Infant benefits of breastfeeding

Author: Richard J Schanler, MD

Section Editor: Steven A Abrams, MD
Deputy Editor: Alison G Hoppin, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2017. | This topic last updated: Dec 09, 2016.

INTRODUCTION Human milk is recommended as the exclusive nutrient source for feeding term infants for
the first six months of life and should be continued with the addition of solid foods after six months of age
[1,2]. Breastfeeding for all infants is strongly supported by both governmental and medical professional
organizations because of its acknowledged benefits with respect to nutrition, gastrointestinal function, host
defense, and psychological well-being [1,3-6]. In addition to these direct short-term benefits, breastfeeding is
associated with long-term benefits to the infant and mother. Systematic reviews of the literature have
demonstrated multiple benefits of breastfeeding for both the infant and mother [7,8].

The benefits of breastfeeding for the infant will be reviewed here. The maternal and economic benefits of
breastfeeding and breastfeeding during the perinatal period, including the contraindications to breastfeeding,
are discussed separately. (See "Maternal and economic benefits of breastfeeding" and "Breastfeeding:
Parental education and support".)

DIRECT BENEFITS Breastfeeding has direct clinical benefits for the infant as well as potential-long term
benefits that are realized after the breastfeeding period. The direct benefits of human milk include
improvement in gastrointestinal function and host defense, and prevention of acute illnesses (eg, acute otitis
media) during the time of breastfeeding [7].

Gastrointestinal function Several components of human milk stimulate gastrointestinal growth and
motility, which enhance the maturity of the gastrointestinal (GI) tract. Other factors are protective and
decrease the risk of necrotizing enterocolitis (NEC) and other infections [9,10].

These stimulatory and protective components include:

Hormones (eg, cortisol, somatomedin-C, insulin-like growth factors, insulin, and thyroid hormone) may
affect intestinal growth and mucosal function [11,12].
Growth factors (eg, epidermal growth factor [EGF] and nerve growth factor) affect development of the
intestinal tract and may be protective against invasive disease [12]. EGF is a polypeptide that stimulates
DNA synthesis, protein synthesis, and cellular proliferation in intestinal cells [13]. EGF resists proteolytic
digestion, is found in the intestinal lumen in suckling animals, and has been associated with protection
from NEC in experimental models [14,15]. Nerve growth factor may play a role in the innervation of the
intestinal tract.
Gastrointestinal mediators (eg, neurotensin and motilin) may affect gastrointestinal motility [11,12,16].
Free amino acids may be trophic for intestinal growth (eg, taurine) and may stimulate enterocyte
growth (eg, glutamine) [13].
Anti-inflammatory agents (eg, interleukin 10) may reduce the risk of NEC. Interleukin-10 is an anti-
inflammatory cytokine that decreases inflammation and injury to the gastrointestinal tract [17,18]. In
addition, polyunsaturated fatty acids modulate inflammatory reactions and may protect the
gastrointestinal tract from NEC [19].
Enzymes (eg, platelet-activating factor [PAF] acetylhydrolase) protect the GI tract. PAF-acetylhydrolase
degrades PAF, a potent mediator of intestinal injury induced during necrotizing enterocolitis [20].

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 Immunoglobulins IgA and IgG may play an important role by enhancing mucosal immunity and, thus,
protecting the GI tract from foreign antigens or microorganisms, and contributing to the prevention of
NEC. (See "Human milk feeding and fortification of human milk for premature infants", section on
'Protection against necrotizing enterocolitis'.)
Human milk is associated with neonatal intestinal colonization by the beneficial microbes of the
Bifidobacteria and Lactobacillus species rather than potential enteropathogenic bacteria, such as
Streptococci and Escherichia coli [21]. Bifidobacteria and Lactobacillus species are the usual microbial
agents used in probiotic preparations, which have been used to prevent necrotizing enterocolitis, and to
treat colic and gastroenteritis in children. (See "Prevention of necrotizing enterocolitis in newborns",
section on 'Probiotics' and "Infantile colic: Management and outcome", section on
'Probiotics' and "Acute viral gastroenteritis in children in resource-rich countries: Management and
prevention", section on 'Probiotics'.)
When compared with formula, human milk has been shown to:
Increase the rate of gastric emptying [22,23].
Increase the intestinal lactase activity in premature infants [24].
Decrease the intestinal permeability early in life in premature infants [25].
Decrease the risk of NEC in premature infants. Premature infants who receive human milk have a
lower incidence of NEC compared with those receiving formula. This lower incidence is observed even if
mother's milk is supplemented with formula. The mechanism for the protection from NEC is unclear.
However, human milk contains several previously mentioned components that may have protective
effects (ie, immunoglobulins A and G, platelet activating factor-acetylhydrolase, polyunsaturated fatty
acids, EGF, interleukin-10, and intestinal colonization with the favorable microbes of the Bifidobacteria
and Lactobacilli species). The benefit of human milk in prevention of NEC is discussed in greater detail
separately. (See "Human milk feeding and fortification of human milk for premature infants", section on
'Protection against necrotizing enterocolitis'and "Pathology and pathogenesis of necrotizing enterocolitis
in newborns".)
Anti-microbial components Human milk contains a variety of heterogeneous agents that possess
antimicrobial activity. Many of these factors have the following traits:
Persist through lactation
Resist the digestive enzymes in the infant's gastrointestinal tract
Act at the mucosal surfaces (eg, gastrointestinal, respiratory, and urinary tracts)

Protein Specific proteins, such as lactoferrin, lysozyme, and secretory component of immunoglobulin A,
are found in the whey fraction of human milk protein. They are generally resistant to proteolytic degradation,
line the mucosal surfaces preventing microbial attachment, and inhibit microbial activity [26-29].

Lactoferrin has antimicrobial activity when not conjugated to iron (apolactoferrin). It may function with
other host defense proteins to affect microbial killing. One study found that supplementing the diet of
premature infants with bovine lactoferrin, which has 77 percent homology with human lactoferrin, was
associated with a significant reduction in late-onset sepsis and NEC [30].
Lysozyme is active against bacteria by cleaving cell walls.
Secretory immunoglobulin A (sIgA) is synthesized by plasma cells against specific antigens. These are
derived from the enteromammary and bronchomammary immune systems. They are major contributors
to the protective nature of human milk [31,32]. Maternal plasma cells produce sIgA antibody when the
mother is exposed to foreign antigens via her respiratory or gastrointestinal tract. In the mammary
gland, sIgA is synthesized by plasma cells in the interstitial spaces of the mammary gland and secreted
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 into milk. Ingestion of human milk provides the infant with passive sIgA antibody against these antigens
[28,31,32]. (See "Physiology of lactation", section on 'Transcytosis'.)
Lipid Components of lipid metabolism may be involved in improving host defenses against microbial
agents in the following manner:
Products of lipid hydrolysis, free fatty acids and monoglycerides, have a detergent-like property that
lyses viruses, bacteria, and protozoa, such as Giardia [33,34]. (See "Treatment and prevention of
giardiasis".)
Human milk bile salt stimulated lipase also may affect host defense because it promotes lipid
hydrolysis, which produces the previously mentioned protective lipid by-products [34].

Carbohydrate Oligosaccharides found in carbohydrate polymers and glycoproteins can change the
intestinal bacterial flora by facilitating the growth of Bifidobacteria and Lactobacillus species [35]. These
oligosaccharides act as receptor analogues for multiple antimicrobial agents, since their structures mimic
bacterial antigen receptors [36,37]. For example, urinary oligosaccharides mimic bacterial epithelial
receptors, thereby reducing bacterial adhesion to urinary epithelial cells [38,39].

White blood cells Human milk contains white blood cells, 90 percent of which are neutrophils and
macrophages. These cells contribute to antimicrobial activity through phagocytosis and intracellular killing
[26]. The lymphocytes in human milk may contribute to cytokine production (T-cells) or IgA production (B-
cells) [26,29].

Prevention of illnesses while breastfeeding- In both resource-rich and resource-poor nations, human milk
compared with formula decreases the risk of acute illnesses during the time period in which the infant is fed.

In resource-poor countries, the overall morbidity and mortality is substantially lower in breastfed versus
formula-fed infants [8,40]. In addition, the incidence of gastroenteritis and respiratory disease is lower in
breastfed infants [41-43]. In a systematic review of worldwide data, infants younger than six months in low-
and middle-income countries who were breastfed had 88 percent lower risk of death compared with those
who had not been breastfed [8].

In resource-rich countries, the attack rate of acute illnesses is lower among breastfed infants compared with
formula-fed infants [44]. The rate of hospitalization and outpatient visits during the first year of life is lower
among breastfed infants [45-49]. These findings suggest that the severity of illness is less in the breastfed
infant [47]. Infant death in the United States and other high-income countries also has been correlated with
lack of breastfeeding [8,50].

Breastfed compared with formula-fed infants have lower rates of diarrhea, respiratory tract illness, acute and
recurrent otitis media, and urinary tract infection. This is illustrated as follows:

Gastroenteritis Episodes of gastroenteritis and hospitalization for diarrhea are decreased in infants who
are breastfed compared with formula-fed infants [6,8]. This is illustrated by the following:
In one study, breastfeeding compared with formula feeding lowered the incidence of gastroenteritis
(defined as vomiting or diarrhea lasting 48 hours or more) during the first 13 weeks of life (3.0 versus
15.7 percent) [51]. These observations remained significant after adjustment for social class, maternal
age, and smoking.
In a second study of infants with mothers who had a high educational level (>16 years of education),
infants who were breastfed had fewer days of diarrhea than those who were formula-fed during the first
12 months of life (2.6 versus 6.3 days) [47]. This study controlled for parents' socioeconomic status,
number of siblings, and the use of day care.

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 In a population-based survey of the United Kingdom, the risk of hospitalization for diarrhea was
reduced in infants exclusively breastfed compared with infants who never breastfed (adjusted OR 0.37,
95% CI 0.18-0.78) [52]. There was a trend in reduced hospitalization in infants who were partially
breastfed compared with those who never breastfed (adjusted OR 0.63, 95% CI 0.32-1.25).

The protective effect of human milk appears to be due to the presence of maternal antibodies. This was
illustrated in a prospective study that demonstrated infants who were exclusively breastfed for over two
weeks compared with those exclusively breastfed for two weeks or less had fewer enterovirus infections by
one year of age (0.38 versus 0.59 infections per child) [53]. In infants exclusively breastfed for over two
weeks, a reduced rate of enterovirus was associated with high maternal enterovirus antibody levels in the
breast milk.

Respiratory disease Respiratory illnesses are reduced in frequency and/or duration in breastfed
compared with formula-fed infants [6,8,51,54-59]. This is illustrated by the following:
In one study, breastfed compared with formula-fed infants had a lower incidence of respiratory illness
during the first 13 weeks of life (25.6 versus 37 percent) [51].
Two studies reported a decrease in the incidence of wheezing and lower respiratory tract infection for
breastfed compared with formula-fed infants in the first four to six months of life [54,56].
A study of former premature infants demonstrated that infants who received human milk had fewer
days of upper respiratory symptoms compared with those who were formula-fed during the first seven
months of life (17.6 versus 38 days) [57].
In the previously mentioned population-based survey, the rate of hospitalization for lower respiratory
illnesses was reduced in infants exclusively breastfed compared with those who never breastfed
(adjusted OR 0.66, 95% CI 0.47-0.92) [52]. There was a trend in reduced hospitalization in infants who
were partially breastfed compared with those who never breastfed (adjusted OR 0.60, 95% CI 0.47-1.0).

The protection from respiratory illnesses derived from breast milk compared with formula appears to
attenuate by one year of age [54,56,57].

Otitis media The incidence of otitis media and recurrent otitis media are reduced in breastfed compared
with formula-fed infants, primarily for those younger than two years [8,60]. As an example, the incidence of
two or more episodes of otitis media was reduced in infants breastfed for one year compared with infants fed
formula (34 versus 54 percent) [47]. Feeding at the breast appears to be more beneficial than feeding
expressed breast milk [61].

Urinary tract infection In a case-control study, infants who were hospitalized for urinary tract infections
were less likely to have been breastfed compared with matched control patients [62]. A mechanism for this
protection has been suggested based on observations that breastfed infants have greater content of
oligosaccharides, lactoferrin, and secretory IgA in their urine compared with formula-fed infants [63].
(See 'Anti-microbial components' above.)

Sepsis The incidence of sepsis is reduced in premature infants receiving human milk. (See "Human milk
feeding and fortification of human milk for premature infants".)

LONG-TERM BENEFITS Breastfeeding may have long-term benefits after the period of breastfeeding.
Although evidence is often inconclusive, breastfeeding compared with feeding with formula may be

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associated with lower risk of subsequent acute illnesses, certain chronic diseases and hospitalization [49],
and improved neurodevelopmental outcome [7].

Acute illnesses Exclusive breastfeeding compared with formula feeding has a protective effect in
reducing acute illnesses even after breastfeeding is discontinued. As an example, infants in the first 12
months of life who were breastfed for more than six months had a lower incidence of recurrent otitis media
(defined by 3 episodes in a 6-month time period or 4 episodes in 12 months) compared with those who had
never breastfed (10 versus 20.1 percent) [64]. This protective effect is observed after adjustment for
confounding variables, such as family history of allergy, family size, use of day care, and smoking. In another
study, although the frequency of otitis media was not different, exclusively breastfed children in their second
year of life compared with those who had never breastfed had fewer symptomatic days during their episode
of otitis media (5.9 3.5 versus 8.8 5.3 days). In another study, increasing the duration of exclusive
breastfeeding resulted in decreasing risk of hospital admissions for acute infections [65].

Post-breastfeeding protection appears to increase with the duration of breastfeeding. This was illustrated in a
secondary analysis of the National Health and Nutrition Examination Survey III (NHANES III) of 2277 children
between 6 and 24 months of age [58]. After adjusting for demographic variables (including ethnicity and
socioeconomic status), childcare, and smoking exposure, infants who were exclusively breastfed for four to
six months compared with those exclusively breastfed >6 months were more likely to develop pneumonia
(OR 4.3, 95% CI 1.3-14.6) and have 3 episodes of otitis media (OR 1.95, 95% CI 1.1-3.6) during the 12-
month period immediately preceding the survey. There were no differences between the groups in the
likelihood of having 3 episodes of cold/influenza, developing wheezing, or having a first episode of otitis
media before one year of age. However, in another survey of patients from 6 to 72 months from NHANES III,
continued protection against respiratory tract infections was not sustained through six years of age.

Chronic disease There are reported associations between the duration of breastfeeding and a reduction
in incidence of obesity [66-70], cancer [66,71-73], adult coronary heart disease [74], certain allergic
conditions [75-78], type 1 diabetes mellitus, and inflammatory bowel disease [79]. However, it
remains uncertain whether there are clinically significant long-term benefits of breast milk versus formula for
these chronic conditions.

Obesity There may be a relationship between breastfeeding and the prevention of obesity. Although a
review has described an association between the two as an "obesity-related myth" [80], this claim may be
incorrect as it does not take into account a number of publications that have observed the protective effect of
breastfeeding against childhood overweight and obesity. These data include the following:
A study from the Centers for Disease Control and Prevention analyzed data from the national
Pregnancy Nutrition Surveillance System (PNSS) and reported that prolonged breastfeeding was
associated with a reduced risk of overweight among non-Hispanic white children for cumulative
breastfeeding for 6 to 12 weeks versus never breastfeeding (adjusted odds ratio [OR] of 0.70, 95% CI
0.50-0.99), and for breastfeeding for >12 months versus never breastfeeding (adjusted OR 0.49, 95%
CI 0.25-0.95) [81].
A comprehensive review from the Agency for Healthcare Research and Quality (AHRQ), which cited
three systematic reviews and meta-analyses of good to moderate methodological quality, reported an
association of breastfeeding with a reduction in the risk of obesity. In this analysis that accounted for
confounding factors, the pooled adjusted OR of overweight comparing ever breastfed with never
breastfed was 0.76 (95% CI 0.67-0.86), and for obesity, was 0.93 (95% CI 0.88-0.99) [82]. The AHRQ
report also referred to an earlier WHO meta-analysis that found increasing duration of breastfeeding
was associated with a 4 percent decrease in the risk of overweight.

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 A subsequent Japanese study that used data analyses of a nationwide longitudinal survey from 2001
to 2009 showed that exclusive breastfeeding when compared with formula feeding was associated with
a decreased risk of overweight (adjusted OR 0.85, 95% CI 0.69-1.05) and obesity (adjusted OR 0.55,
95% CI 0.39-0.78) [83]. This study was able to control for confounding factors including gender,
television viewing time, and computer game playing time, and maternal factors (educational attainment,
smoking status, and working status).
A large meta-analysis estimated that longer periods of breastfeeding were associated with a 26
percent reduction in the odds of overweight or obesity, and the effect was consistent across income
classifications [8].

In contrast, other studies have demonstrated breastfeeding does not prevent overweight or obesity [84-86].
This was illustrated by data from a cluster-randomized controlled trial of birth hospitals from Belarus of 13,880
subjects, infants delivered at birth hospitals that were randomly selected to provide an educational program
promoting exclusive breastfeeding had a higher rate of exclusive breastfeeding at three months of age and of
any breastfeeding through one year of age compared with those born at control hospitals [84]. In a
subsequent publication the (previously randomized) intervention promoting breastfeeding did not prevent
overweight or obesity at 11.5 years of age [85]. However, this study was limited by several factors: 1) it was
powered for evaluation of continuation of breastfeeding at three and six months of age, but not for childhood
outcomes such as obesity [87], 2) exclusively formula-fed infants had been excluded from the study, and 3)
the study was conducted in an area with a low 5 percent prevalence of obesity (compared with the 17 percent
rate in the United States).

Based on available literature, there appears to be an association between breastfeeding and obesity later in
life. The etiology of such a relationship is unclear and the effect may be significant, but small. Nevertheless,
even a small magnitude of effect should not be dismissed. Exposure to antibiotics early in life may attenuate
the protective effect of breastfeeding, raising the possibility that the effect is mediated by changes in the
intestinal microbiome [88]. (See "Definition; epidemiology; and etiology of obesity in children and
adolescents", section on 'Etiology'.)

Cancer Breastfeeding has been associated with a reduction in the overall risk of childhood cancer as well
as lymphoma and leukemia [71-73,89]. In a British population based case-control study, breastfeeding was
associated with small reduction in the risk of leukemia, Hodgkin lymphoma, nonhematologic cancers, and all
childhood cancers [72]. A meta-analysis that included 18 case-control studies reported that breastfeeding for
six months or more reduces the risk of childhood leukemia by 20 percent (odds ratio [OR] 0.80, 95% CI 0.72-
0.90) [89,90]. A protective effect also was detected for any amount of breastfeeding (OR 0.91, 95% CI 0.80-1.04).

Cardiovascular risk factors Data are also conflicted on the effects of breastfeeding on the risk of adult
cardiovascular disease (CVD).
Limited data associate breastfeeding with decreases in cardiovascular disease (CVD) risk factors
(dyslipidemia, obesity, and elevated C-reactive protein [CRP]) [91]. These findings indirectly link
breastfeeding with a reduced risk of adult CVD.
In a randomized trial, adolescents born preterm who received human milk compared with those who
received formula had a lower serum CRP and a lower ratio of low density lipoprotein (LDL) to high
density lipoprotein (HDL) cholesterol, indicative of a lower risk for CVD [92].
In a cross-sectional study of 13 to 16 year old children, breastfeeding was associated with increased
total cholesterol and LDL cholesterol concentrations in infancy but lower concentrations in adolescence
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 when compared with formula feeding [74,93]. However, in a report of adults (mean age 41 years) from
the Framingham Offspring Study, multivariate analysis found no effect of breastfeeding compared with
no breastfeeding during infancy on adult levels of HDL cholesterol after adjusting for BMI [94]. In
addition, a follow-up report from the cluster-randomized trial of birth hospitals from Belarus did not
demonstrate any difference in cardiometabolic risk factors (blood pressure; fasting levels of insulin,
adiponectin, glucose, and apolipoprotein A1; and risk of metabolic syndrome) at 11.5 years of age
between children born at the interventional and control birth centers [95]. In addition to the limiting
factors noted above (eg, low prevalence of obesity, power limitation to detect statically significant
differences, and the exclusion of formula-fed infants), the duration of follow-up may be insufficient to
detect differences in outcome [96].

Malocclusion Breastfeeding is probably associated with reduction in malocclusion. In an analysis of

studies done primarily in low and middle-income countries, breastfeeding was associated with a 68 percent
reduction in malocclusion [97]. (See "Oral habits and orofacial development in children", section on
'Breastfeeding'.)

Allergic conditions Breastfeeding may be beneficial in reducing the risk of allergic disease, however,
data are often conflicting and inconclusive, and are reviewed separately. (See "The impact of breastfeeding
on the development of allergic disease".)

Diabetes mellitus Breastfed compared with formula-fed infants appear to have a decreased risk of
developing type 1 diabetes mellitus [8]. This difference is thought to be due to a cell-mediated response to a
specific cow's milk protein, beta-casein, which may be involved in the pathogenesis of type 1 diabetes
mellitus. (See "Pathogenesis of type 1 diabetes mellitus", section on 'Cow's milk'.)

In addition, there are data suggesting that the incidence of type 2 diabetes mellitus is reduced in breastfed
infants compared with those who were formula-fed [91,98].

Neurodevelopmental outcome Although a number of studies have shown small neurodevelopmental

advantages in children who were breastfed compared with those who received formula, it remains uncertain
whether there is a clinically significant long-term benefit in neurodevelopmental outcome of breastfed
compared with formula-fed infants.

Cognitive development There have been several reports that breastfeeding slightly improves cognitive
development later in childhood and adolescence [8,99-105].

In one study of young adults (mean age 27.2 years), there was a positive association between the duration of
breastfeeding and scores from two cognitive tests [99]. With adjustment for potential confounding factors, the
mean Wechsler Adult Intelligence Scale Intelligence quotients (IQ) according to duration of breastfeeding
were as follows:
Breastfed 1 month: 99.4
Breastfed 1 to 3 months: 101.7
Breastfed 4 to 6 months: 102.3
Breastfed 7 to 9 months: 106.0
Breastfed >9 months: 104
In another report based upon the previously mentioned clinical trial from Belarus, cognitive function
evaluated by Wechsler Abbreviated Scales of Intelligence measured at 6.5 years of age was better in

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 the group of children who had a higher rate of exclusive breastfeeding at three months of age and of
any breastfeeding through one year of age compared with the control group [106]. The average
increases in test scores were 7.5 for verbal IQ and 2.9 for performance IQ.

Similar results were reported from the United Kingdom population-based Millennium Cohort study that
reported modest benefits with average increases in the scores in the British Ability Scales tests between two
and six points when performed at five years of age for children who were breastfed compared with those who
were never breastfed [107]. In addition, a French study from the ongoing EDEN Mother-Child Cohort Study
reported modest gains in language ability and motor function at two to three years of age with longer duration
of breastfeeding [102].

However, it has been challenging to determine whether or not breastfeeding has a positive effect on cognition
because of confounding variables [108]. A study that analyzed data from the 1979 United States national
longitudinal survey of youth reported that breastfeeding had little or no independent effect on the cognitive
ability of offspring when maternal intelligence was controlled [109]. However, a subsequent prospective
cohort study that adjusted for socioeconomic factors, maternal intelligence, and home environment cognitive
stimulation and emotional support, demonstrated that longer breastfeeding duration was associated with
higher scores on cognitive testing at three and seven years of age [103].

Improved long-term cognitive development in premature infants also has been reported with the receipt of
human milk during hospitalization, including in extremely low birth weight (ELBW) infants [110-113].

Improved cognitive function associated with breastfeeding may be due in part to gene-environment
interaction. This was illustrated by one study that evaluated IQ and analyzed genetic samples from 3269
participants of two birth cohorts in Great Britain and New Zealand [114]. Breastfeeding was associated with a
five to six point increase in IQ scores. A polymorphic variant of the FADS2 gene, which is involved with the
genetic control of fatty acid pathways, accounted for all the advantages in cognitive function associated with
human milk after controlling for confounding variables (eg, intrauterine growth, social class, and maternal
cognitive ability). These results suggest that the benefit of breastfeeding upon cognitive function is modulated
by variations of a gene involved in the control of fatty acid metabolism.

Visual function Several studies have indicated that human milk-fed term and premature infants have
improved visual function compared with formula-fed infants. This benefit has been attributed to
docosahexaenoic acid (DHA), which is a component of phospholipids found in brain, retina, and red cell
membranes [115,116]. DHA is present in human milk but not in bovine milk. The severity and incidence of
retinopathy of prematurity are decreased among breastfed compared with formula-fed infants [117-119]. This
association may relate to the substantial antioxidant capacity of human milk compared with formula [120].

In a study of 109 Inuit full term infants, more optimal visual, cognitive, and motor development was
associated with higher cord blood levels of DHA and not with DHA levels in human milk at 11 months of age
[121]. These results support the theory that DHA plays an important role in synaptogenesis of the brain and
photoreceptor during the third trimester, and maternal levels of DHA affect the visual function and
neurodevelopment of their offspring. In preterm infants without the maternal source of DHA, these findings
also support the use of human milk that contains DHA or supplementation of DHA in infants who are formula-
fed. (See "Nutritional composition of human milk and preterm formula for the premature infant", section on
'Long-chain polyunsaturated fatty acids'.)

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 Hearing function Auditory-evoked responses mature faster in breastfed premature infants [122].

Child behavior Data from the English Millennium cohort study based on parental interview and survey
suggested that breastfeeding for four months or longer was associated with a lower risk of behavior problems
in children at five years of age compared with a shorter duration of breastfeeding [123].

Stress reduction There appears to be an analgesic effect of breastfeeding, which may be due to the
enhanced maternal-infant bonding. Breastfed infants experience less stress during painful procedures than
formula-fed infants [124]. The lactation hormones, oxytocin and prolactin, are important components of the
stress axis and have a positive impact on social behaviors, including maternal-infant bonding [125]. Another
possible explanation for the analgesic effect of breastfeeding is a higher cortisol level in breastfed compared
with formula-fed infants [126]. Improved bonding may reduce infant stress.

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics"
and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5 th to
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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Pumping breast milk (The Basics)" and "Patient education:
Deciding to breastfeed (The Basics)")
Beyond the Basics topics (see "Patient education: Pumping breast milk (Beyond the
Basics)" and "Patient education: Deciding to breastfeed (Beyond the Basics)")
SUMMARY
Breastfeeding for all infants is strongly supported by both governmental and medical professional
organizations because of its acknowledged direct benefits to the infant's nutrition, gastrointestinal
function, host defense, and psychological well-being. (See 'Direct benefits' above.)
Human milk compared with formula may provide continued protection against acute illnesses even
after discontinuation of breastfeeding during the first few years of life. (See 'Acute illnesses' above.)
The long-term benefit of human milk on specific chronic diseases and neurodevelopment is uncertain
as data are often conflicting and limited. In addition, if there is an association, the magnitude of effect
may be small and not clinically significant. (See 'Chronic disease' above and 'Neurodevelopmental
outcome' above.)
REFERENCES

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model. Am J Physiol Gastrointest Liver Physiol 2002; 282:G156.
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