Rifat Ashraf

Breast feeding and protection against neonatal sepsis in a high risk population.

Protection against neonatal sepsis by breast feeding was investigated in a developing community. A case-control study was carried out with 42 cases from a hospital and 270 controls, matched for age and socioeconomic conditions from the community. Exclusive breast feeding was extremely rare, most babies being partially breast fed and a few being given formula feed or animal milk. A highly significant odds ratio of 18 was obtained, showing that even partial breast feeding protects against neonatal sepsis in such a population.

Early child health in Lahore, Pakistan: V. Feeding patterns

The feeding practices of children (n=1476) from birth to 24 months, as determined in a longitudinal study, in Lahore, Pakistan, are presented. Four socioeconomic groups at various levels of urbanization were included; a village, periurban slum, urban slum and an upper middle class. Initiation of breastfeeding was delayed in all the neonates. Sixty‐five percent of the periurban slum mothers and 45% of the village mothers had not started breastfeeding at 48 hours after the birth of the infant. Prelacteal feedings, especially of herb water and honey, were the norm. Breastfeeding was highly prevalent. Eighty‐seven to 98% of the infants in all the areas were breastfed at one month of age. Exclusive breastfeeding was rare, with 9% at one month, declining rapidly with age and being highly influenced by season. Partial breastfeeding was the most common mode of feeding. Water in addition to human milk was given by 45–73 % of the mothers living in the urban slum, village and periurban slum at one month of age. Fresh animal milk and/or commercial formula was already being given at 1 month by 22–64% of the mothers in all areas. Commercial formula was the preferred food in the upper middle class, while in the other three areas it was rare and fresh animal milk was mainly used. More than 50% of the mothers in the village and in the periurban slum gave diluted animal milk even beyond the age of 10–15 months. In the upper middle class 50% of the infants were fed semisolids at the age of four months, while in the village, the periurban and the urban slum at 6 months of age only lo%, 12% and 47% of the infants received semisolids. The results of this study indicate that breastfeeding was highly prevalent in the three poorest areas. However, in all the areas initiation of breastfeeding was delayed and prelacteal feeding was the norm. Exclusive breastfeeding was rare, feeding bottles were used by 82–100% of the mothers to feed supplements and human milk substitutes, in the four areas.

Breast feeding: Overview and breast milk immunology

The transfer of host defence capacity to the human offspring provides a remarkable model of passive transfer of immunity. In fact it may also provide an example of active immunization.

Early child health in Lahore, Pakistan: I. Study Design

In this paper, details are given of a community based follow up study of four areas: a village, a periurban slum, an urban slum and an upper middle class control group living in and around Lahore, Pakistan. The aim was to characterize the determinants of child health in a rapidly urbanizing community. The study was undertaken in two steps. An initial cross‐sectional survey collecting socio‐economic and demographic background information was carried out between March to August 1984. This was followed by a longitudinal study of 1476 infants representing the outcome of the pregnancies registered continuously between September 1984 to March 1987 among the 3242 families in the study. These infants were followed monthly from birth to 3 years of age and thereafter less frequently. In this communication we describe the study design, the study population, the organization and the research methodology used, including the reasons for drop outs from birth to 24 months of age. The internal consistency of the data is also presented. After the initial examination of the newborns within between 0–7 days of birth, the infants were visited monthly for 24 months making a total of 20911 examinations. At 24 months of age 70% of the infants were still in the study, 11% had died before reaching this age, 13% had moved from the area and 6% had refused to participate in the study. The economic, conditions, social structure, and the quality of life were found, not surprisingly, to vary significantly among the four areas. This community‐based project provides new, critical and reliable information for local health planners. The study highlights the importance of the development of a useful model for research collaboration between institutions in developed and developing countries.

Additional water is not needed for healthy breast‐fed babies in a hot climate

In Lahore, Pakistan, a community‐based study was conducted to investigate whether or not it was necessary to give water to breast‐fed infants. From May to November 1986,2–4‐month‐old, breast‐fed infants (n= 26) were selected. During the study period the maximum temperature ranged between 27.4 and 40.7 °C and humidity varied between 24 and 77%. Each infant was followed up for 15 days. Water was not allowed from day 1 today 8 and water was allowed ad libitum from day 8 today 15. All infants were subjected to a DDAVP test to estimate the renal concentrating capacity on day 15. A significant gain in weight (p < 0.001) was observed between day I to 8 and 8 to 15. The differences in the values of haematocrit and serum sodium between day 8 and 1 and between day 15 and 8 were not significant. This indicates that the infants were not dehydrated when water was withheld. Furthermore, no significant difference was observed for urine specific gravity between day 8 and 1, but urine specific gravity increased significantly after the administration of DDAVP (p<0.001), indicating that, if needed, the infants could concentrate urine when water was restricted. It was concluded that 2–4‐month‐old, breast‐fed, healthy infants showed no signs of dehydration if additional water was not given during the summer season.

Cytokines in the Placenta of Pakistani Newborns With and Without Intrauterine Growth Retardation

Although intrauterine growth retardation (IUGR) is a major risk factor for increased neonatal mortality and morbidity, the mechanisms behind it are not clear. We analyzed cytokine gene expression and gene polymorphisms in infants with and without IUGR in Pakistan, where IUGR is very common. 45 IUGR and 55 control mother/infant pairs were studied. mRNA for IL-10, IL-8, TNF-α, TGF-β, IL-6, IL-4, IL-1β, IL-12, IFN-γ and GAPDH was quantified with RT-PCR from placenta. Cytokine and cytokine receptor gene polymorphisms for -1087IL10, -308TNFA, -174IL6, +915TGFB1, intron 2 IL1RN, +36TNFR1, 150V IL4RA and -159CD14 were determined from genomic DNA. The serum levels of IL-1β, IL-6, IL-8, IL-10, IL-12, TNF-α and TGF-β were measured.There was a significant decrease of IL-10 and IL-12, but increase of TGF-β in the decidua and similarly decrease of IL-10, but increase of TGF-β in the trophoblasts of the IUGR placentas compared with the non-IUGR placentas. We found significantly lower levels of IL-1β in serum from the mothers of the IUGR infants and of TGF-β in serum of the infants with IUGR compared with the non-IUGR infants. We note that the IL-10 mRNA expression in the decidua was down-regulated, but the TGF-β mRNA up-regulated in IUGR placentas of mothers from a population with multiple risk factors for IUGR. We propose that the low IL-10 in the placenta may be involved in the pathogenesis of IUGR and might possibly be treatable.

Immune System Modulation by Human Milk

The mother’s immune system seems to have a much more active role for the development and protection of her fetus and newborn than previously realized. We have recently learned that various cytokines of the mother’s immune response to her fetus play a major role in actively monitoring pregnancy, such as mediating the implantation in the decidua of the fertilized egg and the growth of the placenta. Breastfeeding we have mainly thought of as a process providing passive protection of the infant by transferring various ready made protective factors like secretory IgA antibodies, lactoferrin, oligosaccharides functioning as receptor analogues etc. Such protection is well proven against numerous infections. Now we realize that breastfeeding also brings various active stimuli for the immune system of the infant providing possibilities for enhanced protection against infections also after the termination of breastfeeding.

Breast feeding is a natural contraceptive and prevents disease and death in infants, linking infant mortality and birth rates

The trend of declining infant mortality has stopped or has increased in at least 21 developing countries. In the last 30 years in Pakistan infant mortality has been over 100/1000 live births. Population size has increased from 35 to 120 million between 1950 and 1993. Pakistan is experiencing a simultaneous rise in urbanization. Breast feeding and postpartum abstinence are often responsible for long birth intervals in certain populations. Breast feeding patterns have changed greatly from exclusive breast feeding to at most partial breast feeding. Partial breast feeding can have a contraceptive effect if sucking is frequent enough. For example mothers who breast fed for less than 4 months had many more new pregnancies than those who breast fed longer than 4 months (p < 0.05). Lymphoid cells that have migrated to mammary glands produce secretory IgA antibodies which are passed to the infant via the milk. These antibodies protect breast fed infants from infection and death. For example in Lahore Pakistan neonatal septicemia occurred 18 times more often among non-breastfed infants than partially breast fed infants. The risk of diarrhea-related death was 23.5 times greater among non-breastfed infants compared to exclusively breast fed infants. Frequent infections brings about undernutrition which only serves to increase the risk of poor growth and development or death. The practice of giving prelacteal feeds and supplementary feeds increases the risk of infection. In conclusion promotion of breast feeding improves the life and prevents the death of many children. Breast feeding campaigns should begin immediately especially in poor societies.

Determinants of stunting at 6, 12, 24 and 60 months and postnatal linear growth in Pakistani children

A “nested” case‐control design was used to identify cases from a longitudinally followed cohort of 1236 newborns registered during 1984–1987, living in three socioeconomically different areas. The children had a length <–2SDS (standard deviation scores) at 6, 12, 24 and 60 mo of age using the NCHS reference. The controls were matched for gender, area and month of birth. A logistic regression analysis was used for determining the risk factors for stunting at each age. Postnatal linear growth was also examined in these two groups of children and body size was compared with the NCHS reference and that of upper‐middle‐class children (n= 240). At 6 mo of age, prematurity and duration of breastfeeding showed a significant association with stunting. At 12 mo, maternal height, birthweight and stunting at 6 mo, while at 24 mo, stunting at 6, 12 and 18 mo were identified as important factors. At 60 mo, no other factors besides previous stunting could be identified. The mean height reached at 60 mo showed a deficit of 6 and 13 cm for the controls and the cases, respectively, compared to the NCHS reference. Twenty‐eight percent of the children from the two poor areas who were stunted at 6 mo had improved by 60 mo of age.

Early child health in Lahore, Pakistan: XI. Growth

This work gives growth reference values at birth to 24 months of age for Pakistan based on upper middle class infants. Growth rate reference values are also included and they are given for various interval lengths. The growth was differently affected in infants living in three poorer areas; the stunting incidence at 24 months of age was 63% in periurban slum, 54% in the village and 26% in the urban slum. Less differences could be seen between the areas in weight for length. There was an age dependency in the incidence of reduced growth; a normal length gain was seen at birth to about six months of age, but they were highly reduced at 6 to 18 months of age. The weight gain was to some degree reduced during the first 12 months of life, followed by a catch‐up growth period. The seasonal influence was also age dependent; weight was highly affected during the summer at birth to 24 months of age, but not in the winter. The seasonal effect in length was marginal at birth to 6 months, little at 6 to 12 months (although, constant below the normal) and large at 12 to 24 months of age. We did not see any seasonality of growth in the reference group. The incidence of reduced growth reflects the socio‐ economic differences in one restricted geographic area, i.e. in the city of Lahore, Pakistan.