Elsevier

Journal of Pediatric Nursing

Volume 45, March–April 2019, Pages e24-e34
Journal of Pediatric Nursing

Determinants of Exclusive and Mixed Breastfeeding Durations and Risk of Recurrent Illnesses in Toddlers Attending Day Care Programs Across Lebanon

https://doi.org/10.1016/j.pedn.2018.12.015Get rights and content

Highlights

  • As much as half of the toddlers in this study were breastfed for <15 days.

  • Mean age of formula introduction was 2.03 (±3.22) months.

  • Half of the toddlers were already exposed to formula milk since day one after birth.

  • A longer breastfeeding duration was linked to better health outcomes in toddlers.

  • Health-care providers are key in initiating and maintaining exclusive breastfeeding.

Abstract

Purpose

Breastfeeding rates continue to decrease in Lebanon. Studies addressing the relationship between breastfeeding duration and health outcomes in Middle Eastern countries are scarce.

This study is the first in Lebanon to have investigated the determinants of both exclusive and mixed breastfeeding durations and the relationship with health in infants and toddlers.

Design and methods

Our sample of 1051 toddlers is nationwide and representative of all toddlers enrolled in daycare centers, and aged between 12 and 36 months.

Results

Median of exclusive breastfeeding duration was 15 days and mean age of formula introduction was 2.03 (±3.22) months. Exclusive breastfeeding was initiated at a mean age of 10.56 (±27.12) hours and half of the toddlers (51.6%) were exposed to formula milk since day one following birth. Determinants of both exclusive and total breastfeeding durations were related to several parents' socio-demographic and behavioral factors. A longer duration of exclusive breastfeeding was associated with a lower frequency of pediatrician visits, antibiotic prescriptions, absence from daycare, and a lower risk of otitis, colic and UTI occurrence, after adjusting for cofounders. Similarly, a longer duration of total breastfeeding was associated with less antibiotic prescriptions and a lower risk of otitis.

Conclusions

Our study highlights the health benefits of extending exclusive breastfeeding duration. It is urgent to address alarmingly low breastfeeding rates in Lebanon. Policy implementation and enforcement along with raising awareness and creating a supportive environment for breastfeeding mothers should involve the various stakeholders in order to succeed in increasing breastfeeding rates and duration.

Introduction

Breastfeeding (BF) rates continue to decrease dramatically in Lebanon (Batal, Boulghourjian, & Akik, 2010; Nabulsi et al., 2014). The Ministry of Health has developed various policies in an attempt to address the disappointingly low rates; however numerous barriers to implementation and enforcement of those BF protection policies have been recently identified (Akik, Ghattas, Filteau, & Knai, 2017). In fact, despite the benefits of BF on infants, toddlers, mothers and the community at large, Batal and Boulghaurjian (2005) report that newborns are being given either glucose-water or formula, instead of breast milk as the initial feeding practice, thus delaying BF initiation post-delivery, with 61.2% of mothers starting BF after six hours. (Batal & Boulghaurjian, 2005). A national survey conducted in 2004 reported that only 18% of mothers breastfed within the recommended 30 min after delivery (Hamade, Chaaya, Saliba, Chaaban, & Osman, 2013). Research has revealed that 83% of hospitals and 90% of maternity clinics in Lebanon did not allow the mother to spend the first 24 h with her newborn, potentially contributing to the delay in BF initiation (Batal & Boulghaurjian, 2005). Furthermore, while up to 89% of infants were ever breastfed, only 24% of infants below four months were exclusively breastfed (Tetulian, Khayyat, & Abdel Monem, 2007), and 14.8% were exclusively breastfed up to six months (United Nations International Children's Emergency Fund, 2013). It should be noted that these studies might not have accounted for fluids intake like water while BF and thus those figures on exclusive BF durations in Lebanon might have been incorrectly reported. Yet inflated, those figures still highlight the alarmingly low rates at the recommended 6 months of exclusive BF (World Health Organization, 2009), when compared to the estimated average exclusive BF rate of 30% at 6 months for infants around the globe, in the same country income group (middle-income), as Lebanon (Victoria et al., 2016). Current literature lacks nationwide studies addressing the determinants of BF duration and its possible relationship with health outcomes in infants and toddlers in a developing country, while strictly applying the WHO definition of exclusive BF (World Health Organization, 2009).

Moreover, the Middle-East region has been largely under-represented in BF-related research until recent years, and findings from studies conducted in high-income and low-income countries on the determinants of BF duration and the relationship with health outcomes may not be applicable to a middle-income country like Lebanon. Studies on BF in Lebanon were mostly descriptive and have reported data on BF initiation (Batal & Boulghaurjian, 2005; Hamade et al., 2013; Osman, El Zein, & Wick, 2009), duration (Batal & Boulghaurjian, 2005), determining factors (Al-Sahab et al., 2008; Hamade et al., 2013; Nabulsi, 2011), weaning age as well as the sequence of foods introduced during the complementary feeding phase (Batal et al., 2010; Batal & Boulghaurjian, 2005).

The aim of this study was to investigate the determinants of both exclusive and mixed BF durations and the relationship with health outcomes in a representative sample of infants and toddlers, aged between 12 and 36 months, attending day care programs across Lebanon.

Section snippets

Study design

The following study has a retrospective and cross-sectional design. Data were collected between February 2016 and April 2016, using a survey that was administered to mothers of toddlers enrolled in daycare centers across all Lebanese regions. This nationwide sample was representative of all toddlers, aged between 12 and 36 months, attending day care programs in Lebanon.

Ethical considerations

The Lebanese University Institutional Review Board (IRB) waived the need for an approval since it is an observational study

Results

Socio-demographic and behavioral characteristics of study participants and their parents

One thousand and fifty-one surveys were collected representative of toddlers between the ages of 12 to 36 months attending day care programs across Lebanon. The mean age of toddlers was 26.93 (±6.18) months, almost equally distributed between boys (52.1%) and girls (47.9%) with almost half of them (48.2%) being the eldest. Delivery was by Cesarean section in as much as 47.6% of women, and only 13.8% of

Discussion

In this study, the association between a longer duration of both exclusive and total BF and positive health outcomes was evaluated after adjusting for socio-demographic and behavioral determinants. Unlike previous studies on BF, we have strictly abided by the WHO definition of exclusive BF in determining its duration and rate (World Health Organization, 2001). In addition, indirect health indicators (such as absence from daycare, frequency of pediatrician visits and antibiotic prescriptions)

Conclusion

Our study highlights the various health benefits of BF in a sample of toddlers recruited from daycare centers across Lebanon, a middle income country. In Lebanon, BF rates are low and witnessing a severe decrease over time. This growing problem needs to be addressed urgently. Policies should thus be implemented and laws protecting BF reinforced. At the community level, it is important to focus on creating a supportive environment for BF mothers and to start raising awareness, while involving

Declaration of interests

None.

Acknowledgments

We would like to thank the Mother and Child Health Unit at the Lebanese Ministry of Public Health for facilitating our access to the selected daycares and encouraging their participation in the study. We would also like to thank Mrs. Nadiya DRAGAN, breastfeeding counsellor and specialist, for her valuable input in the development of the questionnaire and in the final version of the manuscript.

The “Breastfeed for a Healthier Lebanon” study was funded by the Lebanese University Research Grants

Source of funding

The Lebanese University Research Grants Program.

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