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This article is part of the supplement: The Lives Saved Tool in 2013: new capabilities and applications

Open Access Open Badges Review

Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review

Amanda K Debes1, Anjalee Kohli1, Neff Walker1, Karen Edmond2 and Luke C Mullany1*

Author Affiliations

1 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

2 School of Pediatrics and Child Health, University of Western Australia, Crawley, WA, Australia

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BMC Public Health 2013, 13(Suppl 3):S19  doi:10.1186/1471-2458-13-S3-S19

Published: 17 September 2013



Early breastfeeding is defined as the initiation of breastfeeding within twenty four hours of birth. While the benefits of breastfeeding have been known for decades, only recently has the role of time to initiation of breastfeeding in neonatal mortality and morbidity been assessed.


To review the evidence for early breastfeeding initiation practices and to estimate the association between timing and neonatal outcomes.


We systematically reviewed multiple databases from 1963 to 2011. Standardized abstraction tables were used and quality was assessed for each study utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Three meta-analyses were conducted for mortality among babies surviving to 48 hours.


We identified 18 studies reporting a direct association between early breastfeeding initiation and neonatal mortality and morbidity outcomes. The results of random effects analyses of data from 3 studies (from 5 publications) demonstrated lower risks of all-cause neonatal mortality among all live births (RR = 0.56 [95% CI: 0.40 – 0.79]) and among low birth weight babies (RR=0.58 [95% CI: 0.43 – 0.78]), and infection-related neonatal mortality (RR = 0.55 [95% CI: 0.36 – 0.84]). Among exclusively breastfed infants, all-cause mortality risk did not differ between early and late initiators (RR = 0.69 [95% CI: 0.27 – 1.75]).


This review demonstrates that early breastfeeding initiation is a simple intervention that has the potential to significantly improve neonatal outcomes and should be universally recommended. Significant gaps in knowledge are highlighted, revealing a need to prioritize additional high quality studies that further clarify the specific cause of death, as well as providing improved understanding of the independent or combined effects of early initiation and breastfeeding patterns.