes in different breastfeeding practices among various demographic, social, religious, and economic groups during this decade. We have used a multivariate binary logistic regression model to estimate significant determinants of different breastfeeding practices. The results show an 8.4% hike in Exclusive Breastfeeding (EBF), along with a 3.3% and 1% drop in the Continuation of Breastfeeding (CBF) up to one and two years respectively during this decade in India. Significant variation has been found in EBF, CBF1 and CBF2 among various categories of child's birth interval, place of residence, social groups, economic communities, and geographic regions. Maternal nutritional status and anemia levels had significant influence on CBF1 and CBF2, and gender of the children on EBF and CBF2 from 2005-06 to 2015-16. There was no significant variation in CBF1 and CBF2 among children born in different birth orders, whereas EBF was significantly less among higher birth orders children. A dramatic improvement in EBF was found among first birth ordered children, teenage and/or highly educated mother, rich families, and in north India, and CBF2 was significantly raised only among higher educated mothers. The estimation of determinants throughout the decade is essential for improving government policies related to supporting and encouraging breastfeeding. The study suggests more initiatives and investment for the promotion, support and improvement of CBF for one and two years, and reduction of inequality among various demographic and socio-economic groups and geographic regions.
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Affiliation(s)
- Pritam Ghosh
- Department of Geography, University of Calcutta, 35, Ballygunge Circular Road, Kolkata 700019, West Bengal, India; Department of Geography, Ramsaday College, Amta, Howrah 711401, West Bengal, India.
| | - Pratima Rohatgi
- Department of Geography, University of Calcutta, 35, Ballygunge Circular Road, Kolkata 700019, West Bengal, India.
| | - Kaushik Bose
- Department of Anthropology, Vidyasagar University, Midnapore, West Bengal, India.
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Wilde VK. Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates. Cureus 2021; 13:e18478. [PMID: 34659917 PMCID: PMC8491802 DOI: 10.7759/cureus.18478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 11/05/2022] Open
Abstract
Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.
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Affiliation(s)
- Vera K Wilde
- Methods, Ethics, and Technology, Independent Researcher, Berlin, DEU
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Exavery A, Kanté AM, Hingora A, Phillips JF. Determinants of early initiation of breastfeeding in rural Tanzania. Int Breastfeed J 2015; 10:27. [PMID: 26413139 PMCID: PMC4582933 DOI: 10.1186/s13006-015-0052-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 09/17/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Breastfeeding is widely known for its imperative contribution in improving maternal and newborn health outcomes. However, evidence regarding timing of initiation of breastfeeding is limited in Tanzania. This study examines the extent of and factors associated with early initiation of breastfeeding in three rural districts of Tanzania. METHODS Data were collected in 2011 in a cross-sectional survey of random households in Rufiji, Kilombero and Ulanga districts of Tanzania. From the survey, 889 women who had given birth within 2 years preceding the survey were analyzed. Both descriptive and inferential statistical analyses were conducted. Associations between the outcome variable and each of the independent variables were tested using chi-square. Logistic regression was used for multivariate analysis. RESULTS Early initiation of breastfeeding (i.e. breastfeeding initiation within 1 h of birth) stood at 51 %. The odds of early initiation of breastfeeding was significantly 78 % lower following childbirth by caesarean section than vaginal birth (adjusted odds ratio (OR) = 0.22; 95 % confidence interval (CI) 0.14, 0.36). However, this was almost twice as high for women who gave birth in health facilities as for those who gave birth at home (OR = 1.75; 95 % CI 1.25, 2.45). Furthermore, maternal knowledge of newborn danger signs was negatively associated with early initiation of breastfeeding (moderate vs. high: OR = 1.73; 95 % CI 1.23, 2.42; low vs. high: OR = 2.06; 95 % CI 1.43, 2.96). The study found also that early initiation of breastfeeding was less likely in Rufiji compared to Kilombero (OR = 0.52; 95 % CI 0.31, 0.89), as well as among ever married than currently married women (OR = 0.46; 95 % CI 0.25, 0.87). CONCLUSIONS To enhance early initiation of breastfeeding, using health facilities for childbirth must be emphasized and facilitated among women in rural Tanzania. Further, interventions to promote and enforce early initiation of breastfeeding should be devised especially for caesarean births. Women residing in rural locations and women who are not currently married should be specifically targeted with interventions aimed at enhancing early initiation of breastfeeding to ensure healthy outcomes for newborns.
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Affiliation(s)
- Amon Exavery
- />Ifakara Health Institute, Plot 463, Kiko Avenue, P.O. Box 78373, Mikocheni, Dar es Salaam Tanzania
| | - Almamy Malick Kanté
- />Ifakara Health Institute, Plot 463, Kiko Avenue, P.O. Box 78373, Mikocheni, Dar es Salaam Tanzania
- />Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, USA
| | - Ahmed Hingora
- />Ifakara Health Institute, Plot 463, Kiko Avenue, P.O. Box 78373, Mikocheni, Dar es Salaam Tanzania
| | - James F. Phillips
- />Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, USA
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Lakew Y, Tabar L, Haile D. Socio-medical determinants of timely breastfeeding initiation in Ethiopia: Evidence from the 2011 nation wide Demographic and Health Survey. Int Breastfeed J 2015; 10:24. [PMID: 26300951 PMCID: PMC4545700 DOI: 10.1186/s13006-015-0050-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 08/10/2015] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Early initiation of breastfeeding is a simple and cost effective intervention to advance the health of mothers and newborns. The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend that breastfeeding should be initiated within one hour of birth. The aim of this study is to identify factors associated with timely initiation of breastfeeding among mothers in Ethiopia within one hour of birth. METHODS This study used data from the 2011 Ethiopia Demographic and Health Survey. A total of 11,654 households were included in the analysis from 11 administrative states of Ethiopia. Bivariate and multivariable logistic regression models with adjusted odds ratio (AOR) and 95 % confidence intervals (CI) were used to quantify predictors of early breastfeeding initiation. RESULTS The overall prevalence of timely breastfeeding initiation was 52 % (95 % CI: 51.09, 52.91). The prevalence was higher in urban settings (61.4 %; 95 % CI: 58.85, 63.85) than in rural areas (52.3 %; 95 % CI: 51.33, 53.28). The highest prevalence was found in Addis Ababa 71.5 % (95 % CI: 64.88, 77.12) while the lowest prevalence was 41.7 % (95 % CI: 36.62, 47.00) in Somali regional state. Multivariable logistic regression analysis showed that rural mothers had 39 % lower odds of timely breastfeeding initiation (AOR 0.61; 95 % CI: 0.50, 0.76) compared to urban mothers. Mothers who had secondary education or higher had 60 % higher odds of timely breastfeeding initiation (AOR 1.6; 95 % CI: 1.02, 2.44) than never educated mothers. Mothers who had caesarian deliveries had 61 % lower odds of timely breastfeeding initiation (AOR 0.39; 95 % CI: 0.22, 0.71) compared to vaginal deliveries. Working mothers were 23 % less likely to timely initiate breastfeeding (AOR 0.77; 95 % CI: 0.69, 0.85) compared to housewives. Female infants had a 20 % higher chance of timely breastfeeding initiation (AOR 1.2; 95 % CI: 1.05, 1.30) compared to male infants. CONCLUSION Early initiation of breastfeeding within the first hour after birth was not optimal in Ethiopia. Factors such as place of residence, educational level, occupation, gender of the newborn and type of delivery should be considered in any intervention program in order to enhance timely breastfeeding initiation.
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Affiliation(s)
- Yihunie Lakew
- Ethiopian Public Health Association, Addis Ababa, Ethiopia
| | | | - Demewoz Haile
- Department of Reproductive Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health 2013; 13 Suppl 3:S19. [PMID: 24564770 PMCID: PMC3847227 DOI: 10.1186/1471-2458-13-s3-s19] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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.
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Affiliation(s)
- Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anjalee Kohli
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karen Edmond
- School of Pediatrics and Child Health, University of Western Australia, Crawley, WA, Australia
| | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Dykes F, Lhussier M, Bangash S, Zaman M, Lowe N. Exploring and optimising maternal and infant nutrition in North West Pakistan. Midwifery 2012; 28:831-5. [DOI: 10.1016/j.midw.2011.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 09/19/2011] [Accepted: 09/24/2011] [Indexed: 10/15/2022]
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McKinnon R, Campbell H. Systematic review of birth cohort studies in South East Asia and Eastern Mediterranean regions. J Glob Health 2011; 1:59-71. [PMID: 23198103 PMCID: PMC3484744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Few longitudinal studies of children have taken place in the developing world, despite child mortality being concentrated there. This review summarises the methodologies and main outcomes of longitudinal studies of pre-school children (0 to 59 months) in the World Health Organization's South East Asia (SEA) and Eastern Mediterranean (EM) Regions. METHODS A systematic search of literature using pre-defined criteria revealed 7863 papers. After application of quality criteria, 120 studies were selected for analysis. RESULTS The search revealed 83 studies in the SEA region and 37 in the EM region, of which 92 were community-based and 8 facility-based. Objectives were diverse but topics included growth (n = 49 studies), mortality (n = 28), nutrition (n = 24), and infectious diseases (n = 33). Only 12 studies focused on non-communicable diseases. Duration ranged from 7 to 384 months. Measurements included anthropometric (n = 56 studies), socioeconomic (n = 50) and biological sampling (n = 25), but only one study was DNA-based. CONCLUSION Biobanks have emerged as the most successful approach to generating knowledge about disease causes and mechanisms. Little of this is possible to undertake in the in SEA or EM regions, however. Further longitudinal studies of young children with DNA sampling should be set up to better understand determinants of diseases in low-income countries.
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Affiliation(s)
- Rachel McKinnon
- Centre for Population Health Sciences and Global Health Academy, University of Edinburgh, Scotland, UK
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Hanson LA. Macy-György Prize Lecture: My milky way. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2009; 639:283-90. [PMID: 19227548 DOI: 10.1007/978-1-4020-8749-3_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- L A Hanson
- Department of Clinical Immunology, University of Göteborg, Guldhedsgatan 10, Göteborg, Sweden.
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Abstract
Exclusive breastfeeding is acknowledged as important for survival, optimal growth, and development of infants. The current review presents a synthesis of research output by Brazilian nurses on breastfeeding over the last 20 years, analyzes the theoretical and methodological issues emerging from studies on breastfeeding in Brazil, and provides directions for future research and practice by nurses in the area breastfeeding. Studies included in this review were identified through LILACS searches of Portuguese-language sources. Articles were organized and analyzed chronologically by comparing the evolution of the Brazilian Breastfeeding Program. The incomplete research output of the Brazilian nursing profession in regard to breastfeeding research needs to be addressed. In addition, specific cultural, sociological, and anthropological characteristics of Brazilian regional settings remain to be explored. Emphasis on potential confounders and critical interrelations is warranted.
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Hanson LÅ, Korotkova M, Telemo E. Human Milk: Its Components and Their Immunobiologic Functions. Mucosal Immunol 2005. [DOI: 10.1016/b978-012491543-5/50108-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
OBJECTIVES To investigate infant feeding practices followed by Pakistani mothers in Pakistan and in England. To establish if practices conform to current guidelines and to investigate reasons for adherence and nonadherence. METHODS Ninety mothers of weaning age children were interviewed; 45 were in England and 45 in Pakistan. A questionnaire available in English and Urdu sought to find out about the methods of milk feeding and weaning used and the advice received, together with general beliefs about weaning. RESULTS Characteristics of the infants in terms of current age, gender distribution, birth order of baby and age of weaning showed no significant differences between the two groups. Thus, differences between the two groups could be attributed to cultural differences rather than any of these factors. Chi-square analysis showed that the initial method of feeding chosen was significantly different (P < 0.001, d.f. = 2) with 73% of mothers in Pakistan breast-feeding compared with 24% in England. Similar proportions of mothers in both groups commenced weaning between 3 and 4 months. Common weaning foods included rice, cereals and eggs with progression to fruit and vegetables and family food in Pakistan, and fruit, vegetables, meat and convenience foods (especially sweet options) in England. Both groups of mothers wanted more information about infant feeding practices. CONCLUSION Mothers in Pakistan demonstrated more confidence in weaning practices than in England because of experiences with other siblings and advice from relatives. More advice from health professionals was requested and is needed by all mothers in order to improve weaning practices of the infants.
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Affiliation(s)
- T Sarwar
- Nutrition and Dietetics Department, University of Wales Institute-Cardiff, Llandaff, Cardiff, Wales, UK.
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Akuse RM, Obinya EA. Why healthcare workers give prelacteal feeds. Eur J Clin Nutr 2002; 56:729-34. [PMID: 12122548 DOI: 10.1038/sj.ejcn.1601385] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2000] [Revised: 11/07/2001] [Accepted: 11/12/2001] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Because prelacteal feeds can adversely affect breastfeeding, UNICEF/WHO discourage their use unless medically indicated. The study was carried out to determine the proportion of healthcare workers who routinely give prelacteal feeds, and their reasons for doing so; further, to determine whether any differences exist between medically and non-medically trained healthcare workers in their administration of prelacteal feeds. DESIGN Survey. SETTING Primary, secondary and tertiary health facilities in Kaduna township Nigeria. SUBJECTS Of 1100 healthcare workers sampled, 747 (68%) responded. Of these 80% had received medical training, 20% had not. METHODS Use of a pretested validated questionnaire. RESULTS Large proportions of both medical and non-medically trained healthcare workers stated they routinely give prelacteal feeds (doctors, 68.2%; nurses, 70.2%; and non-medical, 73.6%). However their reasons for doing so differed significantly (P=0.00001). Nurses gave mainly for perceived breast milk insufficiency, doctors for prevention of dehydration, hypoglycaemia and neonatal jaundice and non-medical staff to prepare the gastrointestinal tract for digestion and to quench thirst. CONCLUSIONS Most healthcare workers (medical and non-medical) routinely and unnecessarily give prelacteal feeds. Therefore training and retraining programmes in lactation management are necessary and must include non-medical staff. These programmes, while emphasizing the danger of giving prelacteal feeds, must deal with the misconceptions of each group. Deliberate efforts have to be made to incorporate clinical training in breastfeeding in curricula of Schools of Medicine and Nursing.
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Affiliation(s)
- R M Akuse
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
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Bovell-Benjamin AC, Benjamin W, Ivey M, Simeon DT. Breastfeeding knowledge and beliefs among adults in eastern Tobago. J Hum Lact 2001; 17:298-303. [PMID: 11847898 DOI: 10.1177/089033440101700403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Using a cross-sectional survey, the knowledge and beliefs about breastfeeding were evaluated among adults in Eastern Tobago (N = 509). Of the respondents, 95%, 69%, and 48% indicated that a baby should be exclusively breastfed at birth, 3 months, and 6 months, respectively. The baby's mother was thought to have the greatest influence on breastfeeding decisions. Of the respondents, 63% and 80% were unaware of expressed breast milk and cup-feeding a neonate, whereas 82% believed that a solely breastfed baby should receive water. Additionally, 23% and 44% felt that breastfeeding should be terminated before 6 months and between 6 and 12 months, respectively. Inadequate maternal nutrition and employment were reported as the principal factors affecting breastfeeding. There is a lack of knowledge about the anatomy and physiology of lactation and about the benefits of exclusive breastfeeding. These findings are useful for guiding the development and implementation of interventions to promote breast-feeding in Tobago.
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Shirima R, Greiner T, Kylberg E, Gebre-Medhin M. Exclusive breast-feeding is rarely practised in rural and urban Morogoro, Tanzania. Public Health Nutr 2001; 4:147-54. [PMID: 11299086 DOI: 10.1079/phn200057] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate and compare feeding practices among infants of less than 7 months of age in a rural and an urban area in Tanzania. DESIGN Cross-sectional, questionnaire-based interview of mothers and focus group discussions with extension workers and community leaders. SETTING Eleven villages in a rural district and 10 wards in an urban district in the Morogoro region, Tanzania, west of Dar es Salaam. SUBJECTS Probability samples of mothers with infants of less than 7 months of age from each area). RESULTS Exclusive breast-feeding was rarely practised in either the rural or urban areas investigated. However, the urban mothers initiated breast-feeding earlier, discarded colostrum less frequently, breast-fed exclusively for a longer period, gave breast milk as the first feed more often and delayed the introduction of solid foods for longer than their rural counterparts. The rural mothers, on the other hand, breast-fed their previous infants slightly longer than the urban mothers. CONCLUSIONS The better performance of urban mothers could be partly due to sustained breast-feeding support in hospital settings and other campaigns which may not have reached the rural areas. In both the rural and urban areas more efforts are needed to encourage exclusive breast-feeding, to avoid premature complementation and, in the case of the urban areas, to protect extended breast-feeding.
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Affiliation(s)
- R Shirima
- 1Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
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Zetterström R. Breastfeeding and infant-mother interaction. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1999; 88:1-6. [PMID: 10569216 DOI: 10.1111/j.1651-2227.1999.tb01293.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The prevalence of breastfeeding varies very much throughout the world. In some countries, such as in Scandinavia, it is extremely high, whereas it is rather low in many industrialized countries such as northern Italy. In urban areas of many developing countries the prevalence is extremely low, although it may be high in rural areas. For instance, in rural Guinea-Bissau in West Africa it is reported to be 100% at 3 mo of age, and this high prevalence may be explained by the fact that infants who have not been breastfed die before this age. In Sweden the prevalence at 2 mo of age was around 95% in 1945 (including infants fed by milk-mothers) but then gradually dropped until 1972, when it was as low as 20%. However, during the following 10-y period the prevalence gradually increased to around 80%. The main reasons for the decline most probably were that infant formulae, then considered to be safe, became available, that an increasing number of women started to work outside their homes, making formula feeding part of the feminist movement, and finally that no real attempts were made to promote breastfeeding in the maternity wards and well-baby clinics. The reverse trend started in 1972, when the attitude towards breastfeeding changed completely. Well-educated mothers became aware of the new discoveries of the importance of breastfeeding from immunological and nutritional points of view, and organized campaigns. Within a few years, the Swedish parliament passed a law which guaranteed all mothers paid leave from their work (80% of their salary) for 9 mo after childbirth, which has now been increased to 12 mo. The WHO/UNICEF code from 1980, which regulates the marketing of infant formula, has also probably played an important role. After a plateau for the prevalence of breastfeeding between 1982 and 1990, a further increase has taken place, particularly between 6 and 9 mo of age. Whereas the first phase in the increase of the prevalence of breastfeeding was, to a certain extent, the result of the concern of well-educated mothers, the second phase (1990-1998) may, at least partly, be explained by the fact that Swedish maternity wards then implemented the suggestion, launched by WHO/UNICEF, to create "baby-friendly" maternity hospitals with the aim of enabling all women to practise exclusive breastfeeding immediately after birth. Methods to stimulate lactation and proper nutritional suckling behaviour of the newborn were then developed.
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Affiliation(s)
- R Zetterström
- Department of Paediatrics, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden.
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Ransjö-Arvidson AB, Chintu K, Ng'andu N, Eriksson B, Susu B, Christensson K, Diwan VK. Maternal and infant health problems after normal childbirth: a randomised controlled study in Zambia. J Epidemiol Community Health 1998; 52:385-91. [PMID: 9764260 PMCID: PMC1756723 DOI: 10.1136/jech.52.6.385] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVES The main aim of the study was to discover if a midwife home visiting programme has a significant effect on the prevalence of health problems and breast feeding behaviour of mothers who delivered normally and their healthy fullterm newborn babies, during a period of 42 days after delivery. Another aim was to compare the mothers', the midwife's, and the doctor's findings of prevalence of health problems at the end of the puerperium period. DESIGN A randomised controlled trial was carried out. One group of mothers and their infants were randomly allocated to a home visiting group (Group A); the other group (Group B) was only visited at day 42. SETTING The study was carried out at the University Teaching Hospital (UTH) in Lusaka, the capital city of Zambia. PARTICIPANTS A total of 408 mothers who had a normal delivery and gave birth to a healthy fullterm infant, as assessed by the attending midwife, were randomised to two groups. Group A consisted of 208 mother/infant dyads who were visited by a midwife in their homes at days 3, 7, 28, and 42 after delivery and Group B consisted of 200 mother/infant dyads who were only visited at day 42. MAIN RESULTS At day 42 an equal proportion (30%) of mothers in both groups perceived that they had health problems. The prevalence of infant health problems in Group B was significantly higher (p < 0.01) as perceived by mothers. There were more mothers in Group B (p < 0.01) perceiving insufficient milk production and giving supplementary feeding. At day 42, mothers in Group A (56%) took more actions than mothers in Group B (41%) to solve infant health problems (p < 0.03). In both groups the mothers' perceived own health problems, were significantly higher (p < 0.01) than those observed by the obstetrician and those observed by the midwife. The midwife found more infant health problems in Group B (p < 0.01) than in Group A and more infants with health problems in both groups compared with the paediatrician's findings (p < 0.01). CONCLUSIONS There was a significant difference between the mothers' reported health problems and the health problems identified by the midwife and the doctors. The study shows that a midwife home visit and individual health education to mothers, reduce the prevalence of infant health problems, and enables the mother to more often take action when an infant health problem is identified. There is a need to re-evaluate the midwifery training curriculums with the intention to include more infant management care.
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Affiliation(s)
- A B Ransjö-Arvidson
- Department of Obstetrics and Gynaecology, University Teaching Hospital, School of Nursing, University of Zambia
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19
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Abstract
Information obtained from a variety of sources shows different rates of initiation and duration of breast feeding and different supplementation strategies. Among populations of developing countries, in general, the mothers resident in rural-areas are more likely to breast feed than those in urban areas; in addition the better off or more highly educated are less likely to breast feed. In contrast in the developed countries, the better educated and the higher social class mothers are more likely to breast feed. There is some evidence that delay in initiation of breast feeding, lack of professional support, conflicting advice from health professionals and the presence of free samples of artificial milk (whether or not given to the mother) can result in a mother failing to establish breast feeding. Additionally, mothers who smoke cigarettes are less likely to breast feed successfully. Whilst breast feeding is almost universal in a number of developing countries, many also commonly use complementary feeds. In some countries, particularly in Asia, it is still commonplace for a child not to be given the mother's colostrum, and therefore for the first breast feed to occur well after the first 24 h.
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Affiliation(s)
- I S Rogers
- Unit of Paediatric and Perinatal Epidemiology, University of Bristol, UK
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Davies-Adetugbo AA. Sociocultural factors and the promotion of exclusive breastfeeding in rural Yoruba communities of Osun State, Nigeria. Soc Sci Med 1997; 45:113-25. [PMID: 9203276 DOI: 10.1016/s0277-9536(96)00320-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Child survival strategies include prolonged and intensive breastfeeding, together with its early initiation, and breastmilk only for the first six months of life. This paper reports on local knowledge and attitudes of breastfeeding and the sociocultural factors that shape its practice in poor rural Yoruba communities of Southwestern Nigeria. The study has conducted 10 focus group discussions among homogeneous groups of grandmothers, pregnant women, lactating mothers, husbands, and community health workers, and a questionnaire survey of 256 third trimester pregnant women. All women in these communities breastfeed their infants on demand, and for up to two years, because breastmilk is universally accepted as the best food for babies, and breastfeeding spaces births. Prelacteal feedings of water herbal infusions and ritual fluids are the norm, and breastmilk is supplemented, from birth, with water and teas. Exclusive breastfeeding is considered dangerous to the infant: the baby has an obligatory requirement for supplementary water to quench its thirst and promote its normal development, and for herbal teas which serve as food and medicine. Colostrum is discarded because it is dirty, "like pus", and therefore potentially harmful to the infant, although 24% of the survey sample would give it to their babies. Expressed breastmilk is suspect as it can get contaminated, poisoned or bewitched. Complementary foods are introduced as early as two months because of perceived lactation insufficiency. The commonest supplement is a watery maize porridge of low nutrient density. Breastfeeding can also be dangerous, as toxins and contaminants can be passed to the infant through breastmilk. The most serious conflict with the WHO/UNICEF recommendations is the lack of local credibility of exclusive breastfeeding. According to local knowledge, the early introduction of water, herbal teas, and of complementary foods is designed to enhance child survival, while these are supposed to do the exact opposite by the WHO/UNICEF rationale, by exposing the infant to contaminants early, thereby increasing diarrheal morbidity and mortality. Child survival interventions need to address this conflict.
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Affiliation(s)
- A A Davies-Adetugbo
- Department of Community Health, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria
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21
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Davies-Adetugbo AA, Ojofeitimi EO. Maternal education, breastfeeding behaviours and lactational amenorrhoea: studies among two ethnic communities in Ile Ife, Nigeria. Nutr Health 1996; 11:115-26. [PMID: 8994235 DOI: 10.1177/026010609601100204] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Breastfeeding is an important child survival strategy. This report aims to describe the unique contributions of education, ethnicity, and other variables to breastfeeding outcomes. The study was conducted among two groups of lactating mothers in Ile Ife, southwestern Nigeria, using structured questionnaires focusing on their breastfeeding history and current practice. Breastfeeding initiation was delayed in both groups, and primary education is the most significant predictor of initiation of breastfeeding within 6 hours of delivery (OR = 3.92, p = 0.0117). Breastfeeding duration (SD) was 13.7 (4.3) months for the Yorubas and 17.5 (3.4) for the Hausas. Its only significant predictors are education (p < = 0.0001), with an average decrease in breastfeeding duration of 3.2 and 6.6 months with mother's education to the primary and post-primary levels respectively, compared with mothers with no education. In turn, breastfeeding duration is the most significant predictor of the duration of lactational amenorrhoea (p = 0.0000). Mothers with some formal education are also more likely to start feeding human milk substitutes at 2 weeks (OR = 3.83, p = 0.024). The most important variable determining breastfeeding in this study is education. The educated mother is more likely to be involved in economic activity away from the home. To protect breastfeeding in these communities, there is a need for programmes to support the breastfeeding mother who works.
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22
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Abstract
Infant feeding practices are influenced by many factors including culture, household income, literacy, advice from health care workers and advertising. In South India doctors play a very significant role in influencing a mother's decision about when or whether to supplement breastfeeding with formula feeds. Doctors exert their influence on mothers both directly and indirectly, and they are increasingly targeted by commercial infant food companies. Doctors need continuing education about nutrition education, lactation management, and a greater awareness about the influence of inappropriate promotional practices by companies.
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Affiliation(s)
- K Fidler
- University College London Medical School, UK
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23
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Ahmed I, Atiq M, Iqbal J, Khurshid M, Whittaker P. Vitamin D deficiency rickets in breast-fed infants presenting with hypocalcaemic seizures. Acta Paediatr 1995; 84:941-2. [PMID: 7488823 DOI: 10.1111/j.1651-2227.1995.tb13798.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
At the Aga Khan Hospital (AKUH), 65 infants presented with hypocalcaemic seizures, subsequently found to have rickets. Forty-six infants less than 6 months were totally or predominantly breast fed. In a subgroup of 15 mothers and their infants, we found very low plasma levels of 25(OH) vitamin D of < 5 micrograms/l and 7.5 +/- 3.3 micrograms/l, respectively. Neither mothers nor infants received vitamin D supplementation. Maternal vitamin D deficiency and non-supplementation in the infants were the likely causes of rickets in our patients. Prophylactic vitamin D 400 i.u. administered to infants up to 2 years and 800 i.u. to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency.
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Affiliation(s)
- I Ahmed
- Department of Paediatrics and Pathology, Aga Khan University Hospital, Karachi
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Hanson LA, Hahn-Zoric M, Berndes M, Ashraf R, Herias V, Jalil F, Bhutta TI, Laeeq A, Mattsby-Baltzer I. Breast feeding: overview and breast milk immunology. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1994; 36:557-61. [PMID: 7825463 DOI: 10.1111/j.1442-200x.1994.tb03246.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The transfer of host defence capacity to the human offspring provides a remarkable model of passive transfer of immunity. In fact it may also provide an example of active immunization. The transfer of mucosal protection via breast feeding offers many additional advantages for the mother and infant. Through its contraceptive effects it increases the spacing between births, thus diminshing the infant mortality and the burden on the mother. It also enhances bonding between mother and child, it seems to increase the IQ and school result of the infant and might decrease the risk of certain malignancies and perhaps of juvenile diabetes. A fully breast-fed infant receives as much as 0.5-1 g of secretory immunoglobulin A (SIgA) antibodies daily, the predominant antibody of human milk. This can be compared to the production of some 2.5 g of SIgA per day for a 60 kg adult. These SIgA antibodies have been shown to protect against Vibrio cholerae, ETEC, Campylobacter, Shigella and Giardia. Furthermore, milk is rich in receptor analogues for certain epithelial structures which microbes need for attachment to host tissues as an initial step in infections. Thus the adherence of Haemophilus influenzae and pneumococci for example to retropharyngeal cells is efficiently inhibited by human milk. This may be one explanation for the fact that breast-fed babies have less otitis media than the non-breast-fed. Other milk factors like lysozyme and lactoferin may contribute to the host defence, but this has not yet been well defined. However, human milk also supports the well-being of the infant by being anti-inflammatory.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L A Hanson
- Department of Clinical Immunology, University of Göteborg, Sweden
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25
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Affiliation(s)
- S Lang
- Department of Child Health, Royal Devon and Exeter Hospital
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26
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Hanson LA, Ashraf R, Zaman S, Karlberg J, Lindblad BS, Jalil F. Breast feeding is a natural contraceptive and prevents disease and death in infants, linking infant mortality and birth rates. Acta Paediatr 1994; 83:3-6. [PMID: 8193469 DOI: 10.1111/j.1651-2227.1994.tb12942.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- L A Hanson
- Department of Clinical Immunology, University of Göteborg, Sweden
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27
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Ashraf RN, Jalil F, Aperia A, Lindblad BS. Additional water is not needed for healthy breast-fed babies in a hot climate. Acta Paediatr 1993; 82:1007-11. [PMID: 8155914 DOI: 10.1111/j.1651-2227.1993.tb12799.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In Lahore, Pakistan, a community-based study was conducted to investigate whether or not it was necessary to give water to breast-fed infants. From May to November 1986, 2-4-month-old, breast-fed infants (n = 26) were selected. During the study period the maximum temperature ranged between 27.4 and 40.7 degrees C and humidity varied between 24 and 77%. Each infant was followed up for 15 days. Water was not allowed from day 1 to day 8 and water was allowed ad libitum from day 8 to day 15. All infants were subjected to a DDAVP test to estimate the renal concentrating capacity on day 15. A significant gain in weight (p < 0.001) was observed between day 1 to 8 and 8 to 15. The differences in the values of haematocrit and serum sodium between day 8 and 1 and between day 15 and 8 were not significant. This indicates that the infants were not dehydrated when water was withheld. Furthermore, no significant difference was observed for urine specific gravity between day 8 and 1, but urine specific gravity increased significantly after the administration of DDAVP (p < 0.001), indicating that, if needed, the infants could concentrate urine when water was restricted. It was concluded that 2-4-month-old, breast-fed, healthy infants showed no signs of dehydration if additional water was not given during the summer season.
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Affiliation(s)
- R N Ashraf
- Department of Social and Preventive Paediatrics, King Edward Medical College, Lahore, Pakistan
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28
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Jalil F, Lindblad BS, Hanson LA, Khan SR, Yaqoob M, Karlberg J. Early child health in Lahore, Pakistan: IX. Perinatal events. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1993; 82 Suppl 390:95-107. [PMID: 8219471 DOI: 10.1111/j.1651-2227.1993.tb12910.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In Pakistan there are a number of acute problems related to maternal and infant health in the perinatal period. There is also lack of reliable data needed for the formulation of action strategies. To provide a database 1490 women have been followed from the 5th month of pregnancy in four different areas at various levels of urbanization and socio-economic development. After adjusting for gestational age, the proportion of newborns with weight for length < -2SDS in relation to the Swedish National Standard was 12-31% for boys and 12-25% for girls, the figure being highest in the most deprived area. Preterm birth was infrequent compared with IUGR. The overall prevalence rate of birth defects was 21% out of which 8% were severe defects. The overall perinatal mortality rate was 56/1000 births, with rates of 60, 75, 36 and 33/1000 births for the village, periurban slum, urban slum and the upper middle class. Two thirds of the deaths were related to either a continuation of intrauterine disturbances or severe congenital defects incompatible with life. One third of the deaths were due to infection; mostly diarrhoea, clinical sepsis and ARI. Neonatal mortality was significantly related to birth length (< -2SDS, odds ratio 5.5) and length of gestation (< 37 weeks, odds ratio 5.6) and was to a lesser extent related to weight (< -2SDS, odds ratio 2.0) and weight for length (< -2SDS, odds ratio 1.3). Forty percent of the mothers had weight for height below -2SDS, 23-35% had height < -2SDS. Forty percent of mothers from a subset within the cohort had a hemoglobin < 10 gm/dl and 20% showed signs of pre-eclampsia. This presentation raises the issue of expanding the current Child Survival Programs into the perinatal period as well.
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Affiliation(s)
- F Jalil
- Department of Social and Preventive Pediatrics, King Edward Medical College, Lahore, Pakistan
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29
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Karlberg J, Ashraf RN, Saleemi M, Yaqoob M, Jalil F. Early child health in Lahore, Pakistan: XI. Growth. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1993; 82 Suppl 390:119-49. [PMID: 8219460 DOI: 10.1111/j.1651-2227.1993.tb12912.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This work gives growth reference values at birth to 24 months of age for Pakistan based on upper middle class infants. Growth rate reference values are also included and they are given for various interval lengths. The growth was differently affected in infants living in three poorer areas; the stunting incidence at 24 months of age was 63% in periurban slum, 54% in the village and 26% in the urban slum. Less differences could be seen between the areas in weight for length. There was an age dependency in the incidence of reduced growth; a normal length gain was seen at birth to about six months of age, but they were highly reduced at 6 to 18 months of age. The weight gain was to some degree reduced during the first 12 months of life, followed by a catch-up growth period. The seasonal influence was also age dependent; weight was highly affected during the summer at birth to 24 months of age, but not in the winter. The seasonal effect in length was marginal at birth to 6 months, little at 6 to 12 months (although, constant below the normal) and large at 12 to 24 months of age. We did not see any seasonality of growth in the reference group. The incidence of reduced growth reflects the socio-economic differences in one restricted geographic area, i.e., in the city of Lahore, Pakistan.
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Affiliation(s)
- J Karlberg
- Department of Paediatrics, Queen Mary Hospital, University of Hong Kong
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