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.

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)

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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.

Effect of behavioural-educational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial

Stremler R, Hodnett E, Kenton L, Lee K, Weiss S, Weston J, et al.

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1164 

(Published 20 March 2013) Cite this as: BMJ 2013;346:f1164

Objective To evaluate the effectiveness of a behavioural-educational sleep intervention delivered in the early postpartum in improving maternal and infant sleep.

Design Randomised controlled trial.

Setting Postpartum units of two university affiliated hospitals.

Participants 246 primiparous women and their infants randomised while in hospital with an internet based randomisation service to intervention (n=123) or usual care (n=123) groups.

Interventions The behavioural-educational sleep intervention included a 45-60 minute meeting with a nurse to discuss sleep information and strategies to promote maternal and infant sleep, a 20 page booklet with the content discussed, and phone contacts at one, two, and four weeks postpartum to reinforce information, provide support, and problem solve. The usual care group received calls at weeks one, two, and four to maintain contact without provision of advice.

Main outcome measures Primary outcome was maternal nocturnal (9 pm to 9 am) sleep (minutes) and secondary outcome was longest stretch of infant nocturnal sleep (minutes) measured at six and 12 weeks postpartum by actigraphy. Other outcomes measured at six and 12 weeks were number of maternal and infant night time awakenings by actigraphy, fatigue visual analogue scale, general sleep disturbance scale, and Edinburgh postnatal depression scale. Rates of exclusive breast feeding were measured at 12 weeks postpartum only.

Results All women who completed any outcome measures at six or 12 weeks were included in analysis. Sleep outcomes were completed at one or both of six and 12 weeks postpartum for 215 of 246 (87%) women (110/123 intervention and 105/123 usual care). Longitudinal mixed effects model analyses indicated no significant differences between the groups on any of the outcomes. The estimated mean difference in maternal nocturnal sleep between the intervention and usual care groups was 5.97 minutes (95% confidence interval −7.55 to 19.5 minutes, P=0.39). No differences in any outcomes were noted based on the specific nurse delivering the intervention or the number of phone contacts received.

Conclusion A behavioural-educational intervention delivered in the early postpartum, in hospital, and in the first weeks at home, was ineffective in improving maternal and infant sleep or other health outcomes in the first months postpartum.