1.  Timing of breastfeeding initiation has no impact on day 1 deaths.  Early initiation can only reduce the risk of neonatal deaths that happen between days 2 & 28.  We assume this is 65% of all neonatal deaths (mid-point of range given in Paper 1 of the Lancet neonatal series).  The increased risks associated with delayed breastfeeding found in the Ghana study can be applied to all countries.  These increased risks (ORs) reflect a causal relationship & all the excess is attributable to delayed breastfeeding.  Babies who never breastfeed have the same risk as those who start after the first day; this is a conservative estimate. Meeting the child survival MDG: How many newborn lives could we save by improving coverage of early initiation of breastfeeding? Karen M Edmond, Ellie C Bard, Betty R Kirkwood (LSHTM) 274,000 livesAFRICA 25% deaths 26,000 livesAMERICAS 28% deaths 487,000 lives SE ASIA 34% deaths 147,000 lives W PACIFIC 31% deaths CONCLUSIONS AND RECOMMENDATIONS  36% of childhood deaths occur during the first month of life: reducing neonatal deaths is essential if the child survival MDG is to be met.  2005 Lancet Neonatal Series identified 16 interventions with proven efficacy for neonatal survival including exclusive breastfeeding.  Early initiation of breastfeeding was not on this list.  Recent results have become available from a large birth cohort study in Ghana demonstrating that delayed initiation of breastfeeding is associated with increased risk of neonatal mortality (Edmond et al, Pediatrics, in press).  This increased risk is additional to those associated with predominant and partial as compared to exclusive breastfeeding. Background Early BF initiation: Current Coverage  Coverage rates of early initiation of breastfeeding are low (see Figure); only about a third of babies are breastfed within the 1 st hour of birth, and for more than a fifth initiation is delayed until after the first day. The countries  60 UNICEF priority countries: these are countries with  No. of under-five deaths ≥ 50,000 or  U5MR ≥ 90/1000 live-births  We used the numbers of neonatal deaths in each country as reported in the World Health Report 2005.  These 60 countries account for 91% of the approx. 4 million newborns that die each year.  DHS data on current coverage levels of early initiation were available for 38 of the 60 countries.  Regional averages were used for the 22 countries with no coverage data. BF initiated Adjusted OR Attributable Risk (AR)* Day 1, 1st hour1- Day 1, later1.4431.0% After day 12.8865.3% Day 1 vs Later2.4058.3% * AR = (OR-1)/OR * 100% Ghana: Risk of Newborn Death after 1 st day MODEL A Newborn lives saved Deaths prevented NewbornU5 99% babies BF 1st hour 1,117,03231%11% 90% babies BF 1st hour 972,91727%10% MODEL B Newborn lives saved Deaths prevented NewbornU5 99% babies BF 1st day 866,85724%9% 90% babies BF 1st day 680,86419%7% The model  Two intervention models: A: A: breastfeeding initiated within 1 st hour B: B: breastfeeding initiated within 1 st day (but not necessarily 1 st hour)  Lives saved estimated for:  Univeral coverage (defined as 99%)  90% coverage RESULTS  The model is based on a single dataset; Similar data from other countries should be collated/collected as a priority.  If risks from Ghana are confirmed EARLY BF initiation should be added to key child survival interventions & monitored.  Potentially about 30% of newborn deaths (10% of U5 deaths) might be prevented with universal coverage of BF initiation within the 1 st hour 4,000 livesEUROPE 27% deaths 179,000 lives E MED 33% deaths