Letter to the Editor


29 September 2009

Dear Editor,


We thank Pornpai Putthakeo et al. for revealing the imperative need to support exclusive breastfeeding (EBF), particularly in low-income countries such as Laos.1 However, we disagree with the authors' conclusion about the prevalence of EBF in Laos: their sample is not representative of the Lao national population: 52% urban population versus 28% urban population (2005 Census), 66% mothers delivered in hospitals versus less than 20% hospital deliveries nationwide. Their population is more educated, urban and more likely to receive health staff advice or to be more receptive to Thai advertising.

The weight of their urban sampling underestimates the prevalence of EBF (19.4% vs. 26.4% in the last national 2006 Survey).2 The rural area results have a wide confidence interval (CI) due to a small sample size, with a prevalence of 36.4% EBF (95% CI: 28.4–44.9). Unlike the authors, we are unsure about the general trend of EBF in Laos, but we agree that it is dramatically decreasing in urban areas (in their sample: 2.7%, 95% CI: 0.7–7.0). EBF is traditionally low in Laos due to early feeding practices.3 EBF is now in danger by the increase of advertised products that are widely used in remote areas by illiterate mothers.4,5 Of 1098 adults surveyed during a national survey in 2007, 96% believed that a can of coffee creamer contained milk. Over 18% reported giving the product to their infant at a mean age of 4.7 months (95% CI 4.1–5.3).4 Following the second report of death related to the coffee creamer use, a survey was conducted in December 2008 in northern Laos in a remote Hmong village with low literacy rate (45%).5 In this village, 40.8% of the mothers reported giving one or more of the coffee creamers to their infants at a mean age of 3.6 months (95% CI: 1.8–4.5) (Fig. 1).5

Figure 1.

A child from rural area fed coffee creamer (unlabelled can) admitted for malnutrition and pneumoniae in Luang Nam Tha Hospital North of Laos in 2009.

We agree with the conclusion that authorities should focus on urban mothers, but we advocate breastfeeding promotion and support for rural populations to prevent a decreasing trend similar to Thailand, the lowest EBF rate in the region. Decreasing breastfeeding rates have serious implications for the health of children, especially in rural areas.5

Action should be encouraged to decrease the impact of formula advertising that leads mothers to switch from traditional breastfeeding to formula.6 Our research reveals misleading advertising by formula companies, resulting in the feeding of coffee creamer and other inappropriate breast milk substitutes to infants.4 This has severe implications on the survival of children in Laos.5


We thank Percy Aron for revising the draft, Bryan Watt and Gunther Slesak for their support and for providing pictures. We thank the IFMT students, Service Fraternel d'Entraide, Health Frontier and all the people who participated to collect data during the 2005–2008 surveys.