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Revista Brasileira de Saúde Materno Infantil

Print version ISSN 1519-3829

Rev. Bras. Saude Mater. Infant. vol.11 no.1 Recife Jan./Mar. 2011 



Exclusive breast feeding and prevention of diarrheal diseases. A study in Qatar


Aleitamento materno exclusivo na prevenção de doenças diarréicas. Um estudo realizado no Qatar



Abdulbari BenerI; Mohammad S. EhlayelII; Hatim M. AbdulrahmanIII

IDepartment of Medical Statistics & Epidemiology. Hamad Medical Corporation and Weill Cornell Medical College. PO Box3050. Doha-State of. Qatar. Email:
IIDepartment of Pediatrics Allergy and Immunology. HamadMedical Corporation. Qatar
IIIDepartment of Pediatrics. Gastroentrology Unit. Hamad MedicalCorporation. Qatar




OBJECTIVE: to explore the relationships between breast feeding and diarrhea and to assess the effect of exclusive breast feeding (EBF) on reducing the risk of diarrhea in Qatar.
METHODS: this is a cross sectional survey carried out at the Well baby clinics and Pediatric clinics in the 11 Primary Health Care Centers and Hamad General Hospital, Hamad Medical Corporation, in Qatar. A multistage sampling design was used and a representative sample of 1500 Qatari infants and preschool children with an age range of 0-3 years and mothers agedbetween 18 to 47 years were surveyed during the period from October 2006 to September 2008 in Qatar. Out of the 1500 mothers, 1278 agreed to participate in this study, with a response rate of 85.2%. Questionnaires were administered to women who were attending Primary Health Care (PHC) Centers for child immunization. Data about the child gathered included date of birth, gender, birth order, consanguinity, socio-economic conditions, age of mother, level of education of mother, occupation, mode of breast feeding, sterilization of bottle and incident of diarrhea during the interview. Univariate statistical methods were performed for statistical analysis.
RESULTS: of the 1278 infants studied, more than half (59.3%) were exclusively breastfed, and the mean duration was11.4 (SD=6.7). The risk for presenting diarrhea was higher in formula fed (48.7%) and partiallybreastfed children (37.3%) when compared to EBF(32.5%).
CONCLUSION: EBF plays an important role in reducing the incidence and severity of infantile diarrhea.

Key words: Breast feeding, Diarrhea, infantile, Risk factors, Qatar


OBJETIVOS: investigar a relação entre a amamentação e a diarréia e avaliar o efeito do aleitamento maternao exclusivo (AME) na redução do risco de diarréia noQatar.
MÉTODOS: um estudo transversal realizado nos Well Baby Clinics and Pediatric Clinics dos 11 centros de atenção básica do Hamad General Hospital, Hamad Medical Corporation, no Qatar. Um desenho amostral de múltiplos estágios foi empregado com uma amostra representativa de 1500 recémnascidos e crianças de idade pré-escolar catarianos entre outubro de 2006 esetembro de 2008 no Qatar. Entre as 1500 mães, 1278 aceitaram participar neste estudo, uma taxa de resposta de 85,2%. Os questionários foram aplicados a mulheres atendidas pelos centros de atenção básica para imunização infantil. Dados colecionados sobre as crianças incluíram data de nascimento, gênero, ordem de nascimento, consanguinidade, condições socioeconômicas, idade maternal, escolaridade maternal, ocupação maternal, método de amamentação, esterilização dos biberões, e incidência de diarréia durante a entrevista. Métodos univariados e foram utilizados para realizar a análise estatística.
RESULTADOS: dos 1278 recém-nascidos estudados, mais que metade (59.3%) foram exclusivamente amamentados e a duração média foi de 11,4 (DP=6,7). O risco de apresentar a diarréia foi mais alto nas crianças aleitadas com fórmulas (48.7%) e nas que foram parcialmente amamentadas (37.3%) em comparação com a AME(32.5%).
CONCLUSÕES: o AME desempenha um papel importante na redução da incidência e da gravidade da diarréia infantil.

Palavras-chave: Aleitamento materno, Diarréia infantil, Fatores de risco, Qatar




In developing countries breast feeding reduces the incidence and severity of diarrhea in infants,1-3 although this effect may be less pronounced in areas with better water supply and sanitation facilities.4 Modern water supply and sanitation facilities are also thought to at least partly explain the absence of protection by exclusive breast feeding (EBF) against infantile diarrhea seen in some studies in developing countries.2,3,5

There is ample evidence of a positive influence of breastfeeding, especially exclusive breast feeding on diarrhea. Yoon et al.6 reported a higher risk of diarrhea mortality associated with not breast feeding. A similar pattern has also been reported in other studies.3-5 In a recent meta-analysis of data from six developing countries, breast feeding provided a greater degree of protection against diarrhea attributable to acute respiratory infection in the first six months of life, whereas the level of protection was similar for infants who were 6 to 11 months of age.1 The World Health Organization (WHO)1 recommends six months of EBF for all infants. In developing countries, exclusive breast feeding has a large protective effect on infant mortality and severe morbidity.2-3 The objectives of the current study were to explore the relationship between breast feeding and diarrhea and to assess the effect of exclusive breast feeding on reducing the risk of diarrhea.



The infant and pre-school children studied were the subjects of this cross-sectional population study conducted in Qatar. The potential subjects were all male and female children aged 0-3 years and their mothers visiting the child immunization centers at the Primary Health (PHC) Centers. The study was carried out at the Well Baby clinics in the 11 PHC Centers of the Hamad Medical Corporation, in Qatar. The PHC sample was adjusted proportionally for each clinic on the basis of the daily visits for immunization and well baby clinics by way of a systematic sampling technique. A multistage sampling design was used and a representative sample of 1500 infants and pre-school children in the age range of 03 years and mothers aged between 18 to 47 years were surveyed during the period from October 2006 to September 2008 in Qatar. A total of 1278 mothers (85.2%) agreed to participate in this study.

Questionnaires were administered to women who were attending PHC Centers for child immunization. Data on the child collected included date of birth, gender, birth order, consanguinity, socioeconomic conditions, age of mother, level of education of mother, occupation, mode of breast feeding, sterilization of bottle and incidence of diarrhea during the interview.

Diarrhea was defined as the presence of three or more liquid or semi-liquid stools per day accompanied or not by blood, mucus or fever. The total number had to exceed the usual number of daily bowel movements. An incidence diarrhea in the child was defined by the mother as the onset of stools that were more frequent and/or fluid than normal. The end of a diarrheal episode in the child was defined by the mother as the point when both the frequency and fluidity of stools reverted to normal.

The data were entered into a computer and processed using the Statistical Packages for Social Sciences (SPSS) version 18. The Student -t test, Chisquare and Fisher exact test were performed appropriately. The level p<0.05 was considered as the cutoff value for significance.



Of the 1278 infants studied, more than half (59.3%) were exclusively breast fed, while 28.3% were partially breast fed and 12.4% were formula fed. The mean duration of EBF was 11.4 (SD=6.7). Table 1 shows the socio-demographic characteristics of diarrhea morbidity in the children studied. Out of 1278 infants, 458 (35.8%) had episodes of diarrhea. The risk of presenting diarrhea was higher and statistically significant in male children (55.5%, p=0.002) and when the mother had a high level of education (p<0.05). The risk for presenting diarrhea was higher and statistically significant in children who were formula fed (48.7%) when compared to those who were exclusively breast fed, as it was for partially breastfed children (37.3%) (p<0.001) (Figure 1).






Despite the universal access to modern water supplyand sanitation facilities, in Qatar, we detected asubstantial positive association between breastfeeding and diarrhea in a study of children agedbetween 0 and 3 years. These results confirm theprotective effect of exclusive breast feeding againstmorbidity related to infectious diseases in infancy.6-8 The results show that children aged 0-3 years whoare exclusively breast fed are less likely to sufferfrom diarrhea than infants who were not exclusivelybreastfed. The results are consistent with those ofother studies on the association between mode offeeding and diarrhea morbidity in children.9-10

The high prevalence of diarrhea (35.8%) amongchildren in Qatar might be because of its demographic profile.11 In Qatar, approximately 70% ofthe population is made up of expatriates, mostlyAsians, and they are unaware of the travel-relatedinfectious diseases they may have picked up when visiting their home countries. This can lead to imported diarrheal diseases. The risk of diarrhea was significantly higher in boys. Qatar's small popula tion has helped guarantee a high per capita income and most of the population earns a reasonably good monthly income. Furthermore, expatriates pay a very nominal fee for health care services. This may be the reason for the lack of significant influence of family income on the occurrence of episodes of diarrhea.

Studies in developing countries have found variability in the effect of breast feeding. In studies of diarrhea in some developing countries, such as in India,2, Nigeria,4 Malaysia,7 the Philippines,6 and Sri Lanka,10 it has been reported that breast feeding has a stronger protective effect against diarrhea. Similarly, in Bangladesh, it has been shown that breastfeeding has effectively combated diarrhea following a community based health education campaign.3,8,9 A study in Malaysia7 found that formula feeding had a much stronger effect onmortality in infants living in households without piped water or a toilet than in households with toilets.

More recently a study by Quigley et al.12 reported that breast feeding, particularly when exclusive and prolonged, protects against severe morbidity in the United Kingdom. A population level increase in exclusive, prolonged breast feeding would be of considerable potential benefit for publichealth. Our findings are consistent with previous observations of a negative relation between breastfeeding and diarrheal morbidity in children in areas with modem water supply and sanitation facilities.10,13 Finally, the mechanisms through whichbreast feeding may protect children against diarrhea are well known.6-10

Promotion of exclusive breast feeding in the first 4 to 6 months of life and reductions both in the incidence of diarrhea and related deaths are likely to be beneficial for infant survival in this population. Thisis consistent with earlier estimates of potential reductions in diarrhea mortality after increased breast feeding.6-8 Estimates indicate that infant mortality could be reduced by almost one third if the prevalence of exclusive breast feeding in the first four months of life could be raised to nearly 80%,with smaller gains with intermediate improvementsin breast feeding practices. Recent studies in Bangladesh have shown that such improvements inbreast feeding practices can be achieved through community-based interventions.8,9 Furthermore, a study conducted in Brazil13 has shown that the likelihood of presenting diarrhea was 64% higher in children younger than six months who were not breastfed compared with those who were. Exclusive breast feeding and partial breast feeding are a protective factor against diarrhea in the first six months of life. This is confirmed by the present survey carriedout in Qatar.



This study was funded, in part, by a research grant from MSD, Merck Research Laboratories, NJ, USA and supported by the Research Committee of Hamad Medical Corporation, Qatar.



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Recebido em 17 de agosto de 2010
Versão final apresentada em 9 de dezembro de 2010
Aprovado em 11 de janeiro de 2011

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