Indian Pediatrics 1999; 36:484-487 

Hospital Induced Malnutriton in Infants: Prevention by Relactation

Protein-energy malnutrition is still a major cause of health problems in infants in Brazil, despite the decrease in its prevalence in recent years. At hospital level, the rate of malnutrition has been still around 40% in the last decades, significantly contributing to the increase in child mortality(1). Although, hospital induced malnutrition has not yet been well studied, it is of great relevance for poor countries(2). Because of their high rate of growth and vulnerability to infectious agents, infants are the age group most at risk for mal- nutrition. Respiratory and intestinal infections which are major causes of hospital admissions in children in low income areas are associated with a worsening in nutrition status, as they increase the caloric rate and decrease the food intake(3).

Breast milk, mainly through its anti-infectious and nutritional values is thought to protect the nutritional status of hospitalized infants from infectious diseases such as diarrhea and pneumonia. In children who are no longer breastfed or are only partially breastfed, relactation is possible if the mother is made aware of its importance and is well sup- ported ( 4,5). The objective of this study was to compare the incidence of hospital induced malnutrition in infants with diarrhea or pneumonia who were relactated with those who were not during hospitalisation.

Subjects and Methods

This study included 163 infants aged between 30 to 90 days who were hospitalized due to diarrhea or pneumonia at the Instituo Materno Infantile de Pernambuco (IMIP) in Recife, northeast of Brazil, from March 1996 to May 1997. Children with edema, severe malnutrition, sepsis, shock, congenital mal- formation or metabolic diseases were ex- cluded, as were those who had breastfed in the previous 2 weeks. Baseline data was obtained for all infants on demographic, socio- economic and clinical characteristics.

Mothers were counselled regarding ad- vantages of breast milk and were encouraged to reinitiate breastfeeding, by repeatedly suck- ling their babies at breast 10 to 15 minutes on each breast 10 to 12 times per day. Babies who refused to breastfeed were given a lactaid supplementator(6). These children remained receiving top milk during the entire period of hospital admission, which was also offered 10 to 12 times daily. Relactation or complete re-establishment of milk supply was defined as the successful re-introduction of exclusive breastfeeding in a child who had not been receiving breast milk.

The outcome variable was hospital induced malnutrition, defined as the loss of weight during hospital stay. This was compared between relactated and non-relactated children. Three weight measurements were taken each day, one hour after the first feeding in the morning. The first two were carried out independently by two assistant doctors of the Pediatric Ward using a Filizola scale (pesabebe, Brazil). The third measurement was taken on a Soehnle-Waagen (GMBM, Ger- many) electronic scale. The mean of the three values was used unless one of the measurements was different from the other 2 by more than 30 g, in which case the mean of the 2 closest values was used.

Data were entered and analyzed in EPI-INFO 6.0 (CDC, USA). The proportions of children who developed hospital malnutrition (i.e., lost weight) in each group were compared by using chi square test. Means are compared by '1' - test..

Results

The mean age of the infants was 42 days (SD=17 days). Ninety three (57.1%) were male and 70 (42.9%) female. The study included 92 children with acute diarrhea and 71 with pneumonia. Before admission, all children were receiving top milk. One hundred and nine (66.9%) patients had never breastfed and the remaining 54 (33.1 %) had started breastfeeding but stopped at least 2 weeks before this study. Of the children who had never breastfed, 29 (64.4%) were in the relactated group and 80 (67.8%) in the non-relactated group. The mean hospital stay was 6.9 days (SD=1.7 days). At baseline relactated and non-relactated infants were broadly similar (Table I).
 

TABLE I

Baseline Comparison Between Relactated and Non-relactated Infants
 

Characteristic	Relactated (n-45)	Non-relactated (n-118)
Male sex	25 (55.6)	69 (58.4)
Age 1-2 months	22 (48.9)	52 (44.0)
Low birth weight	8 (17.7)	22 (18.6)
previous breastfeeding  Malnutrition	16 (35.6)	38 (32.3)
(<p10 weight/age)	20 (44.4)	54 (45.7)
Infant with diarrhea	20 (44.4)	72 (61.0)
> 10 stools passages/day (n-92)	1 (5.0)	4 (5.6)
Infants with pneumonia	25 (55.6)	46 (39.0)
Chest indrawing (n-71)	3 (12.0)	6 (13.0)
Mothers age 20-40 yrs old Mothers education	30 (66.3)	80 (67.9)
< 4 years of schooling Family income	41 (91.1)	116 (98.3)
<$30 per capita	21 (46.6)	56 (47.4)

Figures in parentheses indicate percentages

TABLE II
 Risk of Hospital Induced Malnutrition in Non-relaetated and Relaetated Infants.
 

	Hospital induced malnutrition
Relactation	Yes (%)	No (%)	Total	Risk ratio (CI 95%)
No	61 (51.6)	57 (48.3)	118	1.00
Yes	7 (15.5)	38 (84.5)	45	0.30
0.15-0.61
Total	68 (41.7)	95 (58.2)	163

P <0.001.

Relactation was obtained in 45 cases (27.6%). Forty one percent of the sample had hospital induced malnutrition, i.e., lost weight during the hospital stay. In the group of relactated children there was a lower incidence of hospital induced malnutrition than in the non-relactated group (Table II); risk ratio = 0.30; 95% CI: 0.15 to 0.61. The average weight gain was 181 g in relactated. infants and 107 g in non-relactated infants (p <0.00l).

Discussion

Hospital induced malnutrition does not seem to be rare. Despite the small number of papers about the subject, mainly in populations with low socio-economic and health status like ours, the few available studies have shown the importance and seriousness of the problem(7,8). In our study, 41.6% of the infants showed hospital induced malnutrition.
Breast feeding among low income infants may decrease the number of cases of diarrhea by four times and of malnutrition, three times, and leads to a significant weight gain(9). At a primary level, the practice of exclusive breast feeding must be the most efficient measure to prevent and to control malnutrition and infection among infants. At hospital level, despite the small number of studies, breastfeeding

seems to contribute to a better prognosis, even in patients in Intensive Care Unit(10). Un- fortunately, the frequency and duration of breastfeeding is still low in ourregion(1); none of the hospitalized children for diarrhea or pneumonia during the period of our study were being exclusively breast-fed.
Relactation, by which is meant the process of restimulation of the lactation, can be obtained in a high percentages of cases, so long as the mother desires so and there is also strong support from the health team. Successful relactation has been reported in even up to 75% of his patients. In our study, with ill infants, we obtained relactation in 27.6% of the cases.

In this study the practice of exclusive breast feeding decreased the incidence of hospital induced malnutrition significantly, as compared to top milk feeding. This suggests that relactation is a feasible and effective intervention which may benefit many acutely ill children. This was an observational study, in which a potential beneficial measure, i.e., relactation was attempted in all individuals; thus any ethical constraints of a randomized trial were avoided. Nonetheless, relactated infants were similar to those who were not relactated in respect to many variables which may have affected the incidence of malnutrition. Therefore we believe that the reduced incidence of weight loss among infants in the relactated group was indeed largely a consequence of the successful relactation. The explanation for the positive effect of relactation, in addition to the anti-infectious action and nutritive value of human milk, is possibly also related to the increased food intake by these ill infants. There is evidence that breast milk is also an important nutrient source for sick children, offering better protection against reduced intake during infections(9). Hoyle et al. found that anorexia induced by diarrhea is better controlled with human milk(10). Another advantage of breastfeeding is that there is no previous timetable for the meal, and the child will be fed only according to his/her wish. In conclusion, we believe that in poor. regions, relactation in hospitalized infants must be stimulated to reduce hospital induced malnutrition in infants.
 

 References

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2. Dilkerson J. The problem of hospital induced malnutrition. Nurs Times 1995; 91: 44-45.

3. Victora CG, Barros FC, Kirkwood BR, Baughan JP. Penumonia, diarrhea, and growth in the first 4 years of life: A longitudinal study of 5914 urban Brazilian children. Am J Clin Nutr 1990; 52: 391-396.

4. Banapurmath CR, Banapurmath SC, Kesaree N. Initiation of relactation. Indian Pediatr 1993; 30: 1329-1332.

5. Auerbach K. Extraordinary breast feeding: Relactation/induced lactation. J Trop Pediatr 1981; 27: 52-55.

6. Lawrence RA. Breastfeeding: A guide for the Medical Profession, 3rd edn. St Louis, CV Mosby Company, 1989; pp 431-448.

7. Brown RE. Relactation with reference to application in developing countries. Clin Pediatr (Phila) 1978; 17: 333-337.

8. Chaturvedi P. Relactation. Indian Pediatr 1994; 31: 858-860.

9. Auerbach KG, Avery JL. Relactation: A study of 366 cases. Pediatrics 1980; 65: 236-242.

10. Hoyle B, Yunus M, Chen LC. Breastfeeding and food intake among children with acute diarrheal disease. Am J Clin Nutr 1980; 33: 2365-2371.