Description
Purpose: To facilitate synthesis across the body of evidence to answer the clinical question and determine if there is sufficient evidence to support a practice change.
Directions:
Using the information extracted in your evidence table, you will synthesize the information by determining the quantity of evidence based on the Level you’ve assigned, evaluate consistency across findings, and assess applicability to your population and feasibility to the organization. Finally, you will appraise the strength of the overall evidence to guide a practice recommendation. See the grading rubric embedded in Brightspace.
Instructions:
1. Complete column 2 titled “# of Sources” by entering the number of articles for that Level of Evidence.
2. Complete column 3 titled “Consistency” by evaluating how consistent the findings were for all articles at that Level of Evidence. Did they all come to the same or similar conclusions/recommendations?
3. Complete column 4 titled “Findings” by reviewing the findings for all articles at that Level of Evidence.
Include only statements that directly answer the PICO question.
Summarize and synthesize findings within each level of evidence. This may require you to make a judgement on conflicting evidence from each study within the level.
4. For the row titled “Fit/Applicability,” enter a narrative explanation on how the practice change is applicable to (or “fits”) your population and the needs of the agency. Consider the following:
Is the evidence relevant to the population in your PICO question?
Are resources and support available to implement the intervention? Consider the amount of time for training, length of training, supplies, and other resources that would need to be used. This should be based on critical thinking about the resources and limits of current healthcare agencies.
5. For the row titled “Recommendation,” synthesize the Level of Evidence + the Consistency of Findings + Applicability to recommend (or not recommend) a practice change. Include a narrative explanation on why you have chosen that option. Use the following as a guide:
Option 1: strong evidence, consistent results, high applicability: Solid indication for a practice change is indicated.
Option 2: good evidence, consistent results, moderate to high applicability: Consider pilot of change or further investigation.
Option 3: Good but conflicting evidence, moderate to low applicability: No indication for practice change; consider further investigation for new evidence or develop a research study.
Option 4: Little or no evidence, no applicability: No indication for practice change; consider further investigation for new evidence, develop a research study, or discontinue project.
If you selected either the 1st option or the 2nd option, full or pilot implementation is indicated. If not, implementation is not indicated.
Note about your recommendations:
When evidence includes multiple studies of Level 1, 2, and 3 evidence, there is a similar population or setting of interest, and there is consistency across findings, EBP teams can have greater confidence in recommending a practice change. However, with a majority of Levels 4, 5, 6 evidence, the team should proceed cautiously in making practice changes. In this instance, recommendation(s) typically include completing a pilot before deciding to implement a full-scale change.
Generally, practice changes are not made on Level 4, 5 or 6 evidence alone. Nonetheless, EBP teams have a variety of options for actions that include, but are not limited to: creating awareness campaigns, conducting informational and educational updates, monitoring evidence sources for new information, and designing and conducting research studies.
Unformatted Attachment Preview
EBP Project, Part 6: Synthesis Table
Level of Evidence
Level 1
Level 2
Level 3
Level 4
Level 5
# of Sources
Consistency
Findings
Level of Evidence
Level 6
# of Sources
Fit/Applicability
Recommendation Option
Recommendation Rationale
Consistency
Findings
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Use and Evaluation of Postpartum Care Services in Rural Malawi – PubMed
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full text links
J Nurs Scholarsh. 2017 Jan;49(1):87-95. doi: 10.1111/jnu.12257. Epub 2016 Oct 25.
Use and Evaluation of Postpartum Care Services in
Rural Malawi
Yenupini Joyce Adams 1 , Manfred Stommel 2 , Adejoke Ayoola 3 , Mildred Horodynski 4 ,
Address Malata 5 , Barbara Smith 6
Affiliations
PMID: 27779814 DOI: 10.1111/jnu.12257
Abstract
Purpose: The purpose of this study was to examine women’s evaluation of postpartum care
services (postpartum clinical assessments, health education, and midwife kindness) received from
midwives prior to discharge in rural health facilities, and to examine husband-and-wife-farmer
dyads’ reasons for their decisions to return or not return for 1-week postpartum care visits in rural
central Malawi.
Design: Cross-sectional matched-pairs survey design.
Methods: Participants included a convenience sample of 70 husband-and-wife-farmer dyads living
in rural communities who had a live birth in the past year at one of four health facilities in Ntcheu
district, central Malawi. Data were collected using an interviewer-administered postpartum care
questionnaire from the World Health Organization (WHO) Safe Motherhood Needs Assessment
Questionnaires. Data analysis included univariate and multivariate statistics.
Findings: Women’s evaluation of postpartum care assessments received from midwives in rural
health facilities prior to discharge included partial assessments of blood pressure (44%),
temperature (41%), abdominal examination (50%), vaginal examination/bleeding (46%), breast
examination/soreness (34%), and baby examination (77%). Only 16% of the women received all six
of these postpartum clinical assessments prior to discharge, while 11% received none. Women also
reported that midwives did not: introduce themselves (50%); ask if patients had questions (44%);
explain what they were doing (43%); or explain what to expect after delivery (50%). Despite this,
77% of women felt midwives paid close attention to them and 83% gave an overall positive
evaluation (3.5-5 on a scale of 1-5). Numbers of postpartum clinical assessments (p = .09) and
overall evaluation (p = .71) did not differ between the four health facilities. The top three reasons for
husbands’ and wives’ decisions to return for 1-week postpartum care visits were: being advised to
return for care, wanted the mother to be examined, and wanted the baby to be examined.
Participants stated prior negative experiences, or not perceiving a need for care (feels fine), may
potentially prevent them from returning for postpartum care visits in a health facility.
Conclusions: Most women reported they received only partial postpartum clinical assessments;
thus, it is important for health facilities to address the adequacy of postpartum clinical assessments
provided to women by midwives before discharge. Women returned for 1-week postpartum care
visits because they were advised to return for care, and also to make sure their babies were
examined. However, the principal reason why husbands permitted their wives to return for
postpartum care was because they wanted their wives to be examined.
Clinical relevance: Midwives need to advise all patients to return for postpartum care visits
consistent with WHO or country guidelines, and continue to educate husbands and wives regarding
the importance of postpartum care even when the wife feels fine. Refresher in-service trainings on
postpartum care are recommended for midwives to encourage them to perform the recommended
postpartum clinical assessments.
https://pubmed.ncbi.nlm.nih.gov/27779814/
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Use and Evaluation of Postpartum Care Services in Rural Malawi – PubMed
Keywords: Adequacy of care; Malawi; decision to return for care; postpartum care; postpartum
clinical assessments; postpartum evaluation.
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
As a library, NLM provides access to scientific literature. Inclusion in an NLM database does
not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of
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Matern Child Nutr. 2018 Jul; 14(3): e12602.
Published online 2018 Apr 14. doi: 10.1111/mcn.12602
PMCID: PMC6866175
PMID: 29655200
Infant formula feeding practices associated with rapid weight gain: A systematic review
Jessica Appleton,
1,2
Catherine Georgina Russell, 1 Rachel Laws, 3 Cathrine Fowler, 1 , 4 , 5 Karen Campbell, 3 and
Elizabeth Denney‐Wilson 1
Abstract
Excess or rapid weight gain during the first 2 years of life is associated with an increased risk of later
childhood and adult overweight and obesity. When compared with breastfed infants, formula fed infants are
more likely to experience excess or rapid weight gain, and this increased risk in formula fed infant popula‐
tions may be due to a number of different mechanisms. These mechanisms include the nutrient composi‐
tion of the formula and the way formula is prepared and provided to infants. This systematic literature re‐
view examines the association between formula feeding practice and excess or rapid weight gain. This re‐
view explores these different mechanisms and provides practical recommendations for best practice formu‐
la feeding to reduce rapid weight gain. Eighteen studies are included in this review. The findings are com‐
plicated by the challenges in study design and accuracy of measurements. Nevertheless, there are some po‐
tential recommendations for best practice formula feeding that may reduce excess or rapid weight gain,
such as providing formula with lower protein content, not adding cereals into bottles, not putting a baby to
bed with a bottle, and not overfeeding formula. Although further well designed studies are required before
more firm recommendations can be made.
Keywords: childhood obesity, infant feeding, infant feeding behaviours, infant formula, infant growth,
systematic review
Key messages
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Preventing early RWG in formula fed infants may reduce their risk of later overweight and
obesity.
There is some evidence to suggest that there are formula feeding practices, such as adding
cereals in bottle, putting an infant to bed with bottle, overfeeding formula, and compositions,
such as higher protein that contribute to RWG.
Parents and health professionals should be provided with accurate evidence of these
associations so they can implement best practice formula feeding.
Much of the current evidence relies on theoretical links and further research is required to
provide a solid evidence base.
1. INTRODUCTION
Rapid or excess weight gain (RWG) in infancy is associated with higher risk of being overweight or obese
in childhood (Baird et al., 2005; Koletzko, von Kries, Monasterolo, 2009; Monteiro & Victora, 2005;
Zheng et al., 2017). In a comprehensive systematic review comprising 282 studies examining modifiable
risk factors for childhood obesity (from the antenatal period until 2 years of age), RWG was one of the
more consistent risk factors of overweight or obesity in later childhood with 45 out of 46 included studies
finding a positive association (Woo Baidal et al., 2016). Another literature review and meta‐analysis on
RWG and subsequent obesity, including 17 studies (meta‐analysis based on 14 of the included studies),
found that, for those infants who experienced RWG, there was a 3.66 times increased odds for overweight
or obesity in later life (Zheng et al., 2017). The proportion of infants experiencing rapid weight gain varied
from approximately 10–50% across studies included in the review (Zheng et al., 2017). Infants fed formula,
as opposed to infants fed breast milk, are more likely to experience RWG (Dewey, 1998; Koletzko, von
Kries, Monasterolo, et al., 2009; Mihrshahi, Battistutta, Magarey, & Daniels, 2011).
It has been understood for some time that infants fed formula have different weight gain patterns to breast‐
fed infants (Dewey, Heinig, Nommsen, Peerson, & Lonnerdal, 1993; Taitz, 1971; Yang & Huffman, 2013).
Heinig, Nommsen, Peerson, Lonnerdal, and Dewey (1993) found that infants fed formula had higher: ener‐
gy intake, protein intake, and weight gain compared with matched breastfed infants. These differences may
be due to physiological and behavioural variances between breastfeeding and feeding formula from a bottle
(Bartok & Ventura, 2009). Such as, the nutrient profile of breast milk and formula milk is different. And
the feeding interaction between the mother and infant when feeding from a breast or a bottle is different,
where feeding via a bottle provides the adult with more control over the feeding situation than the breastfed
infant (Bartok & Ventura, 2009).
Many infants are fed with some formula in their first year of life: In Australia, at least 50% of infants are
fed with some formula milk in their first 6 months, and only 39% are exclusively breastfed to 3 months
(Australian Institute of Health and Welfare, 2011). Similar proportions are found in the United States
where, in 2014 the national rates of exclusive breastfeeding at 3 months were 40.7% (Centre for Disease
Control and Prevention, 2014). Considering the high prevalence of formula feeding, is it possible to use
formula in a way that best mimics breast milk and breastfeeding (Ryan & Hay, 2016) and prevents RWG?
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Identifying how formula feeding practices (which include the type and preparation, the amount provided
and consumed, and the way in which formula is provided) relates to RWG is important to inform public
health and obesity prevention strategies. It is also important to improve the information and advice provid‐
ed to parents who are feeding with formula to reduce the potential for RWG. This systematic review identi‐
fies and assesses the supporting evidence for a range of formula feeding practices associated with RWG in
infancy. It explores the different mechanisms and provides practical recommendations on the basis of the
current evidence for best practice formula feeding to prevent RWG.
2. METHODS
The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines (PRISMA) (Moher,
Liberati, Tetzlaff, & Altman, 2009) and guidance for systematic reviews in epidemiology (Denison et al.,
2013) informed the methods. The study selection criteria for inclusion were based on three biologically
plausible mechanisms by which breastfeeding may be protective and formula feeding may contribute to
RWG. That is, epidemiological and experimental research suggests that the (a) composition of the milk
(nutrient profile), (b) the mode of feeding (e.g., using a bottle, size of teat), and/or (c) the parent feeding
practices may be important mechanisms. These three pathways help conceptualise how formula may be
provided in ways which may closely imitate breast milk and breastfeeding (Ryan & Hay, 2016). These
pathways do not work in isolation: They have overlapping effects. Nor are they simply unidirectional, for
example, an infant’s weight or weight gain may impact parents’ feeding practices (Li, Fein, & Grummer‐
Strawn, 2008).
2.1. Inclusion/exclusion criteria
Studies were selected for inclusion if they (a) addressed one of the pathways outlined above, (b) included a
sample (or a portion of the sample) of infants who were fed with formula milk in their first year since birth,
and (c) included RWG in the first two years as an outcome. Nutrient profile variables included studies
where the composition of formula milks was differentiated. Mode of delivery variables included studies
where the type of bottle or teat was investigated. Parent feeding practice variables included studies where
the parent’s preparation or provision of formula was measured.
“Excess” or “rapid” weight gain is defined and measured a number of different ways in the literature. A
widely agreed upon definition of RWG is a change in weight for age z‐score > 0.67 (Goodell, Wakefield, &
Ferris, 2009; Ong, Ahmed, Dunger, Emmett, & Preece, 2000). However, some studies measure and define
“excess” or “rapid” weight gain in other ways—for example, specific percentile cut offs are used to define
excess weight, for example, body mass index (BMI) above the 85th percentile defined as overweight
(Gubbels, Thijs, Stafleu, Buuren, & Kremers, 2011). Studies were included regardless of the measure or
definition used. Studies of infants or parents afflicted by conditions that may impact on infant feeding or
growth were excluded.
2.2. Search strategy
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Searches were conducted in five electronic databases (Medline, PsycINFO, CINAHL, MIDIRS, and
Scopus) followed by a snowball search strategy through citation searching, hand‐searching, and visual
scanning of reference lists of sentinel papers and relevant systematic reviews. For database searches, key‐
words were used in conjunction with subject heading in CINAHL and PsycINFO and MeSH terms in
Medline (full search terms are available in the Supporting Information). Limits were set to English lan‐
guage, human subjects, and those published from 1990. The primary search was conducted between
August and November 2016 and repeated in July 2017 that revealed no further studies for inclusion.
2.3. Study selection
All papers were imported into an Endnote database and duplicates removed. One researcher (JA) screened
titles and abstracts using a screening checklist (see Supporting Information). Any uncertainties were dis‐
cussed with a second researcher (EDW). After the initial screen, full text of the included articles were re‐
trieved and analysed according to the eligibility criteria (see Supporting Information).
2.4. Data extraction and narrative synthesis
One researcher (JA) extracted data from the included studies using a data extraction checklist which in‐
cluded study description, participant characteristics, exposure definition and measure, outcome definition
and measure, statistical data and results, was derived with guidance from Denison et al. (2013). This
formed a structured table of the included studies organised according to the three pathways of interest, es‐
tablished a priori. Studies within each pathway were then summarised in groups reporting on the same ex‐
posure (e.g., the parent feeding practice of feeding on demand or schedule). The characteristics, study de‐
signs and findings within each group were described, compared, and synthesised.
2.5. Quality assessment
The Mixed Methods Appraisal Tool (MMAT)—Version 2011 (Pluye et al., 2011) was used to assess study
quality. This tool assesses a range of study designs including randomised, nonrandomised, and descriptive
quantitative studies. Two researchers (JA and EDW) independently assessed each of the included studies,
and any discrepancies in the scores were discussed and consensus drawn.
3. RESULTS
Overall, 3,881 papers were retrieved, and one additional paper was found via snowball searching. Title and
abstract screening excluded 3,796 papers, leaving 86 papers. Full text review of these 86 papers excluded a
further 68 papers, leaving 18 for inclusion in the review (Figure 1).
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Figure 1
PRISMA flow diagram
3.1. Study characteristics
Eight papers addressed nutrient profile, two addressed mode of delivery and nine2 addressed parent feeding
practices (Tables 1, 2, 3). The study designs included randomised controlled trials (RCT—six studies),
nonrandomised trials (one study), longitudinal cohort studies (eight studies), and cross section studies
(three studies). The RCTs varied in size, from very large multi‐national studies (Koletzko, von Kries,
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Closa, 2009), to small single site studies (Mennella, Ventura, & Beauchamp, 2011). The longitudinal stud‐
ies varied in length of follow up period and size, with five having greater than 1,000 participants. For most
studies, the samples were taken from general populations defined within a geographical area, or some were
sampled nationwide. A small number of studies included specific populations such as overweight mothers
only (Inostroza et al., 2014), those with a family history of atopic disease (Roche, Guo, Siervogel, Khamis,
& Chandra, 1993; Rzehak et al., 2009), and a Women, Infant, and Children (WIC) population in the United
States (Cartagena, McGrath, & Masho, 2016; Worobey, Lopez, & Hoffman, 2009).
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Table 1
Included studies nutrient profile (n = 7)
First author
Outcome/s,
MMAT
reference
score (*
, ** , *** ,
year
Sample N &
location/setting
key
Exposure &
population &
measurement
Key findings
**** a
•Powdered versus •Weight,
•Higher body
****
ready to feed
change in
weight in
formula
weight, & stan‐
powdered for‐
study name
Design
descriptions
measurement
•Lucas et al.,
•Randomised
•N = 42
1992
control trial
•21 Per group
•UK
)
dardised weight mula group
dropped to 19
per group by
•Randomised at
6 months
enrolment within
2 days of birth
z‐score
(non‐
significant)
•Local refer‐
•Approx. even‐
ence population •Higher body
ly gendered
(Cambridge ref‐ weight change
groups
erence growth
in powdered
centiles)
formula group
(1–6 weeks,
•Infants from
one postnatal
•Directly mea‐
1–12 weeks
ward of parents
sured at birth,
significant, 1–
already decided
1, 2 4, 6, 10, 12, 26 weeks non‐
to feed formula
& 26 weeks
significant)
•Powdered
formula group
standardised
weight from 6
to 26 weeks
around 0.6
compared
with ready to
feed group
around 0.1
•Roche et al.,
•Nonrandomised
1993
control trial
•Canada
a
•N = 288
•Whey hy‐
•Absolute
•Some small
drolysate versus
weight gain &
differences in
•72 Per group.
soy based formula standardised
weight be‐
N = 263 with
versus standard
weight
tween groups
complete data
cow’s milk based,
percentile
*
The MMAT provides a quality score based on four pertinent criteria for each study design, studies receive one * per each
criteria met. Therefore, studies may meet the following:
* One criterion.
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**
Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Two criteria.
*** Three criteria.
****
All criteria.
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Infant formula feeding practices associated with rapid weight gain: A systematic review – PMC
Table 2
Included studies mode of delivery (n = 2)
First author
Outcome/s,
MMAT
reference
score (* ,
** , *** ,
year
Sample N &
location/setting
key
Exposure &
population &
study name
Design
descriptions
measurement
measurement
Key findings
**** a
•Fewtrell et al.,
•Randomised
•N = 63 en‐
•Bottle antivacu‐
•Absolute
•No
**
2012
control trial
rolled & ran‐
um design (2
weight gain &
statistically
domised after
types of bottles)
weight gain z‐
significant
•UK
)
score to 4 weeks difference in
dropout
N = 54 at
•Randomised at
weight or
4 weeks
birth through to
•Standardised to formula
15 days
UK reference
consumed
data (1990)
between the
•43% female
two bottle
•Infants all
•Directly mea‐
formula fed
sured at enrol‐
from
ment, 2, 4 weeks
enrolment
& 3 months
groups
•Wood et al.,
•Longitudinal
•N = 386 (45% •Feeding formula •Change in
•Higher weight
2016
data from a
of all study
from “large” ≥
weight (2–
for length (and
cluster
participants),
6 oz (~177 ml),
6 months),
weight for age)
or “regular” bot‐
weight for
in those infants
tles 1 de‐
sion
States
fants has “low”
er initiated”
fined as excess
(n = 1,187)
weight
found infants
( 98th percentile) at 24 months
(Gibbs & Forste, 2014).
Volume of formula Two studies considered the volume of formula infants consumed by measuring the
number of feeds per day or the amount consumed over a day. Both found weak positive associations be‐
tween the amount of formula consumed and weight gain. One small (n = 96) longitudinal study based in a
WIC population found a higher number of feeds per day, measured at 6 months, was associated with
greater absolute weight gain between 6 and 12 months (Worobey et al., 2009). However, this study only
considered weight change over time—They did not standardise infants’ weight to length, nor compare their
sample to a reference population or control for other foods consumed. The other larger (n = 1,112) longitu‐
dinal study measured the amount of formula consumed at 8 months, dichotomising into low ( 0.67 (Goodell
et al., 2009; Ong et al., 2000) although studies measure and define excess and rapid weight gain in infancy
in other ways—see Section 2. For simplicity throughout this paper, the acronym RWG will be used to refer
to all measures of excess or rapid weight gain during the first 2 years of life.
2One paper involves exposure variables in both the nutrient profile and parent feeding practices section and
is included in the parent feeding practice table (Table 3).
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