Early Human Development 127 (2018) 42–47

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

The relationship between exclusive breastfeeding and infant development: A T

6- and 12-month follow-up study
Hye Jeong Choia, Su Kyoung Kangb, Mi Ra Chunga,b,
⁎

a
Sesalmaul Research Institute, Gachon University, Gyeonggi-do, South Korea
b
Department of Early Childhood Education, Gachon University, Gyeonggi-do, South Korea

ARTICLE INFO ABSTRACT

Keywords: Background: Breastfeeding offers several advantages for infants with research suggesting that it benefits de-
Cognitive development velopment, including cognitive and language development. However, limited research has examined the benefits
Communication development in infants under one year.
Exclusive breastfeeding duration Aims: To investigate the association between breastfeeding duration and infant development.
Formula feeding
Study design: A longitudinal study conducted over 12 months.
Social development
6–12 months
Subjects: Two hundred fifty-five mothers and their infants living in South Korea were seen at three time-points
based on infants' age (4, 6, and 12 months).
Outcome measures: Breastfeeding data were collected at 4 and 6 months. The Korea-Developmental Screening
Test for Infants & Children was administered at 6 and 12 months to measure developmental milestones. We
analyzed the relationship between breastfeeding duration in the first 6 months and infant development at 6 and
12 months using logistic regression analysis.
Results: Compared to infants who did not breastfeed at all, infants who were exclusively breastfed until 4 months
of age followed by mixed breastfeeding had a better communication and social interaction at 6 months, and
better cognition, communication, and social interaction at 12 months. Exclusive breastfeeding until 6 months of
age had no apparent impact on the outcomes at 6 and 12 months.
Conclusions: Exclusive breastfeeding up to 4 months of age followed by mixed breastfeeding might maximize the
effects of infant development in their first year after birth. Breastfeeding programs should effectively commu-
nicate that exclusive breastfeeding for at least 4 months benefits infant development.

1. Introduction
According to the National Survey on Fertility, Family Health and
Welfare in Korea [1] between 2000 and 2012 in South Korea, from
9.5% to 32.3% infants aged 5–6 months were receiving their nutrition
from breastfeeding only1, which may reflect increasing interest in
breastfeeding. The World Health Organization (WHO) recommends that
mothers worldwide exclusively breastfeed (i.e., not using any formula
or food) for the infant's first 6 months to achieve optimal growth, de-
velopment, and health. According to data released by the Korea Com-
mittee for UNICEF in 2016 [2], the exclusive breastfeeding rate in
South Korea is high immediately after birth but gradually decreases as
the child ages, being just 55.8% at 4 weeks of age, 38.1% at 4 months,
and 18.3% at 6 months of age. The exclusive breastfeeding rate for
6 months of age in South Korea is about half of the global average.
Breastfeeding offers several advantages for infants. In particular,
breast milk is known to strengthen infants' immune system and help in
the development of their brain and cognitive function. Attempts to
empirically understand the effects of breastfeeding duration in general
are ongoing. Recent studies on the effects of breastfeeding have noted
declines in infantile infection rates [3,4], improvements in cranial
nerve development [5,6], and enhanced physical and mental develop-
ment [7–10] and cognitive and language development [11–15]. Breast-
fed infants develop language and process language stimuli during the

Abbreviations: K-DST, Korea-Developmental Screening Test for Infants & Children; SES, socioeconomic status; ANOVA, one-way analyses of variance; aOR, adjusted
odds ratio; LCPUFA, long chain polyunsaturated fatty acids; DHA, docosahexaenoic acid
⁎
Corresponding author at: Department of Early Childhood Education, Gachon University, 1342 Seongnam-daero, Sujeong-gu, Seongnam-si, Gyeonggi-do, South
Korea.
E-mail address: mrchung@gachon.ac.kr (M.R. Chung).
1
Family Health and Welfare in Korea [1] investigated the rate of infants aged 5–6 months who were more breast fed than formula fed, including infants who were
exclusively breastfed.

https://doi.org/10.1016/j.earlhumdev.2018.08.011
Received 30 May 2018; Received in revised form 15 August 2018; Accepted 28 August 2018
0378-3782/ © 2018 Elsevier B.V. All rights reserved.
H.J. Choi et al.
first 6 months of life better than formula-fed infants [16] and may also
have higher IQ score during the first year than those fed with formula
[17]. In addition, children breastfed for < 4 months showed an in-
creased risk of delayed development in the adaptive, language, and fine
motor domains during their first three years compared to infants who
were breastfed for > 4 months [14], while continuing breastfeeding for
at least 4 months was associated with increased child cognitive devel-
opment [13]. However, Fewtrell, Wilson, Booth, Lucas [18] have sug-
gested that exclusive breastfeeding to 6 months leaves infants lacking in
iron, which is of concern given the potential for long-term adverse ef-
fects on motor, mental, and social development [19,20]. On the other
hand, exclusive breastfeeding until at least 6 months has also been re-
ported to be positive for development [21,22]. Thus, studies have had
inconsistent results with respect to the optimal duration of exclusive
breastfeeding.
However, most studies have been limited to specific areas of de-
velopment, such as cognition and language. Of the few studies have
examined the effects of exclusive breastfeeding on infants, most focused
on diseases or nutrition [3,4,19,20]. Thus, there is still debate over how
long exclusive breastfeeding should be continued to maximize its ben-
efits for infant development. The combination of breast milk, formula,
and supplementary foods from 4 months after birth is both less bur-
densome for the mother and nutritionally sufficient [18]. Recently, in
South Korea, the Academy of Breastfeeding Medicine Korea released a
report encouraging 6 months of exclusive breastfeeding as re-
commended by the WHO, but in Korea, studies have focused on
breastfeeding itself; its present status [2,23,24], the factors affecting its
duration [25], and the nutrient composition of human milk [26–28].
Korean studies related to effect of breastfeeding and especially to infant
health and development aspects remain insufficient. Therefore, it would
be meaningful to explore the effects of exclusive breastfeeding duration
on infant development for the first year after birth.
Thus, the purpose of this study is to examine the relationships of
exclusive breastfeeding duration with the physical, cognitive, commu-
nicative, and social development of infants at 6 and 12 months of age
compared with those infants under formula. For this purpose, a re-
search design to track infants throughout the first year of life was de-
veloped. We measured the overall development of infants using the
Korea-Developmental Screening Test for Infants & Children (K-DST), an
effective, reliable, and accredited tool in South Korea for measuring
infants' physical, cognitive, communicative, and social development
[29]. Our study addresses the prominent gaps in past literature, which
has largely focused on cognitive functioning, and did not gather follow-
up results on early infant development from 6 to 12 months after birth.
In addition, we adjusted for the sociodemographic characteristics of
infants and mothers to maximize the statistical explanatory power of
the results.
2. Methods
2.1. Participants
The participants were 255 unemployed mothers and their infants
were recruited between August 2015 and May 2017 through the
Sesalmaul Research Institute, Gachon University. The participants were
followed up three times according to infants' age: 4, 6, and 12 months
(Times 1, 2, and 3, respectively). All mothers were briefed about re-
search participation and research ethics, and signed a written consent
form at each follow-up point. The study was approved by the IRB of
Gachon University (Approval number: 1044396-201705-HR-079-01).
Mothers answered a question about breastfeeding at Times 1 and 2, and
completed the K-DST at Times 2 and 3. The breastfeeding information
was collected online. The K-DST was disseminated to participants by a
skilled clinician through home visits; the mothers completed it them-
selves. Among research participants, only those who satisfied the fol-
lowing criteria were included in this study: born at term (≥37 weeks),
43
Early Human Development 127 (2018) 42–47
single birth (i.e., no multiples), and who were not attending childcare.
No infants participating in the study had chronic diseases, such as
cardiovascular diseases or asthma.
Of the original sample of 510, a total of 431 mothers completed the
survey at Time 1 (18.3% dropout rate), 363 at Time 2 (18.6% dropout
rate), and 298 at Time 3 (21.8% dropout rate). Participants who did not
have a completed breastfeeding survey or did not respond to one or
more question on the K-DST were eliminated using listwise deletion.
The final sample size was 255. No statistically significant differences
were found between respondents that dropped out after 4 months
(n = 176) and those that remained in the study for all 12 months
(n = 255) in terms of sociodemographic variables, including maternal
age, maternal education, paternal education, and household income.
2.2. Measures
2.2.1. Breastfeeding duration
Breastfeeding information was collected using one question: “How
have you been feeding your infant until now? (breastfeeding only;
formula only; breastfeeding and formula together).” Participants were
categorized according to their infants' breastfeeding type at 4 and
6 months of age, as follows: never breastfed, mixed breastfeeding until
6 months of age, exclusive breastfeeding until 4 months of age followed by
mixed breastfeeding, exclusive breastfeeding until 6 months of age. Here,
“mixed” means that the infant was both breastfed and fed with formula
and mother's milk, while “exclusive” meant that the infant was only
breastfed during that period without any formula. Other breastfeeding
categories were not represented in the data, and were not presented. All
infants in the four categories of breastfeeding consumed other liquids or
solids food at 6 months, as the 11 infants who did not have other liquids
or solids food were excluded at the sampling stage for homogeneity of
the nutritional environment. In Korea, infants generally begin to con-
sume other liquids or solid food at 4–6 months [30].
Breastfeeding was measured at 4 and 6 months for the following
reasons. In 2011, the WHO released a statement asserting the beneficial
effects of exclusive breastfeeding for 6 months, changing their existing
recommendation of at least 4 months. We chose time points of
4 months, at which the breastfeeding rate dropped sharply to < 40%
[2], and 6 months recommended by the WHO for exclusive breast-
feeding.
2.2.2. Infant development
Infant development was assessed using the K-DST [29] at 6 and
12 months. The K-DST is a screening test designed by the Ministry of
Health and Welfare to assist in monitoring the development of Korean
children aged 4 months to 6 years. It contains 5 dimensions, each with 8
items, as follows: gross motor (e.g., “Can turn over while lying down”),
fine motor (e.g., “Shakes toy when a toy is placed in hand”), cognition
(e.g., “Follows a rolling ball with eyes”), communication (e.g., “Speaks
babbling like ‘ooh’ and ‘ah’”), and social interaction development (e.g.,
“Tries to approach familiar people such as family members”). Each item
is scored on a 4-point Likert-type scale ranging from 0 (cannot perform
at all) to 3 (can perform well). Mothers were asked to assess their infants'
behavior. The K-DST score is calculated by summing the scores of each
dimension, and based on these dimension scores, infants' level of de-
velopment is categorized into two groups: delayed and normal. Infants
who scored above −1 standard deviation from the mean were classified
as being in the normal group, and those who scored below this level
were classified as being in the delayed group.
This scale has been validated against the Korean-Bayley Scale of
Infant Development [31] and the Korean-Wechsler Preschool and Pri-
mary Scales of Intelligence [32] with Korean children. In this study, the
internal consistency reliability (the Cronbach's alpha) was good for the
whole K-DST, ranging between 0.82 and 0.85. The internal consistency
of subscales ranged from 0.45 to 0.84. A coefficient of at least 0.80
shows good consistency, and a coefficient of < 0.70 shows low
H.J. Choi et al. Early Human Development 127 (2018) 42–47

consistency [33]. Among the five dimensions, the cognition (Cronbach's Table 1
alpha = 0.45) showed low internal consistency; however, Gregory [34] Demographic characteristics of participants (N = 255).
suggested that there are no absolute standards for the Cronbach's alpha Variables N (%)
and that tests with reliabilities of 0.70 or lower can still have utility as
measures of individual differences. In this light, the standardized K-DST Infant
Gender (male) 130 (51.0)
still deemed to be a reliable scale for assessing the overall development
Birth order (first) 234 (91.8)
of infants and was used without excluding the cognition dimension. Gestational age at birth (37–42 weeks) 251 (98.4)
Birth weight (g), mean (SD) 3.3 (0.4)
2.3. Confounding factors Kaup index (kg/m2), mean (SD)
6 months 17.4 (2.1)
12 months 17.0 (1.9)
Confounding factors that appear to be related to breastfeeding style
Mother
and infant development were included in the models as control vari- Maternal age (years), mean (SD) 33.1 (5.9)
ables to rigorously examine the predictive effect of breastfeeding Education
duration on infant development: socioeconomic status (SES; maternal Less than or equal to high school 16 (6.3)
College 191 (74.9)
education, paternal education, and family income), mother's age at
Greater than College 48 (18.8)
birth, birth order, birth weight, and gestational age [8,10,35–37]. In- Monthly household income
formation about these variables was obtained via an online ques- < $2600 60 (23.5)
tionnaire at the 4-month visit. < $3500 69 (27.1)
< $4400 56 (22.0)
< $5300 33 (12.9)
2.4. Statistical analysis
≥$5300 37 (14.5)
Duration of breastfeeding
All statistical analyses were conducted using SPSS Statistics 23.0. Never 19 (7.5)
First, the demographic characteristics of the participants were de- Mixed breastfeeding for 6 months 130 (51.0)
scribed as frequencies, percentages, means, and standard deviations. Exclusive breastfeeding for 4 months, followed by mixed 82 (32.2)
breastfeeding
Second, the differences in infant development scores among breast- Exclusive breastfeeding for 6 months 24 (9.4)
feeding groups were examined using one-way analyses of variance K-DST at 6 months, mean (SD)
(ANOVAs) with Duncan's multiple range test as a post-hoc test. Third, Gross motor 15.4 (4.0)
the relationship between exclusive breastfeeding duration and infant Fine motor 21.7 (2.2)
Cognition 20.4 (2.4)
development was analyzed using multiple binary logistic regression
Communication 18.9 (3.2)
analysis. We accounted for confounding factors (SES, mother's age at Social interaction 19.0 (2.5)
time of birth, birth order, birth weight, gestational age) in this analysis K-DST at 12 months, mean (SD)
to isolate the specific benefits of breastfeeding duration. Gross motor 20.3 (4.7)
Fine motor 22.2 (2.1)
Cognition 22.1 (1.8)
3. Results Communication 21.2 (3.0)
Social interaction 21.7 (2.5)
The descriptive statistics for this study are presented in Table 1. The
sample comprised 255 Korean infants and their mothers. Note. Some data were missing for birth weight (n = 2), Kaup index at 6 months
(n = 9), and Kaup index at 12 months (n = 5). K-DST response options range
3.1. Breastfeeding duration and infant development from 0 to 3.

Table 2 shows the results of the one-way ANOVA to examine the
relationship between exclusive breastfeeding duration and infant de-
velopment at 6 and 12 months. Infants who were exclusively breastfed
until 6 months of age had significantly higher mean social interaction
development scores at 6 months than did infants who never breastfed
(p < .05). At 12 months, infants who exclusively breastfed until 4 and
6 months of age had significantly higher mean scores for cognition,
communication, and social interaction development than did infants
who never breastfed (p < .05).
Tables 3 and 4 show the results of the binary logistic regression
analysis on the K-DST dimensions at 6 and 12 months, before and after
adjusting for the confounding variables, respectively. Infants who were
exclusively breastfed until 4 months had greater odds of having normal
scores for communication and social interaction development at
6 months compared to infants who never breastfed (adjusted odds ratio
[aOR]: 4.12 [95% confidence interval: 1.11–15.28] and aOR: 6.04
[1.05–34.66], respectively). At 12 months, similar effects were found
for cognition (aOR: 6.66 [1.02–43.63], aOR: 3.93 [1.07–14.40], and
aOR: 1.59 [1.59–42.05], respectively). No significant effects were
found for the breastfeeding categories, including exclusive breast-
feeding until 6 months.
Compared with the unadjusted analyses, adjustment for the con-
founding variables increased the effects of exclusive breastfeeding on
communication at 6 months and social interaction at 12 months.
Furthermore, the effects on social interaction at 6 months and com-
munication at 12 months were significant only in the adjusted analyses.
The gross motor and fine motor dimensions showed no changes after
adjustment.
4. Discussion
We found that infants who were exclusively breastfed for 4 months
followed by mixed breastfeeding showed better development compared
to infants who were never breastfed. Specifically, they had higher levels
of communication and social interaction at 6 months, and higher cog-
nition, communication, and social interaction development at
12 months.
According to preceding research on cognition and communication
development, a longer duration of breastfeeding appears to improve
cognitive and communication development at 18 months [15]. Ad-
ditionally, infants who breastfed for < 4 months had an increased risk
of developmental delay in terms of adaptability and communication at
ages 1–3 years compared to those who were breastfed for > 4 months
[14]. The longer the breastfeeding period, the faster infants appear to
reach developmental milestones such as polysyllabic babbling [38], and
breastfed infants have an advantage in processing language stimuli over
formula-fed infants [16]. A previous meta-analysis of 20 studies that
compared breastfeeding with formula-feeding reported that breastfed
infants consistently had higher cognitive development mean scores
than did formula-fed infants [11]. The authors went on to point out that
increased cognitive development as a result of breastfeeding begins to
appear in early development and persists throughout childhood and

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H.J. Choi et al. Early Human Development 127 (2018) 42–47

Table 2
Mean and standard deviation of breastfeeding duration and infant development at 6 and 12 months.
Breastfeeding duration p

Exclusive breastfeeding until Exclusive breastfeeding until 4 months of Mixed breastfeeding until Never breastfed
6 months of age age, thereafter mixed breastfeeding 6 months of age

n = 24 n = 82 n = 130 n = 19

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

6 months
Gross motor 17.29 (4.71) 15.71 (3.86) 14.92 (3.89) 15.26 (4.41) NS
Fine motor 22.08 (2.28) 22.01 (2.06) 21.58 (2.15) 21.11 (2.33) NS
Cognition 20.75 (2.97) 20.66 (1.91) 20.24 (2.48) 20.21 (2.25) NS
Communication 19.71 (3.51) 19.37 (2.95) 18.63 (3.18) 18.31 (3.28) NS
Social interaction 19.92b (2.02) 19.50a,b (2.21) 18.68a,b (2.80) 18.37a (1.77) < .05

12 months
Gross motor 19.17 (4.93) 20.90 (4.07) 20.13 (5.00) 20.21 (5.22) NS
Fine motor 22.08 (2.02) 22.02 (2.03) 22.33 (2.14) 21.84 (2.29) NS
Cognition 22.17b (1.55) 22.28b (1.49) 22.09b (1.84) 20.95a (2.46) < .05
Communication 21.13b (2.13) 22.27b (2.19) 20.94b (3.19) 19.53a (4.25) < .05
Social interaction 21.83b (2.68) 22.27b (1.61) 21.53a,b (2.84) 20.58a (2.87) < .05

a b
Note. Significant differences are denoted with and for Duncan's validation. NS = not significant.

adolescence, and that the longer the breastfeeding period, the greater
the cognitive developmental benefits of breastfeeding.
The relationships of breastfeeding with communication and cogni-
tion development can be explained by a special nutritional component
in breast milk not found in formula. There is robust evidence that the
long chain polyunsaturated fatty acids (LCPUFAs), especially doc-
osahexaenoic acid (DHA), contained in breast milk have beneficial ef-
fects on brain development. Makrides et al. [5] found that breastfed
infants had higher levels of DHA in their cerebral cortex and better
scores on measures of visual function and brain development than did
formula-fed infants. Crawford [39] similarly reported that DHA is an
important component of breast milk and supports brain development,
while Willatts et al. [40] demonstrated that 10-month-old infants who
were fed formula containing LCPUFA showed improved problem-sol-
ving skills. In addition, breast milk contains thyroxine and nerve
growth factors, which can influence neural development and cognitive
achievement [12]. Because of the neurophysiological merits of breast
milk, it is perhaps the best proprietary initial nutrition source and is
recommended for all infants for at least four months after birth.
As noted earlier, the majority of previous studies examined the re-
lationship between breastfeeding and cognitive abilities, whereas only a
few have examined social interaction. In this study, infants who were
exclusively breastfed for 4 months followed by mixed breastfeeding
were found to have higher social interaction scores at both 6 and
12 months compared to infants who were never breastfed. Social in-
teraction captures the essential skills infants use in interacting with
others, such as eye contact and conjugate gaze [29]. It has been re-
ported that the breastfeeding process itself involves mother–infant
dyadic interactions that facilitate bonding and enhance interaction
[41], and that through breastfeeding, the mother and the infant natu-
rally make eye contact, and the warm skin contact and immediate sa-
tisfaction of hunger have an increasing effect on interaction with the
infant [42]. In a New Zealand's birth cohort study [43], breastfeeding
children were found to have more positive relationships with their
parents than formula-fed children; more specifically, the longer the
duration of the breastfeeding period, the more likely the child was to

Table 3
Unadjusted binary logistic regression analyses of K-DST scores at 6 months according to duration of breastfeeding.
Breastfeeding duration p

Exclusive breastfeeding until Exclusive breastfeeding until 4 months of Mixed breastfeeding until Never breastfed
6 months of age age, thereafter mixed breastfeeding 6 months of age

n = 24 n = 82 n = 130 n = 19

OR (95% CI) OR (95% CI) OR (95% CI) OR

6 months
Gross motor 0.28 (0.03–2.72) 0.36 (0.04–296) 0.21 (0.03–1.66) Ref NS
Fine motor 0.82 (0.12–5.51) 0.85 (0.17–4.23) 1.58 (0.32–7.95) Ref NS
Cognition 2.71 (0.23–32.34) 4.71 (0.62–35.78) 2.94 (0.53–16.37) Ref NS
Communication 2.50 (0.51–12.18) 3.83a (1.06-13.79) 1.85 (0.60–5.70) Ref < .05
Social interaction 2.06 (0.31–13.81) 4.94 (0.91–26.71) 1.55 (0.40–6.01) Ref NS

12 months
Gross motor 0.32 (0.08–1.23) 0.73 (0.22–2.43) 0.65 (0.20–2.07) Ref NS
Fine motor 0.82 (0.12–5.51) 0.85 (0.17–4.23) 1.58 (0.32–7.95) Ref NS
Cognition 4.31 (0.41–45.28) 7.50a (1.16–48.56) 1.69 (0.43–6.57) Ref < .05
Communication 3.93 (0.67–23.10) 3.30 (0.94–11.59) 1.85 (0.60–5.70) Ref NS
Social interaction 2.93 (0.48–18.10) 7.02a (1.42-34.63) 1.38 (0.42–4.59) Ref < .05

The reference group is the never breastfed infants. NS = not significant.

a
p < .05.

45
H.J. Choi et al. Early Human Development 127 (2018) 42–47

Table 4
Adjusted binary logistic regression analyses of K-DST scores at 6 months according to duration of exclusive breastfeeding.
Breastfeeding duration p

Exclusive breastfeeding until Exclusive breastfeeding until 4 months of Mixed breastfeeding until Never breastfed
6 months of age age, thereafter mixed breastfeeding 6 months of age

n = 24 n = 82 n = 130 n = 19

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

6 months
Gross motor 0.19 (0.16–2.27) 0.24 (0.02–2.35) 0.16 (0.02–1.54) Ref NS
Fine motor 0.87 (0.13–5.86) 0.90 (0.18–4.61) 1.74 (0.34–8.83) Ref NS
Cognition 2.74 (0.22–33.79) 4.11 (0.52–32.37) 2.87 (0.50–16.49) Ref NS
Communication 2.69 (0.55–13.20) 4.12a (1.11-15.28) 2.01 (0.65–6.29) Ref < .05
Social interaction 2.29 (0.34–15.50) 6.04a (1.05-34.66) 1.68 (0.43–6.60) Ref < .05

12 months
Gross motor 0.28 (0.07–1.13) 0.62 (0.17–2.18) 0.61 (0.18–2.03) Ref NS
Fine motor 0.87 (0.13–5.86) 0.90 (0.17–4.61) 1.74 (0.34–8.83) Ref NS
Cognition 4.41 (0.42–46.68) 6.66a (1.02-43.63) 1.65 (0.42–6.49) Ref < .05
Communication 4.34 (0.73–25.79) 3.93a (1.07-14.40) 2.02 (0.65–6.32) Ref < .05
Social interaction 3.21 (0.52–19.98) 8.17a (1.59-42.05) 1.50 (0.45–5.04) Ref < .05

The reference group is the never breastfed infants.

Adjusted for mother's age at birth, birth order, birth weight, gestational age (37–42 weeks = 1), and socioeconomic status (paternal education, maternal education,
household income). NS = not significant.
a
p < .05.

perceive their mother's care as affectionate. In addition, similar findings
have reported in studies on attachment, which is considered to be im-
portant in social development, that breastfeeding enhances secure at-
tachment in mother–child relationships by “skin-to-skin contact” [44].
Attachment here means a strong affectionate tie with special people in
one's life [45]. Consistent with this, Else-Quest et al. [46] reported that
children who were breastfed tend to have stronger emotional bonds
with their mothers; Britton et al. [47] found that mothers who chose
breastfeeding tended to respond more sensitively to infant cues in
mutual interactions during early infancy and that the greater sensitivity
of these mothers directly influenced the infant's secure attachment
formation. In addition, mothers with high sensitivity were more likely
to breastfeed for longer during infancy [47]. These results suggest that
by breastfeeding the infant, the mothers were in physical contact with
their children and as they watched the child breastfeed, they felt that
their emotions were closely communicated to each other, forming a
bond and attachment. Korean mothers try to get used to breastfeeding
the infant and want to use the bottle only partially [48]. It is known that
breastfeeding rather than bottle feeding using a breast pump helps
mothers produce the proper amount of breast milk and adapt to the
infant's breastfeeding [49]. Although this study did not investigate the
variations in breastfeeding, i.e. bottle feeding or breastfeeding, further
research should look at the variations in breastfeeding and how it re-
lates to infant development in the future.
Interestingly, unlike infants who received 4 months of exclusive
breastfeeding followed by mixed breastfeeding, infants with 6 months
of exclusive breastfeeding did not show statistically significant effects
on all developmental areas. Previous studies have reported that the
longer breastfeeding duration has a positive effect on infant develop-
ment. In contrast, in this study, the effects of exclusive breastfeeding
duration on infant's cognitive, language, and social development were
no longer significant when mothers continued to exclusively breastfeed
after 4 months. A review by Fewtrell et al. [18] has suggested that the
benefits of breastfeeding and the benefits of exclusive breastfeeding
should be distinguished. However, caution is needed when interpreting
the results of this study; in particular, it is possible that the sample size
of the 6-month exclusive breastfeeding group was too small, explaining
why it did not show statistical significance. The evidence for this is that,
as with the infants who received 4 months of exclusive breastfeeding
followed by mixed breastfeeding, the infants who received 6 months of
exclusive breastfeeding had higher means scores on the cognition,
communication, and social interaction dimensions at 6 and 12 months
than did the never breastfed group. This indicates a synergistic effect.
Therefore, continued research on the effects of exclusive breastfeeding
for 4 months and 6 months on infant development is needed.
The limitations of this study are as follows. First, the monthly
household income of 50.6% of the participants was less than $3500.
Considering that the monthly household income of Korea in 2017 was
reported to be $4200 [50], the mothers in the sample had relatively
high household income, but the income of the families in our sample
was comparable to the mean household income level of Korea. How-
ever, the fact that participants were a middle-class sample could be a
limitation of this study. Second, due to the small sample size, there are
limits to our ability to generalize the study results and we need to
conduct additional studies to support generalization.
5. Conclusion
A strength of the present study is that we measured the overall
development of infants through a 1-year follow-up. Exclusive breast-
feeding in infants up to 4 months followed by mixed breastfeeding was
associated with significantly better infant development: at 6 months,
the relationship was present for communication and social interaction,
whereas at 12 months, it had expanded to include cognition. We can
conclude that this pattern of breastfeeding maximizes the develop-
mental benefits to infants during the first year of the infant's life.
Further research is, however, needed to support the WHO's re-
commendation for exclusive breastfeeding up to 6 months, rather than
4 months. However, we are reasonably certain that long-term (at least
6 months) continuous breastfeeding is associated with improved early
infant development. Further expansion of this research to include the
long-term follow-up into early childhood to observe the effects of ex-
clusive breastfeeding until 6 months, as well as inclusion of diverse
racial and ethnic groups could strengthen this study.
Acknowledgements
None.

46
H.J. Choi et al.
Funding
This work was supported by the Gachon University Research Fund
of 2018 [GCU-2018-0357].
Declarations of interest
None.
All authors have approved the final article.
Ethical approval
The study was approved by the IRB board of Gachon University
(Approval number: 1044396-201705-HR-079-01).
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