Whitford Heather M, Wallis Selina K, Dowswell Therese, West Helen M, Renfrew Mary J
Mother and Infant Research Unit, School of Nursing and Health Sciences, Dundee Centre for Health and Related Research, University of Dundee, 11 Airlie Place, Dundee, Scotland, UK, DD1 4HJ.
Capacity Research Unit, Liverpool School of Tropical Medicine, Liverpool, UK.
Cochrane Database Syst Rev. 2017 Feb 28;2(2):CD012003. doi: 10.1002/14651858.CD012003.pub2.
There are rising rates of multiple births worldwide with associated higher rates of complications and more hospital care, often due to prematurity. While there is strong evidence about the risks of not breastfeeding, rates of breastfeeding in women who have given birth to more than one infant are lower than with singleton births. Breastfeeding more than one infant can be more challenging because of difficulties associated with the birth or prematurity. The extra demands on the mother of frequent suckling, coordinating the needs of more than one infant or admission to the neonatal intensive care unit can lead to delayed initiation or early cessation. Additional options such as breast milk expression, the use of donor milk or different methods of supplementary feeding may be considered. Support and education about breastfeeding has been found to improve the duration of any breastfeeding for healthy term infants and their mothers, however evidence is lacking about interventions that are effective to support women with twins or higher order multiples.
To assess effectiveness of breastfeeding education and support for women with twins or higher order multiples.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), ClinicalTrials.gov (30 June 2016), the WHO International Clinical Trials Registry Platform (ICTRP) (1 July 2016), the excluded studies list from the equivalent Cochrane review of singletons, and reference lists of retrieved studies.
Randomised or quasi-randomised trials comparing extra education or support for women with twins or higher order multiples were included.
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We planned to assess the quality of evidence using the GRADE approach, but were unable to analyse any data.
We found 10 trials (23 reports) of education and support for breastfeeding that included women with twins or higher order multiples. The quality of evidence was mixed, and the risk of bias was mostly high or unclear. It is difficult to blind women or staff to group allocation for this intervention, so in all studies there was high risk of performance and high or unclear risk of detection bias. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial); of these, data were available from two studies for 42 women with twins or higher order multiples. None of the interventions were specifically designed for women with more than one infant, and the outcomes for multiples were not reported separately for each infant. 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.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 andstopping 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, andstopping breast milk expression before six months postpartum were not reported. Measures ofmaternal 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 multiple births in either study. No adverse events were reported.
AUTHORS' CONCLUSIONS: We found no evidence from randomised controlled trials about the effectiveness of breastfeeding education and support for women with twins or higher order multiples, or the most effective way to provide education and support . There was no evidence about the best way to deliver the intervention, the timing of care, or the best person to deliver the care. There is a need for well-designed, adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.
全球多胞胎出生率不断上升，早产导致并发症发生率更高，住院护理需求更多。虽然有充分证据表明不进行母乳喂养存在风险，但生育多胞胎的女性母乳喂养率低于单胞胎生育的女性。由于分娩或早产相关的困难，母乳喂养多个婴儿可能更具挑战性。频繁哺乳对母亲的额外需求、协调多个婴儿的需求或入住新生儿重症监护病房可能导致开始母乳喂养延迟或过早停止。可以考虑其他选择，如挤奶、使用捐赠母乳或不同的补充喂养方法。已发现关于母乳喂养的支持和教育可改善健康足月儿及其母亲的任何母乳喂养持续时间，然而，缺乏关于有效支持双胞胎或更高阶多胞胎女性的干预措施的证据。
评估母乳喂养教育和支持对双胞胎或更高阶多胞胎女性的有效性。
我们检索了Cochrane妊娠与分娩组试验注册库（2016年6月30日）、ClinicalTrials.gov（2016年6月30日）、世界卫生组织国际临床试验注册平台（ICTRP）（2016年7月1日）、单胞胎等效Cochrane综述的排除研究列表以及检索到的研究的参考文献列表。
纳入比较对双胞胎或更高阶多胞胎女性进行额外教育或支持的随机或半随机试验。
两位综述作者独立评估试验是否纳入及偏倚风险，提取数据并检查其准确性。我们计划使用GRADE方法评估证据质量，但无法分析任何数据。
我们发现了10项关于母乳喂养教育和支持的试验（23份报告），其中包括双胞胎或更高阶多胞胎女性。证据质量参差不齐，偏倚风险大多较高或不明确。对于此干预措施，很难使女性或工作人员对分组分配不知情，因此在所有研究中，实施偏倚风险高，检测偏倚风险高或不明确。试验招募了5787名女性（这包括作为整群随机试验一部分接受访谈的512名女性）；其中，两项研究提供了42名双胞胎或更高阶多胞胎女性的数据。没有一项干预措施是专门为生育多个婴儿的女性设计的，并且没有针对每个婴儿分别报告多胞胎的结果。由于证据稀缺且数据报告格式问题，本文对数据进行叙述性描述，未进行分析，我们也无法对证据进行GRADE分级。两项有双胞胎或多胞胎女性数据的试验比较了家庭访视护士与常规护理（15名女性），以及电话同伴咨询与常规护理（27名女性）。报告了开始母乳喂养的女性人数（一项研究中的所有15名女性，另一项研究中27名女性中的25名）。未明确报告产后四至六周前停止任何母乳喂养、产后四至六周前停止纯母乳喂养、产后六个月前停止任何母乳喂养以及产后六个月前停止纯母乳喂养的情况，且生存数据中没有足够的数据得出任何有意义的结论。未报告产后四至六周前停止挤奶以及产后六个月前停止挤奶的情况。一项针对15名女性的研究报告了产妇满意度的测量结果，但数据不足以得出任何结论；两项研究均未报告双胞胎或多胞胎女性的其他次要结局。未报告不良事件。
我们未从随机对照试验中找到关于母乳喂养教育和支持对双胞胎或更高阶多胞胎女性有效性的证据，也未找到提供教育和支持的最有效方式的证据。没有证据表明实施干预的最佳方式、护理时机或提供护理的最佳人员。需要针对双胞胎或更高阶多胞胎女性设计的干预措施进行精心设计、有足够样本量的研究，以找出哪些类型的教育和支持能有效帮助这些母亲母乳喂养她们的婴儿。
