Exclusive Breastfeeding and Cognition, Executive Function, and Behavioural Disorders in Primary School-Aged Children in Rural South Africa: A Cohort Analysis.
Exclusive breastfeeding (EBF) is associated with early child health; its longer-term benefits for child development remain inconclusive. We examine the associations between EBF, HIV exposure, and other maternal/child factors and the cognitive and emotional-behavioural development of children aged 7-11 y.



The Vertical Transmission Study (VTS) supported EBF in HIV-positive and HIV-negative women; between 2012 and 2014, HIV-negative VTS children (332 HIV exposed, 574 HIV unexposed) were assessed in terms of cognition (Kaufman Assessment Battery for Children Second Edition [KABC-II]), executive function (Developmental Neuropsychological Assessment Second Edition [NEPSY-II]), and emotional-behavioural functioning (parent-reported Child Behaviour Checklist, [CBCL]). We developed population means by combining the VTS sample with 629 same-aged HIV-negative children from the local demographic platform. For each outcome, we split the VTS sample into scores above or at/below each population mean and modelled each outcome using logistic regression analyses, overall and stratified by child sex. There was no demonstrated effect of EBF on overall cognitive functioning. EBF was associated with fewer conduct disorders overall (adjusted odds ratio [aOR] 0.44 [95% CI 0.3-0.7], p ≤ 0.01), and there was weak evidence of better cognition in boys who had been exclusively breastfed for 2-5 mo versus ≤1 mo (Learning subscale aOR 2.07 [95% CI 1.0-4.3], p = 0.05). Other factors associated with better child cognition were higher maternal cognitive ability (aOR 1.43 [95% CI 1.1-1.9], p = 0.02, Sequential; aOR 1.74 [95% CI 1.3-2.4], p < 0.001, Planning subscales) and crèche attendance (aOR 1.96 [95% CI 1.1-3.5], p = 0.02, Sequential subscale). Factors positively associated with executive function were home stimulation (aOR 1.36 [95% CI 1.0-1.8], p = 0.04, Auditory Attention; aOR 1.35 [95% CI 1.0-1.8], p = 0.05, Response Set) and crèche (aOR 1.74 [95% CI 1.0-3.0], p = 0.05, Animal Sorting). Maternal mental health problems and parenting stress were associated with increased emotional-behavioural problems on the total CBCL (aOR 2.44 [95% CI 1.3-4.6], p = 0.01; aOR 7.04 [95% CI 4.2-11.9], p < 0.001, respectively). Maternal HIV status was not associated with any outcomes in the overall cohort. Limitations include the nonrandomised study design and lack of maternal mental health assessment at the child's birth.



EBF was associated with fewer than average conduct disorders and weakly associated with improved cognitive development in boys. Efforts to improve stimulation at home, reduce maternal stress, and enable crèche attendance are likely to improve executive function and emotional-behavioural development of children.
Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa.|Human and Social Development Research Programme, Human Sciences Research Council, Durban, South Africa.|Section of Child and Adolescent Psychiatry, Department of Psychiatry, Oxford University, Oxford, United Kingdom.|Developmental Pathways to Health Research Unit, School of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa.
Tamsen J
TJ
Rochat
MRC/Wits Rural Public Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|School of Demography, The Australian National University, Canberra, Australia.|CU Population Center, Institute of Behavioural Science, University of Colorado at Boulder, Boulder, Colorado, United States of America.
Brian
B
Houle
Section of Child and Adolescent Psychiatry, Department of Psychiatry, Oxford University, Oxford, United Kingdom.|School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
Alan
A
Stein
MatCH Health Systems (Maternal, Adolescent and Child Health), KwaZulu-Natal, South Africa.
Hoosen
H
Coovadia
Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa.
Anna
A
Coutsoudis
Human and Social Development Research Programme, Human Sciences Research Council, Durban, South Africa.
Chris
C
Desmond
School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
Marie-Louise
ML
Newell
Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa.|School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.|Royal Hospital for Sick Children and Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.
Ruth M
RM
Bland
D001942:Breast Feeding / Q000706:statistics & numerical data*; D002648:Child; D002657:Child Development; D003071:Cognition; D056344:Executive Function; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders; D011446:Prospective Studies; D012424:Rural Population / Q000706:statistics & numerical data; D012574:Schools; D013019:South Africa; D013334:Students / Q000706:statistics & numerical data