https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61693-6.pdf

What works? Interventions for maternal and child undernutrition and survival.

The widening array of recognized enteric pathogens and the increasing demand for cost-containment sharpen the need for careful clinical and public health guidelines based on the best evidence currently available. Adequate fluid and electrolyte replacement and maintenance are key to managing diarrheal illnesses. Thorough clinical and epidemiological evaluation must define the severity and type of illness (e.g., febrile, hemorrhagic, nosocomial, persistent, or inflammatory), exposures (e.g., travel, ingestion of raw or undercooked meat, seafood, or milk products, contacts who are ill, day care or institutional exposure, recent antibiotic use), and whether the patient is immunocompromised, in order to direct the performance of selective diagnostic cultures, toxin testing, parasite studies, and the administration of antimicrobial therapy (the latter as for traveler's diarrhea, shigellosis, and possibly Campylobacter jejuni enteritis). Increasing numbers of isolates resistant to antimicrobial agents and the risk of worsened illness (such as hemolytic uremic syndrome with Shiga toxin-producing Escherichia coli O157:H7) further complicate antimicrobial and antimotility drug use. Thus, prevention by avoidance of undercooked meat or seafood, avoidance of unpasteurized milk or soft cheese, and selected use of available typhoid vaccines for travelers to areas where typhoid is endemic are key to the control of infectious diarrhea.

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Practice Guidelines for the Management of Infectious Diarrhea

Background
Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.

Objectives
To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.

Search methods
For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.

Selection criteria
Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.

Data collection and analysis
Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.

Main results
Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.

Authors' conclusions
LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

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Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.

Background. Infant and under-5 childhood mortality rates in developing countries have declined significantly in the past 2 to 3 decades. However, 2 critical indicators, maternal and newborn mortality, have hardly changed. World leaders at the United Nations Millennium Summit in September 2000 agreed on a critical goal to reduce deaths of children Objective. This review of community-based antenatal, intrapartum, and postnatal intervention trials in developing countries aimed to identify (1) key behaviors and interventions for which the weight of evidence is sufficient to recommend their inclusion in community-based neonatal care programs and (2) key gaps in knowledge and priority areas for future research and program learning. Methods. Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed. Evidence was summarized systematically and categorized into 4 levels of evidence based on study size, location, design, and reported impact, particularly on perinatal or neonatal mortality. The evidence was placed in the context of biological plausibility of the intervention; evidence from relevant developed-country studies; health care program experience in implementation; and recommendations from the World Health Organization and other leading agencies. Results. A paucity of community-based data was found from developing-country studies on health status impact for many interventions currently being considered for inclusion in neonatal health programs. However, review of the evidence and consideration of the broader context of knowledge, experience, and recommendations regarding these interventions enabled us to categorize them according to the strength of the evidence base and confidence regarding their inclusion now in programs. This article identifies a package of priority interventions to include in programs and formulates research priorities for advancing the state of the art in neonatal health care. Conclusions. This review emphasizes some new findings while recommending an integrated approach to safe motherhood and newborn health. The results of this study provide a foundation for policies and programs related to maternal and newborn health and emphasizes the importance of health systems research and evaluation of interventions. The review offers compelling support for using research to identify the most effective measures to save newborn lives. It also may facilitate dialogue with policy makers about the importance of investing in neonatal health.

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Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence

Objective To review the literature on breastfeeding initiation and duration and to delineate effective strategies for promoting positive breastfeeding behaviors. Data Sources Computerized searches on MEDLINE, CINAHL, and the Cochrane Library. Study Selection Articles from indexed journals relevant to the objective and published after 1990 (except for classic findings) were reviewed. Although a myriad of pertinent articles was located, referenced citations were limited to three per point. When article selection was required for a specific point, preferences were given to (a) randomized controlled trials; (b) meta-analyses; (c) studies with the largest, most representative samples; and (d) investigations conducted in North America. Data Extraction Data were extracted and organized under the following headings: benefits of breastfeeding, breastfeeding initiation and duration, personal characteristics, attitudinal and intrapersonal characteristics, hospital policies and intrapartum experience, sources of support, breastfeeding interventions, and review implications. Data Synthesis Although the health benefits of breastfeeding are well documented and initiation rates have increased over the past 20 years, most mothers wean before the recommended 6-months postpartum because of perceived difficulties with breastfeeding rather than due to maternal choice. Women least likely to breastfeed are those who are young, have a low income, belong to an ethnic minority, are unsupported, are employed full-time, decided to breastfeed during or late in pregnancy, have negative attitudes toward breastfeeding, and have low confidence in their ability to breastfeed. Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors. Health care professionals can be a negative source of support if their lack of knowledge results in inaccurate or inconsistent advice. Furthermore, a number of hospital routines are potentially detrimental to breastfeeding. Although professional interventions that enhance the usual care mothers receive increase breastfeeding duration to 2 months, these supportive strategies have limited long-term effects. Peer support interventions also promote positive breastfeeding behaviors and should be considered. Conclusions A promising intervention is the complementation of professional services with peer support from a mother experienced in breastfeeding. This lay support appears to be an effective intervention with socially disadvantaged women.

Breastfeeding Initiation and Duration: A 1990-2000 Literature Review

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)03159-7.pdf

Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial

Ciprofloxacin, 500 mg every 12 h, was compared with ampicillin, 500 mg every 6 h, both given for 5 days, in the treatment of 121 adult males hospitalized with severe shigellosis. Treatment was randomized and double-blinded. At the completion of treatment, there was resolution or marked improvement in symptoms in 57 (95%) of 60 ciprofloxacin-treated patients, 23 (88%) of 26 ampicillin-treated patients infected with an ampicillin-susceptible strain of Shigella, and 15 (43%) of 35 ampicillin-treated patients infected with an ampicillin-resistant strain of Shigella (ampicillin-R group) (P less than .01, ciprofloxacin or ampicillin groups vs. ampicillin-R group). Bacteriologic failure was less common (P less than .025) in the ciprofloxacin group (0/60) than in the ampicillin (3/26, 12%) or ampicillin-R groups (5/35, 14%). Ciprofloxacin-treated patients had a mean of 29 stools during the study, compared with 46 for ampicillin-treated patients (P = .004). Thus ciprofloxacin seems to be an effective, and perhaps superior, alternative to ampicillin in treating patients with shigellosis.

Therapy for Shigellosis. II. Randomized, Double-Blind Comparison of Ciprofloxacin and Ampicillin

When infants afflicted with diarrhea were brought to the Hospital of the International Centre for Diarrhoeal Disease Research Bangladesh (ICDDRB) in Dhaka Bangladesh 125 mother-infant pairs received at least three lactation counseling sessions on the benefits of exclusive breast feeding. Researchers compared data on these 125 pairs with data on 125 other mother-infant pairs who were also at ICDDRB due to diarrhea but did not receive any counseling. Infants in the intervention group had a shorter hospital stay than those in the control group (4.3 vs. 3 days; p < .001). The controls left before diarrhea ended while cases were discharged after diarrhea ended. At discharge mothers in the intervention group were more likely than controls to be predominantly breast feeding (breast milk plus oral rehydration solution [ORS]) (30% vs. 19%) as well as exclusively breast feeding (60% vs. 6%) (p < .001). Two weeks after discharge when ORS was stopped mothers in the intervention group were more likely to be exclusively breast feeding than those in the control group (75% vs. 8%) while those in the control group were more likely to bottle feed than cases (49% vs. 12%) (p < .001). Infants in the control group were more likely to have another episode of diarrhea within 2 weeks than those in the intervention group (15 vs. 4; p = .05; odds ratio = 2.92). These findings indicate that individual lactation counseling had a strong influence on mothers to begin exclusive breast feeding during hospitalization and to continue to do so at home. Thus staff at maternal and child health facilities should integrate lactation counseling into their program to improve infant feeding practices.

Breast-feeding counselling in a diarrhoeal disease hospital.

Despite the launching of a national breastfeeding promotion campaign in Bangladesh in 1989, exclusive breastfeeding rates remain low. To understand mothers' perceptions of the campaign messages and the reasons for current practices, a random sample of 1100 lower middle class mothers in Dhaka, with infants aged 0-6 months, were interviewed in 1995. Although 99 per cent of mothers fed colostrum within 3 days of delivery, 92 per cent also gave one or more traditional prelacteals, and 68 per cent gave postlacteals. This could be due to ambiguity of the message, which simply advocated giving colostrum without indicating its exclusive use, thereby appearing compatible with traditional perceptions that colostrum alone is insufficient. Ninety-nine per cent of mothers reported hearing the breastfeeding messages or receiving advice, and 97 per cent stated that they understood the meaning of exclusive breastfeeding. But this concept was not correctly understood, as many thought it meant feeding breastmilk and water. The prevalence of exclusive breastfeeding was 15 per cent, and complementary foods were introduced early (median 30 days). Many mothers doubted the message that breastmilk alone is sufficient for 5 months. Messages to promote improved breastfeeding practices in Bangladesh need to be revised to clear misconceptions.

Are breastfeeding promotion messages influencing mothers in Bangladesh? Results from an urban survey in Dhaka, Bangladesh.

During the hospitalization in the Dhaka hospital of the international Centre for Diarrhoeal Disease Research, Bangladesh, of a group of partially breast-fed infants aged 1-12 weeks who had been admitted with acute diarrhoea, their mothers were individually counselled by breast-feeding counsellors to start exclusive breast-feeding. The counselling was repeated 1 week later at home, and the women's infant-feeding practices were evaluated 2 weeks after their infants had been discharged from hospital. A total of 25% of the mothers failed to breast-feed exclusively despite having been counselled. The case studies of these mothers illustrate that although they generally complained about having "insufficient breast milk" various factors such as domineering grandmothers, lack of financial support by their husbands, too much housework, or disinterest contributed to their failure to breast-feed exclusively. While family support is essential for all lactating mothers, women with familial or financial problems require special attention and extra counselling sessions so that they can be helped to identify how to achieve and sustain exclusive breast-feeding.

Rukhsana Haider

Papers

Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial

Therapy for Shigellosis. II. Randomized, Double-Blind Comparison of Ciprofloxacin and Ampicillin

Breast-feeding counselling in a diarrhoeal disease hospital.

Are breastfeeding promotion messages influencing mothers in Bangladesh? Results from an urban survey in Dhaka, Bangladesh.

Reasons for Failure of Breast-Feeding Counselling: Mothers' Perspectives in Bangladesh