Infant Antibiotic Use, Hospitalizations for Infections, and Breastfeeding
by Anne Eglash MD, IBCLC, FABM
I typically assume that the average person on this planet knows that breastfed infants are healthier. In a 2017 survey among 392 teenagers in Punjab, India, 93% knew that breastfed infants are heathier than those who artificially feed. Among these teens, at least 25% of their mothers had less than a secondary education. On the other hand, a 2018 study among 949 males studying at a public college in Texas, 72% didn’t know that breastfeeding decreases the risk of diarrhea, and more than 50% didn’t acknowledge that breastfeeding reduces ear infections. Among these young men, more than 75% had mothers with education beyond a high school degree.
Therefore, we cannot assume that knowledge on the beneficial health benefits from breastfeeding are ubiquitous. Moving on… The article for this week’s CQW is a French study that evaluated the relationship between breastfeeding and rates of infections, hospitalizations for infections, and antibiotic use in a high-resource country. The researchers gathered prospective data from families on infant feeding among 9703 children, mainly asking about ‘ever breastfed’ or duration of time that the infants were ‘predominantly’ breastfed (no formula or animal milk). They also asked the families about hospitalizations, episodes of bronchiolitis, and frequency of antibiotic use in the last 12 months. They also collected demographic data, such as smoking status, maternal BMI, birthing history, and childcare facility use. The data was compared to infants who were never breastfed.
- There was no relationship between breastfeeding and at least 3 ear infections in the first 2 years of life.
- Any breastfeeding was associated with a lower risk of using antibiotics twice in the first 2 years of life.
- Infants with any breastfeeding were less likely to be hospitalized than those never breastfed.
- Predominant breastfeeding for more than 3 months was associated with a lower risk of longer hospitalizations (> 4 days).
See the Answer
In low- and middle-income countries, the protective effect of breastfeeding against infections is well established, but in high-income countries, the effect could be weakened by higher hygienic conditions. We aimed to examine the association between breastfeeding and infections in the first 2 years of life, in a high-income country with relatively short breastfeeding duration. Among 10,349 young children from the nationwide Etude Longitudinale Française depuis l’Enfance (ELFE) birth cohort, breastfeeding and parent-reported hospitalizations, bronchiolitis and otitis events, and antibiotic use were prospectively collected up to 2 years. Never-breastfed infants were used as reference group. Any breastfeeding for <3 months was associated with higher risks of hospitalizations from gastrointestinal infections or fever. Predominant breastfeeding for <1 month was associated with higher risk of a single hospital admission while predominant breastfeeding for ≥3 months was associated with a lower risk of long duration (≥4 nights) of hospitalization. Ever breastfeeding was associated with lower risk of antibiotic use. This study confirmed the well-known associations between breastfeeding and hospitalizations but also highlighted a strong inverse association between breastfeeding and antibiotic use. Although we cannot infer causality from this observational study, this finding is worth highlighting in a context of rising concern regarding antibiotic resistance.
The researchers had a hard time finding an association between breastfeeding and rate of ear infections and hospitalizations. The researchers indicated that 3 ear infections in 2 years might be too low of a cut-off to see a difference in breastfed vs artificially fed infants. I agree with this, since many breastfed infants will develop upper respiratory infections, and have fluid in their middle ears. Technically these are called ‘ear infections’ but often not bacterial. Parental surveys would not distinguish these events. Using medical records to measure the incidence of ‘otitis media’ for which antibiotics are prescribed would be more accurate.
The strongest finding was the association between any breastfeeding, predominant breastfeeding and frequency of antibiotic use. Longer breastfeeding was associated with less antibiotic use. Given the rise of antibiotic stewardship in communities around the country, it would make sense that breastfeeding promotion and support should be included in ongoing public health messaging about appropriate antibiotic use. More robust research is also needed in this area.