Breastfeeding and the Risk for Diarrhea Morbidity and Mortality

Reference
Lamberti LM, Fischer Walker CL, Noiman A, Victora C, Black RE. Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health 2011 11(Suppl 3): S15.

Background

• Despite evidence supporting the positive and cost-effective health impacts of exclusive breastfeeding on child survival (1) the practice in resource-poor areas of the world remains low.
• Diarrheal disease is the second leading cause of death among children ages 0-59 months of age (2).
• In 2001, a systematic review of sixteen independent studies conducted by the WHO assessed the effects of exclusive breastfeeding for 6 months versus 3-4 months with mixed breastfeeding thereafter, resulting in the recommendation to promote elusive breastfeeding for the first 6 months of life.(3)
• This paper estimates the protective effects conferred by varying levels of breastfeeding exposure against diarrhea incidence, diarrhea prevalence, diarrhea mortality, all-cause mortality, and hospitalization for diarrhea illness.

Intervention Effects

Breastfeeding on Diarrhea Incidence among Infants 0-5 Months of Age (compared to EBF)

• 5 cohort/cross-sectional studies – Moderate outcome-specific quality of evidence
• Predominant breastfeeding resulted in an excess risk (RR: 1.26, 95% CI 0.81-1.95)
• Partial breastfeeding resulted in an excess risk (RR: 1.68, 95% CI 1.03-2.76)
• Not breastfeeding resulted in an excess risk (RR: 2.65, 95% CI 1.72-4.07)
• The estimated relative risk (RR: 1.32, 95% CI 1.06-1.63) of incident diarrhea was elevated when comparing not breastfed to breastfed infants 6-11 months of age.

Breastfeeding on Diarrhea Prevalence among Infants 0-5 Months of Age (compared to EBF)

• 7 cohort/cross-sectional studies – Moderate outcome-specific quality of evidence
• Predominant breastfeeding resulted in an excess risk (RR: 2.15, 95% CI 1.81-2.55)
• Partial breastfeeding resulted in an excess risk (RR: 4.62, 95% CI 2.37-9.00)
• Not breastfeeding resulted in an excess risk (RR: 4.90, 95% CI 2.93-8.21)
• The estimated relative risk (RR: 2.07, 95% CI 1.49-2.88) of prevalent diarrhea was elevated when comparing not breastfed to breastfed infants and young children 6-23 months of age.

Breastfeeding on Diarrhea Mortality among Infants 0-5 Months of Age (compared to EBF)

• 6 cohort/case-control studies – Moderate outcome-specific quality of evidence
• Predominant breastfeeding resulted in an excess risk (RR: 2.28, 95% CI 0.85-6.13) of diarrhea mortality
• Partial breastfeeding resulted in an excess risk (RR: 4.62, 95% CI 1.81-11.76) of diarrhea mortality
• Not breastfeeding resulted in an excess risk (RR: 10.52, 95% CI 2.79-39.6) of diarrhea mortality
• The estimated relative risk (RR: 2.18, 95% CI 1.14-4.16) of diarrhea mortality was elevated when comparing not breastfed to breastfed infants and young children 6-23 months of age.

Breastfeeding on All-cause Mortality among Infants 0-5 Months of Age (compared to EBF)

• 4 cohort studies – Moderate outcome-specific quality of evidence
• Predominant breastfeeding resulted in an excess risk (RR: 1.48, 95% CI 1.14-1.92) of all-cause mortality
• Partial breastfeeding resulted in an excess risk (RR: 2.84, 95% CI 1.63-4.97) of all-cause mortality
•  Not breastfeeding resulted in an excess risk (RR: 14.40, 95% CI 6.13-33.86) of all-cause mortality
• The estimated relative risk (RR: 3.69, 95% CI ) of all-cause mortality was elevated when comparing not breastfed to breastfed infants and young children 6-23 months of age.

Breastfeeding on Diarrhea Hospitalizations among Infants 0-5 Months (compared to EBF)

• 2 cohort/case-control studies – Moderate outcome-specific quality of evidence
• Predominant breastfeeding resulted in an excess risk (RR: 2.28, 95% CI 0.08-6.55)
• Partial breastfeeding resulted in an excess risk (RR: 4.43, 95% CI 1.75-13.84)
• Not breastfeeding resulted in an excess risk (RR: 19.48, 95% CI 6.04-62.87)
• Among infants 6-11 months of age, not breastfeeding had a higher risk of hospitalization for diarrhea when compared to any breastfeeding (RR: 6.05, 9%% CI 2.44-14.97)

Intervention Recommendation:  STRONG

• Findings support the current WHO recommendation for exclusive breastfeeding during the first 6 months of life, and highlight the importance of breastfeeding to protect against diarrhea-specific morbidity and mortality throughout the first 2 years of life.
• Diarrhea Incidence
  • Infants 0-5 months (as compared to EBF)
    • Increased risk with predominant breastfeeding (RR: 1.26; 95% CI 0.81-1.95)
    • Increased risk with partial breastfeeding (RR: 1.68; 95% CI 1.03-2.76)
    • Increased risk with no breastfeeding (RR: 2.65, 95% CI 1.72-4.07)
  • Infants 6-11 months (as compared to any breastfed)
    • Increased risk with no breastfeeding (RR: 1.32, 95% CI 1.06-1.63)
  • Children 12-23 months (as compared to any breastfed)
    •  Increased risk with no breastfeeding (RR: 1.32, 95% CI 1.06-1.63)
• Diarrhea Mortality
  • Infants 0-5 months (as compared to EBF)
    •  Increased risk with predominant breastfeeding (RR: 2.28, 95% CI 0.85-6.13)
    • Increased risk with partial breastfeeding (RR: 4.62, 95% CI 1.81-11.76)
    • Increased risk with no breastfeeding (RR: 10.52, 95% CI 2.79-39.6)
  • Infants 6-11 months (as compared to partial or predominantly breastfed)
    • Increased risk with no breastfeeding (RR: 1.47; 95% CI 0.67-3.25)
  • Children 12-23 months (as compared to partial or predominantly breastfed)
    • Increased risk with no breastfeeding (RR: 2.57; 95% CI 1.10-6.01)

References from Lamberti Paper Cited Here

1. Riordan JM.  The cost of not breastfeeding: a commentary. J Hum Lact 1997, 13: 93-97.
2. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, et al. Global, regional and national causes of child mortality in 2008: a systematic analysis.  Lancet 2010, 375(9730): 1969-87.
3. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: A systematic review.  Cochrane Database Syst Rev 2002, CD003517.