Early Initiation of Breast Feeding But Not Bottle Feeding Increase Exclusive Breastfeeding Practice Among Less Than Six Months Infant in Indonesia

Background: Exclusive breastfeeding is a intervention to reduce neonatal and infant mortality. However,the prevalence of exclusive breastfeeding in Indonesia remains low. The aim of the study was identify the association of early initiation and bottle-feeding with exclusive breastfeeding practice among infant less than six month in Indonesia. Methods: This study was a part of Basic Health Research (RISKESDAS) 2013 data. The sub-sample study was infants under six months. Out of 7226 infant aged less than 6 months, 6397 infant had complete data for the analysis. The Cox regression was used for analysis. Results: Out of 6397 infant, 44% had exclusively breastfeed. Early initiation, bottle-feeding, postnatal care, residence and socio-economic status were associated to exclusive breastfeeding practices. Infant who had early initiation had 66% more exclusively breastfeed compared to delayed initiation [adjusted relative risk (RRa) = 1.66; 95% confidence interval (CI): 1.45 – 1.90]. Infant who had bottle-feeding or using pacifiers had 71% less to be exclusively breastfed compared to infant who did not have use bottle-feeding/ pacifiers (RRa = 0.29; 95% CI: 0.25 – 0.34). Conclusion: Early initiation within one hour of birth increased exclusive breastfeeding practice, however, bottle-feeding decreased exclusive breastfeeding practice. (Health Science Journal of Indonesia 2016;7:44-8)

The World Health Organization (WHO) recommends mothers to sustain exclusive breastfeeding up to six months. 1 6HYHUDO VWXGLHV VKRZHG WKH EHQH¿WV RI exclusive breastfeeding for both, mother and infants. %UHDVW PLON GXULQJ ¿UVW VL[ PRQWKV SURYLGHV HVVHQWLDO nutrients for child growth and cognitive development. In addition, exclusive breastfeed infant are healthier compared to formula-fed. 2 Studies also shows the infant who had exclusive breastfeed for six months are more to be protected from gastrointestinal infections, respiratory illness, morbidity, and death. 3,4 Exclusive breastfeeding is estimated to reduce 10% of child death 4 and nearly 45% reduction of infection-related neonatal mortality. 5 Breastfeeding seems nearly universal in Indonesia. The Demographic and Health Survey (DHS) 2012 revealed about 96% of infant less than two years were ever breastfed. Unfortunately, only 42% infant are exclusively breastfed. 6 Basic Health Research 2013 also showed similar results, which were 93% ever breastfed and 30.2% infant exclusively breastfed up to six months. 7 Several studies indicate that early initiation of breastfeeding may increase exclusive breastfeeding rates. 8,9 There are also several factors associated with exclusive breastfeeding including bottle-feeding practice, age of mothers, maternal education, place of residence, socio-economic status and history of antenatal and postnatal care. 4,5 ,Q RUGHU WR DVVHVV PRUH VSHFL¿F ULVN IDFWRUV UHODWHG to exclusive breastfeeding practice in Indonesia, therefore, we assessed the association of early initiation, bottle-feeding and other risk factors with exclusive breastfeeding practice among infant less than six month.

METHODS
We analyzed a part of nationally representative health survey, Basic Health Research (RISKESDAS) 2013 conducted by the National Institute of Health Research and Development (NIHRD) Indonesia. The sampling frame of Riskesdas 2013 consisted of 12000 census blocks (cluster) which selected from master sample area from the 2010 population census. In each selected cluster, 25 household were selected from a complete list of households. There were 294959 households interviewed from a total of 300000 selected households from the sample, obtained a response rate of 98.3%. The samples were representative from 33 SURYLQFHV GLVWULFWV FLWLHV LQ ,QGRQHVLD 7 A total of 1027763 household members were interviewed using structured questionnaire and data were collected through interviews by trained enumerators. 7 In this study, we restricted our analysis to infant aged less than 6 months (n=7226). For the analysis 829 respondents were excluded because of incomplete data, leaving 6397 infant who had complete data on exclusive breastfeeding, early initiation, bottle-feeding as well as others demographic factors.
The outcome variable, exclusive breastfeeding status ZDV GH¿QHG DV LQIDQW DJHG PRQWKVRU OHVV ZKR received only breast milk and did not other liquids or solids except for drops or syrups consisting of vitamins, minerals supplements or medicines. 1 The exclusive breastfeeding practice was a dichotomous YDULDEOH \HV QR 1 Potential independent variables including early initiation of breastfeeding, bottle-feeding, history of antenatal and postnatal care, age of mothers, maternal education, place of residence and socioeconomic status in order to determine factors associated with exclusive breastfeeding practice. Early initiation of breastfeeding and bottle-feeding SUDFWLFH ZHUH GLFKRWRPRXV \HV QR (DUO\ LQLWLDWLRQ RI EUHDVWIHHGLQJ ZDV GH¿QHG DV PRWKHU ¶V ZKR gave breast milk to infants within 1 hour of birth. %RWWOH IHHGLQJ SUDFWLFH ZDV GH¿QHG DV LQIDQW ZKR experience of using bottle-feeding before six months of age. Antenatal care refers to mothers who had experience RI SUHJQDQF\ H[DPLQDWLRQ DW OHDVW WLPHV LQ ¿UVW trimester, at least 1 times in second trimester and at least 2 times in third trimester. Postnatal care refers to infant who had visit to health care at least 1 times LQ ¿UVW GD\V 0RWKHU ¶V HGXFDWLRQ ZDV GLYLGHG LQWR 3 groups (no education, primary and secondary or higher). Residence was divided into 2 subgroups XUEDQ UXUDO Socio-economic status was an index constructed from household ownership information, using polychoric correlation analysis (PCA). Variables forming the index were: 1) the primary source of drinking water, 2) cooking fuel, 3) defecation facilities ownership, 4) W\SH RI WRLOHW ¿QDO IHFHV GLVSRVDO LOOXPLQDWLRQ source, 7) motorcycles, 8) television, 9) water heater, 10) gas cylinder 12 kg, 11) refrigerator, and 12) cars. Furthermore, socio-economic status was divided into 5 subgroups based on wealth quintile. 7 The lowest 20% of the households was designated as the poorest households and the highest 20% as the richest households.

DISCUSSION
The study had nationally representative sample, comprehensive data on standard infant feeding indicators, appropriate adjustment for sampling design, including sampling weight and a very high response rate (98.3%) to the survey interview. +RZHYHU ¿QGLQJV RI WKH VWXG\ VKRXOG EH LQWHUSUHWHG in the light of the following limitations. First, the overall prevalence of exclusive breastfeeding based on the 24 hour recall methodology. The validity of data on exclusive breastfeeding based on 24 hour periods has been questioned. 11 Studies reported a wide discrepancy on the prevalence of exclusive breastfeeding between current status based on a 24hour recording and exclusive breastfeeding since birth. 12 Second, the cross-sectional nature of this study prevents drawing causal inferences from the association between the determinant factors and exclusive breastfeeding.

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years is important to support the rapid growth and brain development. 13 In order to achieve optimal growth and development, children should be H[FOXVLYHO\ EUHDVWIHG IRU WKH ¿UVW VL[ PRQWKV RI DJH 1 Inadequate nutrition in this period marked by growth IDOWHULQJ PLFURQXWULHQW GH¿FLHQFLHV DQG FRPPRQ childhood illnesses such as diarrhea diseases. 13 Our study revealed that early initiation increased exclusive breastfeeding practice. Children who had early initiation within one hour were 1.66 times more likely to exclusively breastfeed compared to delayed LQLWLDWLRQ 7KH ¿UVW KRXU RI ELUWK LV WKH EHVW WLPH WR initiate breastfeeding to the infant. World Health Organization recommends skin to skin contact for at least 30 minutes and early initiate breastfeeding for normal vaginal deliveries mothers. 1 Early skin-to-skin contact will increase the opportunity of the infants to suckle. Studies show that immediate skin-to-skin and suckling contact prolonged exclusive breastfeeding duration. 14,15 Previous studies also suggested that early touch of the nipple and areola after birth may increase mother and infant relationships, furthermore increase in breastfeeding rates up to 3 months. 16 However, another study shows that high early initiation of breastfeeding rates in Congo is not resulted in high exclusive breastfeeding prevalence.  18 Another study also suggests using spoon-feeding as an alternative method for feeding infant who cannot full breastfeeding. 19 It was found that spoon-feeding infant had shorter time to switch to full breastfeeding compared to infant who were fed using bottle.
%RWWOHV ZLWK DUWL¿FLDO WHDWV PD\ EH FRQVLGHUHG DV an alternative feeding method when infants cannot be fed directly from the breast. However, it can be harmful for carrying infection were hygienic care of ERWWOHV LV GLI¿FXOW %RWWOH IHHGLQJ DOVR UHGXFH WLPH spent suckling at the breast and thereby interfering with demand feeding. 20 Therefore, both cup and spoon feeding are recommended particularly for infants who are expected to breastfeed later. 18,19,20  7KH PDLQ ¿QGLQJ RI WKLV VWXG\ LV WKDW HDUO\ LQLWLDWLRQ may increase exclusive breastfeeding practice, yet bottle-feeding negatively associated with exclusive breastfeeding practice. There is an urgent need to develop interventions to improve early initiation within one hour of birth and reduce bottle-feeding practice among less than six months children. 0RWKHUV VKRXOG EH PRUH LQIRUPHG WKDW FXS IHHGHU glass or spoon as substitute alternative of bottlefeeding if the infant separated from their mother.