Abstract
BackgroundExclusive breastfeeding (EBF) is associated with early child health; its longer-term benefits for child development remain inconclusive. We examine the associations between EBF, HIV exposure, and other maternal/child factors and the cognitive and emotional-behavioural development of children aged 7–11 y.Methods and FindingsThe Vertical Transmission Study (VTS) supported EBF in HIV-positive and HIV-negative women; between 2012 and 2014, HIV-negative VTS children (332 HIV exposed, 574 HIV unexposed) were assessed in terms of cognition (Kaufman Assessment Battery for Children Second Edition [KABC-II]), executive function (Developmental Neuropsychological Assessment Second Edition [NEPSY-II]), and emotional-behavioural functioning (parent-reported Child Behaviour Checklist, [CBCL]). We developed population means by combining the VTS sample with 629 same-aged HIV-negative children from the local demographic platform. For each outcome, we split the VTS sample into scores above or at/below each population mean and modelled each outcome using logistic regression analyses, overall and stratified by child sex. There was no demonstrated effect of EBF on overall cognitive functioning. EBF was associated with fewer conduct disorders overall (adjusted odds ratio [aOR] 0.44 [95% CI 0.3–0.7], p ≤ 0.01), and there was weak evidence of better cognition in boys who had been exclusively breastfed for 2–5 mo versus ≤1 mo (Learning subscale aOR 2.07 [95% CI 1.0–4.3], p = 0.05). Other factors associated with better child cognition were higher maternal cognitive ability (aOR 1.43 [95% CI 1.1–1.9], p = 0.02, Sequential; aOR 1.74 [95% CI 1.3–2.4], p < 0.001, Planning subscales) and crèche attendance (aOR 1.96 [95% CI 1.1–3.5], p = 0.02, Sequential subscale). Factors positively associated with executive function were home stimulation (aOR 1.36 [95% CI 1.0–1.8], p = 0.04, Auditory Attention; aOR 1.35 [95% CI 1.0–1.8], p = 0.05, Response Set) and crèche (aOR 1.74 [95% CI 1.0–3.0], p = 0.05, Animal Sorting). Maternal mental health problems and parenting stress were associated with increased emotional-behavioural problems on the total CBCL (aOR 2.44 [95% CI 1.3–4.6], p = 0.01; aOR 7.04 [95% CI 4.2–11.9], p < 0.001, respectively). Maternal HIV status was not associated with any outcomes in the overall cohort. Limitations include the nonrandomised study design and lack of maternal mental health assessment at the child’s birth.ConclusionsEBF was associated with fewer than average conduct disorders and weakly associated with improved cognitive development in boys. Efforts to improve stimulation at home, reduce maternal stress, and enable crèche attendance are likely to improve executive function and emotional-behavioural development of children.
Highlights
There is strong evidence that exclusive breastfeeding (EBF) for 6 mo, as recommended by the World Health Organization (WHO) [1], optimises infant nutrition and substantially decreases mortality and morbidity from infectious diseases [2,3]
EBF was associated with fewer conduct disorders overall, and there was weak evidence of better cognition in boys who had been exclusively breastfed for 2–5 mo versus 1 mo (Learning subscale adjusted odds ratio (aOR) 2.07 [95% CI 1.0–4.3], p = 0.05)
We considered that the total number of days of EBF in the first 6 mo was more likely to have an impact on child development than whether the days were sequential or not, and we did not wish to exclude children who had received breastmilk for most 180 d except for 1 or 2 d when they received breastmilk and other fluids
Summary
There is strong evidence that exclusive breastfeeding (EBF) for 6 mo, as recommended by the World Health Organization (WHO) [1], optimises infant nutrition and substantially decreases mortality and morbidity from infectious diseases [2,3]. The few studies from resource-limited settings were almost twice as likely to find no association. This suggests that confounding variables, including socioeconomic status and maternal cognitive ability, affect the choice to breastfeed and the positive effects found. Further limitations included small sample sizes [15,16] and predominantly Caucasian populations, with only one small study from Africa [16], which found no association with cognitive development but some advantages for child behaviour in breastfed infants. There was no evidence from HIV-prevalent areas where the long-term effect of EBF on child development remains unquantified. Exclusive breastfeeding (EBF) is associated with early child health; its longer-term benefits for child development remain inconclusive. We examine the associations between EBF, HIV exposure, and other maternal/child factors and the cognitive and emotional-behavioural development of children aged 7–11 y
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