Long-Term Benefits of Breastfeeding:

An Analysis of Current Research

By: Emily Hale

Introduction As in all open areas of scientific investigation, the question of determining the advantages of breastfeeding and analyzing the mechanisms for those advantages requires a twofold approach. Firstly, a thorough aggregation of existing research on the topic must be effectively summarized, and secondly, the path of future research must be determined based on the flaws, inconsistencies, or omissions of research conducted heretofore. In the summary and analysis that follows, breastfeeding is, in general, shown to have a positive correlation with a range of cognitive and physiological benefits, and a careful analysis of the studies considered reveals the need for future work on this topic.

Summary of Existing Research While a correlation between infant nutrition and health later in life seems probable, undeniable evidence to support such a correlation is, as yet, elusive. There have, however, been many studies, which have found evidence to support a correlation between the benefits of breastfeeding on infant nutrition and subsequent lifelong health. Between these studies, the most consistently supported long-term health benefits of infant breastfeeding were lowered cholesterol, increased cognitive ability, and reduced occurrences of gastrointestinal infections (1,5,7). One of the most consistently supported long-term benefits suggested in previous research is the positive effect of breastfeeding on cholesterol levels after infancy. In their meta-analysis of previous breastfeeding research on the consequences of infant breastfeeding, Horta et al, (1) found a consistent correlation between breastfeeding and low cholesterol levels in adulthood.

Human breast milk contains much higher levels of cholesterol than commercially available formulas. It has therefore been suggested that lower cholesterol levels in adulthood may be linked to longer durations of breastfeeding during infancy due to the nutritional programming imparted by high cholesterol content in human breast milk (1). Horton et al. found that lowered cholesterol levels as a result of breastfeeding are less prevalent during youth and adolescence but increase with age so that by adulthood these results are prominent. With respect to the research articles reviewed, the most prevalent and supported longterm effect of breastfeeding was cognitive ability. One possible explanation of this effect is longchain polyunsaturated fatty acids, which are highly prevalent in breast milk unlike the vast majority of formulas which contain comparatively diminutive amounts (2). Structural lipid components including docosahexaenoic (DHA) and arachidonic (AA) acids influence retinal and cortical brain development; Neural cell membranes utilize DHA and AA most rapidly during the last trimester of pregnancy and first months after birth (1). Breastfed infants are found to have more of these long-chain fatty acids, which, as the structure for the cell membranes, provide a more solid infrastructure for brain development. Therefore, the presence of DHA and AA is potentially the source of higher cognitive ability in connection with breastfeeding (1). Klaus (8) and Renfrew (9) present the alternative explanation that the nutritional benefits of breastfeeding have less of an effect on cognitive development than the enhanced maternal bonding with the child. They argue that mothers who breastfeed their infants are more prone to stimulating their children which can influence the cognition and performance on intelligence tests (3). However, most, including Horta et al. (1) in their meta-analysis, conclude that those studies which controlled for socioeconomic status and stimulation at home found a positive correlation between

breastfeeding and cognitive development in children. Therefore it can be concluded that previous research in this field suggests positive correlations between breastfeeding and healthy cognitive development. Studies that considered longer durations of breastfeeding observed an increase in the benefits of breastfeeding and supplementary benefits begin to appear (1). The World Health Organization along with the American Academy of Pediatrics recommends exclusive breastfeeding for approximately the first six months and continued breastfeeding to a year along with the introduction of solid foods. Rossum et al. (6) concluded, In the model in which the health effects are quantified, we estimated that if all children will be breastfed for at least six months (best case scenario), per 1000 person years the largest decreases in incidences are seen for the health of the infant, such as infections. The prolonged duration of breastfeeding has been found to reduce the occurrence of gastrointestinal infections. After compiling a meta-analysis on previous research, Kramer et al. concludes that exclusive breastfeeding for durations over six months may result in lower morbidity rates from gastrointestinal and allergic disease (7). It should be noted that Evenhouse et al. (4) found an unexpected correlation between duration of breastfeeding and negative outcomes beginning when breastfeeding continues beyond a year, suggesting that duration longer than twelve months could possibly be harmful. Most research previously conducted in this field suggests that there are breastfeeding benefits beyond infancy, which while not providing conclusive answers, does provide for good reason further research.

Topics for Further Consideration While in general the sources reviewed seem to support breastfeeding on the basis of its various demonstrated benefits, there are inconsistencies in the literature with respect to definitions, duration of breastfeeding considered, external factors that affect correlation, etc. In order to clarify the positive correlation already demonstrated between breastfeeding and various benefits and in order to establish not only correlation, but some degree of causality, the following issues must be considered. Factors such as duration of breastfeeding, levels of exclusivity, predominance, and partial supplementation of formula, and nutritional content of various human milk substitutes are currently under-regulated in breastfeeding research and should not be difficult to amend. Other, more difficult factors to control in breastfeeding research, including dietary habits of the mother during pregnancy and during lactation, pharmaceuticals used, socioeconomic status, family history and the stimulation/education of the child will be harder to amend in future but should be studied nonetheless for their potential influence on the effectiveness of breastfeeding.

Discrepancies in Research One important inconsistency in breastfeeding research is the factor of duration. A common approach to reporting results is to classify infants as having ever or never been breastfed. This ever vs. never approach, while helpful to some extent, is unnecessarily and potentially detrimentally vague. If research is conducted which only specifies yes, the infant was breastfed, or no, the infant was not breastfed, information that can contribute to longterm effects cannot fully be taken into account. Many researchers, including Dell, Rossum, and Kramer, have concluded that the duration of breastfeeding affects the potential health benefits to

the infant (1, 6, 7, 15). Rossum found that the strongest associations between lower gastrointestinal infections and breastfeeding was most prevalent in those breastfed longer than six months, suggesting that duration of breastfeeding is an important factor in the study of longterm benefits. Studies need to take into account how long the infant was breastfed. An infant breastfed for three months versus an infant breastfed for twelve months most likely will have differences in health corresponding to the differences in breastfeeding duration. An ever vs. never data collection strategy is poor because an infant classified under ever may have been breastfed for 4months or only a week. Because duration has been found to be an important factor, this method is insufficient. To properly define and provide evidence of the long-term health effects of breastfed infants, the duration needs to be noted and identified, thereby enabling a more meaningful data analysis. Another inconsistency in breastfeeding research is the lack of consideration for levels of exclusivity, predominance, and partial supplementation of breast milk in subjects diets. The ratios of breast milk to supplemental formula need to be specified and controlled when considering the health benefits of breastfeeding. Nutrient intake can be affected significantly depending on the levels of nutrient-based human milk substitutes in an infants diet. A diet consisting of only breast milk may have significant nutritional discrepancies with a partially or predominantly supplemented diet. Therefore, variations in levels of supplementation should be considered and controlled in future research. Horta et al. note breastfeeding patterns (exclusive, predominant, or partial) have rarely been assessed. (1) Although some researchers consider formula supplementation as an inclusive part of breastfeeding, others consider formula supplementation as a non-inclusive element which should be controlled. Still others do not consider the level of formula supplementation at all in their subjects. It is important that future 6

research in this field specify the level exclusivity in observing breastfeeding subjects because of the great potential for nutritional variation. This is especially important when monitoring the correlations between breastfeeding and diabetes in children, adolescents and adults. When comparing breastfeeding versus formula feeding, the types of formula used should be specified. All formulas are not created equal; there are varied amounts of nutrients, sugar, and cholesterol and protein sources. Formula varies in each brand and in different countries, therefore when comparing the long-term effects of formula to breast milk; the contents of each formula need to be taken into account (2). This is most important to remember when looking at adolescents or adults that were formula fed more than ten to fifteen years ago, the reason being that HMS formula has significantly improved over time.

Surroundings and Contributing Factors of Infant Health One of the many factors, which should be taken into account when studying the longterm effects of breastfeeding, is the dietary habits of the mother. The mothers nutrition is not just important during gestation; it continues to be important during breastfeeding as the child continues to consume, nutritionally, whatever the mother consumes. For example, a mother who does not have an adequate intake of folic acid before gestation, the child is in danger of having neural tube defects. Dietary habits have changed over time as well as differ in mothers various countries of origin or of current residence. This influences the habits and foods available for the mother and child (2). It is important for researchers to consider the nutritional intake of the mother because of its direct impact on the nutritional quality of her breast milk and the subsequent effects on the

infants short and long-term health. One study in particular observed adults that were born in the UK in 1946 (10). Closely after the end of WWII, the average diet may have been different since certain foods were not available while others were in abundance. If the mother were in a position of not having access to important nutrients or even nutritional satiation during gestation and/or lactation, the infants health would be affected. Quality of food should be taken into consideration as well. Until recently, many foods were not available in smaller, suburban residential towns. Mothers had access to less variety of foods as well as fresh fruits and vegetables unless they grew them themselves. The qualities of foods have also changed over time with more being fortified with specific nutrients to ensure positive health effects. A question that should be answered when analyzing breastfeeding data is, Was this before certain common foods were fortified with various vitamins or minerals? (i.e. salt- iodide) Positive and negative effects should be included in these studies since some of these fortifications and additives could be harmful; i.e. high fructose corn syrup and some preservatives. Immunizations are another factor that can affect the health of either mother or child. Used widely and constantly developing with the advancement of medicine and knowledge of diseases, researchers need to take into account if certain immunizations were available for the mother, infant, child, or adolescent during the time period in which the study took place. Another aspect of maternal health needing to be scrutinized is the pharmaceutical practices and intake of the mother during pregnancy and lactation. It is evident that a variety of medicines taken by a mother can negatively affect the health of a newborn, and later in life. This needs to be taken into consideration if looking at long-term health effects, especially organ

function (1). This facet is closely related to alcohol consumption and smoking of the mother while pregnant and lactating. It is evident that alcohol consumption during pregnancy, especially the first trimester when the brain is developing most rapidly, is dangerous for the infant and can result in fetal alcohol syndrome (16). Although this is the extreme result, other minor, less obvious consequences can happen and could have an impact on the infants health for the rest of their lives. Additional considerations that need to be included are characteristics about the mothers health and life quality. The mothers education needs to be taken into account for the reason that more education results in high quality of health and habits when it comes to pregnancy and lactation. A mother with more education most likely will invest her time in higher quality health participation and strive to be more informed of the health effects and benefits for the child. In the same social group, mothers who breastfeed are likely to be more health-conscious than those who do not breastfeed. This may also lead them to promote other healthy habits among their children, including prevention of overweight, promotion of physical exercise and intellectual stimulation (1). This leads to the factor of maternal working habits. If the mother works outside of the house, there is less involvement with the child and possibly less human milk and interest in infant nutrition. When someone else is involved with the feeding of the child, other factors not noticed by the mother can influence the childs health. If the mother is at home full time, there is more control of the infants nutrition. The maternal and paternal family health history needs to be noted for the prevalence of disease and attributes of health. Diabetes, asthma, allergies, high cholesterol and blood pressure

can all be genetically influenced (16). If health history is not taken into account, the long-term health effects may be over or under estimated, especially in smaller scale studies in which the observed population is not large enough to average out the effects of family history.

Upbringing of the Child and Socioeconomic Status Problems and inherent difficulties that need to be considered are socioeconomic factors as well as the upbringing of the child. Research suggests that socioeconomic status (SES) has an influence on child health, especially cognitive development (1). Families in Low-SES groups have poorer diets, children less likely to be in high-quality education programs or attain higher education, parents less likely to be as involved with schooling, etc. In societies where breastfeeding is more common among upper social groups, the possibility of confounding by parental education level has to be addressed (1). A parent who is at home and able to consistently give cognitive stimulation to the child needs to be taken into consideration when observing cognitive ability, as well as gross and fine motor skills. There also needs to be a specification on the type of stimulation of the child, including how much time is spent watching TV, playing video games, computer time, playing outside, art projects and general play time with the parent. The quality of a childs stimulation is imperative for cognitive development; poor qualities of stimulation could be the inherent downfall of a childs success in school, work and social skills. SES has a large effect on the quality of stimulation for the child. Wealthy families have access to superior childcare and education opportunities. The World Health Organization confirms that, Socioeconomic status is one of the most important confounders in studies on the long-term effects of breastfeeding. In most societies, breastfeeding rates differ among social

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groups (11). Confounding by SES may overestimate and underestimate the beneficial effects of breastfeeding depending upon the setting: high-income and low/middle income populations (breastfeeding more common in high-income setting) vs. low/middle-income setting (breastfeeding more prevalent among the poor (1)). The diet of the child post lactation should be noted or at least considered in looking at the long-term effects. If a poor diet existed after the termination of breastfeeding and continued to lack basic nutrition standards, the long-term effects shown in results could be underestimated and altogether canceled. It will be more difficult to observe positive effects in this case. On the other hand, it could be beneficial to note these poor nutrition habits if the long term effects are still evident in the subject, meaning inferior nutrition habits later in life can be counteracted by superior nutrition as an infant. Huttly et al. (12) discuss the problems that may arise with research methods that obtain data from mothers asked to recall information for the study. Misclassification may occur and can overestimate or underestimate the results (1,12). In Huttlys study, wealthier and more educated mothers reported longer duration of breastfeeding than the actual duration time in retrospective studies, low SES status mothers did not (1,12). Mothers may exaggerate the duration period or quality of the breastfeeding in order to comply with perceived standards. Screening for participants with such specific qualities is a barrier. However, this process needs to be a priority to fully comprehend the information and conclude with certainty that breastfeeding has positive long-term effects. Despite an enormous literature demonstrating better health and cognitive outcomes among breastfed children, the effects of breastfeeding are uncertain. This is because the vast majority of studies share a common weakness: they are non-

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experimental. Their Achilles heel is selection bias (4). Selection bias enervates the possibility of concluding definitively on the long-term health effects of breastfeeding. The existing research provides a better understanding of the possible effects of infant nutrition, whether positive or negative, yet there still cannot be a definitive answer. As with any field of science, a definitive answer may never be fully reached, however, the closer research can come to finding these answers, the better the understanding of how beneficial breastfeeding is to humans.

Conclusion A dual approach needs to be utilized while examining the advantages of breastfeeding and determining sufficient mechanisms to come to a conclusion that can be supported with strong evidence. Current research supports theories that breastfeeding positively affects the immediate health of infants, it further suggests certain long-term benefits including lowered cholesterol, improved cognitive ability, and fewer occurrences of gastrointestinal infections. In order to gain a thorough understanding of previous research confounding factors including misclassification and definition inconsistencies should be taken into consideration. A total elimination of confounding factors and total consistency among the many active breastfeeding researchers, while highly desirable, is a difficult goal to realize. In light of this, we must draw what conclusions we can from the existing body of research on this topic in order to determine the direction of future investigation. Given the legitimate demonstration of the utility of breastfeeding, our current conclusion should be that breastfeeding does produce desirable physiological and psychological effects. Likewise, the direction of future research should be to clarify the mechanisms and conditions under which breastfeeding is beneficial through the

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systematic elimination of confounding factors in research and a careful, deliberate screening of trial participants in order to prevent the conclusion of false correlations.

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14) Owen CG et al. Effect of breastfeeding in infancy on blood pressure in later life: systematic review and meta-analysis. British Medical Journal, 2003, 327 (7425):1189-95 15) Dell S, To T. Breastfeeding and asthma in young children. Arch Pediatr Adolesc Med, 2001;155:1261-1265 16) Brown JE. Nutrition Through the Lifecycle. 3rd ed. Belmont, CA. Thomson Higher Education. 2008:84-150

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