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  • br In the cluster randomised controlled trial by

    2019-06-14


    In the cluster randomised controlled trial by Marcel Yotebieng and colleagues (August, 2015) the addition of Step 10 of the UNICEF Baby Friendly Hospital Initiative (BFHI)—that is, the provision of additional support for breastfeeding—did not enhance the effects of steps 1–9, and may even have lessened them. Consistent findings were reported for a trial of Step 10 in Scotland between 2005 and 2007. In this SAR 405 large cluster-randomised trial, the BIG (Breastfeeding in Groups) trial, 14 primary care organisations were asked either to set up new breastfeeding support groups to cover their geographical area, or to leave their existing group provision for pregnant and postnatal women unchanged. More than 18 000 babies were followed up and there was no significant difference between the two groups in change from baseline in rates of exclusive, or any, breastfeeding 8 weeks after birth. In December, 2012, new standards for BFHI accreditation were introduced and the UNICEF UK 10 steps were updated. Before the BIG trial, Step 10 read “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic”. In the new standards this now reads: ”Identify sources of national and local support for breastfeeding and ensure that mothers know how to access these prior to discharge from hospital”. This change removes the expectation that hospitals and primary care organisations should routinely establish breastfeeding support groups, with consequent cost savings to national health services. Findings from Yotebieng and colleagues\' trial and the BIG trial are not consistent with Cochrane systematic review evidence that professional or lay support increases the duration of exclusive breastfeeding at 4–6 weeks (RR 0·74, 95%CI 0·61–0·89). Since 2000, no UK-based large-scale trials of additional support have reported a significant effect on breastfeeding outcomes. However, a pilot trial of intensive, proactive telephone-based care from a feeding team shows promise. This person-centred intervention is consistent with new UNICEF-UK standards that aim to avoid making women feel pressured to breastfeed, or judged to have failed as mothers if Rolling circle do not breastfeed.
    We welcome the Article by Gretchen Stevens and colleagues (September, 2015), although wish to correct a, no doubt, inadvertent misrepresentation of our views. Stevens and colleagues cite our paper in support of their statement that “large scale or targeted supplementation or fortification strategies will probably have some beneficial effect on mortality in these regions [south Asia and sub-Saharan Africa]”. We advocated a prudent phase-over away from vitamin A capsules to more physiological and locally appropriate methods. We did not advocate “large-scale or targeted supplementation”. In our paper, we suggested that no more than 2–3% of deaths in children younger than 5 years might be prevented by intermittent high-dose vitamin A. This is very similar to the estimate of 1·7% in the Article by Stevens and colleagues. There must be higher priorities than distributing enormous numbers of high-dose vitamin A capsules every 6 months (we estimate 8 billion to date!), which even if effective would have only a small effect on mortality in children younger than 5 years.
    Our reference to the work of Mason and colleagues was in a sentence that stated that “until this [an improvement in the overall nutrition of the population, including through dietary diversification and improved access to vitamin-rich foods, and improved access to treatment for infectious diseases] happens, large scale or targeted supplementation or fortification strategies will probably have some beneficial effect on mortality in these [south Asia and sub-Saharan Africa] regions”. This approach, whose ultimate aim is regular intake, largely through diet, is not inconsistent with the prudent phase-over approach outlined by Mason and colleagues.