Abstract :
on behalf of the (1) Keywords Very preterm infants; Breast milk feeding; Behavior outcomes; Emotional outcomes Highlights * Almost 20% of Portuguese children born very preterm presented behavioral problems. * Internalizing problems were more prevalent than externalizing ones in very preterm children. * Lower exposure to breast milk feeding seemed to increase the risk of adverse behavioral outcomes. Abstract Background Breast milk feeding (BMF) improved neurodevelopment in children born very preterm (VPT, Objective To estimate the association of BMF practices with behavioral and emotional problems at preschool age in children born VPT. Methods We studied 263 children born VPT during 2011--12 and enrolled in the Portuguese EPICE cohort. At the age of 3, information on BMF initiation and duration was collected and behavioral and emotional problems were assessed using the parents' completed Child Behavior Checklist 1.5--5 years (CBCL/1½-5). Children were categorized for all CBCL/1½-5 sub-scales and for Diagnostic and Statistical Manual of Mental Disorders (DSM5)-oriented scales. Risk ratios were estimated to assess the association of BMF with subclinical/clinical problems, fitting a Poisson regression. Results Behavioral or emotional subclinical/clinical problems were found in almost 20% of children (11.8% in the clinical range). BMF was consistently associated with lower adverse behavioral and emotional outcomes, particularly risks of externalizing problems, somatic complaints, aggressive behavior, as well as autism spectrum and attention deficit/hyperactivity symptoms, although the magnitude of the unadjusted risks was attenuated by adjustment for relevant confounders and wider confidence intervals included the null. Conclusion Lower exposure to BMF seemed to increase the risk of adverse behavioral and emotional outcomes at preschool age in children born VPT. These results raise questions about explanatory pathways and strengthen evidence underpinning BMF promotion for VPT children. Abbreviations aRR, adjusted risk ratios; BMF, breast milk feeding; CBCL/1½-5, Child Behavior Checklist for ages 1½-5 years; DSM5, Diagnostic and Statistical Manual of Mental Disorders 5th edition; IPW, inverse probability weighting; NICU, Neonatal Intensive Care Unit; RR, risk ratio; VPT, very preterm Author Affiliation: (a) EPIUnit -- Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal (b) Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal (c) Université de Paris, CRESS, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, F-75004 Paris, France (d) Centro Materno-Infantil do Norte, Centro Hospital Universitário do Porto, Porto, Portugal * Corresponding author at: EPIUnit -- Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas, 135, 4050-600 Porto, Portugal. Article History: Received 28 May 2021; Revised 10 November 2021; Accepted 22 December 2021 (footnote)1 Members of the EPICE-Portugal Network: Adelina Sá Couto, Aldina Lopes, Alexandra Almeida, Alexandrina Portela, Alice Vilas Boas, Almerinda Pereira, Ana Aroso, Ana Berdeja, Ana Bettencourt, Ana Campos, Ana Castilho Santos, Ana Isabel Machado, Ana Maria Andrade, Ana Melo Bento, Ana Neto, Ana Pita, Ana Rute Ferreira, Angelina Tavares, Anselmo Costa, Antónia Nazaré, António Braga, António Fonseca, António Lanhoso, António Vilarinho, Beatriz Sousa, Carla Sá, Carlos Moniz, Cármen Carvalho, Catarina Dâmaso, Célia Araújo, Clara Paz Dias, Cláudia Araújo, Conceição Casanova, Conceição Cunha, Conceição Murinello, Conceição Telhado, Cristina Didelet, Cristina Leite, Cristina Martins, Cristina Trindade, Daniela Almeida, Domingos Jardim da Pena, Dulce Oliveira, Eduarda Reis, Eduardo Fernandes, Ester Casal, Eurico Gaspar, Fátima Fonseca, Fátima Romão, Fernanda Matos, Fernando Cirurgião, Filomena Nunes, Gabriela Pereira, Glória Carvalhosa, Graça Henriques, Gustavo Rodrigues, Helena Almeida, Helena Oliveira, Helena Sousa, Hercília Guimarães, Ilídio Quelhas, Isabel Canelas, Isabel Carolino Silva, Isabel Knoch, Isabel Martins, Jacinto Torres, Joana Saldanha, Joana Sampaio, João Mendes, Joaquim Marinho, Joaquina Baltazar, Jorge Ribeiro, Jorge Silva, José Amorim, José Furtado, José Guimarães, José Luís Fonseca, José Nogueira, José Oliveira, José Pombeiro, José Teixeira, Juan Calviño, Judite Marques, Lucília Araújo, Luís Caturra, Luís Graça, Maria Carmo Serra, Maria Céu Machado, Maria Paula Arteaga, Margarida Cabral, Margarida Pontes, Margarida Seabra, Maria Lurdes Pinho, Maria José Carneiro, Mário Furtado, Mário Paiva, Marisa Cabanas, Marta Aguiar, Marta Barbosa, Micaela Serelha, Nuno Montenegro, Olímpia do Carmo, Óscar Vaz, Osvaldo Soares, Paula Costa, Paula Pinheiro, Paula Soares, Pedro Rocha, Pedro Silva, Pedro Tiago, Raquel Maciel, Ricardo Mira, Rosa Rodrigues, Rosalina Barroso, Rosalinda Rodrigues, Rubina Mendonça, Rui Carrapato, Rui Costa, Rui Pinto, Sara Noéme Prado, Susana Gama de Sousa, Teresa Oliveira, Teresa Rodrigues, Teresa Teles, Teresa Tomé, Teresa Ventura, Valdemar Martins, Vítor Neves, Zélia Nunes. Byline: Carina Rodrigues [carina.rodrigues@ispup.up.pt] (a,b,*), Jennifer Zeitlin (c), Ana Raquel Carvalho (a), Diana Gonzaga (d), Henrique Barros (a,b)