Infant feeding pattern and hospitalization due to infection

Objectives: This case-control study was carried out to evaluate the effects of infant feeding pattern on hospital admission due to infection. Patients and Methods: The study has included 498 infants (320 males and 178 females) who attended primary health centers for routine check up and vaccination, and 250 infants admitted to Basrah Maternity and children Hospital (164 males and 86 females), from the first of March 2008 till the end of June 2008, their ages ranged from 1–12 months. Selected socio-demographic variables were evaluated in addition to child birth variables, feeding pattern, cause of admission, duration of hospitalization and outcome. Results: The study revealed a significantly higher percentage of admissions due to diarrhea and respiratory tract infection among infants peon bottle feeding (23.8%, 15.6%) and partial breast feeding (16.4%, 11.6%), compared to those on exclusive (2% and 1.2%) and predominant breast feeding (11.2% and 10%), P value <0.001 and <0.01 respectively. The effects of feeding pattern on the outcome have shown that there is a significant increase in the mortality among bottle fed infants (4.8%) while none of admitted patients on exclusive breastfeeding died, P value <0.01. In addition, there is a significant association between feeding pattern and duration of hospitalization (P value<0.05), history of previous hospitalization (P value <0.05), mother age (P value<0.05), mother education (P value <0.001), and mother and father employment, (P value <0.001 and 0.05 respectively). Conclusions: Feeding pattern among admitted cases with infections is significantly associated with formula feeding and partial breast feeding compared to exclusive and predominant breast feeding. (MJBU,30,2: 2012, Page 75-84) مهضرعت لامتحأو عضرلا ةيذغت لاخدلإل جمخلا ببسب ىفشتسملل .د ح للهادبع مجن بيب 1 و .د.أ نسح مظاك داعيم 2 1 ماعلا ةزمحلا ىفشتسم / ةيسداقلا ةحص ةرئاد و 2 لافطلأا بط عرف / بطلا ةيلك / ةرصبلا ةعماج :فدهلا ةيذغتل ةفلتخم طامنأ نيب طبارتلا ىلع فرعتلا لافطلأا ةنسلا رمع يف ىلولأا لاخدلإاو جمخلا ببسب ىفشتسملا يف . :ةقيرطلا تزكترا هذه زكارم نوعجاري نيذلا ىضرملا نم تدمتسأ يتلا تايطعملا ليلحت ىلع ةساردلا ةيحصلا ةياعرلا ةيلولأا مهددع ناك ثيح تاحقللا ضرغل ةرصبلا يف ةساردلا ةرتف للاخ 894 لفط ( 023 و ركذ 174 نيدقارلا ىضرملا نمو )ىثنأ ةدلاولل ةرصبلا ىفشتسم يف لافطلأاو مهددع ناكو 253 ( 168 و ركذ 46 رهش ةيادب نم )ىثنأ آ راذ 2334 ناريزح رهش ةياهن ىلا 2334 تناكو مهرامعأ نم حوارتت 1 و 12 ارهش . ةلئسأ ةساردلا تنمضت نع ةددحم ةيعامتجاو ةيئيب لماوع رمع ,نكسلا ,سنجلا ,رمعلا لثم ، ملأا رمع , بلأا ةفيظو , بلأا ملاإو ,بلأاو ملال يميلعتلا ىوتسملاو قلعتت لماوع ,لفطلا ةدلاوب .اقباس ىفشتسملا ىلا ضيرملا لخدأ لهو ىفشتسملا يف دوقرلا ةدمو دوقرلا ببسو ,ةعاضرلا طمن قرطلاب نزولاو لوطلا سايق مت ةصاخ لوادج بسح تاسايقلا هذه ليلحتو لاخدإ مت .لافطلأا عيمجل ةيسايقلا لكل يرايعملا فارحنلاا باسح متو ةيملاعلا ةحصلا ةمظنمل ةعبات لوطلل ةبسنلاب نزولا نم . جئاتنلا : ببسب ىفشتسملا لوخد ةبسن تناك لاهسلإا نم ةعاضرلا مدع عم ىضرملا يف رثكأ يه ةيسفنتلا تاباهتللااو يدثلا ( 20.4 ,% 15.6 )% ( يدثلا نم ةيئزجلا ةعاضرلا و 16.8 ,% 11.6 يف اهنم )% ( يدثلا نم ةعاضرلا ةبلغ 11.2 ,% 13 )% راصتقاو يدثلا نم ةعاضرلا ( 2 ,% 1.2 )% نم لقأ لامتحلاا ةميق تناكو 3.331 و 3.31 .يلاوتلا ىلع ةفاضلإاب كلذ ىلا ريثأت ةيذغتلا طمن تناكو يدثلا نم ةعاضرلا نم رثكأ يدثلا نم ةعاضرلا مدع يف تايفو ةبسن تدجو ثيح ضيرملا ةلاح روطت ىلع نم لقأ يه ةيلامتحلاا ةميق 3.31 . كو ىفشتسملا يف ىضرملا دوقر ةدم لوطو ةعاضرلا طمن نيب ايئاصحإ اهب دتعم ةقلاع دوجو ةساردلا تتبثأ نم لقأ ةيلامتحلاا ةبسن تنا 3.35 , نم لقا ةيلامتحلاا ةبسن تناكو ىفشتسملا ىلا قباس لوخد 3.331 رمع , ملأا نم لقا تناكو 3.35 , ا ىوتسملا ل لقا تناكو ملال يميلعت نم 3.331 , بلأا فظوملا ملأاو ( نم لقأ تناكو ةفظوملا 3.35 و 3.331 يلاوتلا ىلع ) . تاجاتنتسلاا : اهب دتعم ةقلاع دوجو ةساردلا ترهظأ ايئاصحإ يدثلا نم ةعاضرلا ةبلغ عم ةنراقملاب يدثلا نم ةيئزجلا ةعاضرلا عم يدثلا نم ةعاضرلا مدع ةيحان نم ىفشتسملا يف نيدقارلا ىضرملا نيب راصتقاو يدثلا نم ةعاضرلا . MJBU, VOL 30, No.2, 2012___________________________________________________________________________________________________ 76 INTRODUCTION reast feeding is strongly recommended during the first months of life as it contains all the newborns nutritional needs and provides immunological protection which is important in reducing the frequency of infections. [1] Breast-feeding is beneficial in preventing gastrointestinal and, to a lesser extent, respiratory infections in both developing and developed countries. In addition, it has been recognized that protection, provided through breast milk, against some infections may extend well beyond weaning. [2] Protection from mortality by breastfeeding is greatest for the youngest infants. [3] Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breastfeeding in developing countries. [4] Relatively few risks are responsible for a large percentage of deaths and morbidity in developing countries. These risks generally act by increasing the incidence or severity of infectious diseases. In combination, childhood underweight, micronutrient deficiencies and suboptimal breastfeeding cause 7% of deaths and 10% of total disease burden. In developing countries, only 24– 32% of infants are exclusively breastfed at 6 months on average, and these percentages are much lower in developed countries. [5] The risk of death is similar for infants who are predominantly breastfed and those who are exclusively breastfed suggesting that in settings where rates of predominant breastfeeding are already high, promotion efforts should focus on sustaining these high rates rather than on attempting to achieve a shift from predominant breastfeeding to exclusive breastfeeding. [6] This case–control study was carried out to look for feeding pattern among infants hospitalized for infection and compare it with healthy controls and study the association between feeding pattern and certain variables like type of infection, duration of hospitalization and outcome. SUBJECTS AND METHODS A case–control study has been carried out on infants (beyond the neonatal period) over the period from the first of March 2008 till the end of June 2008. Infants. A total of 250 patients who have been admitted to pediatric wards at Basrah Maternity and Children hospital, were included in the study. The control group included a total of 498 age and sex matched infants seen 3 primary health centers in the center of Basrah (AL-Basrah, AL-Razi and ALAshar) for checkup and routine immunizations during the study period were recruited. Cases were terms, singletons, aged from 1-12 months admitted with infection. Infants with congenital anomalies, underlying diseases or risk factors that would either affect the feeding methods or make the infant prone for frequent hospitalizations, like immune deficiency, and congenital heart diseases were excluded. Controls were healthy infants having the same inclusion criteria of cases. Data were collected through a special questionnaire designed for the purpose of the study. Information obtained for hospitalized patients included: age, gender, residence, birth order, mode of delivery, place of delivery, cause(s) of admission, any previous hospitalization (including neonatal period),age at previous hospitalization and diagnosis of illness in the previous hospitalization. In addition, the duration of current hospitalization, the final diagnosis and the outcome on discharge from hospital were recorded. Parental data included age, education, employment, smoking. Maternal and paternal education were coded as low (primary school or less), and high (at least 1 year of intermediate schooling or higher). Information obtained from control group were the same that of patients concerning socio-demographic data, parental data, feeding history and past history. All children were weighed, wearing light clothing, on a calibrated mechanical or electronic scale. The length measured using stadiometer. The questionnaire was filled and examination done by the same person (first author). Weight-for-height Z-scores were assessed as recommended by WHO/NCHS reference curves. [7] B ___________________________________________________________________________________________________MJBU, VOL 30, No.2, 2012 77 WHO classification was used to define the method of feeding: [6,8]  Exclusive breastfeeding: Giving an infant no food or drink, not even water, other than breast milk except for drops or syrup of vitamins, mineral supplements, or medicines.  Predominant breastfeeding: The infant mostly receives breast milk but is also occasionally given other liquids, including water and/ small amounts of ritual or other foods.  Partially breastfed: The infant is given some breast feeds and some artificial feeds, either milk or cereal, or other food or water.  Bottle feeding: The infant is feeding from a bottle, regardless of its contents, including expressed breast milk. Data entry and analysis were done using the SPSS program, version 11. Chi square was measured and P-value of less than 0.05 was considered as statistically significant. Logistic regression analysis was done for all variables to look for any association of these variables with infants feeding pattern and admission to the hospital and odd ratio (OR) was assessed. RESULTS A total of 250 infants; were included in the study. One hundred sixty four (65.6%) were males and 86 (34.4%) were females their ages ranged from 1-12 months (means ±SD was 5.49 ±3.08).There was no significant difference between cases and control regarding age and sex, P value > 0.05, (Table-1). Maternal age has ranged from 16 to 43 years, with a mean age of 24.21± 4.55 years. Among cases, 22 (8.8%) of the infants their mothers were below 20 years of age, compared to 23 (4.62%) in the control group, P value > 0.05. Concerning maternal education, there was no statistically significant difference between cases and controls. A similar result was obtained for father education, P value > 0.05, (Table-1). MJBU, VOL 30, No.2, 2012______________________


INTRODUCTION
reast feeding is strongly recommended during the first months of life as it contains all the newborns nutritional needs and provides immunological protection which is important in reducing the frequency of infections. [1]Breast-feeding is beneficial in preventing gastrointestinal and, to a lesser extent, respiratory infections in both developing and developed countries.In addition, it has been recognized that protection, provided through breast milk, against some infections may extend well beyond weaning. [2]Protection from mortality by breastfeeding is greatest for the youngest infants. [3]Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breastfeeding in developing countries. [4]Relatively few risks are responsible for a large percentage of deaths and morbidity in developing countries.These risks generally act by increasing the incidence or severity of infectious diseases.In combination, childhood underweight, micronutrient deficiencies and suboptimal breastfeeding cause 7% of deaths and 10% of total disease burden.In developing countries, only 24-32% of infants are exclusively breastfed at 6 months on average, and these percentages are much lower in developed countries. [5]The risk of death is similar for infants who are predominantly breastfed and those who are exclusively breastfed suggesting that in settings where rates of predominant breastfeeding are already high, promotion efforts should focus on sustaining these high rates rather than on attempting to achieve a shift from predominant breastfeeding to exclusive breastfeeding. [6]This case-control study was carried out to look for feeding pattern among infants hospitalized for infection and compare it with healthy controls and study the association between feeding pattern and certain variables like type of infection, duration of hospitalization and outcome.

SUBJECTS AND METHODS
A case-control study has been carried out on infants (beyond the neonatal period) over the period from the first of March 2008 till the end of June 2008.Infants.A total of 250 patients who have been admitted to pediatric wards at Basrah Maternity and Children hospital, were included in the study.The control group included a total of 498 age and sex matched infants seen 3 primary health centers in the center of Basrah (AL-Basrah, AL-Razi and AL-Ashar) for checkup and routine immunizations during the study period were recruited.Cases were terms, singletons, aged from 1-12 months admitted with infection.Infants with congenital anomalies, underlying diseases or risk factors that would either affect the feeding methods or make the infant prone for frequent hospitalizations, like immune deficiency, and congenital heart diseases were excluded.Controls were healthy infants having the same inclusion criteria of cases.Data were collected through a special questionnaire designed for the purpose of the study.Information obtained for hospitalized patients included: age, gender, residence, birth order, mode of delivery, place of delivery, cause(s) of admission, any previous hospitalization (including neonatal period),age at previous hospitalization and diagnosis of illness in the previous hospitalization.In addition, the duration of current hospitalization, the final diagnosis and the outcome on discharge from hospital were recorded.Parental data included age, education, employment, smoking.Maternal and paternal education were coded as low (primary school or less), and high (at least 1 year of intermediate schooling or higher).Information obtained from control group were the same that of patients concerning socio-demographic data, parental data, feeding history and past history.All children were weighed, wearing light clothing, on a calibrated mechanical or electronic scale.The length measured using stadiometer.The questionnaire was filled and examination done by the same person (first author).Weight-for-height Z-scores were assessed as recommended by WHO/NCHS reference curves. [7]WHO classification was used to define the method of feeding: [6,8]  Exclusive breastfeeding: Giving an infant no food or drink, not even water, other than breast milk except for drops or syrup of vitamins, mineral supplements, or medicines. Predominant breastfeeding: The infant mostly receives breast milk but is also occasionally given other liquids, including water and/ small amounts of ritual or other foods.

 Partially breastfed:
The infant is given some breast feeds and some artificial feeds, either milk or cereal, or other food or water. Bottle feeding: The infant is feeding from a bottle, regardless of its contents, including expressed breast milk.Data entry and analysis were done using the SPSS program, version 11.Chi square was measured and P-value of less than 0.05 was considered as statistically significant.Logistic regression analysis was done for all variables to look for any association of these variables with infants feeding pattern and admission to the hospital and odd ratio (OR) was assessed.

RESULTS
A total of 250 infants; were included in the study.One hundred sixty four (65.6%) were males and 86 (34.4%) were females their ages ranged from 1-12 months (means ±SD was 5.49 ±3.08).There was no significant difference between cases and control regarding age and sex, P value > 0.05, (Table - Concerning the causes of hospitalization; diarrhea was the commonest cause in 132(52.8%)followed by acute respiratory tract infection in 96(38.4%),UTI in 10(4%), sepsis 6(2.4%), meningitis 4(1.6%) and myocarditis in 2(0.8%).A statistically significant number of infants with diarrhea and respiratory tract infection were on partial and bottle feeding compared to exclusive and predominant breast feeding, P value<0.001 and <0.01 respectively, The same table shows that mild malnutrition was significantly higher among cases compared to control group (OR 1.435).A significantly higher number of infants with history of neonatal hospitalization were on bottle feeding compared to those on exclusive breast feeding, P value <0.01.The same result was obtained for previous hospitalization P<0.05.In addition the duration of hospitalization was significantly longer among infants on bottle feeding compared to exclusive breast feeding, P-value <0.05, (Table-4).The same table shows that all infants on exclusive breast feeding improved and discharged well, compared to 75(71.42%) on bottle feeding, In addition the percentage of infants who died has increased significantly as the frequency of breast feeding decreases, P value <0.01.(Table-5), reveals a significant association between feeding pattern and mother age, P value <0.05, and mother education, where a significantly higher percentage of mothers of low education were giving their infants bottle feeding and partial breast feeding compared to mothers with higher education, P value <0.001.In addition a significantly higher percent of infants of unemployed mothers (housewives) were partial breast feeding and bottle feeding compared to employed mothers, P<0.001.The same results were obtained for father`s education (P-value <0.05) and father`s employment (P value <0.05).Logistic regression analysis concerning feeding pattern among admitted cases has revealed a significant association with bottle feeding and partial breast feeding compared to exclusive and predominant breast feeding, P value<0.001,(Table -6).

DISCUSSION
Infectious diseases are leading causes of morbidity and hospitalization for infants and children.During infancy, breast-feeding protects against infectious diseases, particularly respiratory infections, gastrointestinal infections, and otitis media. [9]Around 6.0% of infants admitted to the hospital were on exclusive breast feeding compared to 10.04% on exclusive breast feeding in the control group, which is similar to the percentage reported from previous WHO studies which has revealed that only 5-10% of infants in Iraq were exclusively breast fed, [10] while bottle feeding accounts for the higher percentage among admitted infants to the hospital reaching 42.0% from the total cases, in contrast to the control group 17.67%.In this study, maternal education shows a significant association with feeding pattern among hospitalized infants.This result is similar to that reported by AL-Awadi et al in Kuwait [11] but in contrast to result of study by Talayero, et al in Spain. [12][14] In this study a significantly higher percent of young mothers of hospitalized infant`s have fed their babies exclusive breast feeding, while none of mothers older than 30 years were feeding their babies exclusive breast feeding.[13][14] Although the current study didn`t reveal a significant difference between parental smoking among cases and controls.It was reported that maternal and family smoking increases the frequency of hospitalization by breastfeeding exposure and stratified on maternal smoking.Although the relationship is not entirely clear, some studies have not found an association. [12,14]nvironmental tobacco smoke exposure was demonstrated to have an effect on frequency of infections during infancy. [15]The study revealed that a significantly higher percent of infants of working mothers were on exclusive and predominant breastfeeding, this in contrast with a result of Shiva et al in Iran, [13] this may indirectly reflect that employed mothers are of higher education and better oriented about the advantage of breast feeding.In addition, father employment, appears to be significantly associated with the feeding pattern.This result similar to study done by Barclay, et al. [16,17] Low family income has a significant association with interruption of breastfeeding. [17]Conditions associated with infant`s birth may affect feeding pattern, in this study mode of delivery demonstrated a significant association with the feeding pattern, this is in agreement to Shiva et al in Iran [13] which has reported a significant association of caesarean delivery with feeding pattern.While in other studies in developed countries didn`t show a significant correlation. [12,14]Birth order had a significant effect on the feeding pattern among hospitalized infants in this study.Rakhshani had reported that birth order is an important factor for continuation of breastfeeding [18] but AL-Awadi, et al in Al-kuwait didn't report such finding. [11]ore than half of admissions were to the diarrheal diseases followed by respiratory tract infection and most of infants were either on partial breastfeeding or bottle fed infants.The findings of protective effect of breast feeding against hospitalizations for diarrhea and respiratory infections is found in this study.This is in agreement with other studies. [9,19]Karmer et al have noted that although breast feeding protect against diarrhea, breast feeding did not protect against respiratory tract infections or hospitalization due to infection. [20]There is a large body of data describing how the immunologic properties of breast milk are likely to protect against infection in the infant.In addition, infection may be attributable to contamination of bottles, teats, milk, and food in infants who are not exclusively breastfed. [12]ahl et al have found in multicentre cohort study that there were no significant differences in the risk of hospitalization between infants who were exclusively breastfed and those who were predominantly breastfed or between those who were partially breastfed and those who were predominantly breastfed, However, nonbreastfed infants were at a substantially higher risk of all-cause hospitalization (P-value<0.001) and diarrhea-specific hospitalization (P-value <0.001), when compared with infants who had been predominantly breastfed.The risk of acute lower respiratory tract infections-specific hospitalization was also higher but was not statistically significant. [6]The current study has revealed that the feeding pattern appears to be significant not only with hospital admission but also with frequency, the duration of hospitalization and the outcome of hospitalized infants.This is in agreement with study done by Barclay et al. [16] A significant association of feeding pattern with infant mortality was also reported in this study.An earlier pooled analysis, by the WHO Collaborative Study Teamon the role of breastfeeding on the prevention of infant mortality, has found point estimates of odd ratios for an increased risk of death ranging from 2.5 to 4.2 at different ages for children who had not been breastfed when compared with those who had had any breastfeeding. [21]From this study it can be concluded that feeding pattern among hospitalized infants has revealed a significant association with bottle feeding and partial breast feeding compared to exclusive and predominant breast feeding in addition to a significant association between the feeding pattern and hospitalization especially for diarrhea and respiratory tract infection.Interventions to improve infant feeding practices could result in a considerable improvement in infant's health and reduction in the risk of hospitalization and death.Mothers and fathers should have access to objective, consistent and complete information about appropriate feeding practices.
In particular, they need to know about the recommended period of exclusive and continued breastfeeding; the timing of the introduction of complementary foods; what types of food to give, how much and how often; and how to feed these foods safely.

Table 6 . Adjusted odd's ratio, and 95% confidence interval for infant hospitalized with four different methods of feeding
* Dependent factor was hospitalized infants while independent factors were feeding pattern