International Journal of Epidemiology, Vol 26, 349-356, Copyright © 1997 by International Epidemiological Association
GS Marquis, JP Habicht, CF Lanata, RE Black and KM Rasmussen
BACKGROUND: Child feeding recommendations include breastfeeding beyond 12
months, however, some researchers have reported increased rates of
malnutrition in breastfed toddlers. A negative association between growth
and breast-feeding may reflect reverse causality; that is, the outcome
(growth) is a determinant of the predictor (breastfeeding), and not vice
versa. We examined this question with data from 134 Peruvian toddlers.
METHODS: A linear regression analysis predicted length at the age of 15
months by length at 12 months, study interval, and 12-14.9- month
breastfeeding, complementary food intake, and diarrhoeal incidence. This
analysis defined the association between breastfeeding and linear growth.
To elucidate the direction of the effect between breastfeeding and linear
growth, logistic regression was used to predict the probability of weaning
by the end of 14 months. Determinants included weight-for-age (W/A) at 12
months, complementary food intake at 9-11.9 months, and change in
diarrhoeal incidence between 9 and 14.9 months. RESULTS: There was a
significant (P < 0.01) interaction of breastfeeding, diarrhoeal
incidence, and complementary food intake on length at 15 months. Increased
breastfeeding was associated with a 1.0 cm decrease in length gain when
dietary intake was low and diarrhoeal morbidity was high, implying that
breastfeeding is harmful. The logistic analysis, however, demonstrated that
the risk of weaning decreased only when W/A and dietary intake were low and
diarrhoeal morbidity was high. CONCLUSIONS: The negative association
between breastfeeding and linear growth reflected reverse causality.
Increased breastfeeding did not lead to poor growth; children's poor growth
and health led to increased breastfeeding. Children's health must be
considered when evaluating the association of breastfeeding with
anthropometric outcomes.
ARTICLES
Association of breastfeeding and stunting in Peruvian toddlers: an example of reverse causality
Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
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