Table. Papers selected through systematic review on the relation between breastfeeding and behavior disorders.
| Author, country, year | Study design, sample size, age | Exposition type and duration | Outcome, scale | Confounders | Main results |
|---|---|---|---|---|---|
| Taylor 30 United Kingdom 1984 | Cohort 13,135 Child (5 years old) | NEBF Non-breastfed 1–2 months ≥ 3 months | Total behavior (Rutter Behavior Scale) | Sociodemographic: social index (family socioeconomic status, domestic crowding, parental education, tenure of accommodation, type of neighborhood, parental occupation), maternal age, older or younger siblings Mother: smoking in pregnancy, mental health Child: sex, birth weight |
1) Total behavior problems (p < 0.05): Non-breastfed: β = 0.01 BF < 1 month: β = 0.04 BF 1–2 months: β = 0.03 BF ≥ 3 months: β = -0.05 |
| Fergusson 37 New Zealand 1987 | Cohort 1,024 Child (6, 7, and 8 years old) | NEBF | Total behavior (Rutter Behavior Scale) | Sociodemographic: family socioeconomic status, family size, maternal marital status, maternal education, maternal ethnicity Child: gestational age, birth weight |
1) Maternal ratings: 6 years: β = -0.16, p < 0.001 7 years: β = -0.11, p < 0.001 8 years: β = -0.14, p < 0.001 2) Teacher ratings: 6 years: β = -0.05, p > 0.10 7 years: β = -0.09, p < 0.01 8 years: β = -0.04, p > 0.20 3) Standardized analysis for BF: 6 years: β = -0.07, p > 0.05 7 years: β = -0.14, p < 0.01 8 years: β = -0.05, p > 0.10 |
| Julvez 40 Spain 2007 | Cohort 500 Child (4 years old) | NEBF 2 weeks - < 3 months 3– ≤ 5 months 5–7 months > 7 months versus < 2 weeks | Hyperactivity Impulsivity symptoms (ASHD-DSM-IV) Social Competence (California Preschool Social Competence Scale) Abnormal: > 80th percentile |
Sociodemographic: parent's social class, parental education level, maternal marital status Mother: maternal parity Child: sex, child's school season e evaluator. |
1) Hyperactivity: 2–11.9 weeks: RR = 1.10, 95%CI 0.68–1.78 12–20 weeks: RR = 0.99, 95%CI 0.62–1.58 20.1-28 weeks: RR = 0.68, 95%CI 0.38–1.23 28.1 weeks: RR = 0.48, 95%CI 0.25–0.94 2) Impulsivity symptoms: 2–11.9 weeks: RR = 1.52, 95%CI 0.84–2.73 12–20 weeks: RR = 1.10, 95%CI 0.59–2.04 20.1-28 weeks: RR = 0.79, 95%CI 0.38–1.67 28.1 weeks: RR = 0.70, 95%CI 0.33–1.50 3) Social competence: 2–11.9 weeks: RR = 0.77, 95%CI 0.56–1.05 12–20 weeks: RR = 0.57, 95%CI 0.52–0.66 20.1-28 weeks: RR = 0.16, 95%CI 0.11–0.22 28.1 weeks: RR = 0.44, 95%CI 0.2 7–0.72 |
| Robinson 27 Australia 2008 | Cohort 1,707 Child (5 years old) | NEBF versus non-breastfed | Total behavior Internalizing behavior Externalizing behavior (CBCL) Abnormal: > 60th percentile |
Sociodemographic: family income, maternal marital status, maternal ethnicity, maternal age, maternal education, number of siblings. Mother: smoking in pregnancy, alcohol in pregnancy, stressful events in pregnancy, baby blues symptoms. Child: gestational age, sex, 5-minute Apgar score. |
1) Total behavior problems: 2 years: OR = 0.99, 95%CI 0.95–1.03 5 years: OR = 0.97, 95%CI 0.94–0.99 2–5 years: OR = 1.00, 95%CI 0.96–1.04 2) Internalizing behavior problems: 2 years: OR = 1.02, 95%CI 0.98–1.06 5 years: OR = 0.98, 95%CI 0.96–1.01 2–5 years: OR = 1.04, 95%CI 0.99–1.08 3) Externalizing behavior problems: 2 years: OR = 0.98, 95%CI 0.94–1.01 5 years: OR = 1.00, 95%CI 0.98–1.03 2–5 years: OR = 0.98, 95%CI 0.94–1.02 |
| Kramer 35 Belarus 2008 | Intervention 13,889 Child (6.5 years old) | NEBF | Total behavior Hyperactivity Emotional symptoms Conduct disorder Peer problems Prosocial behavior (SDQ) Abnormal: ≥ 85th percentile |
Paired variables: Sociodemographic: maternal age, maternal education, number of siblings Mother: smoking in pregnancy, had breastfed a previous child for at least 3 months, cesarean delivery Child: sex, birth weight, gestational age, 5-minute Apgar score |
1) Total behavior problems: parent: β = -0.1; 95%CI -0.7–0.5 teacher: β = -0.5; 95%CI -1.1–0.1 2) Hyperactivity: parent: β = 0.1, 95%CI -0.2–0.3 teacher: β = -0.1, 95%CI -0.4–0.1 3) Emotional symptoms: parent: β = -0.1, 95%CI -0.3–0.1 teacher: β = -0.2, 95%CI -0.3–0.04 4) Conduct disorder: parent: β = 0.0, 95%CI -0.1–0.1 teacher: β = 0.0, 95%CI -0.2–0.1 5) Peer problems: parent: β = 0.0, 95%CI -0.2–0.2 teacher: β = -0.1; 95%CI -0.4–0.1 6) Prosocial behavior: parent: β = 0.1, 95%CI -0.2–0.3 teacher: β = 0.1, 95%CI -0.2–0.5 |
| Kramer 18 Belarus 2009 | Cohort 2,951 Child (6.5 years old) | EBF ≥ 6 months versus
EBF ≤ 3 months + partial ≥ 6 months |
Total behavior Hyperactivity Emotional symptoms Conduct disorder Peer problems Prosocial behavior (SDQ) | Sociodemographic: geographic location, parental education Child: birth weight, age at the follow-up visit, sex |
1) Total behavior = problems: parent: β = 0.5, 95%CI -0.05–1.0 teacher: β = 0.0, 95%CI -0.6–0.6 2) Hyperactivity: parent: β = 0.2, 95%CI -0.02–0.4 teacher: β = -0.1, 95%CI -0.4–0.2 3) Emotional symptoms: parent: β = 0.1, 95%CI -0.1 -0.3 teacher: β = 0.0, 95%CI -0.2–0.2 4) Conduct disorder: parent: β = 0.1, 95%CI -0.1–0.2 teacher: β = 0.0, 95%CI -0.2–0.2 5) Peer problems: parent: β = 0.1, 95%CI -0.04–0.3 teacher: β = 0.1, 95%CI -0.1–0.3 6) Prosocial behavior: parent: β = 0.0, 95%CI -0.2–0.2 teacher: β = -0.1, 95%CI -0.3–0.2 |
| Oddy 26 Australia 2010 | Cohort 2,868 Child (2, 5, and 8 years old) Adolescent (10, and 14 years old) | NEBF < 6 months versus ≥ 6 months | Total behavior Internalizing behavior Externalizing behavior (CBCL) Abnormal: ≥ 60th percentile |
Sociodemographic: family income, maternal marital status, maternal age, maternal education Mother: smoking in pregnancy, stressful events in pregnancy, postnatal depression Child: sex, proportion of optimal birth weight |
1) Total behavior problems - 2 to 14 years: NEBF < 6 m: OR = 1.33, 95%CI 1.09–1.62 β = 1.45, 95%CI 0.59–2.30, p = 0.001 2) Internalizing behavior problems - 2 to 1 4 years: NEBF < 6 m: OR = 1.21, 95%CI 1.00–1.46 β = 0.92, 95%CI 0.1 5–1.68, p = 0.019 3) Externalizing behave problems - 2 to 14 years: NEBF < 6 m: OR = 1.23, 95%CI 1.01–1.49 β = 1.33, 95%CI 0.51–2.15, p = 0.001 |
| Chiu 39 Taiwan 2011 | Cohort 14,621 Child (18 months) | NEBF < 1 month 1 - < 3 months 3- < 6 months ≥ 6 months versus non-breastfed | Personal/social skills (Denver Development Screening Test) Abnormal: > 90th percentile |
Sociodemographic: family structure, income and urbanicity, maternal age, maternal education, maternal country of origin, maternal working situation Mother: smoking in pregnancy, gestational age Child: birth order, birth weight, sex, primary caregiver |
1) Personal/social skills: < 1 month: OR = 1.02, 95%CI 0.86–1.20 1 at < 3 months: OR = 0.97, 95%CI 0.82–1.15 3 at < 6 months: OR = 0.83, 95%CI 0.68–1.00 ≥ 6 months: OR = 0.76, 95%CI 0.64–0.90 |
| Heikkila 29 United Kingdom 2011 | Cohort 9,525 term children Child (5 years old) | NEBF < 2 months 2- < 4 months ≥ 4 months EBF < 2 months 2- < 4 months ≥ 4 months versus non-breastfed | Total behavior Hyperactivity Emotional symptoms Conduct disorder Peer problems Prosocial behavior (SDQ) Abnormal: > 90th percentile |
Sociodemographic: family socioeconomic position, maternal age, maternal education, baby's birth order Mother: mental health, smoking in pregnancy, alcohol in pregnancy Child: mother-baby attachment, admission to neonatal unit, type of childcare the child attended and age when the child started childcare |
1) Total behavior problems: NEBF ≥ 4 months: OR = 0.67, 95%CI 0.54–0.83 EBF ≥ 4 months: OR = 0.61, 95%CI 0.45–0.83 2) Hyperactivity: NEBF 2- < 4 months: OR = 0.65, 95%CI 0.43–1.00 EBF 2- < 4 months: OR = 0.68, 95%CI 0.48–0.95 3) Emotional symptoms: NEBF ≥ 4 months: OR = 0.78, 95%CI 0.55–1.10 EBF ≥ 4 months: OR = 0.63, 95%CI 0.39–1.00 4) Conduct disorder: NEBF ≥ 4 months: OR = 0.70, 95%CI 0.56–0.89 EBF ≥ 4 months: OR = 0.70, 95%CI 0.56–0.89 5) Peer problems: NEBF ≥ 4 months: OR = 0.90, 95%CI 0.75–1.08 EBF ≥ 4 months: OR 0.81, 95%CI 0.65–1.02 6) Prosocial behavior: NEBF ≥ 4 months: OR = 0.85, 95%CI 0.45–1.63 EBF ≥ 4 months: OR = 0.48, 95%CI 0.20–1.18 |
| Shelton 32 United Kingdom and United States 2011 | Retrospective Cohort 870 Child (6 years old) | NEBF | Conduct disorder (SDQ) | Sociodemographic: maternal education Mother: smoking in pregnancy, antisocial behavior, multiple birth status Child: time in a special care baby unit, birth weight, age, sex |
1) Conduct disorder: total sample: β = -0.28, 95%CI -0.49- -0.08 genetically related mother-child: β = -0.33, 95%CI -0.56- -0.09 genetically unrelated mother-child: β = -0.09, 95%CI -0.55–0.38 |
| Cable 31 United Kingdom 2012 | Cohort 6,205 Adolescent (10 years old) | NEBF ≥ 1 month versus < 1 month | Total behavior (Rutter Behavior Scale) | Sociodemographic: maternal marital status, parity, maternal age, maternal education, baby's birth order | 1) Overall effect of NEBF: men: β = -0.025, p > 0.05 women: β = -0.203, p < 0.05 |
| Hayatbakhsh 28 Australia 2012 | Cohort 4,502 Adolescent (14 years) | NEBF < 4 months ≥ 4 months versus non-breastfed | Anxiety/depression Withdrawal problems Social problems Somatic complaints Thought problems Attention problems Aggression Delinquency (YSR) | Sociodemographic: maternal age, maternal education, maternal marital status, planned pregnancy Mother: anxiety, depression, smoking in pregnancy, alcohol in pregnancy Child: sex |
1) Anxiety/depression: NEBF < 4 months: β = -0.14, 95%CI -0.49–0.20 NEBF ≥ 4 months: β = -0.35, 95%CI -0.69–0.01 2) Social problems: NEBF < 4 months: β = -0.1 7, 95%CI -0.34- -0.01 NEBF ≥ 4 months: β = -0.26, 95%CI -0.43- -0.09 3) Attention problems: NEBF < 4 months: β = -0.23, 95%CI -0.47–0.02 NEBF ≥ 4 months: β = -0.39, 95%CI -0.64- -0.14 4) Aggression: NEBF < 4 months: β =-0.15, 95%CI -0.59–0.29 NEBF ≥ 4 months: β = -0.48, 95%CI -0.93- -0.04 5) Delinquency: NEBF < 4 months: β = -0.08, 95%CI -0.27–0.12 NEBF ≥ 4 months: β = -0.16, 95%CI -0.36–0.04 Did not present adjusted analyses for: withdrawal problems, somatic complaints, thought problems. |
| Kwok 42 Hong Kong 2013 | Cohort 5,598 Adolescent (11 years old) | NEBF < 3 months EBF ≥ 3 months versus non-breastfed | Total behavior Conduct disorder Emotional symptoms Hyperactivity (Rutter Behavior Scale) Abnormal: ≥ 97th percentile |
Sociodemographic: family income, mother's birthplace, parental age, parental education, baby's birth order Child: sex, birth weight-for-gestational age, age at assessment, secondhand smoke exposure. |
1) Total behavior problems: NEBF < 3 months: OR = 1.25, 95%CI 1.10–1.44, β = 0.10, 95%CI 0.05–0.16 EBF ≥ 3 months: OR = 1.60, 95%CI 0.80–1.40, β = 0.04, 95 % CI -0.07–0.1 5 2) Conduct disorder: NEBF < 3 months: OR = 1.63, 95%CI 1.20–2.20, β = 0.10, 95 %CI 0.04–0.16 EBF ≥ 3 months: OR = 1.30, 95%CI 0.69–2.46, β = 0.13, 95 %CI 0.02–0.25 3) Emotional symptoms: NEBF < 3 months: OR = 1.05, 95%CI 0.82–1.35, β = 0.04, 95%CI -0.02–0.10 EBF ≥ 3 months: OR = 0.94, 95%CI 0.55–1.62, β = -0.01, 95%CI -0.12–0.10 4) Hyperactivity: NEBF < 3 months: OR = 1.26, 95%CI 0.85–1.89, β = 0.06, 95%CI 0.01–0.12 EBF ≥ 3 months: OR = 0.68, 95%CI 0.24–1.92, β = -0.07, 95%CI -0.19–0.04 |
| McCrory 38 Ireland 2013 | Cohort 11,134 Child (9 months old) | EVER BF NEBF ≤ 1 week 2 weeks at < 1 month 1 - < 3 months 3- < 6 months ≥ 6 months EBF ≤ 1 week 2 weeks at < 1 month 1 - < 3 months 3- < 6 months = 6 months > 6 months versus non-breastfed | Personal-social ability (ASQ) | Sociodemographic: household social class, occupational classification, maternal marital status, maternal age, maternal educational, ethnicity/racial Mother: smoking in pregnancy Child: birth weight, gestational age |
1) Breastfeeding: Ever BF: OR = 1.38, 95%CI 1.23–1.54 NEBF ≤ 1 week: OR = 1.24, 95%CI 1.04–1.48 NEBF 2 weeks at < 1 m: OR = 1.58, 95%CI 1.22–2.05 NEBF 1 at < 3 months: OR = 1.29, 95%CI 1.09–1.53 NEBF 3 at < 6 months: OR = 1.28, 95%CI 1.07–1.54 NEBF ≥ 6 months: OR = 1.64, 95%CI 1.35–2.01 2) Exclusive breastfeeding: EBF ≤ 1 week: OR = 0.71, 95%CI 0.52–0.97 EBF < 1 month: OR = 0.91, 95%CI 0.64–1.39 EBF 1 at < 3 months: OR = 0.78, 95%CI 0.58–1.04 EBF 3 at < 6 months: OR = 0.89, 95%CI 0.67–1.18 EBF = 6 months: OR = 1.75, 95%CI 1.35–2.28 EBF > 6 months: OR = 1.27, 95%CI 0.90–1.80 |
| Lind 33 United States 2014 | Cohort 1,442 Child (6 years old) | NEBF < 6 months; NEBF ≥ 6 months + EBF < 3 months; NEBF ≥ 6 months + EBF ≥ 3 months; versus non-breastfed | Total behavior Hyperactivity Emotional symptoms Conduct disorder Peer problems Prosocial behavior (SDQ) Abnormal: > 90th percentile |
Sociodemographic: poverty-to-income ratio, maternal ethnicity, maternal marital status, maternal age, maternal education, baby's birth order Mother: pre-pregnancy BMI, postpartum depression, smoking in the first year Child: gestational age, participation in the Special Supplemental Nutrition Program, birth weight, sex |
1) Total behavior problems: NEBF < 6 m: OR= 1.25, 95%CI 0.67–2.34 NEBF ≥ 6 m + EBF < 3 m: OR = 1.19, 95%CI 0.60–2.35 NEBF ≥ 6 m + EBF ≥ 3 m: OR = 0.76, 95%CI 0.33–1.78 2) Hyperactivity: NEBF < 6 m: OR = 1.45, 95%CI 0.70–3.02 NEBF ≥ 6 m + EBF < 3 m: OR = 1.1 7, 95%CI 0.53–2.54 NEBF ≥ 6 m + EBF ≥ 3 m: OR = 0.99, 95%CI 0.41–2.38 3) Emotional symptoms: NEBF < 6 m: OR = 1.04; 95%CI 0.59–1.81 NEBF ≥ 6 m + EBF < 3 m: OR = 1.39, 95%CI 0.77–2.49 NEBF ≥ 6 m + EBF ≥ 3 m: OR = 0.78, 95%CI 0.39–1.55 4) Conduct disorder: - NEBF < 6 m: OR = 1.08, 95%CI 0.60–1.95 NEBF ≥ 6 m + EBF < 3 m: OR = 0.87, 95%CI 0.45–1.69 NEBF ≥ 6 m + EBF ≥ 3 m: OR = 0.42, 95%CI 0.1 7–1.02 5) Peer problems: NEBF < 6 m: OR = 0.72, 95%CI 0.38–1.34 NEBF ≥ 6 m + EBF < 3 m: OR = 0.50, 95%CI 0.25–1.03 NEBF ≥ 6 m + EBF ≥ 3 m: OR = 0.70, 95%CI 0.33–1.51 6) Prosocial behavior: NEBF < 6 m: OR = 0.65, 95%CI 0.35–1.21 NEBF ≥ 6 m + EBF < 3 m: OR = 0.53, 95%CI 0.27–1.04 NEBF ≥ 6 m + EBF ≥ 3 m: OR = 0.61, 95%CI 0.30–1.27 |
| Liu 36 China 2014 | Cohort 1,267 Child (6 years old) | EBF versus
NEBF |
Emotionally reactive Anxious/Depressed Somatic Complaints Withdrawn Internalizing behavior CBCL | Sociodemographic: house size, neighborhood, parental education, parents occupation, maternal marital status, presence of biological mother Parents: health status, obstetric complication, (bleeding, hypertension, diabetes, caesarian section, difficult birth) Child: birth weight, difficulty breathing |
1) Emotionally reactive: EBF: β = -0.092, p = 0.168 2) Anxious/Depressed: EBF: β =-0.091, p = 0.175 3) Somatic complaints: EBF: β = -0.153, p = 0,025 4) Withdrawn: EBF: β = -0.105, p = 0.11 5) Internalizing behavior: EBF: β = -0.137, p = 0.04 |
| Boucher 41 Spain 2016 | Cohort 1,346 Child (4 years old) | NEBF EBF |
Attention-Deficit Hyperactivity Disorder DSM-IV | Sociodemographic: social class, parental education, country of mother's birth, Mother: parity, age, smoking in pregnancy, verbal IQ proxy, psychopathology Child: age, sex, cohort, birth weight, child care |
1) Attention symptoms: NEBF: β = -0.01, 95%CI -0.02–0.00 EBF: β = -0.01, 95%CI -0.04–0.02 2) Hyperactivity symptoms: NEBF: β = -0.01, 95%CI -0.02–0.00 EBF: β = -0.01, 95%CI -0.04–0.02 |
| Jackson 34 United States 2016 | Cohort 648 pair Child (4 years old) | NEBF NEBF versus genetic risk NEBF < 6 months NEBF < 6 months versus genetic risk |
Conduct disorder Preschool and Kindergarten Behavior Scales (PKBS-2) | Sociodemographic: index annual household income, maternal education, female-headed household, parental involvement Mother: age, postpartum depression Child: age, race, sex, attachment security, birth weight |
1) Conduct disorder: NEBF: β = 0.030, p > 0.05 NEBF x genetic risk: β = 0.076, p < 0.01 NEBF < 6 months: β = 0.025, p > 0.05 NEBF < 6 months x genetic risk: β = 0.076, p < 0.01 |
EBF: exclusive breastfeeding; NEBF: non-exclusive breastfeeding; CBCL: Child Behavior Checklist; SDQ: Strengths and Difficulties Questionnaire; BMI: body mass index; β: linear regression coefficient; ASQ: Ages and Stages Questionnaire; PKBS-2: Preschool and Kindergarten Behavior Scales; YSR: Youth Self Report; β: linear regression coefficient; Df: difference in means; RR: relative risk