A 2001 study revealed that $3.6 billion could be saved if breastfeeding rates were increased to levels of the Healthy People objectives. It studied 3 diseases and totaled direct and indirect costs and cost of premature death. The 2001 study can be updated by using current breastfeeding rates and adding additional diseases analyzed in the 2007 breastfeeding report from the Agency for Healthcare Research and Quality.
Using methods similar to those in the 2001 study, we computed current costs and compared them to the projected costs if 80% and 90% of US families could comply with the recommendation to exclusively breastfeed for 6 months. Excluding type 2 diabetes (because of insufficient data), we conducted a cost analysis for all pediatric diseases for which the Agency for Healthcare Research and Quality reported risk ratios that favored breastfeeding: necrotizing enterocolitis, otitis media, gastroenteritis, hospitalization for lower respiratory tract infections, atopic dermatitis, sudden infant death syndrome, childhood asthma, childhood leukemia, type 1 diabetes mellitus, and childhood obesity. We used 2005 Centers for Disease Control and Prevention breastfeeding rates and 2007 dollars.
If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year and prevent an excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80% compliance).
Current US breastfeeding rates are suboptimal and result in significant excess costs and preventable infant deaths. Investment in strategies to promote longer breastfeeding duration and exclusivity may be cost-effective.
Comments
Thoughts on Bartick's Pediatric Cost Analysis
This e-letter is in response to the article by Bartick and Reinhold, “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis.”1 The International Formula Council supports the position of the World Health Organization, the American Academy of Pediatrics, and other organizations that breastfeeding is ideal. However, we have three major concerns about this analysis:
(1) The cost estimate of suboptimal breastfeeding: Bartick and Reinhold assigned a value of $10.5 million to each of the calculated “excess deaths.” Every life is of value and, although we strongly disagree with assigning a dollar value to each human life, this was the methodology Bartick and Reinhold employed for their analysis. The resulting $9.5 billion figure calculated due to “excess death” contributes 73% of the total $13 billion “savings to the U.S.” that is referenced in the conclusion. To test the plausibility of these values, we estimated that with a life expectancy of 77.7 years (U.S. average in 2007) and with a 3% annual rate of return, $10.5 million accumulated in a lifetime would yield a constant annuity stream of $342,000 per year. This is 7.9 times the mean real gross domestic product (GDP) per capita in 2007 (Bureau of Labor Statistics, 2009). Thus, the “revealed preference job risk” approach that the authors chose values each year of life saved at almost 8 times the value of per capita annual product or consumption. In addition, their estimate did not incorporate the costs of resources (food, shelter, etc.) needed for an infant to become a productive adult. Given these assumptions and the lack of consideration for the costs of resources needed for each human life, we question the application of a $10.5 million value to each “excess death.”
(2) The data source for disease risk: Bartick and Reinhold relied solely on the 2007 Agency for Healthcare Research and Quality (AHRQ) report on breastfeeding for relative risk for the diseases considered.2 The AHRQ report, as an analysis of meta- analyses, is fundamentally limited by the value of the underlying observational data. More recent studies and research designed as randomized prospective trials (such as the PROBIT trial)3 are not reflected in the AHRQ report and are thus not a part of the Bartick and Reinhold analysis.
Bartick and Reinhold assess three areas as the quantitatively most important contributors to the overall cost estimate: SIDS death, necrotizing enterocolitis (NEC) hospital costs and deaths, and deaths from lower respiratory infection (LRTI).
Regarding SIDS, PROBIT reported a non-statistically significant difference in SIDS between treatment groups, (p = 0.12). These findings were not included in the AHRQ analysis nor in Bartick and Reinhold’s analysis. Further, it is notable that in 2005, the AAP Task Force on SIDS concluded, “Although breastfeeding is beneficial and should be promoted for many reasons, the task force believes that the evidence is insufficient to recommend breastfeeding as a strategy to reduce SIDS.”4
Regarding NEC, a concern is that Bartick and Reinhold estimated each NEC death to have excess direct costs to the U.S. of $10.5 million due to lost contribution of earnings from premature deaths. We once again disagree with assigning a dollar value to each human life. Further, the odds ratio used to determine excess costs due to NEC was calculated based on exclusive breastfeeding rates at 3 months (32.1%) instead of initial breastfeeding rates (74.1%), even through NEC usually occurs in the first few weeks of life (typically between 30-32 weeks post-conceptional age). If one applies the odds ratio to an initial rate of breastfeeding, the excess costs of suboptimal breastfeeding are decreased by more than half, a correction that applies independently from the other factors discussed above.
The third major contributor to excess costs that Bartick and Reinhold identify is LRTI mortality. Bartick and Reinhold used the crude OR from the AHRQ report, which based its conclusions on a meta-analysis that only controlled for confounding by smoking and socioeconomic status.5 The meta -analysis did not control for many other covariates identified by the Centers for Disease Control and Prevention (CDC) as risk factors for LRTI deaths, that also co-vary with breastfeeding.6 Therefore, residual confounding is highly likely, potentially leading to an over-estimate of the relationship between breastfeeding and LRTI. Finally, the PROBIT study for breastfeeding promotion that found no difference in the risk of respiratory tract infections between control and breastfeeding promotion groups was not considered in the Bartick and Reinhold analysis.3
(3) Selection of a 90% exclusive breastfeeding rate: There was no substantiation or detail given on selecting the 90% exclusive breastfeeding rates for six months number. Indeed, this choice seems arbitrary and is not in line with any U.S. government public health goals for breastfeeding. For exclusive breastfeeding rates to reach 90% in the US, barriers to breastfeeding in the US must be identified and widely overcome.
References Cited:
1. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010; 125 (5):e1048-56.
2. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Evidence report/technology assessment No. 153.
3. Kramer, M. S., B. Chalmers, et al. Promotion of Breastfeeding Intervention Trial (PROBIT): A Randomized Trial in the Republic of Belarus. JAMA. 2001; 285(4): 413-420.
4. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics. 2005;116:1245–1255.
5. Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Arch Pediatr Adolesc Med. 2003; 157(3):237-43.
6. Singleton et al, Risk Factors for Lower Respiratory Tract Infection Death Among Infants in the United States, 1999 –2004. Pediatrics. 2009; 124:e768–e776.
Conflict of Interest:
Haley C. Stevens and Mardi K. Mountford are employees of the International Formula Council (IFC), an association of manufacturers and marketers of formulated nutrition products, e.g., infant formulas and adult nutritionals, whose members are based predominantly in North America. IFC members are: Abbott Nutrition; Mead Johnson Nutrition; Nestlé Infant Nutrition; PBM Products, LLC, A Perrigo Company; and Pfizer Nutrition.
Breastfeeding, Formula use and Health: Cost effectiveness and cost benefits
Thank you to Melissa, and to Arnold for his excellent analytic skills, for reopening this discussion!
If there is interest in pursuing this further, we offer the following complementary studies, upon request.
1. We published a piece that include maternal and child health impact and costs as well as cost savings back a few years: Labbok M. Cost Benefit Analysis for Breastfeeding in the United States: Is supporting exclusive breastfeeding worth the costs? In: Breastfeeding Annual International 2001, Michaels D, ed., Platypus Media Press, 2001, pp. 187-194. this is being updated currently.
2. Available online, more recently, we published all the data needed to reference on risks of any formula feeding: McNiel M, Labbok M, Abrahams SW. What are the Risks Associated with Formula Feeding? A Re-Analysis and Review. March 2010 Birth 37(1): 50-58.
I hope these articles will complement thinking on the recent study, and advance the role of enabling women to breastfeed as part of health care reform, and best practices in general.
Sincerely,
Miriam H Labbok, MD, MPH, FACPM, IBCLC, FABM Professor, and Director, Carolina Global Breastfeeding Institute (CGBI) Department of Maternal and Child Health, Gillings School of Global Public Health, CB#7445, The University of North Carolina, Chapel Hill, NC 27599- 7445 Tel: 919-966-0928 Fax: 919-966-0458 [email protected] http://www.sph.unc.edu/breastfeeding
Conflict of Interest:
None declared
Breast-fed babies require vitamin D for optimal health
Sir:
The paper on the burden of suboptimal breastfeeding in the United States1 points out an important way to improve the nation’s health. Unfortunately, the paper did not mention the role of vitamin D during lactation. Vitamin D is very important for optimal health.2 Risks for some of the diseases mentioned in the paper are very likely increased at lower serum 25-hydroxyvitamin D [25(OH)D] levels. There is preliminary evidence that low serum 25(OH)D levels increase the risk of these childhood diseases: asthma,3 lower respiratory tract infection,4 influenza,5 type 1 diabetes mellitus,6 otis media,7 rickets,8,9 bone fractures,9 and sepsis.10 Several of the diseases are linked to viral or bacterial infections. Vitamin D reduces the risk of infection through induction of cathelicidin and defensins.11,12
The importance of vitamin D for pregnancy and lactation has been underscored in a number of recent papers, for example from Pennsylvania,13Massachusetts,7,14 and South Carolina.15,16
Estimates of the reductions in mortality rates and economic benefits of increasing mean population serum 25(OH)D levels to around 42-45 ng/mL have been reported for Western Europe,17 the United States,18 and Canada.19 It is not clear how much increasing maternal and infant serum 25(OH)D levels to 42-45 ng/mL would reduce infant and childhood disease rates and economic burden. However, since vitamin D is very inexpensive, the benefit-cost ratio would be very high.
References
1. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics published online April 5, 2010 (10.1542/peds.2009-1616)
2. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266- 281.
3. Ginde AA, Mansbach JM, Camargo CA Jr. Vitamin D, respiratory infections, and asthma. Curr Allergy Asthma Rep. 2009;9(1):81-87.
4. McNally JD, Leis K, Matheson LA, Karuananyake C, Sankaran K, Rosenberg AM. Vitamin D deficiency in young children with severe acute lower respiratory infection. Pediatr Pulmonol. 2009;44(10):981-988.
5. Urashima M, Segawa T, Okazaki M, Kurihara M, Wada Y, Ida H. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. Am J Clin Nutr. 2010 Mar 10. [Epub ahead of print]
6. Hyppönen E, Läärä E, Reunanen A, Järvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study. Lancet. 2001;358(9292):1500-1503.
7. Linday LA, Shindledecker RD, Dolitsky JN, Chen TC, Holick MF. Plasma 25-hydroxyvitamin D levels in young children undergoing placement of tympanostomy tubes. Ann Otol Rhinol Laryngol. 2008;117(10):740-744.
8. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr. 2004;80(6 Suppl):1697S-1705S.
9. Paterson CR. Vitamin D deficiency rickets and allegations of non- accidental injury. Acta Paediatr. 2009;98(12):2008-2012.
10. Grant WB. Vitamin D supplementation of mother and infant could reduce risk of sepsis in premature infants. Early Human Develop. 2010;86(2):133.
11. Kamen DL, Tangpricha V. Vitamin D and molecular actions on the immune system: modulation of innate and autoimmunity. J Mol Med. 2010 Feb 1. [Epub ahead of print]
12. White JH. Vitamin D as an inducer of cathelicidin antimicrobial peptide expression: Past, present and future. J Steroid Biochem Mol Biol. 2010 Mar 17. [Epub ahead of print]
13. Bodnar LM, Simhan HN, Powers RW, Frank MP, Cooperstein E, Roberts JM. High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates. J Nutr. 2007 Feb;137(2):447-52.
14. Merewood A, Mehta SD, Chen TC, Bauchner H, Holick MF. Association between vitamin D deficiency and primary cesarean section. J Clin Endocrinol Metab. 2009;94(3):940-945.
15. Hollis BW. Vitamin D requirement during pregnancy and lactation. J Bone Miner Res. 2007 Dec;22 Suppl 2:V39-44.
16. Wagner CL, Howard C, Hulsey TC, et al. Circulating 25- hydroxyvitamin D levels in fully breastfed infants on oral vitamin d supplementation. Int J Endocrinol. 2010;2010:235035.
17. Grant WB, Cross HS, Garland CF, et al. Estimated benefit of increased vitamin D status in reducing the economic burden of disease in Western Europe. Prog Biophys Mol Biol. 2009;99(2-3):104-113.
18. Grant WB. In defense of the sun: An estimate of changes in mortality rates in the United States if mean serum 25-hydroxyvitamin D levels were raised to 45 ng/mL by solar ultraviolet-B irradiance. Dermato- Endocrinology, 2009;1(4):207-214.
19. Grant WB, Schwalfenberg GK, Genuis SJ, Whiting SJ. An estimate of the economic burden and premature deaths due to vitamin D deficiency in Canada, Molec Nutr Food Res. 2010 Mar 29. [Epub ahead of print]
Conflict of Interest:
I receive funding from the UV Foundation (McLean, VA), the Sunlight Research Forum (Veldhoven), Bio-Tech-Pharmacal (Fayetteville, AR), and the Vitamin D Council (San Luis Obispo, CA).
An estimate that is missing half the equation
I was pleased to see this effort to appraise US policy-makers of the economic costs of suboptimal breastfeeding. However, any analysis that is missing the effects of lactation on maternal health will grossly underestimate the true costs to the US of suboptimal breastfeeding.
As the 2007 AHRQ report stated, "a history of lactation was associated with a reduced risk of type 2 diabetes, breast, and ovarian cancer" for mothers. In addition, over the last 3 years, considerable evidence has accumulated showing that lactation also has important effects on maternal risk of hypertension, hyperlipidemia, and cardiovascular disease (PMID: 19110223; PMID: 19384111; PMID: 20027032; PMID: 20027032), the leading cause of death for US women.
Conflict of Interest:
None declared