Curr Allergy Asthma Rep (2016) 16:68

DOI 10.1007/s11882-016-0647-0

OTITIS (D SKONER, SECTION EDITOR)

The Role of Breastfeeding in Childhood Otitis Media

Caroline J. Lodge 1,2 & Gayan Bowatte 1 & Melanie C. Matheson 1 & Shyamali C. Dharmage 1,2

# Springer Science+Business Media New York 2016

Abstract Introduction
Purpose of Review The purpose of this review is to summa-
rize the recent literature, both systematic reviews and recently Burden of Otitis Media
published original studies not included within those reviews,
on the relationship between breastfeeding and childhood otitis Acute otitis media (AOM) is usually caused by either a viral or
media (OM). bacterial pathogen and often treated with antibiotics. Young
Recent Findings There is clear evidence that breastfeeding is children are particularly at risk due to limited space in the
associated with a reduced risk of OM in childhood with sound middle ear and poor drainage from relatively tortuous
biological plausibility to support that the association is likely Eustachian tubes. AOM is often accompanied by significant
causal. Any breastfeeding reduces OM risk in early childhood pain along with fever, acute loss of hearing, and general
by 40–50 %. Systematic reviews also support a further re- unwellness. AOM has a number of potential complications.
duced risk for continued breastfeeding. Recent studies have Many AOM-prone children suffer from recurrent episodes in
estimated burden of disease savings if breastfeeding within infancy and early childhood. Commonly, on resolution of the
countries and globally approached WHO guidelines. Cost acute infection, there is a persistent middle ear effusion (otitis
savings per year for reduced cases of OM by increasing ever media with effusion-OME) with accompanying hearing im-
and exclusive breastfeeding rates are estimated to be millions pairment. OME can persist, causing longer term hearing im-
of pounds or dollars for UK and Mexico. pairment and interfering with language development, school
Summary Breastfeeding reduces OM in children. The burden performance, and behavior. AOM may result in perforation of
of disease and economic impact of increasing breastfeeding the eardrum with chronic discharge (chronic suppurative otitis
rates and duration would be substantial. media). Less common complications include mastoiditis,
brain abscess, and meningitis.
Globally, there are an estimated 709 million cases of acute
Keywords Breastfeeding and otitis media . Otitis media . otitis media per year, an incidence of 10.85 % [1]. The peak
Breastfeeding rates . AOM . Breast milk incidence is in the 1–4-year age group (60.99 %), although
rates vary from 3.64 % in Central Europe to 43.36 % in Sub-
Saharan Africa [1]. The disease burden attributed to AOM in
This article is part of the Topical Collection on Otitis both established and emerging nations is considerable. It is the
most common reason for prescription antibiotics in developed
* Caroline J. Lodge countries where AOM is estimated to affect more than 60 % of
[email protected] children under 1 year and more than 80 % of children under
3 years [2–4]. There is also a considerable health burden from
1
Allergy and Lung Health Unit, Centre for Epidemiology and the sequelae of AOM. It is estimated that there are globally
Biostatistics, Melbourne School of Population and Global Health, around 31 million cases of chronic suppurative otitis media,
The University of Melbourne, Melbourne, Australia and the prevalence rate for AOM induced permanent hearing
2
Murdoch Childrens Research Institute, Melbourne, Australia impairment is 30.82 per 10,000 [1]. Furthermore,
68 Page 2 of 8 Curr Allergy Asthma Rep (2016) 16:68

complications of AOM are estimated to cause the deaths of of the mega-review recently published in the Lancet [7••].
21,000 people annually, with mortality rates being the highest Pubmed, Cinahl, and Embase databases were searched from
in the 0–5-year age group [1]. inception yielding 24 studies (18 cohorts and 6 cross-section-
Although updated clinical guidelines have reduced the re- al). Overall, we found a 43 % reduction of the risk of ever
liance on antibiotic therapy for mild, early and uncomplicated having AOM in the first 2 years of life associated with
AOM [5], it is still the most common reason for antibiotic use breastfeeding but no reduced risk after the age of 2. In this
in many countries [6]. Apart from the associated health care systematic review, meta-analyses were possible only for par-
burden, this widespread use of antibiotics increases the risk of ticular exposure categories. Infants exclusively breastfed for
community antibiotic resistance. 6 months compared with those not breastfed or breastfed for
Given the high health care burden, a number of risk factors periods less than 6 months had a reduced risk of AOM up to
for AOM have been investigated. The factors currently iden- the age of 2 years after pooling the ORs of five cohort studies
tified for risk reduction are breastfeeding, avoidance of in (OR 0.57; 95 % CI 0.44–0.75). We also found a risk reduction
utero and childhood passive tobacco smoke exposure, and when comparing ever versus never breastfed infants: OR 0.67;
avoidance of indoor air pollution [1]. A recent Lancet mega- 0.56–0.80 (five studies). An additional meta-analysis was per-
review that summarized the evidence on breastfeeding and formed on 12 cohort studies in a more versus less exposure
maternal and child health outcomes from 28 individual sys- grouping. This category included ORs from all studies which
tematic reviews found that breastfeeding has many health ben- compared a greater exposure of breastfeeding (more) to less
efits for both mothers and children [7••]. The Lancet findings breastfeeding. The meta-analysis also found a reduced risk of
also confirm the vital role that breastfeeding plays in the pre- AOM up to 2 years: OR 0.76; 0.67–0.56.
vention of common childhood infectious diseases including A systematic review by Hornell et al. reviewed the literature
AOM. published between January 2000 and June 2011 [11]. They iden-
tified four publications on AOM; two systematic review/meta-
Breastfeeding and Otitis Media analysis [12, 13] and two prospective cohorts [14, 15]. After
reviewing these publications without performing an overall
Human breast milk is tailor-made for infants [8]. Breast milk pooled estimate, the authors concluded that there was convincing
delivers appropriate nutrition for each infantile developmental evidence of a protective dose and duration of breastfeeding on
stage and is packed with immune substances that may directly OM. The publications included in the Hornell et al. systematic
influence microbial colonization with favorable bacteria, pro- review are described in the following sentences. The included
tect against colonization and infection by harmful bacteria, systematic review by Ip et al. [12] found a pooled adjusted odds
and influence immune programming [9]. The WHO recom- ratio from five cohort studies for the risk of AOM associated
mends exclusive breastfeeding up to the age of 6 months with with any breastfeeding of 0.77; 95 % CI 0.64–0.91 when com-
continued breastfeeding for 2 years and beyond. Despite these pared with never breastfed infants. Additionally, Ip et al. found
recommendations, breastfeeding rates in many countries, es- some evidence that longer duration of breastfeeding may confer
pecially in high-income countries, are poor, with rates of only greater protection; the pooled estimate for the risk of AOM as-
around 20 % at 12 months [7••]. Additionally, in children under sociated with 3–6 months exclusive breastfeeding versus never
the age of 6 months, 63, 61, and 55 % are not exclusively breastfed was OR 0.5; 0.36, 0.70. The other included systematic
breastfed in upper-middle-income countries, low-middle- review by Kramer and Kakuma [13] analyzed two prospective
income countries, and low-income countries, respectively [7••]. cohorts with a total of 3762 children finding an increased risk of
Almost all the recent literature outlining the links between one or more episodes of otitis media in the first 12 months for
breastfeeding and OM supports a reduced risk of OM associ- children exclusively breastfed for more than 6 months compared
ated with breastfeeding. Since 2013, there have been two sys- with those who had exclusive breastfeeding for 3 months (risk
tematic reviews, a non-systematic review and four original ratio 1.28;95 % CI 1.04–1.57). One of the two additional cohort
studies on this subject. studies included in the Hornell et al. systematic review (birth
cohort n = 1764) found a non-significant association between
Data Syntheses: Systematic and Non-systematic Reviews distinct lengths of breastfeeding exposure (<1, 1–3, 4+, 4–6,
(Table 1) 7–11, and 12+ months) and prevalence of ear infections in either
the first or second 6 months of life. Their findings may have been
limited by lack of power in each of the exposure categories. The
There have been three reviews published on the impact of remaining cohort study on 926 children found that infants exclu-
BF on OM over the last 4 years. sively breastfed for 6 months had fewer infections than partially
The most recent data synthesis on this topic is our group’s breastfed or never breastfed children (OR 0.37; 0.13, 1.05).
2015 systematic review and meta-analysis by Bowatte et al. The Bowatte review included all studies within the Hornell
[10], commissioned by the World Health Organization as part review and identified an additional 15 studies related to the
Table 1 Reviews of breastfeeding and otitis media in the past 4 years

Authors & date Study type & inclusion criteria Population & numbers Exposure & how ascertained Outcome & how ascertained Measured effect
& country

Hornell et al. Systematic review (SR) Population Duration of both, any, and Grade of evidence; convincing/ Convincing evidence of a
2013 [11] Short- and long-term effects of General exclusive breastfeeding probable/limited-suggestive/ protective dose/duration effect
breastfeeding and 60 Quality assessed papers limited-no conclusion of breastfeeding on acute otitis
introduction to solids 13 SR/MA; 41 prospective Quality Assessment Tools (QAT) media
Inclusion cohort; 6 from PROBIT from the NNR5 secretariat- Recommend unchanged nnr
Published since January 2000, trial; 13 reports included modified AMSTAR 2004 exclusive breastfeeding
human subjects 4 of these on AOM—2 Ip SLR (grade A) five cohort studies 6 months and continued partial
Search date June 2011 prospective cohorts and 2 BF significant reduction in AOM breastfeeding thereafter
Curr Allergy Asthma Rep (2016) 16:68

English or Nordic language SR/MA Pooled adjusted ORs:

Exclusion ever vs never BF 0.77 (95 % CI:
Pro/pre biotics, special 0.64, 0.91)
formulas e.g., Ex BF 3–6 months vs never:
supplemented (LC-PUFA), 0.50 (0.36, 0.70)
breast milk contamination, Prospective cohort studies:
sick or high-risk mothers Fisk et al.—birth cohort 1764
and children 7 Durations of breastfeeding (<1, 1–
3, 4+, 4–6, 7–11, and
12+ months)—ear infections, 0–6
and 6–12 months. Non-
significant association bw BF
duration and prevention of ear
infections 0–6 and 6–12 months
Ladomenou et al.
Ex BF for 6 months, fewer
infections than partially and non-
BF—adj OR 0.37 (0.13, 1.05)
Bowatte et al. Systematic review and meta- Population Ever vs never breastfeeding 1. physician/doctor diagnosed AOM Reduced risk AOM in the first
2015 [10] analysis (SR/MA) Any 24 studies (USA or More vs less breastfeeding 2. parent or self-reported AOM 2 years of life (not after 2)
Exclusion Europe) Exclusive BF for 6 months vs 3. AOM recorded on health-related Ex BF 6 months—43 %
OME 18 Cohort data bases reduction in ever AOM in first
Non-english 6 Cross-sectional 2 years
EX BF 6 months vs other OR
0.57; 0.44–0.75 (five cohorts)
More vs less BF or 0.67;0.59,
0.76 (12 cohorts)
Ever vs never BF or 0.67;0.56,
0.80 (five studies)
Salone et al. A narrative review: Includes: peer reviewed Not given: OM is a small part Not given Compared with formula-fed
2013 [16] studies published from articles, systematic review of health outcomes assessed children, the health advantages
January 1999–March 2011 and meta-analyses, and associated with breastfeeding
reports from major non- include a lower risk of acute
governmental and otitis media
Page 3 of 8 68

governmental organizations
68 Page 4 of 8 Curr Allergy Asthma Rep (2016) 16:68

timing of the search (Bowatte search conducted in 2014 ver- huge population-based sample, along with the objective ascer-
sus 2011) and the search inclusion criteria ( Hornell limited to tainment of prospectively collected exposure and outcome data,
studies published after 2011 and Bowatte had no limits). contributes to the robustness and importance of this work.
A 2013 non-systematic review performed by the American Jensen et al. [18] investigated a population-based cohort of
Academy of Pediatric Dentistry, Chicago as an update on the 223 Inuit mother-child pairs in two towns on the west coast of
effects of breastfeeding for dental professionals also found Greenland (1999–2007). The primary purpose of this research
that breastfeeding was associated with a reduced risk of OM was to assess the relationship between maternal
[16]. organochloride exposure and OM in their children. The chil-
dren were followed up at the age of 4–10 years. They classi-
Original Articles since 2013 (Table 2) fied breastfeeding status at 6 months as full, partial, or not and
did not find an association with breastfeeding although point
estimates were below 1 suggesting protection for full or par-
There have been four original research articles published tially breastfed children. It may be that there was little power
since 2013 [17–20]. Due to dates of publication (two studies to detect an association given the number of participants.
[17, 19]) and inclusion/exclusion criteria (two studies on se- The final article by Salah et al. was a retrospective hospital-
lected populations) [18, 20], none were included in either of based cohort of 340 children. In a group of children aged less
the systematic reviews mentioned above; however, it is un- than 2 years attending an outpatient clinic for recurrent AOM
likely that their inclusion would have affected the direction of (three or more episodes in 6 months), factors were analyzed
associations found as three of these articles found an associa- which predicted further recurrence and treatment failure. They
tion between breastfeeding and a reduced risk of AOM. found that breastfeeding duration of less than 3 months (com-
Most recently, Martines et al. [19] performed a case–con- pared with more than 3 months) was associated with a signif-
trol study on Sicilian children (204 cases with 204 age and sex icant chance of further recurrence and with treatment failure
matched controls). They found that children who were (failure of antibiotic treatment).
breastfed were much less likely to develop AOM or OME
following an upper respiratory tract infection (URTI) than Mechanisms for the Protective Link
those who had never been breastfed; OR 0.5;95 % CI 0.3– Between Breastfeeding and AOM
0.77 [19].
Ajetunmobi et al. [17] investigated 502,958 children in a Previously, it was believed that the protective effect of
retrospective population-based Scottish cohort using linkages AOM on breastfeeding was largely mechanical; the suction
of birth, death, maternity, infant health, child health surveillance, pressure required and positioning for breast feeding were
and admission records. They included all single births in thought to be advantageous for draining the Eustachian
Scotland between 1997 and 2009, following the children until tubes in young infants, thereby preventing AOM.
March 2012. Based on information collected about feeding at the Another slightly older theory that may underlie the reduc-
6–8-week visit, infants were classified as either exclusively tion in infectious disease enjoyed by breastfed babies is
breastfed, exclusively formula fed, or mixed fed. Compared with related to the immunomodulatory substances contained in
exclusively breastfed children, there was an increased risk of breast milk. This theory has currently been re-invigorated
hospitalization for AOM in the first 6 months of life for infants through the recent interest in the human and more specif-
who were exclusively formula fed (hazard ratio (HR) 2.13; 95 % ically the infant gut microbiome. It is now believed that a
CI 1.26–3.59). This estimate was made following adjustment for specific symbiotic microbiome is established early in life
a range of socio-economic factors. There was also an increased and, among other functions, protects the infant against
point estimate for those both breast and formula fed (mixed pathogenic infections [21].
feeding) compared with exclusive breastfeeding but the 95 % Breast milk is known to contain the building blocks for
confidence interval included 1 (HR 1.5; 0.65–3.48). They also establishment of this microbiome in the form of human milk
found increased risk of hospitalization within the first year of life oligosaccharides (HMOs) along with a distinct breast milk
for formula-fed infants for a large range of illness including microbiota. HMOs are indigestible sugars most prominent in
infections (gastrointestinal, upper and lower respiratory tract, the colostrum. The milk oligosaccharides from primates are
urinary, and non-specific fever), asthma, diabetes, and dental unique in the mammalian kingdom in terms of their diversity
caries. These increased risks persisted after stratification by area and high percentage of fucosylation [22]. There are over 200
deprivation. There was no increased risk of hospitalization for different types of human HMOs [23•], and 50–80 % of these
AOM after the first 6 months of life. The lack of association after are fucosylayted depending on the genetic makeup of the
the age of 6 months is perhaps expected considering that AOM is mother [24]. They feature prominently in the colostrum (20–
usually treated in the community, and it is also remarkable that 25 g/L) and taper off in overall percentage for mature breast
an association was found up to the age of 6 months. The milk (5–20 g/L) [25]. Although these HMOs do not provide a
Table 2 Original studies on the link between breastfeeding and otitis media—published in the last 4 years

Authors & date Study type & inclusion criteria Population & numbers Exposure & how ascertained Outcome & how Ascertained Measured effect
& country

Martines et al. Case–control Population Breastfeeding ever Current AOM or EOM Risk of OM
2016 [19] Inclusion Sicilian children, Palermo Yes vs no ENT specialist on history and breastfed vs non-breastfed
Sicily Children attending ED in Palermo Sep 2012–June 2013 ascertainment otoscopy Chi square—10.16 95 % (p = 0.0014)
with URTI then having OM Number Questionnaire (recall) Ascertainment OR 0.5 CI (0.3, 0.77)
diagnosed 204 Children (106 males and 98 Questionnaire (recall) This appears to be an unadjusted
(either acute otitis media-AOM females) estimate
or otitis media with effusion 204 Age- and sex-matched
EOM) within 21 days and age/ healthy children
Curr Allergy Asthma Rep (2016) 16:68

sex matched controls

Ajetunmobi Retrospective population–based Population Infant feeding at 6–8 weeks age Childhood hospitalization for AOM Risk of hospitalization for OM
et al. 2015 birth cohort Single births in Scotland 1997– review until March 2012 (Follow-up Compared with exclusive
[17] Exclusion 2009 1.Exclusive breastfeeding period varied between 2.25 years breastfeeding (baseline)
Scotland Congenital anomalies, Number 2.Formula feeding and 15 years) All ages
non-Scottish residents 502,948 3.Mixed breast and formula Ascertainment Mixed fed HR 1.04
feeding Linkages of birth, death, maternity, (0.95–1.14)
Ascertainment infant health, child health Formula-fed HR 1.03
Linkages of birth, death, surveillance, and admission (0.97–1.09)
maternity, infant health, child records ≤6 months
health surveillance, and Mixed fed HR 1.5
admission records (0.65–3.48)
Formula-fed HR 2.13
(1.26–3.59)
Adjusted for parental factors, delivery
and infant health characteristics,
features of health care system—exact
variables unclear and deprivation
area index,
maternal ethnic and religious
background
Jensen et al. Population-based cohort Population Breastfeeding status at 6 months OM Risk of OM in first 4 years of life
2013 [18] (Primary aim to assess the effects of 400 Mother–child pairs (400 1.Full Ascertainment compared with no breastfeeding at
Greenland organochloride exposure in pregnant women aged 16–46) 2.Partly Ear examinations with 6 months
mothers on otitis media in their living in three towns on 3.No tympanometry and gradings: Full breastfeeding:
children) west coast of Greenland Ascertainment 1.Chronic otorrhea (>14 days) HR 0.85 (0.47–1.54)
(Nuuk, Ilulissat, Mantisoq) Mothers interviewed at 2.Chronic perforation (>3 months) Partly breastfeeding
1999–2007 6 months 3.Circular atrophy HR 0.90 (0.54–1.49)
Number 4.Myringosclerosis Estimates adjusted for sex, ethnicity,
Limited to 251 children living in 5.Diffuse atrophy mothers history of OM, mothers
Nuuk and Ilulissat and 223 6.Retraction history of smoking
(85 %) of these children 7.Fibrosis
followed up at 4–10 years 8.Unknown (ear wax obstructing
view/uncooperative)
9.Normal
OM history
Ascertainment
Page 5 of 8 68

Medical records
68 Page 6 of 8 Curr Allergy Asthma Rep (2016) 16:68

inclusion of other variables) showed

that short breastfeeding (<3 months)
episodes AOM (SD 1.6) in infants
infants breastfed <3 months cf 5.1
source of energy for the infant, their unique branching and

was a “significant risk factor” for

5.7 Episodes of AOM (SD ± 1.9) in

Logistic regression (with unknown

diversity make them a perfect substrate for particular strains
of bacteria that are known to be beneficial colonizers of the
newborn.

breastfed >3 months

Unadjusted–Chi square Although there is a growing literature on the establish-

failure (p=0.006)
Treatment failure
Measured effect

ment of the infant gut microbiome and its importance for

Recurrent AOM

protection from gastrointestinal morbidity along with its

treatment
(p = 0.005)
capacity to correctly educate the infants’ immature im-
mune system, less is known about the microbiome of
the nasopharynx and its potential effect on protection
from AOM. Recently, Biesbroek et al. [26••] investigated
for up to 1 week following initial
bulging eardrum or otorrhea and

Persistence or worsening of AOM

(≥3 episodes in 6 months) at age

the nasopharyngeal microbiome in 101 exclusively

Outcome & how Ascertained

Otoscopy—congested and/or

presence of acute signs of

breastfed and 101 exclusively formula-fed infants. They

infection (fever, pain, and

treatment (antibiotics)
discovered a distinctly different bacterial community com-
position in the nasopharynx between the two feeding
Treatment failure

modes; with breastfed children having increased represen-

Recurrent AOM

3–24 months

irritability)

tation of Dolosigranulum and Corynebacterium Sp. and

reduced representation of Staphylococcus, Prevotella, and
Veillonella spp. at 6 weeks of age.

Literature Concerning Cost Savings from Reduced AOM

Exposure & how ascertained

Linked to Increased Breastfeeding

Review of hospital charts
Breastfeeding duration

Given the convincingly positive findings for breastfeeding in

>3 vs <3 months

relation to OM, some of the recent literature has focused on

Ascertainment

reductions in OM and cost savings which could be achieved

through greater uptake and continuation of breastfeeding.
Pokhrel et al. [27] assessed the potential economic impact, from
the point of view of the National Health Service, from improv-
ing breastfeeding rates in the UK which are comparatively low
<2 years attending outpatient

internationally with only 55 % of infants breastfed at 6 weeks

Hospital (May 2011–April
Pediatric Otolaryngology

and only 23 % exclusively (2010). They assessed the economic

Unit, Cairo University
Recurrent AOM patients
Population & numbers

impact in terms of four acute childhood conditions in the first

year of life: gastrointestinal illness, lower respiratory tract infec-
tions, AOM, and necrotizing enterocolitis, finding that for wom-
Population

en who have initiated breastfeeding for the first week, an in-

2012)
Number

crease in breastfeeding duration up to 4 months would save 11

340

million pounds per year. For AOM, these costs were based
solely on the costs of treating AOM in primary care and did
Retrospective hospital-based cohort

Chronic otitis media with effusion

not appear to take into account the cost of complications, hos-

Study type & inclusion criteria

pitalizations, or the costs for parents who would need time off
Typanostomy tube insertion

work to care for their children. Specifically, for AOM, the cost
saving was estimated to be between 0.28 and 1.16 million
pounds per year depending on whether exclusive breastfeeding
rates at 6 months increased to 21 or 65 %, respectively. McIsaac
Exclusion

et al. [28] studied potential reductions in common childhood

infections in Aboriginal Canadians where AOM reduction
Table 2 (continued)

may be arguably greater due to the increased prevalence of

severe AOM in this population and relative decrease in
Authors & date

breastfeeding when compared with general Canadian infants.

2013 [20]
Salah et al.
& country

They found a 5.1 to 10.6 % reduction in OM in Aboriginal

infants if they received any breastfeeding. The preventable pro-
portion of infectious disease in Aboriginal infants was
Curr Allergy Asthma Rep (2016) 16:68 Page 7 of 8 68

1.5–2 times greater than the non-Aboriginal Canadian infants. 3. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media dur-
ing the first seven years of life in children in greater Boston: a
Arantxa Colchero et al. [29] investigated the costs of inade-
prospective, cohort study. J Infect Dis. 1989;160(1):83–94.
quate breastfeeding in Mexican infants who experience very 4. Vergison A, Dagan R, Arguedas A, Bonhoeffer J, Cohen R,
low rates of exclusive breastfeeding at 6 months; only 14 % in Dhooge I, et al. Otitis media and its consequences: beyond the
2012. They found that if exclusive breastfeeding rates in- earache. Lancet Infect Dis. 2010;10(3):195–203.
5. Le Saux N, Robinson JL, Canadian Paediatric Society.
creased to 95 % at 6 months and 95 % partial breastfeeding
Management of acute otitis media in children six months of age
between 6 and 12 months, then the savings related to reduced and older. Paediatr Child Health. 2016;21(1):1–8.
AOM could be between US $0.5 and 15.4 million per year. 6. Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ,
This estimate increased when the cost of infant formula was Shekelle PG, et al. Diagnosis, microbial epidemiology, and antibi-
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added: US $289.9 million dollars per year. Furthermore, the
JAMA. 2010;304(19):2161–9.
economic modeling from the Lancet mega-review using the 7.•• Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al.
Lives Saved Tool to estimate global impacts of increasing ex- Breastfeeding in the 21st century: epidemiology, mechanisms, and
clusive breastfeeding to 95 % of all children at 1 month and lifelong effect. Lancet. 2016;387(10017):475–90. This article pro-
vides a recent very comprehensive assessment of what is known
90 % at 6 months with partial breastfeeding of 90 % between 6
about the health effects of breastfeeding for mothers and infants.
and 23 months found a possible prevention of 823,000 deaths in 8. Pediatrics AAo. Breastfeeding and the use of human milk.
children under the age of 5. This was largely from prevention of Pediatrics. 2012;129(3):e827–41.
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11. Hornell A, Lagstrom H, Lande B, Thorsdottir I. Breastfeeding,
There appears to be little doubt that breastfeeding is beneficial introduction of other foods and effects on health: a systematic liter-
for protecting infants from a range of infectious diseases in- ature review for the 5th Nordic Nutrition Recommendations. Food
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Breastfeeding and maternal and infant health outcomes in devel-
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declare no conflicts of interest relevant to this manuscript. Pediatrics. 2010;126(1):e18–25.
16. Salone LR, Vann Jr WF, Dee DL. Breastfeeding an overview of oral
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