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Table 4 Quality assessment of studies measuring the association between suboptimal breastfeeding and selected outcomes

From: Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis

     Directness
No of studies (ref) Design Limitations Consistency Generalizability to population of interest Generalizability to intervention of interest
Pneumonia Incidence: moderate outcome-specific quality
1 [27] Cohort Reverse causality highly likely (-0.5) Study shows benefit of EBF among infants 0-5 mos of age; study shows benefit of any BF among infants 6-23 mos of age (+1) Only Asia (-0.5) EBF not reported for neonates alone
Pneumonia Prevalence: moderate outcome-specific quality
1 [18] Cohort Reverse causality likely (-0.5) Study shows benefit of EBF among infants 0-5 mos of age; study shows benefit of any BF among infants 6-23 mos of age (+1) Only Latin America (-0.5) EBF not reported for neonates alone
Pneumonia Mortality: moderate outcome-specific quality
5 [1923] Cohort/Case-control Reverse causality highly likely or likely for 3 of 5 studies (-0.5) All studies show benefit of EBF among infants 0-5 mos of age; all studies show benefit of any BF among infants 6-23 mos of age (+1) Asia, Latin America, Africa, Western Pacific  
All-Cause Mortality: moderate outcome-specific quality
4 [19, 20, 24, 25] Cohort Reverse causality highly likely or likely for all 4 studies (-0.5) All studies show benefit of EBF among infants 0-5 mos of age; all studies show benefit of any BF among children 6-23 mos of age (+1) Asia, Latin America, Africa  
Pneumonia Hospitalizations: moderate outcome-specific quality
2 [20, 26] Cohort/Case-control Reverse causality highly likely or likely for both studies (-0.5) All studies show benefit of EBF among infants 0-5 mos of age; studies show benefit of any BF among children 0-11 mos of age (+1) Asia, Latin America, Africa EBF not reported for neonates alone; BF not reported for children >11 mos
All-Cause Hospitalizations: moderate outcome-specific quality
1 [20] Cohort Reverse causality highly likely (-0.5) Study shows benefit of EBF among infants 0-5 mos of age (+1) Asia, Latin America, Africa EBF not reported for neonates alone; BF not reported for children >6 mos