 |
|
Promotion of Breastfeeding Intervention Trial (PROBIT)
A Randomized Trial in the Republic of Belarus
Michael S. Kramer, MD;
Beverley Chalmers, PhD;
Ellen D. Hodnett, PhD;
Zinaida Sevkovskaya, MD;
Irina Dzikovich, MD,PhD;
Stanley Shapiro, PhD;
Jean-Paul Collet, MD,PhD;
Irina Vanilovich, MD;
Irina Mezen, BA;
Thierry Ducruet, MSc;
George Shishko, MD,DMSc;
Vyacheslav Zubovich, MD,PhD;
Dimitri Mknuik, MD,PhD;
Elena Gluchanina, MD;
Viktor Dombrovskiy, MD,PhD;
Anatoly Ustinovitch, MD,PhD;
Tamara Kot, MD;
Natalia Bogdanovich, MD,PhD;
Lydia Ovchinikova, RN;
Elisabet Helsing, PhD;
for the PROBIT Study Group
JAMA. 2001;285:413-420.
ABSTRACT
| |
Context Current evidence that breastfeeding is beneficial for infant and child health is based exclusively on observational studies. Potential sources of bias in such studies have led to doubts about the magnitude of these health benefits in industrialized countries.
Objective To assess the effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infection and atopic eczema among infants.
Design The Promotion of Breastfeeding Intervention Trial (PROBIT), a cluster-randomized trial conducted June 1996–December 1997 with a 1-year follow-up.
Setting Thirty-one maternity hospitals and polyclinics in the Republic of Belarus.
Participants A total of 17 046 mother-infant pairs consisting of full-term singleton infants weighing at least 2500 g and their healthy mothers who intended to breastfeed, 16491 (96.7%) of which completed the entire 12 months of follow-up.
Interventions Sites were randomly assigned to receive an experimental intervention (n = 16) modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, or a control intervention (n = 15) of continuing usual infant feeding practices and policies.
Main Outcome Measures Duration of any breastfeeding, prevalence of predominant and exclusive breastfeeding at 3 and 6 months of life and occurrence of 1 or more episodes of gastrointestinal tract infection, 2 or more episodes of respiratory tract infection, and atopic eczema during the first 12 months of life, compared between the intervention and control groups.
Results Infants from the intervention sites were significantly more likely than control infants to be breastfed to any degree at 12 months (19.7% vs 11.4%; adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], 0.32-0.69), were more likely to be exclusively breastfed at 3 months (43.3% vs 6.4%; P<.001) and at 6 months (7.9% vs 0.6%; P = .01), and had a significant reduction in the risk of 1 or more gastrointestinal tract infections (9.1% vs 13.2%; adjusted OR, 0.60; 95% CI, 0.40-0.91) and of atopic eczema (3.3% vs 6.3%; adjusted OR, 0.54; 95% CI, 0.31-0.95), but no significant reduction in respiratory tract infection (intervention group, 39.2%; control group, 39.4%; adjusted OR, 0.87; 95% CI, 0.59-1.28).
Conclusions Our experimental intervention increased the duration and degree (exclusivity) of breastfeeding and decreased the risk of gastrointestinal tract infection and atopic eczema in the first year of life. These results provide a solid scientific underpinning for future interventions to promote breastfeeding.
INTRODUCTION
Breastfeeding has been widely reported to reduce the risk of infection1-11 and atopic disease1, 12-15 in the recipient infant and child. The effect of breastfeeding in protecting against infection is more striking, and thus easier to demonstrate, in settings where poverty, malnutrition, and poor hygiene are prevalent.2-5 All of the scientific evidence regarding breastfeeding and morbidity in healthy, full-term infants is based on observational studies, because it is neither feasible nor ethical to randomly assign such infants to be breastfed vs formula-fed. Such studies are plagued by numerous sources of bias related to measurement, selection, confounding, and reverse causality.16-18 These potential biases have created doubt about the magnitude, and even the existence, of a protective effect of breastfeeding against infection in developed country settings.18
A rigorous and feasible research strategy to overcome these biases would be to assess whether infants who are randomly allocated to a breastfeeding promotion intervention experience a reduced risk of infection. The mother's decision to initiate breastfeeding is usually made prenatally or even before becoming pregnant and prenatal interventions are often logistically difficult and expensive.19 Therefore, it may be preferable to focus on improving duration and exclusivity among women who have decided to initiate breastfeeding. The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) have combined 10 such interventions ("steps") in developing the Baby-Friendly Hospital Initiative (BFHI, available at http://www.unicef.org/programme/nutrition/infantfe/tensteps.htm).20 Based on systematic reviews of controlled clinical trials available in the Cochrane Database of Systematic Reviews,21-24 evidence suggests that duration and exclusivity of breastfeeding are increased by help with positioning and other aspects of breastfeeding technique (step 5), demand feeding (step 8), and postnatal support (step 10).
The Promotion of Breastfeeding Intervention Trial (PROBIT) builds on the scientific evidence concerning components of the BFHI. Not only is PROBIT the first randomized trial of the BFHI as a whole, but the large number of infants and mothers studied provides an opportunity to assess the direct relationship between a breastfeeding promotion intervention and infant health and the experimental link between infant feeding and infant morbidity in healthy mothers and their infants.
METHODS
Research Design
This study was a multicenter randomized controlled trial using cluster randomization. Maternal hospitals and their corresponding polyclinics, the "clusters" randomized in our study, were originally paired according to geographic region within Belarus (Minsk city, Minsk region, Brest, Mogilev, Gomel, Vitebsk, and Grodno), urban vs rural status, number of deliveries per year (±500 if <2500, or  2500), and breastfeeding initiation rates at hospital discharge (±5%). Most of the maternity hospitals located in large cities (Minsk, Vitebsk, Brest, and Mogilev) are affiliated with several polyclinics.
To maximize efficiency, enrollment of mothers was limited to those whose infants were to be followed up at a single selected polyclinic affiliated with each of these large maternity hospitals. Intervention allocation was based on a double-randomization procedure. First, a random number table was used to assign a 2-digit random number to each of the study sites. Within each pair, the hospital and polyclinic sites corresponding to the higher and lower numbers were assigned to interventions A and B, respectively. Later, at a public gathering of the Canadian and Belarussian investigators, a coin flip determined that B sites would receive the experimental intervention, and A sites would receive the control intervention.
We chose to carry out this trial in Belarus rather than North America or Western Europe because maternity hospital practices in Belarus and other former Soviet republics are similar to those in North America and Western Europe 20 to 30 years ago and thus provide a greater potential contrast between intervention and control study sites. However, Belarus resembles Western developed countries in 1 very important respect: basic health services and sanitary conditions are very similar. An uncontaminated water supply is ensured and monitored throughout the republic by public health authorities, and hospital clinics are abundant and readily accessible, even in rural areas.
Mothers were considered eligible for participation if they expressed an intention to breastfeed on admission to the postpartum ward, had no illnesses that would contraindicate breastfeeding or severely compromise its success, and had given birth to a healthy singleton infant of 37 weeks' or more gestation, 2500 g or more birth weight, and Apgar score 5 or higher at 5 minutes. The study received approval from the institutional review board of the Montreal Children's Hospital, and signed consent in Russian was obtained from all participating mothers.
Intervention
The experimental intervention was modeled on the BFHI. Because no breastfeeding support groups existed in Belarus at the time PROBIT was designed, step 10 (postnatal support) of the BFHI was expanded to include the intervention polyclinics. Participants, usually the chief obstetrician and chief pediatrician, from each of the intervention maternity hospitals and polyclinics, respectively, received the 18-hour BFHI lactation management training course, which was organized by the European Regional Office of the WHO. The course emphasized methods to maintain lactation, promote exclusive and prolonged breastfeeding, and resolve common problems.
Full implementation of the experimental intervention required 12 to 16 months to train all midwives, nurses, and physicians providing care to study mothers and infants during labor, delivery, and the postpartum hospital stay, and all pediatricians and nurses working at the polyclinics. Monitoring visits by members of the Canadian and Belarussian Steering prior to and during recruitment and follow-up at each site ensured that the hospital and polyclinic procedures and policies were consistent with the BFHI at the intervention sites, and that the control sites did not institute any changes that would render their maternity hospitals or polyclinics more baby friendly.
Data Collection
Sociodemographic and clinical information was recorded on an enrollment form completed during the postpartum stay. In Belarus, infants are seen monthly for routine well-child visits and whenever they are ill. At 1, 2, 3, 6, 9, and 12 months, polyclinic pediatricians completed a data form containing detailed information about infant feeding; measurement of infant weight, length, and head circumference; the occurrence of symptoms of gastrointestinal or respiratory tract infection, rash, other illnesses; and hospitalizations since birth or the most recent clinic visit. In the case of 1 or more missed clinic visits, data were updated at the next study visit to include all illness occurring since the previous study visit and the date of weaning, if applicable.
The primary study outcome was the risk of 1 or more episodes of gastrointestinal tract infection. Secondary outcomes included the risk of 2 or more episodes of any respiratory tract infection (including upper respiratory tract infection, otitis media, croup, wheezing, or pneumonia), 2 or more upper respiratory tract infections; atopic eczema; recurrent (2 episodes) wheezing; the prevalence of any breastfeeding at 3, 6, 9, and 12 months of age; and the prevalence of exclusive and predominant breastfeeding at 3 and 6 months. Consistent with WHO definitions,25 infants were considered as exclusively breastfed for 3 or 6 months if they received no solids, nonbreast milk, or water or other liquids (other than vitamins or medications) at all visits up to and including the 3- and 6-month visits, respectively. They were considered predominantly breastfed at these ages if they received no solids or nonbreast milk; juices, water, teas, and other liquids were permitted in this category. The criteria for gastrointestinal and upper respiratory tract infection were based on the algorithms of Rubin et al,6 modified to ensure a minimum duration of 2 days: at least 2 symptoms among increased stool frequency, loose stools, vomiting, and temperature greater than 38.5°C for gastrointestinal tract infection and at least 2 symptoms among runny nose, cough, fast breathing, and temperature greater than 38.5°C for upper respiratory tract infection. Rashes were classified as atopic eczema if they lasted at least 2 weeks or recurred after clearing for at least 1 week, were itchy, and occurred on the face and/or the extensor surfaces of the arms and/or the extensor surfaces of the legs.
Sample Size
Based on the available evidence concerning the effectiveness of the individual components of the BFHI, we estimated that the intervention would reduce breastfeeding discontinuation by 3 months from 50% (reported in a prior Belarussian Ministry of Health survey) to 35%. Three months of any breastfeeding was chosen as the primary basis for calculating breastfeeding prevalence based on the data of Howie et al7; in initially breastfed infants who were weaned at 13 weeks vs those breastfed to any degree and for at least 13 weeks, the relative risk of gastrointestinal tract infection (the primary outcome) associated with early weaning was approximately 2. From our previous surveillance studies in French day care centers using similar surveillance techniques and definitions,26 we estimated that the expected delay in weaning would reduce the risk of 1 or more episodes of gastrointestinal tract infection from 60% to 54%.
Assuming 500 mothers and infants enrolled at each maternity hospital, a design using 15 pairs of study sites would provide a power of greater than 80% to detect such a difference at a 2-sided  level of .05, even assuming a worst-case scenario of high variability between sites and totally ineffective pairing.27-28 To ensure that 15 hospital pairs would be included in the final study sample, we randomized 17 pairs to provide a margin of security against withdrawals or unforeseen logistical problems at a few sites. As it turned out, 2 of the maternity hospitals refused to carry out their allocated intervention following randomization, and 1 of the polyclinics was discovered to have falsified their outcome data, leaving 31 sites (16 intervention and 15 control) and 15 intact original pairs (Figure 1).
|
|
|
|
Figure 1. Flowchart of Study Sites and Participants
|
|
|
Cohort Recruitment, Data Validation, and Follow-Up
Recruitment began in June 1996 and by October 1996 all randomized sites were recruiting mothers and infants. To ensure an adequate sample size at each of the study sites, recruitment continued until the end of December 1997. After eliminating the 749 mother-infant pairs enrolled at the site excluded because of falsified outcome data, a total of 17 046 mother-infant pairs were enrolled at the 31 remaining sites, making this, to our knowledge, the largest randomized trial ever undertaken in the area of human lactation.
Because the observers of the clinical outcomes were the same pediatricians involved in implementing the experimental or control interventions, they could not be blinded to the intervention vs control status of the study infants. One routine audit of data validity was therefore carried out at each study site. Twenty polyclinic charts were selected at random and the data contained therein bearing on gastrointestinal tract infections, respiratory tract infections, and any breastfeeding at 3 months were compared with the data on these outcomes recorded on the PROBIT polyclinic visit forms. Of the 20 audited polyclinic charts, maternal interviews were also carried out for 10. The audit compared the occurrence of 1 or more gastrointestinal tract infections and 2 or more respiratory tract infections. For breastfeeding at 3 months, agreement was considered present if the date of weaning in the polyclinic chart or by maternal interview was within 15 days of the date recorded on the PROBIT polyclinic visit forms.
Of the 17 046 mother-infant pairs enrolled, only 555 (3.3%) were lost at some time during their first year, including 297 (3.4%) in the intervention group and 258 (3.2%) in the control group (Figure 1). However, because information on breastfeeding duration and illness episodes was updated at each clinic visit, analysis of each outcome is based on all infants remaining in the study at the time that outcome was measured, even if they were lost to follow-up before 12 months.
Data Analysis
All outcomes were analyzed based on the intention-to-treat principle, ie, according to randomized allocation to the experimental vs control intervention. But removal of 2 study sites from 2 different original pairs and data falsification at a third site undermined our original plan to analyze the trial data using paired t tests. As recommended by an external monitoring committee, we based our primary analytic strategy on stratification rather than pairing, with multivariate modeling of group- and individual-level covariates to allow statistical inference at the level of individual women and infants. We used a dichotomous stratification for region, west (Brest and Grodno) vs east (all others), and urban vs rural location. We compared the intervention and control groups at baseline using the PROC MIXED procedure in SAS for continuous variables and PROC FREQ for categorical variables (version 6.12; SAS Institute, Cary, NC). The primary analysis of study outcomes was implemented using the GLIMMIX procedure in the same version of SAS, with the cluster as the unit of analysis and cluster-based indicators for region and urban vs rural status. To control for individual-level covariates, multivariate models (using GLIMMIX in SAS) for breastfeeding outcomes contained individual-level terms for birth weight (2500-2999, 3000-3499, 3500 g), maternal age (<20, 20-34, 35 years), and history of having breastfed a previous infant for 3 months for longer (yes vs no). For gastrointestinal and respiratory tract infection, the individual-level covariates included birth weight and number of other children living in the household (0, 1, 2); maternal smoking during pregnancy (yes vs no) was also included for respiratory tract infection. Finally, for analysis of atopic eczema and other rashes, only family atopic history (positive history of asthma, allergic rhinitis, or atopic eczema in the mother, the father, or a sibling) was included as an individual-level covariate. Results of all GLIMMIX models are reported as adjusted odds ratios (ORs) and 95% confidence intervals (CIs).
RESULTS
As shown in Table 1, the randomization produced intervention and control sites with similar distributions of maternal age, maternal education, atopic family history, previous breastfeeding experience, other children living in the household, smoking during pregnancy, cesarean delivery, and infant sex distribution. Small differences in several of these categorical variables are attributable to the cluster-based randomization. The mean birth weight, gestational age, and 5-minute Apgar scores were virtually identical in the 2 groups.
|
|
|
|
Table 1. Baseline Comparison of Intervention and Control Groups*
|
|
|
Table 2 summarizes the audit results for any breastfeeding, 1 or more episodes of gastrointestinal tract infection, and 2 or more episodes of respiratory tract infection. Chance-corrected agreement was high for all 3 outcomes, as shown by the high levels of  , and there was no difference in degree of overreporting or underreporting according to intervention vs control status.
|
|
|
|
Table 2. Audit Results for Main Outcome Measures*
|
|
|
Table 3 and Figure 2 summarize the results for any breastfeeding. In the control group, 60% of mothers (range among sites, 46%-78%) were still breastfeeding to some degree at 3 months, considerably higher than the 50% we had estimated based on data prior to initiating our trial. Nonetheless, the intervention group had significantly higher rates of continued breastfeeding at 3 months (73%; range, 64%-87%) and throughout the first year. Even larger differences were observed for degree of breastfeeding, although extremely low rates of exclusive and, at 6 months, predominant breastfeeding in the control group led to GLIMMIX models that did not adequately converge and hence to unreliable estimates of the adjusted ORs. Statistical significance for these comparisons was assessed using unpaired t tests. The proportion of women exclusively breastfeeding at 3 months was 7-fold higher in the experimental group (43.3% vs 6.4%; P<.001 by unpaired t test) and more than 12-fold higher at 6 months (7.9% vs 0.6%; P = .01). Nearly twice as many women in the intervention group were predominantly breastfeeding at 3 months (51.9 vs 28.3%; adjusted OR, 0.28; 95% CI, 0.16-0.49) and nearly 7 times as many at 6 months (10.6% vs 1.6%; P = .003).
|
|
|
|
Table 3. Frequencies for Any Breastfeeding and Odds Ratios for Having Been Weaned at 3, 6, 9, and 12 Months*
|
|
|
|
|
|
|
Figure 2. Comparison of Proportion of Infants Still Breastfeeding (to Any Degree) During Year of Follow-up
|
|
|
As shown in Table 4, the proportion of infants in the control group who experienced 1 or more episodes of gastrointestinal tract infection in the first year was only 13.2%, far lower than the 60% we had estimated. Nonetheless, the intervention significantly reduced this risk by 40%. For the various respiratory tract infection as outcomes under study, reductions in risk in the intervention group were small and statistically nonsignificant.
|
|
|
|
Table 4. Frequencies and Odds Ratios for Infectious Diseases*
|
|
|
Table 5 summarizes the results for atopic eczema and other rashes. The occurrence of atopic eczema was reduced by 46% in the intervention group, with a similar reduction in the risk for noneczematous rashes. To verify that the reduction in risk of noneczematous rashes was not merely due to protection against viral exanthems and other infection-related rashes, we also examined the risk for occurrence of noneczematous, noninfectious rashes; the risk reduction was of comparable magnitude. Multivariate models showed a significant association between positive family atopic history and both noneczematous rash (adjusted OR, 1.50; 95% CI, 1.22-1.85) and noneczematous, noninfectious rash (adjusted OR, 1.49; 95% CI, 1.20-1.85), suggesting that some of these rashes may have been atopic despite not meeting our clinical criteria for atopic eczema.
|
|
|
|
Table 5. Frequencies and Odds Ratios for Atopic Eczema and Other Rashes*
|
|
|
A total of 49 deaths occurred among study infants during the 12 months of follow-up, 21 in the intervention group and 28 in the control group, for a total infant mortality rate of 2.3 vs 3.7 per 1000 live births, and an adjusted OR of 0.78 (95% CI, 0.52-1.42). Of note was the occurrence of only 1 death attributed to the sudden infant death syndrome (SIDS) among infants in the intervention group vs 5 SIDS deaths among infants in the control group (P = .12 by unpaired t test; multivariate model did not converge).
COMMENT
Our breastfeeding promotion intervention, modeled on the BFHI, succeeded in increasing the duration and exclusivity of breastfeeding in the first year of life. These effects occurred against a background of a higher-than-expected breastfeeding duration in the control group. The latter may well be attributable to deteriorating economic conditions in the country during the trial and the higher costs of formula feeding. Even though locally made formula was readily available, it cost nearly 20% of an average monthly salary by the end of the study. The higher-than-expected breastfeeding duration in the control group might also be due to the receding memory and reduced fear of breastfeeding related to the Chernobyl incident in 1986.
Despite our initial overestimate of the incidence of gastrointestinal tract infection, the risk of such infection was reduced by 40% in the intervention group. This represents a clinically substantial reduction in risk of this important cause of infant morbidity and confirms recent results of a small randomized trial in Mexico.29 The lower-than-expected incidence of gastrointestinal tract infection is probably related to the fact that all of the study infants were breastfed initially and that most, even in the control group, were breastfed for more than 3 months. The prolonged (approximately 3 years in most cases) obligatory maternity leave and absence of day care centers for infants in Belarus probably also played a role. The low incidence of otitis media and wheezing may have a similar explanation. We do not believe the low incidence of gastrointestinal tract infection reflects underreporting because the definition and surveillance methods used were similar to those we used previously in France,28 where the incidence was far higher, and because our routine audits confirmed the figures reported on our data forms.
We observed no significant reduction in risk for the respiratory tract infectious outcomes under study. This may also be due to the universal breastfeeding initiation in our study cohort, as well as the high rates of breastfeeding for 3 months or longer, even in the control group. It also reflects the reduced protective effect of breastfeeding against respiratory tract infection that has been noted consistently in previous epidemiologic studies.1-2,7-8 We do not believe that the absence of a protective effect reflects nondifferential error in measurement of respiratory tract infections because these infections were significantly associated with maternal cigarette smoking (OR, 1.45; CI, 1.17-1.79) for the risk of 2 or more respiratory tract infections.
The experimental intervention also appears to have been successful in reducing the risk of atopic eczema in the first year of life. Although we were surprised that the risk of noneczematous, noninfectious rashes was also reduced in the intervention group, our results suggest that some of these rashes may have been true atopic eruptions that were misclassified by our clinical criteria.
Several limitations of our study should be acknowledged. All of the infectious outcomes were based on clinical criteria; no culture or serologic data were collected. Such data would have added substantial costs and logistical problems to an already large and complex study. Nonetheless, our data audits indicate extremely close agreement between the data recorded on our study data forms and those recorded in the polyclinic charts, as well as high concordance with information obtained from direct maternal interviews. More importantly, we saw no evidence from these audits that infectious outcomes were underreported in the experimental group or overreported in the control group. Because we were unable to audit the data for atopic eczema and other rashes, the apparent protective effect of the intervention on these outcomes should be interpreted with caution. Our experimental intervention may have been insufficient to effect a reduction in respiratory tract infectious outcomes; more prolonged and exclusive breastfeeding than we were able to achieve might have succeeded in reducing respiratory tract infection. Our study did not have sufficient statistical power to detect an effect of the intervention on mortality. Nonetheless, the observed trend toward a reduced risk of SIDS in the intervention group, although not statistically significant, is consistent with several previous epidemiologic studies reporting a protective effect associated with breastfeeding.30
Finally, although basic health services and sanitary conditions are quite similar to those in North America and Western Europe, 2 aspects of the Belarussian health care system may limit the generalizability of our findings. First, the highly centralized Belarussian system undoubtedly helped in implementing the experimental intervention; the intervention maternity hospitals and polyclinics made remarkable changes, documented during our monitoring visits, in their approach to breastfeeding within a very brief prerecruitment period (12-16 months). Second, the prolonged (6-7 days) postpartum stay for routine vaginal deliveries far exceeds those currently found in the West and may help establish good breastfeeding practices and instill maternal confidence.
Despite these limitations, we believe that PROBIT provides an essential scientific underpinning, not only for the BFHI, but for future breastfeeding promotion interventions in both developed and developing country settings. Moreover, the creation of 2 large randomized cohorts with substantial differences in the degree and duration of breastfeeding creates a unique opportunity for future study of longer-term health outcomes, including growth, asthma and other atopic diseases, neurocognitive development, and common adult chronic diseases.
AUTHOR INFORMATION
Other Participating Members of the PROBIT Study Group: Baranovitchi: S. Pleskatch; Berestovitsa: D. Iodkovskaya; Bereuza: S. Prihodovskaya, V. Verzhbitskaya; Bobruisk: T. Tichontchouk; Borisov: G. Khotko, Z. Liamkina; Brest: T. Avdeitchouk, A. Tcherenkevich; Dokshitsy: T. Kiva, Z. Solovjeva; Glubokoe: L. Smolskaya; Klimovitchi: A. Lazarenko, E. Pogodkina; Kobrin: L. Cheveleva; Lepel: G. Kovalevskaya; Minsk: N. Charangovitch, L. Degtiareva, L. Kebikova, L. Lazouta; Mogilev: R. Iaroutskaya, G. Ivanova; Mosty: L. Dorochevitch; Mstislavl: I. Rogatch; Novolukoml: T. Nabedo, V. Savitskaya; Oshmiany: G. Boudilovitch, I. Boulko; Ostrovets: A. Lavrentjeva; Retchitsa: V. Minkova, N. Sentchouk; Rogatchev: M. Kravtsova, L. Tcherkachina; Shchutchin: L. Bout-Gousaim, E. Koutchoun; Slonim: R. Orotchko, A. Tourly; Soligorsk: M. Kotlarova, L. Perepetchko; Stolin: R. Misioura; Svetlogorsk: N. Kotoukhova; Svislotch: P. Mosko, V. Shota; Vitebsk: E. Avsiouk, N. Belousova; Volkovysk: Y. Makovetskaya; and Zhlobin: Z. Bisoukova.
Author Contributions: Dr Kramer participated in the study concept and design, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, obtained funding, supplied administrative, technical, or material support, and provided supervision.
Dr Chalmers participated in the study concept, design, and implementation and monitoring of intervention.
Dr Hodnett participated in the study concept and design, drafting of the manuscript, and obtained funding.
Dr Sevkovskaya participated in trial implementation as chair of the Belarussian Steering Committee.
Dr Dzikovich participated as the data center coordinator.
Dr Shapiro participated in the study concept and design, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, supplied statistical expertise, obtained funding, and supplied administrative, technical, or material support.
Dr Collet participated in the study design and data management.
Dr Vanilovich participated in data collection, management, and quality control.
Ms Mezen participated as the Canada-Belarus liaison.
Mr Ducruet participated in data management and analysis.
Dr Shishko participated as polyclinic coordinator and coordinator for Minsk city and Gromel region.
Dr Zubovich participated as coordinator for the Minsk Vitebsk regions.
Dr Mknuik participated as maternity hospital coordinator.
Dr Gluchanina participated as coordinator for the Mogilev and Grodno regions.
Dr Dombrovskiy participated as coordinator for the Brest region.
Dr Ustinovitch participated in the trial implementation.
Drs Kot and Bogdanovitch and Ms Ovchinikova participated in the trial audits and data quality control.
Dr Helsing participated in the design of the intervention.
Funding/Support: PROBIT is supported by grants from the Thrasher Research Fund, the National Health Research and Development Program (Health Canada), UNICEF, and the European Regional Office of WHO. Dr Kramer is a Distinguished Scientist of the Canadian Institutes of Health Research.
Acknowledgment: We acknowledge the contribution of the numerous obstetricians, pediatricians, midwives, and nurses who helped in implementing the PROBIT intervention, in data collection, or both and that of the nearly 18 000 mothers and infants who participated. We also thank the 3 members of the External Monitoring Committee: Mark Klebanoff, MD, PhD, Division of Epidemiology, Statistics and Preventive Research at the US National Institute of Child Health and Human Development, Bethesda, Md; Allan Donner, PhD, Department of Epidemiology and Biostatistics, University of Western Ontario, London; and Armond Goldman, MD, Department of Pediatrics, University of Texas Medical Branch in Galveston.
Corresponding Author: Michael S. Kramer, 1020 Pine Ave W, Montreal, Quebec, Canada H3A 1A2 (e-mail: mkrame{at}po-box.mcgill.ca).
Author Affiliations: Departments of Pediatrics (Drs Kramer and Collet) and Epidemiology and Biostatistics (Drs Kramer, Shapiro, and Collet and Mr Ducruet), McGill University Faculty of Medicine, Montreal, Quebec; Centre for Research in Women's Health (Dr Chalmers), Sunnybrook and Women's College Health Sciences Centre (Dr Chalmers), and Faculty of Nursing (Dr Hodnett), University of Toronto, Toronto, Ontario; Departments of Maternal and Child Health (Drs Sevkovskaya, Mknuik, and Gluchanina) and Foreign Relations (Ms Mezen), Belarussian Ministry of Health and Belarussian Maternal and Child Health Research Institute (Drs Dzikovich, Vanilovich, Shishko, Zubovich, Dombrovskiy, Ustinovitch, Kot, and Bogdanovitch and Ms Ovchinikova), Minsk, Belarus; and the Nutrition Unit, World Health Organization Regional Office for Europe, Copenhagen, Denmark (Dr Helsing).
REFERENCES
| |
1. Kovar MG, Serdula MG, Marks JS, et al. Review of the epidemiologic evidence for an association between infant feeding and infant health. Pediatrics. 1984;74:615-638.
FREE FULL TEXT
2. Jason JM, Nieburg P, Marks JS. Mortality and infectious disease associated with infant-feeding practices in developing countries. Pediatrics. 1984;74:702-727.
FREE FULL TEXT
3. Feachem RG, Koblinsky MA. Interventions for the control of diarrhoeal diseases among young children: promotion of breast feeding. Bull World Health Organ. 1984;62:271-291.
ISI
| PUBMED
4. Habicht J-P, DaVanzo J, Butz WP. Does breastfeeding really save lives, or are apparent benefits due to biases? Am J Epidemiol. 1986;123:279-290.
FREE FULL TEXT
5. Victora CG, Vaughan JP, Lambardi C, et al. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet. 1987;2:319-322.
ISI
| PUBMED
6. Rubin DH, Leventhal JM, Krasilnikoff PA, et al. Relationship between infant feeding and infectious illness: a prospective study of infants during the first year of life. Pediatrics. 1990;85:464-471.
FREE FULL TEXT
7. Howie PW, Forsyth JS, Ogston SA, Clark A, du V Florey C. Protective effect of breast feeding against infection. BMJ. 1990;300:11-16.
FREE FULL TEXT
8. Cunningham AS, Jelliffe DB, Jelliffe EF. Breast-feeding and health in the 1980's: a global epidemiologic review. J Pediatr. 1991;118:659-666.
FULL TEXT
|
ISI
| PUBMED
9. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr. 1995;126:191-197.
FULL TEXT
|
ISI
| PUBMED
10. Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126:696-702.
FULL TEXT
|
ISI
| PUBMED
11. Raisler J, Alexander C, O'Campo P. Breast-feeding and infant illness: a dose-response relationship? Am J Public Health. 1999;89:25-30.
FREE FULL TEXT
12. Saarinen UM, Backman A, Kajosaari M, Simes MA. Prolonged breast-feeding as prophylaxis for atopic disease. Lancet. 1979;2:163-166.
ISI
| PUBMED
13. Hide DW, Guyer BM. Clinical manifestations of allergy related to breast and cows' milk feeding. Arch Dis Child. 1981;56:172-175.
FREE FULL TEXT
14. Golding J, Emmett PM, Rogers IS. Eczema, asthma and allergy. Early Hum Dev. 1997;49(suppl):S121-S130.
15. Oddy WH, Holt PG, Sly PD, et al. Association between breast feeding and asthma in 6 year old children: findings of a prospective birth cohort study. BMJ. 1999;319:815-819.
FREE FULL TEXT
16. Hill AB. A Short Textbook of Medical Statistics. London, England: Hodder & Stoughton; 1977:27.
17. Sauls HS. Potential effect of demographic and other variables in studies comparing morbidity of breast-fed and bottle-fed infants. Pediatrics. 1979;64:523-527.
FREE FULL TEXT
18. Bauchner H, Leventhal JM, Shapiro ED. Studies of breast-feeding and infections: how good is the evidence? JAMA. 1986;256:887-892.
FREE FULL TEXT
19. Losch M, Dungy CI, Russell D, Dusdieker LB. Impact of attitudes on maternal decisions regarding infant feeding. J Pediatr. 1995;126:507-514.
FULL TEXT
|
ISI
| PUBMED
20. WHO/UNICEF. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Geneva, Switzerland: World Health Organization; 1989.
21. Renfrew MJ, Lang S. Feeding schedules in hospitals for newborn infants [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software;2000; issue 4.
22. Sikorski J, Renfrew MJ. Support for breastfeeding mothers [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software;2000; issue 4.
23. Renfrew MJ, Lang S. Early vs delayed initiation of breastfeeding [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software;2000; issue 4.
24. Renfrew MJ, Lang S. Interventions for improving breastfeeding technique [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software;2000; issue 4.
25. Indicators for Assessing Breast-Feeding Practices. Geneva, Switzerland: World Health Organization; 1991. WHO Document WHO/CDD/SER/91.14.
26. Collet J-P, Burtin P, Kramer MS, Floret D, Bossard N, Ducruet T. Type of day-care setting and risk of recurrent infection. Pediatrics. 1994;94(suppl):997-999.
27. Shipley MJ, Smith PG, Dramaix M. Calculation of power for matched pair studies when randomization is by group. Int J Epidemiol. 1989;18:457-461.
FREE FULL TEXT
28. Gail MH, Byar DP, Pechacek TF, Corle DK. Aspects of statistical design for the community intervention trial for smoking cessation (COMMIT). Control Clin Trials. 1992;13:6-21.
FULL TEXT
|
ISI
| PUBMED
29. Morrow AL, Guerrero ML, Shults J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet. 1999;353:1226-1231.
FULL TEXT
|
ISI
| PUBMED
30. Ford RPK, Taylor BJ, Mitchell EA, et al. Breastfeeding and the risk of sudden infant death syndrome. Int J Epidemiol. 1993;22:885-890.
FREE FULL TEXT
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED LETTER
Health Benefits of Breastfeeding Promotion
James Sargent, Madeline Dalton, Lisa Schwartz, and Michael S. Kramer
JAMA. 2001;285(19):2446-2447.
EXTRACT
| FULL TEXT
RELATED ARTICLES
Breastfeeding in Belarus
Ruth A. Lawrence
JAMA. 2001;285(4):463-464.
EXTRACT
| FULL TEXT
January 24/31, 2001
JAMA. 2001;285(4):475-476.
EXTRACT
| FULL TEXT
Breastfeeding
JAMA. 2001;285(4):490.
PDF
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Moderately preterm infants and determinants of length of hospital stay
Altman et al.
Arch. Dis. Child. Fetal Neonatal Ed. 2009;94:F414-F418.
ABSTRACT
| FULL TEXT
Health and development outcomes in 6.5-y-old children breastfed exclusively for 3 or 6 mo
Kramer et al.
Am. J. Clin. Nutr. 2009;90:1070-1074.
ABSTRACT
| FULL TEXT
Time-modified Confounding
Platt et al.
Am J Epidemiol 2009;170:687-694.
ABSTRACT
| FULL TEXT
The double jeopardy of clustered measurement and cluster randomisation
Kramer et al.
BMJ 2009;339:b2900-b2900.
FULL TEXT
Effect of Hospital Practices on Breastfeeding: A Survey in the Italian Region of Lazio
Asole et al.
J Hum Lact 2009;25:333-340.
ABSTRACT
Effect of breastfeeding on asthma, lung function and bronchial hyperreactivity in ISAAC Phase II
Nagel et al.
Eur Respir J 2009;33:993-1002.
ABSTRACT
| FULL TEXT
Hospital Practices and Women's Likelihood of Fulfilling Their Intention to Exclusively Breastfeed
Declercq et al.
AJPH 2009;99:929-935.
ABSTRACT
| FULL TEXT
Effect of early exclusive breastfeeding on morbidity among infants born to HIV-negative mothers in Zimbabwe
Koyanagi et al.
Am. J. Clin. Nutr. 2009;89:1375-1382.
ABSTRACT
| FULL TEXT
Young Children and Media: Limitations of Current Knowledge and Future Directions for Research
Christakis and Zimmerman
American Behavioral Scientist 2009;52:1177-1185.
ABSTRACT
Breastfeeding Rates in Baby-Friendly and Non-Baby-Friendly Hospitals in the Czech Republic From 2000 to 2006
Mydlilova et al.
J Hum Lact 2009;25:73-78.
ABSTRACT
Breastfeeding and reduced risk of childhood obesity: will randomized trials on breastfeeding promotion give the definite answer?
Ruckinger and von Kries
Am. J. Clin. Nutr. 2009;89:653-655.
FULL TEXT
Reply to S Ruckinger and R von Kries
Kramer and Platt
Am. J. Clin. Nutr. 2009;89:655-655.
FULL TEXT
Does Breastfeeding Protect Against Substantiated Child Abuse and Neglect? A 15-Year Cohort Study
Strathearn et al.
Pediatrics 2009;123:483-493.
ABSTRACT
| FULL TEXT
A Randomized Breast-feeding Promotion Intervention Did Not Reduce Child Obesity in Belarus
Kramer et al.
J. Nutr. 2009;139:417S-421S.
ABSTRACT
| FULL TEXT
Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial
Hoddinott et al.
BMJ 2009;338:a3026-a3026.
ABSTRACT
| FULL TEXT
Early introduction of fish decreases the risk of eczema in infants
Alm et al.
Arch. Dis. Child. 2009;94:11-15.
ABSTRACT
| FULL TEXT
Breastfeeding, Breast-Milk Feeding, Breast Feeding, and IQ: Unknown and Known Knowns--Reply
Kramer and Platt
Arch Gen Psychiatry 2008;65:1458-1459.
FULL TEXT
Primary Care Interventions to Promote Breastfeeding: U.S. Preventive Services Task Force Recommendation Statement
U.S. Preventive Services Task Force
ANN INTERN MED 2008;149:560-564.
ABSTRACT
| FULL TEXT
Interventions in Primary Care to Promote Breastfeeding: An Evidence Review for the U.S. Preventive Services Task Force
Chung et al.
ANN INTERN MED 2008;149:565-582.
ABSTRACT
| FULL TEXT
Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence
Owen et al.
Am. J. Clin. Nutr. 2008;88:305-314.
ABSTRACT
| FULL TEXT
Predominant Breast-Feeding from Birth to Six Months Is Associated with Fewer Gastrointestinal Infections and Increased Risk for Iron Deficiency among Infants
Monterrosa et al.
J. Nutr. 2008;138:1499-1504.
ABSTRACT
| FULL TEXT
Effects of Prolonged and Exclusive Breastfeeding on Childhood Behavior and Maternal Adjustment: Evidence From a Large Randomized Trial: In Reply
Kramer
Pediatrics 2008;122:474-475.
FULL TEXT
Breastfeeding and Child Cognitive Development: New Evidence From a Large Randomized Trial
Kramer et al.
Arch Gen Psychiatry 2008;65:578-584.
ABSTRACT
| FULL TEXT
Decreased Full Breastfeeding, Altered Practices, Perceptions, and Infant Weight Change of Prepregnant Obese Women: A Need for Extra Support
Mok et al.
Pediatrics 2008;121:e1319-e1324.
ABSTRACT
| FULL TEXT
Effects of Prolonged and Exclusive Breastfeeding on Child Behavior and Maternal Adjustment: Evidence From a Large, Randomized Trial
Kramer et al.
Pediatrics 2008;121:e435-e440.
ABSTRACT
| FULL TEXT
Breastfeeding and Infant Illness in Low-Income, Minority Women: A Prospective Cohort Study of the Dose-Response Relationship
Freeman et al.
J Hum Lact 2008;24:14-22.
ABSTRACT
Review of NICE guidelines on routine postnatal infant care
Sellwood and Huertas-Ceballos
Arch. Dis. Child. Fetal Neonatal Ed. 2008;93:F10-F13.
FULL TEXT
Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 y: evidence from a large randomized trial
Kramer et al.
Am. J. Clin. Nutr. 2007;86:1717-1721.
ABSTRACT
| FULL TEXT
Study was not designed to test the hypothesis
Silvers et al.
BMJ 2007;335:899-899.
FULL TEXT
The Burden of Proof: A Commentary on "Is Breast Really Best: Risk and Total Motherhood in the National Breastfeeding Awareness Campaign"
Heinig
J Hum Lact 2007;23:374-376.
Effect of prolonged and exclusive breast feeding on risk of allergy and asthma: cluster randomised trial
Kramer et al.
BMJ 2007;335:815-815.
ABSTRACT
| FULL TEXT
Increasing exclusive breast feeding
Quigley
BMJ 2007;335:574-575.
FULL TEXT
Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial
Su et al.
BMJ 2007;335:596-596.
ABSTRACT
| FULL TEXT
Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign
Wolf
Journal of Health Politics, Policy and Law 2007;32:595-636.
ABSTRACT
Exosomes with Immune Modulatory Features Are Present in Human Breast Milk
Admyre et al.
J. Immunol. 2007;179:1969-1978.
ABSTRACT
| FULL TEXT
Infant feeding method and obesity: body mass index and dual-energy X-ray absorptiometry measurements at 9-10 y of age from the Avon Longitudinal Study of Parents and Children (ALSPAC)
Toschke et al.
Am. J. Clin. Nutr. 2007;85:1578-1585.
ABSTRACT
| FULL TEXT
Communicating the benefits of breast feeding
Ong and Forouhi
Arch. Dis. Child. 2007;92:471-472.
FULL TEXT
Breastfeeding Duration Rates and Factors Affecting Continued Breastfeeding Among Infants Born at an Inner-City US Baby-Friendly Hospital
Merewood et al.
J Hum Lact 2007;23:157-164.
ABSTRACT
Understanding Breastfeeding Behavior: Rates and Shifts in Patterns in Quebec
Haiek et al.
J Hum Lact 2007;23:24-31.
ABSTRACT
Evidence Based Breast-Feeding Promotion: The Baby-Friendly Hospital Initiative
Perez-Escamilla
J. Nutr. 2007;137:484-487.
ABSTRACT
| FULL TEXT
Advances in Our Understanding of the Biology of Human Milk and Its Effects on the Offspring
Schack-Nielsen and Michaelsen
J. Nutr. 2007;137:503S-510S.
ABSTRACT
| FULL TEXT
Poor Compliance with Appropriate Feeding Practices in Children under 2 y in Mexico
Gonzalez-Cossio et al.
J. Nutr. 2006;136:2928-2933.
ABSTRACT
| FULL TEXT
A Systematic Review for the Effects of Television Viewing by Infants and Preschoolers
Thakkar et al.
Pediatrics 2006;118:2025-2031.
ABSTRACT
| FULL TEXT
Racial/Ethnic Differences in Breastfeeding Initiation and Continuation in the United Kingdom and Comparison With Findings in the United States
Kelly et al.
Pediatrics 2006;118:e1428-e1435.
ABSTRACT
| FULL TEXT
Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK?
Bartington et al.
Int J Epidemiol 2006;35:1178-1186.
ABSTRACT
| FULL TEXT
Randomized controlled trial of a prenatal and postnatal lactation consultant intervention on infant health care use.
Bonuck et al.
Arch Pediatr Adolesc Med 2006;160:953-960.
ABSTRACT
| FULL TEXT
Trends in Exclusive Breastfeeding: Findings From the 1990s
Labbok et al.
J Hum Lact 2006;22:272-276.
ABSTRACT
Effect of maternal and neonatal vitamin A supplementation and other postnatal factors on anemia in Zimbabwean infants: a prospective, randomized study
Miller et al.
Am. J. Clin. Nutr. 2006;84:212-222.
ABSTRACT
| FULL TEXT
Full Breastfeeding and Hospitalization as a Result of Infections in the First Year of Life
Paricio Talayero et al.
Pediatrics 2006;118:e92-e99.
ABSTRACT
| FULL TEXT
Predictors of Breastfeeding Duration: Evidence From a Cohort Study
Scott et al.
Pediatrics 2006;117:e646-e655.
ABSTRACT
| FULL TEXT
Breastfeeding Does Not Increase the Risk of Asthma at 14 Years
Burgess et al.
Pediatrics 2006;117:e787-e792.
ABSTRACT
| FULL TEXT
Baby-Friendly: snappy slogan or standard of care?
Philipp and Radford
Arch. Dis. Child. Fetal Neonatal Ed. 2006;91:F145-F149.
ABSTRACT
| FULL TEXT
How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study
Quigley et al.
Arch. Dis. Child. 2006;91:245-250.
ABSTRACT
| FULL TEXT
Risk of Infant Anemia Is Associated with Exclusive Breast-Feeding and Maternal Anemia in a Mexican Cohort
Meinzen-Derr et al.
J. Nutr. 2006;136:452-458.
ABSTRACT
| FULL TEXT
The contribution of parental and community ethnicity to breastfeeding practices: evidence from the Millennium Cohort Study
Griffiths et al.
Int J Epidemiol 2005;34:1378-1386.
ABSTRACT
| FULL TEXT
Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level?
Merten et al.
Pediatrics 2005;116:e702-e708.
ABSTRACT
| FULL TEXT
Breast-Feeding and Cancer: The Boyd Orr Cohort and a Systematic Review With Meta-Analysis
Martin et al.
JNCI J Natl Cancer Inst 2005;97:1446-1457.
ABSTRACT
| FULL TEXT
A Controlled Trial of the Father's Role in Breastfeeding Promotion
Pisacane et al.
Pediatrics 2005;116:e494-e498.
ABSTRACT
| FULL TEXT
What works in breastfeeding promotion?
Scott
The Journal of the Royal Society for the Promotion of Health 2005;125:203-204.
Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey
Merewood et al.
Pediatrics 2005;116:628-634.
ABSTRACT
| FULL TEXT
Breastfeeding and Atherosclerosis: Intima-Media Thickness and Plaques at 65-Year Follow-Up of the Boyd Orr Cohort
Martin et al.
Arterioscler. Thromb. Vasc. Bio. 2005;25:1482-1488.
ABSTRACT
| FULL TEXT
Immigration, Race/Ethnicity, and Social and Economic Factors as Predictors of Breastfeeding Initiation
Celi et al.
Arch Pediatr Adolesc Med 2005;159:255-260.
ABSTRACT
| FULL TEXT
The Baby Friendly Hospital Initiative and breast feeding rates in Scotland
Broadfoot et al.
Arch. Dis. Child. Fetal Neonatal Ed. 2005;90:F114-F116.
ABSTRACT
| FULL TEXT
Breastfeeding and the Use of Human Milk
Section on Breastfeeding
Pediatrics 2005;115:496-506.
ABSTRACT
| FULL TEXT
Infant Health of Mothers with Multiple Sclerosis
Gulick and Johnson
West J Nurs Res 2004;26:632-649.
ABSTRACT
Atopic Dermatitis and Breastfeeding: In Reply
Gillman et al.
Pediatrics 2004;114:1129-1130.
FULL TEXT
Predictors of Hospital Readmission of Manitoba Newborns Within Six Weeks Postbirth Discharge: A Population-Based Study
Martens et al.
Pediatrics 2004;114:708-713.
ABSTRACT
| FULL TEXT
Why are babies weaned early? Data from a prospective population based cohort study
Wright et al.
Arch. Dis. Child. 2004;89:813-816.
ABSTRACT
| FULL TEXT
WIC Participation, Breastfeeding Practices, and Well-Child Care Among Unmarried, Low-Income Mothers
Chatterji and Brooks-Gunn
AJPH 2004;94:1324-1327.
ABSTRACT
| FULL TEXT
Are Pediatric Offices "Supportive" of Breastfeeding? Discrepancies between Mothers' and Healthcare Professionals' Reports
Dillaway and Douma
CLIN PEDIATR 2004;43:417-430.
ABSTRACT
Child Health: Reaching the Poor
Wagstaff et al.
AJPH 2004;94:726-736.
ABSTRACT
| FULL TEXT
Opinions and Practices of Clinicians Associated With Continuation of Exclusive Breastfeeding
Taveras et al.
Pediatrics 2004;113:e283-e290.
ABSTRACT
| FULL TEXT
Interventions to promote breast-feeding: applying the evidence in clinical practice
Palda et al.
CMAJ 2004;170:976-978.
FULL TEXT
Evidence-Based Public Health: Moving Beyond Randomized Trials
Victora et al.
AJPH 2004;94:400-405.
ABSTRACT
| FULL TEXT
Exclusive Breastfeeding Rates and Associated Factors in Swiss Baby-Friendly Hospitals
Merten and Ackermann-Liebrich
J Hum Lact 2004;20:9-17.
ABSTRACT
Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding
Graffy et al.
BMJ 2004;328:26.
ABSTRACT
| FULL TEXT
Smoking cessation in New Zealand: education and resources for use by midwives for women who smoke during pregnancy
Pullon et al.
HEALTH PROMOT INT 2003;18:315-325.
ABSTRACT
| FULL TEXT
Human Milk, Breastfeeding, and Transmission of Human Immunodeficiency Virus Type 1 in the United States
Read and Committee on Pediatric AIDS
Pediatrics 2003;112:1196-1205.
ABSTRACT
| FULL TEXT
Formula feed preparation: helping reduce the risks; a systematic review
Renfrew et al.
Arch. Dis. Child. 2003;88:855-858.
ABSTRACT
| FULL TEXT
Assessing the Validity of Published Randomized Controlled Trials in Podiatric Medical Journals
Turlik et al.
J. Am. Podiatr. Med. Assoc. 2003;93:392-398.
ABSTRACT
| FULL TEXT
Sustained Breastfeeding Rates at a US Baby-Friendly Hospital
Philipp et al.
Pediatrics 2003;112:e234-236.
ABSTRACT
| FULL TEXT
Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding
Kramer et al.
Am. J. Clin. Nutr. 2003;78:291-295.
ABSTRACT
| FULL TEXT
Evaluation of the Impact of the Baby-Friendly Hospital Initiative on Rates of Breastfeeding
Braun et al.
AJPH 2003;93:1277-1279.
FULL TEXT
Evaluation of a Lactation Support Service in a Children's Hospital Neonatal Intensive Care Unit
Gonzalez et al.
J Hum Lact 2003;19:286-292.
ABSTRACT
The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventive Services Task Force
Guise et al.
Ann Fam Med 2003;1:70-78.
ABSTRACT
| FULL TEXT
Clinician Support and Psychosocial Risk Factors Associated With Breastfeeding Discontinuation
Taveras et al.
Pediatrics 2003;112:108-115.
ABSTRACT
| FULL TEXT
Initiation of Breastfeeding Among Mothers of Very Low Birth Weight Infants
Smith et al.
Pediatrics 2003;111:1337-1342.
ABSTRACT
| FULL TEXT
Food Allergen Avoidance in the Prevention of Food Allergy in Infants and Children
Zeiger
Pediatrics 2003;111:1662-1671.
ABSTRACT
| FULL TEXT
The Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in a US Neonatal Intensive Care Unit
Merewood et al.
J Hum Lact 2003;19:166-171.
ABSTRACT
Breastfeeding and the Risk of Hospitalization for Respiratory Disease in Infancy: A Meta-analysis
Bachrach et al.
Arch Pediatr Adolesc Med 2003;157:237-243.
ABSTRACT
| FULL TEXT
Commentary: Breastfeeding and child health, growth, and survival
Kramer
Int J Epidemiol 2003;32:96-98.
FULL TEXT
Diarrhea and Malnutrition
Brown
J. Nutr. 2003;133:328S-332.
ABSTRACT
| FULL TEXT
Factors Influencing Continuation of Breastfeeding in a Cohort of Women
McLeod et al.
J Hum Lact 2002;18:335-343.
ABSTRACT
Breast feeding
Nicoll and Williams
Arch. Dis. Child. 2002;87:91-92.
FULL TEXT
|
