Lactation support and breastfeeding duration in jaundiced infants: a randomized controlled trial

Breastfeeding Support Provided by Lactation Consultants: A Systematic Review and Meta-Analysis

Importance

Breast milk offers numerous health benefits, yet breastfeeding recommendations are met less than half of the time in high-income countries.

Objective

To evaluate the effect of lactation consultant (LC) interventions on breastfeeding, maternal breastfeeding self-efficacy, and infant growth compared to usual care.

Data Sources

The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, Scopus, Web of Science, and the gray literature were searched for articles published between January 1985 and July 2024. The search took place on July 10, 2024, and data analysis was performed from July to August 2024.

Study Selection

Randomized clinical trials of LC interventions in high-income countries published in any language were eligible for inclusion.

Data Extraction and Synthesis

Data extracted included study design, participant and intervention characteristics, and outcome data. To account for studies that reported outcomes at multiple time points, effect estimates were pooled with 3-level correlated and hierarchical effects models. Meta-regression was performed for clinically important characteristics, such as the time point when the outcome was measured, intervention intensity, and participant income.

Main Outcomes and Measures

The primary outcome was stopping exclusive breastfeeding. Secondary outcomes included stopping any breastfeeding, exclusive breastfeeding and any breastfeeding duration, maternal breastfeeding self-efficacy, infant overweight and obesity, and infant growth.

Results

The search yielded 6476 records, of which 40 studies were included involving 8582 participants. Studies were published between 1992 and 2024, and most studies (n = 22) were conducted in the US. Compared to usual care, LC interventions reduced the risk of stopping exclusive breastfeeding (risk ratio [RR], 0.96; 95% CI, 0.94-0.99) and any breastfeeding (RR, 0.92; 95% CI, 0.87-0.96) and increased any breastfeeding duration by 3.63 weeks (95% CI, 0.13-7.12). There was weak evidence that LC interventions increased exclusive breastfeeding duration (mean difference [MD], 1.44 weeks; 95% CI, -2.73 to 5.60), maternal breastfeeding self-efficacy (MD, 2.83; 95% CI, -1.23 to 6.90), or the risk of infant overweight and obesity (RR, 1.52; 95% CI, 0.94-2.46). Meta-regression showed that LC interventions were more effective at reducing the risk for stopping exclusive breastfeeding (P = .01) and any breastfeeding (P < .001) the earlier that breastfeeding was measured in the postpartum period. LC interventions with a higher intensity (ie, number of LC visits) were more effective at reducing the risk for stopping any breastfeeding (P = .04).

Conclusions and Relevance

According to the results of this systematic review and meta-analysis, LC interventions are a promising intervention for improving exclusive breastfeeding and any breastfeeding in high-income countries.

The effect of telephone-assisted breastfeeding monitoring on physiological jaundice, exclusive breastfeeding in the first six months, development of colic, and breastfeeding self-efficacy: A randomized controlled trial

This randomized controlled study was conducted to evaluate the effects of telephone-assisted breastfeeding monitoring on physiological jaundice, exclusive breastfeeding in the first six months, colic, breastfeeding success, and breastfeeding self-efficacy. Breastfeeding and infant care training were given to pregnant women by video calls (N = 54). Video call counseling was provided to the mothers in the intervention group (n = 27) every day for the first week after discharge and weekly until the 24th week, and the control group (n = 27) was only telephone called in follow-up weeks. The primary variables were exclusive breastfeeding and breastfeeding success, while secondary variables were physiological jaundice, colic, and breastfeeding self-efficacy. The LATCH Breastfeeding Assessment Tool, the Breastfeeding Self-Efficacy Scale, and the Infantile Colic Scale were used. The mean scores of the intervention and control groups were compared using the Mann-Whitney U test and multivariate analysis of variance in repeated measurements. The telephone-assisted breastfeeding monitoring increased exclusive breastfeeding in the first six months. Physiological jaundice was experienced less in infants in the intervention group. There was no difference in terms of infantile colic, breastfeeding success, and breastfeeding self-efficacy between group and group*time interaction, a difference was found in terms of time. The telephone-assisted breastfeeding monitoring can be used to increase exclusive breastfeeding and prevent physiological jaundice (ClinicalTrials.gov Identifier: NCTXXX).

A Qualitative Study of Breastfeeding Mothers' Perspectives Regarding Lactation Support Services

Although breastfeeding is widely accepted as beneficial, only half of U.S. mothers are breastfeeding at 6 months. This study aimed to learn whether a quality improvement project to embed lactation support services into the newborn visit at a primary pediatric practice met families' needs. Mothers who were aged 18+ years, had an infant born in October 2021 with a well-child visit to the study practice (urban, 85% Medicaid, and 90% African American), and planned to breastfeed were invited to participate in a semi-structured telephone interview about their experience with breastfeeding and lactation support. We interviewed 18 mothers and, using a descriptive qualitative approach (thematic analysis), found that early support was helpful in addressing initial challenges such as latching pain but did not adequately anticipate later barriers to continued breastfeeding. This suggests lactation support offered by pediatric primary care practices should extend beyond the newborn period and be tailored to families' evolving needs.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

The Effect of Breastfeeding and an Intensive Breast Milk Nutritional Support Program on Hospitalization Rates for Hyperbilirubinemia in Term Newborns: An Open Randomized Controlled Trial

OBJECTIVE

The aim of this study was to determine the effect of breastfeeding and intensive breast milk nutritional support program (IBNSP) on hospitalization rates for hyperbilirubinemia in normal term newborns.

METHODS

This study's sample consisted of 68 newborn infants (experimental group: 34; control group: 34) born at a university hospital from October 2020 to April 2021. Five steps of breastfeeding and IBNSP were administered to the experimental group for the first 48 h after birth. This program starts at the postpartum first hour and continues until the 48th hour. It includes face-to-face training, practical support on breastfeeding, and one-to-one demonstration and practice methods. The control group received the standard care recommended by the World Health Organization. Both groups' bilirubin levels were measured 24 and 72 h after birth. Participants in both groups were hospitalized for risky (according to bilirubin values) situations. The groups' bilirubin levels and hospitalization rates for hyperbilirubinemia were compared.

RESULTS

There was no statistically significant difference between the experimental (5.19 ± 1.27) and the control (5.83 ± 1.52) groups' bilirubin levels at 24 h after birth, (t = -1.881, p = 0.064); however, the control group infants (12.03 ± 3.67 mg/dl) had higher bilirubin levels than the infants in the experimental group 72 h after birth (9.55 ± 2.82 mg/dl) (t = -3.122, p = 0.003). The experimental group's hospitalization rate for hyperbilirubinemia (n: 1, 2.9%) was lower than the control group's rate (n: 8, 23.5%), and this difference was statistically significant (X2 = 6.275, p = 0.014).

CONCLUSIONS

Breastfeeding and IBNSP effectively prevent hospitalization for hyperbilirubinemia and reduce newborns' bilirubin levels.

Counselling interventions to enable women to initiate and continue breastfeeding: a systematic review and meta-analysis

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).

Effectiveness of the IBCLC: Have we Made an Impact on the Care of Breastfeeding Families Over the Past Decade?

BACKGROUND

International Board Certified Lactation Consultants (IBCLCs) have been in existence for over 3 decades, are currently represented in 110 countries, and have the only internationally recognized certification to provide safe and evidenced-based care for breastfeeding women and their infants.

RESEARCH AIM

To review the literature about the efficacy of IBCLCs on breastfeeding outcomes as well as studies that have examined the effectiveness of the IBCLC's role.

METHODS

The design was a scoping review of the literature and critical analysis using PRISMA guidelines of existing studies published from 2008-2019. Qualitative and quantitative studies were reviewed.

RESULTS

Twelve (N =12) studies met inclusion criteria. Seven themes emerged in the analysis including studies of the role of IBCLCs in resident physician education; IBCLC's role in breastfeeding interventions and the management of breastfeeding problems; the impact of IBCLCs in inpatient and outpatient settings; and the impact of geographic access to IBCLCs on breastfeeding rates. Certification of and ongoing professional development of IBCLCs are also discussed.

CONCLUSION

In this scoping review of existing literature assessing the effectiveness of IBCLCs in promoting and supporting breastfeeding, it is clear that IBCLCs play a positive role in supporting breastfeeding throughout the world. However, there are certain limitations that must be addressed. Recommendations for future research and clinical practice are discussed in the context of present limitations to breastfeeding expertise and support.

Breastfeeding Support Interventions by International Board Certified Lactation Consultants: A Systemic Review and Meta-Analysis

BACKGROUND

International Board Certified Lactation Consultants (IBCLC) are healthcare professionals who are highly trained in lactation science; however, little is known about the efficacy of IBCLC-specific support on breastfeeding outcomes.

RESEARCH AIMS

This systematic review and meta-analysis aimed to describe interventions containing direct support by IBCLCs during the postpartum period and to analyze the association between study characteristics and the prevalence breastfeeding outcomes.

METHODS

Electronic databases were searched for studies published between January 2001 and December 2018. Meta-analysis and meta-regression were performed on studies containing breastfeeding prevalence data at 3 or 6 months postpartum.

RESULTS

Seventeen interventions met all inclusion and exclusion criteria and eight research teams reported the prevalence of any or exclusive breastfeeding at 3 and/or 6 months. For any breastfeeding at 6 months, the pooled difference was 0.08 [0.04, 0.12] meaning we'd expect to observe 1 additional case of any breastfeeding at 6 months postpartum for every 12 women who received an IBCLC intervention, 95% CI [8, 25] rather than control conditions. Results differed depending on which outcome variable was used to measure breastfeeding and the timing of that measurement.

CONCLUSIONS

Breastfeeding interventions that include IBCLC support in the postpartum period have potential for improving breastfeeding outcomes; however, when designing interventions, the timing and method of data collection for measures of breastfeeding are instrumental to study sensitivity and need to be based on the aims of the intervention itself.

Birthplace is a risk factor for exchange transfusion in outborn infants admitted for jaundice in Myanmar: a case-control study

Aim: To evaluate the role of pathway to admission for jaundice among the risk factors for exchange transfusion in outborn infants in a low resource setting.Methods: This retrospective case-control study (1:1 ratio) was carried out at the Yankin Children's Hospital in Yangon (Myanmar). All cases were neonates admitted for treatment of jaundice between March 2013 and February 2014 and who required an exchange transfusion. Each control was the next noncase neonate admitted for treatment of jaundice and treated with phototherapy. Infant characteristics, pathways of admission and clinically relevant factors for exchange transfusion were collected.Results: One hundred thirty-four cases and 134 controls were included in the study. Among cases, home was the most common place of birth while public hospital was the most frequent source of referral. Among controls, private/public hospitals were the commonest places of birth and referral. At multivariable analysis, homebirth was associated with increased likelihood of receiving exchange transfusion at admission (OR 3.30, 95% C.I. 1.31-8.56).Conclusion: Homebirth was an independent risk factor for exchange transfusion at admission for jaundice in a low-resource setting. Appropriate health education of pregnant women and traditional/home birth attendants may contribute to reduce the need for exchange transfusion in low-resource settings.

Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The World Health Organization (WHO) recommends that mothers practice exclusive breastfeeding (EBF) of their infants for 6 months. Various breastfeeding support interventions have been developed to encourage mothers to maintain breastfeeding practices. Research aim: This study aims to review how effectively breastfeeding support interventions enable mothers to practice EBF for 6 months and to suggest the best intervention strategies.

METHODS

Six databases were searched, including MEDLINE, EMBASE, Cochrane, CINAHL, PsycINFO, and KoreaMed. The authors independently extracted data from journals written in English or Korean and published between January 2000 and August 2017. Randomized controlled trials (RCTs) reporting EBF until 6 months were screened.

RESULTS

A total of 27 RCTs were reviewed, and 36,051 mothers were included. The effectiveness of breastfeeding support interventions to promote EBF for 6 months was significant (odds ratio [OR] = 2.77; 95% confidence interval [CI]: 1.81-3.76). A further subgroup analysis of intervention effects shows that a baby friendly hospital initiative (BFHI) intervention (OR = 5.21; 95% CI: 2.15-12.61), a combined intervention (OR = 3.56; 95% CI: 1.74-7.26), a professional provider led intervention (OR = 2.76; 95% CI: 1.76-4.33), having a protocol available for the provider training program (OR = 2.87; 95% CI: 1.89-4.37) and implementation during both the prenatal and postnatal periods (OR = 3.32; 95% CI: 1.83-6.03) increased the rate of EBF for 6 months.

CONCLUSION

We suggest considering a multicomponent intervention as the primary strategy and implementing BFHI interventions within hospitals. Evidence indicates that intervention effectiveness increases when a protocol is available for provider training, when interventions are conducted from the pre- to postnatal period, when the hospital and community are connected, and when healthcare professionals are involved.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes.

AUTHORS' CONCLUSIONS

When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important, however not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and costs of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2016), handsearched relevant journals and conference proceedings, and contacted experts in the field to seek additional published or unpublished studies. We also examined reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

This updated review includes 41 trials involving 2293 participants, with 22 trials involving 1339 participants contributing data for analysis. Twenty-six of the trials referred to mothers of infants in neonatal units (n = 1547) and 14 to mothers of healthy infants at home (n = 730), with one trial containing mothers of both neonatal and healthy older infants (n = 16). Eleven trials compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and pump types. Twenty studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols, pumping frequency, provision of an education and support intervention, relaxation, breast massage, combining hand expression with pumping and a breast cleansing protocol.Due to heterogeneity in participants, interventions, and outcomes measured or reported, we were unable to pool findings for most of the specified outcomes. It was not possible therefore to produce a 'Summary of findings' table in this update. Most of the included results were derived from single studies. Trials took place in 14 countries under a variety of circumstances and were published from 1982 to 2015. Sixteen of the 30 trials that evaluated pumps or products had support from the manufacturers. The risk of bias of the included studies was variable. Primary outcomesOnly one of the 17 studies examining maternal satisfaction/acceptability with the method or adjunct behaviour provided data suitable for analysis. In this study, self-efficacy was assessed by asking mothers if they agreed or disagreed with the following statement: 'I don't want anyone to see me (hand expressing/pumping)'. The study found that mothers who were using the electric pump were more likely to agree with the statement compared to mothers hand expressing, (mean difference (MD) 0.70, 95% confidence interval (CI) 0.15 to 1.25; P = 0.01, participants = 68). Mothers who were hand expressing reported that the instructions for expression were clearer compared to the electric pump, (MD -0.40, 95% CI -0.75 to -0.05; P = 0.02, participants = 68). Descriptive reporting of satisfaction in the other studies varied in the measures used, did not indicate a clear preference for one pump type, although there was satisfaction with some relaxation and support interventions.We found no clinically significant differences between methods related to contamination of the milk that compared any type of pump to hand expression (risk ratio (RR) 1.13, 95% CI 0.79 to 1.61; P = 0.51, participants = 28), manual pump compared to hand expression, (MD 0.20, 95% CI -0.18 to 0.58; P = 0.30, participants = 142) a large electric pump compared to hand expression (MD 0.10, 95% CI -0.29 to 0.49; P = 0.61, participants = 123), or a large electric pump compared to a manual pump (MD -0.10, 95% CI -0.46 to 0.26; P = 0.59, participants = 141).The level of maternal breast or nipple pain or damage was similar in comparisons of a large electric pump to hand expression (MD 0.02, 95% CI -0.67 to 0.71; P = 0.96, participants = 68). A study comparing a manual and large electric pump, reported sore nipples in 7% for both groups and engorgement in 4% using a manual pump versus 6% using an electric pump; and in one study no nipple damage was reported in the hand-expression group, and one case of nipple damage in each of the manual pump and the large electric pump groups.One study examined adverse effects on infants, however as the infants did not all receive their mothers' expressed milk, we have not included the results. Secondary outcomesThe quantity of expressed milk obtained was increased, in some studies by a clinically significant amount, in interventions involving relaxation, music, warmth, massage, initiation of pumping, increased frequency of pumping and suitable breast shield size. Support programmes and simultaneous compared to sequential pumping did not show a difference in milk obtained. No pump consistently increased the milk volume obtained significantly.In relation to nutrient quality, hand expression or a large electric pump were found to provide higher protein than a manual pump, and hand expression provided higher sodium and lower potassium compared to a large electric pump or a manual pump. Fat content was higher with breast massage when pumping; no evidence of difference was found for energy content between methods.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Variation in nutrient content across methods may be relevant to some infants. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings. Independently funded research is needed for more trials on hand expression, relaxation and other techniques that do not have a commercial potential.

A Randomized Controlled Trial of Innovative Postpartum Care Model for Mother-Baby Dyads

Objective

To evaluate the efficacy, safety, and maternal satisfaction of a newly established integrative postpartum community-based clinic providing comprehensive support for mothers during the first month after discharge from the hospital. Our primary interests were breastfeeding rates, readmission and patient satisfaction.

Methods

A randomized controlled trial was conducted in Ottawa, Canada, where 472 mothers were randomized via a 1:2 ratio to either receive standard of care (n = 157) or to attend the postpartum breastfeeding clinic (n = 315). Outcome data were captured through questionnaires completed by the participants at 2, 4, 12 and 24 weeks postpartum. Unadjusted and adjusted logistic regression models were conducted to determine the effect of the intervention on exclusive breastfeeding at 12 weeks (primary outcome). Secondary outcomes included breastfeeding rate at 2, 4 and 24 weeks, breastfeeding self-efficacy scale, readmission rate, and satisfaction score.

Results

More mothers in the intervention group (n = 195, 66.1%) were exclusively breastfeeding at 12 weeks compared to mothers in the control group (n = 81, 60.5%), however no statistically significant difference was observed (OR = 1.28; 95% CI:0.84–1.95)). The rate of emergency room visits at 2 weeks for the intervention group was 11.4% compared to the standard of care group (15.2%) (OR = 0.69; 95% CI: 0.39–1.23). The intervention group was significantly more satisfied with the overall care they received for breastfeeding compared to the control group (OR = 1.96; 95% CI: 3.50–6.88)).

Conclusion

This new model of care did not significantly increase exclusive breastfeeding at 12 weeks. However, there were clinically meaningful improvements in the rate of postnatal problems and satisfaction that support this new service delivery model for postpartum care. A community-based multidisciplinary postpartum clinic is feasible to implement and can provide appropriate and highly satisfactory care to mother-baby dyads. This model of care may be more beneficial in a population that is not already predisposed to breastfeed.

Trial Registration

ClinicalTrials.gov NCT02043119