Exclusive breastfeeding promotion and neuropsychological outcomes in 5-8 year old children from Uganda and Burkina Faso: Results from the PROMISE EBF cluster randomized trial

PLoS One. 2018 Feb 23;13(2):e0191001. doi: 10.1371/journal.pone.0191001. eCollection 2018.


Background: The beneficial effects from exclusive breastfeeding (EBF) have been widely acknowledged. We assessed the effect of exclusive breastfeeding promotion by peer counsellors in Uganda and Burkina Faso, on cognitive abilities, social emotional development, school performance and linear growth among 5-8 years old children.

Methods: Children in the PROMISE EBF trial (2006-2008) were re-enrolled in the follow-up PROMISE Saving Brains (SB) study (2013-2015). Caretaker interviews captured sociodemographic characteristics and social emotional development using the parent version of the Strengths and Difficulties Questionnaire (SDQ). Overall cognition and working memory were assessed using the Kaufman Assessment Battery for Children, second edition (KABC2), cognitive flexibility was measured with the Child Category Test (CCT), and attention with the Test of Variables of Attention (T.O.V.A), while school performance was measured by a standardized test on arithmetic and reading. Country-pooled, age adjusted z-scores from each of the above outcomes were entered into a linear regression model controlling for confounders.

Results: The number of children re-enrolled in the intervention and control arms were: 274/396 (69.2%) and 256/369 (69.4%) in Uganda and 265/392 (67.6%) and 288/402 (71.6%) in Burkina Faso. Assessment of cognitive ability showed small and no significant differences, of which general cognition (z-scores, 95% CI) showed the largest mean difference: -0.17 (-0.40; 0.05). Social emotional symptoms were similar across arms. There were no differences in school performance or linear growth for age detected.

Conclusion: Peer promotion for exclusive breastfeeding in Burkina Faso and Uganda was not associated with differences at 5-8 years of age in a range of measures of child development: cognitive abilities, emotion-behaviour-social symptoms or linear growth. This study from sub Saharan Africa did not reconfirm findings elsewhere that have shown an association between exclusive breastfeeding and cognitive performance. This might be due to a number of methodological limitations inherent in the current study. For example since the majority of the children were breastfed, the benefits of the intervention could have been diluted. Other factors such as the mental and HIV status of the mothers (which were not assessed in the current study) could have affected our results. Hence regarding the effect of exclusive breastfeeding on measures of child neurocognitive development in sub Saharan Africa, the jury is still out.

Trial registration: ClinicalTrials.gov NCT01882335.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Breast Feeding* / psychology
  • Breast Feeding* / statistics & numerical data
  • Burkina Faso
  • Child
  • Child Development
  • Child, Preschool
  • Cognition
  • Female
  • Health Promotion
  • Humans
  • Male
  • Neuropsychological Tests
  • Outcome Assessment, Health Care
  • Peer Group
  • Social Change
  • Socioeconomic Factors
  • Uganda

Associated data

  • ClinicalTrials.gov/NCT01882335

Grants and funding

The study was funded by Grand Challenges Canada’s Saving Brains programme from 2012: Saving Brains in Uganda and Burkina Faso (PROMISE SB) project number: 0064-03 with James Tumwine, Makerere University (Uganda), as the Principal Investigator. We are very grateful to all the staff at Grand Challenges Canada for the funding and professional support. We would like to thank our respective institutions for facilitation and collaborations; and the Research Council of Norway, Globvac-programme for sponsoring two young researcher grants in this period benefitting the study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.