In a recently released issue of Pediatrics, Dr. Min Zhao and colleagues examine data related to breastfeeding and mortality of children under 2 years of age in Sub-Saharan Africa (10.1542/peds.2019-2209). Their comprehensive work uses cross-sectional data from Demographic and Health Surveys (DHS) conducted between 2000 and 2016 in 35 countries in Sub-Saharan Africa and includes up to 217,112 children aged 4 days-23 months. DHS are nationally representative surveys conducted in low- and middle-income countries (LMIC) with specific multi-stage sampling strategies designed to assess the health and nutritional status of mothers (women ages 15-49 years) and their children (0-59 months old). DHS are approved by the Institutional Review Board (or equivalent body) in each country and verbal informed consent is obtained from each participant; DHS have high quality interviewer training, a high response rate, a nationally representative sampling strategy, and are standardized across countries. Study definitions of breastfeeding as exclusive (only breast milk allowing for vitamins and medicines), predominant (breast milk and water or flavored water only), partial (breast milk and either animal milk, infant formula or solids) or none (no breast milk) were aligned with the WHO (World Health Organization) definitions. Hence this study used a large and reliable source of data, and widely accepted definitions of breastfeeding, both of which increase our ability to accept the accuracy of the study results.
The authors examined the effect of exclusivity and duration of breastfeeding on all-cause mortality among children under 2 years of age. As compared to exclusive breastfeeding in the first 3 days of life, those not breastfed at all had a large and significant increase in mortality (OR = 13.45, 95% CI =11.43-15.83). Those who were predominantly breastfed in the first 3 days of life had a small increase in mortality under 2 years compared to exclusive breastfeeding (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.03-1.21) and those partially breastfed had no significant change in mortality, so as expected given the known dose response effects of breastmilk on health outcomes, any breastmilk (predominant) was better than none, and all (exclusive) breastfeeding was optimal. Among children ages 6-23 months, compared to those who were everbreastfed in the first 6 months of life, those who were not breastfed at all had an increase in mortality under 2 years (OR=5.65, 95% CI= 4.27-7.47). For children who were breastfed for longer periods, i.e. for >6 months compared to <3 months compared to not at all, greater duration of breastfeeding was associated with significantly decreased mortality rates for each additional increment of breastfeeding months. The authors note in their conclusion that 682 children’s lives could have been saved if each mother had breastfed her baby for 6 months.
How is this relevant to pediatricians practicing in developed countries including the United States? I believe this overwhelming endorsement of the extraordinary benefit of breast milk for child health and survival can and should inform our practice. Data like these from LMICs demonstrate the power of exclusive breastfeeding, which can jumpstart discussions with families in every pediatric practice. We should not underestimate the power of human milk to save lives and change health outcomes even in our own neighborhoods. Using available health data and simulation modelling, Dr. Melissa Bartick and colleagues calculated that a change in the US to full breastfeeding, defined as exclusive breastfeeding through 6 months followed by continued breastfeeding through at least 12 months of age with addition of solids, could save 721 infant lives annually, mostly due to reduction in deaths from Sudden Infant Death Syndrome (n=492).1 This analysis also showed that for every 597 women who fully breastfeed, one maternal or child death is prevented, and that (for example) just 3 fully breastfeeding women are needed to prevent an episode of acute otitis media and less than one fully breastfeeding mother is needed to prevent an episode of infant gastrointestinal infection.1 Returning to the work of Dr. Min Zhao and colleagues, I am convinced that their study from Sub-Saharan Africa translates into a powerful breastfeeding promotion message for our own daily work.