Timing of initiation, patterns of breastfeeding and infant survival: prospective analysis of pooled data from three randomised trials

Background: Initiation of breastfeeding within one hour of birth and exclusive breastfeeding for the first six months are currently recommended. The benefits of exclusive breastfeeding for child health and survival, particularly in the post-neonatal period, are established. The independent beneficial effect of early breastfeeding initiation remains unclear. Methods: We examined associations between timing of breastfeeding initiation, post-enrolment neonatal mortality (enrolment-28 days) and post-neonatal mortality up to six months of age (29-180 days) in a large cohort from three neonatal vitamin A trials in Ghana, India and Tanzania. Breastfeeding initiation was categorized as: at ≤1 hour, 2-23 hours, and 24-96 hours. Breastfeeding patterns were defined as exclusive, predominant or partial breastfeeding at four days, one month and three months of age. Relative risks were estimated using log binomial regression and Poisson regression with robust variances. Multivariate models controlled for site and potential confounders. Infants who initiated breastfeeding after 96 hours, did not initiate, or had missing initiation status were excluded. Results Of 99,938 enrolled infants, 57.0% initiated breastfeeding at ≤1 hour, 38.1% at 2-23 hours, and 4.6% at 24-96 hours. 306 infants who did not initiate breastfeeding by 96 hours age were excluded. Compared with infants initiating breastfeeding within the first hour of life, neonatal mortality between enrolment and 28 days was higher among infants initiating at 2-23 hours (adjusted relative risk=1.41 [95% Confidence Interval 1.24,1.62], p value <0.001), and among those initiating at 24-96 hours (1.79, [1.39, 2.30], p value