Improved Breastfeeding Support to Treat Acute Malnutrition amongst Infants under 6 months (IBAMI)

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For the first time, in 2013, the WHO guidelines for treating children with Severe Acute Malnutrition (SAM) included guidance on how to diagnose and treat SAM in infants aged below 6 months. The treatment guidelines for infants under 6 months focused on inpatient treatment and recommended that admitted infants with SAM be supported to re-establish exclusive breastfeeding before they can be discharged. The recommendation was based mainly on programmatic reports and a few studies that had shown that lactation failure is common among infants with SAM, and that re-establishing breastfeeding among infants being treated for SAM is possible using re-lactation techniques such as supplementary suckling. However, since none of the studies followed infants up after discharge, we still do not know i) if exclusive breastfeeding was retained after discharge; ii) if retaining exclusive breastfeeding after discharge is sufficient for nutritional recovery and iii) if additional breastfeeding support offered to mothers of discharged infants would be beneficial. The proposed study is aimed at generating important information to develop a trial to establish the effectiveness of home-based breastfeeding support to mothers of infants discharged from SAM treatment on survival and growth. The main aim of the proposed study is to i) establish the breastfeeding retention rate among infants under 6 months discharged from SAM treatment within the current strategies that are without a specific post discharge breastfeeding support; and ii) establish whether among infants retaining exclusive breastfeeding, breastmilk alone is sufficient for nutritional recovery. This information will form the baseline data from where any success of any applied intervention will be measured. Hence the findings from this study will strengthen the calculations of the sample size required to show an improvement in the outcomes due to an intervention.In addition, the study will provide insight on the acceptability and sustainability of using peer breastfeeding supporters commonly used to encourage breastfeeding in preterm neonates for infants with SAM. It will also provide information on the optimal trial follow-up strategy that could be applied successfully for this group of participants.Apart from providing information for trial development, the study findings will by themselves provide data to previously identified research gap. Within the 2013 updated WHO guidelines on management of SAM in children, http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf (page 66) the question of how breastfeeding is most effectively established is raised. Our study intends to optimize the WHO inpatient treatment guidelines and will in the process develop a step-by-step re-lactation protocol that would be applicable for resource poor settings. Recently, using the well developed and highly recommended Child Health and Nutrition Research Initiative (CHNRI) methodology, researchers, developmental partners and other stakeholders including UN agencies identified that research into the components of a package care for outpatient care as one of the top research priorities for infants with SAM (Angood, McGrath et al. 2015). Findings from the proposed study will provide baseline information useful in designing and testing a package for outpatient care.