Scolaris Content Display Scolaris Content Display

Educación en lactancia materna y apoyo a las pacientes con gemelos o múltiplos de mayor orden

Collapse all Expand all

Antecedentes

Existen tasas crecientes de partos múltiples en todo el mundo, con tasas mayores de complicaciones asociadas y más atención hospitalaria, a menudo debido a la prematurez. Aunque hay evidencias sólidas acerca de los riesgos de no lactar, las tasas de lactancia materna en las pacientes con un parto de más de un lactante son inferiores que con los partos de fetos únicos. La lactancia materna a más de un lactante puede ser más desafiante debido a las dificultades asociadas con el parto o la prematurez. Las exigencias adicionales a la madre debido a la lactancia materna frecuente, la coordinación de las necesidades de más de un lactante o el ingreso a la unidad de cuidados intensivos neonatales puede provocar el retardo en el inicio o el abandono temprano. Se pueden considerar opciones adicionales como la extracción de leche materna, la administración de leche de donante o diferentes métodos de alimentación complementaria. Se ha encontrado que el apoyo y la educación acerca de la lactancia materna mejoran la duración de cualquier lactancia en los lactantes a término sanos y sus madres; sin embargo, faltan evidencias acerca de las intervenciones que son efectivas para apoyar a las pacientes con gemelos o múltiplos de mayor orden.

Objetivos

Evaluar la efectividad de la educación en lactancia materna y apoyo a las pacientes con gemelos o múltiplos de mayor orden.

Métodos de búsqueda

Se hicieron búsquedas en el registro de ensayos del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group's Trials Register) (30 junio 2016), ClinicalTrials.gov (30 junio 2016), la WHO International Clinical Trials Registry Platform (ICTRP) (1 julio 2016), la lista de los estudios excluidos de una revisión Cochrane equivalente de pacientes con fetos únicos, y las listas de referencias de los estudios recuperados.

Criterios de selección

Se incluyeron los ensayos aleatorios o cuasialeatorios que compararon la educación o el apoyo extra a las pacientes con gemelos o múltiplos de mayor orden.

Obtención y análisis de los datos

Dos autores de la revisión evaluaron de forma independiente los ensayos para la inclusión y el riesgo de sesgo, extrajeron los datos y verificaron su exactitud. Se planificó evaluar la calidad de las pruebas utilizando el enfoque GRADE, pero no se pudo analizar ningún dato.

Resultados principales

Se encontraron diez ensayos (23 informes) de educación y apoyo a la lactancia materna que incluyeron pacientes con gemelos o múltiplos de mayor orden. La calidad de las evidencias fue mixta y el riesgo de sesgo fue principalmente alto o incierto. Es difícil cegar a las pacientes o al personal a la asignación a los grupos para esta intervención; por lo tanto, en todos los estudios hubo alto riesgo de sesgo de realización y riesgo alto o incierto de sesgo de detección. Los ensayos reclutaron a 5787 mujeres (lo que incluyó 512 mujeres entrevistadas como parte de un ensayo aleatorio grupal); de éstas, se obtuvieron datos de dos estudios con 42 mujeres con gemelos o múltiplos de mayor orden. Ninguna de las intervenciones estaba diseñada específicamente para pacientes con más de un lactante, y los resultados de los partos múltiples no se informaron por separado para cada lactante. Debido a la escasez de evidencias y el formato en el que se informaron los datos, en esta revisión se presenta una descripción narrativa de los datos, no se muestran análisis y no fue posible evaluar las evidencias según GRADE.

Los dos ensayos con datos de pacientes con partos múltiples compararon visitas domiciliarias del personal de enfermería versus atención habitual (15 pacientes), y asesoramiento telefónico a sus parejas versus atención habitual (27 pacientes). Se informó el número de pacientes que iniciaron la lactancia materna (las 15 pacientes de un estudio, 25 de 27 pacientes de un estudio). La interrupción de cualquier lactancia materna antes de las cuatro a seis semanas posparto, la interrupción de la lactancia materna exclusiva antes de las cuatro a seis semanas posparto, la interrupción de cualquier lactancia materna antes de los seis meses posparto yla interrupción de la lactancia materna exclusiva antes de los seis meses posparto no se informaron explícitamente y no hubo datos suficientes para establecer cualquier conclusión significativa a partir de los datos de supervivencia.

La interrupción de la extracción de leche materna antes de las cuatro a seis semanas posparto, y la interrupción de la extracción de leche materna antes de los seis meses posparto no se informaron. Las medidas de satisfacción materna se informaron en un estudio con 15 pacientes, pero no hubo datos suficientes para establecer conclusiones; no se informaron otros resultados secundarios de las pacientes con partos múltiples en ninguno de los estudios. No se informaron eventos adversos.

Conclusiones de los autores

A partir de los ensayos controlados aleatorios no se encontraron evidencias acerca de la efectividad de la educación en lactancia materna y apoyo a las pacientes con gemelos o múltiplos de mayor orden, ni de la manera más efectiva de proporcionar la educación y el apoyo. No hubo evidencias acerca de la mejor manera de proporcionar la intervención, el momento adecuado de atención ni la mejor persona para prestar la atención. Se necesitan estudios bien diseñados y con poder estadístico suficiente de intervenciones diseñadas para las pacientes con gemelos o múltiplos de mayor orden para determinar qué tipos de educación y apoyo son efectivos para ayudar a estas madres a lactar a los neonatos.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Educación en lactancia materna y apoyo a las pacientes con embarazos múltiples

¿Cuál es el problema?

La lactancia materna tiene muchos efectos beneficiosos que incluyen proteger al recién nacido contra las enfermedades inflamatorias del intestino, los pulmones o los oídos, así como de problemas de salud a más largo plazo como la diabetes y la obesidad, mejorar los resultados cognitivos y proteger a la madre contra el cáncer de mama. Las tasas de lactancia materna son inferiores en las pacientes que han tenido el parto de más de un recién nacido que en las pacientes que tienen un recién nacido único. Sin embargo, hay desafíos a superar en la lactancia materna de los partos múltiples (gemelos, trillizos o más). Se ha encontrado que la educación y el apoyo aumentan el número de pacientes que comienzan a lactar y mejoran la duración de cualquier lactancia materna en los recién nacidos únicos a término sanos. La educación y el apoyo los pueden proporcionar trabajadores no especializados o profesionales sanitarios. Se podrían proporcionar como preparación para el parto o una vez que se produce el parto.

Las madres que tienen más de un recién nacido tienen muchos retos adicionales a superar para lactar a los recién nacidos y pueden necesitar asesoramiento y apoyo adicionales. Tienen exigencias adicionales debido a la lactancia materna frecuente, la coordinación de necesidades potencialmente diferentes de más de un recién nacido o la necesidad de extraerse la leche y alimentar a diferentes recién nacidos por diferentes métodos de alimentación. Las madres tienen una mayor probabilidad de tener un parto prematuro y que los recién nacidos sean ingresados en la unidad de cuidados intensivos neonatales, lo que puede dar lugar al retardo del inicio o a la interrupción temprana de la lactancia materna.

¿Por qué es esto importante?

La lactancia materna ayuda a la salud y el desarrollo del recién nacido. El parto de más de un recién nacido plantea retos adicionales en la planificación de la madre para lactar. Las madres también tienen más probabilidades de tener que considerar opciones como la extracción de leche materna, la administración de leche de donante o la fortificación de la leche, así como diferentes métodos de alimentación complementaria. Algunas madres pueden preferir alimentar con la leche materna extraída porque pueden estar seguras acerca del volumen de leche que se le da al recién nacido y como una manera de permitirle a otros ayudar en la alimentación. Se deseaba determinar si la educación y el apoyo ayudan a las madres con partos múltiples a lactar.

¿Qué pruebas se encontraron?

Se realizaron búsquedas de ensayos controlados aleatorios el 30 de junio de 2016 y el 1 de julio de 2016 y se encontraron 10 estudios (23 informes) para incluir en la revisión. Todos los estudios fueron de educación y apoyo a todas las madres, no sólo a las que tenían el parto de más de un recién nacido, lo que introdujo problemas metodológicos para analizar específicamente los partos múltiples. Los ensayos reclutaron a 5787 mujeres (lo que incluyó 512 mujeres entrevistadas como parte de un ensayo aleatorio grupal). El número de recién nacidos de embarazos múltiples fue pequeño y ninguno de los estudios tuvo números suficientes para proporcionar información acerca de cómo las intervenciones funcionaron en las madres con partos múltiples. Hubo varios problemas relacionados con la forma en la que se realizaron los estudios, incluido el hecho de que las pacientes sabían si estaban en el grupo al que se le proporcionó apoyo.

Los autores de dos de los estudios enviaron los resultados de las pacientes con partos múltiples (42 mujeres en total). Los ensayos compararon visitas domiciliarias del personal de enfermería versus atención habitual (15 pacientes), y asesoramiento telefónico a sus parejas versus atención habitual (27 mujeres). Examinaron el número de pacientes que interrumpieron cualquier lactancia materna o la lactancia materna exclusiva antes de las cuatro semanas después del parto y antes de los seis meses, sin que la intervención proporcionara mejorías claras. Las 15 pacientes de un estudio y 25 de las 27 pacientes del otro comenzaron la lactancia materna. No hubo información sobre la extracción de leche materna. Se informaron otras medidas de resultado que incluyeron una medida de satisfacción materna en el estudio con 15 mujeres, pero no hubo números suficientes para poder establecer conclusiones. No se informaron eventos adversos.

¿Qué quiere decir esto?

No fue posible establecer conclusiones a partir de las evidencias disponibles de los ensayos controlados aleatorios acerca de si la educación y el apoyo ayudan a las madres con partos múltiples a lactar. Ninguno de los estudios se diseñó para ofrecerles apoyo ni educación adaptados a las pacientes que tienen el parto de más de un recién nacido. Se necesitan más estudios de investigación para determinar qué tipos de educación y apoyo podrían ayudar a las madres con partos múltiples a lactar a los recién nacidos. Los datos de estos estudios se deben presentar y analizar de una manera apropiada para los recién nacidos de partos múltiples.

Authors' conclusions

Implications for practice

We found no evidence from randomised controlled trials about forms of breastfeeding support and education for women with multiples, or the most effective way to provide support or education. There was no evidence about the best way to deliver support and education, the timing of the intervention, or the best person to deliver the intervention. Therefore, conclusions for practice cannot be made on the basis of the findings of this review.

Implications for research

Well designed, adequately powered research is needed to answer questions about the education and support that can help mothers of multiples to breastfeed their babies. Trials are needed that examine interventions designed specifically for women with multiples and delivered by people with training about how to overcome the particular challenges of breastfeeding more than one infant. Outcome data needs to be gathered for the mothers of twins and higher order multiples separately so that conclusions can be drawn about what works for all mothers of multiples.

Background

Description of the condition

Description of the condition (breastfeeding multiples)

The incidence of multiple births (birth of two or more infants) in high‐income countries has risen since the 1970s (Blondel 2002; Collins 2007). In the United States, rates increased from 19.3 to 30.7 per 1000 live births between 1980 and 1999 (Russell 2003), while in England and Wales the rate increased from 10 per 1000 in 1980, to 16 per 1000 in 2011 (NICE 2013). In 2013 in England and Wales, this figure was comprised of 10593 sets of twins, 187 triplets, and "three quads and above" (ONS 2014). European rates in 2000 varied from 12.2 per 1000 maternities in Italy to 19.4 per 1000 in the Netherlands (Blondel 2006). In low‐income countries, rates of between nine and 18 per 1000 live births have also been reported (Smits 2011). This rise and variation in rates is due to the use of reproductive techniques, and is partly accounted for by more births to older women and more multiple births in women from more affluent backgrounds (Smith 2014). More recently, rates of higher order births (three or more infants) have declined as changes in assisted reproductive techniques (ART) to reduce multiple pregnancies have been implemented (Smith 2014; Umstad 2013).

Multiple pregnancy carries greater risks for both mother and babies, with around a 50% risk of preterm birth in multiple pregnancy (Blondel 2006; NICE 2013). Additional fetal risks include feto‐fetal transfusion syndrome, intrauterine growth restriction and congenital abnormalities (NICE 2013). There is higher risk of operative delivery (Antsaklis 2013; Kyvernitakis 2013; Lee 2011). Infants conceived through assisted reproductive technology (ART) may be at even higher risk of complications (Murray 2014); consequently, admission to the neonatal unit is more likely. This is likely to cause stress and anxiety for parents, separation of the mother from her babies (Flacking 2006), and has a cost implication for the healthcare provider (Chambers 2014).

There is strong evidence that not breastfeeding or not being fed breast milk carries greater risks, both for the infant and for the mother, with small and sick babies having specific additional risks (Renfrew 2012a, Victora 2016). Breastfeeding protects the infant against gastrointestinal disease, respiratory disease, otitis media and necrotising enterocolitis (NEC), and protects the mother against breast cancer (Renfrew 2012a, Victora 2016). Breastfeeding is also likely to lead to improvements in IQ, reduce rates of Sudden Infant Death Syndrome (SIDS) and reduce obesity in young children, and there is growing evidence that it confers a number of other health and development benefits on the child and health benefits on the mother (Renfrew 2012a, Victora 2016). It has been estimated that even modest increases in the numbers of infants breastfed exclusively could have considerable cost savings for the health service (Renfrew 2012a, Rollins 2016). For preterm infants, the protection breast milk confers against NEC is particularly important.

All mothers have to make decisions about how to feed their baby, however mothers of multiples face more challenges feeding their infants than mothers of singletons and may need additional advice and support. Mothers of twins have been found to have lower intentions to breastfeed (Lustiv 2013), to be less likely to initiate breastfeeding (Yokoyama 2006), and to be less likely to offer any breastfeeding (Multiple Births Foundation 2011) or to breastfeed exclusively (McAndrew 2012; Multiple Births Foundation 2011). A European study found that an overall figure of 36.4% of twins were breastfed at discharge, compared to 39.3% of singleton infants, with the rate of breastfeeding at discharge varying widely between countries (Bonet 2011). In Japan at three to six months, 4.1% of twins or triplets were exclusively breastfed compared to 44.7% of singletons (Yokoyama 2006). A UK‐wide survey found 69% of twins were breastfed initially, compared to 81% of singletons (McAndrew 2012). This study also reported that twins were more likely to be given donor milk, and have formula introduced by one week old (McAndrew 2012). The study found that some mothers reported feeding each baby by differing methods; reasons included one baby being ill or in hospital and needing special formula or drip or tube feeding (8%), one baby starting solids earlier (8%), or babies taking differing amounts of milk (6%) (McAndrew 2012). Prematurity contributes to a higher percentage of twins starting partial breastfeeding and moving to full breastfeeding later (Flidel‐Rimon 2002). In the UK, older women and those living in more affluent circumstances are more likely to breastfeed (McAndrew 2012) and this difference also applies to women who have infants from multiple pregnancies (Ostlund 2010).

Some of the issues faced by mothers of multiples are related to the practicalities of feeding more than one infant at the breast, and this may mean that advice offered to mothers of singletons may not be appropriate (Bennington 2011). While some women may find that breastfeeding multiples is straightforward, mothers of multiples may have more difficulty offering early and continuous skin‐to‐skin contact with their infants, there may be delay in initiation of feeding at the breast, the infants may have a disorganised or immature sucking pattern as a result of prematurity and the demands of facilitating frequent feeding are more challenging (Bennington 2011; Cinar 2013). Women who have given birth by caesarean section are less likely to be mobile, less able to care for more than one infant at once, and may have more difficulty finding a comfortable position to feed (Bennington 2011; Flidel‐Rimon 2002). Decisions may have to be made about whether to feed the infants together or feed separately. There may be conflicting needs; accommodating the individual feeding preferences of each infant may be incompatible with the extra time needed to feed separately (Bennington 2011; Gromada 1998). Simultaneous feeding of two babies is likely to stimulate simultaneous let down, and can facilitate feeding if one infant has weak sucking, however the practicalities of this can be hard to manage without help in the early stages of breastfeeding, particularly if two hands are needed to encourage a satisfactory latch (Flidel‐Rimon 2002; Gromada 1998; Multiple Births Foundation 2011). Waking a sleeping baby for simultaneous feeding may not be easy and is unlikely to result in a satisfactory feed. Simultaneous feeding of more than two babies is not a practical possibility. It is important to note that the challenges of feeding more than one baby at a time also arise with feeding multiples with formula and, in addition, extra time is required to make up formula feeds (Bennington 2011).

Prematurity adds to the already significant challenges of initiating and maintaining lactation for twins and higher order multiples. Twin infants born prematurely are less likely than twins born at term to be breastfed (Ostlund 2010). Problems can be exacerbated by the degree of prematurity and the severity of any additional illness, and the consequences of an operative birth (Bennington 2011). Mothers of infants born early may be motivated to express breast milk as a way of providing a unique contribution to the care of their infants. There have been reports that, for premature infants, breast milk may be seen by staff as a commodity, leading to pressure from neonatal intensive care unit (NICU) staff on mothers to express milk (Flacking 2006), with the consequence that breast milk feeding may be favoured over breastfeeding (Niela‐Vilén 2014). There is some evidence that counselling women who intend to formula feed about the benefits of expressing milk for very low birthweight babies increases the incidence of lactation initiation and breast milk feeding without increasing maternal stress and anxiety (Sisk 2006). Expressing breast milk can lead to women who did not plan to breastfeed, eventually feeding their infants directly at the breast (Sisk 2006).

While feeding directly at the breast is optimal for stimulating a good supply of milk, the above practicalities and the additional challenges of prematurity may mean that feeding at the breast is not possible initially. The mother may express her milk and mother's own or donor expressed breast milk (EBM) can then be given by bottle, tube or cup (Damato 2005; Gromada 1998). The latter two options may increase the chances of a baby subsequently feeding successfully at the breast while in hospital, however cup feeding may increase length of stay and success is likely to be dependent on the experience of the staff (Collins 2008). Within the NICU, a lack of privacy can make expression of breast milk, initiation of skin contact, and breastfeeding difficult for many mothers (Alves 2013; Flacking 2006; Gromada 1998; Niela‐Vilén 2014). Facilities to pump and store EBM in the NICU are essential (Gromada 1998). However, the transition from bottle or alternative feeding methods to breastfeeding may be problematic and involve decisions about when and how to make the transition, particularly if the infants are discharged at different times (Bennington 2011; Gromada 1998). Some mothers report that feeding EBM by bottle is a preferable method because there is certainty about the volume of milk being fed (Niela‐Vilén 2014) and it is also a way of allowing others to assist with feeding, particularly with higher order multiples (Multiple Births Foundation 2011). Milk expression may be by hand or by pump (hand pump or electrical pump, single or double pumping); there is no strong evidence that one method is better than another (Becker 2015). An increase in milk supply can be achieved by early initiation of pumping, increased frequency of pumping, warming of breast, massage of breast, and relaxation and therapeutic touch (Becker 2015). If only one baby is able to latch, the mother can simultaneously pump on the other side (Gromada 1998). There are various options for changing sides or for supplementing and if mothers are advised and supported well, they are likely to find a pattern that suits their circumstances (Bennington 2011; Gromada 1998). Various positioning options such as the underarm hold or the use of a special V‐shaped pillow to support the babies may be helpful (Flidel‐Rimon 2002; Gromada 1998).

If a mother is unable to express sufficient milk, or does not wish to express milk, pasteurised donor breast milk can be used. This has been found to protect against NEC (ESPGHAN 2013). NICE guidelines make recommendations about the safe and effective operation of donor milk banks (NICE 2010), however not all areas operate this service.

When infants are premature or ill and admission to the NICU is required, the consequent likely (though not inevitable) separation of mother and babies, the possibility of long periods of hospitalisation, the mother being discharged home before the babies, her need for rest and recovery, the need to care for older siblings, long periods of pumping, staggered infant discharge and the involvement of many other caregivers can make establishing a good milk supply and initiating breastfeeding very challenging (Bennington 2011; Gromada 1998; Multiple Births Foundation 2011). Success in breastfeeding a premature infant has been reported to compensate for any perceived sense of ‘failure’ a mother may experience in regard to the premature birth, and can give her a sense of achievement (Flacking 2006; Flacking 2007; Niela‐Vilén 2014).

Kangaroo skin‐to‐skin mother care is an effective intervention to improve the duration of breastfeeding in all settings (Renfrew 2009). It is an alternative to conventional neonatal care for low birthweight (LBW) infants and has some benefits for breastfeeding outcomes (Conde‐Agudelo 2014). Early skin contact with the mother soon after birth improves breastfeeding at one to four months post birth and is associated with other benefits for the mother and baby including improvements in attachment and bonding (Moore 2012). However, achieving sufficient skin contact when there is more than one baby can be more challenging and the evidence for this intervention in multiple pregnancies is lacking.

Mothers of multiples can produce sufficient breast milk, especially if given appropriate help and support (Multiple Births Foundation 2011). Anxiety about adequacy of milk supply is a frequently reported concern for mothers of multiples who are breastfeeding, however (Cinar 2013; Flidel‐Rimon 2002; Multiple Births Foundation 2011). For mothers of preterm infants there may also be anxiety about the sufficiency of breast milk to meet the nutritional needs of their infants (Flacking 2007). This concern may be exacerbated by the often routine use of fortification of breast milk with artificial fortifier while the infant is in the NICU and being fed by nasogastric tube (Roze 2012). Supplementation with formula or donor EBM may be considered by staff if it is thought that there is insufficient supply of mother's own EBM, however inadequate pumping can lead to reduced stimulation of the breast, a reduced maternal milk supply and earlier cessation or less likelihood of exclusive breastfeeding (Gromada 1998). The use of supplementary artifical formula has been found to lead to a higher rate of short‐term growth, but also a higher rate of NEC (Quigley 2014).

More widely, just as for singletons, other issues can impact on attitudes and practices towards breastfeeding multiples. These include: cultural beliefs and pressures (e.g. anxiety about breastfeeding in public, beliefs about adequacy of milk supply); lack of availability of trained support; legislation to protect women who are breastfeeding; and commercial pressures from marketing and advertising of formula by manufacturers (Save the Children 2013).

In general, studies are lacking in details about the complexities of feeding multiples and do not specify details of the feeding method such as direct breastfeeding, use of tube, cup or bottle, the use of fortifiers, the use of supplementary milks, the use of donor breast milk or expressed maternal breast milk, and the differences in feeding method between different babies (Renfrew 2009).

Description of the intervention

Education and support for breastfeeding multiples

Critical to success with breastfeeding multiples is information and support from staff (Multiple Births Foundation 2011). Support might be given by a trained healthcare professional (such as a midwife, lactation consultant, or nurse), a peer counsellor or a lay advisor. Advice might include early anticipatory advice in pregnancy, and multidisciplinary support or advice consistent with the mother’s goals and pace (Gromada 1998; Szucs 2009). Specific advice might be needed to help mothers distinguish normal infant feeding behaviour from issues related to caring for multiples (Gromada 1998). Staff may be able to advise about patterns of feeding, avoidance of painful feeding, feeding from both breasts equally, expressing after feeds, and providing sufficient stimulation (both direct feeding and regular and frequent expression of milk) (Bennington 2011). Advice may be provided on a one‐to‐one basis or as part of a group and could take place in hospital or at home. Following discharge from hospital, contact could be face‐to‐face, over the phone or using teleconferencing facilities. Increasingly mothers are turning to websites or online sources of information and support (Newby 2015). For healthy term infants, extra support has been shown to improve the duration of 'any breastfeeding' and the duration of exclusive breastfeeding (McFadden 2017). However, much of this evidence relates to singleton infants; although some studies include multiples, results are not usually reported separately, therefore applicability to infants from multiple pregnancies is uncertain (Renfrew 2009). Many staff lack experience or confidence about feeding multiples, and incorrect or discouraging advice can be detrimental (Cinar 2013; Damato 2005). Staff in NICU may view formula feeding as a way of ensuring faster growth of the preterm baby and therefore quicker discharge home (Niela‐Vilén 2014).

At an organisational level, the UNICEF Baby Friendly Hospital Initiative (BFHI) accreditation of the hospital results in improvement in breastfeeding outcomes for infants including those in NICU (Dall'Oglio 2007; Entwistle 2013; Parker 2013; Renfrew 2009). Other organisational interventions in NICU such as Family Centred Care may have an impact on maternal confidence and success with breastfeeding (POPPY Steering Group; Wataker 2012).

While successfully breastfeeding twins and higher order multiples can be straightforward, it can also be time consuming for the mother, who is likely to need good support at home to ensure she gets sufficient rest and adequate nutrition (Multiple Births Foundation 2011). Feeding babies with formula does, of course, require additional preparation time and equipment when there are two or more babies and, even for mothers with adequate help at home (which not all women have), this can be a significant burden of both time and expense. As with breastfeeding singletons (McFadden 2017), adequate help and support during the weeks after birth is likely to be important for success in breastfeeding. Support can come from non‐professional sources such as peer (mother‐to‐mother) support, community support groups, support groups for multiples (Tamba (Twins & Multiple Births Association), MBF (Multiple Births Foundation), or similar organisations) and support from family. These aspects may be even more important for multiples. Support may take the form of practical support (help with housework, cooking, etc.) or emotional support. Enhancing the mother’s trust and confidence in her ability to sustain a sufficient milk supply is crucial (Gromada 1998). As the babies get older, workplace support and facilities may be especially important for mothers of multiples in long‐term maintenance of breastfeeding (Gromada 1998), while further advice and support may be needed during weaning to help prevent problems with milk stasis and mastitis (Gromada 1998). Women may require advice on specific interventions which may facilitate or inhibit successful breastfeeding of multiples. For example, the use of pacifiers for multiples who may have the additional breastfeeding problems identified above is unknown.

How the intervention might work

Breastfeeding is important for all babies, including multiples, and especially for those born too soon or too small (Renfrew 2012a, Victora 2016). Women with multiples are known to be less likely to intend to breastfeed, and to be less likely to initiate and sustain breastfeeding compared with those with singletons (Lustiv 2013; Yokoyama 2006). Tailored advice on initiating and sustaining breastfeeding or breast milk feeding may be needed for women with multiples, particularly in cultures where breastfeeding is not the norm. The practical challenges of caring for two or more infants may also mean that women require encouragement and emotional support in order to breastfeed their babies (Multiple Births Foundation 2011). It is possible that education and support for women with multiples may increase the number of women initiating breastfeeding and reduce the risk of early discontinuation.

Why it is important to do this review

This review is one in a series of Cochrane reviews examining education and support interventions to promote the initiation of breastfeeding and to increase the duration of breastfeeding and exclusive breastfeeding (Balogun 2016; Lumbiganon 2016; McFadden 2017). Findings of these related reviews suggest that support interventions can be effective in singleton pregnancies. There is some evidence that breastfeeding education and peer and professional support can increase the initiation of breastfeeding (Balogun 2016), and there is good evidence that support interventions by professionals or peers are effective in increasing the duration of any and exclusive breastfeeding for mothers of healthy term singletons (McFadden 2017). There is less conclusive evidence that antenatal education alone is effective to increase the duration of breastfeeding (Lumbiganon 2016). An earlier review examined the promotion and support of breastfeeding in the neonatal unit (Renfrew 2009). While the findings of these related reviews have some relevance for breastfeeding multiples, interventions were not necessarily designed to take account of the special needs of women attempting to feed twins or higher order multiples. A review to guide health professionals about breastfeeding multiples was carried out by the Multiple Births Foundation, but the evidence was low quality and is dated (Denton 2011).

Rates of breastfeeding of twins or higher order multiples are lower than rates of breastfeeding singletons suggesting that further evidence is needed about how to support this group of women. Women have reported that the help and support they received with infant feeding for multiples was insufficient; a UK study found that 34% of mothers of twins said further support with feeding would have helped (McAndrew 2012). Similarly, in Turkey, mothers of twins reported they would have liked more support and better advice during pregnancy (Cinar 2013).

Women who are breastfeeding more than one infant face particular challenges; there is a need for evidence‐based recommendations about what works to help women with multiples initiate and continue to breastfeed.

Objectives

To assess effectiveness of breastfeeding education and support for women with twins or higher order multiples. More detailed specific objectives are:

  1. To describe the forms of breastfeeding education and support for women with twins and high order multiples examined in randomised controlled studies.

  2. To examine the effectiveness of different modes of interventions (e.g. face‐to‐face or over the telephone, or by different sorts of healthcare or lay practitioners), and whether interventions containing both antenatal and postnatal elements are more effective than those taking place in the antenatal or postnatal period alone.

  3. To examine the effectiveness of education and support from different care providers and (where information was available) training for care providers.

Methods

Criteria for considering studies for this review

Types of studies

Randomised or quasi‐randomised trials examining breastfeeding education and support interventions for women with twins and high order multiples. We included cluster‐randomised trials.

We included studies reported in brief abstracts, provided sufficient information was reported to allow us to assess risk of bias; those studies that did not provide sufficient information were considered in the review under the section, Studies awaiting classification, pending publication of the full study report.

Cross‐over studies are not an appropriate research design for this type of intervention and were not included.

Types of participants

Women with multiple pregnancies and births, during pregnancy or after birth and regardless of gestation at time of birth.

We included trials that recruited both women with multiple and singleton births provided that there were separate data available for women with multiples.

Types of interventions

The intervention was defined as breastfeeding education and support during pregnancy, the postnatal period (including immediately after delivery), or both for women with multiples. This included contact with an individual or individuals (either professional or volunteer) offering support which is supplementary to the standard care offered in that setting. ‘Support’ interventions eligible for this review included elements such as reassurance, praise, information, and the opportunity to discuss and to respond to the mother’s questions, and they also included staff training to improve the supportive care given to women. They could be offered by health professionals or lay people, trained or untrained, in hospital and community settings. They could be offered to groups of women or one‐to‐one, including mother‐to‐mother support, and the could be offered proactively by contacting women directly, or reactively, by waiting for women to get in touch. They could be provided face‐to‐face or over the phone, and they could involve only one contact or regular, ongoing contact over several months. Studies were included if the intervention occurred in the postnatal period alone or also included an antenatal component.

We included studies examining interventions which included education and support as part of a broader package of care provided that these elements were an important part of the package of care. We included education and training interventions aimed at staff providing care, provided that these interventions were designed to improve the education and support offered to women.

We included education or support for using any intervention designed to increase breastfeeding or breast milk feeding. This could include education or support interventions to encourage women to express breast milk either in the antenatal or postnatal period, or maternal education and support about other interventions which might increase or interfere with breastfeeding (such as pacifier use or kangaroo skin‐to‐skin mother care).

Comparisons: we compared different modes of interventions with each other or with standard care offered in that setting, and we identified the components of that standard care, wherever possible.

Types of outcome measures

The main outcome measure was the effect of the interventions on stopping breastfeeding or breast milk feeding by specified points in time. Primary outcomes were recorded for stopping any or exclusive breastfeeding before four to six weeks and at the last study assessment (up to six months). Other outcomes of interest were stopping any or exclusive breastfeeding at other time points (two, three, four, nine and 12 months), measures of neonatal and infant morbidity (where available), and measures of maternal satisfaction with care or feeding method.

Primary outcomes

  1. Initiation of breastfeeding (baby put to the breast, even if on one occasion only McAndrew 2012) or breast milk feeding for each baby.

  2. Initiation of breast milk expression by the mother.

  3. Stopping any breastfeeding or any breast milk feeding before four to six weeks postpartum for each baby.

  4. Stopping exclusive breastfeeding or exclusive breast milk feeding (baby has only ever been given breast milk and never given formula, solid foods or any other liquids McAndrew 2012) before four to six weeks postpartum for each baby.

  5. Stopping breast milk expression before four to six weeks postpartum.

  6. Stopping any breastfeeding or any breast milk feeding before six months postpartum for each baby.

  7. Stopping exclusive breastfeeding or exclusive breast milk feeding before six months postpartum for each baby.

  8. Stopping breast milk expression before six months postpartum.

Breast milk feeding could include expressed maternal breast milk, or expressed donor breast milk.

Secondary outcomes

  1. Stopping any breastfeeding or any breast milk feeding before two, three, nine and 12 months postpartum.

  2. Stopping exclusive breastfeeding or exclusive breast milk feeding before two, three, nine and 12 months postpartum.

  3. Frequency of milk collection or number of participants expressing milk, or volume of expressed breast milk at any time point.

  4. Maternal satisfaction with care.

  5. Maternal satisfaction with feeding method.

  6. All‐cause infant or neonatal morbidity (trialist defined).

  7. Maternal morbidity (trialist defined).

  8. Duration of NICU stay (days).

  9. Psycho‐social outcomes including measures of attachment, self‐esteem, mental health, etc.

Search methods for identification of studies

The methods section of this review is based on a standard template used by the Cochrane Pregnancy and Childbirth Review Group.

Electronic searches

We searched Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Information Specialist (30 June 2016).

The Register is a database containing over 22,000 reports of controlled trials in the field of pregnancy and childbirth. For full search methods used to populate Cochrane Pregnancy and Childbirth Group’s Trials Register including the detailed search strategies for CENTRAL, MEDLINE, EMBASE and CINAHL, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service, please follow this link to the editorial information about the Cochrane Pregnancy and Childbirth Group in the Cochrane Library and select the ‘Specialized Register ’ section from the options on the left side of the screen.

Briefly, Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Information Specialist and contains trials identified from:

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);

  2. weekly searches of MEDLINE (Ovid);

  3. weekly searches of EMBASE (Ovid);

  4. monthly searches of CINAHL (EBSCO);

  5. handsearches of 30 journals and the proceedings of major conferences;

  6. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Search results are screened by two people and the full text of all relevant trial reports identified through the searching activities described above is reviewed. Based on the intervention described, each trial report is assigned a number that corresponds to a specific Pregnancy and Childbirth Group review topic (or topics), and is then added to the Register. The Information Specialist searches the Register for each review using this topic number rather than keywords. This results in a more specific search set which has been fully accounted for in the relevant review sections (Included studies; Excluded studies; Ongoing studies).

We searched ClinicalTrials.gov (30 June 2016) and the WHO International Clinical Trials Registry Platform (ICTRP) (1 July 2016) for unpublished, planned and ongoing trial reports using the terms given in Appendix 1.

Searching other resources

In addition, one review author (T Dowswell) checked excluded studies from 'Support for healthy breastfeeding mothers with healthy term babies' (McFadden 2017) for any studies that included sick or preterm infants and which might have included multiples, and we checked reference lists of retrieved studies (H Whitford, T Dowswell and S Wallis).

We did not apply any language or date restrictions.

Data collection and analysis

The methods section of this review is based on a standard template used by Cochrane Pregnancy and Childbirth Group.

Selection of studies

Two review authors (H Whitford and T Dowswell) independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any disagreement through discussion and, as required, we consulted a third review author.

We created a study flow diagram to map out the number of records identified, included and excluded,Figure 1


Study flow diagram.

Study flow diagram.

Data extraction and management

We designed a form to extract data. For eligible studies, two review authors (H Whitford, H West, T Dowswell or S Wallis) independently extracted the data using the agreed form. We resolved any discrepancies through discussion and, as required, we consulted another member of the review team. We entered data into Review Manager software (RevMan 2014) and checked for accuracy. When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

Assessment of risk of bias in included studies

Two review authors (H Whitford, T Dowswell, H West, or S Wallis) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third assessor.

(1) Random sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);

  • high risk of bias (any non‐random process, e.g. odd or even date of birth; hospital or clinic record number);

  • unclear risk of bias.

(2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal allocation to interventions prior to assignment and assessed whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);

  • high risk of bias (open random allocation; unsealed or non‐opaque envelopes, alternation; date of birth);

  • unclear risk of bias.

(3.1) Blinding of participants and personnel (checking for possible performance bias)

Blinding of women and staff to support and education interventions is not straightforward and is usually not attempted. However, we described for each included study any methods used to blind or partially blind study participants and personnel from knowledge of which intervention a participant received. We considered that studies were at low risk of bias if we judged that any attempted blinding was likely to be effective or if we judged that lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low, high or unclear risk of bias for participants;

  • low, high or unclear risk of bias for personnel.

(3.2) Blinding of outcome assessment (checking for possible detection bias)

We described for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed methods used to blind outcome assessment as:

  • low, high or unclear risk of bias.

(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We state whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information was reported, or was supplied by the trial authors, we planned to re‐include missing data in the analyses which we undertook.

We assessed methods as:

  • low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups);

  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomisation);

  • unclear risk of bias (even with fairly low levels of attrition there may be some bias because sample loss may be related to outcome).

(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it is clear that all of the study’s prespecified outcomes and all expected outcomes of interest to the review have been reported);

  • high risk of bias (where not all the study’s prespecified outcomes have been reported; one or more reported primary outcomes were not prespecified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);

  • unclear risk of bias.

(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

We described for each included study any important concerns we have about other possible sources of bias such as baseline imbalance between groups.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;

  • high risk of other bias;

  • unclear whether there is risk of other bias.

(7) Overall risk of bias

We made explicit judgements about whether studies were at overall high risk of bias, according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether it was likely to impact on the findings. We planned to explore the impact of the level of bias through undertaking sensitivity analyses, if appropriate ‐ seeSensitivity analysis.

Assessment of the quality of the evidence using the GRADE approach

We did not have data to assess the quality of the evidence. In future updates, for our main comparison (any education or support intervention versus standard care/no intervention), we plan to assess the quality of the evidence using the GRADE approach as outlined in the GRADE Handbook in order to assess the quality of the body of evidence relating to the following outcomes.

  1. Initiation of breastfeeding or breast milk feeding for each baby.

  2. Stopping any breastfeeding or any breast milk feeding before four to six weeks postpartum for each baby.

  3. Stopping exclusive breastfeeding or exclusive breast milk feeding before four to six weeks postpartum for each baby.

  4. Stopping any breastfeeding or any breast milk feeding before six months postpartum for each baby.

  5. Stopping exclusive breastfeeding or exclusive breast milk feeding before six months postpartum for each baby.

  6. Maternal satisfaction with care.

  7. Maternal satisfaction with feeding method.

We plan to include women's views of feeding methods and care as outcomes to be graded as the focus of the review was on the quality of care for women as well as breastfeeding outcomes for the baby.

In future updates, we will use the GRADEpro Guideline Development Tool to import data from Review Manager (RevMan 2014) in order to create ’Summary of findings’ tables. We plan to summarise the intervention effect and a measure of quality for each of the above outcomes will be produced using the GRADE approach. The GRADE approach uses five considerations (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of the body of evidence for each outcome. The evidence can be downgraded from 'high quality' by one level for serious (or by two levels for very serious) limitations, depending on assessments for risk of bias, indirectness of evidence, serious inconsistency, imprecision of effect estimates or potential publication bias.

Measures of treatment effect

Dichotomous data

In future updates, for dichotomous data, we will present results as summary risk ratios with 95% confidence intervals.

Continuous data

In future updates, for continuous data, we will use the mean difference if outcomes are measured in the same way between trials. We will use the standardised mean difference to combine trials that measure the same outcome, but use different measurement methods.

Unit of analysis issues

Cluster‐randomised trials

If we had found any cluster‐randomised trials, we would have included them in the analyses along with individually‐randomised trials, if such trials were identified and were otherwise eligible. We would have adjusted their sample sizes using the methods described in the Handbook using an estimate of the intracluster correlation coefficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we had used ICCs from other sources, we would have reported this and conducted sensitivity analyses to investigate the effect of variation in the ICC. If we had identified both cluster‐randomised trials and individually‐randomised trials, we planned to synthesise the relevant information. We would have considered it reasonable to combine the results from both if there was little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit was considered to be unlikely.

We also would have acknowledged heterogeneity in the randomisation unit and would have performed a subgroup analysis to investigate the effects of the randomisation unit.

Cross‐over trials

We did not include cross‐over trials; such trials are not appropriate for this type of intervention.

Trials with more than two arms

If we had identified trials with more than two arms, we would have pooled results using the methods set out in the Handbook (Higgins 2011) to avoid double‐counting.

Other unit of analysis issues

This review focuses on twins and higher order multiples. Outcomes for these babies are not independent. For some outcomes (e.g. preterm birth), outcomes for babies from the same pregnancy are likely to be the same, or very highly correlated. For other outcomes, there will be a lower correlation (e.g. fetal death or infant anomaly). For breastfeeding outcomes, outcomes for twins or higher multiples are likely to be highly correlated although women may use different feeding methods for their babies, depending on infant birthweight, behaviour or other considerations. We were not able to include any data for analysis and so did not make any adjustments. In future updates, to take account of the non‐independence of outcomes for babies from multiple pregnancies, we will treat each multiple pregnancy as a cluster, and analyse data using methods described above for cluster‐randomised trials. We will seek ICCs for outcomes for twins and higher multiples from trials (if available) from similar trials or from observational studies. Where published ICCs are not available, we will consult with experts in the field to estimate ICCs, and conduct sensitivity analysis using a range of ICC values.

Dealing with missing data

For included studies, we noted levels of attrition. In future updates we will explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis.

For all outcomes, in future updates, we plan to carry out analyses, as far as possible, on an intention‐to‐treat basis, i.e. we would attempt to include all participants randomised to each group in the analyses, and all participants would be analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial would be the number randomised minus any participants whose outcomes were known to be missing.

Assessment of heterogeneity

In future updates, we will assess statistical heterogeneity in each meta‐analysis using the Tau², I² and Chi² statistics. We will regard heterogeneity as moderate if the I² is greater than 30% and either the Tau² was greater than zero, or there was a low P value (less than 0.10) in the Chi² test for heterogeneity.

Assessment of reporting biases

If there were 10 or more studies in a future meta‐analysis, we would investigate reporting biases (such as publication bias) using funnel plots. We would assess funnel plot asymmetry visually. If asymmetry was suggested by a visual assessment, we would perform exploratory analyses to investigate it.

Data synthesis

We planned to carry out statistical analysis using the Review Manager software (RevMan 2014). In future updates, we will use fixed‐effect meta‐analysis for combining data where it is reasonable to assume that studies are estimating the same underlying treatment effect: i.e. where trials are examining the same intervention, and the trials’ populations and methods are judged sufficiently similar. If there was clinical heterogeneity sufficient to expect that the underlying treatment effects differed between trials, or if substantial statistical heterogeneity was detected, we would use random‐effects meta‐analysis to produce an overall summary, if an average treatment effect across trials is considered clinically meaningful. The random‐effects summary would be treated as the average of the range of possible treatment effects and we would discuss the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful, we would not combine trials.

If we used random‐effects analyses, the results would be presented as the average treatment effect with 95% confidence intervals, and the estimates of Tau² and I².

Subgroup analysis and investigation of heterogeneity

We did not combine data in meta‐analysis, due to insufficient data. In future updates, if we identify substantial heterogeneity, we will investigate it using subgroup analyses and sensitivity analyses. We will consider whether an overall summary is meaningful, and if it is, we will use random‐effects analysis to produce it.

As data permit, we will plan to carry out the following subgroup analysis:

  1. by type of supporter (professional versus lay person, or both);

  2. by type of support (face‐to‐face versus telephone support);

  3. by timing of support (antenatal alone, postnatal alone, or both);

  4. by whether the support was proactive (scheduled contacts) or reactive (women needed to request support);

  5. by background breastfeeding initiation rates (low, medium, or high background rates);

  6. by intensity of support (number of scheduled contacts);

  7. by whether babies were premature or sick or healthy babies delivered at term (> 37 weeks’ gestation);

  8. by whether babies were twins or higher order multiples.

We will use only primary outcomes in subgroup analysis.

We plan to assess subgroup differences by interaction tests available within RevMan (RevMan 2014). We will report the results of subgroup analyses quoting the Chi² statistic and P value, and the interaction test I² value.

Sensitivity analysis

There were insufficient data to carry out any sensitivity analyses to examine any possible effect of risk of bias on results. In future updates of this review, if appropriate, for our primary outcomes, we will temporarily remove studies at high or unclear risk of bias (using the allocation concealment domain) to examine whether this has an impact on results. We will also carry out sensitivity analysis to examine the effects of varying the ICC when adjusting data for a cluster design effect.

Results

Description of studies

Results of the search

The search identified 19 studies (36 reports), see Figure 1. Searching the Cochrane PCG Register retrieved 30 reports, searching ClinicalTrials.gov retrieved one report, searching the WHO International Clinical Trials Registry Platform (ICTRP) retrieved four, and the PCG search identified two additional reports for included studies (Graffy 2004; Paul 2012). We did not identify any studies from those excluded from the publication 'Support for healthy breastfeeding mothers with healthy term babies' (McFadden 2017), or the reference lists of retrieved studies.

We included ten studies (23 reports) (Collins 2004; Graffy 2004; Hoddinott 2012; Junior 2007; Paul 2012; Penfold 2014; Reeder 2014; Sellen 2013; Serwint 1996; Winterburn 2003). See Characteristics of included studies.

Five studies (five reports) are ongoing and only the protocol was available. These studies (Brizot 2009; Kikuchi 2015; Kimani‐Murage 2013; Martin‐Iglesias 2011; Yang 2016) may be eligible for future updates. See Characteristics of ongoing studies.

We excluded four studies (eight reports) (Bonuck 2005; Robling 2012; Simmer 2015; Tomlinson 2014). See Characteristics of excluded studies.

Included studies

See Characteristics of included studies.

Design

Seven studies were two‐arm randomised controlled trials. One compared volunteer counsellor support in antenatal and postnatal period to usual care (Graffy 2004), one compared proactive with reactive telephone support for mothers living in disadvantaged circumstances (Hoddinott 2012), one compared breastfeeding support and encouragement for mothers of preterm infants to usual care (Junior 2007), one compared home nurse visits to usual care for ‘well’ breastfeeding newborns and mothers (Paul 2012), one compared prenatal paediatric home visits to usual care (Serwint 1996), and one compared support from a close female confidante to usual care (Winterburn 2003). One two‐arm cluster‐randomised controlled trial compared home‐based counselling visits to usual care (Penfold 2014). There were two, three‐arm randomised controlled trials. One compared telephone peer counselling (low and high frequency) to usual care (Reeder 2014) and the other compared continuous cell phone support to monthly peer support and usual care (Sellen 2013). One four‐arm randomised controlled trial compared the use of cup +/‐ dummy and bottle +/‐ dummy for infants delivered before 34 weeks, and whose mothers wanted to breastfeed (Collins 2004). This study was included because the intervention was part of a package of care and was designed to find out the effect of cups/dummies on breastfeeding. It included education and support for the hospitals and might have had an effect on the mother, but this detail was not specified.

Sample sizes

Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial). Studies had sample sizes ranging from 69 (Hoddinott 2012) to 1948 (Reeder 2014). However, women with multiples were a small subgroup within these studies, and the only data provided that reported on women with twins and higher order births were from two studies, one with 27 women (Paul 2012) and the other with 15 women (Reeder 2014).

Setting

Seven studies were carried out in high‐income countries: Australia (Collins 2004), Scotland (Hoddinott 2012), England (Graffy 2004; Winterburn 2003), and the USA (Paul 2012; Reeder 2014; Serwint 1996). One took place in an upper‐middle income country: Brazil (Junior 2007), and two in low‐income countries: Tanzania (Penfold 2014) and Kenya (Sellen 2013).

Participants

We included studies in the review if they did not exclude twins or multiples. However in some studies this was not explicitly stated in the methods and further information was sought from authors. Some authors (Paul 2012; Reeder 2014) provided this information.

Participant inclusion specified infant criteria in four studies. Collins 2004 included babies born before 34 weeks' gestation whose mothers wanted to breastfeed, Junior 2007 included babies weighing less than 1500g at birth, Graffy 2004 excluded women if the baby was born before 36 weeks' gestation and Paul 2012 specified ‘well’ newborns born after 34 weeks' gestation who were breastfeeding at discharge and their mothers intended to continue after discharge.

Serwint 1996 recruited women in pregnancy who were between eight to 28 weeks' gestation, Graffy 2004 recruited women between 28 to 36 weeks' gestation and Sellen 2013 recruited women between 32 to 36 weeks' gestation.

The other studies stated criteria for the mother at recruitment. Hoddinott 2012 included women who had started breastfeeding and Graffy 2004 included women who were considering breastfeeding and who did not plan to consult a counsellor anyway. Women were defined by sociodemographic criteria in three studies: living in the three most disadvantaged postcode areas and over the age of 16 (Hoddinott 2012), over 18, nulliparous, low income families, who had not yet selected a paediatrician (Serwint 1996), and low‐income urban women (Sellen 2013). Graffy 2004 excluded women if they intended to move away within four months of the birth or if the home was considered unsafe for home visits. Communication criteria were stated in two studies: an ability to communicate in English on the phone (Hoddinott 2012), and being able to speak English (Paul 2012).

Women or their infants were excluded from participating if the mother was under 16 years (Hoddinott 2012), had a medical contraindication (Hoddinott 2012; Junior 2007; Paul 2012), the physical condition of baby prevented breastfeeding (Junior 2007), if the hospital stay was longer than usual, there were any postnatal complications in the mother or newborn, no phone number, living outside the area, or child protection concerns (Paul 2012), and any prenatal drug use, psychiatric illness, or HIV positive status (Serwint 1996).

Three studies included all women and did not specify any exclusion criteria; all women living in the intervention ward (Penfold 2014), all antenatal women (Winterburn 2003), and no exclusion criteria stated (Sellen 2013).

Interventions and comparisons
Timing of intervention

In two studies, the intervention took place in the antenatal period only (Serwint 1996; Winterburn 2003); five included both the antenatal and postnatal periods (Graffy 2004; Junior 2007; Penfold 2014; Reeder 2014; Sellen 2013), and three took place in the postnatal period only (Collins 2004; Hoddinott 2012; Junior 2007).

Where was the intervention carried out

In eight studies, the intervention was offered to the women at home (Graffy 2004, Hoddinott 2012; Paul 2012; Penfold 2014; Reeder 2014; Sellen 2013; Serwint 1996; Winterburn 2003), one study carried out interventions in hospital only (Collins 2004), and one study carried out interventions, both in hospital and the outpatient clinic (Junior 2007).

Method of intervention

Phone support only was provided in two studies; proactive phone contact was compared to reactive contact in one study (Hoddinott 2012) (from a specialised feeding team for all women), and one study compared proactive phone contact (high frequency or low frequency) to usual care (Reeder 2014). Sellen 2013 compared cell phone support, to monthly peer‐led support groups or usual care. Two studies compared a combination of face‐to‐face and phone contact to usual care (Graffy 2004; Junior 2007). Four studies offered face‐to‐face contact only (Paul 2012; Penfold 2014; Serwint 1996; Winterburn 2003). One study provided a combination of education and support to staff as part of a package of care (Collins 2004)

Breastfeeding support: training and experience

Breastfeeding support was provided by healthcare staff in four studies. In one study, support was provided by a feeding team of staff who had breastfeeding induction and a recognised two‐day training course (Hoddinott 2012), in one study, by a nurse who had extra breastfeeding training (Paul 2012), in one study, by a paediatrician with training in breastfeeding techniques and support to encourage breastfeeding (Serwint 1996), and in one study, by a community midwife who had no extra training (Winterburn 2003).

Support was provided by lay personnel in four studies. In one study, volunteers with five days training provided the support (Penfold 2014), in one study, peer supporters had training in counselling which included breastfeeding support (Reeder 2014), in one study, support was provided by National Childbirth Trust volunteer counsellors (women who had breastfed and had training in non‐directive counselling and strengthening mothers' confidence in their own abilities) (Graffy 2004) and Sellen 2013 used trained peer leaders to provide support.

The training of the supporter was not specified in one study (Junior 2007), and in Collins 2004, details of the personnel who provided training to the staff were not given.

Frequency of contact

In three studies, the extra support was provided during one visit (Paul 2012; Serwint 1996; Winterburn 2003), in two studies it was offered as often as needed (Graffy 2004; Hoddinott 2012), and in one study, it was ongoing while the infant was in hospital (Collins 2004). Sellen 2013 provided cell phone support on a continuous basis, while the comparison support group was held monthly. One study did not specify the frequency of contact; it was delivered as often as the researcher was available while the infant was in hospital, then monthly after discharge (Junior 2007). Two studies had a prescribed regimen of visits: three visits in pregnancy and two in the early postnatal period with extra visits for small babies (Penfold 2014), four visits (two in pregnancy and two up to two weeks postnatal) compared to calls (four extra up to four months) (Reeder 2014).

Outcomes

Although in all studies multiple pregnancies or births (women or their infants) were eligible for inclusion, no outcome data were reported separately for multiples in the published reports. Email enquiries elicited data for multiples from Paul 2012 (see Appendix 2) and Reeder 2014 (see Appendix 3). These authors provided data on initiation of breastfeeding, survival data on duration of any breastfeeding, and duration of exclusive breastfeeding. Paul 2012 also reported infant morbidity and measures of maternal satisfaction for mothers of multiples. However, the outcomes for infants from the same pregnancy were not reported separately, therefore the data could not be reported in the review. If the studies had reported data for multiples individually, correction would need to be applied for correlation between babies with the same mother. The degree of correlation would be likely to vary depending on the outcome, so intracluster correlation coefficients would need to be established.

In most studies, outcomes were reported for all women (including mothers of multiples but not for these women or infants separately). Seven studies collected data about exclusive breastfeeding. The timing of these data varied: at discharge to home (Collins 2004), at three days (Penfold 2014), at six weeks (Graffy 2004), at six to eight weeks (Hoddinott 2012), at discharge to home, then monthly until six months (Junior 2007), at one, three, and six months (Reeder 2014) and at three months of age (Sellen 2013).

Six studies collected data about any breastfeeding: at discharge to home, three and six months (Collins 2004), at six weeks and four months (Graffy 2004), at six to eight weeks (Hoddinott 2012), at discharge to home, then monthly until six months (Junior 2007), at two weeks, two months and six months (Paul 2012), and at one, three, and six months (Reeder 2014).

Two studies reported ‘breastfeeding’ rates, but did not specify whether this was any or exclusive; Serwint 1996 reported rates at 30 and 60 days, while Winterburn 2003 reported initiation at birth, and duration at 10 days, one month, six weeks, three months and six months.

The definition of exclusive breastfeeding was given in six studies: no other types of milk or solids, except vitamins and minerals (Collins 2004), no other liquids of solid foods (Graffy 2004), no other liquids except medicines in past 24 hours (Hoddinott 2012), only mother’s milk (Junior 2007), only breast milk (Penfold 2014), and non‐exclusive breastfeeding derived by date of introduction of formula (Reeder 2014). In four studies the definition of exclusive breastfeeding was not specified (Paul 2012; Sellen 2013; Serwint 1996; Winterburn 2003).

The method of breastfeeding was specified in one study: direct at breast or other feeding device (Collins 2004), but not in any other study (Graffy 2004; Hoddinott 2012; Junior 2007; Paul 2012; Penfold 2014; Reeder 2014; Sellen 2013; Serwint 1996; Winterburn 2003).

Excluded studies

See Characteristics of excluded studies.

Four studies (eight reports) were excluded (Bonuck 2005; Robling 2012; Simmer 2015; Tomlinson 2014). Two studies (six reports) were excluded because women with multiples were excluded from the analysis (Bonuck 2005; Tomlinson 2014). One study (one report) was excluded because the intervention did not include breastfeeding education or support (Robling 2012). One study (Simmer 2015) included insufficient information in the paper about the element of education and support for mothers. As it was potentially eligible, the authors were contacted and data were provided for twins, but no further information was supplied about the intervention and it was still not clear if the intervention included education or support, so it was subsequently excluded.

Risk of bias in included studies

See Figure 2 and Figure 3.


Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.


Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

We considered that only four of the studies used methods that were at low risk of bias to generate the random sequence and conceal allocation to the experimental groups (Collins 2004; Graffy 2004; Hoddinott 2012; Reeder 2014). Three studies used adequate methods for random sequence generation, but their methods for allocation concealment were not clear (Paul 2012; Penfold 2014; Serwint 1996). In two studies, with respect to sequence generation and allocation concealment, these domains were either not described or were unclear (Sellen 2013; Winterburn 2003). One study was at high risk of bias for both domains (Junior 2007).

Blinding

All included studies were at high risk of bias for blinding of participants or staff. In all studies, both women and staff were aware of group allocation and were therefore potentially subject to performance bias (Collins 2004; Graffy 2004; Hoddinott 2012; Junior 2007; Paul 2012; Penfold 2014; Reeder 2014; Sellen 2013; Serwint 1996; Winterburn 2003). With this kind of intervention, it is very difficult for women or staff to be blind to group allocation. Three studies were judged to be at unclear risk of detection bias (Graffy 2004; Hoddinott 2012; Paul 2012). In these studies, investigators made an attempt to blind outcome assessors, however, because women knew their group allocation, and all data were self‐reported, the group allocation could have been revealed during data collection. All the other studies were judged to be at high risk of detection bias because the blinding of outcome assessors was not described (Collins 2004; Junior 2007; Penfold 2014; Reeder 2014; Sellen 2013; Serwint 1996; Winterburn 2003).

Incomplete outcome data

In this review, we considered even low levels of attrition as potentially problematic in terms of risk of bias because sample loss may be related to the true outcome. All studies were assessed at high or unclear risk of attrition bias. Four studies were assessed at high risk of attrition bias: one because there was high loss to follow up and imbalance between arms of the study (Hoddinott 2012), and three because of high loss to follow up (Junior 2007; Sellen 2013; Serwint 1996). The others were at unclear risk of attrition bias: two because of incomplete reporting (Penfold 2014; Winterburn 2003) and four because although there was low attrition, there was no information on loss of twins and any missing data could relate to the true outcome (Collins 2004; Graffy 2004; Paul 2012; Reeder 2014).

Selective reporting

Paul 2012 was assessed at low risk of reporting bias. In all other studies, the protocol was not available or there was insufficient information provided to be able to assess risk of selective reporting (Collins 2004; Graffy 2004; Hoddinott 2012; Junior 2007; Penfold 2014; Reeder 2014; Sellen 2013; Serwint 1996; Winterburn 2003).

Other potential sources of bias

All studies raised concerns about other potential sources of bias. Two were assessed at high risk of bias: Collins 2004 because of baseline imbalance between the groups and high noncompliance with the intervention, and Penfold 2014 because leakage from the intervention to control areas was possible and there was lack of clarity about whether adjustment was made for clusters. All other studies were judged at unclear risk of other sources of bias. Baseline differences were noted between groups in two studies (Graffy 2004; Hoddinott 2012), in one study, the intervention was not delivered to all participants in the intervention group (Reeder 2014), and in one study, the study group differed significantly from the background population (Winterburn 2003). Sellen 2013 was assessed from a series of abstracts, with no full report of the study available.

None of the studies included in this review looked specifically at women with multiples, but instead considered breastfeeding education and support for all women, whether they had one or more babies. Randomisation was not stratified by singleton/multiple birth, and small numbers of women with multiples were recruited. This may result in chance baseline imbalance between the randomised groups. However, as baseline characteristics were not reported separately for multiples, it is not possible to gauge whether the groups were comparable. Sample size power calculations were based on all women, so all the studies were underpowered to show differences in the subgroup of women with multiples.

Where additional data on multiples were provided by trialists (Paul 2012; Reeder 2014), the data were not presented separately for each individual baby. To interpret breastfeeding outcomes, this introduces an assumption that individual multiples were fed in the same manner. This may not be the case, for example, if one baby was admitted to NICU or had difficulty feeding. Paul 2012 reported infant morbidity, however this was presented for only one baby out of each set of multiples. This may have inflated the number of adverse events and introduces a high risk of bias. Where data were given for just one baby of the multiples, we need to know if it was decided beforehand which baby would contribute data (e.g. the first born), or if any adverse event was reported for whichever baby it happened to.

Effects of interventions

The following is a narrative description of the data on the effects of interventions for women with multiples in Paul 2012 and Reeder 2014. Data tables are presented in Appendix 2 and Appendix 3. The methodological and reporting limitations of these studies prevented us from analysing the data in RevMan (RevMan 2014).

Home nurse visits versus usual care

Primary outcomes

One study (Paul 2012) randomised 576 mothers, including 15 women with multiples. Data were not reported separately for mothers of multiples in the paper but were obtained from the authors. A single response from each mother was used to assess outcomes in all babies.

All women included in the study had initiated breastfeeding and intended to breastfeed post discharge (seven out of seven women in the home nurse visit group, eight out of eight women in the routine care group). The duration of breastfeeding was reported using survival data, so stopping any breastfeeding before four to six weeks postpartum was not explicitly reported, however it appears that two out of six women in the home nurse visit group and one out of seven women in the usual care group stopped any breastfeeding before four weeks. Likewise, stopping exclusive breastfeeding before four to six weeks postpartum was not explicitly reported, however it appears that five out of five women in the home nurse visit group and five out of seven women in the usual care group stopped exclusive breastfeeding before four weeks. Similarly, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, however it appears that five out of six women in the home nurse visit group and four out of six women in the usual care group stopped exclusive breastfeeding before six months, and all women in the home nurse visit group and six out of seven women in the usual care group stopped exclusive breastfeeding before six months.

Women in the home nurse group breastfed their babies for an average duration of 67.00 days (standard deviation (SD) 62.00, n = 6), compared with 132.86 days (SD 79.57, n = 7) in the usual care group. The duration of exclusive breastfeeding was 7.58 days (SD 8.32, n = 6) compared with 33.14 days (SD 66.51, n = 7) in the control group. However, the small number of women and wide variation in duration means that these data are very unreliable.

Initiation of breast milk expression, stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported.

Secondary outcomes

The study authors provided data from multiples for infant morbidity (jaundice, infant feeding difficulty, weight loss, dehydration, illness not related to jaundice/feeding, ER visit, and hospitalisation) at two weeks after discharge, and two months after discharge, and measures ofmaternal satisfaction (amount of information on feeding your baby, clarity of information on feeding your baby, amount of help with feeding your baby, and total satisfaction with care), assessed in hospital, two weeks after discharge, and two months after discharge. These data are presented in Appendix 2.

Other secondary outcomes were not reported for women with multiples.

Telephone peer counselling (low and high frequency) versus usual care

Primary outcomes

One study (Reeder 2014) randomised 1948 mothers, including 27 women with a multiples, to three study arms: low frequency telephone contact (two prenatal and two early postpartum calls from a peer counsellor, eight women), high frequency telephone contact (two prenatal and up to six postpartum calls from a peer counsellor, nine women), or usual care (10 women). High and low frequency support were reported together in the main publication, as there was no difference in the number of contacts women received in these groups. Data were not reported separately for multiples in the paper but were obtained from the authors. A single response from each mother was used to assess outcomes in all babies.

The number of women who initiated breastfeeding was 16 out of 17 in the telephone contact groups, and nine out of 10 in the usual care group. The duration of breastfeeding was reported using survival data, so stopping any breastfeeding before four to six weeks postpartum was not explicitly reported, however, it appears that four out of 13 women in the telephone support group and six out of nine women in the usual care group stopped any breastfeeding before four weeks. Likewise, stopping exclusive breastfeeding before four to six weeks postpartum was not explicitly reported, however, it appears that 12 out of 16 women in the telephone support group and six out of six women in the usual care group stopped exclusive breastfeeding before four weeks. Similarly, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, however, it appears that 11 out of 13 women in the telephone support group and eight out of nine women in the usual care group stopped exclusive breastfeeding before six months, and 14 out of 16 women in the telephone support group and six out of six women in the usual care group stopped exclusive breastfeeding before six months.

Initiation of breast milk expression, stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported.

Secondary outcomes

None of the secondary outcomes were reported for women with a multiples.

Discussion

Summary of main results

We identified 10 studies of education and support for breastfeeding that included multiples. All the studies were interventions aimed at all women (or babies), and were studies which did not exclude multiple births. Therefore, none of the forms of breastfeeding education or support included specific advice or expertise relating to the challenges of breastfeeding multiples. Numbers of infants from multiple pregnancies were small and none of the studies were powered to answer questions about multiples. Out of the 10 included studies (a total of 5787 women, including 512 women interviewed as part of a cluster randomised trial), only two studies gathered data for multiples separately and were able to provide us with the data (Paul 2012; Reeder 2014, a total of 42 women with multiples). Due to the scarcity of evidence and the format in which data were reported, we were unable to present any analyses in this review, and we were unable to GRADE the evidence.

The two trials with data for women with multiple births compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). The number of women who initiated breastfeeding was reported (all 15 women in one study, 25 out of 27 women in one study). Stopping any breastfeeding before four to six weeks postpartum, stopping exclusive breastfeeding before four to six weeks postpartum, stopping any breastfeeding before six months postpartum and stopping exclusive breastfeeding before six months postpartum were not explicitly reported, and there were insufficient data to draw any meaningful conclusions from survival data.

Stopping breast milk expression before four to six weeks postpartum, and stopping breast milk expression before six months postpartum were not reported. Measures of maternal satisfaction were reported in one study of 15 women, but there were insufficient data to draw any conclusions; no other secondary outcomes were reported for women with a multiple pregnancy in either study. No adverse events were reported.

Overall completeness and applicability of evidence

In no study did the training of breastfeeding supporters explicitly detail training specific to breastfeeding multiples. None of the studies were designed to offer tailored support or education about breastfeeding for women who had given birth to more than one infant. We were unable to answer questions about the effectiveness of education and support for breastfeeding multiples from different care providers and the training of care providers, nor of the timing, intensity or form of support, as none of the studies examined these issues. We identified two ongoing studies (Brizot 2009; Yang 2016) which appeared to offer interventions specifically designed for twins, but results were not available.

The interventions in the studies that we identified may not be applicable or appropriate for women with multiples. Support and education for women with a singleton may not be relevant to address the particular challenges of breastfeeding more than one infant. Support provided in a single visit or only in the antenatal period may not meet the needs of women breastfeeding more than one infant. Women who have delivered more than one baby may spend more time in hospital or the babies may be premature; interventions provided only at home may not be appropriate. The particular challenges of prematurity and breastfeeding more than one infant were not addressed.

There are other factors related to breastfeeding multiples which were not included in this review, and where evidence is lacking. Evidence is needed about positioning for the babies or the mother while breastfeeding more than one infant at the same time, particularly when the infants are premature or when the mother has undergone operative delivery. Questions about simultaneous or separate feeding remain. For feeding premature multiples (as for premature singleton infants), there is uncertainty about methods of breast milk expression, the use of donor breast milk, the use of supplementary milks or fortifiers and the best way to transition to direct feeding at the breast once the infants are ready. Our review found that evidence is lacking about the optimum timing, frequency, method or person to provide support and education to mothers to promote and encourage breastfeeding of multiples.

Many studies of breastfeeding support or education specifically exclude women or infants who have experienced complications. Women expecting multiple births are more likely to experience complicated births, such as caesarean section, and their infants are more likely to be delivered early or be admitted to special care. These women and infants would therefore be more likely to be excluded from studies of predominantly normal or healthy dyads, and the effectiveness of interventions to address their particular needs not assessed.

The 10 studies were heterogeneous in terms of the setting of the studies, the method of delivery of the intervention, the location of the intervention, the frequency of the intervention, the timing of the intervention, the training of the person or people delivering the intervention, the timing of the data collection, and the definitions used for breastfeeding. These differences limit conclusions that can be drawn about what works for breastfeeding support of multiples. Differences in cultural attitudes to infant feeding and background levels of breastfeeding initiation can have a strong influence on outcomes.

Quality of the evidence

The overall quality of the evidence was mixed, and the risk of bias was mostly high or unclear. In some studies we were unable to judge risk of bias because of a lack of information, for example, when only abstracts were available. Blinding of participants and assessors in this kind of intervention is difficult and response bias is likely. Due to the scarcity of evidence and the format in which data were reported, a narrative description of the data is presented, no analyses are presented in this review, and we were unable to GRADE the evidence.

None of the studies included in this review looked specifically at women with multiples, but instead considered breastfeeding education and support for all women, whether they had one or more babies. Randomisation was not stratified by singleton/multiples, and small numbers of women with multiples were recruited. This may result in chance baseline imbalance between the randomised groups. However, as baseline characteristics were not reported separately for multiples, it is not possible to gauge whether the groups were comparable. Sample size power calculations were based on all women, so the studies are underpowered to show differences in the subgroup of women with multiples.

Potential biases in the review process

Two authors independently assessed eligibility for inclusion, carried out data extraction and assessed risk of bias. Disagreements were resolved by discussion, and by involving a third assessor. The lack of available information in many studies meant the risk of bias was unclear. Our reliance on authors to send unpublished data on multiples may have been open to bias, as authors might be more likely to respond when interventions had shown a positive effect.

Agreements and disagreements with other studies or reviews

A systematic review of feeding twins, triplets and higher order multiples was carried out by Denton 2011 to inform a booklet of information and advice for parents (Multiple Births Foundation 2011). The authors found good quality evidence of breastfeeding rates in multiples. However, most of the evidence for specific practices was of low quality, from small descriptive studies and case reports. Guidance for parents was therefore based on a summary of the options available and recommended good practice points, where available. This review informed the development of our protocol.

Related Cochrane reviews have examined education and support interventions to promote breastfeeding in singletons, and findings suggest that education and support interventions by professionals and lay supporters or peers may increase the initiation of breastfeeding and increase the duration of exclusive or any breastfeeding (Balogun 2016; McFadden 2017). The current review needs to be interpreted in the light of these findings, whilst recognising that women with multiple pregnancies may face additional challenges to initiate and sustain breastfeeding.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.