International Journal of Epidemiology Vol. 25, No.

1
O International EptdemWoglca] Association 1996 Printed in Great Britain

Reason for Termination of

Breastfeeding and the Length of
Breastfeeding
MARIANNE S JAKOBSEN,*'* MORTEN SODEMANN,** KARE M0LBAK* AND PETER AABY*

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

Jakobsen M S (Danish Epidemiology Science Centre, Statens Seruminstitut, Copenhagen, Denmark), Sodemann M,
Molbak K and Aaby P. Reason for termination of breastfeeding and the length of breastfeeding. International Journal of
Epidemiology 1996; 25: 115-121.
Background. In third world countries the length of breastfeeding often has a major influence on child mortality, morbidity
and nutritional status. When evaluating the impact of length of breastfeeding the reason why a mother terminates
breastfeeding is usually not taken Into consideration.
Methods. Risk factors for termination of breastfeeding were studied in a prospective community study following 1678
children in Guinea Bissau, West Africa from birth to cessation of breastfeeding, migration or death.
Results. The median weaning age was 22.6 months. Illness of the child, new pregnancy of the mother and illness of the
mother were associated with a significantly shorter lactation period compared with children weaned because they were
'healthy1 or 'old enough'. These explanations had an impact independent of other determinants for weaning, including
ethnic group, mother's age, mother's education, birth order and number of dead siblings. Weaning before 12 months of
age was only associated with illness of the mother or child and new pregnancy and not with any sodoeconomlc or cultural
factors.
Conclusions. Health workers should pay special attention to the encouragement of breastfeeding In connection with
illness of the mother or child; these considerations may also be important in the planning of breastfeeding promotion
campaigns. Since premature termination of breastfeeding is associated with new pregnancy, family planning should be
part of any breastfeeding promotion programme.
Keywords: breastfeeding, risk factors, weaning, pregnancy, child illness, Guinea Bissau epidemiology

The most appropriate length of the breastfeeding period A mother may make the decision to wean on the basis
has often been a subject of controversey.1"* Particularly of traditional beliefs, nutritional status of the child, or
in third world countries, length of breastfeeding may because she believes that her milk is harming the child.
have a major influence on child mortality and morbid- Apparently, no biological mechanism is telling the
ity. Some authors have found a beneficial effect of mother when to terminate breastfeeding and thus, in
breastfeeding into the second year of life,7 or even into theory, she may continue for years. Which factors does
the third year in special situations.9 Others have recom- the mother take into account when she decides to wean
mended that children should breastfeed no longer her child? Some authors have described different
than 18 months due to a negative impact on nutritional reasons for early termination of breastfeeding, such as a
status among children who breastfeed for more than new pregnancy, illness of the child, ethnic background,
18 months.3 as well as obstetric history and previous experience with
Mothers themselves choose to terminate breast- breastfeeding.1CM2 The actual influence of the reason
feeding, and the reason for this decision has usually not stated by the mother, and other confounding factors,
been considered as a possible confounder when evalu- on length of breastfeeding have only rarely been
ating the impact of length of the breastfeeding period. investigated.
The World Health Organization recommends breast-
* Danish Epidemiology Science Centre, Statens Seruminstitut, feeding until the child is well into the second year of
Copenhagen, Denmark. life. In order to implement such a programme, it is
* Department of Epidemiology and Social Medicine, University of of great importance to know why mothers terminate
Aarhus, Denmark.
Reprint requests to: Marianne S Jakobien, Department of Epidem-
breastfeeding before that age, and if there are specific
iology and Social Medicine, University of Aarhus, Building 02C, child groups which are at risk of having a short
NatTebrogade 44, DK-8000 Aarhus C, Denmark. breastfeeding period.
115
116 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

TABLE 1 Reason for termination of breastfeeding and the length of breastfeeding. Case reference design comparing reason for weaning
with 'healthy child' as the reference—945 children from Guinea Bissau

Reasons for termination Numbers in Median length of Wilcoxon two-

of breastfeeding % (total number) breastfeeding sample test x 2
period in months and P-value
(95% CI)

Healthy child 67.6 (639) 23 (19-24)

III child 7.3 (69) 19 (13-22) 36.1 (/> = 0.00)
Mother pregnant 7.8 (74) 19 (15-22) 27.6 (/"-0.00)

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

Mother ill 9.0 (85) 18 (13-21) 50.4 (/> = 0.00)
Mother travelling/away from home 3.3 (31) 20 (18-24) 3 8 (P = 0.05)
Other reasons 5.0 (47) 20 (15-25) 5.6 (P-0.02)

METHODS were categorized as 'well' when the mother stated that

Study Area the child was in good health, that 'the child was old
The study was conducted in three suburban areas enough', or that the child was able to eat an adult diet.
(Bandim 1, Bandim 2, and Belem) in the capital of When the mother stated that she had terminated breast-
Guinea Bissau, West Africa. Since 1978, there has been feeding because 'the child was not doing well', the
routine recording of children under the age of 3 years in main explanation was that the child had suffered from
these areas. diarrhoea or vomiting for some time. The case was also
categorized in this group if the mother claimed to have
Study Population terminated because her milk was 'bad', since bad milk
The study population consisted of children born 1 May is believed to cause illness of the child.13
1991 to 30 April 1992. The children were identified Since information on early pregnancy is traditionally
through the routine surveillance system. A criterion for taboo, we have done the analysis by using the mother's
inclusion into the study was that the child should be actual answer and by calculating the date of conception
registered as a resident in the area before the age of on the basis of the birthday of her following child. The
18 months and before termination of breastfeeding. pregnancy period was assumed to be 38 weeks.
Children who were stillborn or who died within the Information on new pregnancies as well as other back-
first month of life were not included in the study. ground information was obtained through the routine
During the observation period, the mothers were recording system.
interviewed regularly to determine whether they had In this paper, the term 'weaning' refers to the com-
terminated breastfeeding. In Guinea Bissau, termina- plete termination of breastfeeding and not to the
tion of breastfeeding is usually well-defined and it is introduction of other food in the diet.
not common to recommence breastfeeding after term-
ination. However, the interview usually took place some Loss to Follow- Up
weeks after to ensure that breastfeeding was really The population in Guinea Bissau, and especially the
terminated. A subset of the mothers were interviewed population in the study area, is very mobile. The Pepel
every week as part of a morbidity study. The rest were tribe which constitutes the main part of the population
visited every second month until the mother reported in the study area originates traditionally from an area
that breastfeeding was terminated. about 30 km from the capital. It is therefore very com-
When breastfeeding was terminated, a special ques- mon that the mothers travel between the capital and
tionnaire was completed. The date of termination was their village of origin, and often stay away for months.
recorded as well as the mother's explanation for termin- On the other hand, many women from the countryside
ating breastfeeding. Only one reason could be stated by come to Bissau to give birth, and return to the village
the mother. Information was also collected on the length again shortly after birth. This mobility is the main
of the lactation period of the older sibling nearest to the reason for lack of information on children who had not
child studied as well as the mother's motivation for moved or died. Mothers of dead children were all
terminating breastfeeding at that time. visited to ensure that the child was breastfed until the
Reasons for termination of breastfeeding were day of death, and those who moved out of the area were
divided into five main groups (Table 1). The reasons considered as participants in the study until the last
 DURATION OF BREASTFEEDING 117

known date of the breastfeeding status of the child. It is breastfeeding between different reasons for weaning
therefore unlikely that loss of follow-up caused any was also seen among children breastfeeding for at least
bias. 12 months or 18 months. (Data not shown).
After interviewing the mothers concerning their
Statistical Methods reasons for terminating breastfeeding, we consulted the
Kaplan-Meier estimates were used to calculate median surveillance system and found that 137 of the mothers
lengths of breastfeeding. The Wilcoxon test for two participating in the interview gave birth within 9 months
samples was used to compare means. Cox proportional of termination of breastfeeding. Only 45 of these
hazards regression was used to outline the influence of women indicated pregnancy as a reason for termination.
socioeconomic and cultural risk factors in the whole Among the remaining 92 mothers, 75 claimed to have

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

study population with date of termination of breastfeed- terminated because the child was healthy, six because
ing as the dependent variable. A multivariate analysis the child was ill, four because the mother was ill, and
of variance was used to control for interaction between seven for other reasons. Among the 29 mothers who
reason for terminating breastfeeding and socioeco- claimed to have terminated breastfeeding due to preg-
nomic factors. Wilcoxon signed rank test, two-tailed nancy but who, according to the surveillance system,
with continuity correction, was used to compare median did not give birth within 9 months of termination, 10
length of breastfeeding for the present child with length gave birth within 9 and 11 months, and 19 left the area
of breastfeeding for the nearest older sibling. or have not given birth yet.
The 137 mothers who gave birth within 9 months of
weaning had a significantly shorter lactation period
RESULTS with a median length of 20 months, (x 2 = 31.5
Population P = 0.000, Wilcoxon two-sample test).
In all, 1678 children fulfilled the criteria of the study.
All children in the study were followed until the day Other Risk Factors for Early Termination of
they terminated breastfeeding or until the day they Breastfeeding
moved out of the area or died. When the study period Data for the whole study population were analysed to
ended in October 1994, 1040 children had stopped determine whether there was any influence of different
breastfeeding, 278 children had moved out of the area socioeconomic and cultural risk factors on the length of
and 162 had died before they stopped breastfeeding. breastfeeding (Table 2). In the univariate analysis, be-
Eighty-two children were still breastfeeding when last longing to the ethnic group Balanta, schooling of the
visited. For 116 children no information was obtained mother, birth order, number of dead siblings, and age of
on breastfeeding status, usually because the children mother influenced the length of the breastfeeding
only lived in the area for a few months. These children periods.
have been excluded from all the analyses. Of the 1040 For the 945 mothers participating in the interview, a
children who terminated breastfeeding during the study multivariate analysis of variance was used to examine
period, 945 (90.9%) were interviewed. The last 95 whether the differences in length of breastfeeding due
mothers were travelling or staying for long periods in a to various reasons for weaning could be explained by
rural area, usually together with parents. confounding socioeconomic factors. The multivariate
analysis of variance showed that the mother's reason
Different Reasons for Termination of Breastfeeding for weaning had a significant and major impact, inde-
The median length of lactation for all children was 22.6 pendently of schooling of the mother, birth order, num-
months (Kaplan Meier estimate, 95% CI : 22.2-23.1). ber of dead siblings, and age of the mother. However,
For the 945 children whose mothers participated in the among Balantas we found no difference in the weaning
interview, we looked at the weaning age according to age (P = 0.76, Wilcoxon's two-sample test) between
different reasons of weaning. Table 1 shows the median those who terminated because the child was healthy and
age at weaning according to the mother's reason for those who stopped for other reasons. Healthy children
termination. Using a case-referent design, with a were breastfed longer in all other ethnic groups.
reference group of children who were weaned because
their mothers thought they were healthy or old enough, Mothers' Reasons for Weaning Current Child and
it seems that children weaned either due to the Nearest Older Sibling
child's or the mother's illness or new pregnancy of the Of the children interviewed, 748 had an older sib-
mothers tended to be weaned significantly earlier than ling of which 69 died before termination of breastfeed-
the reference group. The same difference in length of ing. The mothers of the remaining 679 children were
118 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

TABLE 2 Influence of different background factors on length of breastfeeding period for 1678 children. Calculated by a Cox hazards
regression model

Median length of No(%) Hazard ratio

breastfeeding (95% CI)
in months ( 9 5 * CI)

Ethnic group of mothers

Pepel 23.5 (22.8-23.9) 542 (34.7) 1.00
Balanta 24.3 (24.9-23.9) 147 (9.4) 0.70 (0.56-0.87)
Manjaco 20.3 (19.1-20.9) 194 (12.4) 1.63 (1.36-1.98)

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

Other 21.7 (21.2-22.6) 501 (32.1) 1.31 (1.13-1.52)

Schooling of mother
None 24.1 (23.7-24.3) 744 (47.7) 1.00
1-5 years 21.6 (21.0-22.5) 401 (25.7) 1.41 (1.21-1.63)
»6 20.2 (19.3-20.9) 358 (22.9) 1.96 (1.68-2.28)

Sex
Boys 22.5 (21.6-23.1) 815 (52.2) 1 00
Girls 22.9 (22.3-23.5) 747 (47.8) 0.99 (0 88-1.12)

Birth order
Only child 21.3 (20.4-22.4) 348 (22.3) 1.00
No 2^* 21.8 (21.3-22.3) 716 (45.9) 0.96 (0.82-1 13)
No»5 24.2 (23.8-24.5) 433 (27 7) 0.68 (0.57-0.81)

Dead siblings
Only child 21.3 (20.4-22.4) 348 (22.3) 1.00
None 21.9 (21.4-22.5) 632 (40.5) 0.96 (0.81-1.13)
1-3 23.7 (23.0-24.2) 479 (30.6) 0.71 (0.60-0.84)
>4 24.5 (23.3-24.9) 38 (2.4) 0.67 (0.44-0.99)

Mother's age (years)

14-19 22.3 (21.6-23.2) 274 (17.6) 1.00
20-24 20.8 (20.4-21.5) 438 (28.0) 1.23 (1.02-1.48)
25-29 22.6 (21.4-23.3) 301 (19.3) 0.94 (0.77-1.14)
>30 24.2 (23.7-24.5) 327 (20.9) 0.79 (0.66-0.96)

interviewed concerning length of breastfeeding, and or illness of the mother were risk factors for termination
their reason for terminating breastfeeding. In 61 cases, before 12 months of age (Table 4), while none of the
the mother could not answer the question, mainly socioeconomic factors were associated with premature
because she did not remember. When the mother stated termination of breastfeeding (data not shown).
the reason for terminating breastfeeding for both
children, a paired analysis comparing length of breast-
feeding for the present child with length of breast- DISCUSSION
feeding for the nearest older sibling showed that Guinea Bissau has a tradition of prolonged breast-
children weaned because of illness or new pregnancy of feeding as evidenced by the length of breastfeeding of
the mother had a significantly shorter breastfeeding 22.6 months, and by the fact that only five of the chil-
period compared with children who were weaned dren in the study never breastfed. One did not breast-
because they were healthy (Table 3). This was valid for feed because the mother died while giving birth, one
the entire study. mother became paretic after birth, one child was born
with cleft lip/palate and two did not start because the
mothers believed their milk was bad and would harm
Premature Termination of Breastfeeding the child. These results concur with previous studies
In all, 57 mothers terminated breastfeeding before the from Bandim, Guinea Bissau, reporting a median length
child was 12 months old. Illness of the child, pregnancy of breastfeeding of 22 months7 and that only one child
 DURATION OF BREASTFEEDING 119

TABLE 3 Length of breastfeeding. Paired analysis of reasons for termination of breastfeeding for present child compared with the nearest
older sibling for 518 mothers

Median length of breastfeeding Wilcoxon signed

in months rank test
(25-75 percentiles)

Reason for termination of breastfeeding Present child Nearest older P-value in paired test
Present child/nearest older sibiling" sibling

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

Healthy/healthy 23.6 (20.0-24.8) 24.0 (19 0-24.3) 0.414
346 mothers

Ill-pregnant/healthy 19.6 (15.5-22.4) 21.0 (18.0-24.0) < 0.0001

110 mothers

Healthy/ill-pregnant 21 2 (19.1-24.5) 15.0 (12.0-21.0) 0.002

41 mothers

Ill-pregnant/ill-pregnant 18.2 (14.1-20.7) 16.0 (10.5-19.0) 0.144

21 mothers

1
'Healthy' refers to children weaned because they were healthy or old enough. 'Ill-pregnant' refers to a joint group of those children weaned because
of illness or because of illness or pregnancy of the mother.
In 100 cases the reason for stopping breastfeeding for either the present child or the nearest older sibling was categorized as 'other'. These cases were
not included in this Table

TABLE 4 Risk of weaning before 12 months of age related to mothers' reason for termination of breastfeeding (%)

Reason for < I 2 months »12 months Total Risk ratio

stopping (95% CI)
breastfeeding

Healthy child 13 (2.0) 626 (98.0) 639 1

111 child 12 (17.4) 57 (82.6) 69 8.55

(4.06<RR< 17.99)

Mother pregnant 9 (12.2) 65 (87.8) 74 5.98

(2.65<RR<13.51)

Mother ill 13 (15.3) 72 (84.7) 85 7.52

(3.61<RR< 15.67)

Other 10 (12.8) 68 (87.2) 78 6.30

(2.86<RR<13.89)

Total 57 (6.0) 888 (94.0) 945

in a cohort of 1148 healthy, singleton children failed to weaning. Even though a number of socioeconomic fac-
breastfeed at all. 14 tors in the univariate analysis were found to influence
The present study shows that maternal illness or length of breastfeeding, the above mentioned risk
pregnancy and child illness are risk factors connected factors were found to be independent of these
with premature termination of breastfeeding. The ethnic socioeconomic factors.
group of Balantas were observed to breastfeed longer As described by other authors, most children were
than other ethnic groups independent of reason for weaned because the mother thinks they are healthy
120 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

or old enough. 1 0 '" 1 3 1 6 The explanation 'healthy/old tfedtfir for

when focusing exclusively on those breastfeeding
enough' may indicate two different situations; that the at least 12 months. The same was found even when
child is developing normally without any specific focusing on those breastfeeding for at least 18 months.
problems or that the child has been ill, the mother These findings indicate that illness of the child and
therefore continued breastfeeding and the child is now illness or pregnancy of the mother should be regarded
developing well. In both instances, the decision to wean as reasons for terminating breastfeeding that out-
is taken on the grounds that breast milk is beneficial to weigh what the mother, under normal conditions, would
the child and that the child could manage without breast regard as optimal for her child.
milk at the time of weaning. Thus, a 'healthy/old enough' There was a large discrepancy between the number
child may have suffered from an illness and therefore of mothers who stated pregnancy as the reason for term-

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

breastfed for longer than usual to compensate for this. ination, and the number of mothers who actually gave
In contrast, children weaned because of illness are birth within 9 months of stopping breastfeeding. In the
weaned earlier either because the mother believes that early phase of pregnancy, the condition is not talked
breastfeeding is harmful to her child or that it is main- about freely, particularly if the pregnancy has led to
taining the illness. Often the mother is advised by premature cessation of lactation. To ensure that unwil-
elderly relatives. Termination of breastfeeding due to lingness to answer did not constitute a bias, we did the
a new pregnancy is explained by a harmful effect of same analysis including also the mothers who actually
continued breastfeeding on the breastfed child, by a gave birth within 9 months after weaning, even though
harmful effect on the unborn child, and finally by a they did not indicate this at the interview. It was still
harmful effect on the mother, who will become too clear that pregnancy, reported or unreported, was a risk
weak if breastfeeding while pregnant. Weaning because factor for a short breastfeeding period.
the mother is ill is almost exclusively explained by the The impact of breastfeeding is usually measured as
fact that breastfeeding is weakening the mother. differences in growth, morbidity or mortality, and often
Reasons for weaning are not mutually exclusive, i.e. without controlling for factors that could influence
the mother could be pregnant and the child well. In length of the breastfeeding period.19 While some authors
practice we did not have any problems with allowing have reported their results adjusted for socioeconomic
only one answer from each mother since we never met factors,10'17 none have controlled for the reason for
a mother indicating more than one reason. termination. If the mother terminates because the child
Socioeconomic factors, as well as previous history of is ill there is a particular bias in the assessment of the
lactation and/or obstetric history, are often found to be impact of weaning. On the contrary, some children
factors influencing length of breastfeeding. 710121718 In may breastfeed for longer periods because they are ill.
Guinea Bissau, each ethnic group has its own traditions The latter could contribute to the observations in some
concerning length of breastfeeding period. The obser- studies that long breastfeeding is associated with
vation that Pepels are breastfeeding for a shorter period malnutrition.3-5'6
than Balantas and longer than Manjacos is in accordance The association between length of breastfeeding
with common beliefs in Guinean society. and reasons for weaning should be considered when
Observing the individual mother, length of breast- planning breastfeeding campaigns. It should be noted
feeding also tends to be influenced by reason for that weaning before 12 months of age was not asso-
weaning; i.e. a mother who for one child terminated ciated with the socioeconomic and cultural factors but
breastfeeding because the child was healthy will breast- only with disease of the child or the mother or new
feed another child for a shorter period if she terminates pregnancy of the mother. The reasons for termination of
breastfeeding because the child is ill (Table 3). This breastfeeding found in the present study are far more
supports the conclusion that the reason for termination accessible to intervention through health education
of breastfeeding is a risk factor independent of socio- than socioeconomic factors. Mothers who bring their
economic factors. sick children for consultation or who seek consultation
It could be argued that the observed differences in themselves because of illness should be encouraged to
length of breastfeeding based on various reasons for continue breastfeeding during the illness. Health educa-
terminating breastfeeding are due mainly to mothers tion regarding the beneficial effects of breastfeeding
who terminate breastfeeding prematurely (i.e. before should always be given in connection with family plan-
12 months of age) (Table 4). However, our analysis ning. The association between premature termination
shows that the influence of reason for termination on and illness of the child as well as illness or pregnancy
the length of the breastfeeding period is not restricted to of the mother should be incorporated into health
very early weaning, since we found the same impact education. It should be possible to avoid premature
 DURATION OF BREASTFEEDING 121

cessation of lactation by providing appropriate health young children in Burkina Faso. Bull World Health Organ
education and family planning to lactating mothers. 1993; 71: 713-22.
9
Briend A, Wojeyniak B, Rowland M G. Breast feeding,
nutritional state, and child survival in rural Bangladesh.
ACKNOWLEDGEMENT Br Mcd J Clin Res Ed 1988; 296: 879-82.
10
Marandi A, Afzali H M, Hossaini A F. The reasons for early
We are indebted to Queba Djand, Lola Lopes, Maria weaning among mothers in Teheran Bull World Health
Rosa de Andrade, and Angelina da Silva for their Organ 1993; 71: 561-69.
assistance during interviews and the tracking of " Harrison G G, Zaghloul S S, Galal O M, Gabr A. Breastfeeding
mothers. We also wish to thank Michael Vaeth for and weaning in a poor urban neighborhood in Cairo, Egypt:
maternal beliefs and perceptions. Soc Sci Med 1993; 36:
fruitful discussions regarding presentation of the results
1063-69.

Downloaded from https://academic.oup.com/ije/article-abstract/25/1/115/815535 by guest on 22 October 2019

in Table 1. The study was supported by The Danish 12
Martines J C, Ashworth A, Kirkwood B. Breast-feeding among
Council for Development Research (grant no. the urban poor in southern Brazil: reasons for termination
104.Dan8/535) and the Science and Technology for in the first 6 months of life. Bull World Health Organ
1989; 67: 151-61.
Development Programme of the European Community 13
Gunnlaugsson G, Einarsdottir J. Colostrum and ideas about bad
(contract no. TS3-CT92-060). milk: a case study from Guinea Bissau. Soc Sci Med 1993,
36: 283-88.
14
Gunnlaugsson G, da-Silva M C, Smedman L. Determinants of
REFERENCES delayed initiation of breastfeeding: a community and hos-
1
Victors C G, Vaughan J P, Marlines J C, Barcelos L B. Is
pital study from Guinea-Bissau. Int J Epidemiol 1992; 21:
prolonged breast-feeding associated with malnutrition? Am
J Clin Nutr 1984; 39: 307-14. 13
2 Dettwyler K A. Breastfeeding and weaning in Mali: cultural
Cunningham A S, Jelliffe D B, Jelliffe E F. Breast-feeding and
context and hard data. Soc Sci Med 1987; 24: 633-44.
health in the 1980s: a global epidemiologic review. [See 16
Lauber E, Reinhardt M C. Prolonged lactation performance in a
comments] J Pedialr 1991; 118: 659-66.
3 rural community of the Ivory Coast. / Trop Pediatr 1981;
Brakohiapa L A, Yartey J, Bille A et a). Does prolonged
27: 74-77.
breastfeeding adversely affect a child's nutritional status? 17
Swenson I E, Thang N M, Tieu P X. Individual and community
Lancet 1988; II: 416-18.
4 characteristics influencing breastfeeding duration in
Brakohiapa L A. Prolonged breastfeeding. [Letter.] Lancet
Vietnam. Ann Hum Biol 1993; 20: 325-34.
1988; II: 1360-61. l8
3 Waterlow J C, Ashworth A, Griffiths M. Faltering in infant
Thoren A, Stintzing G. Value of prolonged breastfeeding.
gTowth in less-developed countries. Lancet 1980; ii:
Lancet 1988; II: 788-89.
6 1176-78.
Michaelsen K F. Value of prolonged breastfeeding. Lancet
" Lepage P, Munyakazi C, Hennart P. Breastfeeding and
1988; II: 788-89.
7 hospital mortality in children in Rwanda. Lancet 1981;
M0lbak K, Gottschau A, Aaby P, Hojlyng N, Ingholt L, da-Silva
II: 409-11.
A P. Prolonged breast feeding, diarrhoea! disease, and
survival of children in Guinea-Bissau. BrMedJ 1994; 308:
1403-06.
* Cousens S, Nacro B, Curtis V et al. Prolonged breast-feeding: no
association with increased risk of clinical malnutrition in (Revised version received July 1995)