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Community and International nutrition

Low Birth Weight Reduces the Likelihood of Breast-Feeding among Filipino Infants1'2
Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516 environment. How they are fed represents an impor tant determinant of their survival. An extensive and often controversial literature ex ists concerning the feeding of LBW infants in devel oped countries, but it deals almost exclusively with preterm infants or those weighing < 1500 g (American Academy of Pediatrics 1985, Churella et al. 1985, Steichen et al. 1987, Verronen 1985). In developing countries, very little is known about how LBW infants are fed. Furthermore, the relevant issues are very dif ferent (Narayanan 1986). First, in lower income coun tries, early preterm infants have little chance of sur vival in the absence of special care facilities. Second, in contrast to developed countries where most LBW is accounted for by prematurity, the majority of LBW infants in developing countries are mature, but smallfor-gestational-age (Villar and Belizan 1982). Many, particularly those who weigh >2000 g, require no spe cial care (Narayanan 1986). The question of how LBW infants in developing countries are fed is an important one. Some research has suggested that LBW infants are less likely to be breast-fed at all or are breast-fed for shorter periods of time (Barros et al. 1986, Butz and DaVanzo 1981, World Health Organization 1981). Given its proven beneficial effects in reducing morbidity and mortality, breast-feeding is of special importance to infants al ready at risk because of LBW (Popkin et al. 1986). The small amount of available data on feeding of LBW infants in developing countries is based primarily
' Funding for parts of the program design, data collection, and computerization was provided by the National Institutes of Health (NIH) (grants ROI-HD 19983A, ROl-HD 18880 and ROI-HO23137). Data analysis was supported by a grant from Wellstart International. 1 The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 USC section 1734 solely to indicate this fact. 3 To whom correspondence should be addressed at Carolina Pop

ABSTRACT We studied the relationship of low birth weight (LBW) to concordance of mother's feeding in tentions during pregnancy with actual feeding practices; initiation of breast-feeding; and patterns of feeding in the first 6 mo. Data came from the Cebú Longitudinal Health and Nutrition Survey, which followed 3080 mother-infant pairs from urban and rural communities of Metro Cebú,Philippines. We used logistic regression to estimate the effects of LBW on feeding practices, controlling for place of delivery (home, public or private health facility), receipt of free infant formula samples; infant sex, urban residence; primiparity, education level and age of the mother; and family income and assets. Birth of a LBW infant significantly decreased the like lihood that women would initiate breast-feeding. Of particular note is the finding of this decreased likelihood among women who during pregnancy had stated an intention to breast-feed. In a comparison of 6-rno feeding patterns, we also found that LBW increased the likeli hood of not breast-feeding or of weaning before 6 mo. Among breast-feeding mothers, LBW increased the likelihood of full breast-feeding for 6 mo compared with patterns characterized by earlier supplementation with other foods and liquids. The negative relationship of LBW to breast-feeding was strongest when births took place in private or public health facilities. Given the known health risks of LBW and the proven benefits of breast-feeding, these results emphasize the need for special efforts to promote breast-feeding of LBW infants born in clinical settings. J. Nutr. 126: 103-112,1996. INDEXING KEY WORDS:

Downloaded from by guest on August 1, 2013

breast-feeding • infant feeding • • low birth, weight • human milk

Low birth weight (LBW)4 continues

to be a problem

of particular concern for developing countries, where the estimated overall prevalence of LBW is 19% (World Health Organization 1992), and in some countries, up to 50% of infants are born weighing <2500 g (World Health Organization 1984). As a group, LBW infants are less able to cope with the stresses of the postnatal
0022-3166/96 $3.00 © 1996 American Institute of Nutrition. Manuscript received 30 March 1995. Initial review completed

ulation Center, University of North Carolina, University Square, CB #8120, 123 W. Franklin St., Chapel Hill, NC 27516-3997. 4 Abbreviations: CI = confidence interval; LBW = low birth weight; RRR = relative risk ratio.

16 June 1995. Revision accepted 25 August 1995.


To date. some of which were in isolated mountainous areas. even among mothers who were strongly inclined to breast-feed their infants. Infant weight was initially measured by birth attendants who were provided with project scales and instructed in their use.8%) were preterm (completed gestational age of <37 wk. This delayed contact may impair or prevent the establish ment of breast-feeding (de Chateau and Wiberg 1977. community-based survey that followed women from midpregnancy to 24 mo postpartum. 334 (11. Even in mature infants.080 single live births occurring in a 1-y time period (1983-1984). numerous studies have shown that birth weight and breast-feeding are both associated with socioeconomic status and education of the mother (Adair et al. All data were collected using procedures approved by the University of North Carolina School of Public Health Institu tional Review Board for research involving human subjects.104 ADAIR AND POPKIN on retrospective data and is mostly descriptive. range was 25-36 weeks).9 million. a lower percentage of LBW infants were breast-fed at 3 mo of age compared with infants whose weights ex ceeded 2500 g at birth (World Health Organization 1981). normal weight and term LBW vs. among urban poor and rural subjects in Chile. Further more. type of delivery. Within 3-6 d of birth. For example.nutrition. infants weighing <2000 g at birth were less likely to have been breast fed in the first week of life and throughout the entire first year (Barros et al. Forman 1984. All scales were regularly Downloaded from jn. In contrast. and gestational age was known in 2891 of these infants. Before 33 wk of gestation. there is a relationship between sucking behavior and birth weight (Pollitt et al. the relative im portance of LBW compared with other biological. MATERIALS AND METHODS Sample. Salariya et al. 1986). birth attendant. 1993. The confounding effects of variables such as these must be sorted out to determine the relationship between birth weight and patterns of breast-feeding. Acceptable birth weight data were available for 3022 infants. During the pregnancy baseline survey. When this occurs. Data were collected during the CebúLon gitudinal Health and Nutrition Survey. a birth in formation survey was conducted to identify the place of delivery. This study examined feeding of LBW infants in the Philippines. The Cebúsample is drawn from an ecologically and socioeconomically diverse population. Mothers may also differ in their responses to an infant who does not suck well. 1978). 1984). Thus. 1985). Infants were assessed at birth and at bimonthly inter vals until they reached 24 months of age. Their perceptions of the size and capabilities of their infants and their reactions to the stimuli they receive from their infants may influ ence their decisions about by guest on August 1. compli cations of labor and delivery and timing of first mother-infant contact. Guatemala and India. Our major objec tives included the following: 1} to compare feeding patterns among LBWvs. Project in terviewers subsequently weighed infants during the birth information survey. there is no consistency in results from different populations. In an urban Brazil population. 1978). Kenya (Renquist et al. nor was a relationship found in Machakos. 93 (27. Zaire. We used data from a community-based survey that included infants born at home as well as in public or private health facilities. usually presenting only the prevalence of breast-feeding among infants of different weights at birth. Thus. The initial sample included all pregnant women in 33 ran domly selected barangays (smallest administrative units) of Metro Cebú. in a multivariate context. Our target analysis sample consisted of 3. LBW infants born in hospitals may be subject to policies that single them out for special care (Popkin et al. and between 34 and 36 wk may be inefficient or poorly coordinated. About one-quarter of participants lived in rural communities. None of these studies differentiated immature LBW infants from those with intrauterine growth retardation. sociodemographic and economic factors as a determinant of feeding patterns. with a current population of ~ 1. 1983). there have been no systematic studies of how birth weight interacts with other factors known to influence breast-feeding. Nigeria. preterm LBW infants. 2) to determine the extent to which place of delivery (home or hospital) influ enced the feeding of LBW and preterm infants and 3) to assess. The re mainder were residents of urban or peri-urban com munities with varying levels of modernization but fairly high exposure to modern media. Among infants with birth weight and gestational age data. different patterns of feeding LBW infants may be established on the basis of the place of delivery. factors such as LBW may alter feeding choices. Data. Finally. This is a pro spective. the in fant's sucking reflexes are ineffective. Popkin et al. the WHO Collaborative Study on Breast-Feeding (World Health Organization 1981) found no relationship between birth weight and the prevalence of breast-feeding in Ethiopia. initiation of breast-feeding and patterns of feed ing in the first 6 mo of life. and of LBW infants. mothers and infants may be separated for prolonged periods of time.Metro Cebúis one of the most rapidly growing and developing areas of the Philip pines. with special attention to the concordance of feeding intentions and feeding prac tice.55%) were LBW. ex tensive background socioeconomic and demographic data were collected. Physical conditions that influence the infant's ability to suck are likely to pro hibit or complicate the initiation of breast-feeding or affect its duration. 2013 .

Person nel were asked questions about receipt and distribu tion of infant formula.1%).9%). n = 2498 (84. n = 741 (26. 1991) and their concordance with actual feeding practices. 2013 .org by guest on August 1.8%) and 4) did not intend to breast-feed and did not breast-feed. nor did we find differences in predictors of 2 vs. breast feeding education. early weaning. We first analyzed results from six groups in which infants who never breast-fed were differentiated from those who were weaned early. 1. Thus although there may be important policy reasons to identify these groups separately for studies of infant growth and morbidity. Initiation of breast-feeding (n = 2991). n = 388 (14. The Ballard method was used to assess gestational age clinically of all LBW infants. When both Bal lard and last menstrual period estimates of gestational age were available. Of particular interest is the second group. Analysis methods. We defined three feeding outcomes for analysis. For the same period. they received <83 kj (20 kcal) from supplemental foods. Previous analyses have shown a high level of agreement between these two measures in the Cebúsample. nutri tive liquids. we found no consistent effects of LBW on feeding patterns after 6 mo. mothers were asked whether they breast-fed and to recall all foods and liquids fed to the infant in the past 24 h. we focused on the dominant feeding pattern and ig nored the frequent switching of feeding methods typ ical in this sample (Zohoori et al. The analysis samples for the three outcomes differ in size because the feeding pattern analysis requires that in fants have complete data for the first 6 mo and because of missing data critical to the definition of the out come. were still considered to be fully breast-fed for 6 mo. mothers were asked how they planned to feed their infant.5%). and full breast-feeding is rare in this popu lation after 6 mo. n = 112(3. Using a health facilities survey administered to hospital and clinic personnel. detailed information was collected on the types. quantities and method of preparation of all foods and liquids given to infants. and those who fully breast fed for only 2 mo were in a different group than those fully breast-fed for 4 mo. 3) mixed fed throughout. Infants were considered not breast-fed if they never initiated breast-feeding. policies regarding feeding of water and formula. Infants were classified in groups on the basis of overall feeding patterns during the first 6 mo. none of the variables of interest in the present analysis significantly differentiated the groups. 3) did not intend to breast-feed but did breast-feed. in preliminary anal yses. A dichotomous variable indicates whether or not the mother ever initiated breast-feeding. We found no differences in the determinants of never breast-feeding vs. In most cases. Infants were considered fully breast-fed if. Concordance of breast-feeding intentions and practices (n = 2955). 4 mo of full breast-feeding. One major way to understand how biological and other factors in the perinatal period affect feeding behaviors is to explore the role of breast feeding intentions (see Stewart et al. For this analysis. etc. rooming-in policies. Although Cebú data were available for the first 24 mo of life. Only 6. Infants were considered to have been weaned early if they initiated breast-feeding but were totally weaned from the breast before 6 mo of age. For example. n = 85 (2.75% of mothers in this sample never initiated breast-feeding.8%). A review of the estimated coefficients allowed an assessment of how each inde pendent variable in the model affected the likelihood Downloaded from jn.9%). n = 307 (11. During the baseline survey. At each interview. 1993).nutrition. all infants whose mothers had complications such as bleeding during pregnancy and all infants whose mothers were uncertain about the date of their last menstrual period (Ballard et al. we gathered information on facility practices related to infant feeding. n = 1321 (47. n = 260 (8. 1979). These results provided the rationale for a simplifica tion to only four groups as follows: Î) fully breast-fed for at least 6 mo. We compared their intentions with actual feeding practices and defined the following four groups: 1}intended to breast-feed and did breast-fed. we use the Ballard estimates as the most accurate representation.9%).FEEDING OF LOW BIRTH WEIGHT INFANTS 105 checked and calibrated. 2) intended to breast-feed but did not breast-feed. feeding of nonnutritive liquids. Mothers were also asked to recall general feeding patterns (exclusive breast-feeding. Patterns of feeding in the first 6 mo of life (n = 2757). 2. Infant-feeding data were collected during the birth information survey and subsequent bimonthly inter views with mothers. Furthermore. because condition of the infant at birth or other barriers to breast-feeding encountered at delivery may cause the mother to change her mind about feeding. on the basis of the 24-h food recall. infants reported to be fully breast-fed at 2 and 6 mo. Studies of prelacteal feeding patterns in the Cebúsample (Fer nandez and Popkin 1988) showed that women may discard colostrum and not initiate breast-feeding for several days. we focused our work on the first 6 mo because this is the time period during which LBW is likely to influence infant-feeding patterns.1%) and 4) not breast-fed or weaned early. solids and semisolid foods) 7 d before each interview. either in the first several days after birth or subsequently. but who received >83 kj/d from supplemental foods or liquids at 4 mo. 2) fully breast-fed for more than 2 but fewer than 6 mo and then mixed fed. such infants were receiving tastes of weaning foods or sweetened liquids such as herbal teas. We used multinomial logistic regression models to predict membership in the different groups (categories of each outcome variable). 3.

primiparity. The decision of where to give birth is an im portant maternal choice. RRR and 95% confidence intervals (CI) were cal culated for each independent variable in the models. CebúStudy Team 1991 and Maddala 1988 for further information and another example of use of the instrumental variables approach). it should be attributed to the unmeasured maternal health status. Coefficients were ex ponentiated to calculate relative risk ratios (RRR) for a 1-unit change in each independent variable. education level and age of the mother. have less education and lower household in come and assets. An instru ment or variable predicted from a set of strictly ex ogenous factors is substituted in the model for the actual value of the variable. we simulated the effects of specified conditions. inclusion of these variables does not eliminate potential biases associated with endogeneity. Within a facility category. 1993). we tested for significant differ ences in the distribution of feeding practice by birth weight status. and household income and assets. RESULTS Descriptive results. which in volve the use of instrumental variables (see Briscoe et al. Accordingly. 1990. our primary independent variable of in terest was LEW. Exposure to for mula industry practices varied considerably by place of delivery. When the in strument has a statistically significant coefficient. Mothers delivering in private hospitals were most likely to receive free formula samples and had significantly longer hospital stays. Risk was measured for a comparison of each category to a ref erence category. Table 2 shows comparisons of feeding practices in LBW vs. We also compared LEW term with LEW preterm births. primiparae. Within each facility. We controlled for the effects of confounding by including place of delivery (home. We tested the assumption of endogeneity of the LBW and place of delivery vari ables using the Hausman test (Hausman 1978). place of residence (urban or rural). delayed first contact between mother and infant after birth oc curs more frequently in health facilities. Within each place of delivery.106 ADAIR AND POPKIN of membership in each group. Table 1 also shows differences in the prev alence of LBW among sample infants born in different settings. underlying. Consider the case where a mother's innate healthiness affects both the likelihood that she will breast-feed her infant and whether the infant is LBW. re ceipt of a free sample of infant formula at delivery. there was a consistent trend of lower percentages of LBW com pared with normal weight infants breast-feeding at each point in time. we had to take several potentially important statistical problems into consideration. Women who gave birth at home were significantly more likely than mothers delivering in health facilities to be from rural com munities. In addition. This in dicates that unmeasured factors such as the innate healthiness of the mother affect the delivery decision and the likelihood that the infant is LBW. We hypothesized that LBW and place of delivery vari ables would be endogenous to our feeding models. in public or private hospitals or clinics). it is considered endogenous to the model. we may mis takenly attribute part of the variation in feeding prac tices to LBW. For infants born in public facilities.g. although similar across the three delivery settings. we pre dicted the likelihood of membership in each of the groups based on mean values of the independent vari ables. Then. were most often sta tistically significant in public facilities. In other work (Adair et al. unobservable variables. These differences. error terms associated with estimates of feeding and of LBW will be corre lated. Finally. but actual values for all other variables. conditioned by a wide range of sociodemographic factors. Using this method. (Seeadditional examples of endogeneity bias in the article by Briscoe et al. normal birth weight and place of delivery. Variables are considered endogenous to a model when they are jointly deter mined by a set of common. 2013 . In a multiple regression model. normal weight infants by place of delivery.. 1990. Finally. higher parity women were more likely to deliver at home. Economists have developed approaches to correct for endogeneity of explanatory variables. If we ignore these relationships. there was a trend toward increased prevalence of full breast-feeding in LBW infants at all ages. All possible intergroup comparisons were made and used to calculate the predicted prob ability of membership in each feeding category. all models were specified with place of delivery in struments. However. principally LBW vs. then they are potential confounders and can be included in the model as control variables. there was a highly significant difference in the prevalence of full Downloaded from jn. we found place of delivery but not LBW to be highly endogenous in all of our models. which requires that both the instrument and actual values of the variable be included in the model. A higher percentage of LBW infants were born in public facilities. women with complications of preg nancy and women from communities with higher dis ease prevalence). public or private facility). Table 1 presents character istics of sample women in strata defined by place of delivery (at by guest on August 1. sex of the infant. which tended to serve pop ulations at the highest risk for LBW (e. when in fact.nutrition. to assist in the interpretation of results. Because infant birth weight and mothers' decisions about where to deliver and how to feed the infant are highly interrelated. younger women. For each model. we showed that such practices de creased the duration of breast-feeding.) Note that if the variables are observable and measurable. especially private facilities that are more likely to have newborn nurseries.

6.315. Mother's y3Education.53. based on the multivariate model.21. P < 1CT4. c home differs significantly from public and private.3Public 1. 95% CI = 1. 2 Statistical comparisons based on ANOVA for continuous variables or chi-squared for categorical variables.274.7Private ± 0.37.22. Concordance of feeding intentions and prac tices.7% for LBW vs.1% for LBW preterm infants and 6. Other significant predictors of never breast-feeding included delivery in a private facility. P = 0.79). Infant feeding patterns in the first 6 mo.755. no significant differences. The effect of LBW appeared most dra matic in private facilities.832. Predicted probability of never breast-feeding based on the mul tivariate models is presented in Table 5.64).002.1% for normal birth weight infants. The basis for these associations can be best understood after multivariate analyses that ac count for other factors known to influence feeding.3 (n = ±5.9828.912. receipt of a sample of formula after delivery and primiparity.75 1. 95% CI= 1. Comparison of term and pre term LBW infants showed a significant effect of LBW term delivery.3217. % |<37 wk)dHome 52 ±2.nutrition.710. na = not applicable. The effects of LBW can be seen by comparing the LBW . Initiation of breast-feeding.865. we predicted the probability of membership in each of the groups under specified conditions. LBW = low birth weight.1 (n = ± a public differs significantly from home and private. facility 545)25. 2013 breast-feeding of LBW vs. 95% CI = 1.54. this probability was increased to 6.23-9. where the predicted prob ability of not breast-feeding when mothers intended to do so was 16.6 (n = ±5.04 + completed^Urban.49. LBW infants.214.003.7 ±2. " all intergroup differences are significant. P = 0. %Duration a sample of infant formula.3% (7. but not of LBW preterm delivery. LBW decreased the probability that a mother would initiate breast-feed ing. of hospital stay.30-3. LBW significantly incrreased the following: 1} the likelihood of not breast-feeding or of early weaning compared with mixed feeding for 6 mo (RRR = 2. 1843)26. %cHeld %bReceived baby in first 4 h.668.09-2. %aPrêterai. The initiation of breast-feeding model had the same specification as the intention-practice model. P = 0. The full set of results is pre sented in Table 4.02.96± facility 634)26.893. but not breast-feeding a normal birth weight infant was 2.7215.28) compared with LBW term infants (RRR = 2. LBW term infants were less likely to be breast-fed than LBW preterm infants.09-2. normal weight infants at 6 mo. ma ternal age and household income and assets.013.9323. LBW increased by 67% the chances of never breast-feeding. Note that within each facility category. This effect of LBW was slightly stronger for LBW preterm (RRR = 3.019.969.FEEDING OF LOW BIRTH WEIGHT INFANTS 107 TABLE 1 Characteristics of women delivering infants in different settings1'* Place of delivery characteristicsAge.42.0 ±2.95% CI 1.394. maternal education. The overall probability of intending to. 3) the likeli hood of full breast-feeding for 6 mo compared with mixed feeding for 6 mo (RRR = 2. Downloaded from jn.03). y %cParity0Primiparous. P = 0. Results based on multi variate analyses are presented in Table 3.0 ±3. is presented in Table 6.016. Other factors signifi cantly associated with not breast-feeding in those mothers who had intended to do so included delivery in a private hospital. P = 0.52 1.2%.0% for LBW term infants). 95% CI 1. For a clearer interpretation of results.21. P < 0. 95% CI 1. Predicted probability of each feeding pattern by place of delivery for normal vs. 2} the likelihood of not breast-feeding or early weaning compared with full breast-feeding for at least 2 but <6 mo RRR = by guest on August 1.60).45-5.2 ± 1 Values are means ± so. d~LBW.03). where mothers are typ ically more educated and come from higher income households. The lowest overall prevalence of breast-feeding occurred in private facilities. LBW dramatically increased the likelihood of not breast-feeding among women who intended to do so (RRR = 3.2na311.13. whereas for a LBW infant. Furthermore. Multinomial logistic regression models allowed for the identification of significant predictors of mem bership in each of the four feeding pattern groups. The reference group for the multinomial logis tic regression was women who intended to breast-feed and did breast-feed.

08 0.0 70.9 5 9.2 58.6 84.108 ADAIR AND POPKIN TABLE 2 Comparison of feeding patterns among low birth weight {LBWJand normal weight infants Place of delivery Home NBW (n= 1641)LEW (n = 202)P1NBW Feeding patterns Ever breast-fed.3 4.0 49.7 834 33 18.01 ns ns ns ns ns ns ns 93. The predicted probability of never breast feeding or weaning early was higher in LBW compared with normal weight infants. P = 0.nutrition. but since the standard errors were larger for the estimates of the LBWpreterm effect because of the small number of infants in this category.75.2 23.3 64.4 85. in group Never breast-fed or weaned early.6 58. P = 0.5 31.1 54.6 22.2 46. the multivariate analyses also showed that if women elected to breast feed.2 99 45 10. % Breast-fed at 12 mo.3 18.5 4.8 43.6 31 59.6 90.3 74. % No. % Fully breast-fed at 6 mo.5 10.9 82.7 11 6.0 33. 2 ns = not significant.69. the RRR for LBW preterm generally did not reach sta tistical by guest on August 1. The resulting predicted probabilities .6 60.01 ns LEW NBW LEW NEW LEW Distribution of feeding patterns3 No.8 68.0 60.1 60.196.4 2 2. NBW infants.0 Home NBW 0.6 54.4 50. % Breast-fed at 6 mo. % Breast-fed at 2 mo. % No.3 19.1 34. % 1 P values for comparison 270 17. chi-squared = 18. we obtained unbiased estimates of the effects but noted that some of coefficients for place of delivery were very large. The effects of term vs.0 59. This was true for home and public facility deliveries. These predictions were based on the use of instru mental variables for place of delivery.07 0. % Public facility |n = 462)LEW(n = 83)P1NBW Private facility (NBW) in different delivery settings [n-571]LEW |n = 63)P1 85.1 51.2 48 11.4 22 23 4. within each place of delivery are based on ANOVA. 2013 96. Consistent with the frequencies of the different feeding patterns presented in Table 2. P > 0. private facility chi-squared = 1.8 205 15 21.598.05. LBW increased the probability of full breast feeding for 6 mo. % Fully breast-fed at 4 mo. and normal birth weight columns within each place of delivery.6 Private facility ns ns ns ns ns ns ns Downloaded from jn.5 87.6 90. preterm delivery were ex amined in general because a further breakdown by place of delivery resulted in a very small number of preterm LBW infants in each place. Among private deliveries.88.5 147 3. in group Mixed-fed for 6 mo.9 77. public facility. % No.2 83. Using instru ments. The RRRs for term and preterm LBW deliveries were similar for most intergroup comparisons.4 73.2 61. in group Fully breast-fed for > 2 but < 6 mo and then mixed-fed.2 of prevalence of age-specific feeding method in LBW versus NEW infants.7 161 10.7 67.7 80 15.5 45.0 90. % Fully breast-fed at 2 mo.01 0.6 260 17. 3 Results of chi-squared tests for significant differences in distribution of feeding patterns in LBW vs.7 22. probably because full breast-feeding is a rela tively rare practice among women delivering in this setting.1 38 21.8 71.4 Public facility ns2 0.9 14 27.5 119 28. LBW had no impact on the likelihood of full breast-feeding for 6 mo. % Breast-fed at 4 mo.4 66.1 93.03 ns ns 0.3 37. P < 0. The overall pattern was the same across all sites.9 31 44. by place of delivery are as follows: Home.000.7 79.3 28. in group Fully breast-fed for 6 mo.0 75. chi-squared = 4.7 37.8 58.6 262 51.

Giving birth to a LBW infant was a deterrent to breast-feeding. 2013 of full breast-feeding in the public facility group were higher than would be expected on the basis of obser vation of actual feeding practices in the sample. in specified group.28. Within categories of facilities. Between facility types there was considerable variation.31.93. there were no significant differences within facilities in the propor tion of LBW vs. there was little variation in practices related to infant feeding. Mothers were asked whether they thought their infant was of normal size. The magnitude and direction of the effects of LBW were the same. a consistent finding was that LBW significantly increased the probability that an infant would never be breast-fed or would be weaned early. Our analyses were unable to identify clearly the un derlying reasons for the LBW effect on feeding. In the breast-feeding intention model. the infant's LBW status increased the likelihood that mothers would fully breast-feed their infant. How ever. About 18% of mothers thought their infant was small. the results were very similar.02. we estimated the models using actual values for place of delivery instead of instruments. We found a significant association of delayed first contact with infants and reduced like lihood of breast-feeding in general but no significant interaction with LBW. Downloaded from jn. suggesting independent effects of infant biology and mothers' perceptions. showing a larger impact of LBW on feeding decisions of mothers who deliver away from home in private or public health facilities. To try to understand the basis of this result.1 but not 1 Numbers represent predicted probability (%) of membership 2 NBW = normal birth weight. LEW = low birth weight.182.FEEDING OF LOW BIRTH WEIGHT INFANTS 109 TABLE 3 Concordance of breast-feeding intentions and practices among CLHNS women: predicted probabilities of membership in groups are affected by place of delivery and low birth weight1 NBWZ LEW LEW prêterai LEW term GroupIntended. did not facility: tobreast-feed predicted probability of intending breast-feedingHomePublicPrivate85. In the feeding pattern analysis. That is. DISCUSSION The set of analyses presented here shows a strong and consistent effect of LBW on infant-feeding prac tices.682.38.96. big or small at birth. All facilities claimed to have personnel instructing mothers on the initiation and maintenance of breast-feeding. although we found important facility effects on breast-feeding practices in general. our predicted probability of full breast-feeding for 6 mo was quite close to the expected value. both small and LBW significantly predicted membership in the group who intended to breast-feed but did not breast-feed. We initially hypothesized that delayed contact with LBW infants would reduce the likelihood of establish ing breast-feeding.61. we have some important clues from our com- . regardless of whether we used instrumental variables.63. Private hospitals were most likely to receive and distribute formula samples and to offer all infants other liquids in the first several days of life.57.016. We found no significant effects of mothers' perceptions on initiation of breast-feeding.18. 40% were actually LBW.80. but in cases where mothers still elected to breast-feed. to measure the independent effect of mothers' by guest on August 1. but LBW was not significant when both terms were included in that model. we had no information on spe cific treatment of LBW infants. Roomingin was more prevalent in public hospitals.36. Hospital policies. For home deliveries. We used this information in an effort to sort out the effects of mothers' perceptions of the infant from biological factors that influence feeding decisions.33.04. within facilities. breast-feedDid did not breast-fedDid not intend.nutrition. normal weight infants who had early contact with their mothers.81. We also found important effects of place of delivery. breast-feedBy not intend. Mothers' perceptions of the size of the in fant.86.08.782. How ever. Furthermore. We looked at the ef fects of mothers' perceptions by substituting small for LBW in the models and by adding small to the model with LBW. For public facility deliveries. we could not point to specific practices affecting LBW infants in particular. and of these. small was statistically significant. breast-fedIntended. Thus. The most im portant result of this comparison relates to the LBW findings.

450.019.-2.nutrition.07-2.-3..460.7LEW term4. Number of observations = 2847.55010035.000.-1.67 We did not find differences in the percentage of LBW infants with early contact.15 72 1.-12.110 TABLE 4 ADAIR AND POPKIN duration of breast-feeding is increased when the infant has a high ponderal index or relative fatness. We have no additional information on the infant's health status at birth.120. expressed relative to the initiated breast-feeding category. we can show dramatic differences in general deliveryPrivate policies that relate to feeding by place of delivery. shown to be a factor which can explain the decreased 2 LEW model = number of observations = 2976. P < IO"4. as well as some of the multivariate findings.00. 2013 .7511. This strongly suggests that the mother's plans were TABLE 5 altered either by the biological condition of the infant Predicted probability of never initiating breast-feeding among CLHPiS women1 at birth (such as poor infant health or poor sucking ability in preterm infants).36.1. In other analyses of growth of infants with different educationYoung feeding patterns. log likelihood = -613. CI = confidence interval. We know LEW . 200000000038 4. 2 NEW = normal birth weight.460.714.300.312.9 PlacedeliveryHomePublicPrivateAllNEW22. particularly if they sampleMale are fully breast-fed and thus well nourished and more infantUrbanPrimiparousLow protected from infectious diseases (Adair 1989).25 288022034623474608531584744.00251615411215z2. we showed that the Downloaded from jn.010.220.1069.210.48.000. We found dramatic differ educationYoung ences in the percentage of women who had early con yrs)Old (<20 yrs)Lowest (>35 tact with infants across delivery settings.856. whereas 27% who delivered in public hospitals and 68% who delivered parison of characteristics of facilities. ^ LEW term vs. If she perceived that her infant was doing well.798.140.101011. LEW = low birth weight. intended to do so.1995% up growth in the first 2 mo of life.89. by guest on August SES1.5LBW of ability of the infant to breast-feed or the appropriate ness of breast-feeding for a small infant or by barriers to breast-feeding encountered in the postnatal envi ronment. even when she in specified group. nor did we find a significant 1 LEW = low birth weight.-2.9212. In earlier work. particular.501.90. We in Determinants of the likelihood of never initiating breast terpreted this as an effect of positive feedback to the feeding: resalta from multinomial logistic regression mother.4410110010. SES = variate models. Only 4% of mothers who deliv ered at home received a free sample.09 Public delivery 4.410. The good growth y)Lowest (>35 performance of fully breast-fed infants may serve to SESMiddle reinforce the mother's breast-feeding behavior. This is also relevant to our finding that model1'2 mothers who chose to breast-feed a LBW infant were more likely to breast-feed that infant fully.24130. 59 0.112. chi-squared likelihood of breast-feeding among LBW infants in = 152.1086.11 02.-1.98. 1993).1. LEW preterm model.101.170. significant effects of place of delivery on feed infantUrbanPrimiparousLow ing.77SE0. we found a strong effect of LBW among women who had intended to breast-feed their infant. Thus lack of early contact was not socioeconomic status based on household income and asset tertiles.52.84. chi-squared = 146.918.000. SESLEW LEWpreterm term vs. by her perceptions of the preterm4.020.3 162413482515154212140.74909280617508 deliveryFormula Private she was more likely to continue to breast-feed (Adair RRRLEW |z|0.50-11. with private SESMiddle facilities having the lowest prevalence of early contact.1.664.140.781783390341267833P> 0.32300. model^LEW Although we do not have specific information on pol termLEW icies related to possible differential treatment of LBW pretermPublic infants.000.270. a mother's perception that her infant was small tended to increase the like 1 Numbers represent predicted probability (%) of membership lihood that she would not breast-feed.34. P < IO"4.721.1.-2. pseudoR2 = 0. The second set of clues relates to hospital policies.813.070.97-10000000-01002000000000.61-173-291-130-014-087-228-051-105-260-3.75464. RRR = relative risk ratio (for a 1interaction of LBW with early contact in our multi unit change in the corresponding variable. but we explored the possible role of the mother's perceptions and showed that controlling for actual LBW.382.1-2.62 that LBW infants tend to undergo a period of catch .0. livery setting is the provision of free samples of infant formula to mothers.020. and deliveryFormula sampleMale in turn. log likelihood = -627.450. we found that fully breast-fed infants y)Old (<20 weighed more in the first 4 mo of life.-2.39.040. A second policy that varied substantially across de pseudoR2 = 0. Early mother-infant contact is one important as pect of postnatal care that affects the initiation and success of breast-feeding.49.02 CI1 et al.50.71-24.419.76.42.

LEW preterm moFully breast-fed 6 mixed-fedMixed breast-fed for >2 but <6 mo and then moNever fed for 6 breast-fed or weaned early13.0 14.1 13. S.315.7 NEW LBW preterm LBW term Downloaded from jn.9 21. .618. 1: 673-682. suggesting that this policy does not single out LBW infants. a "passport to life. B.6 2.242.849.3 1. in specified group. American Academy of Pediatrics: Committee on Nutrition (1985) Nutritional needs of low-birth-weight infants. The research findings should have important health implications for infants born in less developed coun tries. we found no significant effect of an interaction of LBW and receipt of formula.3 2.3 51.. In our previous work (Adair et al.5 19. 1993) we also showed that receipt of a sample de creased the duration of breast-feeding.6 15. & Guilkey.2 47.0. L. However.332.6 76. special policies are needed to promote breast-feeding of LBW infants.144. we can be more assured that we have true estimates of the effects of LBW status. Furthermore. ACKNOWLEDGMENT We thank Judith Borja from the Office of Population Studies in Cebúfor assistance with data analysis. A lower incidence of breast-feeding among LBW infants is an unfortunate consequence because of the greater health risks they face. receipt of a sample significantly increased the likelihood of not initiating breast-feeding or weaning early compared with the feeding patterns involving full breast-feeding.8 Numbers represent predicted probability (%) of membership 2 NEW = normal birth weight. En hanced education and encouragement of mothers of LBW infants should address their concerns about the infant's size and capabilities. (1989) Growth of Filipino infants who differed in body composition at birth.35. Pediatrics 75: 976986.525.1 20.4 40.111.5 12. Am.9 1. In the present analysis. as well as their special needs.0 17. K. S. The health risks are re lated in part to biological characteristics of the LBW infant but also to poor environmental conditions that contribute to LBW and poor postnatal outcomes. by control ling for a number of factors that we know influence choice of place of delivery as well as feeding practices.77. L.nutrition. D. J. regardless of birth weight status.1 38.FEEDING OF LOW BIRTH WEIGHT INFANTS 111 TABLE 6 Predicted probability of breast-feeding patterns among CLHNS women1 Place of delivery Public facility LBW NEW LEW NEW Private facility LEW Home NEW Feeding pattern Fully breast-fed Fully breast-fed Mixed fed for 6 Never breast-fed 6 mo for >2 but <6 mo and then mixed-fed mo or weaned early 16. LEW = low birth weight. Adair. LITERATURE CITED Adair.7 66. Hum. Given the proven nutritional and immunological su periority of breast milk. Furthermore. sociodemographic. Popkin. breast-feeding is of special importance to the LBW infant. by guest on August 1.3 56.1 6. in private hospitals received samples. An important strength of the Cebústudy is that it is community based and allows for a comparison of home births and those that occur in a wide range of public and private facilities. Biol." Efforts must be made to single out and eliminate policies that hinder the establishment of breast-feeding in clinical settings.3 8. (1993) The duration of breast-feeding: how is it affected by biological. Such policies would benefit all infants. 2013 Overall deliveriesFully effects of LEW term vs. or as Narayanan (1986) has stated.3 30. health sector and food industry factors? Demography 30: 63-80.134.6 5.

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