Acta Psychiatr Scand 2005: 112: 2629 Copyright
2005 Blackwell Munksgaard

All rights reserved ACTA PSYCHIATRICA

DOI: 10.1111/j.1600-0447.2005.00548.x
SCANDINAVICA

Breastfeeding and risk of schizophrenia in

the Copenhagen Perinatal Cohort
Srensen HJ, Mortensen EL, Reinisch JM, Mednick SA. Breastfeeding
and risk of schizophrenia in the Copenhagen Perinatal Cohort.
Acta Psychiatr Scand 2005: 112: 2629.
2005 Blackwell Munksgaard.
Objective: The aim was to study whether early weaning from
breastfeeding may be associated with increased risk of schizophrenia.
Method: The current sample comprises 6841 individuals from the
Copenhagen Perinatal Cohort of whom 1671 (24%) had been breastfed
for 2 weeks or less (early weaning) and 5170 (76%) had been breastfed
longer. Maternal schizophrenia, parental social status, single mother
status and gender were included as covariates in a multiple regression
analysis of the eect of early weaning on the risk of hospitalization
with schizophrenia.
Results: The sample comprised 93 cases of schizophrenia (1.4%).
Maternal schizophrenia was the strongest risk factor and a signicant
association between single mother status and elevated ospring risk of
schizophrenia was also observed. Early weaning was signicantly
related to later schizophrenia in both unadjusted and adjusted analyses
(adjusted odds ratio 1.73 with 95% CI: 1.132.67).
Conclusion: No or <2 weeks of breastfeeding was associated with
elevated risk of schizophrenia. The hypothesis of some protective eect
of breastfeeding against the risk of later schizophrenia is supported by
our data.
H. J. Srensen1,2,
E. L. Mortensen2,3,
J. M. Reinisch2,4,5,
S. A. Mednick2,6
1
Department of Psychiatry, Amager Hospital,
Copenhagen University Hospital, Copenhagen, 2Danish
Epidemiology Science Center, Institute of Preventive
Medicine and 3Department of Health Psychology,
Institute of Public Health, University of Copenhagen,
Copenhagen, Denmark, 4The Kinsey Institute for
Research in Sex, Gender, and Reproduction, Indiana
University, Bloomington, IN, 5R2 Science
Communications, Inc., Bloomington, IN and 6Social
Science Research Center, University of Southern
California, Los Angeles, CA, USA
Key words: schizophrenia; breastfeeding; weaning;
single parent
Erik L. Mortensen, Department of Health Psychology,
Copenhagen University, Blegdamsvej 3, DK-2200
Copenhagen N, Denmark.
E-mail: e.l.mortensen@pubhealth.ku.dk
Accepted for publication February 21, 2005

acid (DHA), an important constituent of cell

Introduction
A number of studies have suggested a positive
association between breastfeeding and cognitive
and intellectual development (13). Schizophrenia
is preceded by childhood cognitive impairment
(4, 5) and it has been suggested that breastfeeding
may be a factor in the aetiology of schizophrenia
(6). Two studies have found that breastfeeding is
less common in babies who have become schizo-
phrenic in adult life (6, 7). However, in a study
based on prospective data from two British
national birth cohorts, no evidence of a protective
eect of breastfeeding against schizophrenia was
observed (8), and some retrospective studies have
also been unable to demonstrate that breastfeeding
is less common in babies who later develop
schizophrenia (9, 10).
A plausible mechanism for the possible protec-
tive eect of breast milk has been suggested (8).
Unlike cows milk or most formula feeds, breast
milk contains large amounts of long-chain poly-
unsaturated fatty acids, especially docosahexaneoic
membranes in the central nervous system. Lack
of postnatal DHA intake from formula feeds could
explain the deviant cognitive and neurological
development seen premorbidly in schizophrenia
(5, 8, 11).
Aims of the study
The aim of the present study was to use the
Copenhagen Perinatal Cohort to test the hypothe-
sis that early weaning is associated with increased
risk of schizophrenia and that there is a protective
eect of breastfeeding against the disease.
Material and methods
Sample
The Copenhagen Perinatal Cohort comprises 9125
individuals born at the Copenhagen University
Hospital, Rigshospitalet, between October 1959
and December 1961. When the cohort was

26

established, demographic, socioeconomic, prena-
tal, and postnatal medical data were recorded
prospectively during pregnancy, at delivery, and at
a 1-year examination (12, 13). The mothers were
mainly residents in Copenhagen, but some were
admitted on obstetrical indications or because of
single mother status. A total of 8400 infants
survived the rst month after birth.
Breastfeeding
A physician had interviewed the mother at the
1-year examination and collected information on
duration of breastfeeding. Data on duration of
breastfeeding was available for 6841 cohort mem-
bers (3485 males and 3356 females) who were
registered as citizens of Denmark by 1 April 1969,
and identiable in the Danish Psychiatric Register.
Duration of breastfeeding was originally recorded
on a 111 point scale (from 12 weeks to
>12 months). It was not possible to include a
separate category for children who were never
breastfed as they had been coded as 12 weeks or
less. Thus, we were unable to use the categorization
bottle-fed, breastfed <1 month, and breastfed
>1 month used in previous studies (8). For
sample size considerations and to facilitate com-
parison with previous studies, we dichotomized the
sample in an early weaning category (12 weeks;
n 1671 or 24%) and a late weaning category
(>2 weeks, n 5170 or 76%).
Single mother status
Information on maternal marital status was
recorded at the time of delivery. Data were
missing for 29 individuals in the study population
(0.4%). For this study, subjects were divided into
two groups: ospring of single mothers (n
2570) and ospring of mothers who were not
single (n 4242).
Parental social status
Information on parental social status was obtained
from an interview with the mother when the child
was 1 year old. The 18 point socioeconomic status
index was based on information about the bread-
winners occupation, breadwinners education,
type of income (wage/salary) and quality of hous-
ing. Sucient data for classication was available
for only 6025 individuals (88.1% of the study
sample). The overall social status mean was sub-
stituted for missing data and a dummy variable
included to indicate missing data on social status in
the logistic regression analysis.
Breastfeeding and schizophrenia
Psychiatric hospitalization with schizophrenia
Written approval to conduct a registry-based
psychiatric follow-up was obtained by the regional
scientic and ethics committee. The Danish Psy-
chiatric Central Register has been computerized
since 1 April 1969 (14). The register contains data
on all admissions to Danish psychiatric in-patient
facilities. The diagnostic system in use when the
Danish Psychiatric Central Register was compu-
terized was the International Classication of
Diseases, 8th Revision (ICD-8) (15). The cohort
and their parents were followed in the Danish
Psychiatric Central Register to identify all admis-
sions with a diagnosis of schizophrenia (ICD-8
code 295 or ICD-10 code F20) until December
1999. In ICD-8, schizophrenia is dened by pro-
totypic descriptions of symptoms, such as bizarre
delusions, delusions of control, abnormal aect,
autism, hallucinations, and disorganized thinking.
In 1994, the more operational ICD-10 criteria were
implemented (16). The cohort and their parents
were categorized with a history of schizophrenia
(ICD-8 code 295 or ICD-10 code F20) if they had
ever been admitted with one of these diagnoses. It
has previously been shown that paternal hospital-
ization with schizophrenia is not a signicant
predictor of ospring risk of schizophrenia in this
cohort (17).
Statistical analysis
Logistic regression analysis was used to estimate
ospring risk (odds ratio, OR with 95% condence
limits) of schizophrenia associated with i) early
weaning (2 weeks duration of breastfeeding or no
breastfeeding), ii) single mother status, and iii)
maternal hospitalization with schizophrenia. These
estimates were subsequently adjusted for gender
and parental social class. The third model estima-
ted the joint inuences of all three variables
adjusted for gender and social class.
Results
Ninety-three subjects (1.4%) (61 males and 32
females) were identied as cases with schizophre-
nia. Table 1 shows that the cumulative incidence of
schizophrenia in the early weaning category was
2.0% (95% CI: 1.52.8), whereas the cumulative
incidence in the later weaning category was 1.1%
(95% CI: 0.91.5).
Table 2 shows the OR of ospring developing
schizophrenia in relation to duration of breast-
feeding, maternal schizophrenia, and single mother
status. The ORs presented in the rst column were
27
Srensen et al.

Table 1. Cumulative incidence of schizophrenia according to breastfeeding cate- gender, and parental social status (adjusted OR
gory in the Copenhagen Perinatal Cohort
1.53 with 95% CI: 1.002.32).
No. of cases Cumulative incidence
Duration of with of schizophrenia (%)
Breastfeeding breastfeeding schizophrenia* with 95% CI Discussion

Early weaning (n 1671) 2 weeks 34 2.0 (1.52.8) This study showed a 1.7-fold higher risk of
Later weaning (n 5170) >2 weeks 59 1.1 (0.91.5) schizophrenia in ospring of mothers who did
Entire sample (n 6841) 93 1.4 (1.11.7) not breastfeed or stopped breastfeeding within
*Schizophrenia identified on the basis of Danish Psychiatric Central Register
2 weeks, when compared with ospring of mothers
records of hospitalization with a diagnosis of schizophrenia (ICD-8 code 295 or ICD- who breastfed longer. This eect remained signi-
10 code F20) until end of 1999. cant after adjustment for gender, social status,
maternal schizophrenia, and single mother status
Table 2. Multiple logistic regression analysis predicting schizophrenia in members when the child was born. A weaker predictive eect
of the Copenhagen Perinatal Cohort of early weaning was observed when 1 month
Odds ratio (95% CI) duration of breastfeeding was used as cuto.
It is an advantage of our prospective study that
Variable Unadjusted Model 1* Model 2 the mothers were interviewed about the duration of
Breastfeeding category breastfeeding by a physician when the child was
>2 weeks (Ref.) 1.00 1.00 1.00 1 year, and that cases of schizophrenia were
2 weeks 1.80 (1.182.75) 1.75 (1.142.68) 1.73 (1.132.67) identied in a national registry independently of
Covariates
Mother 9.42 (4.3820.22) 9.69 (4.4820.93) 10.46 (4.8122.77)
information collected when the Perinatal Cohort
schizophrenia was established. Cohort members were followed
Single mother 1.94 (1.292.92) 1.90 (1.222.94) 1.84 (1.182.85) through most of the risk period for schizophrenia
and the registered cases were eectively incident
*Model outputs were adjusted for gender of the cohort member and parental
social status at 1 year of age. cases. As pointed out elsewhere, this does not lead
Outputs for a model that included breastfeeding, maternal hospitalization with to bias towards chronic illness (8).
schizophrenia, single mother status and also adjusted for gender of the cohort The psychiatric diagnoses in the present study
members and parental social status.
Schizophrenia identified on the basis of Danish Psychiatric Central Register
were clinical diagnoses according to ICD-8 or
records of hospitalization with a diagnosis of schizophrenia (ICD-8 code 295 or ICD- ICD-10. The ICD-8 diagnosis of schizophrenia was
10 code F20) until end of 1999. used conservatively in Denmark, and previous
studies have shown that almost all patients with a
unadjusted, while those presented in the second diagnosis of schizophrenia meet the DSM-III-R
column were adjusted for gender and parental criteria for schizophrenia (18). The rather narrow
social class. The eect of early weaning, adjusted concept of schizophrenia according to ICD-8 is
for maternal schizophrenia, single mother status, likely to have led to diagnostic caution rather than
gender of the cohort member, and parental social over-inclusiveness before the diagnostic system was
status, is shown in the third column of the table. changed in 1994.
Early weaning from breastfeeding was associ- Being ospring of a single mother was associated
ated with increased risk in the unadjusted analysis both with elevated risk of schizophrenia and with
(OR 1.80 with 95% CI: 1.182.75). The eect short duration of breastfeeding. The confounding
remained signicant after adjustment for gender eect of maternal marital status may not have been
and parental social status and was also statistically considered in other studies of the association
signicant when all covariates were analysed between breastfeeding and risk of schizophrenia.
together (OR 1.73 with 95% CI: 1.132.67). Our nding of a robust more than twofold increase
Additional analyses showed no signicant interac- in the risk of schizophrenia of children born to
tion between gender and early weaning with single mothers is compatible with a large popula-
respect to schizophrenia. The association between tion-based cohort study that observed a twofold
single mother status at birth and ospring risk of increase in the risk of schizophrenia in individuals
schizophrenia remained signicant in the adjusted with unknown fathers (19). It is possible that
analysis (OR 1.84 with 95% CI: 1.182.85). growing up in a family without a father is an
Analyses identical to those presented in Table 2 independent risk factor, but it is also possible that
were conducted with early weaning dened as single mother status correlates with other risk
1 month. The association between early weaning factors such as genetic liability for schizophrenia in
and risk of schizophrenia was only marginally the father, prenatal stress, or maternal depression.
signicant for the model that included adjustment It is of interest that the predictive eect of early
for maternal schizophrenia, single mother status, weaning was stronger when the cuto for early

28

weaning was set at 2 weeks than when the cuto
was set at 1 month. It is possible that this relatively
modest variation in risk estimates may be the result
of stochastic variation. However, it is an intriguing
possibility that as little as 1-month exposure to
maternal milk may have a protective eect against
the development of schizophrenia. Consequently,
we nd that further studies are needed, and that it
may be too early to dismiss the hypothesis that
breastfeeding might have a protective eect against
the development of schizophrenia. Because of the
prevalence of early weaning as an exposure in the
general population, it would be of public health
interest, if independent studies were to replicate the
ndings presented here.
Acknowledgements
Supported by Sygekassernes Helsefond (Health Insurance
Foundation) grant to Srensen, grants HD-17655 and HD-
20263 from the National Institute of Child Health and Human
Development to Reinisch, grant from the National Institute of
Drug Abuse to Reinisch, grant 9700093 from the Danish
Research Council to Mortensen, and grant 1400/2-4-1997 from
the Danish National Board of Health to Mortensen. Thanks
are due to Vibeke Munk, BA, for help with the manuscript and
critical comments.
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