Breastfeeding and Mortality Under

2 Years of Age in Sub-Saharan Africa

Min Zhao, PhD,a Han Wu, MS,b Yajun Liang, MD,c Fangchao Liu, PhD,d Pascal Bovet, MD,e Bo Xi, PhDb

BACKGROUND: Several studies have investigated the association of breastfeeding status with abstract
offspring mortality in Africa, but most studies were from one center only or had limited
statistical power to draw robust conclusions.
METHODS: Datacame from 75 nationally representative cross-sectional Demographic and Health
Surveys in 35 countries in sub-Saharan Africa conducted between 2000 and 2016. Our study
relied on 217 112 individuals aged 4 days to 23 months for breastfeeding pattern analysis,
161 322 individuals aged 6 to 23 months for breastfeeding history analysis, and 104 427
individuals aged 12 to 23 months for breastfeeding duration analysis.
Compared with children aged 4 days to 23 months exclusively breastfed in the first
RESULTS:
3 days of life, those not breastfed had a high risk of mortality at ,2 years of age (odds ratio
[OR] = 13.45; 95% confidence interval [CI] = 11.43–15.83). Young children who were
predominantly breastfed or partially breastfed had moderately increased risk of mortality at
,2 years of age (OR = 1.11, 95% CI = 1.03–1.21 for predominant pattern; OR = 1.12, 95% CI =
0.99–1.27 for partial pattern). Compared with children aged 6 to 23 months who were
breastfed within the first 6 months of life, those not breastfed had a high risk of mortality
(OR = 5.65; 95% CI = 4.27–7.47). Compared with children aged 12 to 23 months who were
breastfed for $6 months, those who were breastfed for shorter periods had a higher risk of
mortality (OR = 2.78, 95% CI = 1.45–5.32 for duration of ,3 months; OR = 5.28, 95% CI =
3.24–8.61 for those who were not breastfed).
CONCLUSIONS: Our findings support exclusive breastfeeding during the first 6 months of life and
continued breastfeeding up to 2 years of age recommended by the World Health Organization
for reducing mortality of children ,2 years old in sub-Saharan Africa.

Departments of aNutrition and Food Hygiene and bEpidemiology and Health Statistics, School of Public Health, WHAT’S KNOWN ON THIS SUBJECT: Several studies
Shandong University, Jinan, China; cDepartment of Public Health Sciences, Karolinska Institutet, Stockholm, have investigated the association of breastfeeding
Sweden; dKey Laboratory of Cardiovascular Epidemiology, Department of Epidemiology, Fuwai Hospital, Chinese pattern or history with offspring mortality in Africa,
Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and eCenter for Primary Care and
but most studies were from one center only or had
Public Health, University of Lausanne, Lausanne, Switzerland
limited statistical power to draw robust conclusions.
Prof Xi conceptualized and designed the study and reviewed and revised the manuscript; Dr Zhao
drafted the initial manuscript and reviewed and revised the manuscript; Dr Wu designed the data WHAT THIS STUDY ADDS: This large study pooling data
collation, conducted the initial analyses, and reviewed and revised the manuscript; Drs Bovet, Liang, from 217 674 individuals from sub-Saharan Africa
and Liu critically reviewed the manuscript for important intellectual content; and all authors reveals that exclusive breastfeeding during the first
approved the final manuscript as submitted and agree to be accountable for all aspects of 6 months of life, as well as prolonged breastfeeding,
the work. reduces the risk of deaths in children ,2 years of age.
DOI: https://doi.org/10.1542/peds.2019-2209
Accepted for publication Feb 27, 2020 To cite: Zhao M, Wu H, Liang Y, et al. Breastfeeding and
Mortality Under 2 Years of Age in Sub-Saharan Africa.
Address correspondence to Bo Xi, PhD, Department of Epidemiology and Health Statistics, School of Pediatrics. 2020;145(5):e20192209
Public Health, Shandong University, 44 Wenhuaxi Rd, Jinan 250012, China. E-mail: [email protected]

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PEDIATRICS Volume 145, number 5, May 2020:e20192209 ARTICLE
Child mortality under the age of Using nationally representative and 217 674 children for breastfeeding
5 years has substantially decreased comparable observations in 217 674 pattern analysis, 161 732 children for
between 1990 (90.6‰, 12.7 million) children aged ,2 years from 75 breastfeeding history analysis, and
and 2015 (42.5‰, 5.9 million).1 surveys from 35 countries in sub- 104 676 children for breastfeeding
However, neonatal mortality (age Saharan Africa conducted between duration analysis.
0–28 days) is still a major public 2000 and 2016, we evaluated the
health problem worldwide (2.7 associations of breastfeeding pattern, Outcomes, Exposures, and
million in 2015), especially in sub- history, and duration with under-2 Covariates
Saharan African countries2 where mortality. The study population included
adequate health care to manage at- mothers and their most recent live
risk births is often unavailable or singleton births in the 2 years
difficult to access.3 METHODS preceding the survey. Under-2
mortality (per 1000 live births) was
Breastfeeding has been shown to be Demographic and Health Surveys
defined as deaths within 24 months
a major factor associated with (DHS) are nationally representative
after birth. To limit reverse causality
improved survival of infants. The household sample surveys that use
on association between breastfeeding
World Health Organization (WHO) a multistage stratified sampling
pattern in the first 3 days after
recommends exclusive breastfeeding design to collect health and nutrition
delivery and ,2-year deaths, young
during the first 6 months of life and data for women of reproductive age
children dying in the first 3 days of
continued breastfeeding up to 2 years (15–49 years), their children (0–59
life were excluded. Infants dying
of age.4 It was estimated that scaling months), and their households in
within the first 11 months of life were
up breastfeeding to a near universal LMICs. Detailed information on the
excluded in the analysis on
level could prevent 823 000 annual DHS Program has been described
breastfeeding duration. We grouped
deaths in children ,2 years of age in elsewhere.14 The main advantages of
under-2 mortality by death time as 4
75 high-mortality, low- and middle- the DHS Program include high
to 28 days, 1 to 11 months, and 12 to
income countries (LMICs).5 response rates of the study
23 months for breastfeeding pattern
populations, the national
analysis.
Although the prevalence of representative sampling frame, high-
breastfeeding is high in African quality interviewer training, and the To assess the breastfeeding pattern,
countries (.95%), ,50% of children standardized questionnaire used for mothers who had a child aged
,6 months were reported to be fed data collection across countries and ,2 years at the time of survey were
through exclusive breastfeeding in over time allowing international asked whether and what they offered
2010.5 More specifically, the comparability across populations. to drink or eat to her neonates in the
proportions of exclusive, DHS data collection procedures were first 3 days after delivery.
predominant, partial, and no approved by the Inner City Fund Breastfeeding pattern was
breastfeeding (defined according to international institutional review categorized into exclusive,
whether infants had been given other boards and relevant human subject predominant, or partial
milk, fluids, or foods, etc) in the first committees in each country. Oral breastfeeding. Exclusive
month of life were respectively informed consent was provided by breastfeeding was defined as feeding
53.9%, 26.7%, 13.4%, and 6.1% in each survey respondent (mothers in only breast milk (from the mother or
Africa in 2000–2010.6 It is therefore our study). We used an anonymous a wet nurse) and nothing else with
important to assess the effects of public-use data set. In this study, we the exception of vitamin supplements
pattern, history, and duration of included DHS Program data from all or medicines. Predominant
breastfeeding on young child countries in sub-Saharan Africa breastfeeding was defined as feeding
mortality in sub-Saharan African surveyed between 2000 and 2016 to of breast milk plus plain water or
countries. To date, several studies increase the statistical power of water-based fluids (sweetened or
have investigated the association analyses, given that mortality in flavored water, teas, fruit juice, coffee,
between breastfeeding pattern or children ,2 years of age is a rare etc). Partial breastfeeding was
history and mortality in children event. In Supplemental Figs 2 through defined as feeding breast milk plus
,2 years of age, but findings have 4, we present flow charts of data animal milk, infant formula, or foods.
been inconsistent in Africa.7–11 In selection for breastfeeding pattern No breastfeeding was defined as not
addition, only a few studies have analysis, breastfeeding history feeding breast milk either from the
examined the effect of breastfeeding analysis, and breastfeeding duration mother or a wet nurse. These
duration on under-2 mortality.12,13 analysis, respectively. We used data of definitions are consistent with the

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54 ZHAO et al
recommendations from the WHO.15 and education level; sex of the child, several surveys and these covariates
Breastfeeding history (none versus birth order, and birth mode (cesarean were adjusted only in the sensitivity
ever) and duration were reported by versus vaginal delivery); household analyses.
the mother, and the duration was wealth quintile (first quintile
categorized into ,3, 3 to 5, and $6 [poorest] to fifth quintile [richest] Statistical Analysis
months. within each country) and residence The DHS Program uses a complex
(urban or rural); country; and survey survey design for participant
Covariates for the main analyses year. Smoking status and occupation selection, and clustering, strata, and
included maternal age at birth and of parents, antenatal visits and birth sampling weights were provided for
education level; paternal age at birth size were not consistently collected in each survey across countries. To

TABLE 1 Characteristics of the Study Population for Breastfeeding Pattern Analysis

Variables Breastfeeding Pattern (in the First 3 Days of Life), n (%) P
Exclusive (n = 137 529) Predominant (n = 61 242) Partial (n = 16 140) None (n = 2201)
Maternal
Age, y
,20 14 764 (58.3) 7964 (31.5) 2316 (9.2) 265 (1.0) ,.001
20–29 74 186 (64.3) 31 849 (27.6) 8235 (7.1) 1132 (1.0) —
30–39 41 306 (63.9) 18 075 (27.9) 4623 (7.1) 677 (1.0) —
$40 7273 (62.1) 3354 (28.6) 966 (8.2) 127 (1.1) —
Education level
Illiteracy 55 384 (53.9) 35 417 (34.5) 10 942 (10.7) 968 (0.9) ,.001
Primary 52 916 (72.1) 16 927 (23.1) 2923 (4.0) 591 (0.8) —
Secondary or higher 29 229 (71.2) 8898 (21.7) 2275 (5.5) 642 (1.6) —
Marital status
Married or living with partner 137 529 (63.3) 61 242 (28.2) 16 140 (7.4) 2201 (1.0) —
Single, divorced, or widowed 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) —
Paternal
Age, y
,20 1069 (63.3) 462 (27.4) 116 (6.9) 41 (2.4) ,.001
20–29 41 775 (67.8) 15 269 (24.8) 3906 (6.3) 623 (1.0) —
30–39 55 144 (64.4) 23 533 (27.5) 6091 (7.1) 834 (1.0) —
$40 39 541 (57.9) 21 978 (32.2) 6027 (8.8) 703 (1.0) —
Education level
Illiteracy 44 849 (51.5) 31 205 (35.8) 10 171 (11.7) 874 (1.0) ,.001
Primary 48 428 (71.9) 15 595 (23.2) 2799 (4.2) 529 (0.8) —
Secondary or higher 44 252 (70.6) 14 442 (23.0) 3170 (5.1) 798 (1.3) —
Child
Sex
Male 69 035 (63.0) 31 176 (28.4) 8253 (7.5) 1143 (1.0) .004
Female 68 494 (63.7) 30 066 (28.0) 7887 (7.3) 1058 (1.0) —
Birth order
First 24 241 (62.7) 10 675 (27.6) 3234 (8.4) 486 (1.3) ,.001
Second 26 930 (66.4) 10 511 (25.9) 2646 (6.5) 444 (1.1) —
Third 23 132 (65.7) 9360 (26.6) 2342 (6.7) 350 (1.0) —
Fourth 18 780 (64.6) 7962 (27.4) 2019 (6.9) 291 (1.0) —
$Fifth 44 446 (60.3) 22 734 (30.8) 5899 (8.0) 630 (0.9) —
Household
Wealth quintile, within country
First, poorest 32 044 (60.0) 15 571 (29.2) 5250 (9.8) 514 (1.0) ,.001
Second 29 673 (62.3) 14 014 (29.4) 3548 (7.4) 419 (0.9) —
Third 28 345 (64.6) 12 435 (28.3) 2702 (6.2) 421 (1.0) —
Fourth 25 399 (65.5) 10 705 (27.6) 2304 (5.9) 384 (1.0) —
Fifth, richest 22 068 (66.1) 8517 (25.5) 2336 (7.0) 463 (1.4) —
Residence
Urban 38 636 (66.3) 15 165 (26.0) 3544 (6.1) 897 (1.5) ,.001
Rural 98 893 (62.2) 46 077 (29.0) 12 596 (7.9) 1304 (0.8) —
Survey year
2000–2009 57 673 (58.6) 31 388 (31.9) 8514 (8.7) 792 (0.8) ,.001
2010–2016 79 856 (67.2) 29 854 (25.1) 7626 (6.4) 1409 (1.2) —
—, not applicable.

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PEDIATRICS Volume 145, number 5, May 2020 55
make each survey unique in the
pooled data set, the “survey” variable
was considered.16 The recalculated
clustering, strata, and sampling
weights in consideration of the
survey variable were used for
calculation of overall under-2
mortality prevalence and in the
multivariable logistic regression
analyses. Kaplan-Meier survival
curves were performed according to
breastfeeding pattern. We used
multivariable logistic regression
analysis to examine the effects
of breastfeeding pattern, history,
and duration on under-2 mortality
with adjustment for the mentioned
covariates. Subgroup analyses
were performed by categories
of ,2-year death age (4–28 days,
1–11 months, and 12–23 months).
We calculated attributable cases
to estimate the numbers of
infants who could have been
saved if women offered exclusive
breastfeeding or along other
breastfeeding scenarios. With
the relative risk (RR) being
estimated by the adjusted odds
ratio (OR), the etiologic fraction
was first calculated as (RR21)/RR.
The numbers of attributable FIGURE 1
Kaplan-Meier survival curves of breastfeeding pattern and offspring mortality during age 4 days to
cases were then calculated by 23 months.
multiplying the etiologic fraction
by the deaths in the specific
exposure groups. RESULTS and no breastfeeding were 59.8%,
Several sensitivity analyses 31.0%, 8.3%, and 0.9%, respectively
Breastfeeding Pattern and Under-2 (Supplemental Table 6). The
were performed to test the Mortality (4 Days to 23 Months)
robustness of our findings. First, characteristics of mothers, fathers,
Data on breastfeeding pattern in the offspring, and households in the
other covariates, including smoking
first 3 days of life and under-2 pooled data set by breastfeeding
status and occupation of parents,
mortality (4 days–23 months) were pattern are presented in Table 1.
antenatal visits, and birth size,
available from 75 DHS surveys in 35
were further adjusted separately
countries in sub-Saharan Africa In the pooled analysis, compared with
and simultaneously. Second, the
between 2000 and 2016. The total children aged 4 days to 23 months
gross domestic product per capita
sample size was 217 112 children, exclusively breastfed in the first
on purchasing power parity (PPP)
ranging from 574 (0.3%) in 3 days of life, those who were not
(current international dollar) at
Swaziland to 22 649 (10.4%) in breastfed, predominantly breastfed,
country level in the survey year
Nigeria (Supplemental Table 5). The and partially breastfed were more
was further adjusted.
weighted prevalence of under-2 likely to die during the first 2 years of
All statistical analyses were mortality (4 days–23 months) was life (Fig 1). In multivariable logistic
performed by using SAS 9.4 (SAS 32.1‰, ranging between 11.9‰ in regression analysis, adjusted for
Institute, Inc, Cary, NC). A P value Angola and 45.7‰ in Swaziland. potential covariates, compared with
,.05 was considered statistically Overall, the weighted proportions children aged 4 days to 23 months
significant. of exclusive, predominant, partial, exclusively breastfed, those who were

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56 ZHAO et al
not breastfed had a higher risk of the other 2 periods, we performed mortality before the age of 2 years
mortality during the first 2 years of sensitivity analyses restricted to this (OR = 5.65; 95% CI = 4.27–7.47).
life (OR = 13.45; 95% confidence period, which revealed consistent Subgroup analysis by death time
interval [CI] = 11.43–15.83) and in results (Supplemental Table 7). revealed that the association was
each of the examined periods (OR = consistently significant in the 6- to
23.97, 95% CI = 18.94–30.34 in the Breastfeeding History and Mortality 11-month period (OR = 5.07; 95%
4–28-day period; OR = 9.52, 95% CI = During 6 to 23 Months CI = 3.66–7.04) and in the 12- to
7.68–11.79 in the 1–11-month For the association of breastfeeding 23-month period (OR = 6.38; 95%
period; OR = 8.19, 95% CI = history (in the first 6 months of life) CI = 3.94–10.32). Other sensitivity
5.13–13.09 in the 12–23-month with under-2 mortality (6–23 analyses considering other covariates
period) suggesting that the months), the total sample size was revealed similar findings
association was still high but 161 322 children, ranging from 440 (Supplemental Table 9).
attenuated over time (Table 2). In (0.3%) in Swaziland to 16 668
addition, children aged 4 days to Breastfeeding Duration and
(10.3%) in Nigeria (Supplemental Mortality During 12 to 23 Months
23 months predominantly breastfed Table 5). The weighted under-2
or partially breastfed were also at mortality prevalence (6–23 months) For the association of breastfeeding
increased risk of mortality before the was 18.0‰, ranging from 3.0‰ in duration with mortality during the
age of 2 years compared with Comoros to 25.7‰ in Swaziland. second year of life (12–23 months),
children exclusively breastfed (OR = Overall, the proportion of ever the total sample size was 104 427
1.11, 95% CI = 1.03–1.21 for breastfeeding was 99.0%. The children, ranging from 292 (0.3%) in
predominant pattern; OR = 1.12, 95% characteristics of mothers, fathers, Sao Tome and Principe to 10 656
CI = 0.99–1.27 for partial pattern). offspring, and households in the (10.2%) in Nigeria (Supplemental
However, a statistically significant pooled data set by breastfeeding Table 5). The weighted prevalence of
association was observed only in the history categories are presented in mortality during the second year of
age subgroup of 1 to 11 months in the Supplemental Table 8. life (12–23 months) was 10.6‰,
analysis by age subgroup (Table 2). ranging between 0.0‰ in Sao Tome
In the pooled analysis (Table 3), after and Principe and 15.9‰ in Niger.
Because the association of adjustment for potential covariates, Overall, the proportions of no
predominant and partial compared with children aged 6 to breastfeeding and breastfeeding
breastfeeding patterns on under-2 23 months ever breastfed within the duration of ,3, 3 to 5, and
mortality was larger in the 1- to 11- first 6 months of life, those who were $6 months were 1.1%, 0.7%, 0.6%,
month age category as compared to not breastfed had increased risk of and 97.6%, respectively. The

TABLE 2 Breastfeeding Pattern and Under-2 Mortality (4 Days to 23 Months)

Mortality for Breastfeeding Pattern in the First 3 Days of Life Sample Size, n No. OR (95% CI) P Attributable Cases
Deaths
Mortality: 4 d to 23 mo (N = 217 112)
Exclusive 137 529 3643 1 (Reference)
Predominant 61 242 2056 1.11 (1.03–1.21) .010 204
Partial 16 140 565 1.12 (0.99–1.27) .065 61
None 2201 450 13.45 (11.43–15.83) ,.001 417
Mortality: 4–28 d (N = 217 112)
Exclusive 137 529 758 1 (Reference)
Predominant 61 242 466 1.15 (0.96–1.37) .136 61
Partial 16 140 120 0.92 (0.71–1.19) .522 —
None 2201 192 23.97 (18.94–30.34) ,.001 184
Mortality: 1–11 mo (n = 215 576)
Exclusive 136 771 2352 1 (Reference)
Predominant 60 776 1252 1.13 (1.02–1.25) .017 144
Partial 16 020 358 1.28 (1.10–1.49) .002 78
None 2009 219 9.52 (7.68–11.79) ,.001 196
Mortality: 12–23 mo (n = 211 395)
Exclusive 134 419 533 1 (Reference)
Predominant 59 524 338 1.02 (0.82–1.26) .869 7
Partial 15 662 87 0.92 (0.67–1.25) .583 —
None 1790 39 8.19 (5.13–13.09) ,.001 34
Adjusted for maternal age and education level; paternal age and education level; child’s sex, birth order, and birth mode; household wealth status and residence (urban or rural); country;
and survey year. —, such values cannot be calculated because the OR should be .1.

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PEDIATRICS Volume 145, number 5, May 2020 57
TABLE 3 Breastfeeding History and Mortality During Age of 6 to 23 Months
Age at Death History of Breastfeeding at 0–5 Months Sample Size, n No. OR (95% CI) P Attributable
Deaths Cases
6–23 mo (n = 161 322)
Ever 159 673 2632 1 (Reference)
None 1649 100 5.65 (4.27–7.47) ,.001 82
6–11 mo (n = 161 322)
Ever 159 673 1721 1 (Reference)
None 1649 65 5.07 (3.66–7.04) ,.001 52
12–23 mo (n = 159 536)
Ever 157 952 911 1 (Reference)
None 1584 35 6.38 (3.94–10.32) ,.001 30
Adjusted for maternal age and education level; paternal age and education level; child’s sex, birth order, and birth mode; household wealth status and residence (urban or rural);
country; and survey year.

characteristics of mothers, fathers, young children aged ,2 years; (2) breastfeeding in the first few months
offspring, and households in the ever breastfeeding decreased under-2 of life was associated with all-cause
pooled data set by breastfeeding mortality of children aged 6 to mortality as compared to partial or
duration are presented in 23 months when compared to no no breastfeeding (OR = 2.23; 95%
Supplemental Table 10. breastfeeding; and (3) there was CI = 1.45–3.44) and, in particular,
a dose-response association between increased mortality due to
In the pooled analysis (Table 4), after breastfeeding duration and risk of respiratory infections (OR = 2.40;
adjustment for potential covariates, mortality during the second year of 95% CI = 1.14–5.04) and diarrhea
compared with children aged 12 to life (age 12–23 months). These (OR = 3.94; 95% CI = 1.47–10.57).
23 months breastfed for $6 months, findings are consistent with the WHO This study also revealed that
those who were breastfed for shorter recommendations for exclusive predominant breastfeeding was not
periods were at increased risk of breastfeeding in the first 6 months of associated with under-2 mortality (all
mortality during the second year of life and continued breastfeeding up to P . .05).9 Similarly, another study
life (OR = 2.78, 95% CI = 1.45–5.32 the age of 2 years. including 9424 infants who were
for duration of ,3 months; OR = 5.28, enrolled at the age of 18 to 42 days
95% CI = 3.24–8.61 for those who Compared to Other Studies from Ghana, India, and Peru revealed
were not breastfed). Sensitivity Authors of several studies have the increased mortality between the
analyses considering other covariates assessed the association between ages of 6 weeks and 6 months
revealed similar findings breastfeeding pattern and offspring associated with partial breastfeeding
(Supplemental Table 11). mortality in some countries in Africa, (hazard ratio [HR] = 2.46; 95% CI =
but most studies came from only one 1.44–4.18) or no breastfeeding (HR =
center or had limited statistical 10.5; 95% CI = 5.0–22.0) versus
DISCUSSION power to provide robust finding, exclusively breastfeeding (HR = 1.46;
Using population-based data (N = given that under-2 mortality is 95% CI = 0.75–2.86) when compared
217 112 children) in 35 countries in a fairly infrequent outcome.7–11 To to predominantly breastfeeding.7 In
sub-Saharan Africa, we found that (1) our knowledge, there are no related contrast, 1 subsequent meta-analysis
compared to exclusive breastfeeding, data that are focused entirely on including only 3 studies (N = 22 048
suboptimal breastfeeding Africa. One previous study including children) revealed that compared to
(predominant or partial pattern) and 1677 infants who were followed from exclusive breastfeeding, no
no breastfeeding significantly birth to 12 months of age from breastfeeding was associated with the
increased the risk of mortality of Bangladesh revealed that exclusive highest risk of mortality in offspring

TABLE 4 Breastfeeding Duration and Mortality During 12 to 23 Months

Breastfeeding Duration Sample Size, n No. OR (95% CI) P Attributable Casesa
(n = 104 427) Deaths
$6 mo 101 953 913 1 (Reference)
3–5 mo 589 7 — — —
,3 mo 690 16 2.78 (1.45–5.32) .002 10
None 1195 34 5.28 (3.24–8.61) ,.001 28
Adjusted for maternal age and education level; paternal age and education level; child’s sex, birth order, and birth mode; household wealth status and residence (urban or rural); country;
and survey year. —, such values cannot be calculated because of the limited number of deaths.

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58 ZHAO et al
aged 0 to 5 months (OR = 14.40; 95% mortality, with an OR (95% CI) of other LMICs. Third, we adjusted our
CI = 6.13–33.90), followed by partial 0.62 (0.46–0.82) for 3 months or analyses for several potential
breastfeeding pattern (OR = 2.84; more of breastfeeding.12 Data from confounders and performed several
95% CI = 1.63–4.97) and the US National Health and Nutrition sensitivity analyses, which makes our
predominant breastfeeding pattern Examination Survey III of 2277 findings robust. However, several
(OR = 1.48; 95% CI = 1.13–1.92).17 children aged 6 to 23 months limitations should also be noted.
Estimates from this meta-analysis revealed that prolonged First, there might be reverse causality
were consistent with results from breastfeeding decreased the risk between breastfeeding pattern and
a recent large prospective study of respiratory tract infections, duration and under-2 mortality.
including 99 938 young children.11 including pneumonia,13 which is an Infants who have severe illnesses
The results of our study with a large important risk factor for under-2 may not be adequately breastfed or
sample size (N = 217 674 children) mortality. Our study also supports the weaned in early life. This is why we
are consistent with this previous notion that prolonged breastfeeding excluded infants who died in the first
meta-analysis. However, these is associated with reduced under-2 3 days of life when assessing the
previous other studies were mortality, at least in sub-Saharan association of breastfeeding pattern
only focused on deaths within Africa. on under-2 mortality. In addition,
the first 6 months of life, whereas infants who died within the first
Our findings emphasize that policy
our study reveals that partial 12 months of life were excluded when
makers, health workers, and
or predominant breastfeeding assessing the effect of breastfeeding
mothers in sub-Saharan Africa
pattern also increases risk of duration on mortality at the age of 12
(and likely in all countries) should
death during the period of 1 to 11 to 23 months. These attempts have
promote exclusive breastfeeding
months. likely significantly reduced the
during the first 6 months of life
possibility of a bias due to reverse
Several previous studies have and prolonged exclusive or partial
causality. Second, information on
examined the association between breastfeeding up to the age of 2 years.
breastfeeding pattern, history, and
breastfeeding history (none versus In view of the magnitude of the
duration was reported by the mother,
ever) and risk of under-2 association between breastfeeding
and recall biases might underestimate
mortality,18–23 but the statistical and under-2 mortality, adequate
or overestimate the strength of our
power was generally insufficient, and breastfeeding holds the perspective
observed associations. Third,
control for confounders was limited to reduce substantially the
although several potential
in most of these studies. One previous currently high under-2 mortality
confounders were adjusted for in our
meta-analysis revealed that compared in LMICs. Mechanisms through
analyses, residual confounding may
with children ever breastfed within 6 which breastfeeding is beneficial
not be fully ruled out. Fourth, meta-
months, those not breastfed were at have been widely described,24–26
regression analysis can be better than
increased risk of death (OR = 1.76, including exclusive breastfeeding
pooling diverse data. We did perform
95% CI = 1.28–2.41 among infants necessarily decreasing exposure
a regression analysis in the data from
aged 6–11 months; OR = 1.97, 95% to unsafe water and fecal
each country, but we cannot calculate
CI = 1.45–2.67 among young children contaminants, which may be
reliable ORs because the under-2
aged 12–23 months),17 which is associated with the risk of
mortality is a rare event in the
consistent with our findings among infant mortality due to infectious
population and the statistical power
161 732 African young children. disease.
of analyses from most country studies
However, the magnitude of our
is too low.
estimated associations was larger Study Strengths and Limitations
(OR = 5.07, 95% CI = 3.66–7.04
Our study has several strengths. First,
for infants aged 6–11 months; OR = CONCLUSIONS
to our knowledge, our study has the
6.38, 95% CI = 3.94–10.32 for young
largest study sample (N = 217 112) Our results reveal that exclusive
children aged 12–23 months) than
for assessing the associations of breastfeeding during the first 6
those of that meta-analysis.
breastfeeding pattern, history, and months, as well as prolonged
To our knowledge, few studies have duration on under-2 mortality, breastfeeding up to the age of 2 years,
evaluated the effect of breastfeeding allowing sufficient statistical power was associated with substantially
duration on infant mortality. Data to draw solid conclusions. Second, the decreased risk of under-2 mortality.
from one US study of ∼6000 use of national representative and Of note, 682 (22%) children’s lives
postneonates (28 days–1 year of age) comparable samples made our could have been saved if all mothers
revealed that longer breastfeeding findings generalizable to populations had breastfed their infants for 6
was associated with lower risk of in sub-Saharan Africa and, likely, in months. These findings support the

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PEDIATRICS Volume 145, number 5, May 2020 59
promotion of exclusive breastfeeding
up to the age of 6 months and
ABBREVIATIONS
prolonged breastfeeding up to the age CI: confidence interval
of 2 years as an important mean to DHS: Demographic and Health
reduce the burden of under-2 Surveys
mortality in LMICs, where such HR: hazard ratio
mortality is still much higher than in LMIC: low- and middle-income
other regions. country
OR: odds ratio
PPP: purchasing power parity
ACKNOWLEDGMENT
RR: relative risk
We thank the DHS Program for WHO: World Health Organization
sharing the available data.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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PEDIATRICS Volume 145, number 5, May 2020 61
 Breastfeeding and Mortality Under 2 Years of Age in Sub-Saharan Africa
Min Zhao, Han Wu, Yajun Liang, Fangchao Liu, Pascal Bovet and Bo Xi
Pediatrics 2020;145;
DOI: 10.1542/peds.2019-2209 originally published online April 22, 2020;

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 Breastfeeding and Mortality Under 2 Years of Age in Sub-Saharan Africa
Min Zhao, Han Wu, Yajun Liang, Fangchao Liu, Pascal Bovet and Bo Xi
Pediatrics 2020;145;
DOI: 10.1542/peds.2019-2209 originally published online April 22, 2020;

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located on the World Wide Web at:
http://pediatrics.aappublications.org/content/145/5/e20192209

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