Inuence of Breastfeeding on The Early Aged Children’s Health and Ql Indicators

Background: Promotion and coverage of breastfeeding are considered to be the cost-effective public health measures in terms of Healthcare System. The aim of the research is to assess an inuence of breastfeeding on infants’ health and quality of life (QL) parameters. Methods: This observational prospective study included 1790 newborns selected from Yerevan State Medical University’s Polyclinics (“Mouratsan” (sample=746) and “Heratsi” ” (sample=1044)). Data collection took a period between January 2016 and December 2017. Evaluation of children’s quality of life was performed with the help of the validated and adapted QUALIN questionnaire. The data related to child’s health condition were collected from the “Child Development History” cards available at the polyclinics of the investigated area. Results: Among 1770 one year old children 1681 were ever breastfed, 1224 (69.1%) were exclusively breastfed up to 3 months, the median duration of breastfeeding was 6 -7 months, 45% ≥ 6 months, 15% ≥ 1 year. There is a signicant difference between the QL scores of the ever breastfed and the never breastfed subgroups. Duration of the breastfeeding also have an inuence on QL scores. Conclusions: The given study’s results conrm that breastfeeding among the early aged Armenian children is of great importance in their health, inuencing on quality of life and morbidity rates.


Background
Early contact between a child and the mother has considerable effect on the child's neuropsychological development. It particularly exerts children's rapid social adaptation and reduces stress [21,25,28]. Based on the results of experiments on animals it is more likely that owing to breastfeeding the hypothalamicpituitary-adrenal system (HPAS) reacts to stress in more active way providing adaptation easily due to the feedback mechanism [16].
Functional interconnection between the breastfeeding, immune system development and the further susceptibility to autoimmune diseases is quite interesting. The breast milk is a rich source of immunological defences, which helps the infants to stimulate their own immune system, and so, may have an important role in the establishment of the gut ora and local defence against infection [12].
Researches on breastfeeding show its potential feasibility to reduce the risk of the common infections among newborns, of such illnesses, like atopic dermatitis, asthma, obesity, type 1 or type 2 diabetes, leukemia, the necrotizing enterocolitis, as well as the sudden infant death syndrome, etc. [11,14,15].
Promotion and coverage of breastfeeding are considered to be the cost-effective public health measures in terms of Healthcare System, which is of great importance on maternal health and the infant morbidity and mortality rates decrease [20,31]. Particularly it is important in the developing countries [10, 22,23].
Exclusive breastfeeding in the rst six months of life and its duration up to 11 months is an optimal strategy to improve a child survival in the developing countries and to prevent morbidity of children under ve years of ages by 13% [13].
In Cox regression analyses the duration of breastfeeding showed a positive association with mother's schooling (p = 0.002), her intention to breastfeed (p = 0.001), previous experience with breastfeeding (p < 0.001), self-e cacy with respect to breastfeeding (p < 0.001), her con dence in breastfeeding (p = 0.012) and knowledge about breastfeeding (p = 0.001). The effect of the mother's knowledge depended on the parity of the child [8].
The importance of breastfeeding in low-income and middle-income countries is well recognised, but less consensus exists about its importance in high-income countries. In low-income and middle-income countries, only 37% of children younger than 6 months of age are exclusively breastfed. With few exceptions, breastfeeding duration is shorter in high-income countries than in those that are resource-poor. [5,34].
Breast milk is considered the best source of nutrition for infants, but for a variety of reasons many parents choose to supplement breastfeeding with some formula-feeding or to provide feedings exclusively with infant formula [30].
Mothers rated partners as a powerful in uence on their attitudes toward the obesity-related behaviours of their pre-school children, suggesting that partners could be an important target of obesity-prevention initiatives [1].
A large number of books and researches is available regarding to breastfeeding and life and health of infants and children. However, the data related namely to the problems of breastfeeding and the quality of life and wellbeing of children are relatively few [9,18].
A baby-led weaning approach may encourage greater satiety-responsiveness and healthy weight-gain trajectories in infants. However, the limitations of a self-report correlational study are noted. Further research using randomized controlled trial is needed [4].
Despite attention and improvement priority given to breastfeeding, the latter still remains as a goal that is di cult to achieve for both the developed and the developing countries [3,17,27].
The national program of breastfeeding in the Republic of Armenia has been started since 1993 [24].
The aim of the research is to assess an in uence of breastfeeding on infants' health and morbidity rates, as well as on the QL parameters.

Recruitment and data collection
This observational prospective study included 1790 newborns selected from Yerevan State Medical University's Polyclinics ("Mouratsan" (sample = 746) and "Heratsi" (sample = 1044)). Data collection took a period between January 2016 and December 2017. Inclusion criteria was eligible birth during 2016 year. Exclusion criteria were parental refusal and preterm birth. 1029 practically health children were formed I Group (Healthy) and 761 children with chronic or acute illness formed II Group (Risk). Every Group consists of subgroups according feeding type (exclusively breastfed, ever breastfed and never breastfed).
The study project had been discussed previously and recommended at the meeting of the Ethics Committee of Yerevan State Medical University. Baseline demographic and clinical characteristics were compared between heal thy and risk groups and their subgroups using non-parametric descriptive statistics.
For every newborn up to one year were collected information about feeding type and duration based on "Child Development History" cards. Were also collected data related to child's health condition from same cards available at the polyclinics of the investigated area.

Assessment Of Quality Of Life
Validation and cultural adaptation of QUALIN questionnaire Many different researchers have evaluated children's quality of life with the help of the applied and adapted QUALIN questionnaire [19]. The questionnaire was translated from French into Armenian. It was then checked up for consistency by back-translation to French by language experts. Pretest was conducted two weeks prior to the survey for 100 children (Cronbach's α was 0.8 for parent and 0.9 for pediatrics report). Based on the pretest, the questionnaire was corrected to ensure clarity, wording, and logic sequence. The total evaluation of QL was given with the help of the total cumulative magnitude scale. Every item with 6 possible answers, scored from 0 (quite false) to + 5 (entirely true). Thus, the mean score ranges from 0 (poor QL) to + 5 (excellent QL)

Data Analysis
For analyzing and evaluating of the statistical material the following statistical methods were applied: calculation of medium and relative indicators, reliability evaluation applying Independent Sample Test.
The database was created with the help of SPSS Statistics. The quantitative numbers describing the observation unit were converted to average arithmetic (M), for average veracity evaluation the arithmetic's average error was calculated (m). Differences in proportions were compared by the Chi-square test or Fisher Exact Test and differences of means were compared by the Student's t-test. Module t equals to 2 (95%, veracity p < 0.05).
In the I Group 752 (73.7%) children were exclusively breastfed up to 3 months and in II Group 472 (62.9%) (p < 0.001).
The percentage index of ever breastfeeding among I Group was 96.1% and in II Group 93.5% (p < 0.001). Never breastfed children in I Group were made up 3.9% in II Group 6.5% (p < 0.001) ( Table 1).
In II Group were analyzed morbidity rates for frequently detected neonatal disease according feeding type. It is noteworthy that difference of morbidity between the ever breastfed and the never breastfed children in II Group is of importance ( Table 2).
The iron-de cient anemia indicator made up 39,2 in the subgroup of the never breastfed children and 21,2 -among the ever-breastfed children. The atopic dermatitis indicator was 37,9 in the subgroup of never breastfed children and 21,4 -among the ever-breastfed children.  *the morbidity rate has been calculated for 1000 children Acute respiratory infections were exceptions the indicator of which was 35,7 among the ever-breastfed children and 54,5 -among the never-breastfed children. However, it should be stated that treatment of acute respiratory infections lasted for 3 days among 75,5% of the ever-breastfed subgroup and 30,5% of the never breastfed children. The treatment lasted from 3 to 7 days among 24,0% of the ever-breastfed subgroup and 33,6% among the never breastfed children. Treatment got lasted for more than 7 days among 0,5% of the ever-breastfed children and 25,9% of the never breastfed children.
There is a signi cant difference between the QL scores of the ever breastfed and the never breastfed subgroups for both groups (Table 3). * the average score of quality of life subscales has been calculated in 6 scoring system in which 0 is the minimum possible value and 5 is the maximum possible one.
For both groups in never breast-fed subgroups most affected subscale was ASA.
Duration of breast feeding also have an in uence on QL. Duration of the breastfeeding period and the QL scores for each group presented in the Table 4 and Table 5.  The average score of quality-of-life subscales has been calculated in 6 scoring system in which 0 is the minimum possible value and 5 is the maximum possible one. The average score of quality-of-life subscales has been calculated in 6 scoring system in which 0 is the minimum possible value and 5 is the maximum possible one. In II Group the total score of quality of life was signi cantly different (p < 0.001) depending on whether the child had ever been breastfed or not (Table  6), except for the cases of gastro-esophageal re ux disease (p = 0.0556). * the average of quality-of-life total score has been calculated in 6 scoring system in which 0 is the minimum possible value and 5 is the maximum possible one.
Particularly, in case of anemia the QL total score for the ever breastfed was 3.5 and for the never breastfed -2.7. In case of ambulatory pneumonia, the QL total score was 3.6 for the ever breastfed and 2.9 -for the never breastfed children. In case of rickets the total score of QL for the ever-breastfed children was 3.5 and for the never breastfed children -3.1.

Discussion
The study conducted is important since it enriches the limited literature data devoted to breastfeeding and the quality of life. More common is the literature related to the in uence of breastfeeding on mother's QL [6], while studies devoted to the in uence of breastfeeding on children's QL are quite rare [9].
Mani cat and Dazord [19] examined quality of life among 105 infants (mean age 5.7 months) as a function of feeding, and stated that the duration of breastfeeding for more than 3 months was associated with a higher total quality of life. Our study results were quite similar. There was no signi cant difference in QL scores between never breastfed and ever breastfed (up to 3 months) children (p = 0.14), however, the difference is signi cant in case of children who had been breastfed for 3 months and longer (p < 0.001). In terms of public healthcare resolution, it is necessary to continue breastfeeding at least until 6 months, since the quality of life is signi cantly higher among the children who breastfed for 6 months and longer (p < 0.001), i.e. the duration of breastfeeding in uences on the QL scores. According to WHO counseling the optimal duration of exclusive breastfeeding is making 6 months, therefore breastfeeding is recommended to be continued along with complementary feeding [32].
Data obtained from the given study support the assumption that breastfeeding protects the baby by reducing the morbidity rate. At the same time, it is necessary to conduct some additional studies in order to clarify the underlying mechanisms of the breastfeeding effects. Some literature data referring to the breastfeeding in uence on duration and the whole process of different diseases are represented in the related articles [2,7,26,29,33].
Results of the study are of importance as they show that in case of many diseases among early aged children there is a signi cant difference of QL total scores between the ever breastfed and the never breastfed groups (p < 0.001), excluding the gastro-esophageal re ux (p = 0.0556).
Strength of this study is to be one of the rst studies to explore the relationship between the early aged children breastfeeding and QL in a country with low income.

Conclusion
The given study's results con rm that breastfeeding among the early aged Armenian children is of great importance in their health group, in uencing on the morbidity rate and quality of life.