Association Between Exclusive Breastfeeding and Acute Respiratory Infections Among Infants Under the Age of 6 Months

Abstract

Introduction:

Acute respiratory infection (ARI) is the leading cause of childhood morbidity and mortality. Exclusive breastfeeding is considered the cornerstone of child health; however, the rate of exclusive breastfeeding is suboptimal in low- and middle-income countries (LMICs). This study aimed to assess the association between exclusive breastfeeding and ARI among infants under the age of 6 months in a LMIC.

Methods:

A secondary analysis of the 2014 Egypt Demographic Health Survey data was conducted. Mothers of infants under the age of 6 months (n = 1,340) were included. The outcome of interest was ARI symptoms among infants, defined by mother's report of a cough accompanied by fast or difficult breathing in the 2 weeks preceding the survey. The exposure variable was exclusive breastfeeding, defined by giving infants only breast milk during the first 6 months of life. Descriptive statistics and multivariate regression were performed.

Results:

Forty-one percent of the infants were exclusively breastfed and 9% had ARI symptoms. Exclusive breastfeeding reduced the odds of ARI symptoms (adjusted odds ratio [AOR] = 0.450, 95% confidence interval [CI]: 0.243–0.832). Infants of mothers 20–34 years of age (AOR = 0.421, 95% CI: 0.217–0.817) and ≥35 years (AOR = 0.308, 95% CI: 0.123–0.767) at childbirth were less likely to have symptoms of an ARI when compared with adolescent mothers. The likelihood of having ARI symptoms was higher among infants 2–3 months of age (AOR = 2.437, 95% CI: 1.093–5.435), and 4–5 months (AOR = 2.888, 95% CI: 1.193–6.992) compared with infants less than 2 months.

Conclusion:

Exclusive breastfeeding was protective against ARI symptoms among under-6-month infants, independent of potential confounders.

Introduction

Over the last 30 years, significant progress has been made worldwide in reducing child mortality. The global under-five mortality rate has declined by nearly two-thirds, from 93 deaths per 1,000 live births in 1990 to 38 deaths per 1,000 live births in 2021.¹ Despite such a remarkable reduction, the global under-five death rate remains above the target defined by the Sustainable Development Goals (SDGs) of 25 deaths per 1,000 live births.² It has been estimated that nearly 5 million under-five children lost their lives in 2019.³ According to the UNICEF, respiratory and diarrheal diseases are the leading causes of infant mortality worldwide.⁴

Respiratory infections to vulnerable populations such as infants result in 463.7 deaths/100,000 infants annually.⁵ Respiratory infections are also a major cause for hospitalization among under-five children.⁶ In 2019, respiratory infections were ranked as the second leading cause of disability-adjusted life-years among children younger than 10 years of age.⁷ Respiratory infections are associated with various risk factors, including sociodemographic, environmental, and nutritional factors.^8–11

Adequate nutrition during infancy and early childhood is critical to ensure the optimal health, growth, and development of children.¹² The World Health Organization (WHO) recommends initiating breastfeeding within the first hour of birth and up to 6 months of exclusive breastfeeding for all infants and continuing breastfeeding up to 2 years. Exclusive breastfeeding is the practice of only giving an infant breast milk for the first 6 months of life, except for oral rehydration solution, vitamin/mineral drops, or medicines.¹³

Breastfeeding can play a significant role in boosting immunity and mitigate the risk of infectious diseases, including respiratory illnesses in infancy.^14,15 Nearly 14% of the deaths of children younger than 2 years could be prevented if breastfeeding practice is optimal.¹⁵ Despite these benefits, the rate of exclusive breastfeeding is suboptimal in low- and middle-income countries (LMICs),¹⁵ where the majority of child morbidity and mortality has been attributed to suboptimal breastfeeding practices.¹⁶ In Egypt, the majority (71%) of infants up to 2 months of age are exclusively breastfed, but this number dramatically declines as the infant ages, with only 13% of infants exclusively breastfed by the time they are 4 to 5 months old.¹⁷

Reducing under-five mortality is a crucial target of the SDGs. Since the burden of acute respiratory infection (ARI)-related mortality in LMICs is estimated to be 83%,¹⁸ the present study aimed to examine the association between exclusive breastfeeding and symptoms of ARI among infants under 6 months of age using data from the 2014 Egypt Demographic Health Survey (EDHS).

Methods

Data sources

A secondary data analysis using the 2014 EDHS was conducted. The 2014 EDHS was the tenth in a series of Demographic and Health Surveys conducted in Egypt and conducted with the primary objective of providing up-to-date information on fertility and childhood mortality levels; fertility preferences; awareness, approval, and use of family planning methods; and maternal and child health and nutrition. All ever-married women 15–49 years of age who were usual members of the selected households and those who spent the night before the survey in the selected households were eligible to be interviewed in the survey.¹⁷ A detailed description of the sample design, survey instrument, and other methodological aspects of the survey is available elsewhere.¹⁷

Study population and sample size

The current analysis was restricted to last-born infants under 6 months of age and cohabiting with their mother at the time of the survey (n = 1,487). Participants with missing data on ARI symptoms, breastfeeding status, or any of the other covariates utilized in the current study were excluded from the analysis (n = 147), resulting in a final analytic sample of 1,340 infants.

Operational definitions and study variables

The outcome variable was symptoms of ARI among infants in the 2 weeks preceding the survey. It was determined based on asking mothers three questions, the first one aimed to identify infants who had a cough in the 2 weeks before the survey. Mothers of infants with cough were asked if their infant experienced a faster breath than usual with short rapid breaths or had difficulty breathing. To exclude non-pulmonary causes, the mothers were asked if the cough and rapid or difficult breathing was related to chest, a sign of a severe infection, or a blocked or runny nose.¹⁷

The exposure variable was exclusive breastfeeding of infants under the age of 6 months. An exclusively breastfed infant was defined by the EDHS, if the infant was still being breastfed and received no liquids or solids, except breast milk during the 24-hour period before the survey.¹⁷

Covariates

Several variables were included in the current analysis based on documented confounders,^8–11 such as mother's age at childbirth (<20, 20–34, ≥35 years), mother's education (no education, primary, secondary, or higher), mother's occupation (no, yes), residence (urban, rural), and wealth index (poor, middle, rich). Sex of the infant (male, female), age (0–1, 2–3, 4–5 months), and birth order (first, second or third, ≥fourth) were included in the analysis. Utilization of maternal health services was also included such as number of antenatal care (ANC) visits (none, 1–3, ≥4) and place of delivery (public health facility, private health facility, home). Mode of delivery of the index infant (cesarean section, vaginal) and timing of breastfeeding initiation (early, delayed) were also added. Exposure to secondhand smoke was also included in the analysis (no, yes).

Based on the EDHS, the wealth index was determined according to household ownership of selected assets, such as televisions and bicycles, materials used for housing construction, and water access and sanitation facilities. The wealth index classified the household population into five categories, from quintile one (lowest–poorest) to quintile five (highest–wealthiest).¹⁷ In the current study, participants were classified as poor if they belonged to the first or second wealth quintile, middle if they belonged to the third quintile, and rich if they belonged to fourth and fifth quintile. With reference to ANC visits, a woman was considered to have regular visits if she attended at least four visits during pregnancy according to WHO recommendations.¹⁹ For timing of breastfeeding initiation, early timing was determined if breastfeeding was initiated within an hour of birth, and delayed initiation was defined if breastfeeding was initiated more than 1 hour after delivery.¹⁷

Statistical analysis

Descriptive analysis was conducted to summarize the characteristics of the study participants. Chi-square tests were used to compare the study participants according to symptoms of ARI. Multivariate logistic regression was conducted to identify the predictors of ARI symptoms. Independent variables with a p-value ≤0.2 in the bivariate analysis were retained and included in the multivariate analysis. Adjusted odds ratios (AORs) and the corresponding 95% confidence intervals (CIs) were reported. A complex sample design analysis, which accounted for the cluster sampling design, sample weight, and strata, was performed to provide generalizable and accurate estimates for the population parameters. Thus, weighted percentages were presented. Multicollinearity was checked using a variance inflation factor. Statistical tests were performed using SAS University Edition for Windows (SAS Institute, Inc., Cary, NC). Two-tailed p-value <0.05 was considered statistically significant.

Ethical considerations

The datasets are freely available upon request from the DHS website at https://dhsprogram.com/data/available-datasets.cfm . The current study was approved by the Institutional Review Board, Ohio University. It was deemed exempt from a full review because it was based on anonymous public use of a secondary dataset with no identifiable information on the survey participants.

Results

Among the 1,340 participants, 72% were rural residents and 35.8% belonged to the poor household wealth index. The majority of the mothers attended the recommended number of ANC visits during their pregnancy (83.2%), and 87.4% gave birth at a health care facility. Regarding feeding practices, 41% of the mothers exclusively breastfed their infants and only 26.4% initiated breastfeeding within the first hour of birth. Regarding infants' characteristics, 54.2% were males and 49.3% were exposed to secondhand smoking. Nearly one in every 10 infants had symptoms of an ARI 2 weeks preceding the survey (9%). Other characteristics of the study participants are presented in Table 1.

Table 1.

Characteristics of the Study Participants (N = 1,340)

Characteristics	n (Wt. %)
Mother's age at childbirth, years
<20	105 (8.9)
20–34	1,091 (80.6)
≥35	144 (10.5)
Mother's education
None	233 (17.3)
Primary school graduate	112 (8.3)
Secondary school graduate or higher	995 (74.4)
Mother's occupation
No	1,203 (90.3)
Yes	137 (9.7)
Residence
Urban	507 (28.0)
Rural	833 (72.0)
Wealth index
Poor	496 (35.8)
Middle	303 (27.0)
Rich	541 (37.2)
Age of the infant, months
0–1	339 (27.1)
2–3	497 (36.5)
4–5	504 (36.4)
Sex of the infant
Male	717 (54.2)
Female	623 (45.8)
Birth order of the infant
First	329 (24.7)
Second or third	698 (53.8)
≥Fourth	313 (21.5)
Pregnancy intention
Intended	1,132 (83.3)
Not intended	208 (16.7)
ANC visits
None	122 (8.6)
1–3	112 (8.2)
≥4	1,106 (83.2)
Mode of delivery
Vaginal	586 (42.0)
Cesarean section	754 (58.0)
Place of delivery
Public health facility	352 (24.3)
Private health facility	814 (63.1)
Home	174 (12.6)
Exclusive breastfeeding
No	803 (59.0)
Yes	537 (41.0)
Initiation of breastfeeding
Early	370 (26.4)
Delayed	970 (73.6)
Symptoms of ARIs among infants
No	1,221 (91.0)
Yes	119 (9.0)
Exposure to secondhand smoke
No	692 (50.7)
Yes	648 (49.3)

wt. % = weighted percentage.

ANC, antenatal care; ARI, acute respiratory infection.

Bivariate analysis showed that ARI symptoms were significantly higher among non-exclusively breastfed infants compared with exclusively breastfed infants (12.2% vs. 4.3%, p < 0.0001). ARI symptoms were also significantly higher among infants whose mothers aged younger than 20 years at their childbirth compared with mothers 20–34 years of age and 35–49 years of age, respectively (16.1% vs. 8.4% vs. 7.4%, p = 0.0334). Additionally, ARI symptoms were significantly higher among infants aged 4–5 months compared with infants 2–3 months of age and less than 2 months, respectively (13.0%, vs. 9.3% vs. 3.1% p < 0.0001) (Table 2).

Table 2.

Characteristics of the Study Participants by Symptoms of Acute Respiratory Infection Among Infants (N = 1,340)

Characteristics	Symptoms of ARIs, n (Wt. %)		p
	No	Yes
	1,221 (91.0)	119 (9.0)
Mother's age at childbirth, years
<20	88 (83.9)	17 (16.1)	0.0334^a
20–34	1,002 (91.6)	89 (8.4)
≥35	131 (92.6)	13 (7.4)
Mother's education
None	210 (90.3)	23 (9.7)	0.7820
Primary school graduate	103 (92.8)	9 (7.2)
Secondary school graduate or higher	908 (91.0)	87 (9.0)
Mother's occupation
No	1,098 (91.6)	105 (8.4)	0.0881
Yes	123 (86.1)	14 (13.9)
Residence
Urban	469 (91.1)	38 (8.9)	0.9506
Rural	752 (91.0)	81 (9.0)
Wealth index
Poor	447 (90.0)	49 (10.0)	0.7003
Middle	276 (91.8)	27 (8.2)
Rich	498 (91.4)	43 (8.6)
Age of the infant, months
0–1	330 (96.9)	9 (3.1)	<0.0001^a
2–3	448 (90.7)	49 (9.3)
4–5	443 (87.0)	61 (13.0)
Sex of the infant
Male	659 (92.1)	58 (7.9)	0.1894
Female	562 (89.8)	61 (10.2)
Birth order of the infant
First	300 (90.9)	29 (9.1)	0.934
Second or third	637 (90.8)	61 (9.2)
≥Fourth	284 (91.6)	29 (8.4)
Pregnancy intention
Intended	1,037 (91.7)	95 (8.3)	0.0968
Not intended	184 (87.8)	24 (12.2)
ANC visits
None	116 (93.3)	6 (6.7)	0.5640
1–3	97 (88.5)	15 (11.5)
≥4	1,008 (91.0)	98 (9.0)
Mode of delivery
Vaginal	531 (90.9)	55 (9.1)	0.9164
Cesarean section	690 (91.1)	64 (8.9)
Place of delivery
Public health facility	324 (92.8)	28 (7.2)	0.4568
Private health facility	739 (90.7)	75 (9.3)
Home	158 (89.2)	16 (10.8)
Exclusive breastfeeding
No	706 (87.8)	97 (12.2)
Yes	515 (95.7)	22 (4.3)	<0.0001^a
Initiation of breastfeeding
Early	332 (89.2)	38 (10.8)	0.2158
Delayed	889 (91.7)	81 (8.3)
Exposure to secondhand smoke
No	642 (92.5)	50 (7.5)	0.0994
Yes	579 (89.2)	69 (10.8)

wt. % = weighted percentage, ^ap < 0.05.

Multivariate logistic regression showed several predictors of ARI symptoms. Being exclusively breastfed reduced the occurrence of ARI (AOR = 0.450, 95% CI: 0.243–0.832). Infants of mothers aged 20–34 years (AOR = 0.421, 95% CI: 0.217–0.817) and ≥35 years (AOR = 0.308, 95% CI: 0.123–0.767) at childbirth were less likely to have symptoms of ARI when compared with adolescent mothers. Compared with infants less than 2 months of age, the odds of having ARI symptoms were higher among infants 2–3 months of age (AOR = 2.437, 95% CI: 1.093–5.435), and 4–5 months (AOR = 2.888, 95% CI: 1.193–6.992) (Table 3).

Table 3.

Predictors of Acute Respiratory Infection Symptoms Among Infants (N = 1,340)

Predictors of ARI	Adjusted OR, (95% CI)	p
Mother's age at childbirth, years		—
<20	Reference
20–34	0.421 (0.217–0.817)	0.0107^a
≥35	0.308 (0.123–0.767)	0.0115^a
Mother's occupation
No	Reference	—
Yes	1.808 (0.924–3.536)	0.0837
Sex of the infant
Male	Reference	—
Female	1.244 (0.787–1.966)	0.3493
Age of the infant, months
0–1	Reference	—
2–3	2.437 (1.093–5.435)	0.0295^a
4–5	2.888 (1.193–6.992)	0.0188^a
Pregnancy intention
Intended	Reference	—
Not intended	1.611 (0.946–2.745)	0.0791
Exclusive breastfeeding
No	Reference	—
Yes	0.450 (0.243–0.832)	0.0110^a
Exposure to secondhand smoke
No	Reference	—
Yes	1.362 (0.846–2.193)	0.2030

p < 0.05.

AOR, adjusted odds ratio; CI, confidence interval.

Discussion

The current study indicated that the practice of exclusive breastfeeding was protective against ARI during the first 6 months of the infant's life, reducing the likelihood of ARI by 55%. Similarly, a previous study reported that exclusive breastfeeding was negatively associated with ARI among infants under the age of 6 months.²⁰ In addition, an international multicenter study conducted in USA, Germany, Finland, and Sweden also found that exclusive breastfeeding reduced the odds of respiratory infections with fever among infants 3–6 months of age.²¹ Another study indicated that the lack of exclusive breastfeeding practice up to 6 months of age could increase the risk of ARI by 1.43.²² Based on a recent systematic review of 29 studies, exclusive breastfeeding was found to significantly reduce hospitalization, length of stay, supplemental oxygen demand, and admission to intensive care units in infants with acute lower respiratory infections.²³

Breast milk contains the necessary nutrition and several bioactive factors (e.g., hormones, cytokines, leukocytes, immunoglobulins, lactoferrin, and microbiota) needed to support infant growth and development, enhance immunity, and develop neonatal gut microbiota.²⁴ Microbiota in breast milk has potentially contributed in mitigating and preventing infectious diseases. Moreover, the composition of breast milk changes over the course of lactation to meet the needs of the developing infant.²⁵

In the current study, only 4 in 10 infants under 6 months of age were exclusively breastfed, which is below the WHO's global targets of 50% by 2025 and 70% by 2030.²⁶ In a pooled analysis of 83 LMICs, prevalence of exclusive breastfeeding increased from 35.4% in 2000 to 48.6% in 2019, except in the Middle East and north Africa, where a reduction in exclusive breastfeeding rate from 42.9% in 2000 to 30.2% in 2019 was found.²⁷ Compared with 30 high-income countries, prevalence of exclusive breastfeeding at 6 months ranged from 0.1% in Brunei Darussalam up to 57% in Chile, with a median of 18%.²⁸

A variety of barriers against exclusive breastfeeding have been identified such as social norms, mother's lack of information regarding the benefits of exclusive breastfeeding, cesarean section pain, maternal exhaustion, and unsupported environment from spouse, health care system, or workplace.^29–32 Also, marketing of formula milk has negatively influenced exclusive breastfeeding practices, especially in LMICs.^33,34 Formula milk marketing has undermined mothers confidence in breastfeeding, and targeted health care providers who have a strong influence on feeding decisions.³⁴

Early motherhood was found to increase the likelihood of ARI symptoms among infants. Nshimiyimana and Zhou⁸ observed similar findings in that children of adolescent mothers had a higher risk of having ARI symptoms than children of mothers 21–24 years of age. In sub-Saharan Africa and South Asia, it was estimated that children born to mothers <16 years of age, 16–17 years of age and 18–19 years were at a higher risk of death 2–4 times, 1.5–2 times, and 1.2–1.5 times higher, respectively, than among children of mothers 23–25 years of age.³⁵ A qualitative study in a LMIC reported that adolescent mothers might experience many difficulties such as higher burden of responsibility, physical illness, inadequate support, inefficiency in maternal role, and psychological distress,³⁶ which could explain the negative health outcomes among infants of adolescent mothers. Another explanation of the current findings could be due to poverty and other inequities in the social determinants of health among adolescent mothers.³⁷

The age of the infant was also identified as a predictor of ARI symptoms in the current study. However, the findings of previous studies were equivocal. Merera¹¹ stated that the rate of ARI was more prevalent among children 6–11 months of age (11.6%), followed by 12–23 months (11%), and the lowest rate was among children 48–59 months of age (3.7%). Another study reported that children 12–23 months of age had a higher risk of developing ARI symptoms than infants, while children 48–59 months of age reduced the odds of symptoms compared with infants.⁸ During the first months of life, infants are highly vulnerable to infections as their immune system are still immature. Such a risk can be reduced by the neonatal passive immunity derived from the transplacental transfer of maternal antibodies during pregnancy, which might explain the present finding.³⁸ The peak of exclusive breastfeeding during the first 2 months of an infant's life could be another plausible explanation for early life immunity.¹⁷

Strengths and limitations

The analysis of a nationally representative sample of infants under the age of 6 months was considered as a point of strength, allowing the results to be generalizable. On the other hand, the cross-sectional design limited the causality of breastfeeding to ARI symptoms. The EDHS, like all DHS surveys, relies upon self-reporting; thus, the findings of the current study might be susceptible to social desirability, recall bias, underreporting, or selective reporting. However, restricting the sample to mothers of last-born infants under the age of 6 months and the short reference period (2 weeks) likely helped to reduce the recall bias. Furthermore, data on the number of siblings and daycare exposure that could contribute to the likelihood of ARI, were not captured in the EDHS.

Conclusions

This population-based study concluded that exclusive breastfeeding had a protective effect against ARI in infants under the age of 6 months. Additionally, infants of adolescent mothers and older infants showed a higher risk of ARI. Interventions encouraging mothers to initiate breastfeeding within the first hour of birth and maintain exclusive breastfeeding for the first 6 months of their infants' life are highly required, such as breastfeeding counseling sessions, baby-friendly hospital initiative, skin-to-skin contact, and rooming-in. Furthermore, health care providers should emphasize the benefits of exclusive breastfeeding for both mother and her infant during ANC and postnatal care visits. Mass media could be helpful to address misconceptions, cultural beliefs, and social norms regarding exclusive breastfeeding. Facilitating exclusive breastfeeding in the workplace is also needed such as providing a dedicated space for lactation, in addition to an adequate maternity leave. In settings where exclusive breastfeeding is suboptimal, investigating challenges and barriers facing mothers could be an area of interest for further studies.

Additionally, health education programs should target pregnant adolescents to provide them with the adequate support, knowledge, and resources to deal with early parenting.

Footnotes

Acknowledgments

The authors are grateful to DHS for providing access to data for the 2014 Egypt Demographic and Health Survey.

Authors' Contributions

Conceptualization: N.H.F., Z.T.H., G.I., and D.B.; Methodology: N.H.F., Z.T.H., G.I., and D.B.; Data Analysis: Z.T.H. and A.R.; Writing–Original Draft Preparation: N.F.; Writing–Review and Editing: N.H.F., Z.T.H., G.I., D.B., A.V.S.R., and N.F. All the authors have read and agreed to the published version of the article.

Data Availability

The datasets are freely available upon request from the DHS website at .

Disclosure Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

The research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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