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Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil.

Summary Background Breastfeeding has clear short-term benefi ts, but its long-term consequences on human capital are yet to be established. We aimed to assess whether breastfeeding duration was associated with intelligence quotient (IQ), years of schooling, and income at the age of 30 years, in a setting where no strong social patterning of breastfeeding exists.

Methods A prospective, population-based birth cohort study of neonates was launched in 1982 in Pelotas, Brazil. Information about breastfeeding was recorded in early childhood. At 30 years of age, we studied the IQ (Wechsler Adult Intelligence Scale, 3rd version), educational attainment, and income of the participants. For the analyses, we used multiple linear regression with adjustment for ten confounding variables and the G-formula.

Findings From June 4, 2012, to Feb 28, 2013, of the 5914 neonates enrolled, information about IQ and breastfeeding duration was available for 3493 participants. In the crude and adjusted analyses, the durations of total breastfeeding and predominant breastfeeding (breastfeeding as the main form of nutrition with some other foods) were positively associated with IQ, educational attainment, and income. We identifi ed dose-response associations with breastfeeding duration for IQ and educational attainment. In the confounder-adjusted analysis, participants who were breastfed for 12 months or more had higher IQ scores (diff erence of 3·76 points, 95% CI 2·20–5·33), more years of education (0·91 years, 0·42–1·40), and higher monthly incomes (341·0 Brazilian reals, 93·8–588·3) than did those who were breastfed for less than 1 month. The results of our mediation analysis suggested that IQ was responsible for 72% of the eff ect on income.

Interpretation Breastfeeding is associated with improved performance in intelligence tests 30 years later, and might have an important eff ect in real life, by increasing educational attainment and income in adulthood.

Methods

Participants In 1982, fi ve maternity hospitals in Pelotas, Brazil, were visited daily and all births were identifi ed from labour ward records; 5914 neonates whose families lived in the urban area of the city were examined and their mothers were interviewed soon after delivery. The initial refusal rate was less than 1%, and the cohort has been followed up on several occasions.13 The study protocol is available online. Members of the original cohort were traced in 1984 (5161 [87%] individuals) and 1986 (4979 [84%] individuals). Between June 4, 2012, and Feb 28, 2013, cohort members were invited to visit a research clinic to be interviewed and examined. The Ethical Review Board of the Faculty of Medicine of the Federal University of Pelotas approved the study, and we obtained written informed consent from all participants.

Introduction 

Breastfeeding has clear short-term benefi ts for child survival through reduction of morbidity and mortality from infectious diseases.1 Breastfeeding also has longterm benefi ts. The results of a meta-analysis2 of 14 observational studies showed that breastfeeding was associated with an increase of 3·5 points (95% CI 1·9–5·0) on intelligence tests at childhood and adolescence.

Two randomised trials3,4 have also investigated this topic. In Belarus, intelligence quotients (IQs) at 6·5 years of age were, on average, 7·5 points higher in a group whose mothers received breastfeeding promotion than in a comparison group.3 In the UK, the mean IQ was higher in preterm children who were randomly allocated to receive breast milk than in those who received formula.

4 Three observational studies5–7 have explored the association between breastfeeding and performance in intelligence tests in adults. In Denmark, Mortensen and colleagues5 noted that breastfeeding duration was positively associated with performance on the Wechsler Adult Intelligence Scale (mean age 27 years), while Richards and colleagues6 reported a positive association with performance in the National Adult Reading Test in participants aged 53 years in the 1946 British cohort.

In the Hertfordshire cohort, participants were classifi ed as being bottle-fed, breastfed, or mixed fed; the breastfed group had increased mean scores in the AH4 IQ test, but the association disappeared after the investigators controlled for confounding variables.7 Evidence from observational studies.

Statistical analysis

We used ANOVA to compare means, and multiple linear regression to adjust the estimates for confounders. In the linear regression models, we graphically tested the normality of residuals and homoscedasticity (homogeneity of variance). We assessed multicollinearity between the explanatory variables using the variance infl ation factor. We based statistical comparisons between categories on tests of heterogeneity and linear trend, and we present the one with the lower p value. We used Stata 13·0 for the analyses. We did four sets of analyses to compare breastfeeding categories in terms of arithmetic means, geometric means, median income, and to exclude participants who were unemployed and therefore had no income.

Discussion

In this population-based, prospective birth cohort, breastfeeding duration was positively and linearly associated with performance in intelligence tests, educational attainment, and income at age 30 years. The magnitude of the identifi ed eff ects was important in public health terms. The diff erence in IQ between the most extreme groups was nearly four points, or about a third of a standard deviation; the increase of 0·9 years in education corresponds to roughly a quarter of a standard deviation, and the diff erence in income of R$341 was equivalent to about a third of average income.

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