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Breastfeeding & Infant Mortality

Obeng, Cecilia S.
Foster, Darian L.
School of Public Health - IUB

Infant Mortality, death before the age of one, is becoming increasingly more common in

both developed and developing countries. There are multiple causes for infant mortality

including: low birth weight, infections, birth defects, lack of prenatal care and other factors.

Perhaps one of the most prominent factors can be attributed to the decreased exposure infants

have to human milk and the increase in commercial formula usage. A study done by Palloni in

Mexico, found that an infants morbidity risk was increased 10 times when exclusively formula

fed for an entire year, compared to infants who were breastfed exclusively for one year

(Gonzalez de Cosio, Escobar, Gonzalez, Gatell, & Hernandez, 2013). Infants are dying at an

alarming rate from preventable factors which emphasizes the importance of promoting

breastfeeding and providing evidence-based education about human milk.

Historically, breastfeeding has been the traditional first food for infants until the

introduction of commercialized infant formula in 1867. Breastmilk has been noted as the most

complete, non-replicable nutrition for infants. However, breastfeeding has suffered incredible

losses due to miseducation, conflicting information, false advertising from formula companies

and numerous other factors. The aforementioned issues have lead women to supplementing with

artificial milk. In lieu of this, many infants around the globe have not consumed their mothers

milk, therefore have not been exposed to the important antibodies, vitamins, minerals and other

protective factors that breastmilk naturally contains. Science has already proven and researched

in-depth why human milk is vital for human babies. Biologically plausible mechanisms through

which breastfeeding may impact neonatal mortality have been proposed, such as composition of

breast milk changing according to the newborn's need for passive immunological protection

Early breast milk has an abundance of cytokines at a time when neonatal organ systems are
immature, suggesting that these bioactive components of breast milk may be important in

neonatal development (Oddy, 2013).

Since breastfeeding rates have decreased, we have seen a significant rise in infant

mortality rates globally. The United States, in particular, has shocking rates. Although the U.S. is

considered to be medically and technologically advanced in comparison to its global

counterparts, Americas infant mortality rates are some of the worst among developed countries.

While countries such as Sweden and Finland have infant mortality rates as low as 2 or 3 deaths

per 1,000 births; the United States had an infant mortality rate of 6 deaths per 1,000 births in

2014 (Texas A&M University, 2016). These statistics are a huge cause for concern and are an

indication that changes need to be made.

Demographics of Infant Mortality (Whos most at-risk)

Certain populations are more at-risk for infant mortality than others. For instance, those

infants who are exclusively formula-fed are the most at-risk, because there is no exposure to their

mothers milk. Why is this exposure so important? An infant is born with an extremely immature

immune system and the mothers body protects the infant by detecting bacteria in the childs

saliva and synthesizing antibodies to attack germs that the infant has been exposed to; therefore,

the infant receives personalized protection from specific bacteria that can cause harmful

illnesses, such as: necrotizing enterocolitis, diarrhea, and other infections. Minority populations

are also more at-risk than others. African Americans and American Indian populations have a

higher risk compared to other ethnic groups [Caucasian, Hispanic, and Asian American]; one of

the most substantial factors influencing this increased risk is the higher proportion of low birth

weight and preterm births in these populations (Matthews, MacDorman, & Thoma, 2015, pp.6-

7). This is similar even in developed countries (Texas A&M University, 2016). In addition,

those with lower income and less education are also at a higher risk for infant mortality.
What We Know


The substantial effect that breastfeeding has on reducing infant mortality despite income,

race, or education level has been well documented through current literature on breastfeeding

and infant mortality. The biggest barrier to exclusive breastfeeding is commercial infant

formulas. Formulas main purpose should be to provide adequate nutritional sustenance to

infants only in cases where breastmilk is not available; however, in most cases formula is forced

upon families and falsely advertised as just as good or even better than breastmilk, leaving

todays infants immune systems sorely lacking in strength. One research article reads, Infant

formula was designed to be a medical nutritional tool for babies who are unable to breastfeed.

Formula does not fully meet the nutritional and immunity needs of infants, leaving their immune

systems flailing. An infant's immune system has three aspects: her own immature, developing

immune system; the small component of immunities that passes through the placenta during

natural childbirth (and to a lesser degree with premature births and cesarean sections); and the

most valuable, living portion that is passed on through mother's milk on an ongoing basis.

Remove any of these components and you take away a vital support structure (Palmer, 2003).


The longer the duration of breastfeeding, the less likely infants will perish before the age

of one (Chen & Rogan, 2004). The American Academy of Pediatrics recommends that, babies

be exclusively breastfed for about the first 6 months of life. This means your baby needs no

additional foods (except Vitamin D) or fluids unless medically indicated. Babies should continue

to breastfeed for a year and for as long as is mutually desired by the mother and baby (American
Academy of Pediatrics). Additionally, the World Health Organization, recommends

continued breastfeeding up to 2 years of age or beyond (Center for Disease Control).


Current research also suggests that exclusive breastfeeding reduces not only risk of all-

cause infant mortality but also infection-related infant mortality. In fact, a literature review

conducted in 2015 compared predominately, partially, and non-breastfed infants with exclusively

breastfed infants and found the following: Infants 05 months of age who were predominantly,

partially or not breastfed had significantly higher risk of all-cause and infection-related mortality

compared to exclusively breastfed infants. Children aged 623 months who were not breastfed

had higher risk of all-cause and infection-related mortality than children who were continued on

breastfeeding (Sankar, et al., 2015).

Breastfeeding is also the most preventative and protective measure against infant

mortality (Golding, Emmett, & Rogers, 1997). Some may question what exactly makes

breastmilk so protective. The answer lies in breastmilks composition changing according to the

childs immunological needs. A research article, examining the importance of breastfeeding in

the first hour after birth, surveyed 67 countries and how breastfeeding in this time frame reduced

infant mortality rates. The article explains the unique protection human milk offers. Several

components in breast milk reduce the inflammatory response to stimuli in the newborn intestine.

These components include transforming growth factor beta, interleukin-10, erythropoietin, and

lactoferrin, which act individually or pleiotropically to contain the immature inflammatory

response.7More broadly, protection may be provided through a myriad of factors in maternal

milk including bioactive enzymes, hormones, growth factors, cytokines, and immunological

agents that increase and stimulate host defense (Oddy, 2013). A 2015 literature review, also
stated, The better the breastfeeding practice, the higher the protection. Even partial

breastfeeding had a modest protective effect compared to no breastfeeding (Sankar, et al.,


In the literature, exclusive breastfeeding is emphasized as the most protective against

infant mortality in different populations. An infant mortality research study was conducted in

Ethiopia, which had a high infant mortality rate of 88 deaths per 1,000 births (November 2009 to

August 2011), with a cohort of 1,752 infants. The study found that exclusive breastfeeding was

not only protective in rural areas but was the strongest indicator of survival for those infants

(Biks, Berhane, Worku, & Gete, 2015). UNICEF also indicated that optimal breastfeeding

practices would prevent numerous deaths in developing countries, including 10% of neonatal

deaths in India alone (Chan, 2011). The text reads, It has been estimated that optimal

breastfeeding of children under two years of age has the potential to prevent 1.4 million deaths in

children under five in the developing world annually, based on a report in The Lancet 2008

Nutrition Series (Chan, 2011). This research reveals that whether in developed or developing

countries, rural or urban areas, in every ethnic group and income bracket, exclusive breastfeeding

prevents the deaths of infants.


With information from current literature, there is a further understanding that exclusive

breastfeeding can prolong many lives; with this knowledge, we must ask, what can we do to

ensure that breastfeeding happens in our society as a whole? For instance, more research can be

done on how breastfeeding decreases infant mortality in developed countries, since most

neonatal morbidity in this population is caused by low birth weight and Sudden Infant Death

Syndrome; this includes studying how breastfeeding decreases the risk of SIDS. In addition to

this research, providing evidence-based breastfeeding information is crucial for not only

expectant mothers but family members as well. This information discredits breastfeeding myths

and allows families to get questions answered to help support the mother during her

breastfeeding journey.

Another vital component of increasing breastfeeding rates is extended paid family leave

for mothers and fathers to help with the adjustment period after birth. This will give mothers

more time to get breastfeeding established. Parental leave policies have tremendous influence

on health outcomes for both mom and baby, as well as long-term economic impact, McKyer

said. Studies show that in countries where there is a generous parental leave policy, there are

tremendous effects on morbidity and mortality rates of infants and young children. Theyre

considerably less likely to get sick enough to require hospitalization or to die. Again, its

investing on the front end so that were not paying on the back end (Texas A&M University,


Another research article stated, Unfortunately, many parents in rural areas have been

forced to leave their children in the care of their grandparents while they work in the cities, and
replace breastmilk with low-quality commercial milk powder and formula substitutes (Chan,

2011). This leads into the next step to improve breastfeeding rates; decreasing and creating strict

standards against the aggressive and false advertising of formula companies. UNICEF also

stated, Besides societal pressures to stop breastfeeding, aggressive marketing and promotion by

formula producers and inaccurate medical advice from health workers have also led mothers to

stop exclusive breastfeeding early (Chan, 2011). In addition to monitoring formula company

advertising, medical personnel need quality training on, at minimum, the basics of breastfeeding

that come from an evidence-based source so they can accurately promote human milk for human

babies. Nationally, preventative methods against infant mortality, such as breastfeeding, need to

be promoted before pregnancy and further built upon during the prenatal period. The CDC

suggested additional tactics for decreasing infant mortality, Strategies include 1) improving

women's health before pregnancy, 2) promoting quality and safety in prenatal care, 3) investing

in prevention and health promotion, 4) promoting coordination among health services, 5)

strengthening surveillance and research, and 6) promoting public/private and community

collaboration (Barfield, et al., 2013).

Families should be well-educated on how human milk helps infants health, not just the

mother. Free visits from registered nurses were also found to benefit new parents and could help

increase breastfeeding rates. These visits could effectively answer questions and disqualify false

information, as long as the nurses are educated thoroughly with evidence-based breastfeeding

information (Texas A&M University, 2016).

Two articles touched on the importance of breastfeeding during the first hour after birth.

The faster breastfeeding is initiated, the more likely it is that breastfeeding will be successful for

the mother and child. The text reads, In countries with neonatal mortality rates higher than 29
per 1,000 live births, the correlation with maternal milk in the first hour of life was stronger in

relation to the percentage of deliveries in health facilities and people with secondary education or

higher. In countries with the highest mortality rates, those included in the lowest tertile of

breastfeeding in the first hour of life had the highest rate of neonatal deaths per 1,000 live births,

and those included in the highest tertile had the lowest rate of deaths (Oddy, 2013).

To ensure that babies are getting to the breast as soon as possible, more breastfeeding-

friendly practices need to be established in hospitals and clinics. Policies such as, skin-to-skin

after birth, delayed cord clamping, delaying postpartum procedures to give time for bonding,

gentle cesarean sections that allow skin-to-skin after a Cesarean birth and the mother to have

more control during the surgery, and open availability of Lactation professionals will promote

breastfeeding during the first hour. Of the nutritional factors, early initiation of breast-feeding

associated with reduced risk of infant mortality was consistent with the previous studies reported

showing a strong relationship between infant mortality and early initiation of breast milk. The

risk of infant death increases when breast milk is not initiated immediately after birth [13,14].

About 20% of all neonatal deaths could be prevented if all newborns were initiated breastfeeding

within one hour of birth [16,21,22]. Early breastfeeding initiation reduces the risk of infectious

diseases, which is one of the most common causes of death during the neonatal period (Biks,

Berhane, Worku, & Gete, 2015).

The literature surrounding breastfeeding and infant mortality is extensive and one major

theme is clear from each resource; many infant deaths can be prevented with exposure to human

milk. One may assume that promoting breastfeeding is complicated but on the contrary, it is as

simple as changing our priorities. If we shift our priorities from societal profits to well-being for

all, these changes will be easy to apply and maintain. Medical professionals knowing basic
knowledge about breastfeeding and promoting accordingly. Formula companies advertising their

product as being available only if medically necessary. Families, including grandparents, aunts,

uncles, siblings, fathers and mothers being well-educated about breastfeeding and equipped to

have a positive, successful breastfeeding journey together. It is all possible, if we shift our focus

from financial profits to prospering families.

Barfield, W., MD, D'Angelo, D., MPH, Moon, R., MD, Lu, M., MD, Wong, B., MPH, &
Iskander, J., MD. (2013). CDC Grand Rounds: Public Health Approaches to Reducing U.S.
Infant Mortality. Morbidity and Mortality Weekly Report, 62(31), 625-628. Retrieved April
18, 2017, from
Biks, G. A., Berhane, Y., Worku, A., & Gete, Y. K. (2015). Exclusive breast feeding is the
strongest predictor of infant survival in Northwest Ethiopia: a longitudinal study. Journal
of Health, Population and Nutrition, 34(9), 1-6. doi: 10.1186/s41043-015-0007-z
Chan, J. (2011). UNICEF: Lack Of Optimal Breast Feeding In Developing Countries
. Asian Scientist. Retrieved April 18, 2017, from
Chen, A., Ph.D., & Rogan, W. J., M.D. (2004). Breastfeeding and the Risk of Postneonatal
Death in the United States. Pediatrics, 113(5), E435-E439. doi:10.1542/peds.113.5.e435
Golding, J., Emmett, P. M., & Rogers, I. S. (1997). Breastfeeding and infant
mortality. Early Human Development, 49, S143-S155. doi:
Gonzalez de Cosio, T., Escobar, L., Gonzalez, L. D., Gatell, H. L., & Hernandez, M. (2013).
Breastfeeding protection against infant mortality in Mexico, adjusting for reverse
causality. The Faseb Journal, 27(1). Retrieved April 18, 2017, from
Matthews, T., MacDorman, M. F., & Thoma, M. E. (2015). Infant Mortality Statistics
From the 2013 Period Linked Birth/Infant Death Data Set. National Vital Statistics
Reports, 64(9), 1-30. Retrieved April 26, 2017, from
Oddy, W. H. (2013). Breastfeeding in the first hour of life protects against neonatal
mortality. Jornal de Pediatria, 89(2).
Palmer, L. F. (2003). The Deadly Influence of Formula in America, Part I. Natural Family
Online. Retrieved April 18, 2017, from
Sankar, M. J., Sinha, B., Chowdhury, R., Bhandari, N., Taneja, S., Martines, J., & Bahl, R.
(2015). Optimal breastfeeding practices and infant and child mortality: a systematic review
and meta-analysis. Acta Paediatrica, 104(S467), 3-13. doi:10.1111/apa.13147
Texas A&M University. (2016). Why American Infant Mortality Rates Are So
High. Newswise. Retrieved April 18, 2017, from