ArticlesEffect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis
Introduction
The recognition that HIV is transmitted through breastmilk raised the important question of whether strategies that promote breastfeeding in areas of high HIV prevalence should be changed.1 This policy decision is particularly difficult, given that breastfeeding provides important protection against infectious diseases,2, 3, 4, 5, 6 which account for over two-thirds of the 12 million annual deaths in children younger than 5 years in less developed countries.7
Theoretical models have been developed to assess the advantages and disadvantages of breastfeeding for HIV-positive women, as well as for women of unknown HIV status who live in areas of high HIV prevalence.8, 9, 10, 12, 13 These models have taken into account the risk of transmission through breastfeeding with regard to the age of the infant, the protection afforded by breastmilk against infectious disease mortality, the underlying HIV prevalence, and the rate of infant and child mortality. However, according to a recent WHO/UNAIDS review,14 an important limitation of these models was the poor quantification of the relative risks for mortality associated with lack of breastfeeding. Such models used relative risk estimates ranging from 1·3 to 7·9, and no model allowed for variable levels of protection within the first year of life. We did a comprehensive pooled analysis of existing studies of the effect of not breastfeeding on risk of infant and child mortality due to infectious diseases.
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Methods
Through consultations with experts in international health, the Division of Child and Adolescent Health (WHO, Geneva, Switzerland) obtained a list of published and unpublished datasets that might provide information on the risk of infant and childhood mortality according to feeding practices. The search was limited to studies carried out in the 1980s and 1990s, to those that provided data on deaths in the first year of life (and if possible on second-year deaths as well), and to those in which
Results
We identified eight studies that met our criteria; data were obtainable from six of them.18, 19, 20, 21, 22, 23 Of those we could not obtain, one dataset had been destroyed, and the author of the other failed to respond to repeated attempts to contact him. The studies were all done between 1983 and 1991, and covered both urban and rural areas (table 1). table 2 shows the number of deaths by age, excluding deaths in the first week of life and non-infectious deaths. All studies except those from
Discussion
This paper presents the findings from a comprehensive attempt to obtain available data on all studies on cause-specific mortality according to breastfeeding. A large number of investigators were contacted by WHO, and datasets from those willing and able to participate were included. Nevertheless, only three datasets provided information on deaths in the first year of life, and six provided data on deaths in the second year. Also, we have not been able to rule out publication bias, which is
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