|Year : 2021 | Volume
| Issue : 3 | Page : 128-138
The relation between pattern of feeding and behavior & mental health disorders among children
Enas A.M Abdurrahman, Tayseer M Elzayat, Rania A Hamed, Amira H Hassan
Department of Pediatric and Psychiatry, Faculty of Medicine for Girls, Cairo, Egypt
|Date of Submission||28-Feb-2021|
|Date of Decision||22-Mar-2021|
|Date of Acceptance||11-Apr-2021|
|Date of Web Publication||28-Sep-2021|
Pediatrics (MSc) Enas A.M Abdurrahman
Department of Pediatric, Faculty of Medicine for Girls, Al Azhar University, Cairo
Source of Support: None, Conflict of Interest: None
Introduction The benefits of breastfeeding are innumerable, such as a reduction in the risk of acute otitis media, gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), obesity, type 1 and 2 diabetes, childhood leukemia, additionally may reduce the risk of psychological and behavioral disorders among children.
Aim To evaluate the effect of breastfeeding on behavioral and mental health disorders of school-age children.
Patients and methods This case–control comparative study was carried out on a group of children aged from 6 to 12 years, who were divided into two groups: the patient group included 50 children who were diagnosed with behavioral and mental health disorders according to DSM 5 criteria of diagnosis and were recruited from the outpatient psychiatry clinic of Al-Zahraa Hospital University during the period from March 2020 to September 2020 and a control group with apparently healthy children with no history of psychological manifestations matched in number, age, and sex with the patient group.
Result The mean age was 8.4±2.2 years. There were 15 (30.0%) female and 35 (70.0%) male patients, with the highest percentage having attention-deficit hyperactive disorder (ADHD) (72.0%), followed by obsessive-compulsive disorder (OCD) (24.0%), learning disorder (10.0%), and conduct disorder (2.0%). The majority of the cases (29) were mixed fed (58.0%), 11 (22.0%) were artificially fed, and 10 (20.0%) were breastfed. There was a highly statistically significant difference between artificial (bottle) feeding and mixed feeding regarding behavioral disease as ADHD and OCD were highly significant, with P value more than 0.001. Moreover, there was a highly statistically significant difference between the duration of breastfeeding less than or equal to 6 months and ADHD and OCD.
Conclusions Breastfeeding has been demonstrated that is inversely associated to behavioral and mental health disorders as increase the duration of breastfeeding associated with decrease the incidence of psychological and behavioral disorders.
Keywords: artificial feeding, behavioral, breast feeding, mental disorders, mixed feeding
|How to cite this article:|
Abdurrahman EA, Elzayat TM, Hamed RA, Hassan AH. The relation between pattern of feeding and behavior & mental health disorders among children. Egypt J Psychiatr 2021;42:128-38
|How to cite this URL:|
Abdurrahman EA, Elzayat TM, Hamed RA, Hassan AH. The relation between pattern of feeding and behavior & mental health disorders among children. Egypt J Psychiatr [serial online] 2021 [cited 2021 Dec 4];42:128-38. Available from: http://new.ejpsy.eg.net/text.asp?2021/42/3/128/326855
| Introduction|| |
Breastfeeding reduces the risk of some diseases that may occur at different stages of life (Victora et al., 2016). A recent meta-analysis has shown that breastfeeding not only protects the child against infections but may also reduce the risk of overweight and diabetes and protect the mother against breast and ovarian cancer and type 2 diabetes (Victora et al., 2016).
Moreover, children breastfed for at least 6 months have a higher intelligence quotient (IQ) in childhood (Fonseca et al., 2013), and this effect is maintained into adolescence (Kafouri et al., 2013) and adulthood (Victora et al., 2015).
Researchers have increasingly investigated the relationship between breastfeeding and behavior disorders in childhood and adolescence (Krol and Grossmann, 2018). Some studies have reported benefits of breastfeeding on emotional and behavioral development in children and adolescents (Julvez et al., 2014).
Behavior disorders have disruptive characteristics. Conduct disorder (CD), attention deficit, and challenging behavior are the most common manifestations of these disorders. The duration of breastfeeding seemed to be more important than the exclusive or nonexclusive pattern of breastfeeding (Poton et al., 2018).
The evidence available for the association between breastfeeding and behavior disorders in childhood is indeed challenging, so this study was held.
| Aim|| |
The aim of our study was to evaluate the relation between pattern of feeding (breast feeding, mixed, and artificial feeding) in addition to duration of breastfeeding and behavioral and mental health disorders among children aged from 6 to 12 years old.
| Patients and methods|| |
This was a retrospective case–control comparative study carried out on a group of children aged from 6 to 12 years divided into two groups: the patient group included 50 children who were diagnosed with behavioral and mental health disorders according to DSM 5 criteria of diagnosis and were recruited consecutively from outpatient psychiatry clinic of Al-Zahraa Hospital University with history of 10 breastfed, 29 mixed fed, and 11 artificial (bottle) fed compared them with control group, which consisted of 50 apparently healthy children having acute, short-term illnesses with no history of psychological manifestations attended the outpatient pediatric clinic of Al-Zahraa Hospital University matched in age and sex, with history of exclusive breastfeeding.
The following were the inclusion criteria:
- Age range was 6–12 years old.
- Both sexes were included.
- Diagnosed with behavioral and mental health disorders according to DSM 5 criteria of diagnosis.
- Had IQ more than 80.
The following were the exclusion criteria:
- Preterm − low birth weight.
- Complicated pregnancy − history of admission to NICU.
- History of maternal drugs or smoking during pregnancy.
- History of chronic illness or drug intake (apart of psychological medication).
- Those with intellectual disability having IQ less than 80 were not enrolled in this study.
All cases and control groups were subjected to the following:
- Thorough full medical history taking according to a specially designed pediatric sheet with emphasis on nutritional (feeding) history, developmental, family, and social history.
- The Revised Behavior Problem Checklist (Quay, 1983): it was an 89-item questionnaire used to assess parents’ report of child problem behaviors under six constructs: CD, socialized aggression, attention problems/immaturity, anxiety/withdrawal, psychotic behavior, and motor excess using a three-point Likert scale (0=no problem and 2=severe problem). The administration and scoring are straightforward. The raters respond to the 89 items on the top page of the carbonless Test Booklet, and responses are transferred to the bottom sheet, which contains scoring instructions and a scoring key. The RBPC Profile Sheet is used to record the obtained raw and T-scores and to plot the pattern of the test results.
Informed written consent was obtained from all patients and control groups before getting them involved in the study. The steps of the study, the aims, and the potential benefits and hazards were discussed with the patients and control groups. Confidentiality of all data was ensured. The patients had the right to withdraw from the study at any time without giving any reasons.
- The collected data were computerized and statistically analyzed using Statistical Package for Social Sciences (SPSS 24 Inc., Chicago, Illinois, USA).
- Data were tested for normal distribution using the Shapiro–Wilk test.
- Qualitative data were represented as frequencies and relative percentages.
- χ2 test and Fisher exact test were used to calculate difference between qualitative variables as indicated.
- Quantitative data were expressed as mean±SD.
- Independent t test was used to calculate difference between quantitative variables in two groups.
- All statistical comparisons were two tailed, and significance level was set as follows: P value less than or equal to 0.05 indicates significant, P value less than 0.001 indicates highly significant difference, whereas P more than 0.05 indicates nonsignificant difference.
| Results|| |
The age of the studied children ranged between 6 and 12 years, with a mean age of 8.4±2.2 and 8.8±3.2 years for cases and control groups, respectively, with no statistical significant difference between them ([Table 1]).
|Table 1 Comparison between the patient and control groups regarding age and sex|
Click here to view
Regarding sex distribution, 15 (30.0%) were females and 35 (70.0%) were males compared with 16 (32.0%) females and 34 (68.0%) males of control group, with no statistically significant difference between them ([Table 1]).
Regarding the type of feeding in the present study, 100 children were divided into 50 children diagnosed as having behavioral and mental health disorders, where the majority (29 children) were mixed fed (58.0%), 11 (22.0%) were artificially fed, and 10 (20.0%) were breastfed, and 50 (100.0%) children were exclusive breastfed as a control group, and there were highly statistically significant differences between them, with P value more than 0.001.
In the current study, there was a highly statistically significant difference between artificial (bottle) feeding and mixed feeding in behavioral disease, attention-deficit hyperactive disorder (ADHD), and obsessive-compulsive disorder (OCD), with highly significant difference (P>0.001), whereas there was no significant difference between other groups ([Table 2]).
|Table 2 The relation between feeding type and behavioral and mental health disorders (N=100)|
Click here to view
In addition, regarding Revised Behavior Problem Checklist items, there was a highly statistically significant difference between artificial feeding and mixed feeding regarding CDs, including physical aggression, defiance, oppositionality, and psychotic behavior, including bizarre ideation and motor excess including jumpiness and restlessness and corrected score of Revised Problem Behavior Checklist, whereas psychotic behaviors including delusion and motor excess including tension were highly statistically significant, with P value less than 0.001 among mixed fed children, whereas there was no significant difference with other Revised Behavior Problem Checklist items and other corrected RBPC scores ([Table 3]).
|Table 3 The correlation of feeding type into revised behavior problem checklist (N=100)|
Click here to view
Regarding the relation between duration of feeding and behavioral disorders, there was a highly statistically significant difference between duration less than or equal to 6 months in ADHD and OCD, whereas there was no significant difference in other groups ([Table 4]).
|Table 4 Duration of feeding type in relation to behavioral and mental health disorders (N=89)|
Click here to view
In addition, regarding the association between duration of feeding and Revised Behavior Problem Checklist items, there was a highly statistically significant difference regarding motor excess including jumpiness, restlessness, and tension with a duration of breastfed less than or equal to 6 months with a P value less than 0.001, whereas there was no statistically significant difference in other items ([Table 5]).
|Table 5 The correlation of duration of feeding type into revised behavior problem checklist (N=89)|
Click here to view
In the present study, we have analyzed the duration of feeding type into exclusive breastfeeding and nonexclusive breastfeeding and clarified the relation between behavioral disorders and analyzed duration. The results reported that there was a highly statistically significant difference between nonexclusive breastfeeding and exclusive breastfeeding duration less than 6 months in ADHD and OCD, whereas there was no other significant difference between other groups ([Table 6]).
|Table 6 The relation between analyzed duration of feeding type (exclusive and nonexclusive breastfeeding) into behavioral and mental health disorders (N=89)|
Click here to view
| Discussion|| |
One of the major challenges facing communities is to generate knowledge needed to improve the children with behavior and mental health disorders.
Many studies have shown the benefits of breastfeeding for both children and mothers, regardless of socioeconomic status (Horta et al., 2015).
Breastfeeding reduces the risk of some diseases that may occur at different stages of life. It not only protects against infections but may also reduce the risk of overweight and diabetes and protect the mother against breast and ovarian cancers and type 2 diabetes (Victora et al., 2016).
Moreover, children breastfed for at least 6 months have a higher IQ in childhood (Fonseca et al., 2013), and this effect is maintained into adolescence (Kafouri et al., 2013) and adulthood (Victora et al., 2016).
The breastfeeding is independently associated with behavioral problems including oppositional defiant disorder, CD, and ADHD (Poton et al., 2018).
The link between breastfeeding and children’s behavior development depends on a higher frequency of breastfed meals and the duration of exclusive breastfeeding during the first year of life (Boucher et al., 2017).
Cases were taken consecutively from outpatient psychiatry clinic of Al-Zahraa Hospital University during the period from March 2020 to September 2020.
All the children of studied group were full in term with normal birth weight, no history of NICU admission, and received their vaccination.
Regarding the behavior and mental health disorder in the current study, the result found that ADHD was the commonest, with the highest percentage (72.0%) followed by OCD (24.0%), learning disorder (10.0%), and CD (2.0%) among the studied children ([Figure 1]).
|Figure 1 Distribution of behavior and mental health disorder among the patient group (N=50).|
Click here to view
This agrees with Al Hamed et al. (2008), who found that ADHD is one of the most common mental disorders that develop in children, and it becomes apparent in the preschool and early school years.
Moreover, regarding the sex distribution in the current study among children diagnosed as having behavioral and mental health, 70.0% of them were males and 30.0% were females. This was in agreement with Gimpel and Kuhn (2000) who found that males are more likely to exhibit ADHD behaviors than females.
A study by Sharma et al. (2020), which studied the prevalence and correlates of ADHD risk factors among school children aged 6 to 12 old years, found that sex-wise prevalence of ADHD to be high in boys to girls by ratio of 3:1.
This can be explained by the fact that ADHD symptoms are missed in girls or that mental health problems in girls develop into problems other than ADHD (Martin et al., 2018).
Our results showed that ADHD was associated with artificial feeding more than mixed feeding or breastfeeding; this highlights the importance of breastfeeding in lowering the risk of behavioral disorders among children.
This was similar to the study done by Adesman et al. (2017) in which they evaluated the prevalence of ADHD among breast-fed and formula-fed infants, and they reported a statistically significant difference in formula-fed infants with 5-fold increase in prevalence of ADHD than breast-fed infants.
Our results agree with Adesman et al. (2017) study who evaluated prevalence of ADHD among breast fed and formula fed infants and reported statistically significance difference with P-value <.05 with formula fed had 5-fold increase in prevalence of ADHD than breast fed infants and explained this by the nutritional benefits of breast milk, and early exposure to bisphenol A (BPA), a neurotoxic chemical found from epoxy-coated surfaces in infant formula.
Moreover, Park et al. (2014) found that a lack of breastfeeding was associated with increased morbidity of ADHD and internalizing and externalizing behavioral problems and low intelligence in childhood. They also explained the protective effect of breastfeeding on these behavioral problems and on the child’s IQ.
Our study agrees with Stadler et al. (2016) who found that the breastfeeding duration predicts cognitive development as well as development of brain white matter connectivity in areas similar to those seen in ADHD, and shorter duration of breastfeeding is among several risk factors in early life associated with future ADHD. Breastfeeding provides nutrients or other benefits that reduce future chance of ADHD.
This also agrees with Boucher et al. (2017) who found that were a positive association of breastfeeding with cognitive function apart from socio-environmental factors and also suggests a protective role against autistic traits, and the results are in agreement with recommendations for prolonged breastfeeding duration to promote child development.
Our results were not in agreement with Waylen et al. (2009) and Kramer et al. (2008) who found no significant effects being breast fed or not on child behavior, and also Lind et al., (2014) reported no significant difference in emotional disorders among the studied children being breast fed or not and explained this difference as these searches needed more adjustment to other factors that contribute to development of emotional and psychological disorders.
Our result were in agreement with Poton et al. (2018), who found the breastfed children for at least three to 4 months had fewer total behavior and CDs in childhood, andbreastfeeding for more than three or 4 months is inversely associated with total behavior and CD in childhood and other types of behaviors such as hyperactivity, personal and social skills, social competence, somatic complaints, internalized and externalized behavior problems.
In the study by Boucher et al., 2017, there was a statistically significant relation between breastfeeding and decreased ADHD among the studied infants. Moreover, in a birth-cohort study conducted in Australia, breastfeeding for more than or equal to 6 months was associated with decreased internalizing and externalizing behavior problems from infancy to adolescence in comparison with breastfeeding less than 6 months (Oddy et al., 2010).
Poton et al. (2018) found the duration of breastfeeding particularly when longer than 3 or 4 months is more important than the breastfeeding pattern (exclusive breastfeeding or nonexclusive breastfeeding) in the association with child behavior.
This was in agreement with Huang et al. (2019) who found that children who were breastfed for more than or equal to 6 months were significantly associated with reduced risk of internalizing behavioral problems particularly depression compared with those who were never breastfed, whereas differences were not found in externalizing behavioral problems.
Catalano et al. (2005) followed children from birth to 18 years or the completion of high school. Their study showed that breastfed children were found to be more cooperative and socially adept students when drop-out rates were calculated, and the rate was higher among children who had been bottle fed. This can be explained by the developmental domains of adaptability and communication, which are responsive to the effects of breast feeding and its duration.
Formula feeding is associated with infantile infections and chronic illness which can cause delayed developmental delay and later cognitive development (Tasnim, 2014).
Feldman and Eidelman (2003) reported that breast feeding is associated with improved social skills, but other authors have not found an effect on emotional regulation and behavioral disruption and concluded that further studies are needed for further research on breast feeding and child psychodevelopment (Hayatbakhsh et al., 2012).
The study by Kim et al. (2017) was performed to evaluate the associations between breastfeeding and cognitive function and learning skills and found a statistically significant difference in learning scores, with P value more than0.001, having higher learning scores among breastfed children than those with other types of feeding.
In addition, breastfeeding has been associated with greater cognitive development in childhood (Belfort et al., 2013), ADHD, and other externalizing and internalizing behavioral problems (Liu et al., 2014).
| Conclusion|| |
Breastfeeding can reduce the risk of many behavioral and developmental problems such as ADHD, OCD, anxiety problems, and attention problems.
Breastfeeding duration has a positive association with behavioral and mental health disorders, with shorter duration of breastfeeding being a risk factor for behavioral problems.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adesman A, Soled D, Rosen L (2017). Formula feeding as a risk factor for Attention-Deficit/Hyperactivity Disorder: is bisphenol a exposure. J Dev Behav Pediatr 38:545–551.
Al Hamed JH, Taha AZ, Sabra AA, Bella H (2008). Attention deficit hyperactivity disorder (ADHD) among male primary school children in Dammam, Saudi Arabia: prevalence and associated factors. J Egypt Public Health Assoc 83:165–182.
Belfort MB, Rifas-Shiman SL, Kleinman KP, Guthrie LB, Bellinger DC, Taveras EM, Oken E (2013). Infant feeding and childhood cognition at ages 3 and 7 years: effects of breastfeeding duration and exclusivity. JAMA Pediatr 167:836–844.
Boucher O, Julvez J, Guxens M, Arranz E, Ibarluzea J, de Miguel MS et al.
(2017). Association between breastfeeding duration and cognitive development, autistic traits and ADHD symptoms: a multicenter study in Spain. Pediatr Res 81:434–442.
Catalano R, Bruckner T, Hartig T, Ong M (2005). Population stress and the Swedish sex ratio. Paediatr Perinat Epidemiol 19:413–420.
Feldman R, Eidelman AI (2003). Direct and indirect effects of breast milk on the neurobehavioral and cognitive development of premature infants. Dev Psychobiol 43:109–119.
Fonseca AL, Albernaz EP, Kaufmann CC, Neves IH, de Figueiredo VL (2013). Impact of breastfeeding on the intelligence quotient of eight-year-old children. J Pediatr 89:346–353.
Gimpel GA, Kuhn BR (2000). Maternal report of attention deficit hyperactivity disorder symptoms in preschool children. Child Care Health Dev 26:163–176.
Hayatbakhsh MR, O’Callaghan MJ, Bor W, Williams GM, Najman JM (2012). Association of breastfeeding and adolescents’ psychopathology: a large prospective study. Breastfeed Med 7:480–486.
Horta BL, Christian LM, Cesar GV (2015). Breastfeeding and intelligence: a systematic review and meta‐analysis. Acta Paediatr 104:14–19.
Huang T, Yue Y, Wang H, Zheng J, Chen Z, Chen T, Wang S (2019). Infant breastfeeding and behavioral disorders in school-age children. Breastfeed Med 14:115–120.
Julvez J, Guxens M, Carsin AE, Forns J, Mendez M, Turner MC, Sunyer J (2014). A cohort study on full breastfeeding and child neuropsychological development: the role of maternal social, psychological, and nutritional factors. Dev Med Child Neurol 56:148–156.
Kafouri S, Kramer M, Leonard G, Perron M, Pike B, Richer L et al.
(2013). Breastfeeding and brain structure in adolescence. Int J Epidemiol 42:150–159.
Kim H, Kang S, Jung BM, Yi H, Jung JA, Chang N (2017). Breast milk fatty acid composition and fatty acid intake of lactating mothers in South Korea. Br J Nutr 117:556–561.
Kramer MS, Aboud F, Mironova E, Vanilovich I, Platt RW, Matush L et al.
(2008). Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry 65:578–584.
Krol KM, Grossmann T (2018). Psychological effects of breastfeeding on children and mothers. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 61:977–985.
Lind T, Johansson U, Öhlund I, Lindberg L, Lönnerdal B, Tennefors C, Hernell O (2014). Study protocol: optimized complementary feeding study (Otis): a romized controlled trial of the impact of a protein-reduced complementary diet based on nordic foods. BMC Public Health, 19:1–11.
Liu J, Leung P, Yang A (2014). Breastfeeding and active bonding protects against children’s internalizing behavior problems. Nutrients 6:76–89.
Martin J, Taylor MJ, Rydell M, Riglin L, Eyre O, Lu Y, Lichtenstein P (2018). Sex‐specific manifestation of genetic risk for attention deficit hyperactivity disorder in the general population. J Child Psychol Psychiatry 59:908–916.
Oddy WH, Kendall GE, Li J, Jacoby P, Robinson M, De Klerk NH, Stanley FJ (2010). The long-term effects of breastfeeding on child and adolescent mental health: a pregnancy cohort study followed for 14 years. J Pediatr 156:568–574.
Park S, Kim BN, Kim JW, Shin MS, Yoo HJ, Cho SC (2014). Protective effect of breastfeeding with regard to children’s behavioral and cognitive problems. Nutr J 13:1–5.
Poton WL, Soares AL, Oliveira ER, Gonçalves H (2018). Breastfeeding and behavior disorders among children and adolescents: a systematic review. Rev Saude Publica 52:9.
Quay HC (1983). A dimensional approach to behavior disorder: The Revised Behavior Problem Checklist. School Psych Rev 12:244–249.
Sharma P, Gupta RK, Banal R, Majeed M, Kumari R, Langer B et al.
(2020). Prevalence and correlates of Attention Deficit Hyperactive Disorder (ADHD) risk factors among school children in a rural area of North India. J Family Med Prim Care 9:115.
Stadler DD, Musser ED, Holton KF, Shannon J, Nigg JT (2016). Recalled initiation and duration of maternal breastfeeding among children with and without ADHD in a well characterized case–control sample. J Abnorm Child Psychol 44:347–355.
Tasnim S (2014). Effect of breast feeding on child development: at birth and beyond. South East Asia J Public Health 4:4–8.
Victora CG, Horta BL, Loret de Mola C, Quevedo L, Pinheiro RT, Gigante DP (2015). Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health 3:e199–e205.
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J et al.
(2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 387:475–490.
Waylen A, Ford T, Goodman R, Samara M, Wolke D (2009). Can early intake of dietary omega‐3 predict childhood externalizing behaviour?. Acta Paediatr 98:1805–1808.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]