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Breast-feeding initiation time and neonatal mortality risk among newborns in South India



To examine the association between breast-feeding initiation time and neonatal mortality in India, where breast-feeding initiation varies widely from region to region.

Study Design:

Data were collected as part of a community-based, randomized, placebo-controlled trial of the impact of vitamin A supplementation in rural villages of Tamil Nadu, India. Multivariate binomial regression analysis was used to estimate the association between neonatal mortality and breast-feeding initiation time (<12 h, 12 to 24 h, >24 h) among infants surviving a minimum of 48 h.


Among 10 464 newborns, 82.1% were first breast-fed before 12 h, 13.8% were breast-fed between 12 and 24 h, and 4.1% were breast-fed after 24 h. After adjusting for birth weight, gestational age and other covariates, late initiators (>24 h) were at 78% higher risk of death (relative risk=1.78 (95% confidence interval (CI)=1.03 to 3.10)). There was no difference in mortality risk when comparing babies fed in the first 12 h compared with the second 12 h after birth.


Late (>24 h) initiation of breast-feeding is associated with a higher risk of neonatal mortality in Tamil Nadu. Emphasis on breast-feeding promotion programs in low-resource settings of India where early initiation is low could significantly reduce neonatal mortality.

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  1. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010; 375: 1969–1987.

    Article  Google Scholar 

  2. UNICEF. State of the World's Children 2009 Executive Summary: Maternal and Newborn Health. UNICEF: New York, NY, USA, 2008.

  3. UN Millennium Project. Investing in Development: A Practical Plan to Achieve the Millennium Development Goals. UN Millennium Project: New York, 2005.

  4. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS . How many child deaths can we prevent this year? Lancet 2003; 362: 65–71.

    Article  Google Scholar 

  5. Lawn JE, Cousens S, Zupan J . 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900.

    Article  Google Scholar 

  6. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de BL . Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365: 977–988.

    Article  Google Scholar 

  7. Sobhy SI, Mohame NA . The effect of early initiation of breast feeding on the amount of vaginal blood loss during the fourth stage of labor. J Egypt Public Health Assoc 2004; 79: 1–12.

    PubMed  Google Scholar 

  8. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India: Volume I. IIPS: Mumbai, 2007.

  9. Ashraf RN, Jalil F, Zaman S, Karlberg J, Khan SR, Lindblad BS et al. Breast feeding and protection against neonatal sepsis in a high risk population. Arch Dis Child 1991; 66: 488–490.

    Article  CAS  Google Scholar 

  10. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant, child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000; 355: 451–455.

    Article  Google Scholar 

  11. Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S . Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics 2001; 108: E67.

    Article  CAS  Google Scholar 

  12. Clemens J, Elyazeed RA, Rao M, Savarino S, Morsy BZ, Kim Y et al. Early initiation of breastfeeding and the risk of infant diarrhea in rural Egypt. Pediatrics 1999; 104: e3.

    Article  CAS  Google Scholar 

  13. Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, Bhandari N et al. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bull World Health Organ 2005; 83: 418–426.

    PubMed  PubMed Central  Google Scholar 

  14. Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR . Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 2006; 117: e380–e386.

    Article  Google Scholar 

  15. Mullany LC, Katz J, Li YM, Khatry SK, LeClerq SC, Darmstadt GL et al. Breast-feeding patterns, time to initiation, and mortality risk among newborns in southern Nepal. J Nutr 2008; 138: 599–603.

    Article  CAS  Google Scholar 

  16. Bhandari N, Mazumder S, Bahl R, Martines J, Black RE, Bhan MK . Use of multiple opportunities for improving feeding practices in under-twos within child health programmes. Health Policy Plan 2005; 20: 328–336.

    Article  Google Scholar 

  17. Tielsch JM, Rahmathullah L, Katz J, Thulasiraj RD, Coles C, Sheeladevi S et al. Maternal night blindness during pregnancy is associated with low birthweight, morbidity, and poor growth in South India. J Nutr 2008; 138: 787–792.

    Article  CAS  Google Scholar 

  18. Tielsch JM, Rahmathullah L, Thulasiraj RD, Katz J, Coles C, Sheeladevi S et al. Newborn vitamin A dosing reduces the case fatality but not incidence of common childhood morbidities in South India. J Nutr 2007; 137: 2470–2474.

    Article  CAS  Google Scholar 

  19. Rahmathullah L, Tielsch JM, Thulasiraj RD, Katz J, Coles C, Devi S et al. Impact of supplementing newborn infants with vitamin A on early infant mortality: community based randomised trial in southern India. BMJ 2003; 327: 254.

    Article  Google Scholar 

  20. Habicht JP, DaVanzo J, Butz WP . Does breastfeeding really save lives, or are apparent benefits due to biases? Am J Epidemiol 1986; 123: 279–290.

    Article  CAS  Google Scholar 

  21. Bauchner H, Leventhal JM, Shapiro ED . Studies of breast-feeding and infections. How good is the evidence? JAMA 1986; 256: 887–892.

    Article  CAS  Google Scholar 

  22. Kishore S, Garg BS, Mathur JS, Nayar S . Determinants of breast feeding practices in rural community of Wardha. Indian J Matern Child Health 1995; 6: 11–13.

    CAS  PubMed  Google Scholar 

  23. Iyengar SD, Iyengar K, Martines JC, Dashora K, Deora KK . Childbirth practices in rural Rajasthan, India: implications for neonatal health and survival. J Perinatol 2008; 28 (Suppl 2): S23–S30.

    Article  Google Scholar 

  24. Tawiah-Agyemang C, Kirkwood BR, Edmond K, Bazzano A, Hill Z . Early initiation of breast-feeding in Ghana: barriers and facilitators. J Perinatol 2008; 28 (Suppl 2): S46–S52.

    Article  Google Scholar 

  25. The Young Infants Clinical Signs Study Group. Clinical signs that predict severe illness in children under 2 months: a multicentre study. Lancet 2008; 371: 135–142.

    Article  Google Scholar 

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Sources of support: This study was conducted with support received under Cooperative Agreement No. HRN-A-00-97-00015-00 between the Johns Hopkins Bloomberg School of Public Health and the Office of Health and Nutrition, US Agency for International Development, Washington DC, the National Institutes for Health Grant R03 HD049406-01, a grant from the Bill and Melinda Gates Foundation, Seattle, Washington, and commodity support from Task Force Sight and Life, Roche, Ltd, Basel, Switzerland

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Correspondence to L C Mullany.

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Garcia, C., Mullany, L., Rahmathullah, L. et al. Breast-feeding initiation time and neonatal mortality risk among newborns in South India. J Perinatol 31, 397–403 (2011).

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