REVIEW ARTICLES

Breastfeeding and Reduced Risk of Sudden Infant

Death Syndrome: A Meta-analysis
AUTHORS: Fern R. Hauck, MD, MS,a John M. D. Thompson,
PhD,b Kawai O. Tanabe, MPH,a Rachel Y. Moon, MD,c and
Mechtild M. Vennemann, MD, PhDd
a

Department of Family Medicine, University of Virginia,

Charlottesville, Virginia; bDepartment of Paediatrics; Child and
Youth Health, University of Auckland, Auckland, New Zealand;
cDivision of General Pediatrics and Community Health, Childrens
National Medical Center and George Washington University
School of Medicine and Health Sciences, Washington, DC; and
dInstitute of Legal Medicine, University of Muenster, Muenster,
Germany
KEY WORDS
SIDS, sudden infant death syndrome, risk factors, breastfeeding
ABBREVIATIONS
SIDSsudden infant death syndrome
ORodds ratio
SORsummary odds ratio
CIcondence interval
The authors had full access to all of the data in the study and
take responsibility for the integrity of the data and the accuracy
of the data analysis. The results, conclusions, and
recommendations presented in this article are endorsed by the
Epidemiology Working Group of the International Society of the
Prevention of Infant Deaths.
www.pediatrics.org/cgi/doi/10.1542/peds.2010-3000
doi:10.1542/peds.2010-3000
Accepted for publication Mar 14, 2011
Address correspondence to Fern R. Hauck, MD, MS, Department
of Family Medicine, University of Virginia School of Medicine, PO
Box 800729, Charlottesville, VA 22908. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2011 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.

PEDIATRICS Volume 128, Number 1, July 2011

abstract
CONTEXT: Benets of breastfeeding include lower risk of postneonatal
mortality. However, it is unclear whether breastfeeding specically
lowers sudden infant death syndrome (SIDS) risk, because study results have been conicting.
OBJECTIVE: To perform a meta-analysis to measure the association
between breastfeeding and SIDS.
METHODS: We identied 288 studies with data on breastfeeding and
SIDS through a Medline search (1966 2009), review articles, and metaanalyses. Twenty-four original case-control studies were identied that
provided data on the relationship between breastfeeding and SIDS risk.
Two teams of 2 reviewers evaluated study quality according to preset
criteria; 6 studies were excluded, which resulted in 18 studies for
analysis. Univariable and multivariable odds ratios were extracted. A
summary odds ratio (SOR) was calculated for the odds ratios by using
the xed-effect and random-effect inverse-variance methods of metaanalysis. The Breslow-Day test for heterogeneity was performed.
RESULTS: For infants who received any amount of breast milk for any
duration, the univariable SOR was 0.40 (95% condence interval [CI]:
0.35 0.44), and the multivariable SOR was 0.55 (95% CI: 0.44 0.69). For
any breastfeeding at 2 months of age or older, the univariable SOR was
0.38 (95% CI: 0.27 0.54). The univariable SOR for exclusive breastfeeding of any duration was 0.27 (95% CI: 0.24 0.31).
CONCLUSIONS: Breastfeeding is protective against SIDS, and this effect is stronger when breastfeeding is exclusive. The recommendation
to breastfeed infants should be included with other SIDS risk-reduction
messages to both reduce the risk of SIDS and promote breastfeeding
for its many other infant and maternal health benets. Pediatrics 2011;
128:000

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There are many physical and emotional benets to breastfeeding,1 including a reduced risk of postneonatal
mortality.2 However, it is unclear
whether breastfeeding specically
lowers the risk of sudden infant death
syndrome (SIDS). Physiologic sleep
studies have shown that breastfed infants have lower arousal thresholds
than formula-fed infants,3,4 which may
provide a mechanism for protection
against SIDS. However, epidemiologic
studies have been inconsistent in
showing a protective effect of breastfeeding on the risk of SIDS; some study
results have supported a protective effect,511 and others have not.2,5,8,1219
The authors of a meta-analysis and
qualitative literature review published
in 2000 concluded that there was a statistically signicant increase in SIDS
risk for bottle-fed infants.20 These authors, however, dened SIDS loosely
(as any sudden and unexplained death
in an infant or young child) and included studies in which the denitions
of breastfeeding exposure differed,
and there were other methodologic
aws. A more recent meta-analysis
conducted by the Agency for Healthcare Research and Quality analyzed 6
studies and found a statistically significant decrease in SIDS in infants who
were ever breastfed compared with infants who were never breastfed (adjusted summary odds ratio [SOR]: 0.64
[95% condence interval (CI): 0.51
0.81]).21 We performed our metaanalysis to quantify and evaluate the
protective effect of breastfeeding
against SIDS, including the inuence of
exclusive breastfeeding and longer
breastfeeding duration, and to make a
recommendation on the potential utility of breastfeeding as a strategy for
reducing the risk of SIDS. Our hypotheses were that (1) breastfeeding is associated with a decreased risk of SIDS
and (2) exclusive breastfeeding and
breastfeeding for longer duration are
associated with the greatest reduction
2

HAUCK et al

265 abstracts identified in Ovid Medline

23 studies identified through review

articles and meta-analyses

288 abstracts reviewed

184 reports excludeda

104 articles pulled for full review

80 articles excluded for not meeting

first-level inclusion criteriab

24 articles included in second-level review

6 articles excluded for not meeting

second-level inclusion criteriac

18 articles included in meta-analysis

FIGURE 1
Study inclusion and exclusion ow diagram. a Exclusion criteria: duplication, no apparent relevance.
b First-level inclusion criteria: articles that reported an association between breastfeeding and SIDS.
c Second-level inclusion criteria: see criteria listed in Table 1; an additional study was excluded for not
providing ORs that could be used in calculating an SOR.

in risk. This report of our methods and

ndings follows the guidelines for reporting meta-analyses of observational studies proposed by Stroup et
al22 and the PRISMA Group.23

METHODS
Data Sources and Study Selection
We searched the Ovid Medline database (January 1966 through December
2009) to collect data on breastfeeding
and its association with SIDS. The
search strategy included published articles limited to humans with the Medical Subject Headings terms sudden
infant death and breast feeding with
key words sudden infant death syndrome, SIDS, cot death, and
breastfeeding. Combining searches
resulted in 265 abstracts (Fig 1). An
additional 23 studies were identied
through review articles and metaanalyses, for a total of 288 studies.
These studies were reviewed by teams
of 2 independent reviewers who evaluated each abstract for relevance on
the basis of title and abstract. One hun-

dred eighty-four reports were excluded on the basis of the abstracts

alone, and 104 articles were pulled for
further review. Two reviewers (Dr Hauck
and Ms Tanabe) reviewed all pulled articles for inclusion and for overlapping
data. Twenty-four original case-control
studies that provided data on the relationship between breastfeeding and
SIDS risk2,511,1419,2433 were identied.
Two teams of 2 reviewers independently evaluated 12 studies each according to preset criteria; in cases of
disagreement, a third reviewer evaluated the study, and a consensus opinion was reached.
Because the search was not limited to
articles written in English, 12 of the articles were in other languages (3 German, 3 Italian, 1 Japanese, 1 Spanish, 1
Polish, and 3 Norwegian). After reviewing the articles and abstracts, either in
the original language or the English
translation, none of these studies was
deemed relevant except 1 Norwegian
study, for which an article published in

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REVIEW ARTICLES

English with the same content replaced

the one published in Norwegian.
Data Extraction
The teams evaluated the eligible studies on the basis of the 6 criteria developed by the American Academy of Pediatrics Task Force on Positioning and
SIDS for its literature review on the relationship between sleeping position
and SIDS. These criteria are (1) an appropriate denition for SIDS, (2) autopsies performed in 98% of cases, (3)
an adequate description of SIDS ascertainment in the study population, (4)
matched control subjects, (5) an adequate description of the process of control selection, and (6) inclusion of sufcient data to calculate ORs and 95% CIs
or inclusion of the actual ORs and CIs. In
our review, 19 of 24 studies satised all 6
criteria; the failed criteria of 5 studies
are listed in Table 1.2,9,16,19,32 Another
study could not be included because
the ORs were presented in a way that
was not compatible with our analyses,33 which resulted in a total of 18
studies for the meta-analysis.
Statistical Analysis
Several different denitions for
breastfeeding were examined: (1)
breastfeeding of any amount (partial
or exclusive) or duration, including
breastfeeding at discharge from hospital (any breastfeeding); (2) breastfeeding of any amount at the age of 2
months or older (breastfeeding 2
months); and (3) exclusive breastfeeding (ie, no formula supplementation) for any duration (exclusive
breastfeeding).
The univariable and multivariable ORs
were extracted from each study for the
different associations between breastfeeding and SIDS. A separate SOR was
calculated for the univariable and multivariable ORs by using the xed-effect
and random-effect inverse-variance
methods of meta-analysis. The BreslowPEDIATRICS Volume 128, Number 1, July 2011

Day test for heterogeneity was performed. A P value of .05 was considered to indicate that heterogeneity
was present. Analyses were conducted
independently by 2 authors (Drs
Thompson and Vennemann), one by using RevMan 5.0 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark) and one by using
Comprehensive Meta Analysis 2.2.048
(Biostat, Englewood, NJ). Any discrepancies were investigated and resolved.

RESULTS
Eighteen case-control studies were included in the meta-analysis (Table 1),
and data for any breastfeeding were
provided for all of them.* The forest
plot for the univariable ORs with the
random-effect model is shown in Fig 2;
the SOR was 0.40 (95% CI: 0.35 0.44;
I 2 71%). Multivariable ORs were reported for only 7 of the 23 studies5,7,8,10,17,18,34; a univariable pooled
analysis of the results from these 7
studies resulted in an OR of 0.36 (95%
CI: 0.31 0.42), which is consistent with
the results when all 18 studies were
included. The multivariable pooled estimate revealed a movement of the OR
toward the null; however, it remained
statistically signicant at 0.55 (95% CI:
0.44 0.69) (Fig 3). There was no heterogeneity (I 2 40%).
Three studies provided information
about any breastfeeding at 2 months of
age or older.5,11,15 The summary univariable estimate for the 3 studies was
0.38 (95% CI: 0.27 0.54; I 2 78%). Because only 2 of the studies provided
multivariable ORs,5,11 meta-analysis to
obtain a summary multivariable estimate was not performed.
Eight studies provided information
on exclusive breastfeeding of any duration.57,14,15,26,29,34 The univariable SOR
was 0.27 (95% CI: 0.24 0.31; I 2 87%)
(Fig 4). None of these studies provid*Refs 58, 10, 11, 14, 15, 17, 18, 2430, and 34.

ed multivariable ORs for exclusive

breastfeeding.
As noted previously, 5 studies failed to
meet 1 or more quality criteria.2,9,16,19,32
A sensitivity analysis was conducted to
determine the SORs for any breastfeeding with these 5 studies included.
The resulting univariable SOR was 0.49
(95% CI: 0.45 0.53). The multivariable
SOR was 0.68 (95% CI: 0.58 0.80).
These results are slightly higher than
the SORs that excluded the respective
studies.

DISCUSSION AND
RECOMMENDATIONS
Our meta-analysis of 18 studies reveals that breastfeeding to any extent
and of any duration is protective
against SIDS. The protective effect is
stronger for exclusive breastfeeding.
The summary multivariable OR suggests that breastfeeding itself is protective and not merely a marker of
other potentially protective factors
such as the absence of smoke exposure or sociodemographic factors.
Therefore, we recommend that mothers breastfeed their infants as a potential way to reduce their risk of SIDS.
Ideally, breastfeeding should be exclusive (ie, formula should not be given)
for at least 4 to 6 months and should be
continued until the infant is at least 1
year of age. Exceptions to this recommendation include conditions under
which breastfeeding is contraindicated, such as for infants whose mothers use illegal drugs.35 This recommendation is consistent with the American
Academy of Pediatrics policy statement on breastfeeding and the use of
human milk, which endorses exclusive
breastfeeding to 6 months and continuation for at least the rst year of life.35
Some breastfeeding advocates have
expressed concern that promotion of
other factors shown in epidemiologic
studies to be protective against SIDS,
such as pacier use and room-sharing

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HAUCK et al

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Tasmania
United States
New Zealand
Denmark, Norway,
Sweden
Germany
United Kingdom

Ponsonby et al18 (1995)

Klonoff-Cohen and Edelstein31 (1995)
Mitchell et al5 (1997)
Wennergren et al10 (1997)

19561971
19911993
19931994

19661970
19751979

Denmark
New Zealand
Germany

United Kingdom
United Kingdom

United States
Norway
France

Denmark, Norway,
Sweden

Chen and Rogan2 (2004)

Stray-Pedersen et al19 (2005)
Jonville-Bra et al9 (2001)

Alm et al33 (2002)

239

591
23
111

154
308

97
64
58

260
333

58
195

58
200
120
244

121
167
356
98

79
125
123
80
94
99

Total
Cases, N

841

7740
72
341

409
236

503
778
156

260
998

156
780

120
200
918
863

153
334
1529
196

79
375
520
157
135
47 223

Total
Controls, N

109 (46)

187 (32)
16 (73)
37 (33)

63 (37)
164 (53)

22 (23)
46 (72)
7 (12)

55 (21)
165 (50)

29 (50)
88 (45)

22 (38)
114 (57)
98 (82)
184 (75)

53 (44)
115 (69)
275 (77)
56 (57)

15 (19)
16 (13)
98 (75)
21 (26)
22 (23)
16 (16)

Breastfeeding
Cases, n (%)

626 (74)

3073 (40)
65 (90)
160 (47)

157 (31)
161 (68)

278 (55)
600 (77)
50 (32)

130 (50)
827 (83)

129 (83)
470 (60)

63 (53)
151 (76)
809 (88)
729 (84)

101 (66)
252 (75)
1371 (90)
144 (73)

25 (32)
60 (16)
480 (92)
75 (48)
71 (53)
14 223 (30)

Breastfeeding
Controls, n (%)

1, 4
3, 4, 6, 13, 17
16, 7, 9, 11, 12, 19
4, 6, 9

Covariatesa

0.29 (0.210.39) 46, 8

0.70 (0.590.84) 1, 3, 4, 5, 9, 12, 19

0.29 (0.090.97) 4, 7
0.57 (0.350.92) 3, 4, 6, 9, 14, 17, 19

1.11 (0.751.65)
0.53 (0.370.76)

0.24 (0.140.41)
0.76 (0.411.39) 16, 7, 9, 11, 12, 19
0.29 (0.110.74) 4, 6, 15, 16, 19

0.21 (0.100.44) 4, 6, 15, 16, 19

0.50 (0.350.71) 17, 9, 10, 14, 16,
18, 19
0.20 (0.120.35) 1, 5, 11, 13
0.19 (0.140.25) 17, 15, 16, 18

0.50 (0.260.98)
0.43 (0.270.68)
0.60 (0.351.03)
0.59 (0.410.85)

0.40 (0.240.67)
0.72 (0.471.11)
0.39 (0.290.53)
0.48 (0.270.84)

0.51 (0.231.13)
0.77 (0.411.44)
0.33 (0.180.59)
0.39 (0.210.73)
0.28 (0.150.52)
0.54 (0.291.01)

Crude OR
(95% CI)

No interview
2 interviews; immediately
and 3 wk later
NA
1 mo after death
2 interviews; day of death
and 3 mo after death
NA

No interview
NA
Within 2 wk of death

Within 2 wk
2 interviews; within 5 d
and 2 wk of death
2 wk after death
1 mo after death

No interview
Up to 5 wk after death
Within 1 mo of death
2 interviews; immediately
and at 23 mo
6 wk after death
NA
NA
NA

2 wk after death
No interview
No interview
NAc
No interview
NA

Time to Interviewb

Nonec

14
4, 5
2

13
13

None
None
None

None
None

None
None

None
None
None
None

None
None
None
None

None
None
None
None
None
None

Failed
Criteria

Studies were scored on the following criteria: (1) an appropriate denition for SIDS; (2) autopsies performed in 98% of cases; (3) an adequate description of SIDS ascertainment in the study population; (4) matched control subjects; (5) an adequate
description of the process of control selection; and (6) inclusion of sufcient data to calculate ORs and 95% CIs or the actual ORs and CIs were provided. NA indicates not available, not provided.
a Covariates: 1, maternal age; 2, parity; 3, birth weight; 4, infant exposure to tobacco smoke (before or after delivery); 5, factors related to socioeconomic status; 6, infant sleep position; 7, bed-sharing; 8, infant age; 9, infant gender; 10, gestation; 11,
marital status; 12, race/ethnicity; 13, factors related to prenatal care; 14, factors relating to surface on which infant was placed; 15, pillow/cushion use; 16, factors related to overheating; 17, postneonatal infant health problems; 18, pacier use; 19, other.
b Time to interview was dened as time from infants death or identication of controls to interview with parents.
c ORs in the article were provided for intervals of breastfeeding duration; thus, we could not identify an OR to use in calculating the SOR for this meta-analysis.

19921995

1988
19892003
19951997

19931996
19982001

United States
Germany

19931994
19931995

Unknown
19521966
19561971
19601961
19601972
19651973,
19751977
19701976
19801986
19871990
19871989,
19901991
19881991
19891992
19911993
19921995

Years of
Study

Hauck et al8 (2003)

Vennemann et al7 (2009)
Breastfeeding 2 mo
Biering-Srensen et al15 (1978)
Mitchell et al5 (1997)
Schellscheidt et al11 (1997)
Studies excluded for not meeting
eligibility criteria
Fedrick31 (1974)
Watson et al16 (1981)

Schellscheidt et al11 (1997)

Fleming et al17 (1996)

Tasmania
Tasmania
New Zealand
United Kingdom

Scotland
United States
Denmark
Canada
United Kingdom
United Kingdom

Country

Grice and McGlashan29 (1981)

McGlashan30 (1989)
Ford et al6 (1993)
Gilbert et al14 (1995)

Any breastfeeding
Bartholomew and MacArthur24 (1988)
Naeye et al25 (1976)
Biering-Srensen et al15 (1978)
Steele and Langworth26 (1966)
Protestos et al27 (1973)
Murphy et al28 (1982)

Study (Year)

TABLE 1 Studies Included in the Meta-analysis

REVIEW ARTICLES

Study or Subgroup

log[]
24

Bartholomew and MacArthur (1988)

Biering-Srensen et al15 (1978)
Fleming et al17 (1996)
Ford et al6 (1993)
Gilbert et al14 (1995)
Grice and McGlashan29 (1981)
Hauck et al8 (2003)
Klonoff-Cohen and Edelstein31 (1995)
McGlashan30 (1989)
Mitchell et al5 (1997)
Murphy et al28 (1982)
Naeye et al25 (1976)
Ponsonby et al18 (1995)
Protestos et al27 (1973)
Schellscheidt et al11 (1997)
Steele and Langworth26 (1966)
Vennemann et al7 (2009)
Wennergren et al10 (1997)

SE Weight

-0.67334
-1.10866
-0.69315
-0.94161
-0.73397
-0.91629
-1.60944
-0.84397
-0.3285
-0.51083
-0.61619
-0.26136
-0.69315
-1.27297
-1.56065
-0.94161
-1.66073
-0.530268

0.403828
0.298488
0.180442
0.153826
0.286481
0.261898
0.280258
0.231851
0.21923
0.275352
0.319582
0.32047
0.341077
0.312188
0.372096
0.317841
0.147913
0.18724

Total (95% CI)

IV, Fixed, 95% CI

2.0%
3.6%
9.8%
13.5%
3.9%
4.7%
4.1%
6.0%
6.7%
4.2%
3.1%
3.1%
2.8%
3.3%
2.3%
3.2%
14.6%
9.1%

0.51 [0.231.13]
0.33 [0.180.59]
0.50 [0.350.71]
0.39 [0.290.53]
0.48 [0.270.84]
0.40 [0.240.67]
0.20 [0.120.35]
0.43 [0.270.68]
0.72 [0.471.11]
0.60 [0.351.03]
0.54 [0.291.01]
0.77 [0.411.44]
0.50 [0.260.98]
0.28 [0.150.52]
0.21 [0.100.44]
0.39 [0.210.73]
0.19 [0.140.25]
0.59 [0.410.85]

100.0%

0.40 [0.350.44]

IV, Fixed, 95% CI

Heterogeneity: = 57.66, df = 17 (P < .00001); I = 71%

Test for overall effect: z = 16.35 (P < .00001)

0.01
0.1
1
10
100
Favors breastfeeding Favors not breastfeeding

FIGURE 2
Univariable analysis of any breastfeeding versus no breastfeeding.

SE Weight

log[]

Study or Subgroup
17

0.058269 0.317657
Fleming et al (1996)
-0.91629 0.319582
Hauck et al8 (2003)
Klonoff-Cohen and Edelstein31 (1995) -0.89159812 0.3346305
-0.07257 0.420337
Mitchell et al5 (1997)
-0.15082 0.401245
Ponsonby et al18 (1995)
-0.84397 0.239354
Vennemann et al7 (2009)
0.21979
-0.693147
Wennergren et al10 (1997)
Total (95% CI)

IV, Fixed, 95% CI

12.6%
12.4%
11.4%
7.2%
7.9%
22.2%
26.3%

1.06 [0.571.98]
0.40 [0.210.75]
0.41 [0.210.79]
0.93 [0.412.12]
0.86 [0.391.89]
0.43 [0.270.69]
0.50 [0.330.77]

100.0%

0.55 [0.440.69]

Heterogeneity: = 10.08, df = 6 (P = .12); I = 40%

Test for overall effect: z = 5.28 (P < .00001)

IV, Fixed, 95% CI

0.01
0.1
1
10
100
Favors breastfeeding Favors not breastfeeding

FIGURE 3
Multivariable analysis of any breastfeeding versus no breastfeeding.

Study or Subgroup

log[]

Biering-Srensen et al15 (1978)

Ford et al6 (1993)
Gilbert et al14 (1995)
Grice and McGlashan29 (1981)
Klonoff-Cohen and Edelstein31 (1995)
Mitchell et al5 (1997)
Steele and Langworth26 (1966)
Vennemann et al7 (2009)

-0.91629
-1.89712
-0.74149
-0.91879
-0.77436
-0.43078
-0.94161
-1.60944

SE Weight
0.324736
0.130313
0.30895
0.24995
0.2042
0.2325
0.295269
0.149946

Total (95% CI)

Heterogeneity: = 54.32, df = 7 (P < .00001); I = 87%
Test for overall effect: z = 18.11 (P < .00001)

IV, Fixed, 95% CI

4.9%
30.5%
5.4%
8.3%
12.4%
9.6%
5.9%
23.0%

0.40 [0.210.76]
0.15 [0.120.19]
0.48 [0.260.87]
0.40 [0.240.65]
0.46 [0.310.69]
0.65 [0.411.03]
0.39 [0.220.70]
0.20 [0.150.27]

100.0%

0.27 [0.240.31]

IV, Fixed, 95% CI

0.01
0.1
1
10
100
Favors breastfeeding Favors not breastfeeding

FIGURE 4
Univariable analysis of exclusive breastfeeding of any duration.

PEDIATRICS Volume 128, Number 1, July 2011

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without bed-sharing, is inconsistent

with promotion of breastfeeding. Although some observational studies
have revealed an association between
pacier use and decreased breastfeeding duration,3638 this association
was not borne out by several randomized clinical trials3941 and 1 systematic
review.42 The American Academy of Pediatrics policy statements on breastfeeding and the use of human milk35
and SIDS43 both indicate that paciers
can be used by breastfed infants once
breastfeeding has been well established. Mother-infant bed-sharing (or
sleeping in the same bed) is often promoted as a way to increase breastfeeding rates4446; however, although
bed-sharing is associated with increased breastfeeding duration, it is
unclear whether the practice of bedsharing increases the practice of
breastfeeding or if parents who
choose to breastfeed subsequently decide to bed-share.47 Room-sharing
without bed-sharing (sleeping in the
same room with the infants crib or
bassinet close to the parents bed) is
recommended for all infants as a way
to reduce the risk of SIDS and accidental suffocation while facilitating feeding and monitoring of the infant.43 One
study from the Netherlands revealed
that the benets of breastfeeding do not
outweigh the increased risk of SIDS associated with bed-sharing.48 Additional
studies to analyze the contribution of
multiple simultaneous factors (such as
bed-sharing and breastfeeding or pacier use and breastfeeding) to SIDS risk
are needed.
Although causation cannot be proven
in case-control studies, on which these
results are based, the factors that
have been proposed to support causality in observational studies are found
in this meta-analysis: (1) consistent
ndings; (2) strong association; (3)
dose-response effect; (4) causal factor
preceding the outcome; and (5) biolog6

HAUCK et al

ical plausibility.49 Although the studies

were from many different countries,
and heterogeneous populations were
represented, the individual ORs for
breastfeeding in relation to SIDS were
similar. The association between
breastfeeding and SIDS risk reduction
is strong, there is a dose response,
and the causal factor (ie, breastfeeding) precedes the outcome. The protective effect of breastfeeding against
SIDS also has biological plausibility.
Breastfed infants are more easily
aroused from active sleep than
formula-fed infants at 2 to 3 months of
age, which is within the 2- to 4-month
peak age during which SIDS occurs.4
Breastfeeding also confers immunologic advantages over formula feeding
by providing immunoglobulins and cytokines that may protect infants during the vulnerable period for SIDS,
when their own production of immunoglobulin G is low and their maternally
acquired levels are decreasing. Infants
who die from SIDS often have had a
minor infection in the days preceding
death that was not sufcient alone to
have caused death. These infections
may induce proinammatory cytokines that may cause respiratory or
cardiac dysfunction, fever, shock, hypoglycemia, and arousal decits.7,50 Although the possibility of reverse causality cannot be ruled out entirely (ie,
certain infants may be difcult to
breastfeed because of underlying
health conditions that may make them
more susceptible to SIDS), most SIDS
deaths occur in previously healthy infants; therefore, it would not likely account for many of the SIDS deaths. Another potential concern is that
inadequate recall of breastfeeding duration may bias results. However, the time
to interview after the infant death in the
included studies was generally short.
The 2005 American Academy of Pediatrics policy statement on SIDS did not
endorse breastfeeding as a means to

reduce the risk of SIDS because of the

insufcient strength of evidence available at that time.43 Although there
were several studies that had found a
protective effect of breastfeeding, after controlling for possible confounding factors, the protective effect had
been eliminated for some, so clear
conclusions could not be drawn. Studies published since that statement,
which are included in our current
meta-analysis, notably the more detailed analysis of Vennemann et al,7
showed a strongly protective effect of
breastfeeding even after controlling
for confounders. The meta-analysis by
Ip et al21 consisted of many but not all
of the studies included in our current
analysis, and our ndings were similar
to theirs. In the Ip et al analysis, ever
breastfeeding was associated with
crude and adjusted SORs of 0.41 (95%
CI: 0.28 0.58) and 0.64 (95% CI: 0.51
0.81), respectively. The authors did not
report results for exclusive breastfeeding or specic durations.
A potential limitation of our metaanalysis is that studies from which signicant associations are reported may
be preferentially published, which
could result in an overestimate of the
true effect and could bias the results.22
It is unlikely that this was the case for
several reasons. The breastfeeding results were all part of larger studies
that examined potential risk and protective factors for SIDS; thus, results
were published along with other ndings. There was some heterogeneity of
results, which indicates that results
were not selectively reported. Studies
published in languages other than English were included. Finally, we attend
international SIDS meetings regularly,
participate in SIDS organizations and
Listservs, and have frequent contact
with SIDS researchers around the
world; we are not aware of other unpublished studies that would contradict these ndings. A limitation identi-

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REVIEW ARTICLES

ed by this meta-analysis was the

small number of studies that presented data on breastfeeding duration, and when presented, there were
different ways in which duration was
dened, which made it difcult to pool
the results. This is an area that needs
further investigation.

CONCLUSIONS
There are many known benets to
breastfeeding, and breastfeeding
should be recommended for all newborn infants to enhance maternal and

infant well-being. The best time to begin the dialogue with mothers about
breastfeeding plans is the prenatal period, and it should be included with
other SIDS risk-reduction messages
and materials that are traditionally
given to expectant mothers during
pregnancy. The same benets of
breastfeeding in protecting against
SIDS are found for black infants as for
those in other groups.8 However,
breastfeeding initiation and continuation occur less frequently among black
mothers and those of other racial/eth-

nic minorities and among socially disadvantaged mothers.51 In addition,

these same groups have a higher incidence of SIDS.52 Thus, it is essential
that breastfeeding interventions target these higher-risk populations,53,54
and future research should focus on
developing and evaluating innovative
intervention methods. All health professionals should speak in 1 voice
about the importance of breastfeeding, which now adds SIDS risk reduction to its long list of maternal and infant health benets.

Paris-Llado J; French Reference Centers for

SIDS. Sudden unexpected death in infants
under 3 months of age and vaccination
status: a case-control study. Br J Clin Pharmacol. 2001;51(3):271276

and Deaths Regional Coordinators and Researchers. BMJ. 1996;313(7051):191195

Ponsonby AL, Dwyer T, Kasl SV, Cochrane JA.
The Tasmanian SIDS Case-Control Study:
univariable and multivariable risk factor
analysis. Paediatr Perinat Epidemiol. 1995;
9(3):256 272
Stray-Pedersen A, Arnestad M, Vege A,
Sveum L, Rognum TO. Bed sharing and sudden infant death [in Norwegian]. Tidsskr
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McVea KL, Turner PD, Peppler DK. The role of
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Ip S, Chung M, Raman G, et al. Breastfeeding
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Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A

Meta-analysis
Fern R. Hauck, John M. D. Thompson, Kawai O. Tanabe, Rachel Y. Moon and
Mechtild M. Vennemann
Pediatrics; originally published online June 13, 2011;
DOI: 10.1542/peds.2010-3000
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A

Meta-analysis
Fern R. Hauck, John M. D. Thompson, Kawai O. Tanabe, Rachel Y. Moon and
Mechtild M. Vennemann
Pediatrics; originally published online June 13, 2011;
DOI: 10.1542/peds.2010-3000

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2011/06/08/peds.2010-3000

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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