Breastfeeding and Respiratory Tract Infection in Infants

Abstract

Breastfeeding during the first months of life minimizes the likelihood of respiratory tract infections and prevents recurrent infections. Such infections are much more common among formula-fed infants. Numerous studies regarding the subject conclude that formula-fed infants are at a higher risk of being hospitalized with acute respiratory infections than breastfed infants. In line with this observation, the proposed research intends to determine whether breastfeeding during the first six months of life decreases the risk of respiratory tract infections in infants.

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The research will involve a quantitative study of a sample size of 200 infants below the age of six months. Key outcome measures include doctor visits and hospital admission due to respiratory tract infections in the first six months of life. Core exposure measures include the duration of breastfeeding (prolonged – > 6 months; partial – < 4 months). Confounders include older siblings, gender, maternal age, and maternal education. Hypothetically, the incidence of respiratory tract infections in infancy should be inversely related to the extent of breastfeeding.

Keywords: breastfeeding, infants, respiratory tract infections

Introduction

Respiratory tract infections of both viral and bacterial origin cause the highest morbidity and mortality in neonates and infants. This fact is true for both industrialized and developing countries (M’Rabet, Vos, Boehm, & Garssen, 2008). Decreased immune responsiveness and increased susceptibility to respiratory tract infections continue to be present within the first 24 months of life. Despite registering numerous developments in the recent past, respiratory infections continue to be among the leading causes of death among infants globally. In a systematic analysis conducted between 2000 and 2013 regarding the national, regional, and global causes of child mortality, it was approximated that over 935,000 deaths among children below the age of 5 years were instigated by pneumonia (Liu et al., 2015).

Breastfeeding is documented as one of the most cost-effective interventions against such respiratory tract infections among children below 5 years of age (Horta & Victora, 2013). The World Health Organization (WHO) recommends breastfeeding children within the first hour of life and for at least the first six months, with a well-timed introduction to safe, adequate, and properly-fed complimentary food while breastfeeding for the first two years.

Given that the frequency of doctor visits and hospital admission due to respiratory tract infections are often recorded in a pediatric care diary (PCD), the information from these diaries will be used to establish the relationship between the cases of infections and the duration of breastfeeding. It is in line with this reasoning that the proposed research paper intends to establish whether breastfeeding during the first six months of life decreases the risk of respiratory tract infections in infants.

Statement of the Problem

Breastfeeding is an important issue for public health consideration because it provides considerable protection against infections in newborns and infants. If every infant is breastfed within the first hour of life and for the first six months, and partially up to the age of 2 years, approximately 800,000 lives may be saved annually. Currently, less than 40% of infants below the age of six months are exclusively breastfed (WHO, 2015). Since researchers claim that breastfeeding significantly protects infants against infections in both developing and developed countries (Duijts, Jaddoe, Hofman, & Moll, 2010), an increase in breastfeeding globally will profoundly reduce deaths from respiratory infections in infants. Respiratory infections and diseases may be the risk factors for asthma and other acute respiratory diseases in children.

Consequently, the relation between respiratory infections and infant feeding needs to be studied further, especially in relation to infants under six months of age. Taking into consideration that the majority of the studies analyzing the relationship between breastfeeding and respiratory infections are observational and mostly orders than 5 years, the proposed research is intended to improve the insights on the aforementioned relationship in terms of infants below the age of six months. By investigating different feeding regimes in relation to respiratory infections in a prospective birth cohort, the proposed study will document the connection of breastfeeding to respiratory infections as measured by the clinic, doctor, or hospital visits and hospital admissions in the first six months of life.

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Research Purpose

The purpose of this research is to determine whether breastfeeding during the first six months of life decreases the cases of respiratory tract infections in infants. To achieve this objective, the research strives to achieve the following secondary objectives: to determine the relationship between the duration of breastfeeding and respiratory tract infections in infants and to determine the prevalence of exposures and primary outcomes in the first six months of life.

Research Question/Hypothesis

To achieve the primary research objective, the study will address the following question: Does breastfeeding during the first six months of life decrease the incidence of respiratory tract infections in infants?

As an integral part of the proposed study, the researcher included the following hypotheses:

Ha: Breastfeeding during the first six months of life decreases the incidence of respiratory tract infections in infants.

H0: Breastfeeding during the first six months of life has no significant impact on the incidence of respiratory tract infections in infants.

Definition of Terms

Exclusive breastfeeding. Refers to a scenario where only breast milk is given to a newborn during the first six months.

Predominant breastfeeding. Refers to a scenario where breast milk and other water-based fluids are given to a newborn.

Theoretical Framework

The study is designed to determine relationships between breastfeeding and respiratory tract infections in infants. It will employ preventive and responsive paradigms as the logical framework for the study. This research proposes a protective framework to understand the relationship between breastfeeding and the incidence of respiratory infections in infants. The proposed protective paradigm posits that prolonged breastfeeding practice results in fewer illnesses and infections. In infants, lower rates of respiratory infections could be associated with preventive practices.

In other words, infants who are regularly breastfed are healthier than partially breastfed infants. As per the responsive paradigm, parents will detect the infection in infants and seek medical attention or increase the frequency of breastfeeding after being educated by healthcare practitioners. Therefore, it is logical that breastfeeding may serve both protective and responsive roles, especially when considered over a prolonged duration. In the end, the effectiveness of breastfeeding in either a protective or a responsive capacity has a significant impact on the health of an infant.

Literature Review

In any review regarding human breast milk and breastfeeding, it is essential to first highlight the breast milk’s unique and exceptional value to infants. Species specificity entails all the benefits of being breastfed because breast milk is vital beyond its nutritional value (Lawrence, 2010). Human breast milk is beneficial for the fundamental needs of human infants, including the optimal growth of the body and brain, as well as the needed protection against infections. In addition, human breast milk plays a part in the development of the infant’s immunity.

Biological Plausibility of Breastfeeding

The distinct composition of human breast milk provides the ideal nutrients for the optimal body and brain development, especially at infancy. Taurine, cholesterol, and docosahexaenoic acid (DHA) are particularly vital nutrients for infants. Cholesterol is a constituent of the fat globule membrane, and it is present in almost equal amounts in both breast milk and cow milk. In contrast to the cholesterol in cow milk, maternal dietary intake of cholesterol has no impact on the content of cholesterol in breast milk (Lawrence, 2010).

Infant formula, in its turn, lacks human taurine and DHA. Irrespective of the additives manufactured and added to infant formula, the composition is chemically processed under heat, which affects the bioavailability of essential nutrients in infant formula. The optimal bioavailability of essential nutrients, such as micro minerals, implies that the digestion and absorption of breast milk is highly efficient. Compared with modified cow milk and infant formula, breast milk has a better fraction of absorbed nutrients.

Breast milk nourishment is a combination process in which the interaction between nutrients is important. The process of mixing independent nutrients in infant formula fails to guarantee the nutrient benefits gained from natural breast milk. According to Lawrence (2010), the composition of breast milk is an elusive balance of micro- and macronutrients, each in an appropriate proportion to augment absorption. For instance, enzymes present in breast milk contribute to both the digestion and absorption of nutrients. In addition, ligands bind to nutrients to facilitate their absorption. An apt example of the delicate balance is the digestion and absorption of lactoferrin, which binds iron needed for Escherichia coli.

Moreover, Breakey, Hinde, Valeggia, Sinofsky, and Ellison (2015) noted that elevated lactoferrin is positively related to the symptoms of illness. By binding iron, E. coli fails to flourish, providing room for the flourishment of the normal flora of the infant gut, Lactobacillus Bifidus (Lawrence, 2010). Furthermore, the biggest part of the small content of iron in breast milk is absorbed by an infant’s organism, whereas only approximately 10% of the iron in infant formula is absorbed by infants. Most importantly, nutrients, such as natural proteins, are constituents in breast milk, and they have various functions, including the prevention of inflammation and infections, the synthesis of nutrients, the promotion of growth, the catalysis of reactions, and the transportation of micronutrients.

Infection Protection

Breastfeeding is one of the most cost-effective interventions against respiratory infections. Specific antibodies, leukocytes, and other microbial factors present in breast milk protect infants against common infections. Protection against infection of the lower and upper respiratory systems is less recognized but well documented (Chantry, Howard, & Auinger, 2006). Upper respiratory infections include throat infection, ear infection, and serious cold. On the other hand, lower respiratory infections include bronchitis, pneumonia, and bronchiolitis. Such infections result in more emergency room visits, treatment with antibiotics, hospitalizations, and increased healthcare costs for infants who are not adequately breastfed.

The incidence of acute lower respiratory infection in infants has been explored in various studies that investigated the relationship between breastfeeding and respiratory infections or infant formula-feeding and respiratory infections (Chantry, Howard, & Auinger, 2006; Quigley, Kelly, & Sacker, 2007). These studies confirm that breastfed infants are less inclined to respiratory infections. Consequently, infants who are well breastfed are less likely to be hospitalized, and if hospitalized, their condition is usually better than of those infants who are not adequately breastfed.

Breastfeeding Duration and Respiratory Tract Infections in Infancy

Duijts, Jaddoe, Hofman, and Moll (2010) examined the relationship between the duration of exclusive breastfeeding with infections in the low respiratory (LRTI), upper respiratory (URTI), and gastrointestinal tracts (GI) at infancy. The researchers embedded the study in the Generation R Study, in the course of which they conducted a population-based prospective cohort study of infants in the Netherlands.

Breastfeeding rates during the first six months and hospital-attended infections in GI, LRTI, and URTI were determined by the questionnaires for 4164 subjects under the age of 12 months. When compared to infants who have never been breastfed, infants who were breastfed exclusively for a minimum of 4 months and partially breastfed thereafter demonstrated lower risks of infection in GI, LRTI, and URTI until the age of six months (Duijts, Jaddoe, Hofman, & Moll, 2010).

A similar trend was noted among infants who have been exclusively breastfed for over six months. Partial breastfeeding during at least six months had an insignificant impact on the lowering of risks of the contraction of the same infections. One of the conclusions of the research was that the prolongation of breastfeeding improves protection from respiratory tract infections. Duijts, Jaddoe, Hofman, and Moll (2010) reported that exclusive breastfeeding for a minimum of 4 months was associated with a significant reduction of gastrointestinal and respiratory morbidity in infancy. These findings support the existing health policy strategies meant to promote exclusive breastfeeding for at least four months, but most preferably six months.

Breastfeeding and Hospitalizations Secondary to Respiratory Tract Infections in Infancy

According to a recent report from the World Health Organization (WHO) about the short-term effects of breastfeeding, it was noted that breastfeeding is associated with a reduction in the risk of hospitalization secondary to pneumonia and diarrhea (Horta & Victora, 2013). Horta and Victoria (2013) selected observational and randomized researches published in Spanish, French, and English that evaluated the relationships between breastfeeding and respiratory infections or diarrhea in children under 5 years of age. Categorization was in terms of more breastfeeding practices against less breastfeeding practices. They compared partially or not breastfed infants versus exclusively breastfed newborns, infants who have never been breastfed, and those who have been breastfed for six months as opposed to those breastfed for less than 6 months.

The two reviewers used a standardized protocol independently, and they solved differences by consensus. I-square and Q-test were used to assess the heterogeneity of studies. Horta and Victoria (2013) identified 16 observational studies that restricted the analysis of the effect of breastfeeding on respiratory infections in infants below 6 months of age. The study indicated that breastfeeding minimized the risk of hospitalization because of respiratory infections by 57%. Additionally, studies that compared breastfed infants against non-breastfed infants reported a significant positive effect of the aforementioned practice on the rates of hospitalization because of respiratory tract infections.

Methodology

The main purpose of the proposed research is to establish the relationship between breastfeeding and respiratory tract infections in infants below the age of six months. In order to achieve this research objective, there is a need to gather quantitative data from identified healthcare institutions in the selected location. The proposed study is quantitative in nature. Some of the key methodological aspects of the study include research design, study population, informed consent, data collection, and instrumentation.

Research Design

The proposed research will employ a quantitative research design in exploring the relationship between breastfeeding and respiratory tract infections. The choice of the quantitative research approach is based on the quantitative nature of the proposed study. The researcher will employ a multimethod quantitative approach. Quantitative research entails the collection and analysis of numerical data. On the other hand, qualitative research focuses on textual data. The quantitative nature of the proposed research arises from the fact that it will have certain descriptive, correlational, and confirmatory aspects. According to Fischer (2007), descriptive research allows us to classify and identify participants’ traits and ascertain the relationships that exist between the variables of concern.

The study will use independent and dependent variables to determine the association between them. In the proposed research, the independent variable will be the duration of breastfeeding, whereas the dependent variables will be the frequency of doctor visits and hospital admissions secondary to respiratory tract infections. In regard to confirmatory research, a set of priority hypotheses has been generated from the literature review, where it was summarized that prolonged breastfeeding reduces hospital visits and admissions caused by respiratory tract infections.

Population and Sample

The study population will entail infants below the age of six months. The investigator seeks to generalize the results of the study to the population of interest. Since the target population is relatively large, a prospective birth cohort study sample of 200 infants selected randomly from various healthcare institutions in the chosen geographical location will be used. A total of 200 women at the stage of 8 weeks gestation will be enrolled. Data that will be collected from the parents at the time of enrollment include socioeconomic status and respiratory health. The number of successful births at the end of the pregnancy phase will also be noted to highlight the exact number of subjects to follow up for six months. Diversity in the sample in terms of gender and race is also expected.

Ethical Considerations

The research involving human subjects demands that the researcher provides participants with enough information regarding the study for the participants to make an informed consent. In the proposed study, the parents of the infants will be given sufficient information to decide whether or not to provide their infants’ information to the researcher. Additionally, no participant will be subjected to discomfort or harmed during the survey.

Instrumentation

Parents will be provided with a pediatric caregiver diary (PCD) at the time of their infants’ birth and will be requested to fill the diary on a daily basis throughout the first six months by recording breastfeeding history and respiratory tract infections. The PCD to be used in the research evolved from the pediatric asthma diary, a research instrument designed and validated to evaluate the effectiveness of asthma interventions among children (Santanello et al., 2005).

The independent variable is the duration of breastfeeding. The outcome measures include doctor visits and hospital admission due to respiratory tract infections in the first six months of life. The main exposure measures include the duration of breastfeeding, which can either be partial or exclusive. The recorded illnesses must only be the ones that led to doctor visits or hospital admissions.

After a period of six months, the parents will fill a questionnaire based on the PCD as a prompt for recalling actions. The validation of hospitalization data from the PCD will be conducted by counterchecking parents’ reports against the hospital’s records to ensure that parental recall is reliable and valid (Santanello et al., 2005). To ensure that the information collected by means of the questionnaires is valid, Cronbach’s alpha will be used to establish internal consistency (Fisher, 2007). Typically, Cronbach’s alpha ranges from 0 to 1, whereby 1 indicates higher reliability, and 0 indicates lesser reliability.

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Data Collection and Analysis

A primary research approach, entailing questionnaires and structured interviews, will be used to collect primary data. Breastfeeding data will be recorded prospectively in the pediatric caregiver diary by the parents and later transcribed to the six months questionnaire by a pediatric nurse through a structured interview. The structured nature of the questionnaire will enable the researcher to collect precise information for data analysis. Information regarding either upper or lower respiratory tract infections will be collected using questionnaires.

Additionally, semi-structured interviews will be essential in collecting open-ended information from parents. The statistical analysis of the numerical data gathered from the pediatric diaries will make use of the Statistical Package for the Social Sciences (SPSS) software. The statistical significance test will be based on a series of covariates and logistic regression.

Discussion/Significance of the Study

The proposed study is limited to 200 subjects randomly selected from various healthcare institutions. Therefore, it assumes that the findings are generalizable to the target population. Breastfeeding has long been explored and documented to protect infants from infections, but protection against respiratory tract infections has not been consistently illustrated in studies in both industrialized and developing countries. Consequently, the findings of this research will not only supplement the existing vast literature about the benefits of breastfeeding but also set a foundation for future research in neonatal care.

Moreover, the study findings will add to the growing evidence that exclusive breastfeeding is positively correlated with a child’s growth and development. The results of the study will provide crucial insights regarding the benefits of breastfeeding as it relates to the improvement of immunity in infants. Prolonged breastfeeding will greatly benefit public health. Additionally, the results of the research may be used to determine the cost-effectiveness of breastfeeding interventions.

Conclusion

The main objective of the proposed research is to determine the relationship between breastfeeding and respiratory tract infection in infants. The research hypothesizes that the degree to which an infant is breastfed has a positive impact on an infant’s resistance to respiratory tract infections. The literature review confirms that breastfeeding, especially when exclusive and prolonged, protects infants against respiratory infections. Therefore, the quantitative study is expected to reveal significant correlations between breastfeeding and the prevention of respiratory tract infections in infants.

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