1. The Importance of Breastfeeding: An Evidence Update David Meyers, MD Breastfeeding Summit Washington, DC June 11, 2009

2. Disclaimer Clinician Clinician

3. Disclaimer Researcher Researcher

4. Disclaimer Clinician Clinician Researcher Researcher Policy advocate Policy advocate

5. Disclaimer Clinician Clinician Researcher Researcher Policy advocate Policy advocate Federal staff Federal staff

6. Disclaimer Clinician Clinician Researcher Researcher Policy advocate Policy advocate Federal staff Federal staff – Agency for Healthcare Research and Quality Convene and translate among clinicians, researchers, and policy makers Convene and translate among clinicians, researchers, and policy makers

7. Goal To highlight findings from the medical literature on the importance of breastfeeding for the health of women and children To highlight findings from the medical literature on the importance of breastfeeding for the health of women and children

8. Goal – Primary audience: Policy Makers Not focusing on the clinical aspects of breastfeeding Not focusing on the clinical aspects of breastfeeding Not focusing on research methods Not focusing on research methods

9. Framing Breastfeeding is a complex, living, adaptable system Breastfeeding is a complex, living, adaptable system – Multidimensional

10. Framing Breastfeeding is a complex, living, adaptable system Breastfeeding is a complex, living, adaptable system – Multidimensional – Relational Between a mother, child, and their environment Between a mother, child, and their environment

11. Framing Breastfeeding is a complex, living, adaptable system Breastfeeding is a complex, living, adaptable system – Multidimensional – Relational – Developing

12. Framing Breastfeeding is a complex, living, adaptable system Breastfeeding is a complex, living, adaptable system – Multidimensional – Relational – Developing Breastfeeding optimizes a child’s chances of reaching its potential Breastfeeding optimizes a child’s chances of reaching its potential – But is not a magic guarantee

13. Framing - continued Population view versus Individual view Population view versus Individual view

14. Framing - continued Population view versus Individual view Population view versus Individual view – Number Needed to Treat Good pain control after a sprain with NSAID = 2 Good pain control after a sprain with NSAID = 2 Ear Infection with antibiotics = 7 Ear Infection with antibiotics = 7 Statin to prevent one heart attack = 69 Statin to prevent one heart attack = 69 – Number Needed to Screen High blood pressure to prevent on MI = 275 High blood pressure to prevent on MI = 275 High cholesterol to prevent one MI = 400 High cholesterol to prevent one MI = 400 Colon cancer to prevent one death = 1300 Colon cancer to prevent one death = 1300 Breast cancer = 2400 Breast cancer = 2400

15. Evidence

16. The breastfeeding literature >600 articles in the past year >600 articles in the past year >1500 articles in the past two years >1500 articles in the past two years >3000 articles in the past five years >3000 articles in the past five years

17. Evidence of Importance Focus on Health Outcomes Focus on Health Outcomes – Children – Women

18. Evidence of Importance Focus on Health Outcomes Focus on Health Outcomes – Children – Women Not covering: Not covering: – Economic benefits for families, health care system, or society – Social outcomes Attachment/bonding, child emotional/social development, child abuse Attachment/bonding, child emotional/social development, child abuse

19. Systematic Evidence Review Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries – Prepared by the Tufts-New England Medical Center Evidence-Based Practice Center – Published April 2007

20. Commercial Break AHRQ Evidence-Based Practice Center Program AHRQ Evidence-Based Practice Center Program – AHRQ awards 5-year contracts to institutions in the United States and Canada to review all relevant scientific literature on clinical, behavioral, and organization and financing topics to produce evidence reports and technology assessments. – These reports are used for informing and developing coverage decisions, quality measures, educational materials and tools, guidelines, and research agendas. – The EPCs also conduct research on methodology of systematic reviews.

21. EPC Evidence Reviews EPC reports are based on rigorous, comprehensive syntheses and analyses of the scientific literature on topics relevant to clinical, social science/behavioral, economic, and other health care organization and delivery issues. EPC reports are based on rigorous, comprehensive syntheses and analyses of the scientific literature on topics relevant to clinical, social science/behavioral, economic, and other health care organization and delivery issues. EPC reports emphasize explicit and detailed documentation of methods, rationale, and assumptions. These scientific syntheses may include meta-analyses and cost analyses. EPC reports emphasize explicit and detailed documentation of methods, rationale, and assumptions. These scientific syntheses may include meta-analyses and cost analyses. EPCs collaborate with external medical and research organizations so that a broad range of experts is included in the development process. EPCs collaborate with external medical and research organizations so that a broad range of experts is included in the development process. The resulting evidence reports and technology assessments are used by Federal and State agencies, private sector professional societies, health delivery systems, providers, payers, and others committed to evidence-based health care. The resulting evidence reports and technology assessments are used by Federal and State agencies, private sector professional societies, health delivery systems, providers, payers, and others committed to evidence-based health care.

22. To learn more, visit: http://www.ahrq.gov/clinic/epc/ http://www.ahrq.gov/clinic/epc/

23. Methods Searches through November 2005 / May 2006 Searches through November 2005 / May 2006 English language only English language only Multiple study types Multiple study types – All with comparison group All studies graded for methodological quality All studies graded for methodological quality Over 9000 articles screened Over 9000 articles screened Final report included Final report included – 29 systematic reviews/meta-analyses Covering approximately 400 studies Covering approximately 400 studies – 43 studies on infant health outcomes – 43 studies on maternal health outcomes

24. Results: Short-term Infant Health Outcomes A history of breastfeeding found to be associated with a reduction in the risk of common illnesses: A history of breastfeeding found to be associated with a reduction in the risk of common illnesses: – Acute otitis media – Non-specific gastroenteritis

25. Results: Short-term Infant Health Outcomes A history of breastfeeding found to be associated with a reduction in the risk of common illnesses: A history of breastfeeding found to be associated with a reduction in the risk of common illnesses: – Acute otitis mediaEar infections – Non-specific gastroenteritis Vomiting and diarrhea

26. Rough Translation Ear InfectionNNT ~ 6 Ear InfectionNNT ~ 6 – 2 million infants younger than 6 months each year – If 80% of infants breastfed, >300,000 fewer would have an ear infection before 6 months Vomiting and diarrhea Vomiting and diarrhea – Almost all formula fed infants experience in the first year – Fewer than half of exclusively breastfed infants experience in the first year

27. Results: Short-term Infant Health Outcomes A history of breastfeeding found to be associated with a reduction in the risk of serious illnesses: A history of breastfeeding found to be associated with a reduction in the risk of serious illnesses: – Severe lower respiratory infections – Sudden Infant Death Syndrome (SIDS)

28. Results: Long-term Child Health Outcomes A history of breastfeeding found to be associated with a reduction in the risk of common conditions: A history of breastfeeding found to be associated with a reduction in the risk of common conditions: – Eczema – Obesity

29. Results: Long-term Child Health Outcomes A history of breastfeeding found to be associated with a reduction in the risk of serious conditions: A history of breastfeeding found to be associated with a reduction in the risk of serious conditions: – Type 2 diabetes – ALL and AML (childhood leukemia)

30. Results: Premature Infants Limited review of two potential outcomes: Limited review of two potential outcomes: – Confirmed association between human milk feeding and reduced risk of necrotizing enterocolitis (NEC) 5% absolute risk reduction 5% absolute risk reduction – Unable to confirm an association between breastfeeding and long term cognitive development

31. Other Results Suggested association between breastfeeding and both asthma and type 1 diabetes Suggested association between breastfeeding and both asthma and type 1 diabetes More evidence needed to understand potential association between breastfeeding and cardiovascular disease More evidence needed to understand potential association between breastfeeding and cardiovascular disease Breastfeeding not found to be associated with improved cognitive development when potential cofounders controlled for Breastfeeding not found to be associated with improved cognitive development when potential cofounders controlled for

32. Results: Maternal Health Outcomes A history of breastfeeding found to be associated with a reduction in the risk of: A history of breastfeeding found to be associated with a reduction in the risk of: – Breast cancer With caution, breastfeeding found to be associated with a reduction in the risk of: With caution, breastfeeding found to be associated with a reduction in the risk of: – Ovarian cancer – Type 2 diabetes in women without gestational diabetes

33. Hot off the presses Note: I am no longer being systematic Note: I am no longer being systematic

34. Hot off the presses Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-82. Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-82.

35. Hot off the presses Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-82. Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-82. – Data from 139,681 postmenopausal women enrolled in the Women's Health Initiative – Multivariable modeling – Controlled for confounder (age, parity, race, education, income, age at menopause), lifestyle, and family history variables – Examined the effect of duration of lactation on prevalence and incidence of CVD and risk factors for cardiovascular disease

36. Hot off the presses Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-82. Schartz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009 May;113(5):974-82. – Women who never breastfed were significantly more likely than women who breastfed >12 months to have: High blood pressure 42.1% vs 38.6% High blood pressure 42.1% vs 38.6% High cholesterol14.8% vs 12.3% High cholesterol14.8% vs 12.3% Diabetes 5.3% vs 4.3% Diabetes 5.3% vs 4.3% CVD 9.9% vs 9.1% CVD 9.9% vs 9.1%

37. Back to the 2007 Evidence Review

38. Presenter’s Opinion EPC team was: EPC team was: – conservative with their methods, – conservative in the body of the report – and liberal with their conclusions in the executive summary

39. Closer look: Pneumonia One meta-analysis (Bachrach 2003) One meta-analysis (Bachrach 2003) – 7 cohort studies – Meta-analysis quality rating: Grade A Results: ‘exclusive’ breastfeeding for four or more months associated with a 72% reduction in hospitalizations for lower respiratory tract disease when compared to formula feeding Results: ‘exclusive’ breastfeeding for four or more months associated with a 72% reduction in hospitalizations for lower respiratory tract disease when compared to formula feeding – NNT = 26

40. Closer Look: Obesity 3 meta-analyses 3 meta-analyses – One quality Grade A (Arnez 2004) – Two quality Grade Bs (Harder 2005, Owen 2005) Consistent conclusion that breastfeeding associated with reduced risk of obesity in later life Consistent conclusion that breastfeeding associated with reduced risk of obesity in later life – Magnitude of effect reduced when cofounders adjusted for – No evidence available to allow conclusions about exclusive breastfeeding – Limited evidence that increased duration of breastfeeding associated with increased reduction in risk

41. Closer look: SIDS One poor quality meta-analysis One poor quality meta-analysis 4 additional studies identified 4 additional studies identified EPC conducted new meta-analysis EPC conducted new meta-analysis – Limited to studies with autopsy confirmed SIDS, clear reporting of breastfeeding data, and cofounder controlling: 6 studies – Results: ever breastfeeding associated with a statistically significant reduction in risk of SIDS Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81) Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81)

42. Closer look: SIDS One poor quality meta-analysis One poor quality meta-analysis 4 additional studies identified 4 additional studies identified EPC conducted new meta-analysis EPC conducted new meta-analysis – Limited to studies with autopsy confirmed SIDS, clear reporting of breastfeeding data, and cofounder controlling: 6 studies – Results: ever breastfeeding associated with a statistically significant reduction in risk of SIDS Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81) Adjusted odds ratio: 0.64, 95% CI (0.51, 0.81) u Approximately 1 in 2000 children die from SIDS u Rough translation: One death from SIDS is prevented for every 5500 children breastfed

43. Other Issues

44. Breastfeeding and Human Milk Feeding Challenging to separate out the importance of human milk from its delivery system Challenging to separate out the importance of human milk from its delivery system – Human milk is important – Greater value from breastfeeding

45. Importance of Exclusive Breastfeeding Research evidence limited by variable data collection Research evidence limited by variable data collection In some areas, association only found for exclusive breastfeeding In some areas, association only found for exclusive breastfeeding – In general, mixed feeding associated with better outcomes than formula feeding

46. Duration In many areas, increased duration of breastfeeding associated with increasing importance (Dose-effect relationship) In many areas, increased duration of breastfeeding associated with increasing importance (Dose-effect relationship) – No upper limit shown

47. Policy Implications The value of breastfeeding is no longer debatable The value of breastfeeding is no longer debatable The policy relevant question is how to support women and families The policy relevant question is how to support women and families – What can the health care system do? – What can employers do? – What can society do? – What can government do?

48. Health Care System 2008 US Preventive Services Task Force Recommendation 2008 US Preventive Services Task Force Recommendation – http://www.ahrq.gov/clinic/uspstf/uspsbrfd.htm http://www.ahrq.gov/clinic/uspstf/uspsbrfd.htm – Focused on role of health care system – Based on a systematic evidence review – Concluded interventions within the health care system in the prenatal, birth, and post-partum periods are effective in increasing the initiation and duration of breastfeeding Evidence for specific interventions limited Evidence for specific interventions limited u Issues of context u Multi-dimensional interventions likely important

49. Discussion

50. Thanks David.Meyers@AHRQ.hhs.gov