Primary Care Interventions to Support Breastfeeding: An Updated Systematic Review for the U.S. Preventive Services Task Force.

Agency for Healthcare Research and Quality U.S. Department of Health and Human Services.
Evidence Synthesis Number 143 . AHRQ Publication No. 15-05218-EF-1April 2016.

Objective: We conducted this systematic review to support the U.S. Preventive Services Task Force in updating its 2009 recommendation on counseling for breastfeeding. Our review addressed three questions: 1) What are the effects of prenatal, peripartum, and postpartum individual-and health care system-level interventions to promote and support breastfeeding on child and maternal health outcomes? 2) What are the effects of interventions on the initiation, duration, and exclusivity of breastfeeding? 3) Are there adverse events associated with interventions to promote and support breastfeeding?
Data Sources: We performed a search of MEDLINE, PubMed Publisher-Supplied, Cumulative Index for Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and PsycInfo for studies published between January 1, 2008, and September 25, 2015. Studies included in the original U.S. Preventive Services Task Force review were re-evaluated. We supplemented searches by examining bibliographies from retrieved articles and consulting outside experts. We searched federal and international trial registries for ongoing trials.
Study Selection: Two researchers reviewed 2769 abstracts and 211 articles against the pre-specified inclusion criteria. Eligible studies included English-language studies conducted in a developed country that evaluated the effectiveness of an individual-or system-level breastfeeding intervention among pregnant women or mothers of full-or near-term infants. We included randomized or cluster randomized controlled trials for individual-level interventions and controlled before-and-after or prospective cohort studies for health system or policy interventions that reported health or breastfeeding outcomes. We conducted dual, independent critical appraisal of all provisionally included studies and abstracted all important study details and results from fair-and good-quality studies. Data were independently abstracted by one reviewer and confirmed by another.
Data Analysis: We qualitatively synthesized the results for health outcomes and adverse events. For breastfeeding outcomes, we synthesized the results by population (adults separately from adolescents or young adults) and intervention focus (individual-versus system-level approaches). Because of the small number of system-level interventions, we report those results narratively and do not pool the data. For individual-level interventions, we conducted random effects meta-analyses using the DerSimonian and Laird method and calculated pooled risk ratios for breastfeeding initiation and for any or exclusive breastfeeding at postpartum time points less than 3 months, 3 to 6 months, and 6 months. We explored potential effect modification by various population and intervention characteristics, such as intention to breastfeed and intervention type, and timing through stratified analyses and meta-regression. We generated funnel plots and conducted tests for small-study effects for all pooled analyses.
Results: We included 52 studies that were reported in 57 publications. The included studies were highly variable in terms of the country, study population, intervention and control conditions, specific outcome measures, and timing of measurements.

 on a range of infant health outcomes, such as gastrointestinal illness, otitis media, respiratory tract illness, and healthcare use. None of the studies reported maternal health outcomes.
Breastfeeding Outcomes. On the basis of 43 trials, breastfeeding support and education interventions targeting individuals were associated with a statistically significant higher likelihood of any and exclusive breastfeeding at less than 3 months and at 3 to 6 months compared with usual care among adults. Pooled estimates indicated beneficial associations for any breastfeeding at less than 3 months (risk ratio [RR], 1.07 [95% confidence interval {CI}, 1.03 to 1.11]; k=26) and at 3 to 6 months (RR, 1.11 [95% CI, 1.04 to 1.18]; k=23) and for exclusive breastfeeding at less than 3 months (RR, 1.21 [95% CI, 1.11 to 1.33]; k=22) and at 3 to 6 months (RR, 1.20 [95% CI, 1.05 to 1.38]; k=18). At 6 months, individual-level interventions with adults were associated with a 16 percent higher likelihood of exclusive breastfeeding (RR, 1.16 [95% CI, 1.02 to 1.32]; k=17) but not with any breastfeeding. The association between individual-level interventions and breastfeeding initiation was not statistically significant based on the pooled point estimate, but the confidence interval did not rule out potential benefit (RR, 1.00 [95% CI, 0.99 to 1.02]; k=14). There was some suggestion that interventions that took place during a combination of prenatal, peripartum, or postpartum time periods were more effective than those that took place only during one time period. There was no indication of effect modification by other intervention characteristics or by population subgroups. All four trials of individual-level interventions among adolescents or young adults reported higher rates of breastfeeding among intervention versus control group participants. For system-level interventions, there was limited, mixed evidence of an effect on rates of breastfeeding initiation or the duration of any or exclusive breastfeeding from well-controlled studies.
Adverse Events. Two trials among adults reported on adverse events related to a breastfeeding support intervention. One trial found no significant differences between groups in maternal anxiety at 2 weeks. The other reported that a few mothers expressed feelings of anxiety and decreased confidence in their breastfeeding abilities despite breastfeeding going well and therefore discontinued their participation in the peer counseling intervention.
Limitations: There were a number of threats to internal validity within the included studies. Detail regarding the measurement of breastfeeding outcomes, sociodemographic and breastfeeding-related population characteristics, and intervention and usual care characteristics were lacking. Our pooled analyses relied on unadjusted breastfeeding rates and did not control for potential confounding.

Conclusions: The body of fair-to-good quality evidence related to primary care interventions to support breastfeeding has nearly doubled since the release of the 2009 U.S. Preventive Services Task Force review and recommendation. The updated evidence confirms that breastfeeding support and education provided by professionals and peers to individual women, regardless of the mother’s age, is associated with an increase in the duration of any and exclusive breastfeeding. There are limited well-controlled studies examining the effectiveness of system-level policies and practices.

Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement

Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement FREE

Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force*

Ann Intern Med. 2014;161:894-901. doi:10.7326/M14-1965

In 2008, the USPSTF recommended high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults who were at increased risk for STIs (B recommendation). At that time, the USPSTF also found that the evidence was insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in non–sexually active adolescents and in adults who were not at increased risk for STIs (I statement). This updated recommendation reaffirms that the evidence is adequate to recommend high-intensity behavioral counseling for persons who are at increased risk (including all sexually active adolescents) and recognizes that some interventions of lesser intensity are also effective

Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Acceso a texto completo

http://www.ncbi.nlm.nih.gov/pubmed/24615535?dopt=Abstract

Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force*
Ann Intern Med. 2014 May 6;160(9):634-9. doi: 10.7326/M14-0334

Description: Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for illicit drug use.

Methods: The USPSTF reviewed the evidence on interventions to help adolescents who have never used drugs to remain abstinent and interventions to help adolescents who are using drugs but do not meet criteria for a substance use disorder to reduce or stop their use.

Population: This recommendation applies to children and adolescents younger than age 18 years who have not been diagnosed with a substance use disorder.

Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. (I statement)

---

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Meta-analysis of Parental Protection of Children From Tobacco Smoke Exposure.

Pediatrics. 2014 Mar 24. [Epub ahead of print]  

Rosen LJ(1), Myers V, Hovell M, Zucker D, Ben Noach M. 

BACKGROUND AND OBJECTIVE: Worldwide, roughly 40% of children are exposed to the damaging and sometimes deadly effects of tobacco smoke. Interventions aimed at reducing child tobacco smoke exposure (TSE) have shown mixed results. The objective of this study was to perform a systematic review and meta-analysis to quantify effects of interventions aimed at decreasing child TSE. 

METHODS: Data sources included Medline, PubMed, Web of Science, PsycNet, and Embase. Controlled trials that included parents of young children were selected. Two reviewers extracted TSE data, as assessed by parentally-reported exposure or protection (PREP) and biomarkers. Risk ratios and differences were calculated by using the DerSimonian and Laird random-effects model. Exploratory subgroup analyses were performed. 

RESULTS: Thirty studies were included. Improvements were observed from baseline to follow-up for parentally-reported and biomarker data in most intervention and control groups. Interventions demonstrated evidence of small benefit to intervention participants at follow-up (PREP: 17 studies, n = 6820, relative risk 1.12, confidence interval [CI] 1.07 to 1.18], P < .0001). Seven percent more children were protected in intervention groups relative to control groups. Intervention parents smoked fewer cigarettes around children at follow-up than did control parents (P = .03). Biomarkers (13 studies, n = 2601) at follow-up suggested lower child exposure among intervention participants (RD -0.05, CI -0.13 to 0.03, P = .20). 

CONCLUSIONS: Interventions to prevent child TSE are moderately beneficial at the individual level. Widespread child TSE suggests potential for significant population impact. More research is needed to improve intervention effectiveness and child TSE measurement.

Behavioural interventions for the prevention of sexually transmitted infectionsin young people aged 13-19 years: a systematic review. 

Health Educ Res. 2012 Jun;27(3):495-512. Epub 2012 Feb 20.
Picot J, Shepherd J, Kavanagh J, Cooper K, Harden A, Barnett-Page E, Jones J, Clegg A, Hartwell D, Frampton GK.
Southampton Health Technology Assessments Centre, University of Southampton, First Floor, Epsilon House, Enterprise Road, University of Southampton Science Park, Southampton, SO16 7NS, UK. j.picot@soton.ac.uk 

We systematically reviewed school-based skills building behavioural interventions
for the prevention of sexually transmitted infections. References were sought
from 15 electronic resources, bibliographies of systematic reviews/included
studies and experts. Two authors independently extracted data and
quality-assessed studies. Fifteen randomized controlled trials (RCTs), conducted 
in the United States, Africa or Europe, met the inclusion criteria. They were
heterogeneous in terms of intervention length, content, intensity and providers. 
Data from 12 RCTs passed quality assessment criteria and provided evidence of
positive changes in non-behavioural outcomes (e.g. knowledge and self-efficacy). 
Intervention effects on behavioural outcomes, such as condom use, were generally 
limited and did not demonstrate a negative impact (e.g. earlier sexual
initiation). Beneficial effect on at least one, but never all behavioural
outcomes assessed was reported by about half the studies, but this was sometimes 
limited to a participant subgroup. Sexual health education for young people is
important as it increases knowledge upon which to make decisions about sexual
behaviour. However, a number of factors may limit intervention impact on
behavioural outcomes. Further research could draw on one of the more effective
studies reviewed and could explore the effectiveness of 'booster' sessions as
young people move from adolescence to young adulthood.