In a recently released issue of Pediatrics(10.1542/peds.2020-030643), Cianté Pretorius and colleagues examine the economic impact of exclusive breastfeeding (EBF) practices with respect to mortality of children under age 5 years (U5M) in Sub-Saharan Africa. This powerful article is accompanied by a must-read commentary (10.1542/peds.2020-040824) written by Mamta Murthi, Vice President, Human Development, World Bank, and Meera Shekar, Global Lead, Nutrition, World Bank. This incredibly impactful combination of a thoughtful research study and a knowledgeable commentary by global leadership gives all of us an opportunity to think broadly about the worldwide economic importance of exclusive breastfeeding.

Rates of U5M in the 43 countries that comprise Sub-Saharan Africa are the highest in the world, averaging 78 per 1,000 live births; the World Health Organization Sustainable Development Goal for 2030 is to reduce that rate to 25 per 1,000 births, which requires an almost unimaginable reduction of 70% in U5M. Malnutrition and related illness are the main causes of death for under-five children in this continent, and hence exclusive breastfeeding, which provides safe and sustainable calories in the face of food and water insecurity, is uniquely relevant to survival. Briefly, Ms. Pretorius and colleagues gathered their data from the World Bank’s database (2000-2018), and obtained per country rates of EBF and U5M, total and U5 population estimates, gross domestic product (GDP) estimates, rates of poverty and per capita health expenditures. They also obtained variables most Western researchers would be unlikely to consider, including rates of child wasting and stunting, and rates of open defecation and safe water availability. The authors carefully walk us through their analytic approach, which leads to an estimate of the economic impact of U5M due to absence of EBF, by means of GDP reduction due to years of life lost. The chain of causality here takes a moment to think through, but is intuitive. They then report the “Total Cumulative Non-Health Gross Domestic Product Loss,” abbreviated by an acronym that defies pronunciation: “TCNHGDPL”.

Even with large variability between countries in rates of EBF and U5M, and given slowly increasing (EBF) and slowly decreasing (U5M) rates, the results are astounding. There was a direct relationship between EBF and U5M:  for every 10% increase in the prevalence of EBF, total U5M would decrease by about 5.6 per 1,000 children. You can quickly do some “back of the envelope” math to grasp how urgent and lifesaving an increase in rates of exclusive breastfeeding in Sub-Saharan Africa would be, and please read the article for the key financial and economic results. Ms. Pretorius and colleagues spell out the economic consequences for the region in the article’s Discussion section, and in the well written linked commentary, Ms. Murthi and Ms. Shekar bring home the urgent need to invest in exclusive breastfeeding due to its impact on economic growth, productivity, and human capital development. Even for breastfeeding advocates who are used to trumpeting the many, varied and evidence-based benefits of breastfeeding, this article begs for a megaphone and a mountaintop.