Prevalence and associated factors of prelacteal feeding among neonates admitted to neonatal intensive care units, North central Ethiopia, 2019

The World Health Organization and United Nations Children’s Fund recommend an exclusive and early initiation of breastfeeding following birth [1, 2]. This recommendation of optimal breastfeeding is however contravened by prelacteal feeding, which is a nutritional malpractice of providing newborns with any food before breast feeding during the first 3 days of birth. If a newborn is prelacteal fed, it isn’t exclusively breastfed and hence the nonexclusive breastfeeding in the first 3 days of neonatal life is often followed by giving further prelacteal foods resulting in suboptimal breastfeeding (i.e forming a vicious cycle of prelacteal feeding and suboptimal breastfeeding) [2‐5].

As of the 2013 Ethiopian Health and Nutrition Research Institute appraisal of the achievements and identified gaps about status of infant and young child feeding (IYCF) practice policy and programs, the implementation of Baby friendly Hospital Initiatives (BFHI) was zero (0%). Therefore, since then, different programs like health extension programs and working in collaboration with non-governmental organizations have been extensively implemented [6]. Moreover, though there is no Ethiopian hospital currently certified as “Baby Friendly Hospital”, many hospitals in the country including our study hospital have been following the ‘Baby-Friendly Hospital Initiatives’. For example, the ten steps of successful breastfeeding have been given emphasis. However, there are still several myths towards exclusive breast feeding in Ethiopia thereby challenging the implementation of the ‘Baby-Friendly Hospital Initiatives’ in several areas of the country (including our study setting) [7]. More specifically, participants of this study were only sick neonates (both home and health facility delivered neonates) whose mothers might have given them prelacteal foods at home or on the way to NICU before admission. Thus, influence of the hospital setting was thought to be lower than it would be if the study had been among mother-neonate pairs in the postnatal ward. Prelacteal feeding is a major bottleneck to optimize neonatal survival because a prelacteal food is nutritionally inferior and deprives the neonate of the most valuable perfect combination of proteins, fats, carbohydrates, minerals and fluids in breast milk [1, 2]. Furthermore, if breastfeeding is replaced by prelacteal foods, the physiologic pattern of breast milk production becomes suppressed thereby compromising both the quality and quantity of anti-infective proteins that in turn increase neonatal susceptibility to different infections. Contamination of the foods and utensils used for introducing prelacteal foods can also increase neonatal vulnerability to infections especially due to permeability of their immature gut lining [3‐6]. Therefore, prelacteal feeding increases the risk of early neonatal morbidity and mortality by limiting the health and emotional benefits of optimal breastfeeding [1, 3]. Annually, nearly 1.4 million under five deaths could be attributed to suboptimal breastfeeding [2]. Studies also showed that survivors of early nutritional deficits from prelacteal feeding are more likely to have poor intellectual performance, adverse reproductive outcomes [8] and chronic non-communicable diseases in their latter lives [9].

The practice of prelacteal feeding is common in Ethiopia contributing to 70,000 infant deaths per year, i.e., 24% of the total infant death annually [7]. Despite its harmful effects, prelacteal feeding is a deep rooted common nutritional malpractice that raises global concern. For example, country wise, its prevalence was: Jammu and Kashmir, India (88.0%), Vietnam (73.3%), Nepal (26.5%), western Uganda (31.3%), Nigeria (60.5%), Mansoura, Egypt (58%) and Ethiopia (26.95%) [10‐16]. Moreover, the 2016 Ethiopian Demographic and Health Survey (EDHS) has shown that 25.9% of the neonates were given different prelacteal feeds. These feeds were: plain water (12.6%), non milk liquids like juice, juice drinks, clear broth or other liquids (2.6%), cow milk (1.5%) and solid or semi-solid complementary foods (3.1%). The demographic survey has also shown that Amhara regional state (a region of the study area) had the highest (47.8%) prevalence of pre-lacteal feeding practice next to Somali region (72.5%) in the country [17].

Community based studies conducted at different parts of Ethiopia have shown burden of prelacteal feeding along the spectrum of the national pediatric nutrition system; for instance, in Raya Kobo town (11.1%), Motta town (20.3%), Afar region (42.9%), Harar city (45.4%), Fiche town (24.4%), Aksum town (10.1%), Sidama zone (25.5%) and Debre Markos town (19.1%) [18‐25]. Both the global and national studies have shown that common prelacteal foods include plain water [13, 22], raw butter [20], sugar (glucose) water, honey, tea and fruit juice [13, 16, 25]. The pre-lacteal use of these foods was found to be positively associated with many factors like delayed initiation of breast feeding [19‐21, 25], home delivery [16, 21, 25], cesarean delivery [11, 23, 25], inability to read and write [12, 25], male neonate [25], maternal belief on the purported advantages of prelacteal feeding [23], less than four ANC visits [12, 15, 21, 23], previous experience of prelacteal feeding [25] and influence from somebody else [21]. The stated reasons to give pre-lacteal feeds were: to clean the infant’s stomach, to quench neonatal thirst, breast problems, maternal medical illness, inadequate breast milk secretion, colostrums is dirty, colostrums is inadequate for the neonate, being prelacteal fed is a guarantee of healthier growth in later life and presence of neonatal feeding problem [10‐25]. An Ethiopian study at Raya Kobo district also showed that the main reason to give prelacteal feeds for sick neonates were to treat neonatal illness believing that their illness is attributable to ‘evil eye’ [18]. Furthermore, different studies in different Ethiopian towns namely at Ambo [26], Dabat [27], Mizan Aman [28] and Bedelle [29] revealed the presence of maternal knowledge and practice gap about WHO recommendations of exclusive breast feeding.

Despite the aforementioned community based evidence of prelacteal feeding in Ethiopia [18‐25], there has been no prior study about the burden and associated factors of prelacteal feeding among neonatal admissions in the country in general and in the study area in particular. Therefore, in cognizance of the severity of prelacteal feeding among sick neonates, it is the authors’ firm conviction about significance of studying the prevalence and associated factors of prelacteal feeding practice by mothers of these neonates. Besides, public health importance of maternal residence, spousal accompaniment of ANC and having twin neonates are originally explored in this study. Findings of the study will be valuable to draw neonatal care providers’ attention towards maternal counseling of optimal Infant and Young Child Feeding (IYCF) practice during maternal stay at NICU. The counseling could help warrant safe IYCF after discharge thereby optimizing neonatal survival.

The practice of giving prelacteal food to neonates is a traditionally accepted culture in the Ethiopian community despite its risks. In this study, mother-neonatal pairs visiting neonatal ICU were selected for the purpose of assessing the burden and associated factors of pre-lacteal feeding among sick neonatal admissions to the intensive care units. Assessing the prevalence and predictors of pre-lacteal feeding in these settings could provide neonatal care providers with focused counseling of the admitted mothers about optimal breastfeeding of their neonates to prevent further neonatal illness owing to prelacteal feeding after discharge. It was found that one out of five sick neonates (20.2%) was given prelacteal feeds. Moreover, rural residence, primiparity, less than four ANC visits, home delivery, giving twin birth and maternal belief on the purported advantages of prelacteal feeding were significant factors associated with increased odds of prelacteal feeding practice whereas spousal accompaniment of ANC reduced likelihood of the practice.

In this study, the prevalence of pre-lacteal feeding (20.2%) was lower as compared to Ethiopian studies at Afar (42.9%) [20] and Harari regions (45.4%) [21], and this variation might be due to differences in study period, setting and sample size. Moreover, the prevalence was lower than studies in India (88%) [10], Vietnam (73.3%) [11], Nigeria (60.5%) [14], western Uganda (31.3%) [13] and Egypt (58%) [15], and the variation may be attributed to sample size and cultural differences among the study populations of the respective studies. The prevalence of prelactal feeding in the current study also revealed about 5 % decline in less than 5 years compared to the EDHS report of 2016 (26.5%) [17]. The most likely reasons of such a decline could be due to hospital based setting of our study by employing a smaller sample size compared to the EDHS report that involved millions of Ethiopian neonates in the community setting. However, the prevalence of pre-lacteal feeding in the study area was higher than other Ethiopian studies at Aksum town (10.1%) [23] and Raya Kobo district (11.1%) [18], and it could be due to differences in study setting i.e. for this study, sick neonates admitted to NICU were considered. In this case, sick neonates might have received prelacteal feeds because it is obvious that they might not be able to be breastfed due to some complications.

Regarding prelacteal food type, plain water (32.3%) was predominantly given in the study area which was consistent with studies at Nepal [12], Vietnam [11] and Fiche (Ethiopia) [22] but different from results of other studies done in Nigeria [14], Raya Kobo [18], Aksum [23], Sidama [24] and Debre Markos towns [25] where the most commonly given prelacteal feeds were sugar solution, sugar or glucose water, boiled water, formula milk and cow milk. The possible reason for this discrepancy might be due to differences in study setting (i.e other Ethiopian studies used only urban residents while ours included both urban and rural neonatal population). Prelacteal feeds were given for several misconceived reasons. In this study, the main reason of mothers to practice prelacteal feeding was due to cultural habit. This was found congruent with an Egyptian study [15] and several Ethiopian studies [18‐25]. The resemblance may be due to the deep rooted cultural correlation of prelacteal feeding practice with its misconceived advantages in the community.

Adjusting for other factors, the odds of prelacteal feeding among primiparous mothers were 4.5 times higher than for multiparous mothers and it was in line with a Nepalese study [12]. This may be due to the usual challenges faced by primiparous mothers regarding proper positioning and attachment. This is because when a mother fails to position and attach her neonate to the breasts properly, the neonate becomes malnourished and irritable. Just at this time, the mother feels that her neonate isn’t getting adequate breast milk and try to introduce prelacteal foods to quench its hunger feelings. This challenge is often attributed to the less knowledge and skill that primiparous mothers have about proper newborn feeding practice [2, 6, 7, 31‐33]. They may also rely on the advice from older women in the household or community who often prefer the earliest introduction of traditional practices like prelacteal feeding [10, 15].

This study revealed that less number of ANC visits has a good opportunity for mothers to practice prelacteal feeding. Thus, the odds of prelacteal feeding among mothers who had less than four ANC visits were 4.7 times higher as compared to those having four and above visits. This finding was congruent with those studies conducted at Nepal [12], Egypt [15], Aksum [23] and Harar [21] where the odds of prelacteal feeding among mothers having less than 4 ANC visits were 2 to 10 times greater than those mothers having at least 4 ANC visits. The best likely reason for the congruency may be the less often a mother is exposed to ANC clinic, the less information on neonatal exclusive breast feeding she will get from ANC providers.

Regarding spousal accompaniment of ANC, mothers who were accompanied by their spouses to ANC were 80% less likely to practice prelacteal feeding as compared to those who came lonely. The possible justification may be due to the golden opportunity of accessing husbands to teach the couples about the harmful effects of prelacteal feeding. This taught body of knowledge can be talked about and shared among the couples in the sphere of early and exclusive breastfeeding of their neonates [31‐33].

In principle, twin breastfeeding is similar with breastfeeding of singletons because breast milk supply works on the principle of supply and demand (i.e. with twin newborns, more milk is removed from the breasts, so more milk is produced). This demand - supply based breastfeeding helps ensure an exclusive breastfeeding [1, 2, 31‐34]. However, in this study, the odds of prelacteal feeding among mothers who possessed twin newborns were 6.7 times higher as compared to those having single newborns. This may be due to the wrong belief that mothers have insufficient breast milk for two newborns, their inexperience in twin breastfeeding and inadequate knowledge of optimal breastfeeding. Moreover, it can be attributed to the sleepy nature and suckling problems often associated with low birth weight of twin newborns which in turn causes late initiation of breastfeeding. Therefore, during her ANC sessions, a twin pregnant mother should be counseled of ensuring good breast milk supply through proper positioning and attachment.

Home delivery was found to be associated with increased odds of prelacteal feeding as compared to mothers who gave their birth at health facility. The most practical explanation to support this current finding could be mothers who delivered at home are often influenced by traditional birth attendants to give prelacteal feeds. Moreover, most of these mothers may be deprived of the first postnatal visit so that they can’t get health professionals’ counseling and support of optimal breast feeding. This finding was consistent with prior Ethiopian studies at Harar city [21] and Debre Markos town [25] where the odds of prelacteal feeding among mothers who delivered at home were 3.4 times and 4.4 times higher than those who delivered at health institution respectively.

Concerning residence, being a rural mother was found to be a risk for prelacteal feeding practice because the odds of prelacteal feeding among rural mothers were found to be 4.1 times higher than urban mothers. This could be due to rural dwelling mothers had less access to different communication media that raises awareness about optimal breastfeeding and risks of prelacteal feeding. Moreover, rural mothers couldn’t get an easy access to various health institutions that integrate optimal breastfeeding in their ANC and PNC (post natal care) programs. Unlike this finding, the study reported from Egypt showed urban residence was a risk for prelacteal feeding practice [15].

Findings of this study are supposed to have substantial contribution for the promotion of optimal breastfeeding practices that serve as a spring board to achieve the sustainable development goal by reducing Ethiopian neonatal mortality rate to as low as 12/1000 live births by 2030. However, despite our data quality control measures, these findings could have been influenced due to interviewers’ bias, maternal socially desirable answers for some factors and maternal failure to recall of pertinent data like her age. Besides, despite very high home delivery in Ethiopia, the study considered only postnatal mothers presenting to NICU that might have introduced selection bias. Therefore, our estimate might not be close to the truth of the general population in the community. Moreover, the results may not be representative of the entire Ethiopian situation due to a smaller sample size. Being a cross sectional study, its ability to draw any causal inference was limited. Lack of support with qualitative data is also another limitation. Therefore, a community based follow up study with qualitative support is recommended to show wider picture of prelacteal feeding practice and to further understand its maternal reasons in the specific context of the study setting i.e. South Gondar Zone.

Prelacteal feeding practice among sick neonates was found to be a problem of public health importance in the study area. Fortunately, its enablers were modifiable. Therefore, the existing programs of promoting optimal breastfeeding should be strengthened during routine peri-natal healthcare contacts of every mother. Moreover, mothers should be advocated of spousal accompaniment while implementing these programs to give couple counseling of early and exclusive breastfeeding. The existing compassionate and respectful caring approach should also be enhanced to increase number of ANC visits and institutional delivery rate.

According to different literatures, a mother’s breast milk is sufficient for multiple neonates. Therefore, mothers expecting twin birth should be given more due emphasis of optimal breastfeeding during their antenatal follow up. Lastly, the existing educational programs that involve community agents should be reinforced to bring behavioral change about misconceived advantages of prelacteal feeding practices.