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breastfeeding for 6 months versus 3-4 months with
mixed breastfeeding thereafter, resulted in the recommendation
to promote exclusive breastfeeding for the
first 6 months of life [9]. More recently, the authors of
the Lancet nutrition series published a random effects
meta-analysis estimating the increased risk of diarrheaspecific
morbidity and mortality among children
younger than 2 years in relation to suboptimal breastfeeding
practices [7]. While these estimates provide confirmation
of the protective effect of breastfeeding, they
were based on a limited data set, rather than a complete
systematic review, and thus a more thorough and
updated revision is warranted.
Building upon previous reviews, this systematic review
and meta-analyses use carefully developed and standardized
methods to focus on the effects of breastfeeding
practices as they relate to diarrhea incidence, prevalence,
mortality and hospitalization among children 0-23
months of age. Here we present a comprehensive systematic
review and meta-analysis as evidence to be utilized
by the Lives Saved Tool (LiST) to model the effect
of breastfeeding practices on diarrhea-specific morbidity
and mortality [10,11]. The results of our analysis will
serve as the basis for generating projections of child
lives that could be saved by increasing exclusive breastfeeding
until 6 months of age and continued breastfeeding
until 23 months of age.
We systematically reviewed all literature published from
1980 to 2009 to identify studies with data assessing
levels of suboptimal breastfeeding as a risk factor for
diarrhea morbidity and mortality outcomes. We conducted
our initial search on July 28, 2009 and two
updated searches on April 8 and May 5, 2010. All
searches were completed in Pubmed, EMBASE, the Global
Health Library Global Index and Regional Index,
and the Cochrane central register for controlled trials
using combinations of key search terms: breastfeeding,
breast milk, human milk, diarrhea, gastroenteritis, morbidity,
mortality, infant and child. To ensure the identification
of all relevant literature, we also reviewed the
references of included papers.
After initially screening for eligibility based on title and
abstract, we thoroughly reviewed full publications for
inclusion and exclusion criteria outlined a priori. We
included randomized controlled trials (RCT), cohort and
observational studies that assessed suboptimal breastfeeding
as a risk factor for at least one of the following
outcomes: diarrhea incidence, diarrhea prevalence, diarrhea
mortality, all-cause mortality, and diarrhea hospitalizations.
Included studies were published in any language
from 1980 – 2009 and were conducted in developing
countries with a target population of children 0-23
months of age. We excluded studies reporting diarrhea
as a result of only one microbial cause, and those with
unclear methodology or data in a form that could not be
extracted for meta-analysis. We also excluded studies
reporting exclusive breastfeeding for children beyond 6
months of age and those failing to restrict the allocation
of diarrhea outcomes to concurrent breastfeeding status.
Additionally, we excluded morbidity studies with diarrhea
recall beyond two weeks and mortality studies
where the removal of deaths occurring within the first
three to seven days of life was not possible. For studies
reporting outcomes stratified by HIV status, we only
abstracted data on HIV-negative infants and children.
We abstracted data for each diarrhea outcome by
breastfeeding exposure levels, which were classified
according to current WHO definitions (Table 1) [12,13].
To allow for the comparability of breastfeeding labels
and definitions derived from studies published over multiple
decades, during which time breastfeeding definitions
and terms evolved, we assigned the exposure
categories described by each study to a WHO category
on the basis of the study’s definition of that exposure
category, not the authors’ category label. The majority
of discrepancies between breastfeeding label and definition
arose over the term ‘exclusive breastfeeding’. By
current standards, ‘exclusive breastfeeding’ does not
include the ingestion of anything other than breastmilk
and prescribed vitamins and medications, and infants
receiving non-nutritive liquids, such as waters and teas,
are classified as ‘predominantly breastfed’ [12]. This distinction
was not formally recommended until 1988
when a meeting of the Interagency Group for Action on
Breastfeeding first proposed the development of a set of
standardized breastfeeding definitions [14]. WHO officially
integrated indicators differentiating between exclusive
and predominant breastfeeding in 1991 [12]. As
such, for this review we assumed the ‘exclusive breastfeeding’
category was more appropriately labelled ‘predominant
breastfeeding’ for studies published prior to
1991, unless the study specifically defined exclusive
breastfeeding according to the current definition.
For studies that grouped exclusively and predominantly
breastfed infants into a ‘fully breastfeeding’ category,
we employed a conservative approach in which
fully breastfeeding exposure was treated as predominant.
We excluded studies that combined exposures other
than exclusive and predominant breastfeeding into one
breastfeeding category.
In this review we did not seek to address the issue of
early initiation of breastfeeding and prelacteal feeds.
Thus, in assigning breastfeeding exposure, we did not
differentiate between exclusive and predominant breastfeeding
on the basis of receipt of prelacteal feeds during
the first 3 days of life.
Lamberti et al. BMC Public Health 2011, 11(Suppl 3):S15
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