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    A Meta-Analysis of Breastfeeding and Osteoporotic Fracture Risk in The Females

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    A Meta-Analysis of Breastfeeding and Osteoporotic Fracture Risk in The Females

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    A Meta-Analysis of Breastfeeding and Osteoporotic Fracture Risk in The Females

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    Osteoporos Int

    DOI 10.1007/s00198-016-3753-x

    ORIGINAL ARTICLE

    A meta-analysis of breastfeeding and osteoporotic


    fracture risk in the females
    X. Duan 1 & J. Wang 1 & X. Jiang 1,2

    Received: 23 June 2016 / Accepted: 19 August 2016


    # International Osteoporosis Foundation and National Osteoporosis Foundation 2016

    Abstract analysis, breastfeeding was associated with a decreased


    Summary Our meta-analysis included 12 studies from risk of osteoporotic fracture in case-control study (RR =
    PubMed, Embase, and Web of Science. Finding indicated 0.70, 95 % CI 0. 49– 0.99) and postmenopausal
    breastfeeding may well reduce the risk of osteoporotic women (RR = 0.66, 95 % CI 0.47–0.93). In dose-response
    fracture. analysis, osteoporotic and hip fracture risk decreased by
    Introduction Several epidemiologic studies have 0.9 and 1.2 % for each month increment of breastfeeding,
    investigated that breastfeeding is associated with short-term respectively.
    bone loss in the women, but the long-term effect on Conclusions Our meta-analysis revealed that breastfeeding
    osteoporotic fracture risk remains unclear. Thus, we may well reduce the risk of osteoporotic fracture. More cohort
    conducted this meta-analysis to explore the potential studies with large sample sizes are needed to confirm the
    association between breastfeeding and osteoporotic conclusion.
    fracture risk in the females and possible dose- response
    relationship between them. Keywords Breastfeeding . Hip fracture . Lactation
    Methods We searched PubMed, Embase, and Web of . Meta-analysis . Osteoporotic fracture
    Science (ISI) up to April 2016 for relevant articles
    associated between breastfeeding and osteoporotic
    fracture. Pooled relative risks (RRs) with 95 % confidence Introduction
    intervals (CIs) were calculated with a random-effects
    model. Dose-response analysis was per- formed by Osteoporotic fracture occurs after a fall from a standing
    restricted cubic spline. height or less, without major trauma. The most common
    Results Twelve articles including 14,954 participants were osteoporotic fracture comprises fractures on the proximal
    identified. The pooled RRs of osteoporotic hip and forearm femur (hip), verte- brae (spine), and distal forearm (wrist) [1].
    fracture for the highest vs lowest duration of breastfeeding As fragility fracture, osteoporotic fracture is associated with
    were 0.84 (95 % CI 0.67–1.05), 0.72 (95 % CI 0.52–0.99), high morbidity, mortali- ty, and huge financial burden of
    and 0.82 (95 % CI 0.56–1.19), respectively. In subgroup healthcare in the elderly, espe- cially in postmenopausal
    women. Therefore, osteoporotic frac- ture has been an
    Electronic supplementary material The online version of this important public health concern in our aging society. It is
    article (doi:10.1007/s00198-016-3753-x) contains supplementary estimated that annual incidence of osteoporotic fracture was
    material, which is available to authorized users.
    9.0 million worldwide, 61 % of whom were in women [2].
    * X. Jiang
    Hip fracture is the most serious osteoporotic frac- ture, with an
    [email protected] estimated annual incidence of 2.6 million by the year 2025
    [3]. In Korea, the costs of osteoporotic fracture among
    1
    Department of Epidemiology and Health Statistics, school of women older than 50 years were 66.2 billion Korean won
    public health of Qingdao University, Qingdao, Shandong from 2002 to 2004 [4]. In the USA, annual costs of
    Province, People’s Republic of China osteoporotic fracture among women older than 55 years were
    2
    Department of Epidemiology and Health Statistics, the 5.1 billion dollars from 2000 to 2011 [5]. Given the total
    Medical College of Qingdao University, 38 Dengzhou Road, burden, it is vital to investigate the preventive measures of
    Qingdao, Shandong 266021, People’s Republic of China
    osteoporotic fracture.
    Osteoporos Int

    Osteoporotic fracture is influenced by combined effects case report; (3) participants were men, children, or adoles-
    of inheritance, anthropometric factors, nutrient, and cents; and (4) articles reported on fractures due to fall
    lifestyle [6–9]. Besides that, fracture is influenced by greater than standing height or severe trauma. And we have
    gynecological and reproductive history among women added the above exclusion criteria in our meta-analysis.
    [10]. Breastfeeding is an essential reproductive function In our meta-analysis, the searching and screening of all
    among women, protecting mater against many diseases, retrieved studies were reviewed by two investigators
    such as cancer and diabetes. [11–14]. As is known to all, indepen- dently. If the two investigators met bilaterally, it
    breastfeeding has a deleterious effect on bone mass during was resolved by discussing with the third one.
    lactation. After at least 6 months of lactation, 5–10 %
    transient bone loss was found in the mother [15, 16], but it Data extraction
    recovered completely after weaning [17, 18]. Moreover,
    several epidemiologic studies indicated that prolonged Information from each study was extracted by two
    breastfeeding was associated with increased bone mineral investigators independently, including first author’s name,
    density (BMD) and lower prevalence of osteo- porosis in publication year, country of study population, follow-up years,
    postmenopausal women [19, 20]. However, the long-term study design, age range, diagnostic method, location of
    effects of breastfeeding on maternal bone health are still fracture, sample size, num- ber of cases, RRs (we presented
    uncertain. Several studies suggested that breastfeeding was all results with RR for simplic- ity) with corresponding 95 %
    a risk factor of osteoporotic fracture in the women [21, 22]. CIs, and adjustment for covari- ance. For dose-response
    Several studies found that breastfeeding protected against analysis, the number of cases and par- ticipants (person-years)
    osteoporotic fracture [23, 24], whereas others showed no and RR (95 % CI) for different durations of breastfeeding
    as- sociation between breastfeeding and osteoporotic were also extracted. The median or mean level of different
    fracture [25, 26]. We conducted this meta-analysis to durations of breastfeeding was assigned to the cor- responding
    explore the potential association between breastfeeding and RR for every study. And units of breastfeeding time were
    osteoporotic fracture and possible dose-response converted to month among different studies. If the upper
    relationship between them. boundary of the highest duration of breastfeeding was not pro-
    vided, we assumed that the boundary had the same amplitude
    as the adjacent category. If available, we extracted
    Methods multivariate- adjusted RRs with corresponding 95 % CIs.

    We referred to Preferred Reporting Items for Systematic Statistical analysis


    Review and Meta-Analyses (PRISMA) guidelines for
    reporting of meta-analysis [27]. Pooled measure was calculated as the inverse variance-
    weighted mean of the logarithm of RR with 95 % CI to
    Search strategy assess the strength of associations between breastfeeding
    and osteo- porotic fracture. The I² statistic was used to
    The available English literatures were searched in PubMed, evaluate hetero- geneity, and the random effect model
    Embase, and Web of Science (ISI) up to April 2016. (REM) was used to calculate pooled RR with 95 % CI.
    Search terms were as follows: Breastfeeding, lactation, Meta-regression analysis was used to analyze the sources
    breastfeeding, and fracture. The following were search of heterogeneity. Subgroup analysis was conducted
    strategies in PubMed: (((Breastfeeding) OR lactation) OR stratified by continent, study design, menopausal status,
    breast feeding) AND fracture. Moreover, we also manually and whether adjusted for age and body mass index (BMI).
    reviewed the reference lists of relevance articles for Influence analysis was performed with one study removed
    additional studies. at a time to assess whether the results could have been
    affected markedly by a single study. Funnel plot and
    Eligibility criteria Egger’s test were used to examine publication bias.
    For dose-response analysis, a two-stage random-effects
    Studies were included if they met the following criteria: (1) dose- response meta-analysis was performed to compute the
    study design was cohort or case-control studies; (2) the trend from the correlated logRR estimates across duration
    exposure of interest was breastfeeding; (3) the outcome of of breastfeeding. In the first stage, a restricted cubic spline
    interest was osteoporotic fracture; (4) relative risk (RR), odds model with three knots at the 10th, 50th, and 90th percentiles
    ratio (OR), or hazard ratio (HR) with 95 % confidence of dura- tion of breastfeeding was estimated using
    interval (CI) was pro- vided; and (5) the objects of study were generalized least- square regression, taking into account the
    women. If data were duplicated, we chose the most recent and correlation within each set of published RRs. Then the study-
    complete article. specific estimates were combined using the restricted
    Exclusion criteria are as follows: (1) articles were pub- maximum likelihood method in a multivariate random-
    lished in other language rather than English; (2) study effects meta-analysis. A P value for
    design was cross sectional, clinical or animal experimental
    study, or
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