The Importance of Breastfeeding: An Evidence Update David Meyers, MD Breastfeeding Summit Washington, DC June 11, 2009

The Importance of Breastfeeding: The Importance of Breastfeeding: An Evidence UpdateAn Evidence Update

David Meyers, MDDavid Meyers, MD

Breastfeeding SummitWashington, DCJune 11, 2009

DisclaimerDisclaimer

ClinicianClinician


ClinicianClinician ResearcherResearcher


ClinicianClinician ResearcherResearcher Policy advocatePolicy advocate


ClinicianClinician ResearcherResearcher Policy advocatePolicy advocate Federal staff Federal staff


ClinicianClinician ResearcherResearcher Policy advocatePolicy advocate Federal staffFederal staff

– Agency for Healthcare Research and Agency for Healthcare Research and QualityQuality Convene and translate among clinicians, Convene and translate among clinicians,

researchers, and policy makersresearchers, and policy makers

GoalGoal

To highlight findings from the medical To highlight findings from the medical literature on the importance of literature on the importance of breastfeeding for the health of women breastfeeding for the health of women and childrenand children

GoalGoal

To highlight findings from the medical To highlight findings from the medical literature on the importance of literature on the importance of breastfeeding for the health of women breastfeeding for the health of women and childrenand children

– Primary audience: Policy MakersPrimary audience: Policy Makers Not focusing on the clinical aspects of Not focusing on the clinical aspects of

breastfeedingbreastfeeding Not focusing on research methodsNot focusing on research methods

FramingFraming

Breastfeeding is a complex, living, Breastfeeding is a complex, living, adaptable systemadaptable system– MultidimensionalMultidimensional

FramingFraming


– RelationalRelational Between a mother, child, and their Between a mother, child, and their

environmentenvironment

FramingFraming


– RelationalRelational

– DevelopingDeveloping

FramingFraming

Breastfeeding is a complex, living, Breastfeeding is a complex, living, adaptable systemadaptable system– MultidimensionalMultidimensional– RelationalRelational– DevelopingDeveloping

Breastfeeding optimizes a child’s Breastfeeding optimizes a child’s chances of reaching its potentialchances of reaching its potential– But is not a magic guaranteeBut is not a magic guarantee

Framing - continuedFraming - continued

Population view versus Individual viewPopulation view versus Individual view

Framing - continuedFraming - continued

Population view versus Individual viewPopulation view versus Individual view– Number Needed to TreatNumber Needed to Treat

Good pain control after a sprain with NSAID = 2Good pain control after a sprain with NSAID = 2 Ear Infection with antibiotics = 7Ear Infection with antibiotics = 7 Statin to prevent one heart attack = 69Statin to prevent one heart attack = 69

– Number Needed to ScreenNumber Needed to Screen High blood pressure to prevent on MI = 275High blood pressure to prevent on MI = 275 High cholesterol to prevent one MI = 400High cholesterol to prevent one MI = 400 Colon cancer to prevent one death = 1300Colon cancer to prevent one death = 1300 Breast cancerBreast cancer = =

24002400

EvidenceEvidence

The breastfeeding literatureThe breastfeeding literature

>600 articles in the past year>600 articles in the past year >1500 articles in the past two years>1500 articles in the past two years >3000 articles in the past five years>3000 articles in the past five years

Evidence of ImportanceEvidence of Importance

Focus on Health OutcomesFocus on Health Outcomes– ChildrenChildren

– WomenWomen

Evidence of ImportanceEvidence of Importance

Focus on Health OutcomesFocus on Health Outcomes– ChildrenChildren– WomenWomen

Not covering:Not covering:– Economic benefits for families, health care Economic benefits for families, health care

system, or societysystem, or society– Social outcomesSocial outcomes

Attachment/bonding, child emotional/social Attachment/bonding, child emotional/social development, child abuse development, child abuse

Systematic Evidence ReviewSystematic Evidence Review

Breastfeeding and Maternal and Infant Breastfeeding and Maternal and Infant Health Outcomes in Developed Health Outcomes in Developed CountriesCountries– Prepared by the Tufts-New England Prepared by the Tufts-New England

Medical Center Evidence-Based Practice Medical Center Evidence-Based Practice CenterCenter

– Published April 2007Published April 2007

Commercial BreakCommercial Break

AHRQ Evidence-Based Practice Center AHRQ Evidence-Based Practice Center ProgramProgram– AHRQ awards 5-year contracts to institutions in AHRQ awards 5-year contracts to institutions in

the United States and Canada to review all the United States and Canada to review all relevant scientific literature on clinical, behavioral, relevant scientific literature on clinical, behavioral, and organization and financing topics to produce and organization and financing topics to produce evidence reports and technology assessments. evidence reports and technology assessments.

– These reports are used for informing and These reports are used for informing and developing coverage decisions, quality measures, developing coverage decisions, quality measures, educational materials and tools, guidelines, and educational materials and tools, guidelines, and research agendas. research agendas.

– The EPCs also conduct research on methodology The EPCs also conduct research on methodology of systematic reviews. of systematic reviews.

EPC Evidence ReviewsEPC Evidence Reviews

EPC reports are based on rigorous, comprehensive EPC reports are based on rigorous, comprehensive syntheses and analyses of the scientific literature on syntheses and analyses of the scientific literature on topics relevant to clinical, social science/behavioral, topics relevant to clinical, social science/behavioral, economic, and other health care organization and economic, and other health care organization and delivery issues. delivery issues.

EPC reports emphasize explicit and detailed EPC reports emphasize explicit and detailed documentation of methods, rationale, and documentation of methods, rationale, and assumptions. These scientific syntheses may include assumptions. These scientific syntheses may include meta-analyses and cost analyses. meta-analyses and cost analyses.

EPCs collaborate with external medical and research EPCs collaborate with external medical and research organizations so that a broad range of experts is organizations so that a broad range of experts is included in the development process. included in the development process.

The resulting evidence reports and technology The resulting evidence reports and technology assessments are used by Federal and State assessments are used by Federal and State agencies, private sector professional societies, health agencies, private sector professional societies, health delivery systems, providers, payers, and others delivery systems, providers, payers, and others committed to evidence-based health care.committed to evidence-based health care.

To learn more, visit:To learn more, visit:

http://www.ahrq.gov/clinic/epc/http://www.ahrq.gov/clinic/epc/

MethodsMethods

Searches through November 2005 / May 2006Searches through November 2005 / May 2006 English language onlyEnglish language only Multiple study typesMultiple study types

– All with comparison groupAll with comparison group All studies graded for methodological qualityAll studies graded for methodological quality Over 9000 articles screenedOver 9000 articles screened Final report includedFinal report included

– 29 systematic reviews/meta-analyses29 systematic reviews/meta-analyses Covering approximately 400 studiesCovering approximately 400 studies

– 43 studies on infant health outcomes43 studies on infant health outcomes– 43 studies on maternal health outcomes43 studies on maternal health outcomes

Results:Results: Short-term Infant Health OutcomesShort-term Infant Health Outcomes

A history of breastfeeding found to be A history of breastfeeding found to be associated with a reduction in the risk of associated with a reduction in the risk of commoncommon illnesses: illnesses:– Acute otitis mediaAcute otitis media

– Non-specific gastroenteritisNon-specific gastroenteritis


A history of breastfeeding found to be A history of breastfeeding found to be associated with a reduction in the risk of associated with a reduction in the risk of commoncommon illnesses: illnesses:– Acute otitis mediaAcute otitis media Ear infectionsEar infections

– Non-specific gastroenteritisNon-specific gastroenteritis

Vomiting and Vomiting and diarrheadiarrhea

Rough TranslationRough Translation

Ear InfectionEar Infection NNT ~ 6NNT ~ 6– 2 million infants younger than 6 months each year2 million infants younger than 6 months each year– If 80% of infants breastfed, >300,000 fewer would If 80% of infants breastfed, >300,000 fewer would

have an ear infection before 6 months have an ear infection before 6 months

Vomiting and diarrhea Vomiting and diarrhea – Almost all formula fed infants experience in the Almost all formula fed infants experience in the

first yearfirst year– Fewer than half of exclusively breastfed infants Fewer than half of exclusively breastfed infants

experience in the first yearexperience in the first year


A history of breastfeeding found to be A history of breastfeeding found to be associated with a reduction in the risk of associated with a reduction in the risk of seriousserious illnesses: illnesses:

– Severe lower respiratory infectionsSevere lower respiratory infections

– Sudden Infant Death Syndrome (SIDS)Sudden Infant Death Syndrome (SIDS)

Results:Results: Long-termLong-term Child Health Outcomes Child Health Outcomes

A history of breastfeeding found to be A history of breastfeeding found to be associated with a reduction in the risk of associated with a reduction in the risk of common conditions:common conditions:

– EczemaEczema

– ObesityObesity

Results:Results: Long-term Child Health OutcomesLong-term Child Health Outcomes

A history of breastfeeding found to be A history of breastfeeding found to be associated with a reduction in the risk of associated with a reduction in the risk of serious conditions:serious conditions:

– Type 2 diabetesType 2 diabetes

– ALL and AML (childhood leukemia)ALL and AML (childhood leukemia)

Results: Premature InfantsResults: Premature Infants

Limited review of two potential Limited review of two potential outcomes:outcomes:– Confirmed association between human Confirmed association between human

milk feeding and reduced risk of milk feeding and reduced risk of necrotizing enterocolitis (NEC)necrotizing enterocolitis (NEC) 5% absolute risk reduction5% absolute risk reduction

– Unable to confirm an association between Unable to confirm an association between breastfeeding and long term cognitive breastfeeding and long term cognitive developmentdevelopment

Other ResultsOther Results

Suggested association between Suggested association between breastfeeding and both asthma and type breastfeeding and both asthma and type 1 diabetes1 diabetes

More evidence needed to understand More evidence needed to understand potential association between potential association between breastfeeding and cardiovascular breastfeeding and cardiovascular diseasedisease

Breastfeeding Breastfeeding notnot found to be found to be associated with improved cognitive associated with improved cognitive development when potential cofounders development when potential cofounders controlled forcontrolled for

Results: Results: Maternal Health OutcomesMaternal Health Outcomes

A history of breastfeeding found to be A history of breastfeeding found to be associated with a reduction in the risk of:associated with a reduction in the risk of:– Breast cancerBreast cancer

With caution, breastfeeding found to be With caution, breastfeeding found to be associated with a reduction in the risk of:associated with a reduction in the risk of:– Ovarian cancerOvarian cancer

– Type 2 diabetes in women without Type 2 diabetes in women without gestational diabetesgestational diabetes

Hot off the pressesHot off the presses

Note: I am no longer being systematicNote: I am no longer being systematic


Schartz EB, Ray RM, Stuebe AM, et al. Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for Duration of lactation and risk factors for maternal cardiovascular diseasematernal cardiovascular disease. . Obstet Obstet GynecolGynecol. 2009 May;113(5):974-82. . 2009 May;113(5):974-82.


Schartz EB, Ray RM, Stuebe AM, et al. Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for Duration of lactation and risk factors for maternal cardiovascular diseasematernal cardiovascular disease. . Obstet Obstet GynecolGynecol. 2009 May;113(5):974-82. . 2009 May;113(5):974-82. – Data from 139,681 postmenopausal women Data from 139,681 postmenopausal women

enrolled in the Women's Health Initiative enrolled in the Women's Health Initiative – Multivariable modelingMultivariable modeling– Controlled for confounder (age, parity, race, Controlled for confounder (age, parity, race,

education, income, age at menopause), lifestyle, education, income, age at menopause), lifestyle, and family history variables and family history variables

– Examined the effect of duration of lactation on Examined the effect of duration of lactation on prevalence and incidence of CVD and risk factors prevalence and incidence of CVD and risk factors for cardiovascular diseasefor cardiovascular disease


Schartz EB, Ray RM, Stuebe AM, et al. Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for Duration of lactation and risk factors for maternal cardiovascular diseasematernal cardiovascular disease. . Obstet Obstet GynecolGynecol. 2009 May;113(5):974-82. . 2009 May;113(5):974-82. – Women who never breastfed were Women who never breastfed were

significantly more likely than women who significantly more likely than women who breastfed >12 months to have:breastfed >12 months to have: High blood pressure High blood pressure 42.1% vs 38.6%42.1% vs 38.6% High cholesterolHigh cholesterol 14.8% vs 12.3% 14.8% vs 12.3% DiabetesDiabetes 5.3% vs 4.3% 5.3% vs 4.3% CVDCVD 9.9% vs 9.1% 9.9% vs 9.1%

Back to the Back to the 2007 Evidence Review2007 Evidence Review

Presenter’s OpinionPresenter’s Opinion

EPC team was:EPC team was:– conservative with their methods, conservative with their methods,

– conservative in the body of the reportconservative in the body of the report

– and liberal with their conclusions in the and liberal with their conclusions in the executive summaryexecutive summary

Closer look: PneumoniaCloser look: Pneumonia

One meta-analysis (Bachrach 2003)One meta-analysis (Bachrach 2003)– 7 cohort studies7 cohort studies– Meta-analysis quality rating: Grade AMeta-analysis quality rating: Grade A

Results: ‘exclusive’ breastfeeding for Results: ‘exclusive’ breastfeeding for four or more months associated with a four or more months associated with a 72% reduction72% reduction in hospitalizations for in hospitalizations for lower respiratory tract disease when lower respiratory tract disease when compared to formula feedingcompared to formula feeding– NNT = 26NNT = 26

Closer Look: ObesityCloser Look: Obesity

3 meta-analyses3 meta-analyses– One quality Grade A One quality Grade A (Arnez 2004)(Arnez 2004)

– Two quality Grade Bs Two quality Grade Bs (Harder 2005, Owen 2005)(Harder 2005, Owen 2005)

Consistent conclusion that breastfeeding Consistent conclusion that breastfeeding associated with reduced risk of obesity in later associated with reduced risk of obesity in later lifelife– Magnitude of effect reduced when cofounders Magnitude of effect reduced when cofounders

adjusted foradjusted for– No evidence available to allow conclusions about No evidence available to allow conclusions about

exclusive breastfeedingexclusive breastfeeding– Limited evidence that increased duration of Limited evidence that increased duration of

breastfeeding associated with increased reduction breastfeeding associated with increased reduction in riskin risk

Closer look: SIDSCloser look: SIDS

One poor quality meta-analysisOne poor quality meta-analysis 4 additional studies identified4 additional studies identified EPC conducted new meta-analysisEPC conducted new meta-analysis

– Limited to studies with autopsy confirmed Limited to studies with autopsy confirmed SIDS, clear reporting of breastfeeding SIDS, clear reporting of breastfeeding data, and cofounder controlling: 6 studiesdata, and cofounder controlling: 6 studies

– Results: ever breastfeeding associated Results: ever breastfeeding associated with a statistically significant reduction in with a statistically significant reduction in risk of SIDSrisk of SIDS Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81)Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81)

Closer look: SIDSCloser look: SIDS

One poor quality meta-analysisOne poor quality meta-analysis 4 additional studies identified4 additional studies identified EPC conducted new meta-analysisEPC conducted new meta-analysis

– Limited to studies with autopsy confirmed SIDS, Limited to studies with autopsy confirmed SIDS, clear reporting of breastfeeding data, and clear reporting of breastfeeding data, and cofounder controlling: 6 studiescofounder controlling: 6 studies

– Results: ever breastfeeding associated with a Results: ever breastfeeding associated with a statistically significant reduction in risk of SIDSstatistically significant reduction in risk of SIDS Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81)Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81)

Approximately 1 in 2000 children die from SIDSApproximately 1 in 2000 children die from SIDS Rough translation: One death from SIDS is prevented for Rough translation: One death from SIDS is prevented for

every 5500 children breastfedevery 5500 children breastfed

Other IssuesOther Issues

Breastfeeding and Breastfeeding and Human Milk FeedingHuman Milk Feeding

Challenging to separate out the Challenging to separate out the importance of human milk from its importance of human milk from its delivery systemdelivery system– Human milk is importantHuman milk is important

– Greater value from breastfeedingGreater value from breastfeeding

Importance of Exclusive Importance of Exclusive BreastfeedingBreastfeeding

Research evidence limited by variable Research evidence limited by variable data collectiondata collection

In some areas, association only found In some areas, association only found for exclusive breastfeedingfor exclusive breastfeeding– In general, mixed feeding associated with In general, mixed feeding associated with

better outcomes than formula feedingbetter outcomes than formula feeding

DurationDuration

In many areas, increased duration of In many areas, increased duration of breastfeeding associated with increasing breastfeeding associated with increasing importance (Dose-effect relationship)importance (Dose-effect relationship)– No upper limit shownNo upper limit shown

Policy ImplicationsPolicy Implications

The value of breastfeeding is no longer The value of breastfeeding is no longer debatabledebatable

The policy relevant question is how to The policy relevant question is how to support women and familiessupport women and families– What can the health care system do?What can the health care system do?

– What can employers do?What can employers do?

– What can society do?What can society do?

– What can government do?What can government do?

Health Care SystemHealth Care System

2008 US Preventive Services Task Force 2008 US Preventive Services Task Force RecommendationRecommendation– http://www.ahrq.gov/clinic/uspstf/uspsbrfd.htmhttp://www.ahrq.gov/clinic/uspstf/uspsbrfd.htm

– Focused on role of health care systemFocused on role of health care system

– Based on a systematic evidence reviewBased on a systematic evidence review

– Concluded interventions within the health care Concluded interventions within the health care system in the prenatal, birth, and post-partum system in the prenatal, birth, and post-partum periods are effective in increasing the initiation periods are effective in increasing the initiation and duration of breastfeedingand duration of breastfeeding Evidence for specific interventions limitedEvidence for specific interventions limited

Issues of contextIssues of context Multi-dimensional interventions likely importantMulti-dimensional interventions likely important

http://www.ahrq.gov/clinic/uspstf/uspsbrfd.htm

DiscussionDiscussion

ThanksThanks

[email protected]@AHRQ.hhs.gov

Documents

The Importance of Breastfeeding: An Evidence Update David Meyers, MD Breastfeeding Summit Washington, DC June 11, 2009