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      Breastfeeding and the risk of respiratory tract infections after infancy: The Generation R Study

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          Abstract

          Background

          The protection of breastfeeding against respiratory tract infections in the first year of life has often been suggested. Few studies examined the effect of breastfeeding on respiratory tract infections after infancy.

          Objective

          To examine the association between breastfeeding with lower respiratory tract infections (LRTI) and upper respiratory tract infections (URTI) after infancy up to 4 years of age (n = 5322).

          Methods

          This study was embedded in The Generation R study, a Dutch population-based prospective cohort study from fetal life until young adulthood. Information on breastfeeding duration (never; <3 months; 3–6 months; ≥6 months) and dose (never; partially until 4 months; predominantly until 4 months) were collected by questionnaire at 2, 6, and 12 months of age. Information on doctor attendance for LRTI and URTI were obtained by questionnaire at 2, 3, and 4 years of age.

          Results

          Breastfeeding for 6 months or longer was significantly associated with a reduced risk of LRTI up to 4 years of age (aOR: 0.71; 95% CI: 0.51–0.98). Similar ORs for LRTI were found with breastfeeding for less than 3 months and 3–6 months. Although in the same direction, weaker ORs were found for URTI and breastfeeding duration. The same trend was found for partial and predominant breastfeeding until 4 months and LRTI and URTI.

          Conclusion

          Breastfeeding duration for 6 months or longer is associated with a reduced risk of LRTI in pre-school children. These findings are compatible with the hypothesis that the protective effect of breastfeeding for respiratory tract infections persist after infancy therefore supporting current recommendations for breastfeeding for at least 6 months.

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          Most cited references19

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          The impact of confounder selection criteria on effect estimation.

          R Mickey, S Greenland (1988)
          Much controversy exists regarding proper methods for the selection of variables in confounder control. Many authors condemn any use of significance testing, some encourage such testing, and other propose a mixed approach. This paper presents the results of a Monte Carlo simulation of several confounder selection criteria, including change-in-estimate and collapsibility test criteria. The methods are compared with respect to their impact on inferences regarding the study factor's effect, as measured by test size and power, bias, mean-squared error, and confidence interval coverage rates. In situations in which the best decision (of whether or not to adjust) is not always obvious, the change-in-estimate criterion tends to be superior, though significance testing methods can perform acceptably if their significance levels are set much higher than conventional levels (to values of 0.20 or more).
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            Breastfeeding provides passive and likely long-lasting active immunity.

            Lars Hanson (1998)
            The reader of this review will learn about the mechanisms through which breastfeeding protects against infections during and most likely after lactation, as well as possibly against certain immunologic diseases, including allergy. I have followed the literature in the area closely for the last 30 to 40 years and have made repeated literature searches through MEDLINE, most recently in 1998. Textbooks and peer-reviewed journals have been sought for, as well as books representing meeting reports in English, French, German, and Spanish. Human milk protects against infections in the breastfed offspring mainly via the secretory IgA antibodies, but also most likely via several other factors like the bactericidal lactoferrin. It is striking that the defense factors of human milk function without causing inflammation, some components are even directly anti-inflammatory. Protection against infections has been well evidenced during lactation against, e.g., acute and prolonged diarrhea, respiratory tract infections, otitis media, urinary tract infection, neonatal septicemia, and necrotizing enterocolitis. There is also interesting evidence for an enhanced protection remaining for years after lactation against diarrhea, respiratory tract infections, otitis media, Haemophilus influenzae type b infections, and wheezing illness. In several instances the protection seems to improve with the duration of breastfeeding. Some, but not all studies have shown better vaccine responses among breastfed than non-breastfed infants. A few factors in milk like anti-antibodies (anti-idiotypic antibodies) and T and B lymphocytes have in some experimental models been able to transfer priming of the breastfed offspring. This together with transfer of numerous cytokines and growth factors via milk may add to an active stimulation of the infant's immune system. Consequently, the infant might respond better to both infections and vaccines. Such an enhanced function could also explain why breastfeeding may protect against immunologic diseases like coeliac disease and possibly allergy. Suggestions of protection against autoimmune diseases and tumors have also been published, but need confirmation. Breastfeeding may, in addition to the well-known passive protection against infections during lactation, have a unique capacity to stimulate the immune system of the offspring possibly with several long-term positive effects.
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              Breastfeeding protects against infectious diseases during infancy in industrialized countries. A systematic review.

              Liesbeth Duijts, Made Ramadhani, Henriëtte A. Moll (2009)
              Firstly, this review was performed to assess the effect of breastfeeding on infections during infancy in industrialized countries. Secondly, the effect of duration and exclusiveness of breastfeeding were explored. Studies were identified using Medline, Cochrane Library, Science Citation Index and by a manual search from bibliographies of articles from August 1986 to January 2008. Follow-up, case-control and randomized controlled trial (RCT) studies performed in an industrialized country, published in English, with breastfeeding as a determinant, with overall infections, gastrointestinal or respiratory tract infections as a major outcome, and at least 40 participants in the study were included. Using Bauchner's criteria published in a review in 1986, two reviewers and a peer reviewer assessed the internal validity of those studies. Twenty-one studies that met the inclusion and internal validity criteria were included. These included 16 follow-up and four case-control studies and one RCT. Four out of five studies observed decreased effects on overall infections in breastfed infants. With regard to gastrointestinal infections, six out of eight studies suggested that breastfeeding had a protective effect. Thirteen out of 16 studies concluded that breastfeeding protects infants against respiratory tract infections. Five studies combined duration and exclusiveness of breastfeeding. All studies observed a protective dose/duration-response effect on gastrointestinal or respiratory tract infections. These studies strongly suggest that breastfeeding protects infants against overall infections, gastrointestinal and respiratory tract infections in industrialized countries. The optimal duration of exclusive breastfeeding for protection against infectious diseases needs to be studied in more detail.
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                Author and article information

                Contributors
                Stephania A. Cormier: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 23 February 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 2
                Electronic Location Identifier: e0172763
                Affiliations
                [1 ]The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
                [2 ]The Department of Pediatrics, Sophia Children’s Hospital, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
                [3 ]The Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
                [4 ]The Department of Global Public Health, Leiden University College, The Hague, The Netherlands
                [5 ]The Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
                University of Tennessee Health Science Center, UNITED STATES
                Author notes

                Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: J.C. Kiefte-de Jong and O.H. Franco work at ErasmusAGE, a center for aging research across the life course funded by Nestlé Nutrition (Nestec Ltd.); Metagenics Inc.; and AXA. The other authors have indicated they have no potential conflicts of interest to disclose. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                • Conceptualization: VJ AH HM.

                • Formal analysis: IT JKJ.

                • Funding acquisition: VJ AH HM OF HR JJ.

                • Investigation: IT JKJ HM.

                • Methodology: IT JKJ HM.

                • Project administration: VJ.

                • Resources: VJ AH HR OF JJ HM.

                • Supervision: JKJ HM.

                • Writing – original draft: IT JKJ.

                • Writing – review & editing: HR VJ OF AH JJ HM.

                Article
                Publisher ID: PONE-D-16-10693
                DOI: 10.1371/journal.pone.0172763
                PMC ID: 5322970
                PubMed ID: 28231310
                SO-VID: 064d1a6c-02b5-47e0-8981-ab37c3ce018d
                Copyright © © 2017 Tromp et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 14 March 2016
                Date accepted : 9 February 2017
                Page count
                Figures: 0, Tables: 4, Pages: 12
                Funding
                This phase of the Generation R Study was supported by the Erasmus Medical Center, the Erasmus University Rotterdam, the Netherlands Organization for Health Research and Development (Zon Mw) and Europe Container terminals B.V. The funders had no role in the design of the study, the data collection and analyses, the interpretation of data, or the preparation of, review of, and decision to submit the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Maternal Health
                Subject: Breast Feeding
                Subject: Medicine and Health Sciences
                Subject: Pediatrics
                Subject: Neonatology
                Subject: Breast Feeding
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Respiratory Infections
                Subject: Upper Respiratory Tract Infections
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Respiratory Infections
                Subject: Lower Respiratory Tract Infections
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Respiratory Infections
                Subject: Research and Analysis Methods
                Subject: Research Design
                Subject: Survey Research
                Subject: Questionnaires
                Subject: People and Places
                Subject: Population Groupings
                Subject: Age Groups
                Subject: Children
                Subject: Infants
                Subject: People and Places
                Subject: Population Groupings
                Subject: Families
                Subject: Children
                Subject: Infants
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Maternal Health
                Subject: Pregnancy
                Subject: Medicine and Health Sciences
                Subject: Women's Health
                Subject: Obstetrics and Gynecology
                Subject: Pregnancy
                Subject: Biology and Life Sciences
                Subject: Nutrition
                Subject: Diet
                Subject: Beverages
                Subject: Milk
                Subject: Breast Milk
                Subject: Medicine and Health Sciences
                Subject: Nutrition
                Subject: Diet
                Subject: Beverages
                Subject: Milk
                Subject: Breast Milk
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Body Fluids
                Subject: Milk
                Subject: Breast Milk
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Body Fluids
                Subject: Milk
                Subject: Breast Milk
                Subject: Biology and Life Sciences
                Subject: Physiology
                Subject: Body Fluids
                Subject: Milk
                Subject: Breast Milk
                Subject: Medicine and Health Sciences
                Subject: Physiology
                Subject: Body Fluids
                Subject: Milk
                Subject: Breast Milk
                Custom metadata
                Data Availability All relevant data are within the paper and its Supporting Information files.

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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