DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
Breastfeeding and child neurodevelopment a role for gut
microbiota?
NATALIE PARLETTA
School of Population Health, Samsom Institute for Health Research, University of
South Australia, Adelaide, SA, Australia.
doi: 10.1111/dmcn.12330
This commentary is on the original article by Julvez et al. on pages
148156 of this issue.
The cohort study by Julvez et al.1 extends the body of
research that shows a link between breastfeeding and neu-
rodevelopment. Although it is well established that breast-
fed children have better neurodevelopment, it has been
contended that this could be due to confounding factors
such as socio-economic status and maternal IQ, which are
fairly easy to control for, and less easily controlled factors
such as mother-child bonding. Randomized controlled
trials in this area are not feasible or ethical. However, one
cleverly designed study randomized mothers to a breast-
feeding promotion condition and showed superior neuro-
developmental outcomes with the higher numbers of
mothers in the promotion arm who breastfed their
children,2 although this latter study has been criticized for
unblinded assessments of the children. This latest cohort
study addressed the potential confounding of maternal
bonding by measuring and controlling for maternal attach-
ment and psychopathology, along with a comprehensive
array of other variables including maternal education, IQ,
socio-economic status, and environmental contaminants.
The outcomes still showed a significant, independent link
between exclusive, long-term breastfeeding and improved
neurocognitive development in children at 4 years of age.
The developing brain relies on a supply of essential
macro- and micronutrients, and will not develop optimally
(or at all) without them. It is becoming increasingly accepted
that absence of nutritional deficiency and observable out-
comes (e.g. cretinism as a result of iodine deficiency) does
not necessarily equate to optimal brain development.
There is a continuum of nutritional sufficiency with a
range between deficiency and optimal levels, and subopti-
mal levels can be observed in psychological performance
before physical symptoms are apparent. This provides a
plausible platform for observed links between breastfeeding
and neurodevelopmental outcomes.
The cohort study published here found improved out-
comes with more than 6 months exclusive breastfeeding.
This is interesting given that a review for the World
Health Organization identified that very little iron and zinc
2013 Mac Keith Press
COMMENTARIES
(essential for neurodevelopment) is provided by breast milk
and the infant can rely on prenatally supplied stores for up
to 6 months.3 However, the definition of exclusive breast-
feeding in this study did not exclude non-milk liquids and
allowed for syrup forms of vitamins, minerals, and medi-
cines. In either case, this nutritional component does not
fully account for nutrients supplied by infant formula,
which is increasingly including nutrients of previously
unknown importance such as omega-3 fatty acids. Are
there other compositional factors that contribute to
associations between extended breastfeeding and neurode-
velopment?
Recent years have seen an explosion of interest in the
tens of trillions of microbiota that inhabit the human body
(outnumbering our own cells), and a growing understand-
ing of the numerous important roles they play in human
health including micronutrient synthesis.4 It is suggested
that the adult microbiota profile is largely determined in
infancy. The strongest determinants of beneficial infant
gut microbiota are method of delivery (vaginal home birth)
and breastfeeding.5 In terms of neurodevelopment, the
gut-brain axis is of interest, given the rich and complex
concentration of microbiota in our gut and the enteric
nervous system, which has been described as our second
brain. Animal studies have shown altered emotional
responses and brain biochemistry with modification of gut
flora. A recent study was the first to show this in humans:
brain regions controlling emotional and sensory processing
were altered in a group of healthy females provided with a
probiotic yoghurt formula compared with controls, show-
ing a link between gut microbiota and brain function.6 It is
possible, therefore, that the beneficial microbial environ-
ment provided by breast milk may play a role in influenc-
ing childrens neural development.
Although there is still much to understand about mecha-
nisms of benefit, this latest cohort study combined with
growing understanding of the beneficial properties of
human breast milk provide further support for clinicians to
recommend exclusive, long-term breastfeeding to mothers
of newborn infants. It is possible that supplementary liquid
nutrients are needed after 6 months; as this does not
appear to have been factored into the present study, this is
yet to be elucidated.
A CK N O W L E D G E M E N T
NP is supported by NHMRC Program Grant funding (grant
numbers 320860 and 631947).
101
REFERENCES
1. Julvez J, Guxens M, Carsin A-E, et al. A cohort study
about full breastfeeding and child neuropsychological
development: the role of maternal, social, psychological,
and nutritional factors. Dev Med Child Neurol 2014; 56:
14856.
2. Kramer MS, Aboud F, Mironova E, et al. Breastfeeding
and child cognitive development: new evidence from a
large randomized trial. Arch Gen Psychiatry 2008; 65: 578
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3. Butte NF, Lopez-Alarcon MG, Garza C. Nutrient ade-
quacy of exclusive breastfeeding for the term infant dur-
ing the first six months of life. World Health
Organization 2002; http://www.who.int/mater-
nal_child_adolescent/documents/9241562110/en/
4. Kau AL, Ahern PP, Griffin NW, Goodman AL, Gor-
don JI. Human nutrition, the gut microbiome and the
immune system. Nature 2011; 474: 32736.
5. Penders J, Thijs C, Vink C, et al. Factors influencing
the composition of the intestinal microbiota in early
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6. Tillisch K, Labus J, Kilpatrick L, et al. Consumption of
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Cerebral dysfunction in children: should this be the central tenet

for a new system of classification?
LENA JACOBSON
Karolinska Institutet Clinical Neuroscience, Ophthalmology and Vision,
Stockholm, Sweden.
doi: 10.1111/dmcn.12328
This commentary is on the original article by Creavin et al. on pages
164170 of this issue.
The study by Creavin et al.1 demonstrates ophthalmic
abnormalities such as defects of binocular vision and ocular
alignment, refractive errors, and anisometropia in a popu-
lation-based group of children who fulfil the criteria for
the functional diagnosis of developmental coordination dis-
order (DCD).
Other functional diagnoses such as autism,2 attention-
deficithyperactivity disorder,3 cerebral palsy,4 and intellec-
tual disability5 are all known to be associated with visual
problems such as subnormal visual acuity, refractive errors,
visual field defects, strabismus, eye motility difficulties, and
cognitive visual impairment.
Cerebral dysfunction caused by brain damage,6 cerebral
malformation, or cerebral intracellular pathology may
impair many functions such as intellectual ability, motor
function, attention and behaviour, communication, breath-
ing, nutrition, hearing, as well as visual function. The eyes
are developmentally a part of the central nervous system
and a large proportion of the brain serves visual function.6
Therefore visual and ophthalmic abnormalities should be
expected in all groups of children who fulfil the criteria for
any of the above mentioned functional diagnoses.
However, we have to be careful when drawing conclu-
sions about causal connections. Is the clumsiness found in
children with DCD caused by visual problems? No, we
should see these functional disabilities as parallel conse-
quences of the same pathology. Indeed, they may com-
pound each other and significantly limit activities of daily
living.
The time has come to re-evaluate the diagnostic system
in which some functional diagnoses due to brain damage
are currently recognized and given an ICD code, whereas
others, such as cerebral visual and cerebral hearing impair-
ment, are not included. Maybe a new approach would be
better: a diagnostic code for cerebral dysfunction with sub-
codes for each of the specific functions that are impaired.

REFERENCES
1. Creavin AL, Lingam R, Northstone K, Williams C.
Ophthalmic abnormalities in children with developmen-
tal coordination disorder. Dev Med Child Neurol 2014;
56: 16470.
2. Ikeda J, Davitt BV, Ultmann M, Maxim R, Cruz OA.
Incidence of ophthalmic disorders in children with aut-
ism. J Autism Dev Disord 2013; 43: 144751.
3. Martin L, Aring E, Landgren M, Hellstr
om A. Anders-
son Gr
onlund M. Visual fields in children with atten-
tion-deficit=hyperactivity disorder before and after children with intellectual disability: a controlled study. J
treatment with stimulants. Acta Ophthalmol 2008; 86: AAPOS 2008; 12: 47781.
25964. 6. Dutton GN, McKillop EC, Saidkasimova S. Visual
4. Fazzi E, Signorini SG, La Piana R, et al. Neuro-oph- problems as a result of brain damage in children. Br J
thalmological disorders in cerebral palsy: ophthalmolog- Ophthalmol 2006; 90: 9323.
ical, oculomotor, and visual aspects. Dev Med Child
Neurol 2012; 54: 7306.
5. Akinci A, Oner O, Bozkurt OH, Guven A, Degerliyurt
A, Munir K. Refractive errors and ocular findings in

102 Developmental Medicine & Child Neurology 2014, 56: 101102

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