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Exclusive breastfeeding duration during the first 6 months of life is positively

associated with length-for-age among infants 6–12 months old, in Mangochi
district, Malawi

Article  in  European Journal of Clinical Nutrition · August 2014

DOI: 10.1038/ejcn.2014.148 · Source: PubMed

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 European Journal of Clinical Nutrition (2015) 69, 96–101
© 2015 Macmillan Publishers Limited All rights reserved 0954-3007/15
www.nature.com/ejcn

ORIGINAL ARTICLE
Exclusive breastfeeding duration during the first 6 months of
life is positively associated with length-for-age among infants
6–12 months old, in Mangochi district, Malawi
P Kamudoni1, K Maleta2, Z Shi3 and G Holmboe-Ottesen1

OBJECTIVES: To examine the association between breastfeeding pattern and growth in the first year of life.
METHODS: A cross-sectional survey was carried out on 349 mothers with infants o12 months in a rural and a semi-urban
community in Mangochi district, Malawi. Data on socio-demographic characteristics, infant weight, length and feeding patterns
since birth were collected. Multivariate linear regression was performed to test the association between feeding pattern and infant
anthropometric status.
RESULTS: Exclusive breastfeeding (EBF) until 6 months was practised by 13.1% semi-urban and 1.3% rural mothers. No infant was
exclusively breastfed beyond 6 months. Breastfeeding was continued among all infants who had stopped EBF. Among infants
6–12 months of age, duration of EBF during the first 6 months was positively associated with length-for-age Z-score (LAZ)
(regression coefficient = 0.19, 95% confidence interval: 0.06, 0.31) in a model adjusted for socio-demographic factors. Urban
residence and female gender yielded positive associations in the same model. The model explained 27% of the variation in LAZ.
Among infants o6 months, duration of EBF was not significantly associated with LAZ, but being female and urban residence
yielded positive associations. Breastfeeding patterns were not associated with weight-for-age Z-score (WAZ) or weight-for-height
Z-score (WLZ) either in the 0–6-month or in the 6–12-month group. Birth outside a health facility was negatively associated with
WAZ and WLZ in the older group.
CONCLUSION: EBF in the first 6 months of life was associated with increased linear growth, but not weight gain, in later infancy.
Promotion of EBF could reduce the prevalence of chronic child undernutrition in the study area.
European Journal of Clinical Nutrition (2015) 69, 96–101; doi:10.1038/ejcn.2014.148; published online 6 August 2014

INTRODUCTION all the dietary requirements of infants in the first 6 months.9

Undernutrition is a critical health and welfare problem among However, there has been variation in the actual reported effect
infants and young children under 5 years in developing countries.1 sizes of duration of EBF in the first 6 months or the duration of
Although numerous studies have elucidated its causes, progress in continued breastfeeding thereafter on growth.10–13
addressing it has been slow and even non-existent in some Earlier studies in Malawi have looked at the effect of either
countries.1 The lack of progress may point to the fact that there is partial or predominant (that is, breastfeeding supplemented with
no single model that can be universally applied to understand and fluids only) but not EBF on growth. For instance, in a cross-
intervene against child undernutrition. Even in homogeneously sectional study by Kerr et al.,14 a shorter predominant breastfeed-
poverty-stricken communities where its prevalence is high, there ing duration in the first 6 months was reported to be associated
are children who grow and thrive optimally.2 It is this scenario that with poor weight-for-age and weight-for-length, but not with
necessitates the gathering of robust evidence to better under- length-for-age, among 6–48-month-old infants. Findings from a
stand factors associated with this problem in any given context. longitudinal study by Kalanda et al. on mother–infant pairs from
Over a third of the burden of child undernutrition in the world is birth to 12 months showed a similar trend. The study reported
present in the sub-Saharan Africa.1 Malawi has the second highest that a longer predominant breastfeeding duration in the first
rate of stunting among under-five children in this region, 6 months was associated with better weight-for-age at 3, 6 and
amounting to 49%, which has hardly declined in the past 15 9 months; and also improved length-for-age at 9 months although
years.3 not before then.15 However, findings from another Malawian
The conceptual framework of the causes of undernutrition, as longitudinal study by Espo et al.,16 with a follow-up from birth to
suggested by UNICEF and other studies, shows dietary intake to 36 months, showed that a longer predominant breastfeeding
be immediate and socio-economic status to be distal in the causal duration in the first 6 months was not associated with weight-
pathway of child undernutrition.4–8 Exclusive breastfeeding (EBF; for-age but with better length-for-age at 12 months.
that is, giving infant breast milk only, and if necessary—medicinal In the present study we sought to investigate the effect of
supplements) until 6 months of age has been recommended by breastfeeding pattern on growth in the Malawian context; by
the World Health Organization (WHO) to be adequate in meeting examining the extent to which an infant’s anthropometric status

1
Department of Community Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; 2Department of Community Health, College of Medicine, University of Malawi,
Blantyre, Malawi and 3Population Research and Outcome Studies, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia. Correspondence:
Dr P Kamudoni, Department of Community Medicine, Faculty of Medicine, University of Oslo, PO Box 1130, Blindern, 0318 Oslo, Norway.
E-mail: [email protected] or [email protected]
Received 29 March 2013; revised 11 June 2014; accepted 24 June 2014; published online 6 August 2014
 Infant anthropometrical status in Malawi
P Kamudoni et al
97
in the first year of life is associated with the duration of EBF during Statistical analysis
the first 6 months relative to breastfeeding supplemented with Data from all 349 mother–infant pairs were entered in an Access database
water or complementary foods during the same period. (Microsoft Office, Oslo, Norway) and analysed using Statistical Package for
Social Scientists (PASW, IBM, Oslo, Norway). WHO Anthro was used to
calculate Z-scores from the anthropometric measurements.
MATERIALS AND METHODS Descriptive analyses of the Z-scores were used to summarise the
Sample and procedures prevalence of infants who were stunted, underweight and wasted. The
association between feeding patterns and anthropometric status (LAZ,
A cross-sectional study was conducted in two communities in Mangochi WAZ and WLZ) was assessed by multivariable linear regression analysis.
district, Malawi, from August to December 2004. Mangochi is a relatively Inclusion of explanatory variables into the models was based on the
less urbanised district with higher infant mortality rates than the rest of the strength of association (with any of the outcomes: LAZ, WAZ and WLZ) in
country.17 The study communities were 36 km apart and included a bivariate analysis (Po 0.10) and our understanding of the aetiology of
remote rural community, Lungwena, and a semi-urban locality, Mangochi undernutrition. Analyses were separate for infants o6 months and those
Township. The sample was 349 mother–infant pairs with the infants aged over 6 months of age. Two models were constructed. In the first model,
0–12 months. Participation was limited to infants from singleton births (as age and sex were adjusted for. In the second model, socio-demographic
multiple birth infants may likely have unusual feeding patterns) and variables were adjusted for. The effect of cluster sampling was tested using
mothers who had been resident in the studied area for 6 months mixed linear modelling where clustering was taken into account as a
preceding the study. random effect. However, no effect was detected. Multicollinearity among
One-stage cluster sampling was used for selecting the participants. explanatory variables was checked using a variance inflation factor
Livelihoods forms and dietary patterns were similar in the study area. In exceeding a cut off of 10. Two variables (age and duration of
addition, the entire study area was served by the same health facility. Thus, complementary feeding after 6 months) were detected as being collinear
we assumed that clustering would not yield any biases and, hence, did not in the linear regression modelling of the 46-month group. Therefore, the
adjust the sample size for the cluster sampling design. Local government models for this group were re-run using only one or the other of the two
wards served to designate clusters in Mangochi Township. Random collinear variables. The models that had the lower Akaike information
numbers were allocated to all the 10 wards of the township. The wards criterion and Bayesian information criterion values (a better fit to the data)
were selected in ascending order of their random numbers until the were selected, that is, the model where duration of complementary
feeding after 6 months was included and not age. No variables were found
required number of respondents was obtained. All mother–infant pairs
to be collinear in the modelling for the o 6-month group. EBF duration
who met the inclusion criteria in a selected ward were enrolled. A similar
was determined using survival analysis, in which case the event of interest
procedure was repeated to select participants in Lungwena where villages was the first time that non-breastmilk fluids/foods were introduced.
served as clusters. Three of the 10 wards were selected in Mangochi while Therefore, if an infant was still being exclusively breastfed at the time of
5 out of 26 villages were selected in Lungwena. A total of 192 (55%) and the interview, its EBF duration was the same as its age at the time of the
157 (45%) mothers were recruited in Mangochi Township and Lungwena, interview. Cox regression was used to identify the determinants of EBF. The
respectively. details of the cox regression have been presented elsewhere.16
The sample size was adequate to detect a minimal difference of at least
0.5 length-for-age Z-scores (LAZ) between infants who had been
exclusively breastfed for at least 4 months and those breastfed for less RESULTS
at an α error of 0.05 and power (1 − β) of 0.80.
Feeding patterns and anthropometric status
We collected data on socio-demographic factors and feeding patterns
through interviews using a structured questionnaire. Infants’ lengths and The infants’ age were fairly evenly distributed between 0 and
weights were measured during the interviews. The questionnaire was 12 months as shown in Table 1.
pretested among 40 eligible mothers in a nearby non-study area and Sixty-five percent of the mothers had initiated breastfeeding
adapted accordingly. For consistency all interviews and anthropometric within the first hour of the infant’s birth. Breastfeeding patterns
measurements were conducted by the first author. differed by area of residence. EBF until 6 months was practised by
7.5% of all the mothers, that is, 13.1% of the semi-urban and 1.3%
Measures of the rural mothers. None of the infants were exclusively
Socioeconomic status. Socioeconomic status was measured based on a breastfed beyond 6 months. However, all the infants who had
total score summed up from a selection of household assets. Each asset stopped EBF (had started receiving complementary foods/non-
was given a score relative to its monetary value and functionality as caloric fluids) were still continuing breastfeeding.16 The rural
follows: car = 8; fridge or TV or motorcycle or fishing canoe = 4.0; mattress mothers were mainly subsistence farmers/casual farm labourers
or bicycle = 2.0; radio = 1.0; blankets = 0.5; mosquito net = 0.25. The range (63%) or small-scale traders (22%), whereas the semi-urban
of scores in the sample was 0–8.75. Total scores below 25th percentile mothers were mainly unemployed (71%) and small-scale traders
were categorised as ‘very poor’; 25th–75th percentile as ‘poor’; and above (27.1%).
75th percentile ‘better-off’. Prevalences of stunting and underweight, based on the 2006
WHO growth standards, are shown in Table 1. Stunting and being
Anthropometric status. Infant’s anthropometric status was assessed using underweight were higher among rural than semi-urban infants
the 2006 WHO growth standards for the three variables: (Table 1). Wasting was fairly similar in the two areas. Bivariate
LAZ: dichotomised as stunted/not stunted, of which o− 2 Z-scores was associations between LAZ, WAZ or WLZ and socio-demographic
stunted.
Weight-for-age Z-scores (WAZ): dichotomised as underweight/not
characteristics are shown in Table 1; bivariate associations with
underweight, of which o− 2 Z-scores was underweight. feeding patterns (among infants 6–12 months of age) in
Weight-for-length Z-scores (WLZ): dichotomised as wasted/not wasted, Supplementary Table.
of which o− 2 Z-scores was wasted.
Recumbent length to the nearest 0.1 cm was taken using a locally made Factors associated with anthropometric status among 0–6-month-
length board placed on a flat surface. Weights were taken by using a old infants
standardised digital bathroom scale with 100 g increments. It was placed
on a flat surface and calibrated daily using a weight of 1 kg. The infant’s EBF was not associated with LAZ, WAZ or WLZ among infants
weight was calculated by subtracting the mother’s weight from her weight o6 months in multivariate linear regression analysis either before
while carrying her infant as described by Espo et al.16,18 The infants were or after adjusting for socio-demographic variables. Results (with
nude during the measurement of weights. Three repeated weight LAZ and WAZ as outcomes) of the linear regression modelling are
measurements were taken per mother/mother–infant pair to prevent shown in Table 2a. Male gender was negatively associated with
measurement and recording bias. One of the three measurements that both LAZ and WAZ both before and after adjusting for socio-
coincided best with one of the other two was recorded. demographic variables. However, rural residence was associated

© 2015 Macmillan Publishers Limited European Journal of Clinical Nutrition (2015) 96 – 101
 Infant anthropometrical status in Malawi
P Kamudoni et al
98
Table 1.
Mean Z-scores of length-for-age, weight-for-age and weight-for-length based on 2006 WHO growth standards for infants by socio-
demographic factors (N = 349)

Length-for-age Weight-for-age Weight-for-length

a b
% Stunted Z-score P-value Underweight Z-score P-value Wastedc Z-score P-value
(%) (mean ± s.d.) (%) (mean ± s.d.) (%) (mean ± s.d.)

Total sample 100 17 − 0.80 ± 1.54 17.8 − 0.77 ± 1.61 13.3 − 0.30 ± 1.92

Infant characteristics
Age 0.560 0.870 0.570
0–3.00 25.0 16.1 − 0.81 ± 2.00 18.4 − 0.73 ± 1.93 17.6 − 0.14 ± 2.31
3.01–6.00 29.3 13.7 − 0.63 ± 1.42 19.6 − 0.75 ± 1.75 17.6 − 0.35 ± 2.26
6.01–9.00 24.1 20.2 − 0.89 ± 1.32 14.3 − 0.73 ± 1.28 3.6 − 0.19 ± 1.35
9.01–12.00 21.6 18.7 − 0.93 ± 1.33 18.7 − 0.91 ± 1.32 13.3 − 0.53 ± 1.41
Sex o 0.001*** o0.001*** 0.120
Female 49 10 − 0.42 ± 1.40 11.8 − 0.41 ± 1.50 10.6 − 0.13 ± 1.86
Male 51 22.7 − 1.17 ± 1.58 23.3 − 1.12 ± 1.63 15.9 − 0.45 ± 1.96

Socio-demographic/-economic characteristics
Food shortage 0.070 0.210 0.870
None 44.4 9.7 − 0.64 ± 1.56 15.6 − 0.65 ± 1.74 12.3 − 0.28 ± 2.01
⩾1 month 55.6 21.9 − 0.93 ± 1.52 19.3 − 0.87 ± 1.49 14.1 − 0.31 ± 1.01
Area of residence o 0.001*** 0.010** 0.680
Semi-urban 45 10.5 − 0.45 ± 1.37 13.6 − 0.56 ± 1.44 13.6 − 0.33 ± 1.75
Rural 55 23.9 − 1.24 ± 1.63 22.6 − 1.02 ± 1.76 12.9 − 0.25 ± 2.10
Place of birth 0.020* o0.001*** 0.050*
Within a health 31.5 13.6 − 0.68 ± 1.57 13.2 − 0.59 ± 1.62 11.5 − 0.16 ± 1.91
facility
Outside a health 68.5 22.7 − 1.09 ± 1.42 27.3 − 1.18 ± 1.50 17.3 0.60 ± 1.91
facility
Literacy 0.060 0.020* 0.250
Literate 52.7 12.3 − 0.64 ± 1.63 12.3 − 0.55 ± 1.62 10.5 − 0.17 ± 1.76
Illiterate 47.3 20.1 − 0.95 ± 1.45 12.3 − 0.97 ± 1.58 15.8 − 0.41 ± 2.04
Assets ownership 0.170 0.030* 0.260
Very poor 25.1 24.1 − 1.04 ± 1.48 23.0 − 1.14 ± 1.46 17.2 − 0.58 ± 1.95
Poor 59.7 15.9 − 0.76 ± 1.42 15.9 − 0.68 ± 1.51 12.1 − 0.21 ± 1.84
Well-off 15.2 9.4 − 0.56 ± 2.01 15.1 − 0.49 ± 2.06 9.6 − 0.12 ± 2.13
Parity 0.810 0.950 0.770
⩾2 62.8 16.4 − 0.79 ± 1.63 18.3 − 0.77 ± 1.63 13.8 − 0.32 ± 1.89
o2 37.2 17.8 − 0.83 ± 1.39 17.1 − 0.78 ± 1.58 12.4 − 0.26 ± 1.96
Abbreviation: WHO, World Health Organization. P-values correspond to comparisons across mean Z-scores. aStunted was defined as o −2 length-for-age
Z-scores. bUnderweight was defined aso−2 weight-for-age Z-scores. cWasted was defined as o−2 weight-for-height Z-scores. *Significant difference at
Po0.05, **Significant difference at Po 0.01, ***Significant difference at Po 0.001.

(negatively) with LAZ (Table 2a) only. None of the socio- predominant breastfeeding (that is, breastfeeding supplemented
demographic variables yielded an association with WLZ. The with water or fluids) on infant growth. We have found that EBF
models explained 13% of the variation in LAZ and 9% in WAZ. duration in the first 6 months of life was positively associated with
linear growth (LAZ) in later, but not in early, infancy. However, we
Factors associated with anthropometric status among found no association between EBF in the first 6 months and
6–12-month-old infants weight gain (WAZ or WLZ) in either phase of infancy. We also
In both model 1 and model 2, EBF duration before 6 months observed that being male and living in a rural area were
exhibited a positive association with LAZ, whereas breastfeeding negatively associated with LAZ in both age groups. Birth outside
supplemented with water or complementary foods before a health facility exhibited a negative association with WAZ and
6 months did not (Table 2b). Results (with LAZ and WAZ as WLZ in the 6–12-month group.
outcomes) of the linear regression analyses for the 6–12-month
group are shown in Table 2b. No significant association was Association between EBF and anthropometric status
observed between EBF and WAZ or WLZ. Rural residence and male Similar studies elsewhere have arrived at varying results with
gender were also associated (negatively) with LAZ. Birth outside a regard to effects of EBF on growth. A Ugandan study assessing
health facility had a negative association with WAZ and WLZ. The nutritional status among infants 0–6 months old reported a risk for
models explained 25% of the variation in LAZ, 21% in WAZ and lower LAZ when EBF was stopped early;11 but not a risk for lower
15% in WLZ. WAZ or WLZ. Studies in Vietnam among 6–18-month-old as well
as 0–59-month-old children and in Kenya among children
0–59 months old reported that early supplementation was
DISCUSSION negatively associated with both WAZ and LAZ.13,19,20 Subgroup
The present study is the first in Malawi to measure the association analyses for younger and older infants were not done.13,19,20
between EBF and infant growth. Previous studies have rather However, in Bangladesh and Burkina Faso, the independent effect
examined the combined effect of the duration of exclusive and of breastfeeding combined with complementary feeding among

European Journal of Clinical Nutrition (2015) 96 – 101 © 2015 Macmillan Publishers Limited
 Infant anthropometrical status in Malawi
P Kamudoni et al
99
Table 2a. Linear regression model for length-for-age Z-scores and weight-for-age Z-scores based on 2006 WHO growth standards for 0–6-month-old
infants (N = 188)

Length-for-age Z-scores Weight-for-age Z-scores

Model 1 Model 2 Model 1 Model 2

B (95% CI) P-value B (95% CI) P-value B (95% CI) P-value B (95% CI) P-value

Constant − 0.45 (−1.01, 0.10) 0.106 − 0.05 (−0.89, 0.78) 0.903 0.05 (−0.63, 0.72) 0.894 0.24 (−0.81, 1.28) 0.653
Age of child 0.08 (−0.15, 0.30) 0.506 0.07 (−0.16, 0.29) 0.562 − 0.01 (− .28; 0.26) 0.941 −0.02 (−0.30, 0.26) 0.886
Being male (vs female) − 0.69 (−1.10, − 0.29) 0.001** − 0.65 (−1.07, − 0.24) 0.002** − 0.92 (−1.41, − 0.42) o 0.001*** − 0.85 (−1.37, − 0.33) 0.001***
Duration of exclusively breastfeeding 0.04 (−0.16, 0.24) 0.684 − 0.05 (−0.26, 0.17) 0.674 − 0.08 (−0.32, 0.16) 0.528 − 0.12 (−0.39, 0.15) 0.386
Duration of being fed on breastmilk and − 0.13 (−0.39, 0.14) 0.358 − 0.06 (−0.33, 0.21) 0.643 − 0.11 (−0.44, 0.22) 0.508 − 0.09 (−0.43, 0.25) 0.61
water before 6 months
Duration of being fed on breastmilk and − 0.02 (−0.28, 0.24) 0.887 − 0.03 (−0.28, 0.22) 0.813 − 0.03 (−0.35, 0.28) 0.829 − 0.04 (−0.36, 0.27) 0.791
complementary feeds before 6 months
Duration of food shortage − 0.08 (−0.19, 0.02) 0.101 0.01 (−0.12, 0.13) 0.904
Rural residency − 0.52 (−1.05, 0.01) 0.055* − 0.09 (−0.75, 0.58) 0.795
Birth outside a health facility (vs within a 0.32 (−0.15, 0.80) 0.181 − 0.02 (−0.62, 0.58) 0.943
health facility)
Mother being illiterate (vs literate) − 0.22 (−0.66, 0.23) 0.342 − 0.39 (−0.95, 0.17) 0.175
Socioeconomic status score 0.01 (−0.09, 0.12) 0.789 0.03 (−0.10, 0.16) 0.654
R2 0.08 0.13 0.076 0.09

Abbreviations: CI, confidence interval; WHO, World Health Organization. *Significant difference at Po 0.05, **Significant difference at Po0.01, ***Significant
difference at Po 0.001.

Table 2b. Linear regression model for length-for-age Z-scores and weight-for-age Z-scores based on 2006 WHO growth standards for 6–12-month-
old infants (N = 159)

Length-for-age Z-scores Weight-for-age Z-scores

Model 1 Model 2 Model 1 Model 2

B (95% CI) P-value B (95% CI) P-value B (95% CI) P-value B (95% CI) P-value

Constant − 1.00 (−1.71, − 0.29) 0.006 − 0.51 (−1.37, 0.35) 0.245 − 0.52 (−1.26, 0.22) 0.169 − 0.28 (−1.15, 0.60) 0.534
Being male (vs female) − 0.59 (−0.99, − 0.18) 0.005** − 0.56 (−0.95, − 0.16) 0.006** − 0.29 (−0.72, 0.13) 0.173 − 0.27 (−0.68, 0.13) 0.186
Duration of exclusive breastfeeding 0.19 (0.06, 0.31) 0.003** 0.13 (0.00, 0.26) 0.043* 0.10 (−0.03, 0.22) 0.149 0.04 (−0.09, 0.17) 0.51
Duration of being fed on breastmilk 0.03 (−0.11, 0.17) 0.668 0.06 (−0.08, 0.20) 0.426 − 0.07 (−0.21, 0.08) 0.346 − 0.06 (−0.20, 0.09) 0.43
and water
Duration of being fed on breastmilk and − 0.11 (−0.26, 0.05) 0.191 − 0.07 (−0.23, 0.09) 0.381 − 0.03 (−0.19, 0.14) 0.757 0.04 (−0.12, 0.20) 0.621
complementary feeds before 6 months
Duration of complementary feeding after 0.07 (−0.06, 0.20) 0.26 0.07 (−0.06, 0.19) 0.309 0.00 (−0.14, 0.13) 0.949 − 0.02 (−0.15, 0.11) 0.747
6 months
Duration of food shortage − 0.06 (−0.17, 0.05) 0.29 − 0.06 (−0.17, 0.05) 0.276
Rural residence − 0.52 (−1.01, − 0.03) 0.039* 0.16 (−0.34, 0.67) 0.516
Birth outside a health facility (vs within a − 0.34 (−0.83, 0.14) 0.163 − 0.82 (−1.32, − 0.33) 0.001***
health facility)
Mother being illiterate (vs literate) − 0.04 (−0.47, 0.40) 0.872 − 0.34 (−0.78, 0.10) 0.131
Socioeconomic status score −0.02 (−0.12, 0.08) 0.696 0.06 (−0.04, 0.16) 0.263
R2 0.177 0.247 0.083 0.205

Abbreviations: CI, confidence interval; WHO, World Health Organization. *Significant difference at Po 0.05, **Significant difference at Po0.01, ***Significant
difference at Po 0.001.

children above 6 months showed similar patterns to the ones that also with WAZ at 3 and 6 months, thus differing from our findings.
we observed with regard to associations with LAZ, WAZ and In both studies the study communities were generally poor.
WLZ.21,22 Findings by Espo et al. are in tandem with our results showing a
Comparisons with earlier studies from Malawi are limited as lack of a significant association with WAZ and WLZ. However,
they did not differentiate between EBF and predominant those of Kalanda et al. differ in respect to the association with
breastfeeding. Breastfeeding, with or without giving water, was WAZ, perhaps due to the differences in environmental factors and
consistently called ‘predominant breastfeeding’. disease patterns, as their study was conducted in a different study
Nevertheless, one of the Malawi studies by Espo et al., being area from ours and Espo et al.’s. Although the breastfeeding
longitudinal and taking place in the same rural area, 8 years before pattern examined in both Kalanda et al.’s and Espo et al.’s allowed
ours, reported that introducing complementary cereal porridges for giving the infants other feeds (that is, not exclusively
before 2 months (that is, a shorter predominant breastfeeding breastfeeding as was our case) they still found a significant
duration) was a risk factor for poor LAZ at 12 months, but not for association with LAZ. This could be due to the fact that, even
WAZ or WLZ.16 The other longitudinal study from Malawi, 3 years when mothers could introduce other foods to the child, they
before Espo et al., by Kalanda et al.15 found that predominant could still breastfeed most of the time, as was observed during our
breastfeeding was not only associated with LAZ at 9 months but study. In the present study, we found that, when the linear

© 2015 Macmillan Publishers Limited European Journal of Clinical Nutrition (2015) 96 – 101
 Infant anthropometrical status in Malawi
P Kamudoni et al
100
regression analyses were done using a less strict definition of EBF CONCLUSION
(that is, allowing for supplementation with herbal drinks); a A strong association has been observed between the duration of
borderline significance was observed with LAZ. Furthermore, EBF EBF during the first 6 months of life and LAZ among infants older
duration of just above 4 months was still yielding a significant than 6 months. It is likely that the beneficial effect of EBF in early
association with LAZ in bivariate analyses. Thus implying that infancy may be obscured by other factors like small stature at
there are beneficial effects on an infant’s linear growth when a birth. Moreover, the effect of breastfeeding on linear growth is
mother breastfeeds, even without strictly adhering to the likely to be cumulative thus a stronger association among older
recommendation to exclusively breastfeed as is commonly the infants is most likely to be observed.
case.23 On the other hand, our finding on the association between The findings suggest that EBF could be critical in determining
EBF and LAZ, not WAZ or WLZ, implies that the growth of the prevalence of chronic undernutrition in the area. Sustaining
exclusively breastfed infants may not be seen as being enhanced promotion of EBF in the semi-urban area and research to explore
in settings where child growth is monitored by weight gain, which more effective means for promotion in the rural area are
is the case in most low-resource settings. recommended.
Our findings on the lack of significant associations between
breastfeeding and anthropometric status in the 0–6-month group
may not necessarily imply that breastfeeding per se has lesser CONFLICT OF INTEREST
The authors declare no conflict of interest.
benefit on anthropometric status before 6 months, but that its
positive effect could be obscured by other factors, such as low
birth weight. We observed that when the regression model for the ACKNOWLEDGEMENTS
0–6-month group was run by excluding infants below 2 months, The study was funded by the Norwegian Agency for Development Cooperation.
the association between EBF and LAZ was strengthened to a
borderline significance.
Associations between some socio-demographic factors and REFERENCES
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