1. Calcutta National Medical College and Hospital, West Bengal, India; anan.gopal@gmail.com
2. Calcutta National Medical College and Hospital, West Bengal, India; nanditashetty90@gmail.com

*             Correspondence: anan.gopal@gmail.com

Keywords: long term effects, breast feeding, infacts, neurocognitive, gross-development

1. INTRODUCTION

Human milk, or breastmilk, is intricately tailored to meet the nutritional needs of human infants, representing the biologically inherent method of infant feeding. In contrast to the use of breastmilk substitutes such as infant formula, breastfeeding offers a plethora of health advantages. Despite this, there has been a proactive promotion of infant formula as an alternative on par with breast milk. Consequently, it is imperative for the research evidence elucidating the health benefits of breastmilk and breastfeeding to compellingly advocate for breastfeeding as the optimal choice [1]. The recommendation is for exclusive breastfeeding during the initial six months of an infant’s life to support their optimal growth and development while reducing the risks of morbidity and mortality. Nevertheless, in cases where breastfeeding isn’t possible for certain mothers, the necessity arises for infant formulas designed to replicate human milk. It becomes essential to rigorously assess the safety and effectiveness of each formula to ensure its suitability for infant consumption [2]. In stark contrast, breast milk’s nutrient composition undergoes substantial changes during lactation, particularly in its early stages, with noticeable variations throughout lactation for various nutrients. The objective is to make the performance of formula-fed infants as closely aligned with breastfed infants as possible, leading to efforts to adjust infant formula composition accordingly. Yet, there hasn’t been a systematic effort to gradually adapt the composition of infant formula to mimic the evolving pattern of breast milk. This presents both technical and nutritional challenges but is now within the realm of possibility [3,4]. The act of exclusive breastfeeding until 6 months is associated with significantly favourable effects on weight, length gain in infants and lower probability of stunting, wasting, and infections. Breast milk provides the optimal balance of essential minerals and vitamins to achieve healthy weight and height milestones [5]. Breastfeeding has been widely acknowledged as a highly advantageous practice for both mothers and children. It supplies vital nutrients and antibodies crucial for infant immune system development, simultaneously nurturing a profound emotional connection between parent and child [6]. Despite these clear benefits, there is still much to be learned about the specific ways in which breastfeeding impacts overall health and development. For this reason, further research in this area is necessary to explore the potential benefits of prolonged breastfeeding, as well as to identify any potential risks or limitations associated with this practice [7]. Through careful study and analysis, this research can be used to inform public policy, guide clinical practices, and ultimately improve the health outcomes of mothers and children throughout the world.

2. MATERIALS AND METHODS

We carried out a systematic review following the established guidelines and protocols for conducting systematic reviews, with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic review is a meticulous and exhaustive research approach used to compile current evidence related to a particular research query or subject in an open and impartial fashion. The study design involved a comprehensive and rigorous approach to gather, evaluate, and synthesize the available evidence on the topic of interest. This systematic review followed the guidelines outlined in the ‘Preferred Reporting Items for Systematic Review and Meta-analysis’ protocols (PRISMA) protocol. We conducted searches across three databases namely MEDLINE, Google Scholar and PubMed encompassing a time span from January 2002 to December 2022, covering global research. The search strategy employed a set of keywords, including exclusive breastfeeding, exclusive formula feeding, health outcomes, motor development, and infants. The specific search query utilized was as follows: (“Exclusive breastfeeding” OR “Exclusive Breastmilk” OR “Exclusive Formula Feeding”) AND (“Positive health outcomes” OR “Neural Development” OR “Immune status”). Variables like height, weight, BMI, cognitive function and motor development were assessed using randomized controlled trials, observational analysis and cohort study. Only full-text study in the English language was included. Duplicate records were removed, studies conducted in low-income countries were excluded, as were those lacking pertinent outcomes. Additionally, articles which focused exclusively on breastfeeding duration, the influence of maternal health on milk composition, comparisons between various infant formula formulations, investigations concerning low birth weight (LBW) infants and molecular genomics, as well as systematic reviews and articles with solely abstracts were excluded from the analysis. The initial database search left us with 1324 articles.

Figure 1: PRISMA Flow Chart

Each author was tasked with reviewing specific articles to determine their suitability for inclusion in the study. They independently evaluated the titles and abstracts of these articles, applying predefined eligibility criteria. Articles that passed this initial screening phase proceeded to the next stage, where they were comprehensively examined in full-text format. During this phase, each article underwent an independent assessment to ensure that important contributions were not inadvertently excluded and to mitigate any potential bias. In the end, 37 articles were found to meet the inclusion criteria and were then used for data extraction. The items of data that were extracted included the year of study, the country where the study was conducted, study design, the target year of the study, the central area of focus in the respective study i.e., parameters of growth in children after the promotion of breastfeeding e.g., height, weight, BMI, cognitive function and motor development of children who are breastfed.

3. RESULTS AND DISCUSSION

In our systematic review encompassing 13 eligible studies, we scrutinized the influence of various breastfeeding practices on key developmental parameters in infants. The studies diverged in their interventions, including exclusive breastfeeding, predominant breastfeeding, any breastfeeding, promotion of breastfeeding, and exclusive formula feeding, or by comparing different modes of intervention. Among the 13 studies, 5 (38.4%) focused on height. Two (40%) found a positive correlation with breastfeeding, while 2 (40%) found no significant impact, and one (20%) reported a negative correlation. Weight was investigated in 7 out of the 13 studies (53.8%). Four (57.14%) showed a positive relationship with breastfeeding, while 2 (28.57%) revealed a negative correlation, and one (14.3%) found no significant association. BMI was studied in 3 of the 13 studies (23%), with 2 (66.6%) indicating a positive connection and one (33.3%) suggesting no significant correlation. Cognitive function and IQ were examined in 5 of the 13 studies (38.4%). Among them, 3 studies (60%) found a positive correlation with breastfeeding, while 2 (40%) did not observe a significant correlation. Motor development was considered in 4 out of 13 studies (30.7%), with 3 studies reporting improved gross and fine motor skills associated with breastfeeding. One study, however, did not report any remarkable outcome.

Figure 2: Forest plot demonstrating the number of studies that mention each variable

Breastfeeding extends far beyond its nutritional and health benefits; it plays a pivotal role in fostering the essential mother-infant relationship and nurturing the healthy development of an infant’s brain and overall physical well-being [8]. However, practices around breastfeeding vary widely, with observations revealing the use of often small quantities of warm, energetic, and natural foods. In certain communities, rituals like ‘ghutti’ carry religious and medicinal significance, serving as a means to welcome newborns, purify their bodies, and construct their identity. Unfortunately, the methods used to introduce these first feeds can sometimes be unhygienic, leading to potential infections [9]. Additionally, urban women in Lahore exhibit good knowledge and positive attitudes towards breastfeeding, but there’s a need to strengthen optimal breastfeeding practices [10]. Short tongue-tie, restricting tongue movement, has emerged as a potential cause of breastfeeding difficulties in infants, affecting a significant percentage of them [11]. Despite extensive efforts to promote breastfeeding, top feeding and mixed feeding remain prevalent, contributing to malnutrition among children [12]. This highlights    the   urgent   need    for    further initiatives to encourage and support exclusive breastfeeding, as evident from the study’s findings. This systematic review included 13 studies examining infant development in various aspects, including height, weight, BMI, cognitive function, and motor skills. The studies looked at interventions like exclusive breastfeeding, predominant breastfeeding, partial breastfeeding, breastfeeding promotion, and exclusive formula feeding, sometimes making comparisons between them. Out of the five studies that examined the impact of breastfeeding on height, three found a notable correlation, while the remaining two did not report any significant influence on height. These findings align with Ahmed et al.’s study [26], indicating breastfeeding’s importance for infant height. In one of two studies with a positive correlation, breastfed infants exhibited greater height growth than those on the standard formula, while infants fed lipid-enriched formula showed even more pronounced height gain than those receiving breast milk [21]. Among the 4 studies revealing a positive link between breast milk and weight, one study showed that breastfed infants displayed higher initial weight gain, while formula-fed infants showed progressively increasing weight gain as they matured [15]. The findings match those found in a study by Iguacel et al [27], in which it was observed that during the complementary feeding period, formula-fed infants tend to exhibit faster rates of weight gain compared to infants who are breastfed. In another one out of those 4 studies, we found that weight gain is greater in breastfed infants than those on the standard formula, while infants on lipid-rich formula show more weight gain compared to those receiving breast milk [21]. Among the two studies showing a positive link between breastfeeding and BMI, one revealed that breastfed infants displayed a more substantial initial increase in BMI, while formula-fed infants exhibited a progressively higher increase in BMI as they advanced in age [15]. This finding is similar to that found in a study by Owen et al [28], stating that breastfeeding correlated with a somewhat lower average BMI compared to formula  feeding. However,   the   distinction   was modest and was susceptible to significant influence from publication bias and the presence of confounding variables. Research has yielded varying outcomes regarding breastfeeding’s impact on child development. In one study, infants who were never breastfed exhibited an elevated risk of experiencing both gross and fine motor delays [13]. Importantly, a robust correlation was observed between breastfeeding duration and the attainment of developmental milestones, and these relationships held significance even after adjusting for multiple variables [18]. In a separate investigation, extended breastfeeding was positively linked to heightened cognitive, language, and motor development scores among infants at 18 months of age. This correlation remained independently significant after meticulously accounting for an extensive array of parental and infant factors [16,17]. However, despite these positive associations, the precise connection between the duration of breastfeeding and its influence on infant motor and cognitive development remains a subject of debate [29]. This contentious issue arises from establishing a definitive causal link between breastfeeding patterns and developmental         outcomes proves challenging due to complexities like the intricate interplay of numerous confounding factors, including socioeconomic variables and the health of both mother and child. While some studies highlight the cognitive benefits of prolonged and exclusive breastfeeding, contrasting results and ongoing debate persist in the field. Understanding the nuanced nature of these associations, the role of diverse contributing factors, and the inherent limitations of such research endeavors remains crucial for advancing our comprehension of breastfeeding’s impact on infant development.

4. CONCLUSION

In conclusion, this systematic review of 13 studies reveals that breastfeeding can influence various aspects of infant development, including height, weight, BMI, cognitive function/IQ, and motor development. The findings are mixed, with some studies showing positive correlations, while others report no significant impact or even negative associations. This underscores the need for a nuanced understanding of how breastfeeding can affect infant development, taking into account the specific context and methodologies of individual studies.

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