Effectiveness of Breastfeeding Support Packages in Low- and Middle-Income Countries for Infants under Six Months: A Systematic Review

Small and nutritionally at-risk infants under six months, defined as those with wasting, underweight, or other forms of growth failure, are at high-risk of mortality and morbidity. The World Health Organisation 2013 guidelines on severe acute malnutrition highlight the need to effectively manage this vulnerable group, but programmatic challenges are widely reported. This review aims to inform future management strategies for small and nutritionally at-risk infants under six months in low- and middle-income countries (LMICs) by synthesising evidence on existing breastfeeding support packages for all infants under six months. We searched PubMed, CINAHL, Cochrane Library, EMBASE, and Global Health databases from inception to 18 July 2018. Intervention of interest were breastfeeding support packages. Studies reporting breastfeeding practices and/or caregivers’/healthcare staffs’ knowledge/skills/practices for infants under six months from LMICs were included. Study quality was assessed using NICE quality appraisal checklist for intervention studies. A narrative data synthesis using the Synthesis Without Meta-analysis (SWiM) reporting guideline was conducted and key features of successful programmes identified. Of 15,256 studies initially identified, 41 were eligible for inclusion. They were geographically diverse, representing 22 LMICs. Interventions were mainly targeted at mother–infant pairs and only 7% (n = 3) studies included at-risk infants. Studies were rated to be of good or adequate quality. Twenty studies focused on hospital-based interventions, another 20 on community-based and one study compared both. Among all interventions, breastfeeding counselling (n = 6) and education (n = 6) support packages showed the most positive effect on breastfeeding practices followed by breastfeeding training (n = 4), promotion (n = 4) and peer support (n = 3). Breastfeeding education support (n = 3) also improved caregivers’ knowledge/skills/practices. Identified breastfeeding support packages can serve as "primary prevention" interventions for all infants under six months in LMICs. For at-risk infants, these packages need to be adapted and formally tested in future studies. Future work should also examine impacts of breastfeeding support on anthropometry and morbidity outcomes. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO 2018 CRD42018102795).

Symbols used-↑, positive effect; ↓, negative effect; ↔, no effect; ↕ mixed effect; †, analysis included comparison of IG1/IG2 with CG; ‡, analysis included before after comparison in intervention and control  − BF importance and duration − factors that interfere with the production of milk − the technique of BF − the consequences of using a pacifier and the baby's crying and communication Doubts specific to each mother and grandmother were addressed and clarified. IG1: AG not living with mother, with intervention, CG1: AG not living with mother, without intervention, IG2: AG living with mother, with intervention CG2: AG living with mother, without intervention Delivery: Researchers, Follow-up: up to 6m

Education Froozani et al., 1999 Mother-infant pairs BF education by trained nutritionist (40h BF course)
The BF education was given by a trained nutritionist in a 40-hour breastfeeding course (adapted from Breastfeeding counselling: a training course) in which each mother (after delivery) learned about the advantages of breastfeeding for herself and her child. The topics covered included-− the anatomy and physiology of the mammary gland − how to position the infant on the breast and prevent breastfeeding problems − rooming-in − breastfeeding on demand − the importance of exclusive breastfeeding, i.e., using the breast as the only source of nutrients (except for vitamin drops) during the first 4 months of life IG: Education, face-to-face, after delivery and during follow-up, CG: Usual care Delivery: Trained nutritionist, Follow-up: Delivery to 4m

Neyzi et al., 1991 Mother-infant pairs Educational intervention by paediatric residents
[During the 1 st home visit, the mothers were given an appointment card to bring their infants to the University Children's Hospital for follow-up at age 2 weeks. Two paediatric residents were assigned to the care of these infants. The infants were given routine care with subsequent follow-up visits to the hospital at ages 1,2,3 and 4months. The same resident doctor continued to look after the same group of infants throughout study duration. The mothers were also given the doctors' contact details and informed they could call/visit doctors whenever problem arises. During the visits, the doctors spent 5-15 minutes with the mother discussing BF. If needed, the doctors were free to ask the mothers for more frequent visits and to ask them to bring a relative with them. IG: 2 sessions after delivery, CG: Usual care Delivery: Hospital staff, Follow-up: 1,2,3 and 4m Susin & Giugliani, 2008 Mother-father-infant triads Educational session by a trained paediatrician [Intervention included of an educational session about BF by a trained paediatrician. Participants watched an 18-minute video on BF, followed by an open discussion and distribution of an explanatory handout. Both the video and the handout were particularly produced for this study. The video discussed some important aspects of BF, such as-− the WHO recommendations, − prevention and management of common BF problems − the importance of paternal participation It directly stated that fathers could support the BF mother by helping with household tasks and child care. It also showed several images of fathers helping with household tasks, such as changing diapers, washing dishes, or vacuum cleaning the carpet IG1: Intervention to mother+father, IG2: Intervention to mother only, CG: No intervention Delivery: Paediatrician, Follow-up: 1,2,4 and 6m

Ozluses & Celebioglu, 2014 Couples with their infants Educating fathers
[EBF education was provided to the mothers (20 min/d) in the first intervention group, and to the mothers and fathers (20 min/d for each parent) in the second intervention group; while there was no intervention for the mothers or the fathers in the control group. Education manuals for mothers (28 pages) and fathers (20 pages), prepared by the researchers, were provided to all the parents. The educational materials were selected from WHO and La Leche League International websites. In the intervention group, a ''father support'' model was used to foster father involvement in decision making with mothers on a feeding model and in supporting BF practices through emotional and physical aspects. The educational intervention was tested by 3 obstetricians, 3 senior midwives, and 3 senior nurses working in an obstetrics unit. The breastfeeding education programme lasted 60-90 minutes, and there were 4-8 participants in each class. PowerPoint presentations, breast models, and newborn dolls were used during the class. Each participant was given a booklet about BF following the education programme. IG: Education to mother+father, CG: Education to mother only Delivery: Researchers, Follow up: 1,2,4 and 6m

Ahmed, 2008 Mothers and preterm infants (born <37wk) Educational Programme based on PRECEDE model
The 5 session BF educational programme designed using the PRECEDE (Predisposing, Reinforcing, Enabling Constructs in Educational Diagnosis and Evaluation) model included- Mother-infant (term LBW) pairs Training programme for counsellors A 2-tier programme was implemented to select and train the counsellors. An invitation to a postpartum care seminar was sent to key local health centres in 13 cities of Metro Manila. Training material was provided to participants at no cost.