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

2013年，世卫组织《严重急性营养不良儿童治疗指南》首次纳入了关于如何诊断和治疗6个月以下婴儿严重急性营养不良的指导。6个月以下婴儿的治疗指南侧重于住院治疗，并建议支持患有急性呼吸窘迫症的入院婴儿在出院前重新建立纯母乳喂养。该建议主要基于计划性报告和一些研究，这些研究表明，乳汁衰竭在患有急性乳腺炎的婴儿中很常见，并且可以使用补充哺乳等重新哺乳技术在患有急性乳腺炎的婴儿中重新建立母乳喂养。然而，由于没有一项研究在婴儿出院后进行随访，我们仍然不知道：(1)出院后是否保留纯母乳喂养；Ii)是否在出院后保持纯母乳喂养足以恢复营养，iii)是否向出院婴儿的母亲提供额外的母乳喂养支持将是有益的。本研究旨在提供重要的信息，以开展一项试验，以确定家庭母乳喂养支持对接受急性呼吸窘迫综合征治疗出院婴儿的母亲的生存和生长的有效性。拟议研究的主要目的是：(1)确定在目前没有特定出院后母乳喂养支持的策略下，从SAM治疗出院的6个月以下婴儿的母乳喂养保留率；ii)确定纯母乳喂养的婴儿是否仅靠母乳就足以恢复营养。这些信息将形成基线数据，用于衡量任何应用干预措施的成功与否。因此，本研究的结果将加强样本量的计算，以显示干预措施对结果的改善。此外，该研究将提供关于使用同伴母乳喂养支持者的可接受性和可持续性的见解，这些支持者通常用于鼓励患有SAM的早产儿母乳喂养。它还将提供关于可成功应用于这组参与者的最佳试验随访策略的信息。除了为试验开发提供信息外，研究结果本身将为先前确定的研究差距提供数据。在2013年更新的世卫组织儿童SAM管理指南http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf（第66页）中，提出了如何最有效地建立母乳喂养的问题。我们的研究旨在优化世卫组织住院治疗指南，并将在此过程中制定适用于资源贫乏环境的逐步重新哺乳方案。最近，研究人员、发展合作伙伴和包括联合国机构在内的其他利益攸关方使用完善且备受推荐的儿童健康与营养研究倡议（CHNRI）方法，确定了对门诊护理一揽子护理组成部分的研究是SAM婴儿的首要研究重点之一（Angood， McGrath等人，2015）。该研究的结果将为设计和测试门诊护理方案提供有用的基线信息。

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.