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Table 5 Quality assessment of studies measuring the association between suboptimal breastfeeding and selected outcomes

From: Breastfeeding and the risk for diarrhea morbidity and mortality

     Directness
No of studies (ref) Design Limitations Consistency Generalizability to population of interest Generalizability to intervention of interest
Diarrhea Incidence: moderate outcome-specific quality
5 [22, 23, 2628] Cohort/Cross-sectional Reverse causality highly likely or likely for all 5 studies (-0.5) Consistent and all studies showing benefit of EBF among infants 0-5 mos of age and benefit of any BF among children 6-23 mos of age (+1) Mostly Latin America (-0.5) EBF not reported for neonates alone
Diarrhea Prevalence (1-2 week): moderate outcome-specific quality
7 [21, 22, 27, 3032, 34] Cohort/Cross-sectional Reverse causality highly likely or likely for all 7 studies (-0.5) All but one study showing benefit of EBF among infants 0-5 mos of age; all studies showing benefit of any BF among children 6-23 mos of age (+1) Mostly Asia (-0.5) EBF not reported for neonates alone
Diarrhea Mortality: moderate outcome-specific quality
6 [15, 19, 20, 25, 33, 35] Cohort/Case-control Reverse causality highly likely or likely for 5 of 6 studies (-0.5) Consistent and all studies showing benefit of EBF among infants 0-5 mos of age and benefit of any BF among children 6-23 mos of age (+1) Mostly Asia & Latin America (-0.5) EBF not reported for neonates alone
All-Cause Mortality: moderate outcome-specific quality
4 [1921, 24] Cohort Reverse causality highly likely or likely for all 4 studies (-0.5) All but one study showing benefit of EBF among infants 0-5 mos of age; all studies showing benefit of any BF among children 6-23 mos of age (+1) Mostly Asia (-0.5)  
Diarrhea Hospitalizations: moderate outcome-specific quality
2 [20, 29] Cohort/Case-control Reverse causality highly likely or likely for both studies (-0.5) Consistent and all studies showing benefit of EBF among infants 0-5 mos of age and benefit of any BF among children 6-23 mos of age (+1) Equal amount of data from Asia, Latin America, Africa & Eastern Mediterranean EBF not reported for neonates alone