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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 28
| Issue : 1 | Page : 62-67 |
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Non-exclusive breastfeeding amongst high-risk children: Factors and barriers associated with non-exclusive breastfeeding at a tertiary care hospital in Southern India
Mary Magdalene Rynjah1, Jayaseelan Venkatachalam1, B Adhisivam2, Jeby Jose Olickal1, Shanthosh Priyan Sundaram1, Palanivel Chinnakali1
1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| Date of Submission | 10-Sep-2020 |
| Date of Decision | 08-Dec-2020 |
| Date of Acceptance | 15-Dec-2020 |
| Date of Web Publication | 25-Feb-2021 |
Correspondence Address:
Dr. Jayaseelan Venkatachalam
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/npmj.npmj_294_20
Background: In the first 6 months of life, non-exclusive breastfeeding (NEBF) is estimated to be the cause of 1.4 million deaths worldwide and contributes to 10% of the disease burden in under-five children. Aims and Objectives: The objective of the study was to determine the prevalence of NEBF amongst the high-risk children and the factors associated with NEBF. Methods: This cross-sectional study was conducted amongst high-risk babies admitted between August 2016 and February 2018 who also attended the high-risk follow-up clinic at the neonatology department. Data were collected using a pre-tested structured questionnaire. Chi-square test was used to determine the factors associated with NEBF and prevalence ratios (PR) with 95% confidence interval (CI) were calculated. Results: Amongst 304 children, 56.3% were male and 87% had birth weight <2500 g. Nearly three-fourth of the mothers were <30 years of age. The prevalence of NEBF was 49.3% (95% CI: 43.7–55.0). There was a significant association of NEBF with employment status of the mother (PR = 1.45; 95% CI: 1.1–1.9), NEBF in previous child (PR = 2.3; 95% CI: 1.4–3.9) and EBF at the point of discharge (PR = 2.3; 95% CI: 2–2.6). The barriers reported by the mothers leading to NEBF were insufficient or less milk secretion, poor breastfeeding attachment, perceived thirst and poor maternal health. Conclusion: One out of every two children admitted in neonatal intensive care unit were non-exclusively breastfed before 6 months of age. The employment status of mother, practice of exclusively breastfeeding the previous child and EBF at the time of discharge were significantly associated with NEBF.
Keywords: High-risk children, newborns, non-exclusive breastfeeding
How to cite this article:
Rynjah MM, Venkatachalam J, Adhisivam B, Olickal JJ, Sundaram SP, Chinnakali P. Non-exclusive breastfeeding amongst high-risk children: Factors and barriers associated with non-exclusive breastfeeding at a tertiary care hospital in Southern India. Niger Postgrad Med J 2021;28:62-7 |
How to cite this URL:
Rynjah MM, Venkatachalam J, Adhisivam B, Olickal JJ, Sundaram SP, Chinnakali P. Non-exclusive breastfeeding amongst high-risk children: Factors and barriers associated with non-exclusive breastfeeding at a tertiary care hospital in Southern India. Niger Postgrad Med J [serial online] 2021 [cited 2021 Jun 13];28:62-7. Available from: https://www.npmj.org/text.asp?2021/28/1/62/310159 |
| Introduction | |  |
Non-exclusive breastfeeding (NEBF) is estimated to be the cause of 1.4 million deaths worldwide in the first 6 months of life and contributes to 10% of the disease burden in under-five children. With the adoption of proper and optimal breastfeeding practices amongst children aged 0–23 months, 45% of childhood deaths and about 820,000 children's lives could have been saved globally.[1] According to the World Health Organization (WHO), the under-five mortality in 2016 was around 5.6 million with 15,000 deaths per day. Nearly 75% of the under-five deaths have been found to be occurring within the 1st year of life.[2] The fourth round of National Family Health Survey (NFHS-4) showed that 45.1% amongst the children belonging to 0–6-month category in our country are non-exclusively breastfed, with at least half of them undernourished and at risk of many infections.[3] A study carried out at a tertiary hospital at Rajkot (2009), reported the prevalence of NEBF to be 38% amongst 462 newborns while a community-based study at a rural setting at Tamil Nadu reported as much as 66%.
The WHO expert consultation recommends exclusive breastfeeding (EBF) in all normal infants as well as low birth weight and preterm babies until 6 months of age, for optimal growth and reduction in morbidity and mortality.[4] There is an increased risk of neonatal morbidity and mortality due to hypothermia, infection, respiratory problems and immaturity of vital organs, especially amongst the high-risk newborns. A greater challenge is faced in initiation and continuation of breastfeeding in these babies as they may also need additional nutrition to supplement their needs[4] and underdeveloped neurological system. Studies have reported that EBF is lower in high-risk newborns as compared to normal infants.[5] There is a paucity of evidence from India on EBF practice amongst the high-risk infants, hence in this study, we aimed to determine the prevalence of NEBF and to find the factors as well as the barriers leading to discontinuation of EBF.
| Methods | | |
Ethical clearance
The study protocol was approved by the Institutional Ethics Committee (IEC) of Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India and assigned the approval number JIP/IEC/2018/0261 on 23/07/2018. Written informed consent was obtained from the parents/caretaker at the time of recruitment.
Study design and setting
The study is a hospital-based cross-sectional descriptive one which is conducted amongst a cohort of children, aged between 6 and 24 months. They were chosen according to their hospital stay which was August 2016 to February 2018 from neonatal intensive care unit (NICU) of Neonatology Department at a tertiary care hospital, Puducherry, South India. This tertiary care centre caters to 1500 deliveries approximately in a month and 30% of those babies delivered are low birth weight and mostly preterm babies. The neonatology department provides services including Kangaroo Mother Care, immunisation services and a follow-up clinic for hospitalised infants from NICU.
Study population and sample size estimation
Babies delivered as preterm or low birth weight attending the outpatient department of high-risk clinic between September and October 2018 were approached for the study. The mothers of the eligible children were interviewed using a pre-tested structured questionnaire. A total of 304 children were included in the study, and we assumed the proportion of NEBF in preterm children at 6 months of age as 59%.[5] The absolute precision was assumed to be 6%, 95% confidence level and 15% non-response. This sample size was calculated using OpenEpi version 3.03. (Open Source Epidemiologic Statistics for Public Health, www.OpenEpi.com). All newborn high-risk children admitted in NICU during March–April 2018, were included for the study and assessed for NEBF during the months of September and October 2018 (data collection period).
Operational definitions
We considered NEBF as 'feeding of food, water or water-based liquids other than breast milk (including milk expressed or from a wet nurse) before 6 months of life but allows the infant to receive Oral Rehydration Solution, drops and syrups (vitamins, minerals and medicines)'.[1] For predominant breastfeeding, we used the following definition: 'the feeding with breast milk expressed or from a wet nurse as the predominant source of nourishment but allows infant to receive certain liquids such as water and water-based liquids.[6]
Statistical analysis
Data were entered in Epicollect5 (Version 1.14) EpiCollect5 Version 1.14 (Centre for Genomic Pathogen Surveillance, Cambridgeshire, UK) and analysed using SPSS (Version 19) (IBM Corp. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY, USA). Categorical variables such as gender of the child, type of family, birth weight, birth order, indication of NICU admission, place of residence, educational qualification, age and working status of the mother, socioeconomic class, number of antenatal care (ANC) visits, type of delivery, place of delivery, family support, post-natal complications, initiation of breastfeeding, type of feeds, predominant feeding and use of pacifier were expressed in frequencies and percentages. Continuous variables such as age of the child and duration of stay were presented as median and interquartile range (IQR). Prevalence of NEBF and reasons for the discontinuation of EBF was summarised as percentages with 95% confidence interval (CIs). Possible association of sociodemographic, obstetric and health system factors with NEBF was assessed by calculating prevalence ratio (PR) with 95% CI.
| Results | | |
The sociodemographic details of the children and the mother are described in [Table 1]. The median (IQR) age was 13 (9–16) months, more than half (56.3%) of them were males out of which, those belonged to joint families (57.6%). Two-third (73%) of the mothers were less than 30 years of age and 82% were homemakers. | Table 1: Sociodemographic characteristics of the children and mothers attending the follow up high-risk clinic at neonatal department, Puducherry (n=304)
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Most of the mothers (89.5%) had completed four or more ANC visits. Out of the total respondents, around one-fourth (23.4%) had more than one child and 75% amongst them practiced recommended EBF for their previous child. The median (IQR) duration of NICU admission was 14.5 (7–25) days and prematurity (38.5%) was the main reason for admission to NICU. Majority (87%) had a birth weight of <2500 g [Table 2]. | Table 2: Obstetric characteristics of the mothers of children attending the follow-up high-risk clinic at neonatal department, Puducherry (n=304)
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The prevalence of NEBF was 49.3% (95% CI 43.7–55.0) [Figure 1]. A small proportion (6.9%) of the children had initiated breastfeeding within 1 h of delivery, 49.7% were initiated after 24 h after the delivery, whereas majority of the infants were on EBF (90.5%) at the time of discharge. Considering the water-based liquids, 57.6% of the children were predominantly fed with breast milk. Amongst exclusively breastfed children (154), around 39% were initiated complementary feeds after 7 months of age. | Figure 1: Flow chart depicting non-exclusive breastfeeding amongst the high-risk children (n = 304)
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The employed mothers were 1.45 (95% CI: 1.1–1.9) times more likely to practice NEBF (P = 0.03) than unemployed. The mothers who did not exclusively breastfeed their previous child were 2.34 (95% CI: 1.4–3.9) times more likely to not exclusively breastfeed their present child. EBF at the point of discharge showed that those infants who were not EBF at the time of discharge were 2.27 (95% CI 2–2.6) times more likely not to exclusively breastfed up to 6 months of age as compared to infants who were EBF at the time of discharge (P = 0.001) [Table 3] and [Table 4]. | Table 3: Sociodemographic factors associated with of nonexclusive breastfeeding amongst the children admitted at neonatal intensive care unit attending the follow-up high-risk clinic at neonatal department, Puducherry (n=304)
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 | Table 4: Obstetric factors and infant characteristics associated with nonexclusive breastfeeding amongst the children admitted at neonatal intensive care unit and attending the follow-up high-risk clinic at neonatal department, Puducherry (n=304)
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Amongst 145 mothers practicing NEBF, 40.7% reported insufficient/low milk secretion, 20.7% discontinued EBF due to poor breastfeeding attachment, 10% of the mothers reported perceived thirst and thus the child was given water on a routine basis and 8% of mothers expressed poor health as the reason for discontinuation [Table 5]. | Table 5: Reasons for discontinuation of exclusive breastfeeding amongst the children admitted at neonatal intensive care unit and attending the follow-up high-risk clinic at neonatal department, Puducherry (n=145*)
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| Discussion | | |
We found that one out of every two children who attended the high-risk follow-up clinic were not exclusively breastfed till 6 months of age, which was lower in comparison to NFHS-4 Puducherry[7] as well as a community based study conducted in a rural district of Tamil Nadu.[8] The difference in the finding might be due to the study setting, as our study was conducted in a tertiary care centre. In addition, our hospital is equipped with a Human Milk Bank, breastfeeding counselling services, early intervention centre and a high-risk follow-up clinic, thus promoting EBF practice. However, a study conducted at a tertiary care hospital at Rajkot revealed 38% of the children were non-exclusively breastfed.[9] The lower prevalence found in the study can be due to the difference in the birth weight amongst the study's population as previous studies identified that birth weight and subnormal weight gain are infant-related factors that determine breastfeeding cessation.[10],[11]
Moreover, the prevalence of initiation of breast milk amongst the current cohort within 1 h of birth was 6.9%, which is very low compared to the total estimate of Puducherry (64.6%)[3] and the Rajkot study (22.4%).[9] Nearly half of the present cohort was initiated on mother's breast milk after 24 h. This result can be attributed to the cohort's high-risk characteristics and feed intolerance. This leads to the late initiation on mother's breast milk when the infant's condition is suitable for oral feeds. Furthermore, most of the children in the current study were premature and low birth weight infants and they require more time to develop their neurological system since they have poor sucking and swallowing reflexes.
In the present study, we found that there has been an increasing trend in NEBF from the time of discharge to 6 months of age. There was a 40% difference in this cohort at the two timelines which was also found to be consistent with other studies.[5],[9] The study conducted in Sweden showed a 12% increase in NEBF amongst the preterm infants at the time of discharge to 6 months.[12] Similarly, a study conducted at Rajkot showed an increasing trend of NEBF from 3% at 3 months to 38% at 6 months of age.[9] Thus, the practice of NEBF increases over time.
In our current study, we found that the EBF status of the infants at the time of discharge was strongly associated with NEBF status at 6 months. Mothers who have gained confidence in successfully breastfeeding the child at the hospital are more likely to follow the same at home. The current study revealed an association of the employment status of the mother with NEBF. Working mothers are found to not exclusively breastfeed their infants which is 1.45 times than the normal level, till 6 months of age. This result is similar to the study conducted in Vietnam, Myanmar and Dhaka.[12],[13],[14] Homemakers have the opportunity to spend more time with their infants in comparison with those who are working and breastfeed their children. The association of practicing NEBF in previous child was also found to be statistically significant in the present study. Successful EBF in the previous child and experiences in its benefits also drive the mothers in using the same practice with the next child. This finding was consistent with the study conducted at Thane[15] and Gujarat[16] which revealed a significant association of the primi mothers and NEBF. Our study found that insufficient milk or less milk secretion was the main reason for discontinuation of EBF and it is consistent with other similar studies conducted.[8],[13],[17],[18]
The study has several strengths. A face-to-face interview was conducted with the mothers of the children for data collection which reduces the chance of information bias. Second, a standard WHO definition for EBF was used to distinguish between those who are EBF from NEBF children. The study also has some limitations. We included children with a wide range of ages from 6 up to 24 months of age. Hence, there are chances of recall bias. We did not study anthropometric characteristics of the child which could have helped to assess the consequences of NEBF.
| Conclusion | | |
Amongst children admitted to NICU and attending the high-risk clinic, half were NEBF before 6 months of age. The employment status of mother, practice of NEBF in the previous child and NEBF at the time of discharge were significantly associated with NEBF. Health education, reorientation of workplace infrastructures and interventions for mothers training could improve EBF amongst high-risk newborns.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 15. | Sharmin l, Chowdhury A, Ahmed N. Barriers to exclusive breastfeeding amongst working mothers. J. Enam med. Coll 2016;6:88-92. |
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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