See corresponding editorial on page 1120.
Effect of breastfeeding and sociodemographic factors on visual
outcome in childhood and adolescence1–3
Alicja R Rudnicka, Christopher G Owen, Marcus Richards, Michael EJ Wadsworth, and David P Strachan
ABSTRACT
Background: It has been suggested that early life factors, including
breastfeeding and birth weight, program childhood myopia.
Objective: We examined the relation of reduced unaided vision
(indicative of myopia) in childhood and adolescence with infant
feeding, parental education, maternal age at birth, birth weight, sex,
birth order, and socioeconomic status.
Design: Three British cohorts recruited infants born in 1946 (n ҃
5362), 1958 (n ҃ 18 558), and 1970 (n ҃ 16 567). Adjusted odds
ratios (ORs) for unaided vision of 6/12 or worse at ages 10 –11 and
15–16 y from each cohort were pooled by using fixed-effects meta-
analyses.
Results: The prevalence of reduced vision ranged from 4.4% to
6.5% at 10 –11 y and from 9.4% to 11.4% at 16 y, with marginally
higher levels in later cohorts. Breastfeeding declined across succes-
sive cohorts (65%, 43%, and 22% in those breastfed for 쏜1 mo,
respectively). Pooled ORs showed no associations between infant
feeding and vision after adjustment at either age. Parental education
(OR: 1.48, high versus low education; 95% CI: 1.23, 1.79), maternal
age (OR: 1.10, per 5-y increase; 95% CI: 1.04, 1.17), birth weight
(OR: 0.85, per 1-kg rise; 95% CI: 0.76, 0.95), number of older
siblings (OR: 0.89, per older sibling; 95% CI: 0.83, 0.94), and sex
(OR: 1.10, girls versus boys; 95% CI: 0.98, 1.23) were related to
adverse visual outcome in childhood. Stronger associations were
observed in adolescence, except that the association with birth
weight was null.
Conclusions: Infant feeding does not appear to influence visual
development. Consistent associations of reduced vision with paren-
tal education, sex, maternal age, and birth order suggest that other
environmental factors are important for visual development and
myopia in early life. Am J Clin Nutr 2008;87:1392–9.
INTRODUCTION
Myopia is a leading cause of correctable visual impairment in
the developed world and a leading cause of blindness in devel-
oping countries (1). It has been estimated that 30.4 million Amer-
icans aged 욷40 y are myopic (2). Reduced vision in childhood is
predominantly due to myopia (3– 6) with a shift toward higher
levels of myopia with increasing age (7). Marked geographic
variations in the prevalence of myopia have been reported in both
children and adults (8, 9). These variations coupled with the
recent rapid increases in the prevalence of myopia, especially
among children in Asian (10) and other industrialized societies
(11), suggest that environmental factors are important determi-
nants of visual outcome.
1392 Am J Clin Nutr 2008;87:1392–9. Printed in USA. © 2008 American Society for Nutrition
Vision is immature at birth and is programmed in response to
visual stimuli in early life. There has been considerable interest
in whether early nutrition might also influence visual develop-
ment, particularly whether initial infant feeding may play a role.
It has been suggested that those initially breastfed have better
vision and are less likely to be myopic in later life than are those
who are formula fed (12–15). The presence of long-chain poly-
unsaturated fatty acids (LCPUFAs) in breast milk, which are
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needed for rapid growth and neural development in early life
(16, 17), has been proposed as a potential explanation for these
findings, because formula milk does not universally contain
LCPUFAs (15). Although this has been supported by experimen-
tal evidence showing the benefit on visual outcome of formula
milk supplemented with LCPUFAs relative to nonsupplemented
formula (13, 18), other experimental and observational evidence
has been less supportive (19 –23). Inconsistencies in results may
reflect variation in statistical power and/or differences in the
extent of adjustment for potentially confounding factors, such as
socioeconomic status (14, 15, 24), maternal factors at delivery
(14, 15, 25, 26), parental smoking and education (14, 15, 27),
birth order (24, 27, 28), and differences in size at birth between
feeding groups (14, 15, 20).
Some evidence links these potential confounding factors to
visual outcomes in early life. Increasing maternal age at birth
seems to be related to poorer visual outcomes in infancy (14) and
is strongly associated with the degree of myopia in early child-
hood (29). In agreement with this latter finding, recent work has
suggested a positive association between birth weight and eye
size in young children (30, 31). A retrospective cohort study did
not find birth weight to be related to visual function in the elderly
(32). Higher levels of parental education (15, 27), higher socio-
economic status (15, 24, 33), and smaller family size (or birth
order) (24, 27) have been reported to be positively related to the
prevalence of myopia. Higher levels of myopia among girls than
1
From the Division of Community Health Sciences, St George’s, Univer-
sity of London, London, United Kingdom (ARR, CGO, and DPS), and the
Medical Research Council National Survey of Health and Development,
Department of Epidemiology and Public Health, Royal Free Hospital, Uni-
versity College Medical School, London, United Kingdom (MR and MEJW).
2
Supported by grant no. G0000934 from the Medical Research Council
(ARR) and grant no. PG/04/072 from the British Heart Foundation (CGO).
3
Address reprint requests and correspondence to AR Rudnicka, Division
of Community Health Sciences, St George’s, University of London, Cranmer
Terrace, London SW17 ORE, United Kingdom. E-mail: arudnick@
sgul.ac.uk.
Received August 1, 2007.
Accepted for publication November 1, 2007.
Supplemental Material can be found at:
http://www.ajcn.org/content/suppl/2008/05/15/87.5.1392.DC
1.html
 INFANT FEEDING AND VISION
among boys observed among some studies (33–35) may also
suggest environmental influences on refractive outcome, al-
though not all studies have shown similar sex differences (15,
24). A comparable finding was observed in studies that examined
the association between infant feeding and cognitive develop-
ment, a neurological outcome related to vision, where failure to
adjust systematically for similar confounders (36, 37) may ex-
plain the apparent inconsistencies in the findings (28, 37– 43).
To examine the association of early nutrition on vision further,
we examined the association between pattern of infant feeding
and visual outcome in childhood and adolescence in 3 large
British birth cohorts accounting for the potential confounding
factors identified above. The cross-cohort comparison allows for
the association between infant feeding and visual outcome to be
gauged over a period when there has been stark changes in the
rates of breastfeeding and social patterning of feeding in early
life, together with considerable improvements in childhood nu-
trition (44, 45). In addition, parental educational attainment, es-
pecially maternal education, would also have changed over this
time frame, and this would influence both diet and educational
attainment in the offspring. The available data also allow the
strength and consistency of the association between vision and
other sociodemographic factors across cohorts to be gauged.
SUBJECTS AND METHODS
Participants were drawn from 3 British birth cohorts with
information on infant feeding practices, vision outcome in child-
hood and adolescence, and information on potential confounding
factors, including socioeconomic status in early childhood or
infancy, birth weight, maternal age at delivery, parental educa-
tion, and the number of younger and older siblings (birth order).
Ethical approval for the examination of the cohort members was
obtained from the relevant ethical committees at the time of each
survey.
British birth cohort studies
From all those born in England, Scotland, and Wales during 1
wk in March 1946, a sample was selected for follow-up of single
infants born to married women. All such births to wives of non-
manual and agricultural workers were selected together with 1 in
4 of all such infants born to wives of manual workers to form the
Medical Research Council National Survey of Health and De-
velopment (NSHD; n ҃ 5362), also known as the British 1946
birth cohort (46). The next cohort recruited all persons born in
England, Scotland, and Wales during 1 wk in March 1958 for a
Perinatal Mortality Survey (n ҃ 17 638); this then became
known as the National Child Development Study (NCDS), or the
British 1958 birth cohort (47). The third cohort, the 1970 British
Cohort Study (1970 BCS), recruited 98% of persons (n ҃ 16567)
born in Great Britain during 1 wk in April 1970 (48). Participants
from all cohorts were followed up periodically from birth
through childhood and into adulthood. The current analysis is
based on data collected from birth up to age 16 y.
Definition of visual outcome
Vision was measured when the children were aged 11 and 15 y
in the 1946 cohort, 11 and 16 y in the 1958 cohort, and 10 and 16 y
in the 1970 cohort. In all 3 cohorts, unaided distance vision (ie,
without optical correction) was measured with the use of con-
ventional Snellen charts of block capitals under standardized
1393
conditions; each eye was tested separately. In the 1958 and 1970
cohorts, near vision was also tested at both ages using the Sheri-
dan and Gardiner reduced Snellen near acuity cards at 앒25 cm
(10 inches) (49 –51). Two dichotomous outcomes of presumed
myopia were derived from these vision outcomes. The first used
a cutoff of unaided distance vision in the better eye of 6/12
Snellen acuity or worse. The second, used for the 1958 and 1970
cohorts only, was based on an unaided distance vision of 6/12
Snellen acuity or worse and unaided near vision of 6/6 or 6/9 at
25 cm (in the better eye); those with both poor distance and near
vision were excluded. This latter definition of presumed myopia
was used previously in the 1958 NCDS (24) and is considered to
be analogous with Ҁ1 to Ҁ5 diopters of myopia. Results from our
analyses using this definition were not materially different from
the visual outcome based on an unaided distance alone and,
therefore, are not presented. This is not unexpected because it
was shown in the 1958 cohort that those with reduced distance
vision at 16 y (91%) had myopia in adulthood (6). Children in the
1946 cohort with distance vision 6/12 or worse at 16 y received
an ophthalmic examination; the results showed that 욷61% were
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myopic, but 30% with reduced vision were not assessed, so the
proportion of myopia in this group is an underestimate and is
likely to be higher.
Definition of breastfeeding
In the 1946 NSHD, mothers were interviewed when the cohort
member was 2 y old; infant feeding status and duration of breast-
feeding was ascertained for 4784 (89% of the cohort at the outset)
participants. In the other 2 cohorts, infant feeding was recalled by
parental interview when the child was 5 (1970 BCS) or 7 (NCDS)
y of age, and the number with data on breastfeeding status was
12 981 (74%) and 14498 (88%), respectively. Infant feeding
status was classified as not breastfed at all, breastfed (partially or
wholly) for 쏝1 mo, and breastfed for 욷1 mo (in NSHD 1946,
duration of breastfeeding in months up to 10 mo was available
and in the 1970 BCS it was also possible to identify those breast-
fed for 욷3 mo). Those with unknown infant feeding status were
excluded from the analyses throughout.
Definition of other risk factors
1946 NSHD
In the 1946 cohort, socioeconomic status was defined in the
study sampling design according to the Registrar General system
and was dichotomized to manual and nonmanual groups at birth;
this dichotomization was preserved for the analyses. Birth
weight, sex, maternal age, parental education, and birth order
were recorded during the birth survey. Parental education at birth
was classified as primary schooling only, primary or secondary
education with formal qualifications after secondary school (but
no diploma), and diplomas and professional degrees (highest
group); the highest level achieved by either parent was used.
From birth order the number of older siblings was defined, and
the number of children at age 11 y was obtained by parental
questionnaire, thereby allowing the number of younger siblings
to be determined. In the analyses, the number of younger and
older siblings was used to take account of birth order and family
size.
1394 RUDNICKA ET AL
1958 NCDS
Maternal age, birth weight, and sex were obtained from the
1958 Perinatal Mortality Survey. Socioeconomic status in child-
hood was based on Registrar General classification of the father’s
occupation in 1958 or at age 7 y if data were unavailable at birth.
The age at which the father left full-time education was ascer-
tained when the cohort member was 7 and 11 y of age. Data at age
7 y were preferred; however, data from age 11 y were used if data
at age 7 y were missing. The age at which the mother left full-time
education was also ascertained when the cohort member was
11 y. Parental education was classified into 3 groups: left school
at the minimum age of 15 y (or younger), remained in full-time
education to the age of 18 y, and remained in full-time education
beyond the age of 18 y; the highest level achieved by either parent
was used in the analyses. At age 11 y, the number of younger
siblings and the child’s position in relation to all siblings was
obtained by parental questionnaire.
1970 BCS
Birth weight and sex were recorded in the original birth survey.
Age of the mother at delivery was ascertained by parental inter-
view when the child was 5 y of age. Socioeconomic status in
childhood was defined by paternal occupation (using the Regis-
trar General classification) if available; if not available, it was by
maternal occupation when the child was 10 y old. Family size,
including the number of older and younger siblings, and parental
education were determined at the same age. Parental education
was classified into 3 groups using qualifications indicative of
leaving full-time education at 울16 y, 16 –18 y, or 쏜18 y of age.
Again, the highest level achieved by either parent was used in the
analyses.
Statistical analysis
Statistical analyses were performed by using STATA version
9 (STATA Corporation, College Station, TX). The prevalences
of unaided distance vision 6/12 or worse at ages 10 –11 and
15–16 y were compared by a chi-square test in those breastfed for
쏜1 mo and those never breastfed. Chi-square tests were also used
to compare the prevalences of reduced vision by social class
(manual versus nonmanual), sex, level of parental education,
maternal age (쏝25 y, 25 to 쏝35 y, and 욷35 y), quintiles of birth
weight, and number of younger (0, 1–2, and 욷3) and older (0,
1–2, and 욷3) siblings. On the basis of the number of individuals
in each cohort with vision outcome data, we used logistic regres-
sion of grouped data to examine trends in the log odds of poor
visual outcome over the 3 cohorts. Trends were examined for
child and adolescent age groups separately. Within each cohort,
multiple variable logistic regression was used to obtain mutually
adjusted odds ratios for the vision outcomes for infant feeding
group, socioeconomic position in childhood, sex, and parental
education as categorical variables and maternal age at delivery,
birth weight, and number of younger and older siblings as con-
tinuous variables. Adjusted odds ratios from each cohort were
pooled by using a fixed-effects (inverse variance) meta-analysis
throughout. Heterogeneity across cohorts was examined by us-
ing chi-square tests (52), and tests for trend of the odds ratios
across the 3 cohorts were examined by using meta-regression
analysis (metareg command in STATA). All analyses were re-
stricted to those with complete data on the relevant vision out-
come and all risk factors considered above.
RESULTS
The overall prevalence of reduced vision at 10 –11 and 15–16
y in the 3 cohorts is summarized by all risk factors considered in
the analyses in Table 1. Overall, the prevalence of distance
vision of 6/12 or worse at 10 –11 and 15–16 y was 6.0% and 9.4%
in the 1946 NSHD, 6.5% and 10% in the 1958 NCDS, and 4.4%
and 11.4% in the 1970 BCS. The lower prevalence of poor vision
in childhood for the 1970 BCS may in part be explained by the
fact that vision was assessed 1 y earlier in this cohort. It is known
that myopia increases with age, and rapid changes in prevalence
occur at these ages (11). Logistic regression of the log odds of
poor vision at 15–16 y showed some evidence of an increase from
1948 to 1970 (P ҃ 0.004), but vision was assessed 1 y earlier in
the 1946 NSHD. Hence, this trend may have been partly or
wholly confounded by age.
The prevalence of breastfeeding fell markedly across the 3
successive cohorts. Of those with complete data for these anal-
yses, the proportions breastfed for 쏜1 mo were 65% in the 1946
NSHD, 43% in the 1958 NCDS, and 22% in the 1970 BCS. The
prevalence of breastfeeding for 쏜1 mo was more common in
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nonmanual social classes and with increasing parental education,
especially among the latter 2 cohorts (See Table S1 under “Sup-
plemental data” in the online issue.). There is some evidence that
infants with lower birth weights and older siblings were less
likely to have been breastfed. No clear association of infant
feeding to maternal age was observed (See Table S1 under “Sup-
plemental data” in the online issue.). The patterns observed
among those with complete data on all risk factors did not ma-
terially change when those without complete data were included.
Infant feeding and visual outcome in later life
In the 1946 NSHD and 1958 NCDS, the prevalence of distance
vision of 6/12 or worse at 10 –11 and 15–16 y of age was similar
in those breastfed and formula fed. In the 1970 BCS, the preva-
lence of reduced vision was marginally lower in those who were
formula fed, but these crude differences were not statistically
significant (Table 1). None of the corresponding odds ratios
showed any evidence of an association of breastfeeding with
reduced vision after adjustment for potential confounders, in-
cluding socioeconomic status in childhood, sex, parental educa-
tion, maternal age, birth weight, and number of younger and older
siblings (Table 2). The pooled fixed-effects estimate of reduced
vision comparing those breastfed for 쏜1 mo with those never
breastfed was 1.03 (95% CI: 0.90, 1.18) at 10 –11 y and 1.02
(95% CI: 0.89, 1.16) at 15–16 y.
The duration of breastfeeding defined in each cohort was 욷1
mo, and this potentially diluted associations with longer dura-
tions of breastfeeding. It was possible to examine the association
of breastfeeding for 욷3 mo in the 1970 BCS, and, in the 1946
NSHD, the duration of exclusive breastfeeding in months up to
12 mo was available. There was still no association between infant
feeding on visual outcome, either in childhood or adolescence,
when this prolonged duration and exclusivity of breastfeeding
(1946 birth cohort only) was considered (data not presented).
Other factors associated with visual outcome in childhood
and adolescence
In general, the adjusted odds ratios were consistent across
the cohorts, and tests for heterogeneity were not statistically
significant for any risk factor, except for mid versus low level
 INFANT FEEDING AND VISION 1395
TABLE 1
Prevalence of unaided distance vision of 6/12 or worse by all risk factors included in the analyses in the participants with complete data on vision outcome

Prevalence of unaided distance vision of 6/12 or worse

10 –11 y 15–16 y
1946 NSDH 1958 NCDS 1970 BCS 1946 NSHD 1958 NCDS 1970 BCS
Risk factor (n ҃ 3510) (n ҃ 10 588) (n ҃ 9076) (n ҃ 3288) (n ҃ 8239) (n ҃ 3925)

%
Infant feeding
Formula fed 6.0 6.4 4.0 9.3 9.4 10.5
Breast fed 쏜1 mo 5.7 6.8 5.2 9.6 10.6 12.1
P1 0.30 0.53 0.07 0.86 0.23 0.09
Sex
Male 5.7 6.3 4.1 8.5 9.0 10.5
Female 6.3 6.8 4.8 10.4 11.0 12.2
P1 0.42 0.25 0.09 0.07 0.002 0.09
Socioeconomic status
Nonmanual 6.1 7.4 4.9 10.8 12.4 13.3
Manual 5.8 6.2 4.2 7.8 9.0 10.0
P1 0.70 0.03 0.12 0.003 쏝0.001 0.001
Parental education

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Left school at minimum age 5.7 5.8 4.1 7.6 8.9 10.0
Further education 6.5 6.8 4.5 12.5 9.8 10.6
Higher education 6.8 10.3 5.8 13.5 17.0 16.5
P1 0.55 쏝0.001 0.01 쏝0.001 쏝0.001 쏝0.001
Maternal age at birth
쏝25 y 6.0 5.8 4.2 9.2 8.4 9.8
25 to 쏝35 y 6.3 7.0 4.4 9.6 10.6 12.2
욷35 y 4.9 6.4 6.2 9.1 11.3 14.6
P1 0.38 0.05 0.05 0.93 0.003 0.01
Birth weight quintile2
1 6.3 7.2 5.5 9.7 10.2 11.4
2 6.5 6.7 5.3 10.7 10.2 10.0
3 6.0 7.0 3.4 8.7 10.7 8.7
4 4.9 5.9 4.6 6.9 8.7 14.1
5 5.8 6.0 3.4 10.2 10.1 12.1
P1 0.76 0.30 0.002 0.15 0.31 0.007
Number of younger siblings
0 6.4 6.0 4.1 9.3 10.0 10.8
1–2 5.7 7.0 4.8 9.4 10.3 12.1
욷3 5.3 6.2 4.5 10.1 8.6 5.6
P1 0.60 0.17 0.31 0.92 0.27 0.32
Number of older siblings
0 6.9 7.5 4.7 11.2 11.2 12.5
1–2 5.5 6.0 4.1 8.4 9.5 10.3
욷3 4.7 5.0 4.9 7.3 6.4 12.1
P1 0.13 0.02 0.35 0.01 쏝0.001 0.11
Total prevalence 6.0 6.5 4.4 9.4 10.0 11.4
1
P values are from chi-square tests for crude comparisons of proportions.
2
Birth weight quintile groups are as follows: 1946 Medical Research Council National Survey of Health and Development (NSHD): 1st ҃ 쏝2.9 kg, 2nd
҃ 2.9 to 쏝3.3 kg, 3rd ҃ 3.3 to 쏝3.6 kg, 4th ҃ 3.6 to 쏝3.8 kg, 5th 욷3.8 kg; 1958 National Child Development Study (NCDS): 1st ҃ 쏝2.9 kg, 2nd ҃ 2.9 to
쏝3.2 kg, 3rd ҃ 3.2 to 쏝3.5 kg, 4th ҃ 3.5 to 쏝3.8 kg, 5th 욷3.8 kg; and 1970 British Cohort Study (BCS): 1st ҃ 쏝2.9 kg, 2nd ҃ 2.9 to 쏝3.2 kg, 3rd ҃ 3.2
to 쏝3.4 kg, 4th ҃ 3.4 to 쏝3.7 kg, 5th 욷3.7 kg.

of parental education in adolescence (Table 2 and Table 3).
Females were more likely to have reduced vision than were
males (Tables 2 and 3), especially in adolescence, with a
pooled odds ratio of 1.23 (95% CI: 1.11, 1.37). Individuals
from a manual social class were less likely to have poor vision
at both ages than were those from a nonmanual social class.
Although socioeconomic status did not show a strong associ-
ation within each cohort, the pooled estimate at 15–16 y sug-
gests a 12% reduction in the odds of reduced vision in the
manual versus nonmanual social classes (95% CI: 0.78, 0.99).
In all 3 cohorts, unaided distance vision of 6/12 or worse was
more likely in those with higher levels of parental education
than in those with lower levels; this was highly statistically
significant at both ages (Tables 2 and 3) with stronger asso-
ciations in adolescence. The pooled odds ratio for the com-
parison of the highest with the lowest level of parental edu-
cation in adolescence showed a 69% increase in the odds of
poor unaided distance vision (95% CI: from 43% to 100%
1396 RUDNICKA ET AL

TABLE 2
Adjusted odds ratios (and 95% CIs) for the association of each risk factor listed with unaided distance vision of 6/12 or worse at 10 –11 y of age1

Adjusted odds ratios (95% CI)

1946 NSHD 1958 NCDS 1970 BCS Pooled estimate2 P for

Risk factor (n ҃ 3510) (n ҃ 10 588) (n ҃ 9076) (n ҃ 23 174) heterogeneity3

Breast fed 쏜1 mo vs formula fed 0.91 (0.65, 1.29) 0.99 (0.83, 1.19) 1.19 (0.93, 1.53) 1.03 (0.90, 1.18) 0.39
Female vs male 1.13 (0.85, 1.50) 1.07 (0.92, 1.25) 1.14 (0.93, 1.40) 1.10 (0.98, 1.23) 0.85
Manual vs nonmanual socioeconomic status 1.02 (0.75, 1.38) 0.98 (0.81, 1.17) 1.00 (0.78, 1.28) 0.99 (0.87, 1.13) 0.97
Parental education
Mid vs low 1.10 (0.79, 1.54) 1.15 (0.96, 1.37) 1.10 (0.78, 1.56) 1.13 (0.98, 1.31) 0.96
High vs low 1.18 (0.72, 1.92) 1.76 (1.32, 2.34)4 1.34 (1.00, 1.80) 1.48 (1.23, 1.79)4 0.26
Maternal age at birth per 5-y increase 1.02 (0.88, 1.19) 1.09 (1.00, 1.18) 1.18 (1.06, 1.31)4 1.10 (1.04, 1.17)4 0.26
Birth weight
per 1-kg rise 0.95 (0.72, 1.27) 0.89 (0.76, 1.07) 0.75 (0.62, 0.91)4 0.85 (0.76, 0.95)5 0.26
Per no. of younger siblings 0.93 (0.80, 1.08) 1.04 (0.97, 1.11) 1.18 (1.03, 1.36)5 1.04 (0.99, 1.10) 0.06
Per no. of older siblings 0.88 (0.76, 1.01) 0.85 (0.78, 0.92)4 0.95 (0.86, 1.05) 0.89 (0.83, 0.94)4 0.24
1
Odds ratio within each cohort are from logistic regression adjusted for all exposures listed in the table, and those breast fed for 쏝1 mo were included in
the analysis as a separate group. NSHD, Maternal Research Council National Survey of Health and Development; NCDS, National Child Development Study;
BCS, British Cohort Study.
2
Fixed-effects meta-analysis using inverse variance weighting.

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3
Chi-square test for heterogeneity.
4
P 쏝 0.01.
5
P 쏝 0.05.

increase). Parental education was related to social class in the
cohorts, and exclusion of social class from the model resulted
in stronger associations for parental education and vice versa
(data not shown). A higher maternal age at birth was related to
reduced vision both in childhood (odds ratio: 1.10 per 5-y
increase in maternal age; 95% CI: 1.04, 1.17) and in adoles-
cence (odds ratio: 1.15; 95% CI: 1.09, 1.22); this association
possibly strengthened across successive cohorts (P value for
trend in odds ratios: 0.06). In childhood, heavier birth weight
was marginally associated with a reduced risk of poor visual
outcome, especially in the 1970 BCS. However, no associa-
tion was observed by adolescence. The number of younger
siblings showed no consistent association with visual out-
come at either age. However, an increase in the numbers of
older siblings was consistently associated with a decreased
risk of reduced vision, both at 10 –11 and at 15–16 y of age and
across cohorts (Tables 2 and 3). In childhood, the risk of poor
vision decreased by 11% (95% CI: 6% to 17% reduction) and
by 16% (95% CI: 11% to 20% reduction) in adolescence per
number of older siblings.

TABLE 3
Adjusted odds ratios (and 95% CIs) for the association of each risk factor listed with unaided distance vision of 6/12 or worse at 15–16 y of age1

Adjusted odds ratios (95% CIs)

1946 NSHD 1958 NCDS 1970 BCS Pooled estimate2 P for

Risk factor (n ҃ 3288) (n ҃ 8239) (n ҃ 3925) (n ҃ 15 452) heterogeneity3

Breast fed 쏜1 mo vs formula fed 0.97 (0.73, 1.30) 1.05 (0.88, 1.25) 0.99 (0.77, 1.26) 1.02 (0.89, 1.16) 0.88
Female vs male 1.27 (1.00, 1.61) 1.24 (1.10, 1.43)4 1.20 (0.98, 1.47) 1.23 (1.11, 1.37)4 0.94
Manual vs nonmanual socioeconomic status 0.84 (0.65, 1.09) 0.85 (0.72, 1.01) 0.96 (0.75, 1.21) 0.88 (0.78, 0.99)5 0.69
Parental education
Mid vs low 1.60 (1.21, 2.10)4 1.09 (0.92, 1.29) 1.02 (0.72, 1.43) 1.18 (1.03, 1.35)5 0.04
High vs low 1.66 (1.13, 2.45)4 1.79 (1.38, 2.31)4 1.60 (1.21, 2.10)4 1.69 (1.43, 2.00)4 0.83
Maternal age at birth per 5-y increase 1.04 (0.92, 1.19) 1.15 (1.06, 1.24)4 1.23 (1.11, 1.37)4 1.15 (1.09, 1.22)4 0.16
Birth weight
per 1-kg rise 1.01 (0.79, 1.28) 0.96 (0.83, 1.10) 1.08 (0.89, 1.31) 1.00 (0.90, 1.11) 0.61
Per no. of younger siblings 1.03 (0.92, 1.16) 1.00 (0.94, 1.07) 0.94 (0.81, 1.10) 1.00 (0.95, 1.06) 0.65
Per no. of older siblings 0.88 (0.78, 0.99)5 0.82 (0.76, 0.89)4 0.85 (0.76, 0.96)4 0.84 (0.80, 0.89)4 0.57
1
Odds ratio within each cohort are from logistic regression adjusted for all exposures listed in the table, and those breast fed for 쏝1 mo were included in
the analysis as a separate group. NSHD, Maternal Research Council National Survey of Health and Development; NCDS, National Child Development Study;
BCS, British Cohort Study.
2
Fixed-effects meta-analysis using inverse variance weighting.
3
Chi-square test for heterogeneity.
4
P 쏝 0.01.
5
P 쏝 0.05.
 INFANT FEEDING AND VISION
DISCUSSION
Analyses of data from these 3 birth cohorts showed that there
were no differences in visual outcome in childhood or adoles-
cence among those initially breastfed for 쏜1 mo compared with
those formula fed. Rates of breastfeeding fell across successive
cohorts considerably, but there was no evidence of a subsequent
increase in adverse visual outcome in childhood, although, there
was a small increase in adverse visual outcome in adolescence
from 1946 to 1970. However, this latter observation does not take
into consideration important confounding factors, especially the
age at which vision was assessed. Notably, within each individ-
ual cohort there was no relation between mode of infant feeding
and visual outcome. The strongest determinants of unaided dis-
tance vision of 6/12 or worse at both ages were educational
attainment of the parents, maternal age, and number of older
siblings; birth weight appeared to be important at age 10 –11 y,
with no influence at 15–16 y. A higher prevalence of adverse
visual outcome in girls than in boys emerged in childhood and
was more apparent by adolescence.
Infant feeding and adverse visual outcomes
Previous studies have suggested better visual outcome in in-
fancy (12, 13) and early childhood (14) among those who were
breastfed than among those who were formula fed. A cross-
sectional study in Singaporean children of an age (10 –12 y)
similar to that of the participants in the present study suggested
that this association may persist into later childhood, when the
risk of myopia was found to be 42% lower in those initially
breastfed than in those who were formula fed (adjusted odds
ratio: 0.58; 95% CI: 0.39, 0.84) (15). However, the refractive
status of this South Asian population was markedly different
from that of UK children (ie, Singaporean children had myopia
levels 10 times those of UK children), and the findings may not
be comparable. Although, we do not have direct data on refrac-
tive status during childhood for these UK cohorts, impaired un-
aided distance vision was predominantly due to refractive error
(mostly myopia) in this age group. Reassuringly, the prevalence
of reduced vision in these cohorts was comparable with estimates
from other white populations of similar age (3, 53) and agrees
well with estimates of myopia in contemporary studies of white
children.(54, 55) Unlike the South Asian study in this age group
(15), these UK cohorts collected data on exposures prospectively
without knowledge of visual outcome, eliminating the potential
for bias in recalling initial feeding status. The detailed informa-
tion ascertained on early feeding practices, particularly in the
1946 and 1970 birth cohorts, enabled us to show that the duration
and exclusivity of breastfeeding (1946 birth cohort only) exerted
little influence on visual outcome. In addition, childhood vision
has remained relatively stable over a time period when there has
been a stark decline in rates of initial breastfeeding (65%, 43%,
and 22% in those breastfed for 쏜1 mo in the 1946, 1958, and
1970 cohorts, respectively). Hence, our findings provide strong
evidence that infant feeding is unrelated to visual outcome in
childhood and adolescence in a European setting. This result may
not be applicable to populations in developing countries with
poorer nutrition in early life. It remains possible that the benefits
of breastfeeding on visual outcome in later life might be masked,
particularly in later cohorts, by overall improvements in early
nutrition (44, 45). Comparison of heights, as a marker of early
nutrition, across the cohorts at the same age showed that at 11 y
1397
of age, children born in 1958 were 앒3.5 cm taller than those born
in 1948. Similarly, at age 16 y, those born in 1970 were 앒2.5 cm
taller than those born in 1958. However, there was no evidence
of any differential association of breastfeeding versus formula
feeding, at either age, on vision by tertiles of height in childhood
or adolescence (data not shown).
Factors associated with unaided distance vision of 6/12 or
worse
Although early feeding showed little association with visual
outcome, other sociodemographic factors showed stronger in-
fluences. A 10% higher prevalence of poor unaided vision in girls
than in boys was consistently observed at 10 –11 y of age across
the 3 cohorts. Similar sex differences have been reported in visual
outcome with the use of the same cutoffs used in this study, in
children aged as young as 6 y (35), and in levels of myopia among
Singaporean children aged 7–9 y (10). The magnitude of differ-
ence between girls and boys was more marked in adolescence
(23%), and a higher prevalence of myopia in females has been
shown to persist into adulthood in contemporary cohorts (2). The
Downloaded from www.ajcn.org by guest on February 12, 2012
reason for this sex difference remains unclear, but the develop-
ment of the difference over time may reflect that this is environ-
mentally programmed from an early age. There is a consistent
association across cohorts of parental education, maternal age,
and number of older siblings (indicating a higher risk for first
births) to unaided distance vision, with trends emerging in child-
hood and becoming stronger by adolescence. These associations
were observed previously, but were not quantified collectively,
with adjustment for potential confounders (24, 27, 49, 50). This
study has enabled us to show that parental education was more
strongly related to poor vision than was social class in this age
group. This pattern appears to develop in childhood and appears
stronger in adolescence, which may explain why associations
were not observed in other subjects at an earlier age (35). The
positive association between risk of adverse visual outcome and
maternal age may partly be explained by maternal education,
because highly educated mothers tend to postpone their first
birth. The average age at first birth was lowest in the 1970 BCS
and highest in the 1946 NSHD. This agrees with population
values from England and Wales, which showed a decline in the
average age of first births during this time period (56). Despite
the strong association observed between maternal age and visual
outcome, these time trends in maternal age do not appear to have
materially influenced levels of vision in these different cohorts.
In the current analyses, a 1-kg increase in birth weight reduced
the risk of poor vision in childhood, with no effect being observed
by adolescence. Measures of growth in early life, including birth
weight (31), length, and head circumference at birth (30, 31) and
height in childhood have been found to be associated with re-
fractive error and ocular biometric measures in young children
(57, 58). A study from Denmark showed that the association
between birth weight and reduced vision might persist into adult-
hood (59). However, in the current study, it is not clear why the
relation observed in childhood was not replicated in adolescence.
The degree to which myopia is determined by genes or envi-
ronmental influences (or both) is much debated. Although family
studies have reported correlations in refractive error across gen-
erations and within twins (60 – 63), this may reflect shared envi-
ronments rather than shared genes. We have shown that first
births are at highest risk of poor vision, and this risk declines as
1398 RUDNICKA ET AL
the number of older siblings increases. It is likely that environ-
mental factors related to prolonged near vision and emphasis on
academic achievements are also likely to be correlated with sib-
ship and birth order. In the 1946 cohort, those from smaller
families received better care and had higher cognitive perfor-
mance than did those from relatively larger families (64). There
is a large body of evidence of an association between the indi-
vidual level of educational attainment and prevalence of myopia
(11), but the causal pathways remain unclear. Certainly, the
worldwide urban versus rural comparisons of the prevalence of
myopia are consistent with a near work hypothesis that increased
reading and computer use may be a risk factor for myopia (65).
Gene loci for high levels of myopia have been identified (66 –70),
but not for low to mid levels. Hence, these lower levels of my-
opia, which are more common, may be more environmentally
determined.
Conclusions
Eyes are part of the wider base of neurodevelopment, and our
findings are contrary to the results of studies linking improved
cognitive development with breast feeding rather than formula
feeding (37, 39 – 42). It has been has suggested that these effects
are subject to residual confounding (36), especially from mater-
nal intelligence (43). Breastfeeding is associated with early life
social environment, and this influences both childhood behavior
and lifestyle. It is important that such confounders operating
across the life course are identified and taken into consideration,
as we have done in the current study, to examine the association
between early nutrition and vision outcomes in later life. Breast-
feeding is beneficial for many reasons, but does not appear to
offer any protection against poor unaided vision (as a marker of
myopia) in childhood or adolescence in a Westernized setting. In
countries with poorer nutrition in early life, the associations
between breastfeeding and visual outcome may be different.
Whether early myopia can be regarded as a neurological outcome
is debatable, because it may represent a physiologic response to
the wider environment associated with educational levels and
near work that accompanies modern economic development
(11). We have shown that more important predictors of poor
unaided vision include parental education, maternal age, birth
order, and possibly birth weight. However, unlike infant feeding
practices, these latter factors are less modifiable. Hence, the
burden of early myopia seems likely to increase because of in-
creasing economic development.
We acknowledge the original data creators, depositors, copyright holders,
and funders of the Data Collections and the UK Data Archive (University of
Essex, Colchester, United Kingdom) for use of data from the 1970 BCS and
the National Child and Development Survey. They bear no responsibility for
the analysis or interpretation of this data.
The authors’ responsibilities were as follows—ARR and CGO: drafted the
manuscript, carried out the statistical analysis, and as guarantors accepted full
responsibility for the integrity of the work as a whole. All authors contributed
substantially to the conception and design of this study, had access to the data,
contributed to the revision of the manuscript, and approved the final version
to be published. None of the authors had any conflicts of interest to declare.
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