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Infant benefits of breastfeeding

Author: Joan Y Meek, MD, MS
Section Editor: Steven A Abrams, MD
Deputy Editor: Alison G Hoppin, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2020. | This topic last updated: Jun 04, 2020.

INTRODUCTION

Human milk is the optimal source of nutrition for virtually all infants. Exclusive breastfeeding is
recommended for approximately the first six months of life, followed by continued breastfeeding,
with the introduction of appropriate complementary solids for at least the first year of life and
beyond. These recommendations are supported strongly by multiple medical and professional
organizations, such as the American Academy of Pediatrics (AAP) [1], the American Academy of
Family Physicians (AAFP) [2], the American College of Obstetricians and Gynecologists (ACOG)
[3], the World Health Organization (WHO) [4], and the Canadian Pediatric Society (CPS) [5], based
upon both short- and long-term benefits for the mother and child. The WHO recommends
continued breastfeeding at least through the child's second birthday. Suboptimal breastfeeding is
associated with increased risk of infant and childhood morbidity and mortality, and increased risk of
certain chronic conditions.

Benefits of breastfeeding that are specific to the infant and child will be reviewed here. Maternal,
societal, and economic benefits are discussed separately. (See "Maternal and economic benefits
of breastfeeding".)

In analyzing the data, it is important to recognize that not all studies differentiate between exclusive
breastfeeding and any breastfeeding, or quantify the differences between predominantly breastfed
infants and partially breastfed. Dose dependency, in terms of duration, intensity, and quantity, in
addition to exclusivity, has been shown to be important in quantifying the benefits of breastfeeding
for both children and mothers.

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BIOLOGICALLY ACTIVE COMPONENTS OF HUMAN MILK

Human milk is a living biologic substance that is much more complex than the sum of its nutritional
components. Human milk contains not just macro- and micronutrients but also living cells, growth
factors, and immunoprotective substances [6,7]. Many of these factors are resistant to digestive
enzymes in the infant's gastrointestinal tract and are biologically active at mucosal surfaces.

Biologically active components include:

● Antimicrobial activity – Immunoglobulins (especially secretory immunoglobulin A [IgA]),

lysozyme, lactoferrin, free fatty acids and monoglycerides, human milk bile salt-stimulated
lipase, mucins, white blood cells, stem cells, human milk oligosaccharides (prebiotic and
antimicrobial activities). These antimicrobial actions help to protect against gastrointestinal
and other infections, as well as against developing necrotizing enterocolitis (NEC).

● Immunomodulatory activity – Platelet-activating factor (PAF) acetylhydrolase, interleukin 10,

polyunsaturated fatty acids, glycoconjugates. These factors help to protect against NEC
[8-11].

● Factors that promote gastrointestinal development and function – Proteases (enzymes that
help digest proteins), hormones (eg, cortisol, somatomedin C, insulin-like growth factors,
insulin, and thyroid hormone), growth factors (eg, epidermal growth factor and nerve growth
factor), gastrointestinal mediators (neurotensin, motilin), and amino acids that stimulate
enterocyte growth (eg, taurine and glutamine) [12-17]. Human milk also influences optimal
development of the gut microbiome and virome [18,19].

These biologically active components of human milk, as well as its nutritional characteristics
(macronutrient and micronutrient content), are discussed in more detail separately. (See
"Nutritional composition of human milk and preterm formula for the premature infant".)

SHORT-TERM BENEFITS WHILE BREASTFEEDING

Breastfeeding confers direct health benefits to the infant during the time of breastfeeding, some of
which persist after weaning. The best studied benefits are the impacts upon the development of
the gastrointestinal and immunologic systems, as well as prevention of infection.

Neurobehavioral benefits — Breastfeeding appears to have some direct neurobehavioral

benefits. The precise mechanisms have not been established, but some may be related more to

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skin-to-skin contact than the human milk feeding itself [20].

Early skin-to-skin contact between mothers and newborns has some short-term neurobehavioral
benefits and may program other benefits during this sensitive period of adaptation to extrauterine
life. In the short term, early skin-to-skin contact appears to reduce infant crying, increase blood
glucose levels, and promote greater cardiorespiratory stability in late preterm infants [21]. Early
skin-to-skin contact also helps to establish lactation and promote ongoing breastfeeding, which
enhances the other benefits of breastfeeding outlined below.

In addition, there appears to be an analgesic effect of breastfeeding, which may be due to the
enhanced maternal-infant bonding. Breastfed infants experience less stress during painful
procedures than formula-fed infants [22-24]. Skin-to-skin care during a single painful procedure
appears to be both safe and effective as analgesia, as measured by composite pain indicators with
both physiologic and behavioral indicators and, independently, using heart rate and crying time
[25]. A possible mechanism is radiant warmth from the skin-to-skin contact [26,27]. Higher salivary
cortisol levels found in breastfed infants, compared with formula-fed infants, also are postulated to
mediate the analgesic effect of breastfeeding [28].

Gastrointestinal function — Human milk stimulates optimal growth, development, and function of
the gastrointestinal system and influences optimal development of the microbiota [18]. Exclusive,
early breastfeeding protects the infant's gastrointestinal system from exposure to highly antigenic
substances.

When compared with formula, human milk has been shown to:

● Reduce the risk of gastroenteritis and diarrheal disease (see 'Prevention of illnesses while
breastfeeding' below)
● Increase the rate of gastric emptying [29,30]
● Increase intestinal lactase activity in premature infants [31]
● Decrease the intestinal permeability early in life in premature infants [32,33]
● Reduce the risk of developing necrotizing enterocolitis (NEC) in preterm infants [34,35]

Several components of human milk stimulate gastrointestinal growth and motility, including growth
factors and gastrointestinal mediators. Other factors are protective and decrease the risk of NEC
and other infections, including immunoglobulins, platelet-activating factor (PAF) acetylhydrolase,
polyunsaturated fatty acids, epidermal growth factor, and interleukin 10. In addition, human milk
influences optimal development of the microbiota, including neonatal intestinal colonization by the
beneficial microbes of the Bifidobacteria and Lactobacillus species rather than potential
enteropathogenic bacteria, such as streptococci and Escherichia coli [18,36,37] (see 'Biologically

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active components of human milk' above). The benefit of human milk in prevention of NEC is
discussed in greater detail separately. (See "Human milk feeding and fortification of human milk for
premature infants", section on 'Protection against necrotizing enterocolitis' and "Neonatal
necrotizing enterocolitis: Prevention", section on 'Human milk feeding'.)

For these reasons, the American Academy of Pediatrics (AAP) recommends human milk, either
mother's own or pasteurized donor milk, for all premature infants born weighing less than 1500
grams [38]. (See "Approach to enteral nutrition in the premature infant", section on 'Milk strength
and content'.)

Prevention of illnesses while breastfeeding

In both resource-rich and resource-poor nations, human milk, compared with infant formula,
decreases the risk of acute illnesses during the time period in which the infant is fed. Most of these
benefits are related to protection from infectious diseases [39]:

● Gastroenteritis and diarrhea – Breastfeeding lowers the risk of gastrointestinal infections

and diarrhea in many populations, but this is particularly important in low-resource settings
[40-42]. In a meta-analysis that included studies from both low- and high-resource settings,
the risk of diarrhea in infants <6 months was lower in those who were breastfed (pooled
relative risk 0.37, 95% CI 0.27-0.50) [40]. The protective effects are greater for infants living in
low-resource countries, likely due to formula contamination and nutritional status of non-
breastfed infants. In a study in the higher-resource setting of the United Kingdom, infants who
were breastfed exclusively for six months had a decreased risk of severe or persistent
diarrhea compared with infants who breastfed exclusively for less than four months [41].

● Respiratory disease – Breastfeeding lowers the risk of respiratory disease in the infant,
based on results of studies from several different types of populations. As examples, in an
study from the United Kingdom, infants who were exclusively breastfed for six months had a
decreased risk of lower respiratory tract infections than infants who exclusively breastfed for
less than four months [41]. In another study conducted in the United States and Europe,
breastfeeding reduced the risk of respiratory infections in three- to six-month-old infants by
approximately 20 percent [42]. Optimizing breastfeeding in the United States to current
recommendations has been estimated to prevent almost 21,000 hospitalizations and 40
deaths for lower respiratory tract infections in the first year of life [43].

● Otitis media – The incidence of otitis media and recurrent otitis media are reduced in
breastfed compared with formula-fed infants, primarily for those younger than two years
[42,44,45]. The incidence of two or more episodes of otitis media was reduced in infants

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breastfed for one year compared with infants fed formula (34 versus 54 percent) [46]. Feeding
directly at the breast appears to be more beneficial than feeding expressed human milk [47].

● Urinary tract infection – In a case-control study conducted in Sweden, there was a

significantly higher risk of urinary tract infection for infants who were not breastfed compared
with those who were. Longer duration of exclusive breastfeeding reduced the probability of
urinary tract infection, especially in females up to seven months of age [48]. A separate case-
control study found that human milk feeding was associated with a lower risk of urinary tract
infection in premature infants in the neonatal intensive care unit [49]. A mechanism for this
protection has been suggested, based on observations that breastfed infants have greater
contents of oligosaccharides, lactoferrin, and secretory IgA in their urine compared with
formula-fed infants [50]. (See 'Biologically active components of human milk' above.)

● Sepsis – Early institution of exclusive breastfeeding decreases the risk of developing neonatal
sepsis [51-54]. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late
preterm infants".)

● Sudden infant death syndrome (SIDS) – Any breastfeeding is associated with a decreased
risk of SIDS [55,56]. Exclusive breastfeeding and longer duration of breastfeeding confers the
greatest protection [57,58]. (See "Sudden infant death syndrome: Risk factors and risk
reduction strategies", section on 'Protective factors'.)

Mortality and hospitalization — In low- and middle-resource countries, breastfeeding

substantially decreases the risk of childhood mortality [59-61]. In a meta-analysis of 13 studies
conducted in these populations, children exclusively breastfed through five months had lower risk
of all-cause and infection-related mortality compared with those only partially or not breastfed [59].
Children aged 6 to 23 months who were not breastfed had higher risk of all-cause and infection-
related mortality than children who continued breastfeeding. A separate systematic review showed
that initiation of breastfeeding within one hour of birth decreased neonatal mortality compared with
later initiation [60]. It has been estimated that improving global breastfeeding could prevent
823,000 annual deaths in children younger than five years [44].

In high-resource countries, the rate of hospitalization and outpatient visits during the first year of
life is lower among breastfed infants [44,62-65]. These findings suggest that severity of illness is
reduced in the breastfed infant [46]. Infant death in the United States and other high-resource
countries also has been correlated with lack of breastfeeding [44,66].

LONG-TERM BENEFITS

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Limitations of this evidence — Evidence supporting associations between breastfeeding and

beneficial long-term outcomes is inherently limited because it is based primarily on longitudinal
cohort studies, raising the concern of unmeasured or residual confounding from inadequately
controlled factors associated with both breastfeeding and health outcomes [67]. In particular,
breastfeeding in high-resource countries is associated with higher socioeconomic and educational
status and lower rates of maternal obesity and smoking, and these variables may not be fully
captured by available markers. Moreover, these long-term studies are limited by recall bias,
especially for breastfeeding duration. Evidence from studies designed to better control for
confounding (sibling-pair and cross-population studies and one randomized trial [68-70]) tends to
show little or no effect on obesity or cognitive outcomes.

Nonetheless, certain long-term benefits have been reported in large studies and in a variety of
populations, suggesting the possibility of a true causal effect. The mechanism for such
associations is unclear and may vary among the health outcomes. Possible mediators include
development of the microbiota in this early period [18]; modulation of the immune system
development; and the beneficial impact of skin-to-skin contact on maternal-child bonding and
interactions, with potential decrease in toxic stress [20].

Acute illnesses — Exclusive breastfeeding, compared with formula feeding, has a protective
effect in reducing acute illnesses, even after breastfeeding is discontinued. As an example, infants
in the first 12 months of life who were breastfed for more than six months had a lower incidence of
recurrent otitis media (defined by ≥3 episodes within six months or ≥4 episodes within 12 months)
compared with those who were breastfed for less than four months (10 versus 20.5 percent) [71].
This protective effect is observed after adjustment for confounding variables, such as
socioeconomic status, family history of allergy, family size, use of daycare, and smoking. A
systematic review and meta-analysis provides evidence that breastfeeding protects against acute
otitis media until two years of age, but protection is greater for exclusive breastfeeding and
breastfeeding of longer duration [45].

Post-breastfeeding protection against infectious illnesses appears to increase with the duration of
breastfeeding [72,73]. This was illustrated in a secondary analysis of the National Health and
Nutrition Examination Survey III (NHANES III) of 2277 children between 6 and 24 months of age
[73]. After adjusting for demographic variables (including ethnicity and socioeconomic status),
childcare, and smoking exposure, infants who were fully breastfed for 4 to <6 months compared
with those fully breastfed 6 months or longer were more likely to develop pneumonia (odds ratio
[OR] 4.3, 95% CI 1.3-14.4) or to have ≥3 episodes of otitis media (OR 1.95, 95% CI 1.1-3.6) during
the 12-month period immediately preceding the survey. There were no differences between the
groups in the likelihood of having ≥3 episodes of cold/influenza, developing wheezing, or having a

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first episode of otitis media before one year of age. In another survey, breastfeeding for ≥9 months
was associated with continued protection against ear, throat, and sinus infections through six years
of age but not upper or lower respiratory tract infections [74].

Chronic disease — There are reported associations between the duration of breastfeeding and a
reduction in incidence of certain chronic conditions [44,75], such as obesity, type 1 and type 2
diabetes mellitus, adult cardiovascular disease, certain allergic conditions, celiac disease, and
inflammatory bowel disease (IBD). Studies demonstrate the importance of a critical period in the
first year of life, during which breastfeeding can promote long-term effects.

Moderate evidence of benefit

● Type 1 diabetes – Breastfeeding appears to substantially reduce the risk for developing type
1 diabetes. This was shown in an analysis of two large birth cohorts from Denmark and
Norway. Children who were never breastfed had a twofold increased risk of type 1 diabetes
compared with those who were breastfed for ≥12 months (hazard ratio [HR] 2.29, 95% CI
1.14-4.61) or those who were exclusively breastfed for ≥6 months (HR 2.31, 95% CI
1.11-4.80) [76]. Among the breastfed cohort studied, there was no evidence that greater
duration or intensity of breastfeeding had additional protective effect. Systematic reviews
(which did not include the above study), however, supported the protective effect of
breastfeeding but concluded that longer breastfeeding duration was more protective than
shorter durations [77,78].

Effects of breastfeeding on type 2 diabetes are discussed below. (See 'Limited evidence for
benefit' below.)

● IBD – Breastfeeding probably reduces the risk of developing IBD. In a meta-analysis of 35

studies, any breastfeeding compared with no breastfeeding reduced the risk of Crohn disease
(OR 0.71, 95% CI 0.59-0.85) and ulcerative colitis (OR 0.78, 95% CI 0.67-0.91) [79].
Moreover, longer durations of breastfeeding were associated with lower rates of IBD.
Systematic reviews that included a subset of these studies also concluded that breastfeeding
duration is associated with reduced risk of IBD, based on limited but consistent evidence
[77,80].

● Wheezing – Breastfeeding appears to be associated with a lower incidence of wheezing in

early childhood. This association may reflect a reduction in the number of upper respiratory
infections because infections are a prominent cause of wheezing in infants and young
children, which is not necessarily associated with later development of asthma. Associations
between breastfeeding and wheezing later in childhood (eg, after six years, which is more

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likely to represent atopic asthma) and other atopic conditions have not been established.
These issues are discussed in more detail separately. (See "The impact of breastfeeding on
the development of allergic disease".)

● Dental health

• Malocclusion – Several systematic reviews and meta-analyses suggest that

malocclusion is more prevalent among children who are not breastfed [81-83]. Exclusive
breastfeeding and longer duration of breastfeeding (>12 months) has additional benefits,
regardless of the type of occlusion disorder. (See "Preventive dental care and counseling
for infants and young children", section on 'Dietary habits'.)

• Dental caries – Breastfeeding lowers the risk for developing dental caries compared with
formula feeding from a bottle [84]. A systematic review showed that children with more
breastfeeding exposure up to 12 months had reduced risk of dental caries [85]. There
was an increase in dental caries after 12 months, which may be associated with night
feedings and poor oral hygiene practices. (See "Preventive dental care and counseling for
infants and young children", section on 'Dietary habits'.)

Limited evidence for benefit

● Leukemia – Breastfeeding has been associated with a modest reduction in the risk of
developing childhood lymphoma and leukemia. A case-control study reported that ever
breastfeeding was associated with decreased risk for childhood leukemia and lymphoma (OR
0.36, 95% CI 0.22-0.60), with a dose-response effect [86]. A meta-analysis of 18 studies
reported that breastfeeding for six or more months reduced the risk of childhood leukemia by
19 percent (OR 0.81, 95% CI 0.73-0.89) [87]. A systematic review concluded that feeding
human milk for six months or longer is associated with a slight reduction in risk of childhood
leukemia compared with never feeding human milk, although the quality of evidence was
limited [77,88]. The evidence for an effect of shorter breastfeeding duration was mixed. For
other less common childhood cancers, there is insufficient evidence to determine an effect of
breastfeeding.

● Allergic conditions – There is limited evidence for benefit of breastfeeding on atopic asthma
in older children (after six years of age) or on eczema or allergic rhinitis (in all age groups). As
noted above, breastfeeding appears to be associated with a lower incidence of wheezing in
younger children, which may reflect reductions in upper respiratory infections rather than
atopic wheezing (see 'Moderate evidence of benefit' above). These issues are discussed in
more detail separately. (See "The impact of breastfeeding on the development of allergic

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disease".)

Limited evidence suggests that breastfeeding in the first four months of life may decrease the
risk of cow's milk allergy in early childhood [89]. A more general or long-term impact of
breastfeeding on food allergies has not been established. (See "The impact of breastfeeding
on the development of allergic disease", section on 'Breastfeeding and food allergy'.)

● Obesity – Several large prospective cohort studies and meta-analyses report that
breastfeeding or breastfeeding duration is associated with a modestly reduced risk for
overweight or obesity during childhood [90-94]. As an example, a study of almost 200,000
children from low-income families in the United States reported that breastfeeding for 6 to 12
months was associated with a reduced risk of overweight among non-Hispanic white children
compared with no breastfeeding (adjusted OR 0.70, 95% CI 0.50-0.99) [90]. No such effect
was noted for Hispanic or black children. A Canadian study found a dose-dependent
protective effect of breastfeeding, which was diminished, but not eliminated, if the breast milk
was given by bottle rather than directly from the breast, suggesting that the effect might be
related to the feeding method rather than the human milk itself [95]. A large randomized trial in
Belarus, however, reported no effect of breastfeeding promotion on childhood obesity (OR
1.17, 95% CI 0.97-1.41) [68].

A meta-analysis of 113 studies reported a 26 percent reduction in risk of overweight or obesity

for children who were ever breastfed compared with those who were never breastfed (OR
0.74, 95% CI 0.70-0.78), but the effect for the 11 high-quality studies was marginal (OR 0.87,
95% CI 0.76-0.99) [92]. In general, the reported effect size is greater in studies that adjust for
socioeconomic status and also greater in high-resource countries (where breastfeeding is
more common among mothers with higher socioeconomic status) versus low- and middle-
resource countries (where the opposite is true) [92,96,97]. Together, these observations
suggest the possibility of residual confounding from socioeconomic status [67]. (See
'Limitations of this evidence' above.)

● Type 2 diabetes – A meta-analysis of 14 studies suggested that breastfeeding decreases the

risk of developing type 2 diabetes (pooled OR 0.67, 95% CI 0.56-0.80) [98]. The protective
effect of breastfeeding was higher for adolescents but also protective in adults [92,98]. Of
note, this analysis did not adjust for body mass index (BMI), so it is possible that the
association is mediated by effects of breastfeeding on obesity. A systematic review (which did
not include the above study) found insufficient evidence to determine the association between
breastfeeding and risk of type 2 diabetes, prediabetes, or related biomarkers including
hemoglobin A1c [77].

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● Cardiovascular risk factors – Very limited evidence suggests an association between

breastfeeding and cardiovascular risk factors. The best evidence is for effects on blood
pressure. In a study of more than 1500 healthy children, breastfeeding for ≥12 months was
associated with slightly lower blood pressure (reduction of approximately 1 mmHg), which may
not be clinically significant [99]. A systematic review also concluded that breastfeeding is
associated with lower blood pressure during childhood but found insufficient evidence to
determine an effect on blood lipids or other cardiovascular disease risk factors [77,99,100].
Similarly, a protective effect of breastfeeding on metabolic syndrome or non-alcoholic fatty
liver disease in the offspring is uncertain [100,101].

● Celiac disease – A few small case-control studies have reached conflicting conclusions
regarding whether breastfeeding is associated with a lower risk for developing celiac disease,
as summarized in systematic reviews [77,80]. However, the reviews concluded that there may
be a protective effect because the two studies that controlled for confounding supported this
conclusion [77]. An earlier meta-analysis reached a similar conclusion [102]. Interpretation of
these and other studies is complicated by the potential relationship of breastfeeding to the
timing and quantity of gluten introduction, which may affect the expression of celiac disease.
(See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children",
section on 'Feeding practices in infancy and early childhood'.)

Neurodevelopmental outcomes — Moderate-quality evidence from a variety of populations

suggests that human milk feeding may be associated with slightly improved neurodevelopmental
outcomes compared with formula feeding. However, as for the chronic disease outcomes
discussed above, the evidence is limited by lack of randomized trials, and the findings may be
affected by residual confounding or reverse causation. (See 'Limitations of this evidence' above.)

Although a mechanism has not been established, proposed mediators are the long-chain
polyunsaturated fatty acids and, particularly, docosahexaenoic acid (DHA) and arachidonic acid in
human milk, which may promote myelinization of and development of the nervous system.
However, trials of DHA supplementation for preterm infants or formula-fed infants are inconsistent
for cognitive or visual outcomes, as outlined in a separate topic review. (See "Long-chain
polyunsaturated fatty acids (LCPUFA) for preterm and term infants".)

● Cognitive development – A meta-analysis shows that breastfeeding may be associated with

slightly improved performance in intelligence tests, and this association persists after
adjustment for maternal intelligence quotient (IQ) [103]. Children who were ever breastfed
scored an average of 3.4 points higher on intelligence tests than those who were never
breastfed. Among the studies that adjusted for maternal intelligence, a breastfeeding benefit

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of 2.6 points was revealed (95% CI 1.25-3.98). As with many other studies of long-term
breastfeeding outcomes, these conclusions are limited by the possibility of residual
confounding. Indeed, sibling-pair studies (which tend to have less residual confounding) show
a smaller effect of breastfeeding (<1 point) [70]. Similarly, a Cochrane meta-analysis found no
significant effect of donor breast milk versus formula feeding on neurodevelopmental
outcomes in preterm infants [104]. (See 'Limitations of this evidence' above.)

Other studies suggest that these effects are also seen in adulthood. A prospective, population-
based birth cohort study from Brazil reported that by age 30 years, participants who were
breastfed for 12 months or more had higher IQ scores of 3.8 points, more years of education,
and higher monthly incomes compared with those who were breastfed for less than one
month in the adjusted analysis [105]. The analysis suggested that IQ was responsible for 72
percent of the effect on income. This long-term cohort study is also limited by potential
residual confounding, similar to the shorter-term studies described above.

● Visual function – Several studies have indicated that human milk-fed term and premature
infants have improved visual function compared with formula-fed infants [106]. The severity
and incidence of retinopathy of prematurity is lower among breastfed compared with formula-
fed infants [107-110]. In a randomized trial, severe retinopathy of prematurity was less
common in infants fed mother's milk (5 percent) compared with donor human milk (19 percent)
or preterm formula (14 percent), suggesting that the effect may not be related to human milk
per se [109].

These benefits have been attributed to DHA, a component of phospholipids found in brain,
retina, and red cell membranes and found in human milk but not in bovine milk [111,112].
These associations also may relate to the substantial antioxidant capacity of human milk
compared with infant formula [113]. However, trials of DHA supplementation for preterm
infants or formula-fed infants are inconsistent for visual or cognitive outcomes, as outlined in
separate topic reviews. (See "Nutritional composition of human milk and preterm formula for
the premature infant", section on 'Long-chain polyunsaturated fatty acids' and "Long-chain
polyunsaturated fatty acids (LCPUFA) for preterm and term infants".)

● Auditory function – Auditory-evoked responses mature faster in breastfed premature infants

[114].

● Attention deficit hyperactivity disorder (ADHD) – A meta-analysis revealed that children

with ADHD had significantly less breastfeeding duration than controls and were less likely to
have been breastfed for 6 to 12 months (OR 0.69, 95% CI 0.49-0.98) or >12 months (OR
0.58, 95% CI 0.35-0.97) [115]. Affected children were more likely to not have been breastfed

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(OR 3.71, 95% CI 1.94-7.11).

● Autism spectrum disorder (ASD) – The association between breastfeeding and ASD is
unclear, and analyses are limited by the possibility of reverse causation. In a sibling case-
control study, exclusive breastfeeding was associated with lower odds for ASD, while early
introduction of supplemental formula was associated with higher odds of ASD [116]. Similarly,
a meta-analysis showed that children with ASD were less likely to have been breastfed (OR
0.61, 95% CI 0.45-0.83) [117]. In a multisite, case-control study, breastfeeding initiation rates
were no different comparing children diagnosed with ASD versus not, after adjusting for
sociodemographic and pregnancy characteristics [118]. Among those who were breastfed,
children with ASD had a shorter duration of breastfeeding, which remained significant after
adjusting for confounding variables. While this could result in fewer nutrients available to
support neurodevelopment, the authors postulated that children who later developed ASD
may be more difficult to breastfeed or may have early disturbances in emotion, motor
development, or sucking activity, leading to shorter breastfeeding duration, reflecting reverse
causation. Analysis of data from the National Survey of Children's Health in 2007 and 2011
showed no association between ASD and breastfeeding (adjusted OR 0.97, 95% CI
0.97-1.10) for each additional month of breastfeeding and for each additional month of
exclusive breastfeeding (adjusted OR 1.04, 95% CI 0.96-1.13) [119]. These data, collected by
phone survey, may be impacted by low response rates and recall bias.

● Child behavior – Data from the English Millennium Cohort study suggests that breastfeeding
for four months or longer was associated with a lower risk of behavior problems in children at
five years of age compared with a shorter duration of breastfeeding [120].

Abuse and neglect — Data from the National Longitudinal Study of Adolescent to Adult Health
found adolescents breastfed for nine months or longer had a reduced odds of having experienced
neglect (OR 0.54 [0.35-0.83]) and sexual abuse (OR 0.47 [0.24-0.93]) compared with adolescents
never breastfed, after controlling for covariates [121].

SUMMARY

● Breastfeeding for virtually all infants is strongly supported by both governmental and medical
professional organizations because of its acknowledged direct benefits to the infant's nutrition,
gastrointestinal function, host defense, and psychological well-being. The unique composition
of human milk, which contains antiinfective and antiinflammatory factors, along with the skin-
to-skin contact from direct breastfeeding, promotes optimal health, protects from

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environmental exposures, and promotes development of the child's innate immune system.
(See 'Biologically active components of human milk' above.)

● The best established health benefits of human milk feeding are prevention of illnesses during
the period that the infant is breastfed. These benefits are most impactful in low- and middle-
resource countries, in which lack of breastfeeding is associated with higher mortality. (See
'Prevention of illnesses while breastfeeding' above and 'Mortality and hospitalization' above.)

● Human milk, compared with infant formula, also appears to provide continued protection
against acute illnesses, such as otitis media and pneumonia, even after discontinuation of
breastfeeding, during the first few years of life. (See 'Acute illnesses' above.)

● Breastfeeding has been associated with long-term benefits by reducing risk for several chronic
diseases. The evidence for these long-term effects is based primarily on observational cohort
studies, which are necessarily limited by the possibility of residual confounding. (See
'Limitations of this evidence' above.)

• Moderate-quality evidence exists for prevention of type 1 diabetes mellitus, inflammatory

bowel disease (IBD), and wheezing in young children. (See 'Moderate evidence of benefit'
above.)

• Effects of breastfeeding may exist but are not as well established for leukemia, atopic
asthma, eczema, food allergies, obesity, and neurodevelopmental outcomes. (See
'Limited evidence for benefit' above and 'Neurodevelopmental outcomes' above.)

ACKNOWLEDGMENT

The editorial staff at UpToDate would like to acknowledge Richard J Schanler, MD, who
contributed to an earlier version of this topic review.

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