Breastfeeding as a means to prevent infant morbidity and mortality in aboriginal Canadians: a population prevented fraction analysis.
McIsaac, Kathryn E. ; Moineddin, Rahim ; Matheson, Flora I. 等
Although infection and sudden infant death syndrome (SIDS) are
common causes of morbidity and mortality in all infants, (1,2)
Aboriginal infants appear to be disproportionately burdened. (3) This is
true in indigenous populations worldwide. (3) In Canada, such
disparities exist in our three Aboriginal populations--First Nations,
Inuit and Metis. (4)
Three infectious outcomes that Canadian Aboriginal infants
experience in excess frequency are gastrointestinal infection, lower
respiratory tract infection, and otitis media. (5-9) Older Canadian data
support a higher risk of gastrointestinal infection in Aboriginal groups
compared to non-Aboriginal groups (9) and there is similar evidence for
American Indian and Alaska Native infants. (8) Respiratory tract
infections are not only more frequent among Aboriginal infants, they
tend to result in more severe presentations requiring hospitalization.
(7) The same is true of otitis media. One study found that First Nations
infants have a slightly elevated risk of any otitis media (10%) but a
six times greater risk of hospitalization from otitis media compared
with other Canadians. (6) The substantial burden of otitis media has
been well documented in Inuit Canadians. (5) Canadian Aboriginal infants
are also disproportionately affected by SIDS. First Nations infants are
approximately five times more likely to die from SIDS compared with
other Canadian infants; Inuit infants are approximately 12 times more
likely to die. (10) Infant health indicators for Metis are not readily
available, but those of which we are aware suggest similar health
profiles to other Aboriginal Canadians. (4)
Interventions and programs to decrease health disparities early in
the life-course may not only impact the immediate health of Aboriginal
Canadian infants, but could improve their overall health trajectories.
One potential intervention is to promote breastfeeding. The World Health
Organization (WHO) recommends infants receive exclusive breastfeeding to
six months and continued breastfeeding with the addition of
complementary foods to two years of age and beyond. (11) Several
Canadian organizations, including Health Canada, concur. (12) The
recommendation is substantiated by many short- and long-term benefits,
including protection against SIDS, (13) gastrointestinal infection, (14)
respiratory tract infection (15) and otitis media. (16)
In recent years, the majority of Canadian mothers have initiated
breastfeeding (87.4%). (17) Canadian Aboriginals are less likely to do
so (77.8%) (17) and, accordingly, proportionally fewer Aboriginal
children can reap the benefits of breastfeeding. Protecting, promoting
and supporting breastfeeding could be a cost-effective means to
improving population health outcomes in Canadian Aboriginal infants.
The objective of this research was to determine the proportion of
excess cases of SIDS, gastrointestinal infection, respiratory tract
infection, and otitis media that breastfeeding could potentially prevent
in Aboriginal Canadian infants.
METHODS
The population attributable fraction (PAF) describes the proportion
of disease in a population that can be attributed to a particular
exposure. There are many approaches to calculating the PAF, but
Levin's formula is the most frequently used. (18,19) In its most
basic form, Levin's formula includes the prevalence of exposure in
the population ([p.sub.p]) and a single relative risk--the risk of the
outcome in the exposed relative to unexposed (RR).
Levin's PAF = [p.sub.p](RR - 1)/1 + [p.sub.p](RR - 1)
A corollary of the population attributable fraction (PAF) is the
population prevented fraction (PPF): the fraction of cases that could be
prevented in the population if everyone were exposed to the preventive
behaviour. The PPF reframes the PAF formula in one important way: the
prevalence of exposure in the population ([p.sub.p]) is defined as the
proportion of the population that does not engage in the preventive
behaviour. (20) In other words, if we were interested in the PPF
attributable to any breastfeeding and 90% of the population was
breastfed for some duration, the prevalence of exposure (i.e., not
receiving breastfeeding) would be 10%. Accordingly, all relative
measures of association should be expressed in relation to the
protective factor.
Our research used Levin's formula to estimate the PPF of
select health outcomes attributable to breastfeeding in Aboriginal
infants. Relative risks (RR) were extracted from previously published
meta-analyses and the prevalence of exposure ([p.sub.p]) from publicly
available population-based surveys. (21,22)
Data sources: prevalence of breastfeeding
Breastfeeding prevalence was abstracted from two national surveys:
the Canadian Community Health Survey (CCHS) (21,23) and the First
Nations Regional Health Survey (RHS). (22) We were specifically
interested in breastfeeding initiation: all infants for whom
breastfeeding was initiated were considered breastfed as infants.
Estimates of breastfeeding in Inuit, Metis and First Nations living
off-reserve were abstracted from the CCHS (2007-2010) using the
Government of Canada's Open Data. (21) We also abstracted estimates
for non-Aboriginal Canadians for comparison. Survey methodology for the
CCHS is described in detail elsewhere. (23) Briefly, the CCHS is an
annual population-based cross-sectional survey. Approximately 65,000
Canadians aged 12 years and older from each of the provinces (n = 10)
and territories (n = 3) are sampled each year. (23)
Estimates of breastfeeding of First Nations living on-reserve were
abstracted from the First Nations RHS, 2008/2010). (22) This was a
cross-sectional national survey of First Nations communities conducted
between June 2008 and November 2010. Participants in the RHS were
recruited from 216 First Nations communities in Canada, covering all of
the nation's provinces and territories except Nunavut: there are no
reserves in this territory. The child component of the RHS contained the
relevant questions on breastfeeding and was distributed to approximately
6,000 primary caregivers. More detailed methodology for the RHS is found
elsewhere. (22)
The CCHS asked all females aged 15 to 55 years of age who gave
birth in the last five years if their child was ever breastfed. A
similar question was asked of caregivers of children aged 11 years or
younger in the RHS and our estimates were restricted to reports from
biological mothers. Biological mothers generally have accurate recall of
breastfeeding initiation: the sensitivity and specificity are 82% and
93% respectively up to 15 years after birth. (24) Table 1 presents the
proportion of Aboriginal and other Canadian infants who were breastfed,
as reported by the CCHS (2007-2010) and the RHS (2008/2010). Between 60%
and 82% of Aboriginal Canadian infants were breastfed, compared to 88%
of non-Aboriginal Canadian infants.
Data sources: relative risk of failing to breastfeed
The relative risks of not being breastfed on four separate health
outcomes--SIDS, gastrointestinal infection, respiratory tract infection
and otitis media--were abstracted from published meta-analyses. (13-16)
These outcomes were selected because Aboriginal Canadians are
disproportionately affected by these conditions (6-8,10) and
breastfeeding reduces their incidence. (13-16)
Meta-analyses were identified from a Medline search, exploding the
terms 'meta-analysis' and 'breastfeeding' separately
and then combining with an ' and' statement. This search
generated 152 potential articles; of these, we identified 9 potential
meta-analyses through a title screen. For the current analyses, we
selected the 4 most recently published meta-analyses of studies in
healthy, term infants living in developed countries. (13-16) The
comparator of interest was receiving any vs. no breastfeeding, (25)
which was not reported for respiratory tract infection. (15) Instead we
used a risk estimate comparing at least four months of any breastfeeding
with no breastfeeding. (15) We also preferred adjusted risk estimates,
where available. A summary of the abstracted results is presented in
Table 2.
Sudden Infant Death
The relative odds of SIDS in infants receiving any relative to no
breastfeeding was abstracted from a meta-analysis of 18 case-control
studies. (13) Because SIDS is a rare outcome, the odds ratios from these
studies will approximate risk ratios and can be substituted in
Levin's formula to produce unbiased PPF estimates. (19) Included
studies used an "appropriate definition" of SIDS, which
generally meant a sudden and unexpected infant death with competing
causes ruled out by autopsy. (13) The relative effect of any compared
with no breastfeeding on SIDS was based on the pooling of 7 studies. All
relative risks in this pooled estimate were adjusted for at least one of
19 covariates, including but not limited to maternal age, parity and
social class. (13)
Gastrointestinal Infection
The relative risk of developing a gastrointestinal infection among
infants receiving any compared with no breastfeeding was extracted from
a meta-analysis of 14 cohort studies. (14) The maximum follow-up was 12
months. Gastrointestinal infection was defined as any illness that
resulted in vomiting or diarrhea or that was caused by a bacterial or
viral agent known to result in enteric infection. The pooled relative
risk was based on unadjusted measures of effect. (14)
Lower Respiratory Tract Infection
The effect of breastfeeding on developing a lower respiratory tract
infection in infancy was taken from a meta-analysis pooling 4
prospective cohort studies. (15) Follow-up in individual studies ranged
from 6 to 24 months. The specific outcome of interest was
hospitalization from lower respiratory tract infection, defined as
bronchiolitis, asthma, bronchitis, pneumonia, empyema and other
infections of the lower respiratory tract. The comparison of interest
was breastfeeding for at least four months relative to no breastfeeding.
The pooled relative risk estimate was adjusted for social class. (15)
Acute Otitis Media
Relative risk estimates for developing acute otitis media in
infants who received any breastfeeding relative to no breastfeeding were
obtained from a meta-analysis of 2 cohort studies. (16) Follow-up was up
to 12 months. Acute otitis media was defined by the presenting clinical
symptoms and was physician-diagnosed. The pooled relative risk was
adjusted for confounding factors, which could have included maternal
age, number of siblings or maternal smoking, among other variables. (16)
Statistical analysis
We estimated the PPF of four selected health outcomes that could be
attributed to breastfeeding for Inuit, Metis and First Nations. First
Nations may live on- or off-reserve and PPFs were estimated for both. We
also estimated the PPF in the Canadian non-Aboriginal identity
population. The exposure of interest was the prevalence of those who did
not receive any breastfeeding (i.e., [1-prevalence.sub.initiation]). All
abstracted risk estimates were inverted (i.e., 1/RR). Confidence limits
were estimated using the substitution method. (26)
RESULTS
PPF calculations used prevalence estimates of breastfeeding for
Aboriginal and non-Aboriginal Canadians (Table 1) and relative risks
from previously published meta-analyses (Table 2). The results of PPF
calculations are presented in Table 3.
Inuit
We estimated that 6.5% of otitis media, 29.2% of gastrointestinal
infection and 17.1% of hospitalizations from lower respiratory tract
infections could potentially be prevented if Inuit Canadian infants were
breastfed. We also found that 16.0% of cases of SIDS in Inuit infants
may be preventable.
First Nations
Among First Nations infants living off-reserve, we estimated that
breastfeeding could potentially prevent 5.1% of otitis media, 24.3% of
gastrointestinal infection, 13.8% of hospitalizations from lower
respiratory tract infections, and 12.9% of SIDS. It is possible that
breastfeeding could prevent even more of such outcomes in First Nations
infants living on-reserve: 10.6% of otitis media, 41.4% of
gastrointestinal infection, 26.1% of hospitalizations from lower
respiratory tract infections, and 24.6% of SIDS.
Metis
We estimated that breastfeeding could potentially prevent 6.1% of
otitis media, 27.9% of gastrointestinal infection, 16.2% of
hospitalizations from lower respiratory tract infections, and 15.1% of
instances of SIDS in Metis infants.
Non-Aboriginal
Non-Aboriginal Canadian infants would also benefit from
breastfeeding, although we estimated that proportionately fewer
instances of otitis media (3.5%), gastrointestinal infection (17.8%),
hospitalizations from lower respiratory tract infection (9.7%), and SIDS
(9.1%) were preventable.
DISCUSSION
This study estimated the proportion of excess cases of SIDS,
gastrointestinal infection, respiratory tract infection and otitis media
that potentially could be prevented if all Aboriginal infants were
breastfed. We found that a substantial proportion of select infant
health indicators may be prevented: between 13% and 25% of SIDS, 24% and
40% of gastrointestinal infection, 14% and 26% of hospitalizations from
respiratory tract infections and 5% and 11% of otitis media. This
proportion was between 1.5 to 2 times greater among Aboriginal as
opposed to non-Aboriginal Canadian infants.
It has been suggested the PPF should be estimated only when the
exposed group--in this case, those who do not receive any
breastfeeding--can realistically become unexposed. (18) There are very
few contraindications to breastfeeding. (12) Exceptions include mothers
with HIV, with concurrent substance use, or on certain medications and
therapies (e.g., radiotherapy with iodine); (27) breastfeeding is also
contraindicated for infants with galactosemia--a rare genetic disorder
affecting lactose metabolism. (12) Aboriginal Canadians are
disproportionately burdened by HIV (28) and accordingly, infants of
affected mothers should not be breastfed. However, we do not expect the
latter to constitute a large proportion of infants: a study in British
Columbia estimated that 30 of 10,000 pregnant First Nations mothers
tested positive for HIV between 2000 and 2003 representing a rate three
times higher than among other mothers, but still relatively rare. (28)
The PPF also has utility when public health programs can be
realistically developed and administered. (18) Programs across the globe
have been implemented to protect, promote and support breastfeeding. Our
finding that a high proportion of infection and SIDS in Aboriginal
Canadians could be prevented if they were breastfed underscores the
importance of targeting this population for focused intervention. One
approach may be to promote breastfeeding to the women themselves.
However, we agree with the recent recommendation to shift the bulk of
responsibility for failure to breastfeed away from the woman and on to
the health care system. (29)
Measures such as implementing the Baby Friendly Hospital Initiative
(BFHI)--an internationally embraced 10-item program put forward by
WHO--may improve breastfeeding in Aboriginals and other Canadians and in
turn reduce infant infection and mortality. Previous research suggests
that adhering to BFHI recommendations improves breastfeeding initiation
and duration. (30,31) Prioritizing the adoption of the BFHI in hospitals
where Aboriginal women give birth could be one potential approach.
Another strategy that has shown some success is providing access to
community-based programs, such as the Canadian Prenatal Nutrition
Program (CPNP), which aims to improve the well-being of vulnerable
infants through a variety of public health measures, including
education, support and counselling. Women who accessed this program the
most intensely were more likely to initiate and continue breastfeeding,
and Aboriginal women who participated were more likely to initiate
breastfeeding compared with non-Aboriginal participants. (32) Any and
all programs that are implemented to promote Aboriginal breastfeeding
should be developed in consultation with Aboriginal women and, where
possible, delivered by Aboriginal Canadians.
It is not surprising that the proportion of preventable illness and
mortality was greater in Aboriginal compared with non-Aboriginal
Canadians: the prevalence of breastfeeding was the only factor to vary
across PPF calculations and Aboriginal Canadians were less likely to
breastfeed. That said, the overall number of preventable infections and
sudden infant deaths attributable to breastfeeding would almost
certainly be greater in non-Aboriginal Canadians. Fewer than 10% of
Canadian children aged 0 to 4 years report Aboriginal identity. (33)
Even though the relative risk for each of this study's outcomes was
greater in Aboriginal infants, (6-9) Aboriginal Canadians would likely
constitute a small fraction of the overall number of cases. We did not
have access to the appropriate data to confirm, but this has been found
elsewhere; for example, Aboriginal Canadians have a substantially higher
incidence of TB but non-Aboriginal Canadians report the greatest number
of TB cases. (34) As such, we also encourage mass population-based
strategies that target breastfeeding in all new mothers. This approach
will have the greatest impact on reducing the overall number of cases of
infant infection and mortality.
There are several limitations which should be considered. Our PPF
calculations were based on estimates abstracted from other sources.
Prevalence estimates were from recent Canada-wide population-based
surveys, and arguably provide some of the best estimates of
breastfeeding practices in Aboriginal Canadians. Relative risks were
from meta-analyses conducted in healthy, term infants in developed
countries. Meta-analyses allow for more robust conclusions about the
true magnitude of effects compared to individual studies, yet using
relative risks from a variety of populations, the underlying assumption
is that the risk of endpoints--infection or mortality from SIDS--would
be the same for Canadian Aboriginal infants. We do not expect this to be
a concern since there is an established biological relationship between
breast milk and immune function in infancy, existing irrespective of
race and ethnicity. (35)
The final abstracted relative risk estimates may have been biased
as a result of a) residual confounding or b) heterogeneity in the
unexposed group (i.e., those receiving breastfeeding). In regards to the
former, risk estimates for gastrointestinal infection were unadjusted
while risk estimates for respiratory tract infection were adjusted only
for social class. In regards to the latter, the unexposed group may have
included infants who were breastfed exclusively for 6 months as well as
infants who were breastfed for less than one week. In either case, the
magnitude of these abstracted relative effects may be exaggerated,
resulting in an over-estimation of the PPF.
Finally, estimates of the PPF were generated using Levin's
formula, which produces biased estimates with adjusted relative risks.
(25) Alternative approaches that have the capacity to estimate an
unbiased PPF using an adjusted relative risk require raw data that we do
not have: we need to know the proportion of cases of disease (e.g.,
respiratory tract infection) where there was no breastfeeding. (18,19)
It is not uncommon to use Levin's formula in these circumstances,
(36) and a recent article studied the anticipated direction of bias from
adjusted estimates. (25) Most relevant to the current study, using
Levin's formula when adjusted estimates are positively confounded
results in an underestimation of the PPF. Positive confounding occurs
when an exposure (e.g., not breastfeeding) is positively associated with
the outcome, and a confounder is negatively associated with both the
exposure and outcome. (37) Our adjusted risk estimates were likely
positively confounded, resulting in a more conservative PPF. Consider
how social class would affect the relationship between breastfeeding and
respiratory tract infection. Not breastfeeding is positively associated
with risk of lower respiratory tract infection, (15) and higher social
class is negatively associated with both a) not breastfeeding (17) and
b) respiratory tract infection. (15) Thus, the anticipated direction of
bias from failing to adjust for social class would be further from the
null, i.e., a positive confounder. (37)
In spite of these limitations, this research provides quantitative
support for prioritizing breastfeeding promotion in Aboriginal
Canadians. Combining effective breastfeeding programs with interventions
and measures to improve social conditions in Aboriginal communities is
an important step toward eliminating health disparities in Aboriginal
and other Canadian infants.
CONCLUSION
Respiratory tract infection, gastrointestinal infection, otitis
media and SIDS are important causes of infant morbidity and mortality
that disproportionately affect Aboriginal Canadians. Interventions and
programs to protect, promote and support breastfeeding may prevent a
substantial proportion of these. These interventions should be developed
in consultation and collaboration with indigenous populations to enhance
cultural acceptability.
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Received: October 22, 2014
Accepted: February 22, 2015
Kathryn E. McIsaac, PhD, [1,2] Rahim Moineddin, PhD, [1,3] Flora I.
Matheson, PhD [1,2]
Author Affiliations
[1.] Dalla Lana School of Public Health, University of Toronto,
Toronto, ON
[2.] Centre for Research on Inner City Health, Li Ka Shing
Knowledge Institute, Saint Michael's Hospital, Toronto, ON
[3.] Department of Family and Community Medicine, University of
Toronto, Toronto, ON
Correspondence: Kathryn E. McIsaac, PhD, St. Michael's
Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Tel: 416-864-6060, ext.
77438, E-mail: kathryn.mcisaac@alum.utoronto.ca
Acknowledgements: Kathryn McIsaac is a CIHR Strategic Training
Fellow in the ACHIEVE Research Partnership: Action for Health Equity
Interventions; she gratefully acknowledges the support of the Canadian
Institutes of Health Research Grant #96566 and the Ontario Ministry of
Health and Long-Term Care.
Disclaimer: The views expressed in this publication are the views
of the authors and do not necessarily reflect the views of the Ontario
Ministry of Health and Long-Term Care.
Conflict of Interest: None to declare.
Table 1. Prevalence of breastfeeding practices in Canada,
by Aboriginal identity, 2007-2010
Breastfeeding practice
Aboriginal Any breast- No breast-
identity feeding * feeding
First Nations--
on-reserve (22) 60.2 39.8
First Nations--
off-reserve (21) 81.9 18.1
Inuit (21) 76.8 23.2
Metis (21) 78.2 21.8
Non-Aboriginal
Canadians (21) 87.8 12.2
* Also referred to as initiated breastfeeding.
Table 2. Relative risk estimates of breastfeeding on select
infant health outcomes, abstracted from meta-analyses
Source of risk
Health outcome estimate Comparator
Sudden infant Hauck et al. Any vs. none
death (2011) (13)
Gastrointestinal Chien et al. Any vs. none
infection (2011) (14)
Hospitalization, Bachrach At least 4
lower et al. months vs. none
respiratory (2003) (15)
tract infection
Otitis media Ip et al. Any vs. none
(2009) (16)
Health outcome RR (95% CI) 1/RR * (95% CI)
Sudden infant 0.55 (0.44-0.69) 1.82 (1.45-2.27)
death
Gastrointestinal 0.36 (0.32-0.41) 2.78 (2.44-3.12)
infection
Hospitalization, 0.53 (0.30-0.93) 1.89 (1.08-3.33)
lower
respiratory
tract infection
Otitis media 0.77 (0.64-0.91) 1.30 (1.10-1.56)
* 1/RR = Inverted risk estimate.
Table 3. Population prevented fraction (PPF) of infant health outcomes
attributed to breastfeeding, by Aboriginal identity, 2007-2010
Aboriginal Canadians
First Nations: First Nations:
on-reserve off-reserve
Health outcome PPF (95% CI) PPF (95% CI)
Sudden infant 24.6 (15.2, 33.6) 12.9 (7.5, 18.7)
death
Gastrointestinal 41.4 (36.4, 45.8) 24.4 (20.7, 27.7)
infection
Hospitalization, 26.1 (2.9, 48.2) 13.9 (1.4, 29.7)
lower
respiratory
tract infection
Otitis media 10.6 (3.8, 18.3) 5.2 (1.8, 9.2)
Aboriginal Canadians
Inuit Metis
Health outcome PPF (95% CI) PPF (95% CI)
Sudden infant 16.0 (9.4,22.8) 15.1 (8.9, 21.7)
death
Gastrointestinal 29.2 (25.0, 33.0) 27.9 (23.9, 31.6)
infection
Hospitalization, 17.1 (1.7, 35.1) 16.2 (1.6, 33.7)
lower
respiratory
tract infection
Otitis media 6.5 (2.2, 11.5) 6.1 (2.1, 10.9)
Non-
Aboriginal
Canadians
Health outcome PPF (95% CI)
Sudden infant 9.1 (5.2, 13.4)
death
Gastrointestinal 17.8 (14.9, 20.6)
infection
Hospitalization, 9.7 (1.0, 22.2)
lower
respiratory
tract infection
Otitis media 3.5 (1.2, 6.4)