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Running head: OUTCOMES OF BREASTFED INFANTS 1

Outcomes of Breastfed Infants Compared to Alternative Feeding Methods

Michelle Russell

University of South Florida – College of Nursing

NUR 4165

12-9-12

Word Count: 4,301

OUTCOMES OF BREAST-FED INFANTS 2

Outcomes of Breastfed Infants Compared to Alternative Feeding Methods

Introduction

There has been controversy, especially among mothers and pregnant women, about

which feeding method is more beneficial for infants – breastfeeding, formula fed, or even a

combination of both. This synthesized literature review focuses on the benefits of breastfeeding

and what makes it stand apart from other infant feeding alternatives. The American Association

of Pediatrics (AAP) (2012) has established recommendations such as exclusive breastfeeding

within the first six months of an infant’s life, iron-rich formula for those infants formula fed

(since the nutrition is not equivalent to that of breast feeding), no cow’s milk during the first year

of life, and recommends the introduction of jarred baby food at 6 months of life. The World

Health Organization (WHO) (2012) also agrees with the AAP on exclusive breastfeeding during

the first 6 months of life. Five unique and reliable peer reviewed articles, written within the last

five years, were reviewed and critiqued to address this controversy. Despite these authoritative

recommendations, only 20% of the women population who mother an infant in the United States,

exclusively breastfeed (Center for Disease Control and Prevention (CDC), 2009). Healthy

People 2020 (2012) has a goal for 60.6% of all infants to be breastfed at 6 months by year 2020.

All five articles reviewed here are unique in that they each address various aspects of

breastfeeding such as: nutritional benefit, prevention of illness, the long term affect on brain

function, mental health, and overall health outcomes amongst minority populations. The articles

utilized are titled the following: (1) “Breastfeeding Protects against Current Asthma up to 6

Years of Age” (Silvers et al., 2011), (2) “The Long-Term Effects of Breastfeeding on Child and

Adolescent Mental Health: A Pregnancy Cohort Study Followed for 14 Years” (Oddy et al.,

2010), (3) “ Breast-Fed Infants Process Speech Differently From Bottle-Fed Infants: Evidence

From Neuroelectrophysiology,” (Ferguson and Molfese, 2007), (4) “Associations Among


Feeding Behaviors During Infancy and Child Illness at Two Years,” (Philipsen, Razza, Malone,

and Brooks-Gunn, 2008) and (5) “Breastfeeding and Health Outcomes among Citizen Infants of

Immigrant Mothers” (Neault et al., 2007). The articles were purposefully reviewed in this order

to synthesize from narrow studies to broader in terms of the benefits associated with

breastfeeding.

Reliable databases were used to search for these articles including ‘MDConsult,’

‘Medline,’ and “CINAHL.’ both funded by the Shimberg Library to provide the full article for

review. Search terms used to obtain the articles include ‘breastfeeding benefits formula fed’ and

other variations of that phrase to obtain articles that can provide a comparison of both feeding

methods. Articles not chosen were those not peer-reviewed, not recent within five years, reviews

of studies, meta-analysis, if the study was not reliable or credible, or if the study failed to address

the clinical problem entirely.

Synthesized Literature Review

Silvers et al., (2011) conducted a research study to investigate the effects of breastfeeding

on children between ages 2 to 6 who are currently suffering with asthma. The sample included

1105 infants; they were categorized in a prospective birth cohort in New Zealand. Expectant

mothers were recruited by their midwives before their child’s birth, and consent was provided.

Methods to collect information consisted of questionnaires given to mothers at their child’s birth,

and at 3, 6, and 15 months. Questionnaires asked the participants questions to provide detailed

information on breastfeeding. There were two ways in which breastfeeding was assessed through

the questionnaire- the duration of ‘exclusive’ breastfeeding and the duration of ‘any’

breastfeeding. ‘Exclusive’ breastfeeding questions contained components such as the age when

infant formula, food or drinks were introduced. While mothers who fell into the ‘any’


breastfeeding category were asked to provide information regarding the age when the

breastfeeding ceased. Based off the responses, questionnaires were compiled to determine the

durations of exclusive breastfeeding and partial breastfeeding. There was a total of 1105 infants

enrolled in the study before birth, and questionnaires were completed for 1064 children at 3

months, 1011 at 15 months, 1011 at 2 years, 1007 at 3 years, 986 at 4 years, 990 at 5 years, and

920 at 6 years. Secondly, information about any wheezing or current asthma at 2, 3, 4, 5, and 6

years was collected amongst children as a secondary measure. The article defined asthma as:

ever having a diagnosis, any wheeze in the last 12 months, or use of inhaler within the last 12

months.

A table was included to provide a breakdown of participant demographics including

gender, age when breastfeeding began and/ or ended, and compiled other variables such as

smoking during pregnancy or in the household, atopy, parental history of allergic diseases,

maternal history of asthma (Silvers et al., 2011). The ‘Exclusive’ breastfeeding category was

further broken down by age when infant formula, food or drinks were introduced. Whereas the

‘any’ breastfeeding group was broken down to the age when the breastfeeding ceased. Based on

the results, of the 987 of the infants who were exclusively breastfed, 337 began ingesting infant

formula, food, or drinks within or equal to the first week of life. Furthermore, of the 1011 infants

who fell into the ‘any’ breastfeeding category, 335 stopped breastfeeding between 6-12 months.

The outcomes for current children with asthma and current children who are wheezing

from ages 2 through 6, were compared to the number of the individuals who fell into that age

group to the number of individuals who were diagnosed with asthma or presented with wheezing

(Silvers et al., 2011). Further analysis of the results and table demonstrate that for each month of

exclusive breastfeeding, asthma was reduced by 17% for children 2 years old, 12% for 3 years,


11% by 4 years, 12% by 5 years and 9% by 6 years. Atopic children were also factored in-

exclusive breastfeeding for ages greater than 3 months reduced asthma in atopic children by 63%

by 4 years, 56% by 5 years of age, and 59% by 6 years.

The purpose of the study conducted by Oddy et al. (2010), was to determine if

breastfeeding independently affected child and adolescent mental health. A longitudinal study

was conducted in Australia on a total of 2900 recruited pregnant women who were then followed

for 14 years. The participant’s criteria for enrollment included gestational age between 16 and 20

weeks, proficiency in English, expectation to deliver at a hospital, and plan to remain in Western

Australia for long term follow-up. Demographic data from each expecting mother including

family, social, economic, and obstetric history were compiled during the enrollment process.

Once each mother delivered their child, the new born was examined by a pediatrician. By using a

Child Behavior Checklist (CBCL), mental status assessments were achieved at ages 2, 6, 8, 10,

and 14 years. According to the California Evidence Based Clearinghouse (CEBC), the CBCL is a

reliable scale which obtains report from parents, or guardians about their child’s competencies or

behaviors (Achenbach, 2009). A total of 20 competencies were assessed by the caregiver at all

age intervals including the child’s activities, social relations, and school performance; as well as

118 behavior and emotional problems based off a likert scale (Oddy et al., 2010). In addition to

the CBCL, a questionnaire, structured interview and clinical examination were completed on all

available children at ages 2, 6, 8, 10, and 14 years as well. The questionnaires were sent by mail

to be completed before the interview and assessments, and contained information regarding the

general health and well-being of the family and child.

After statistical analysis of the results through T-scores was established, it was

determined that breastfeeding less than 6 months was correlated with increased child behavioral


problems; whereas breastfeeding for longer than 6 months was associated with less occurrence of

mental health problems amongst children (Oddy et al., 2010). There were 28% of infant’s

breastfed between 6 and 12 months, and 24% were breastfed for 12 months of longer. Of the

infant’s breastfed at least 6 months or more, there was a significantly lower CBCL scores across

all domains; the lower score is indicative of decreased mental health problems. Variables such as

smoking during pregnancy, low family income, young mothers (usually without college

education), stressful events, and absence of the biological father were correlated with mothers

who breastfed less than 6 months, as well as a higher CBCL score.

A study conducted by Ferguson and Molfese, from the department of psychological and

brain sciences at the University of Louisville, examined how breast-fed infants process speech

differently from bottle-fed infants (2007). This study identified that polyunsaturated fatty acids

(PUFAs) in breast milk are correlated with increasing nutritional benefits, and are thought to

have an impact on brain and cognitive development. Although, there is PUFA enriched formula

on the market as well, which claims to have the same effects on the brain and cognitive

development as breast milk. The purpose of this study was to analyze the differences on brain

function between breast milk and PUFA containing formula.

A total of 12 infants participated in this study between ages 5 months and 7 months

(Ferguson and Molfese, 2007). Two different phases of testing took place: (1) a behavioral

assessment session which evaluated the infant’s developmental level and (2) an Event Related

Potential (ERP) portion which evaluated wavelengths of brain responses to auditory speech. Two

groups were established for participants: exclusive breastfeeding and exclusive bottle fed

(PUFA) formula. Each group contained 3 males and 3 females, and both had a mean age of 6

months. Much of the other demographic information was the same between both groups such as


birth weight, apgar scores, maternal age, and maternal education level (majority of the mothers

had college education). A Mental Development Index (MDI) was first administered to assess

each infant’s development level; there were no significant differences of development level

between each infant group. The next portion of the study consisted of auditory stimuli which

contained 6 consonant- vowel syllables. Efforts were implemented to improve the ‘naturalness’

of the sounds by using a Klatt synthesizer to model the amplitude and frequency of natural

speech. The stimulus was centered midline over each infant’s head and the stimulus intervals

varied to reduce expectation and habituation effects. Immediately following the auditory

simulation, the infants head circumference was measured to determine an appropriate size 128-

electrode net; this was then used to record auditory ERPs. Electrophysiological data was

recorded with Net Station 3.0, and the infants were continuously monitored with the EEG.

Infants were awake during the entire procedure, and testing was temporarily suspended if there

was motor or state change.

Statistical analysis supported the original hypothesis that breast-fed infants were

advantaged for later cognitive development and was more sensitive to speech stimuli (Ferguson

and Molfese, 2007). Furthermore, infants who received the exclusive PUFA enriched formula

did not generate similar brain activity in comparison to the breast-fed infants. Based on the

results, it is assumed that breast-fed infants are more advantaged specifically in linguistic and

cognitive development.

The purpose of the study conducted by Hetzer et al. (2008) was to examine different

feeding combinations, and the effects each one has with toddlerhood child illness such as asthma,

respiratory, gastrointestinal infections, and ear infections. Participants were excluded from the

study if: (1) the infant was fed cow milk during the first 6 months of life, (2) the biological


mother was not still the caregiver of the child at 9 months and 2 years mark, (3) if the child was

less younger than 23.4 months by the time of the second data collection, (4) children with long

term disabilities (i.e. spinal bifida), (5) if there was not complete parents interviews at the child’s

9 months and 2 year age, or (6) if there was missing data on the child’s feeding or illness. This

left the study with a final sample of approximately 7,900 children. Three distinct parts of the

study was collected: (1) demographic, background information, (2) feeding methods/

combinations that occurred during the first 6 months of life, (3) the occurrence of childhood

illness by 2 years of age.

Background/ demographic information were collected at the 9 months mark (Hetzer et

al., 2008). More specifically, this information included the infant’s demographics such as race/

ethnicity, sex, birth weight. Family demographics was also collected including the mothers age,

marital status, education level, health status, body mass index (BMI), maternal depression,

income (and if they were receiving WIC – a nutritional program for children). Information was

further collected about the pregnancy to account for variables about neonatal nutrition (including

vitamin intake), alcohol or tobacco use, number of visits to the obstetrician, or any other habits

or nutritional intake that could influence the child’s health outcome. Further information was

also collected about the home environment including other children present in the household,

food insecurity, or if the child received any non-parental care before 6 months of age. The

mother-child relationship was also assessed using the Nursing Child Assessment Teaching Scale

(NCATS), which measured 73 behaviors of the mother’s cognitive and social growth fostering,

responsiveness, sensitivity, and the child’s reactivity. This portion took 9 months to assess and

mother-infants were categorized in low engagement, average engagement, or high engagement

categories.


The second portion of information collection consisted of infant feeding practices;

whether exclusive formula, exclusive breast feeding, a combination of both or other feeding

methods and combinations during the infants first 6 months of life (Hetzer et al., 2008). (The

final portion of the study assessed the health and illness of infants at both the 9 months interview

and at the 2 year mark. There were four illnesses reported on: (1) Asthma, (2) respiratory

infection, (3) gastrointestinal infection, and (4) ear infection. Mothers were asked to report if

their child experienced any of these four illnesses or had symptoms of by the time of the 2 year

interview. The multiple variables were analyzed and were examined separately to assess whether

they had an impact on the health outcomes of the children during this study.

The results concluded that nearly 70% of feeding practices during the infants first 6

months of life consisted of breastfeeding (Hetzer et al., 2008). Of the 70% who were fed some

breast milk, 78% were also fed formula at some point during the 6 months (typically starting at 2

months), 74% were fed solid food (i.e. babyfood), and 15% were fed some sort of finger food

(i.e. Cheerios). Only 8% of the infants were exclusively breast fed during the first 6 months of

life – which followed the AAP’s recommendation.

There were two models created in this study- model 1, which specifically examined the

association of breastfeeding and combinations feeding methods with childhood illness, and

model 2, which controls for variables in the family-child background and demographics (Hetzer

et al., 2008).. Children were breast fed exclusively for 6 months had the lowest occurrence of

respiratory and ear infections when specifically looking at feeding combinations. In regards to

asthma, model 1 showed that children who were exclusively breastfed had lower rates of asthma

compared to other feeding combinations. However, when model 2 was analyzed to control the

variables, there was no statistical difference in children who were exclusively breastfed versus


those who had a combination in acquiring asthma. Model 1 also found that exclusively breast-fed

infants had lower rates of respiratory infections as well. Once the variables were accounted for in

model 2, infants exclusively breast-fed still had lower rates of respiratory infection and were

statistically different compared to other feeding combination groups, except for the breast milk

and formula group. Model 1 also suggested that there is no significant predictor of

gastrointestinal infections when analyzing feeding methods alone. However, model 2 determined

that when variables were controlled, exclusively breast-fed infants were no different in the

likelihood of contracting a gastrointestinal infection in comparison to the other feeding

combination groups. In regard to likelihood of acquiring ear infections, infants who were

exclusively breast fed had significantly less odds of acquiring the infection compared to the other

groups. Model 2 supported model 1 with the variables accounted for.

The study conducted by Neault et al. (2007), was broader in that its purpose was to

examine the effects of breastfeeding’s health outcomes on infants on a specific population –

immigrant mothers with food insecurity. Investigation is needed to analyze why immigrant

mothers are more likely to breast-feed and yet their children are at higher risk for poor health and

nutrition compared to their United States born peers. The participants were recruited from 5

regions throughout the Unites States at urban pediatric health care sites. To qualify for the study,

mothers must be immigrants with food insecurity, and the children must be less than 1 year of

age. A total of 3,592 immigrant mothers and 5,208 U.S. born mothers participated in this study.

Participants were excluded if they could not speak English, Spanish or Somali, unknowledgeable

about their demographics or child household, if the household lives in a different state than

where the interview is taking place, if the child was critically ill or if they refused consent. A

total of 21,564 caregivers were interviewed, however due to participants not meeting the


requirements, refusal to sign the consent form, or incompletion of the interview, there was a

result of 3,592 infants of immigrant mothers and 5,208 infants of U.S. born mothers.

The participating mothers were interviewed in private in the clinic, after consenting to the

study, and were surveyed by the Children’s Sentinel Nutrition Assessment Program (Neault et

al., 2007). Children aged 0-3 were interviewed in private settings during the waiting periods at

the clinics/ emergency department. Measurements such as weight and length were also recorded.

The initial interview contained topics of breastfeeding initiation (feeding combinations) and

duration, child’s current health status and past medical history, household sociodemographic

information, use of any federal assistance aid program and food security. Infants were

categorized based on if they have ever been fed breast milk, and for how long. However,

exclusive breast feeding was not recorded. Background and demographics of the infants and

mothers were compiled in a chart for comparison. T tests were used to determine statistical

significance between demographic information, breastfeeding status, and overall child health and

growth.

The results of this study concluded that of the U.S. mothers who were interviewed, they

breast-fed their infants less frequently (typically less than 1 month) compared to immigrant

mothers (Neault et al. 2007). There was also no significant health decline in infants who were

born to U.S. born mothers, which corresponds with the food insecurity associated with

immigrant mothers. Majority of the immigrant mothers were from Mexico, and others were from

Africa, other parts of Central America, Caribbean Islands, South America, Asia/ Pacific, and a

small amount from other regions. Of the infants from immigrant mothers, 83% of them were

breast-fed with a mean duration of about 3 months.


The first table provided, compares demographic information among both groups and

really associates the differences among breast feeding status (Neault et al. 2007).. There was also

a correlation amongst the immigrant mothers between breastfeeding, federal aid benefits, lower

income and food insecurity. Table 2 was un-adjusted (did not include variables) to analyze the

health outcomes associated breast fed infants to immigrant mothers. This table showed that the

breast-fed infants alone were associated with lower rates of poor health and also were correlated

with faster growth (weighing more and were longer for age). Table 3 was adjusted to control for

the background and demographic variables, and even still it was consistent with table 2 that

breast-fed infants were less likely to endure poor health despite the adjustment. Table 4 used z-

scores to include the food insecurity variable in the immigrant population and found that of the

children who were born to immigrant mothers with food insecurity and were breast fed were still

less likely than the non-breast-fed group to acquire illness and poor health; however, this

difference was not significant. The same was for those infants born to immigrant mothers with

food insecurity who were breast-fed – they still weighed more and were longer than the other

infant counterparts who had the same demographic information but were not breast-fed.

Discussion

All of the studies were similar in that they all focused on the benefits of breastfeeding but

contrasted since they all focused on different aspects of breastfeeding benefits (Silvers et al.,

2011; Oddy et al., 2010; Ferguson and Molfese, 2007; Philipsen et al., 2008; Neault et al., 2007).

While the first three studies analyzed focused on more specific breast feeding benefits (asthma,

mental health, and intellectual outcomes), the last couple focused on broader topics (illnesses and

immigrant mothers). All the studies contrasted in design, methods, and sample characteristics;

however, even with these variations, they all supported exclusive breastfeeding to other methods.


Majority of the studies also accounted for major confounding variables, which could have altered

the results.

The strength of the study conducted by Silvers et al. (2011) was that the definition of

breastfeeding was specific, data collection was prospective, and there was a wide range of

breastfeeding duration. The study also examined other similar studies with similar birth cohorts

to analyze why there were differences – this is beneficial to analyze the necessity of further

research and validity of the results. A disadvantage was some of the variables which were not

taken into account that could have altered the results, including the exclusion of infant formula,

food and drinks containing potential allergic components.

The major strength of the study conducted by Oddy et al. (2010) was that it was

longitudinal and majority of the participants followed through with the study. The study was also

able to produce evidence of the association between breast-fed infants and mental health

outcomes in relation to social, biological, and demographic factors. The analysis of all of these

different mental health domains allowed the study to account for multiple variables that could

have influenced the studies outcomes. However, accuracy and reliability could have further been

achieved if there was biochemical analysis of breast milk samples. Other possible explanation

that needs to further be explored are factors such as maternal contact and positive stress response

in infants that is associated with breast feeding and if those aspects contribute to positive health

outcomes.

In the study conducted by Ferguson and Molfese (2007), there was a positive outcome

with the study that there was statistical significance in electrophysiology between breast fed

infants and those infants who received PUFA enriched formula. Another strength of this study

was that the study supported all three hypothesis: (1) breast-fed infants are advantaged in later


cognitive development, (2) infants fed with PUFA enriched formula only generated activity on

one brain hemisphere (whereas breast-fed infants were stimulated on both hemispheres), and (3)

breast-fed infants would have wavelength variation and PUFA formula fed infants would be

more restricted. Another benefit of this study was the ability to measure the part of the brain

being stimulated. Breast-fed infants had more stimulation in the frontal and temporal lobe and

PUFA enriched formula fed infants experienced stimulation among more of the parietal and

occipital lobes. This suggested that breast-fed infants are advantaged in linguistic and cognitive

development. However, it would be interesting to see a longitudinal study conducted to measure

the proposed breast-fed versus PUFA enriched formula fed infants to further examine the results

and improve accuracy.

The study conducted by philipsen et al. (2009) was interesting in that is examined the 4

major childhood illnesses and the effects feeding methods have on them. It took into account all

feeding methods, exclusive breast feeding or formula, and combinations which improved

accuracy of results. It further analyzed family demographics and backgrounds to control other

variables that might influence childhood health. This study was very thorough and careful in its

analysis; it was able to account for other possible explanations in the results. A limitation to this

study was that with particular feeding combinations, duration and age of initiation was not fully

addressed. Furthermore, diagnosis of the illnesses examined in the study may not always be

diagnosed or found in toddlerhood – there might not have been enough variation in the sample to

detect the differences.

One major benefit of the study conducted by Neault et al. (2007), was that it was

consistent with other similar studies which improved the credibility and reliability of the results.

There was also a large sample size which improves the outcome of results. This study further


carefully examined the demographics and background of the participants. There were also some

limitations to this study – the Children’s Sentinel Nutrition Assessment Program study excluded

immigrants who were excluded for language purposes, and this assessment does not ask about

exclusive breastfeeding. Because of those missing components, not all immigrants who could

have contributed to the study were accounted for, and there was no way to know which

immigrants exclusively breast-fed or breast-fed along with formula.

Conclusion

All of the research articles synthesized were unique in they each focused on different

benefits of breast feeding and supported breastfeeding benefits on all different domains. It can be

determined that breastfeeding specifically improves infants health outcomes on illnesses and

mental health – despite socioeconomic and household variables, or immigration status. However

researchers need to continue to explore the question of why there continues to be a low

percentage of mothers who do not exclusively breastfeed despite the positive outcomes and

current authoritative recommendations. That major topic can be further broken down to analyze

limitations to exclusive breastfeeding such as maternal or infant illnesses and disabilities, social

and familial factors that may contribute, and even lack of education about the benefits amongst

pregnant women and current mothers. Healthcare professionals need to further educate their

patients more about breastfeeding and the positivity that is associated with the infant’s health. If

parents understand how beneficial natural breast feeding is for the child and themselves, mothers

may be more receptive to the method in the future.


References

AAP. (2012). American academy of pediatrics. Retrieved from

http://www2.aap.org/breastfeeding/faqsbreastfeeding.html

Achenbach, T. (2009). Child behavior checklist for ages 6-18 (cbcl/6-18). Retrieved from

http://www.cebc4cw.org/assessment-tool/child-behavior-checklist-for-ages-6-18/

CDC. (2012). Retrieved from Department of Health and Human Services website:

http://www.cdc.gov/breastfeeding/data/reportcard.htm

Ferguson, M., & Molfese, P. J. (2007). Breast-fed infants process speech differently from bottle-fed

infants: Evidence from neuroelectrophysiology. Developmental Neuropsychology, 31(3), 337-

347.

Healthy People 2020. (2012, October 30). Healthypeople.gov. Retrieved from

http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26

Neault, N. B., Frank, D. A., Merewood, A., Philipp, B., Levenson, S., Cook, J., Meyers, A. F., & Casey, P. H.

(2007). Breastfeeding and health outcomes among citizen infants of immigrant mothers. Journal

of the American Dietetic Association, 107(12), 2077-2086.

Oddy, W. H., Kendall, G. E., Li, J., Jacoby, P., Robinson, M., De Klerk, N. H., Silburn, S. R., & Zubrick, S. R.

(2009). The long- term effects of breastfeeding on child and adolesvent mental health: A

pregnancy cohort study followed for 14 years. The Journal of Pediatrics, 156(4), 568-573.

Philipsen Hetzner, N. M., Razza, R. A., Malone, L. M., Brooks-Gunn, J., & , (2008). Associations among

feeding behaviors during infancy and child illness at two years. 795-804.

Silvers, K. M., Frampton, C. M., Wickens, K., Pattemore, P. K., Ingham, T., Fishwick, D., Crane, J., & Town,

I. (2011). Breastfeeding protects against current asthma up to 6 years of age. The Journal of

Pediatrics, 160(6), 991-996.


World Health Organization. (2012). World health organization. Retrieved from

http://www.who.int/topics/breastfeeding/en/

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