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Meng Y, Yu H, Zhang M, Li H, Zhou Y, Liu J. The Effects of Breastfeeding on Childhood Behavioral and Emotional Development: A Prospective Cohort Study in China. Nutrients 2024; 16:1743. [PMID: 38892676 PMCID: PMC11174704 DOI: 10.3390/nu16111743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Breastfeeding could improve a child's health early on, but its long-term effects on childhood behavioral and emotional development remain inconclusive. We aimed to estimate the associations of feeding practice with childhood behavioral and emotional development. METHODS In this population-based birth cohort study, data on feeding patterns for the first 6 mo of life, the duration of breastfeeding, and children's emotional and behavioral outcomes were prospectively collected from 2489 mother-child dyads. Feeding patterns for the first 6 mo included exclusive breastfeeding (EBF) and non-exclusive breastfeeding (non-EBF, including mixed feeding or formula feeding), and the duration of breastfeeding (EBF or mixed feeding) was categorized into ≤6 mo, 7-12 mo, 13-18 mo, and >18 mo. Externalizing problems and internalizing problems were assessed with the Child Behavior Checklist (CBCL) and operationalized according to recommended clinical cutoffs, corresponding to T scores ≥64. Multivariable linear regression and logistic regression were used to evaluate the association of feeding practice with CBCL outcomes. RESULTS The median (interquartile range) age of children at the outcome measurement was 32.0 (17.0) mo. Compared with non-EBF for the first 6 mo, EBF was associated with a lower T score of internalizing problems [adjusted mean difference (aMD): -1.31; 95% confidence interval (95% CI): -2.53, -0.10], and it was marginally associated with T scores of externalizing problems (aMD: -0.88; 95% CI: -1.92, 0.15). When dichotomized, EBF versus non-EBF was associated with a lower risk of externalizing problems (aOR: 0.54, 95% CI: 0.34, 0.87), and it was marginally associated with internalizing problems (aOR: 0.75, 95% CI: 0.54, 1.06). Regarding the duration of breastfeeding, breastfeeding for 13-18 mo versus ≤6 mo was associated with lower T scores of internalizing problems (aMD: -2.50; 95% CI: -4.43, -0.56) and externalizing problems (aMD: -2.75; 95% CI: -4.40, -1.10), and breastfeeding for >18 mo versus ≤6 mo was associated with lower T scores of externalizing problems (aMD: -1.88; 95% CI: -3.68, -0.08). When dichotomized, breastfeeding for periods of 7-12 mo, 13-18 mo, and >18 mo was associated with lower risks of externalizing problems [aOR (95% CI): 0.96 (0.92, 0.99), 0.94 (0.91, 0.98), 0.96 (0.92, 0.99), respectively]. CONCLUSIONS Exclusive breastfeeding for the first 6 mo and a longer duration of breastfeeding, exclusively or partially, are beneficial for childhood behavioral and emotional development.
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Affiliation(s)
- Ying Meng
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China; (Y.M.); (H.Y.); (M.Z.); (H.L.)
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China
| | - Hongzhao Yu
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China; (Y.M.); (H.Y.); (M.Z.); (H.L.)
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China
| | - Mingxuan Zhang
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China; (Y.M.); (H.Y.); (M.Z.); (H.L.)
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China
| | - Hongtian Li
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China; (Y.M.); (H.Y.); (M.Z.); (H.L.)
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China
| | - Yubo Zhou
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China; (Y.M.); (H.Y.); (M.Z.); (H.L.)
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China
| | - Jianmeng Liu
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China; (Y.M.); (H.Y.); (M.Z.); (H.L.)
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd., Beijing 100191, China
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Morales MF, Girard LC, Sawrikar V, MacBeth A. An examination of behavioural and emotional problems in children exposed prenatally to the 27F Chilean earthquake: findings from the ELPI cohort. Soc Psychiatry Psychiatr Epidemiol 2023; 58:1065-1073. [PMID: 36799991 PMCID: PMC10261207 DOI: 10.1007/s00127-023-02433-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Associations between prenatal earthquake exposure and children's mental health remain unclear. Moreover, there is a paucity of research using quasi-experimental statistical techniques to diminish potential selection bias. Thus, this study aimed to explore the impact of prenatal exposure to the Chilean earthquake of 2010 on children's behavioural and emotional problems between 1½ and 3 years old using propensity score matching. METHODS Participants included 1549 families from the Encuesta Longitudinal de la Primera Infancia cohort in Chile. Maternal reports using the Child Behaviour Checklist (CBCL) were used to assess behavioural and emotional problems between 1½ and 3 years old. Information on prenatal earthquake exposure was collected via maternal report. The Kernel matching estimator was used to compare the average treatment effects of children who were exposed to the earthquake compared to those who were not. RESULTS Five of the seven CBCL outcomes were statistically significant after matching and adjustment for multiple testing, suggesting greater difficulties for exposed children which included emotional reactivity, anxious/depressed, sleep problems, attention problems, and aggression (mean difference of 0.69, 0.87, 0.73, 0.85, 3.51, respectively). The magnitude of the effect was small to medium. CONCLUSION Findings contribute to the potential causal inferences between prenatal earthquake exposure and increased behavioural and emotional problems in early childhood. Results suggest that in utero experiences may have long-term consequences for infants' well-being, supporting the need for specific interventions in pregnancy after natural disasters.
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Affiliation(s)
- María Francisca Morales
- Department of Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK.
| | | | - Vilas Sawrikar
- Department of Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Angus MacBeth
- Department of Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
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McGowan C, Bland R. The Benefits of Breastfeeding on Child Intelligence, Behavior, and Executive Function: A Review of Recent Evidence. Breastfeed Med 2023; 18:172-187. [PMID: 36749962 DOI: 10.1089/bfm.2022.0192] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Background: The effects of breastfeeding on neurodevelopmental outcomes are unclear. Inconsistent findings have been reported and confounding factors make interpretation of studies difficult. The World Health Organization published a systematic review on breastfeeding and intelligence in 2013, demonstrating a positive association with improved performance on intelligence tests. The objective of this review is to explore published literature since 2013 to examine the association between breastfeeding, cognition, executive function, and behavior. Methods: Duplicate searches were carried out using Web of Science and OVID for publications between January 2012 and March 2022. Non-English articles and those not correcting for maternal IQ or home environment were excluded. Results: Twenty-three studies were included, examining the effects of breastfeeding on cognition (21), executive function (3), and behavior (6). Most studies showed a modest dose-dependent increase in cognitive scores in children who were breastfed, test score differences ranging from 0.19 to 0.96 points per month of breastfeeding comparing any breastfeeding, predominant and exclusive breastfeeding. Four out of six studies showed a positive correlation between breastfeeding and behavior. One out of three studies assessing breastfeeding and executive function showed a positive dose-dependent correlation. Discussion: Recent evidence demonstrates that breastfeeding has a small positive effect on IQ in later childhood. Evidence suggesting that breastfeeding is a protective factor in developing conduct disorders and achieving higher executive function is limited. Further research is required. Limitations include potential confounders and recall bias of breastfeeding.
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Affiliation(s)
- Catherine McGowan
- Department of General Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
| | - Ruth Bland
- Department of General Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom.,Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Johannesburg, South Africa
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Abstract
Objective: The objective of this study was to examine postpartum, inpatient mother-lactation educator (LE) breastfeeding education, resulting perceptions, and patient-reported worries and outcomes. In the breastfeeding literature, there is inadequate insight into the mother-LE relationship, and specifically, the extent to which contextual factors are elicited and information is tailored accordingly. In this study, we were specifically interested in maternal contextual factors. Materials and Methods: Using a mixed methods approach, we (1) captured 20 postpartum, inpatient mother-LE breastfeeding education sessions and analyzed them for the presence of maternal contextual factors, (2) administered separate perception questions to mothers and LEs, and (3) conducted 13 follow-up interviews with mothers after being discharged from the hospital. Results: Inpatient breastfeeding education is delivered in dynamic and busy clinical settings, characterized by potential distractions such as delivery of medical care. Maternal contextual factors are infrequently elicited during the education. Although both LEs and mothers rate the sessions positively, potential gaps remain as highlighted by the analyses of semistructured interviews with mothers. Conclusion: Human factors perspective, theories, and methods are relevant to the characterization of facilitators and barriers of current breastfeeding education, as well as to the development of interventions to support the delivery of human-centered, effective, and timely breastfeeding education.
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Affiliation(s)
- Elizabeth Lerner Papautsky
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois Chicago, Chicago, Illinois, USA
| | - Mary Dawn Koenig
- Department Human Development Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
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Wiessinger D. Watch Your Step. J Hum Lact 2021; 37:464-468. [PMID: 33934666 DOI: 10.1177/08903344211011950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Use of propensity score matching to create counterfactual group to assess potential HIV prevention interventions. Sci Rep 2021; 11:7017. [PMID: 33782485 PMCID: PMC8007631 DOI: 10.1038/s41598-021-86539-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/17/2021] [Indexed: 11/08/2022] Open
Abstract
The design of HIV prevention trials in the context of effective HIV preventive methods is a challenge. Alternate designs, including using non-randomised 'observational control arms' have been proposed. We used HIV simulated vaccine efficacy trials (SiVETs) to show pitfalls that may arise from using such observational controls and suggest how to conduct the analysis in the face of the pitfalls. Two SiVETs were nested within previously established observational cohorts of fisherfolk (FF) and female sex workers (FSW) in Uganda. SiVET participants received a licensed Hepatitis B vaccine in a schedule (0, 1 and 6 months) similar to that for a possible HIV vaccine efficacy trial. All participants received HIV counselling and testing every quarter for one year to assess HIV incidence rate ratio (IRR) between SiVET and non-SiVET (observational data). Propensity scores, conditional on baseline characteristics were calculated for SiVET participation and matched between SiVET and non-SiVET in the period before and during the SiVET study. We compared IRR before and after propensity score matching (PSM). In total, 3989 participants were enrolled into observational cohorts prior to SiVET, (1575 FF prior to Jul 2012 and 2414 FSW prior to Aug 2014). SiVET enrolled 572 participants (Jul 2012 to Apr 2014 in FF and Aug 2014 to Apr 2017 in FSW), with 953 non-SiVET participants observed in the SiVET concurrent period and 2928 from the pre-SiVET period (before Jul 2012 in FF or before Apr 2014 in FSW). Imbalances in baseline characteristics were observed between SiVET and non-SiVET participants in both periods before PSM. Similarly, HIV incidence was lower in SiVET than non-SiVET; SiVET-concurrent period, IRR = 0.59, 95% CI 0.31-0.68, p = 0.033 and pre-SiVET period, IRR = 0.77, 95% CI 0.43-1.29, p = 0.161. After PSM, participants baseline characteristics were comparable and there were minimal differences in HIV incidence between SiVET and non-SiVET participants. The process of screening for eligibility for efficacy trial selects participants with baseline characteristics different from the source population, confounding any observed differences in HIV incidence. Propensity score matching can be a useful tool to adjust the imbalance in the measured participants' baseline characteristics creating a counterfactual group to estimate the effect of interventions on HIV incidence.
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Farkas C, Girard LC, MacBeth A. Predictors of emotional problems in 5-year-old children: an international comparison between two cohorts in Chile and Scotland. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-020-01336-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Laksono AD, Wulandari RD, Ibad M, Kusrini I. The effects of mother's education on achieving exclusive breastfeeding in Indonesia. BMC Public Health 2021; 21:14. [PMID: 33402139 PMCID: PMC7786474 DOI: 10.1186/s12889-020-10018-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Even though the Indonesian government have set regulations for maintaining exclusive breastfeeding practices, the coverage remains low. The study aims to analyze the effects of mother's education level on the coverage of exclusive breastfeeding in Indonesia. METHODS This study used data from the 2017 Nutrition Status Monitoring Survey. It covered data of 53,528 children under 5 years old (7-59 months) as the samples. Variables included exclusive breastfeeding status, mother's education level, mother's age, marital status, employment status, gender, residence, under five's age and gender. A binary logistics regression was performed in the final test. RESULTS Mothers who graduated from elementary school were 1.167 times more likely to perform exclusive breastfeeding compared to mothers who never attended schools. Additionally, those who graduated from junior high school had 1.203 times possibilities to give exclusive breastfeeding compared to mothers without educational records. While, mothers who graduated from high school were 1.177 times more likely to perform exclusive breastfeeding compared to those without educational records. Mothers who graduated from tertiary education had 1.203 times more possibilities to perform exclusive breastfeeding compared to mothers who were never enrolled to schools. Other variables also became affecting predictors on exclusive breastfeeding, such as mother's age, mother's employment status, child's age, and residence. CONCLUSIONS The mother's education level positively affects exclusive breastfeeding practice in Indonesia.
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Affiliation(s)
- Agung Dwi Laksono
- National Institute of Health Research and Development, the Ministry of Health of the Republic of Indonesia, Jakarta, Indonesia.,Doctoral Program, Faculty of Public Health, University of Airlangga, Surabaya, Indonesia
| | | | - Mursyidul Ibad
- Faculty of Health, Nadlatul Ulama University, Surabaya, Indonesia
| | - Ina Kusrini
- Unit of Health Research and Development Magelang, Ministry of Health, Center Java, Java, Indonesia
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Dressler A, Häfele C, Giordano V, Benninger F, Trimmel-Schwahofer P, Gröppel G, Samueli S, Feucht M, Male C, Repa A. The Ketogenic Diet Including Breast Milk for Treatment of Infants with Severe Childhood Epilepsy: Feasibility, Safety, and Effectiveness. Breastfeed Med 2020; 15:72-78. [PMID: 31770024 DOI: 10.1089/bfm.2019.0190] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective: The ketogenic diet (KD) is a high-fat and restricted carbohydrate diet for treating severe childhood epilepsy. In infants, breast milk is usually fully replaced by a ketogenic formula. At our center, mothers are encouraged to include breastfeeding into the KD if still breastfeeding. This retrospective study describes achievement and maintenance of ketosis with or without inclusion of breast milk. Methods: Data were retrieved from a prospective longitudinal database of children treated with KD for epilepsy analyzing infants <1 year of age. The time to achieve clinically relevant ketosis (≥2 mmol/L beta-hydroxybutyrate) was compared with and without inclusion of breast milk into standard KD. Ketosis, nutritional intakes, effectiveness, adverse effects, and successful continuation of breastfeeding were evaluated. Results: A total of 79 infants were eligible for analysis. In 20% (16), breast milk was included. Infants with breast milk included into the KD achieved relevant ketosis in 47 hours (interquartile range [IQR] 24-95) compared with 41 hours (IQR 22-70; p = 0.779) in infants with standard KD. Beta-hydroxybutyrate at day 2 was 3.1 mmol/L (IQR 0.5-4.9) and 3.8 mmol/L (IQR 2.2-4.9). Infants with breast milk included received higher amounts of carbohydrates at baseline and calories at 3 months. Seizure freedom and adverse effects showed no relevant differences. No infections occurred in infants receiving breast milk. In two infants, KD was initiated with breast-feds after bottle-feeding KD formula. In 31%, breastfeeding was continued after the KD, and in 25%, inclusion of breast milk and breastfeeding was maintained until complete weaning. Before discharge from hospital, the amount of breast milk included was median 90 mL/day (IQR 53-203) equivalent to median 9% (IQR 6-15). Conclusions: Appropriate ketosis was achieved in most infants and maintained within 48 hours. Incorporation of breast milk into KD is feasible, safe, and effective.
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Affiliation(s)
- Anastasia Dressler
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Chiara Häfele
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Vito Giordano
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Franz Benninger
- Department of Child and Adolescent Neuropsychiatry, Medical University Vienna, Vienna, Austria
| | | | - Gudrun Gröppel
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Sharon Samueli
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Christoph Male
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Andreas Repa
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
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McFadden A, Siebelt L, Marshall JL, Gavine A, Girard LC, Symon A, MacGillivray S. Counselling interventions to enable women to initiate and continue breastfeeding: a systematic review and meta-analysis. Int Breastfeed J 2019; 14:42. [PMID: 31649743 PMCID: PMC6805348 DOI: 10.1186/s13006-019-0235-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Many infants worldwide are not breastfeeding according to WHO recommendations and this impacts on the health of women and children. Increasing breastfeeding is identified as a priority area supported by current policy targets. However, interventions are complex and multi-component and it is unclear which elements of interventions are most effective to increase breastfeeding in which settings. Breastfeeding counselling is often part of complex interventions but evidence is lacking on the specific effect of counselling interventions on breastfeeding practices. The aim of this systematic review is to examine evidence on effectiveness of breastfeeding counselling to inform global guidelines. Methods A systematic search was conducted of six electronic databases in January 2018. Randomised controlled trials comparing breastfeeding counselling with no breastfeeding counselling or different formulations of counselling were included if they measured breastfeeding practices between birth and 24 months after birth. Results From the 5180 records identified in searches and a further 11 records found by hand searching, 63 studies were included. Of these, 48 were individually-randomised trials and 15 were cluster-randomised trials. A total of 69 relevant comparisons were reported involving 33,073 women. There was a significant effect of counselling interventions on any breastfeeding at 4 to 6 weeks (Relative risk [RR] 0.85, 95% CI 0.77, 0.94) and 6 months (RR 0.92, 95% CI 0.87, 0.94). Greater effects were found on exclusive breastfeeding at 4 to 6 weeks (RR 0.79, 95% CI 0.72, 0.87) and 6 months (RR 0.84, 95% CI 0.78, 0.91). Counselling delivered at least four times postnatally is more effective than counselling delivered antenatally only and/or fewer than four times. Evidence was mostly of low quality due to high or unclear risk of bias of the included trials and high heterogeneity. Conclusions Breastfeeding counselling is an effective public health intervention to increase rates of any and exclusive breastfeeding. Breastfeeding counselling should be provided face-to-face, and in addition, may be provided by telephone, both antenatally and postnatally, to all pregnant women and mothers with young children. To inform scale-up globally there is a need to further understand the elements of breastfeeding interventions such as counselling and their effectiveness in different contexts and circumstances. Study registration This systematic review was registered in Prospero (CRD42018086494).
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Affiliation(s)
- Alison McFadden
- 1School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ Scotland
| | - Lindsay Siebelt
- 1School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ Scotland
| | - Joyce L Marshall
- 2School of Human and Health Sciences, Harold Wilson Building, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH Scotland
| | - Anna Gavine
- 1School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ Scotland
| | - Lisa-Christine Girard
- 3School of Health in Social Science, The University of Edinburgh, Doorway 6, Room 1m04, Old Medical School, Edinburgh, EH8 9AG Scotland
| | - Andrew Symon
- 1School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ Scotland
| | - Stephen MacGillivray
- 1School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ Scotland
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