The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis

This e-letter is in response to the article by Bartick and Reinhold, “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis.”1 The International Formula Council supports the position of the World Health Organization, the American Academy of Pediatrics, and other organizations that breastfeeding is ideal. However, we have three major concerns about this analysis:

(1) The cost estimate of suboptimal breastfeeding: Bartick and Reinhold assigned a value of $10.5 million to each of the calculated “excess deaths.” Every life is of value and, although we strongly disagree with assigning a dollar value to each human life, this was the methodology Bartick and Reinhold employed for their analysis. The resulting $9.5 billion figure calculated due to “excess death” contributes 73% of the total $13 billion “savings to the U.S.” that is referenced in the conclusion. To test the plausibility of these values, we estimated that with a life expectancy of 77.7 years (U.S. average in 2007) and with a 3% annual rate of return, $10.5 million accumulated in a lifetime would yield a constant annuity stream of $342,000 per year. This is 7.9 times the mean real gross domestic product (GDP) per capita in 2007 (Bureau of Labor Statistics, 2009). Thus, the “revealed preference job risk” approach that the authors chose values each year of life saved at almost 8 times the value of per capita annual product or consumption. In addition, their estimate did not incorporate the costs of resources (food, shelter, etc.) needed for an infant to become a productive adult. Given these assumptions and the lack of consideration for the costs of resources needed for each human life, we question the application of a $10.5 million value to each “excess death.”

(2) The data source for disease risk: Bartick and Reinhold relied solely on the 2007 Agency for Healthcare Research and Quality (AHRQ) report on breastfeeding for relative risk for the diseases considered.2 The AHRQ report, as an analysis of meta- analyses, is fundamentally limited by the value of the underlying observational data. More recent studies and research designed as randomized prospective trials (such as the PROBIT trial)3 are not reflected in the AHRQ report and are thus not a part of the Bartick and Reinhold analysis.

Bartick and Reinhold assess three areas as the quantitatively most important contributors to the overall cost estimate: SIDS death, necrotizing enterocolitis (NEC) hospital costs and deaths, and deaths from lower respiratory infection (LRTI).

Regarding SIDS, PROBIT reported a non-statistically significant difference in SIDS between treatment groups, (p = 0.12). These findings were not included in the AHRQ analysis nor in Bartick and Reinhold’s analysis. Further, it is notable that in 2005, the AAP Task Force on SIDS concluded, “Although breastfeeding is beneficial and should be promoted for many reasons, the task force believes that the evidence is insufficient to recommend breastfeeding as a strategy to reduce SIDS.”4

Regarding NEC, a concern is that Bartick and Reinhold estimated each NEC death to have excess direct costs to the U.S. of $10.5 million due to lost contribution of earnings from premature deaths. We once again disagree with assigning a dollar value to each human life. Further, the odds ratio used to determine excess costs due to NEC was calculated based on exclusive breastfeeding rates at 3 months (32.1%) instead of initial breastfeeding rates (74.1%), even through NEC usually occurs in the first few weeks of life (typically between 30-32 weeks post-conceptional age). If one applies the odds ratio to an initial rate of breastfeeding, the excess costs of suboptimal breastfeeding are decreased by more than half, a correction that applies independently from the other factors discussed above.

The third major contributor to excess costs that Bartick and Reinhold identify is LRTI mortality. Bartick and Reinhold used the crude OR from the AHRQ report, which based its conclusions on a meta-analysis that only controlled for confounding by smoking and socioeconomic status.5 The meta -analysis did not control for many other covariates identified by the Centers for Disease Control and Prevention (CDC) as risk factors for LRTI deaths, that also co-vary with breastfeeding.6 Therefore, residual confounding is highly likely, potentially leading to an over-estimate of the relationship between breastfeeding and LRTI. Finally, the PROBIT study for breastfeeding promotion that found no difference in the risk of respiratory tract infections between control and breastfeeding promotion groups was not considered in the Bartick and Reinhold analysis.3

(3) Selection of a 90% exclusive breastfeeding rate: There was no substantiation or detail given on selecting the 90% exclusive breastfeeding rates for six months number. Indeed, this choice seems arbitrary and is not in line with any U.S. government public health goals for breastfeeding. For exclusive breastfeeding rates to reach 90% in the US, barriers to breastfeeding in the US must be identified and widely overcome.

References Cited:

1. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010; 125 (5):e1048-56.

2. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Evidence report/technology assessment No. 153.

3. Kramer, M. S., B. Chalmers, et al. Promotion of Breastfeeding Intervention Trial (PROBIT): A Randomized Trial in the Republic of Belarus. JAMA. 2001; 285(4): 413-420.

4. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics. 2005;116:1245–1255.

5. Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Arch Pediatr Adolesc Med. 2003; 157(3):237-43.

6. Singleton et al, Risk Factors for Lower Respiratory Tract Infection Death Among Infants in the United States, 1999 –2004. Pediatrics. 2009; 124:e768–e776.

Conflict of Interest:

Haley C. Stevens and Mardi K. Mountford are employees of the International Formula Council (IFC), an association of manufacturers and marketers of formulated nutrition products, e.g., infant formulas and adult nutritionals, whose members are based predominantly in North America. IFC members are: Abbott Nutrition; Mead Johnson Nutrition; Nestlé Infant Nutrition; PBM Products, LLC, A Perrigo Company; and Pfizer Nutrition.