Drinking-water quality, sanitation, and breast-feeding: their interactive effects on infant health

The promotion of proper infant feeding practices and the improvement of environmental sanitation have been two important strategies in the effort to reduce diarrhoeal morbidity among infants. Breast-feeding protects infants by decreasing their exposure to water- and foodborne pathogens and by improving their resistance to infection; good sanitation isolates faecal material from the human environment, reducing exposures to enteric pathogens. Taken together, breast-feeding and good sanitation form a set of sequential barriers that protect infants from diarrhoeal pathogens. As a result, breast-feeding may be most important if the sanitation barrier is not in place. This issue is explored using data from a prospective study of 2355 urban Filipino infants during the first 6 months of life. Longitudinal multivariate analyses are used to estimate the effects of full breast-feeding and mixed feeding on diarrhoeal disease at different levels of sanitation. Breast-feeding provides significant protection against diarrhoeal disease for infants in all environments. Administration of even small portions of contaminated water supplements to fully breast-fed infants nearly doubles their risk of diarrhoea. Mixed-fed and weaned infants consume much greater quantities of supplemental liquids, and as a result, the protective effect of full breast-feeding is greatest when drinking-water is contaminated. Similarly, full breast-feeding has stronger protective effects among infants living in crowded, highly contaminated settings.