Despite improvements over time, sub-Saharan Africa has the highest rate of “under-5 mortality” in the world (75.8 per 1000 live births in 2019) and persistently high child stunting (33% in 2019). High under-5 mortality and stunting, along with other factors, contribute to poor human capital outcomes and lost economic productivity.1–3 Breastfeeding is the child’s first immunization and the single most important life-saving intervention for young children4–6 and, by implication, is likely to have a big impact on productivity and economic growth. In this issue of Pediatrics, Pretorius et al7 explore linkages between breastfeeding and economic growth at the country level in Africa.
The Human Capital Index, a summary estimate of the economic productivity of an individual given prevailing health and education in her country, averages 0.4 out of 1.0 in sub-Saharan Africa (much lower than the global average of 0.57). This means that, on average, a child born in sub-Saharan Africa today is likely to reach only 40% of her full earnings potential, as compared to 88% for a child born in Singapore.3 Both undernutrition and child mortality rates contribute significantly to the Human Capital Index. By enhancing nutrition and reducing child mortality, breastfeeding is a key contributor to human capital development.
Undernutrition is the underlying cause of approximately half of under-5 deaths globally,8 and breastfeeding is the most effective preventive intervention to reduce under-5 mortality.4 It is widely understood that children need exclusive breastfeeding for the first 6 months of their lives and continued breast milk, alongside other foods, until they reach 2 years of age to reduce undernutrition and promote child health.
The economic returns of breastfeeding have been documented in different ways.9,10 At the individual level, a recent study in the United States reveals lifetime labor earning gains for a breastfed child of ∼$20 000 (L. Lutter, PhD, unpublished observations). At the program level, the World Bank estimates that every $1 invested in breastfeeding promotion strategies in sub-Saharan Africa generates, on average, $18 in economic returns over the productive lives of children, making breastfeeding one of the more profitable investments for countries. This means a modest $1.1 billion investment in breastfeeding in Africa over 10 years ($110 million per year) will generate economic gains estimated at $20 billion. Not investing, in contrast, would result in almost 21 million children not exclusively breastfed and 137 000 child deaths that could otherwise have been averted, in addition to foregone economic gains.11,12
The economic returns and costs of inaction would likely be even higher if links between breastfeeding and lowered risks of obesity and noncommunicable diseases (NCDs), such as diabetes and cardiovascular diseases, in adulthood were factored in. Nonbreastfed children have a higher risk of becoming obese in later life, which makes them more susceptible to NCDs and pandemic-related infections. Breastfeeding also affords women protection against breast cancer and helps regulate maternal weight gain in the postpartum period, protecting against obesity and NCDs later in life.13 Higher morbidity and cognitive losses associated with undernutrition add a further burden on future human capital and economic productivity.
The coronavirus disease 2019 pandemic creates further impetus to promote breastfeeding because emerging evidence suggests that the milk of previously infected mothers may contain severe acute respiratory syndrome coronavirus 2–specific antibodies, offering potential passive immunity via breastfeeding.14 New evidence also indicates that obesity increases the risk of coronavirus disease 2019–related death by ∼50%.15
In the article by Pretorius et al,7 researchers add to the literature by linking breastfeeding to economic growth at the country level in Africa. Recent trends reveal that exclusive breastfeeding rates in sub-Saharan Africa have increased to 44.9% in 2016 from 34.7% in 2010. Under-5 mortality rates, however, remain higher than in low-income countries (75.8 compared to 68 per 1000 live births on average in 2019). We hope that studies such as this one can be used as a further call to action. When combined with allocative efficiency modeling tools, such as Optima Nutrition,16,17 which can help countries prioritize spending to a point at which it can have the biggest impact, progress can be made.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-030643.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.