Early Initiation of Breastfeeding and the Risk of Infant Diarrhea in Rural Egypt John Clemens, MD*; Remon Abu Elyazeed, MD, PhD‡; Malla Rao, MEngg, MPH*; Stephen Savarino, MD‡; Badria Z. Morsy, MBBCh§; Yongdai Kim, PhD*; Thomas Wierzba, PhD‡; Abdollah Naficy, MD, MPH*; and Y. Jack Lee, PhD* ABSTRACT. Background. Initiation of breastfeeding shortly after delivery may enhance breastfeeding’s pro- tective effect against diarrhea because of the protective properties of human colostrum contained in early breast milk. Objective. To evaluate whether initiation of breast- feeding within the first 3 days of life, when breast milk contains colostrum, was associated with a lower rate of diarrhea in rural Egyptian infants during the first 6 months of life. Methods. Infants initially breastfed (n  198) were monitored prospectively with twice-weekly home visits to ascertain dietary practices and diarrheal illnesses. Results. The burden of diarrhea during the first 6 months of life in the cohort was high: seven episodes per child-year of follow-up. Only 151 (76%) infants initiated breastfeeding during the first 3 days of life (“early initi- ation”). Infants in whom breastfeeding was initiated early had a 26% (95% CI: 2%,44%) lower rate of diarrhea than those initiated late. The protective association be- tween early initiation and diarrhea was independent of the pattern of postinitiation dietary practices and was evident throughout the first 6 months of life. Conclusions. Early initiation of breastfeeding was as- sociated with a marked reduction of the rate of diarrhea throughout the first 6 months of life, possibly because of the salutary effects of human colostrum. These data high- light the need for interventions to encourage early initi- ation of breastfeeding in less developed settings. Pediatrics 1999;104(1). URL: http://www.pediatrics.org/ cgi/content/full/104/1/e3; breastfeeding, colostrum, diar- rhea, Egypt. ABBREVIATIONS. GEE, generalized estimating equation; OR, odds ratios. B reastfeeding of infants living in developing countries has been documented to reduce their risk of diarrhea. 1,2 In addition, ingestion of ma- ternal colostrum, produced in breast milk during the first days after delivery, has long been thought to confer additional protection against infantile diar- rhea, because of the immune and nonimmune prop- erties of colostrum. 3,4 However, a preventive effect of initiation of breastfeeding shortly after birth, when colostrum is produced, on the occurrence of diarrhea during infancy has never been demonstrated con- vincingly. A prospective birth cohort study of dietary prac- tices and diarrheal illness in rural Egypt gave us the opportunity to evaluate the association between early initiation of breastfeeding and the rate of diar- rhea during infancy. Data from this cohort demon- strate that early initiation of breastfeeding was asso- ciated with a notably lower rate of diarrhea during the first 6 months of life and that this protective association was independent of the pattern of dietary practices during infancy. METHODS Protocol Approvals The protocol for this study was approved by institutional re- view boards of the US Naval Medical Research Unit-3, the US National Institute of Child Health and Human Development, and the World Health Organization. Setting The cohort was assembled in two villages located in the Abu Homos district of Beheira Governorate, 40 km from Alexandria. Abu Homos is a rural area, and most adults there are engaged in agricultural occupations. Assembly of the Cohort In January 1995, a house-by-house census of the two study villages was undertaken. At this time, households were character- ized according to selected sociodemographic characteristics as well as to various aspects of household hygiene, including water use and facilities for defecation. Neonates 28 days were enrolled for the study beginning in February 1995, after ascertaining that they had neither major congenital abnormalities nor current ill- nesses serious enough to require hospitalization, and after obtain- ing written informed consent from their parents (for parents who were illiterate, the form was read to the parent in the presence of a witness; if the parent consented to the protocol, this consent was documented by a fingerprint). Because the focus of the present analysis was to assess the impact of early initiation of breastfeed- ing, we included only those neonates who had ever been breast- fed. Moreover, because patterns of breastfeeding and infant mor- bidity may be substantially different for twin births, we included only singleton births in our analysis. Enrollment of newborns ended in September 1997. A total of 211 neonates were identified, of whom 204 were singleton births. Only 3 (1%) of these neonates had never breastfed. Among the remaining 201 neonates, all of whom met the eligibility criteria cited above, the 3 for whom the day of onset of breastfeeding was unknown were excluded, leaving a total of 198 initially breastfed From the *National Institute of Child Health and Human Development, Bethesda, Maryland; ‡US Naval Medical Research Unit-3, Cairo, Egypt; and §Ministry of Health and Population, Abu Homos, Egypt. Received for publication Sep 17, 1998; accepted Feb 26, 1999. Reprint requests to (J.D.C.) Division of Epidemiology, Statistics, and Pre- vention Research, National Institute of Child Health and Human Develop- ment, Bldg 6100, Rm 7B03, Bethesda, MD 20892. E-mail: clemensj@ exchange.nih.gov PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- emy of Pediatrics. http://www.pediatrics.org/cgi/content/full/104/1/e3 PEDIATRICS Vol. 104 No. 1 July 1999 1 of 5 by guest on April 11, 2016 Downloaded from