Severe events in the first 6 months of life in a cohort of HIV-unexposed infants from South Africa: effects of low birthweight and breastfeeding status.
ABSTRACT: OBJECTIVE: To report on risk factors for severe events (hospitalisation or infant death) within the first half of infancy amongst HIV-unexposed infants in South Africa. METHODS: South African data from the multisite community-based cluster-randomised trial PROMISE EBF promoting exclusive breastfeeding in three sub-Saharan countries from 2006 to 2008 were used. The South African sites were Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal. This analysis included 964 HIV-negative mother-infant pairs. Data on severe events and infant feeding practices were collected at 3, 6, 12 and 24 weeks post-partum. We used a stratified extended Cox model to examine the association between the time to the severe event and covariates including birthweight, with breastfeeding status as a time-dependent covariate. RESULTS: Seventy infants (7%) experienced a severe event. The median age at first hospitalisation was 8 weeks, and the two main reasons for hospitalisation were cough and difficult breathing followed by diarrhoea. Stopping breastfeeding before 6 months (HR 2.4; 95% CI 1.2-5.1) and low birthweight (HR 2.4; 95% CI 1.3-4.3) were found to increase the risk of a severe event, whilst maternal completion of high school education was protective (HR 0.3; 95% CI 0.1-0.7). CONCLUSIONS: A strengthened primary healthcare system incorporating promotion of breastfeeding and appropriate caring practices for low birthweight infants (such as kangaroo mother care) are critical. Given the leading reasons for hospitalisation, early administration of oral rehydration therapy and treatment of suspected pneumonia are key interventions needed to prevent hospitalisation in young infants.
Project description:Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa's child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal).This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18-24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt.Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6).Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children's rights, more efforts are needed to improve and ease access to this cash transfer program.
Project description:Timely vaccination is important to induce adequate protective immunity. We measured vaccination timeliness and vaccination coverage in three geographical areas in South Africa.This study used vaccination information from a community-based cluster-randomized trial promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008. Five interview visits were carried out between birth and up to 2 years of age (median follow-up time 18 months), and 1137 children were included in the analysis. We used Kaplan-Meier time-to-event analysis to describe vaccination coverage and timeliness in line with the Expanded Program on Immunization for the first eight vaccines. This included Bacillus Calmette-Guérin (BCG), four oral polio vaccines and 3 doses of the pentavalent vaccine which protects against diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type B.The proportion receiving all these eight recommended vaccines were 94% in Paarl (95% confidence interval [CI] 91-96), 62% in Rietvlei (95%CI 54-68) and 88% in Umlazi (95%CI 84-91). Slightly fewer children received all vaccines within the recommended time periods. The situation was worst for the last pentavalent- and oral polio vaccines. The hazard ratio for incomplete vaccination was 7.2 (95%CI 4.7-11) for Rietvlei compared to Paarl.There were large differences between the different South African sites in terms of vaccination coverage and timeliness, with the poorer areas of Rietvlei performing worse than the better-off areas in Paarl. The vaccination coverage was lower for the vaccines given at an older age. There is a need for continued efforts to improve vaccination coverage and timeliness, in particular in rural areas.ClinicalTrials.gov: NCT00397150.
Project description:<h4>Background</h4>Performance in intelligence tests tends to be higher among individuals breastfed as infants, but little is known about the association between breastfeeding and achieved schooling. We assessed the association of infant feeding with school achievement in five cohorts from low- and middle-income countries. Unlike high-income country settings where most previous studies come from, breastfeeding is not positively associated with socioeconomic position in our cohorts, thus reducing the likelihood of a spurious positive association.<h4>Methodology and principal findings</h4>Participants included 10,082 young adults from five birth cohorts (Brazil, India, Guatemala, the Philippines, and South Africa). The exposures variables were whether the subject was ever breastfed, total duration of breastfeeding, and age at introduction of complementary foods. We adjusted the estimates for age at follow up, sex, maternal age, smoking during pregnancy, birthweight and socioeconomic position at birth. The key outcome was the highest grade achieved at school. In unadjusted analyses, the association between ever breastfeeding and schooling was positive in Brazil, inverse in the Philippines, and null in South Africa; in adjusted analyses, these associations were attenuated. In Brazil, schooling was highest among individuals breastfed for 3-12 months whereas in the Philippines duration of breastfeeding was inversely associated with schooling; and null associations were observed in South Africa and Guatemala. These associations were attenuated in adjusted models. Late introduction of solid foods was associated with lower schooling achievement in Brazil and South Africa.<h4>Conclusion</h4>Measures of breastfeeding are not consistently related to schooling achievement in contemporary cohorts of young adults in lower and middle-income countries.
Project description:BACKGROUND: Despite compelling evidence that exclusive breastfeeding for the first 6 months of life provides important health benefits to both mothers and their infants, most mothers do not follow this practice. We conducted a study to identify predictors of early cessation of exclusive breastfeeding (before 6 months after delivery). METHODS: For this population-based longitudinal cohort study, we linked data from a perinatal database and a public health database for infants born between 2006 and 2009 in 2 regions in the province of Nova Scotia, Canada. The cohort was followed from the mother's first prenatal visit until her infant was 6 months old. Hazard ratios (HRs) for early cessation of exclusive breastfeeding were determined through Cox proportional hazards regression modelling. RESULTS: Overall, 64.1% (2907/4533) of the mothers in the cohort initiated breastfeeding. Only 10.4% (413/3957) exclusively breastfed for the recommended 6 months. The largest drop in exclusive breastfeeding occurred within the first 6 weeks after birth. Among the mothers who initiated breastfeeding, significant predictors of early cessation of exclusive breastfeeding identified by multivariable modelling included less than high school education (HR 1.66, 95% confidence interval [CI] 1.35-2.04), lowest neighbourhood income quintile (HR 1.35, 95% CI 1.13-1.60), single motherhood (HR 1.24, 95% CI 1.10-1.41), prepregnancy obesity (HR 1.43, 95% CI 1.23-1.65), smoking throughout pregnancy (HR 1.39, 95% CI 1.21-1.60), no early breast contact by the infant (< 1 hour after birth) (HR 1.44, 95% CI 1.29-1.62) and no intention to breastfeed (HR 1.78, 95% CI 1.44-2.16). INTERPRETATION: We found that most predictors of early cessation of breastfeeding were intertwined with social determinants of health. However, we identified potentially modifiable risk factors. Providing opportunities for early breast contact by the infant and continued efforts in smoking cessation and obesity reduction may contribute to a longer duration of exclusive breastfeeding.
Project description:Background:Kangaroo mother care is a comprehensive intervention given for all newborns especially for premature and low birthweight infants. It is the most feasible and preferred intervention for decreasing neonatal morbidity and mortality. Even though time to initiating breastfeeding has been examined by randomized controlled trials, varying findings have been reported. Therefore, the main objective of this meta-analysis was to estimate the pooled mean time to initiate breastfeeding among preterm and low birthweight infants. Methods:The authors searched for randomized controlled trial studies conducted on the effects of kangaroo mother care on the time to breastfeeding initiation among preterm and low birthweight infants. Published articles were identified through a computerized search of electronic databases that includes MEDLINE via PubMed, EMBASE, CINAHL and CENTRAL. The search terms were kangaroo mother care or (skin to skin), or conventional care, newborns, preterm infants, low birthweight infants and randomized controlled trial. A total of 467 eligible titles were identified and eight studies met the inclusion criteria. The extracted data were entered and analyzed using Cochrane Review Manager-5-3 software. Heterogeneity across studies was evaluated by Chi2 test and inconsistency index (I2). Publication bias was assessed using a funnel plot. The random effect model was applied to estimate the pooled mean time to initiate breastfeeding with 95% confidence interval. Results:In this meta-analysis, the overall pooled mean time to initiate breastfeeding was 2.6?days (95% CI 1.23, 3.96). Preterm and low birthweight infants receiving kangaroo mother care intervention initiated breastfeeding 2?days 14?h 24?min earlier than conventional care of radiant warmer/incubator method. Conclusions:Kangaroo mother care promotes early initiation of breastfeeding as compared to conventional care method. Therefore, health facilities need to implement the kangaroo mother care for preterm and low birthweight infants.
Project description:This birth cohort study investigated longitudinal infant growth and associated factors in a multiethnic population living in a low-resource district surrounding the town of Paarl in South Africa.Between March 2012 and October 2014, all mothers attending their second trimester antenatal visit at Paarl Hospital were approached for enrolment. Mother-infant pairs were followed from birth until 12 months of age. Comprehensive socio-demographic, nutritional and psychosocial data were collected at birth, two, six and 12 months. Infant anthropometry was analysed as z-scores for weight and height. Linear regression was used to investigate predictors of birthweight, and linear mixed-effects models were used to investigate predictors of infant growth.Longitudinal anthropometric data from 792 infants were included: 53% were Black African, 47% were mixed race, and 15% were born preterm. Stunting occurred in 13% of infants at 12 months. Maternal height, antenatal alcohol and tobacco use, ethnicity and socioeconomic status were significant predictors of birthweight. In the adjusted mixed-effects model, birthweight was a significant predictor of growth during the first year of life.Birthweight was an important predictor of growth trajectory during infancy. Birthweight and growth were influenced by several important modifiable factors.
Project description:Breastfeeding is a critical component of interventions to reduce child mortality. Exclusive breastfeeding practice is extremely low in South Africa and there has been no improvement in this over the past ten years largely due to fears of HIV transmission. Early cessation of breastfeeding has been found to have negative effects on child morbidity and survival in several studies in Africa. This paper reports on determinants of early breastfeeding cessation among women in South Africa.This is a sub group analysis of a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008 (ClinicalTrials.gov no: NCT00397150). Infant feeding recall of 22 food and fluid items was collected at 3, 6, 12 and 24 weeks postpartum. Women's experiences of breast health problems were also collected at the same time points. 999 women who ever breastfed were included in the analysis. Univariable and multivariable logistic regression analysis adjusting for site, arm and cluster, was performed to determine predictors of stopping breastfeeding by 12 weeks postpartum.By 12 weeks postpartum, 20% of HIV-negative women and 40% of HIV-positive women had stopped all breastfeeding. About a third of women introduced other fluids, most commonly formula milk, within the first 3 days after birth. Antenatal intention not to breastfeed and being undecided about how to feed were most strongly associated with stopping breastfeeding by 12 weeks (Adjusted odds ratio, AOR 5.6, 95% CI 3.4 - 9.5 and AOR 4.1, 95% CI 1.6 - 10.8, respectively). Also important was self-reported breast health problems associated with a 3-fold risk of stopping breastfeeding (AOR 3.1, 95%CI 1.7 - 5.7) and the mother having her own income doubled the risk of stopping breastfeeding (AOR 1.9, 95% CI 1.3 - 2.8).Early cessation of breastfeeding is common amongst both HIV-negative and positive women in South Africa. There is an urgent need to improve antenatal breastfeeding counselling taking into account the challenges faced by working women as well as early postnatal lactation support to prevent breast health problems.
Project description:OBJECTIVES:Breastfeeding is known to reduce infant morbidity and improve well-being. Nevertheless, breastfeeding rates remain low despite public health efforts. Our study aims to investigate the effect of controlled limited formula usage during birth hospitalisation on breastfeeding, using the primary hypothesis that early limited formula feeds in infants with early weight loss will not adversely affect the rate of exclusive or any breastfeeding as measured at discharge, 3 and 6 months of age. MATERIAL AND METHODS:We randomly assigned 104 healthy term infants, 24 to 48 hours old, with ? 5% loss of birth weight to controlled limited formula (CLF) intervention (10 ml formula by syringe after each breastfeeding, discontinued at onset of lactation) or control group (standard approach, SA). Groups were compared for demographic data and breastfeeding rates at discharge, 3 months and 6 months of age (p-values adjusted for multiple testing). RESULTS:Fifty newborns were analysed in CLF and 50 in SA group. There were no differences in demographic data or clinical characteristics between groups. We found no evidence of difference between treatment groups in the rates of exclusive as well as any breastfeeding at discharge (p-value 0.2 and >0.99 respectively), 3 months (p-value 0.12 and 0.10) and 6 months of infants' age (p-value 0.45 and 0.34 respectively). The percentage weight loss during hospitalisation was significantly higher in the SA group (7.3% in CLF group, 8.4% in SA group, p = 0.002). CONCLUSION:The study shows that controlled limited formula use does not have an adverse effect on rates of breastfeeding in the short and long term. Larger studies are needed to confirm a possible potential in controlled limited formula use to support establishing breastfeeding and to help to improve the rates of breastfeeding overall. TRIAL REGISTRATION:ISRCTN registry ISRCTN61915183.
Project description:Length of postnatal hospitalization has decreased and has been shown to be associated with infant nutritional problems and increase in readmissions. We aimed to evaluate if guidelines for breastfeeding counselling in an early discharge hospital setting had an effect on maternal breastfeeding self-efficacy, infant readmission and breastfeeding duration. A cluster randomized trial was conducted and assigned nine maternity settings in Denmark to intervention or usual care. Women were eligible if they expected a single infant, intended to breastfeed, were able to read Danish, and expected to be discharged within 50 hr postnatally. Between April 2013 and August 2014, 2,065 mothers were recruited at intervention and 1,476 at reference settings. Results show that the intervention did not affect maternal breastfeeding self-efficacy (primary outcome). However, less infants were readmitted 1 week postnatally in the intervention compared to the reference group (adjusted OR 0.55, 95% CI 0.37, -0.81), and 6 months following birth, more infants were exclusively breastfed in the intervention group (adjusted OR 1.36, 95% CI 1.02, -1.81). Moreover, mothers in the intervention compared to the reference group were breastfeeding more frequently (p?<?.001), and spend more hours skin to skin with their infants (p?<?.001). The infants were less often treated for jaundice (p?=?0.003) and there was more paternal involvement (p?=?.037). In an early discharge hospital setting, a focused breastfeeding programme concentrating on increased skin to skin contact, frequent breastfeeding, good positioning of the mother infant dyad, and enhanced involvement of the father improved short-term and long-term breastfeeding success.
Project description:We aimed to describe ethnic variations in infant mortality and explore the contribution of area deprivation, mother's country of birth, and prematurity to these variations.We analyzed routine birth and death data on singleton live births (gestational age?22 weeks) in England and Wales, 2006-2012. Infant mortality by ethnic group was analyzed using logistic regression with adjustment for sociodemographic characteristics and gestational age.In the 4,634,932 births analyzed, crude infant mortality rates were higher in Pakistani, Black Caribbean, Black African, and Bangladeshi infants (6.92, 6.00, 5.17 and 4.40 per 1,000 live births, respectively vs. 2.87 in White British infants). Adjustment for maternal sociodemographic characteristics changed the results little. Further adjustment for gestational age strongly attenuated the risk in Black Caribbean (OR 1.02, 95% CI 0.89-1.17) and Black African infants (1.17, 1.06-1.29) but not in Pakistani (2.32, 2.15-2.50), Bangladeshi (1.47, 1.28-1.69), and Indian infants (1.24, 1.11-1.38). Ethnic variations in infant mortality differed significantly between term and preterm infants. At term, South Asian groups had higher risks which cannot be explained by sociodemographic characteristics. In preterm infants, adjustment for degree of prematurity (<28, 28-31, 32-33, 34-36 weeks) fully explained increased risks in Black but not Pakistani and Bangladeshi infants. Sensitivity analyses with further adjustment for small for gestational age, or excluding deaths due to congenital anomalies did not fully explain the excess risk in South Asian groups.Higher infant mortality in South Asian and Black infants does not appear to be explained by sociodemographic characteristics. Higher proportions of very premature infants appear to explain increased risks in Black infants but not in South Asian groups. Strategies targeting the prevention and management of preterm birth in Black groups and suboptimal birthweight and modifiable risk factors for congenital anomalies in South Asian groups might help reduce ethnic inequalities in infant mortality.