Cochrane Database of Systematic Reviews

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Bryanton J, Beck CT, Montelpare W

Bryanton J, Beck CT, Montelpare W. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD004068. DOI: 10.1002/14651858.CD004068.pub4.

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Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Education on sleep enhancement versus usual care, Outcome 1 Total infant sleep >= 15 hrs per 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.2. Comparison 1 Education on sleep enhancement versus usual care, Outcome 2 Total minutes of infant sleep in 24 hrs (mean diff ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.3. Comparison 1 Education on sleep enhancement versus usual care, Outcome 3 Night-time minutes of infant sleep in 24 hrs (mean diff ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.4. Comparison 1 Education on sleep enhancement versus usual care, Outcome 4 Longest uninterrupted nighttime minutes of infant sleep in 24 hrs (mean diff ). . . . . . . . . . . . . . . . . . . . . . Analysis 1.5. Comparison 1 Education on sleep enhancement versus usual care, Outcome 5 Day-time minutes of infant sleep in 24 hrs (mean diff ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.6. Comparison 1 Education on sleep enhancement versus usual care, Outcome 6 Longest uninterrupted daytime minutes of infant sleep in 24 hrs (mean diff ). . . . . . . . . . . . . . . . . . . . . . Analysis 1.7. Comparison 1 Education on sleep enhancement versus usual care, Outcome 7 Infant crying time in 24 hrs (mean diff ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.8. Comparison 1 Education on sleep enhancement versus usual care, Outcome 8 Night-time minutes of infant sleep in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.9. Comparison 1 Education on sleep enhancement versus usual care, Outcome 9 Longest uninterrupted nighttime minutes of infant sleep in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.10. Comparison 1 Education on sleep enhancement versus usual care, Outcome 10 No. of infant night-time sleeping episodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.11. Comparison 1 Education on sleep enhancement versus usual care, Outcome 11 Day-time minutes of infant sleep in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.12. Comparison 1 Education on sleep enhancement versus usual care, Outcome 12 Longest uninterrupted daytime minutes of infant sleep in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.13. Comparison 1 Education on sleep enhancement versus usual care, Outcome 13 No. of infant day-time sleeping episodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.14. Comparison 1 Education on sleep enhancement versus usual care, Outcome 14 Night-time minutes of infant fussing/crying in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.15. Comparison 1 Education on sleep enhancement versus usual care, Outcome 15 Longest uninterrupted night-time minutes of infant fuss/cry in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . Analysis 1.16. Comparison 1 Education on sleep enhancement versus usual care, Outcome 16 No. of infant night-time fussing/crying episodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.17. Comparison 1 Education on sleep enhancement versus usual care, Outcome 17 Day-time minutes of infant fussing/crying in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.18. Comparison 1 Education on sleep enhancement versus usual care, Outcome 18 Longest uninterrupted daytime minutes of infant fuss/cry in 24 hrs. . . . . . . . . . . . . . . . . . . . . . . . . Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.19. Comparison 1 Education on sleep enhancement versus usual care, Outcome 19 No. of infant day-time fussing/crying episodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.20. Comparison 1 Education on sleep enhancement versus usual care, Outcome 20 Maternal stress score. Analysis 2.1. Comparison 2 Education on infant behaviour versus usual care, Outcome 1 Knowledge of infant behaviour. Analysis 2.2. Comparison 2 Education on infant behaviour versus usual care, Outcome 2 Child-rearing anxiety. . . Analysis 2.3. Comparison 2 Education on infant behaviour versus usual care, Outcome 3 Mother distance. . . . . Analysis 2.4. Comparison 2 Education on infant behaviour versus usual care, Outcome 4 Mutuality. . . . . . . Analysis 2.5. Comparison 2 Education on infant behaviour versus usual care, Outcome 5 Synchronous co-occurrences during free play - visual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.6. Comparison 2 Education on infant behaviour versus usual care, Outcome 6 Synchronous co-occurrences during free play - vocal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.7. Comparison 2 Education on infant behaviour versus usual care, Outcome 7 Mothers’ perception of their infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.8. Comparison 2 Education on infant behaviour versus usual care, Outcome 8 Maternal confidence interpreting infant behaviour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.1. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 1 Maternal general post-birth knowledge score (mean). . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.2. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 2 Maternal general post-birth knowledge score (per cent correct). . . . . . . . . . . . . . . . . . . . . Analysis 3.3. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 3 Infant weight (kg). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.4. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 4 Infant length (cm). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.5. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 5 Head circumference (cm). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.6. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 6 Appropriate immunization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.7. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 7 Knowledge of signs of infant pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.8. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 8 Knowledge of action to take in the case of infant diarrhoea. . . . . . . . . . . . . . . . . . . . . . . Analysis 4.1. Comparison 4 Education on infant safety versus usual care, Outcome 1 Infant restraint seat fastened by lap belt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.2. Comparison 4 Education on infant safety versus usual care, Outcome 2 Post-hospitalization awareness of tap water burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.3. Comparison 4 Education on infant safety versus usual care, Outcome 3 Greater use of temperature testing. Analysis 4.4. Comparison 4 Education on infant safety versus usual care, Outcome 4 Supine infant sleep position. . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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[Intervention Review]

Postnatal parental education for optimizing infant general health and parent-infant relationships Janet Bryanton1 , Cheryl T Beck2 , William Montelpare3 1 School of Nursing, University of Prince Edward Island, Charlottetown, Canada. 2 School of Nursing, University of Connecticut, Storrs,

Connecticut, USA. 3 Department of Applied Human Sciences, Faculty of Science, University of Prince Edward Island, Charlottetown, Canada Contact address: Janet Bryanton, School of Nursing, University of Prince Edward Island, 550 University Avenue, Charlottetown, C1A 4P3, Canada. [email protected]. Editorial group: Cochrane Pregnancy and Childbirth Group. Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 11, 2013. Review content assessed as up-to-date: 17 September 2013. Citation: Bryanton J, Beck CT, Montelpare W. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD004068. DOI: 10.1002/14651858.CD004068.pub4. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Many learning needs arise in the early postpartum period, and it is important to examine interventions used to educate new parents about caring for their newborns during this time. Objectives The primary objective was to assess the effects of structured postnatal education delivered to an individual or group related to infant general health or care and parent-infant relationships. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 March 2013). Selection criteria We included randomized controlled trials of any structured postnatal education provided to individual parents or groups of parents within the first two months post-birth related to the health or care of an infant or parent-infant relationships. Data collection and analysis Two review authors (JB, CTB) assessed trial quality and extracted data from published reports. Main results Of the 27 trials (3949 mothers and 579 fathers) that met the inclusion criteria, only 15 (2922 mothers and 388 fathers) reported useable data. Educational interventions included: five on infant sleep enhancement, 12 on infant behaviour, three on general post-birth health, three on general infant care, and four on infant safety. Details of the randomization procedures, allocation concealment, blinding, and participant loss were often not reported. Of the outcomes analyzed, only 13 were measured similarly enough by more than one study to be combined in meta-analyses. Of these 13 meta-analyses, only four were found to have a low enough level of heterogeneity to provide an overall estimate of effect. Education about sleep enhancement resulted in a mean difference of 29 more night-time minutes of infant sleep in 24 hours at six weeks of age (95% confidence interval (CI) 18.53 to 39.73) than usual care. However, it had no significant effect on the mean difference in minutes of crying time in 24 hours at six weeks and 12 weeks of age. Education related to infant behaviour increased maternal knowledge of infant behaviour by a mean difference of 2.85 points (95% CI 1.78 to 3.91). Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors’ conclusions The benefits of educational programs to participants and their newborns remain unclear. Education related to sleep enhancement appears to increase infant sleep but appears to have no effect on infant crying time. Education about infant behaviour potentially enhances mothers’ knowledge; however more and larger, well-designed studies are needed to confirm these findings.

PLAIN LANGUAGE SUMMARY Postnatal parental education for optimizing infant general health and parent-infant relationships The benefits of post-birth parental education for infant health or care and parent-infant relationships remain unclear. Parenting is important in the development of healthy children. New parents have much to learn soon after the birth of an infant and parents do not always have social support or role models to follow. This makes it essential to examine the effectiveness of interventions used by health personnel to educate new parents about caring for their newborn infants in the best possible way. This review sought to assess educational programs delivered to one or both parents individually or in a group in the first two months after birth. Although the review identified 27 trials involving 3949 mothers and 579 fathers, only 15 (2922 mothers and 388 fathers) provided useable data on outcomes of interest. Infant sleep, crying, and maternal knowledge of infant behaviours were the only outcomes that could be effectively analyzed. Results showed that educational interventions aimed at sleep enhancement increased the amount of infant sleep by an average of 29 minutes in 24 hours but had no significant effect on the average infant crying time in 24 hours at six weeks and 12 weeks of age. Education on infant behaviour increased mothers’ knowledge of infant behaviour four weeks after birth by an average of 2.85 points. Further research is required.

BACKGROUND

Description of the condition Parenting is recognized as a key determinant in fostering healthy child development (CCCF 2001; Maas 2012). Current research on brain sculpting emphasizes the important role that parenting plays in the development of the infant brain following birth and on into childhood. At this time, the brain is creating neural pathways that help to ensure lifelong good health, and it is important to provide the best possible environment for this growth (CCCF 2001; McCain 2011; Mustard 2008). Infancy is a distinctive period and a formative phase in human development and parents play a central role in an infant’s physical survival, cognitive development, emotional maturation, and social growth (Bornstein 2002; Dusing 2012). Four interconnected factors have been identified as key to creating a positive environment for infant brain development after birth: (a) protection from harm, (b) healthy attachment, (c) responsive care, and (d) breast milk/breastfeeding (CCCF 2001). The first three are the primary focus of this review. The transition to parenting is an exciting yet stressful time (de Montigny 2008), and many learning needs arise in the early postpartum period. In order for parents to be competent and confi-

dent in their parenting role, they must acquire new knowledge and skills (Mercer 2006). Many new parents may not have the social support or role models readily available to them to teach them positive parenting behaviours (Wilkins 2006). Education by health personnel has the potential to play a key role in assisting new parents in their parenting efforts.

Description of the intervention In developed countries, education for new parents is most often provided by nurses, midwives, and physicians. It can be hospitalor community-based and takes on many forms, using a variety of teaching-learning methods. Educational interventions can be directed towards individuals or groups and can be provided faceto-face, by phone, through print media, or by DVD, for example (Murray 2010). Educational interventions are offered at different times in the early postpartum period and are of varying lengths. Interventions include mothers, fathers, or both parents. There is great variation in the topics covered including: newborn care, feeding, and preventive care (e.g., positioning, car seat use, vaccination, smoke detector use); normal infant behaviour and development (e.g., crying and sleeping); and maternal/paternal and infant interaction (Brown 2006; Murray 2010).

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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How the intervention might work To parent effectively, parents not only need knowledge and skills of appropriate parenting behaviours, but also need to have the confidence in their ability to carry out these behaviours (Bandura 1989; de Montigny 2008). It is conceivable that educational interventions will enhance parenting behaviours by addressing knowledge and skill deficits, as well as increasing parental confidence and competence. Indeed, studies of various postnatal educational interventions have demonstrated that they have been effective in improving parenting and infant outcomes such as: maternal-infant interaction; infant language development; parental attitudes and knowledge (Mercer 2006); paternal competence in parenting, including fostering infant cognitive growth and sensitivity to infant cues (Magill-Evans 2007); and usage of infant healthcare resources (El-Mohandes 2003).

Why it is important to do this review The key to healthy child development is positive parenting. It is important to examine how positive parenting is enacted. One avenue for exploration is the role that postnatal education plays in the transition to parenting. It is important to examine the current interventions being used to educate new parents in their parenting role postdischarge. Do educational interventions promote optimal infant health and care and parent-infant relationships, and if they do, what is the best approach to this education? Because of the variety of approaches and topics covered, it is important to capture the heterogeneous nature of postpartum education in conducting a systematic review of its effects. This review will include reports of interventions with a variety of objectives, content, timing, and teaching-learning methods/media employed, offered to a variety of populations, in a variety of formats. The review will be broad, rather than specific, in an attempt to determine if there is any effect of any structured postnatal educational intervention with any population. This review aims to systematically search for and combine all evidence currently available from randomized controlled trials of the effects of structured postnatal education on infant general health or care and parent-infant relationships including: infant growth and development, crying, and sleeping; infant preventive care; maternal/paternal knowledge acquisition; maternal/paternal infant care confidence; maternal/paternal-infant interaction, and maternal/paternal stress/anxiety.

OBJECTIVES The primary objective was to assess the effects of structured postnatal education delivered to an individual or group related to infant general health or care and parent-infant relationships.

A secondary objective was to determine whether the effects of structured postnatal education vary by length or type of intervention and by population.

METHODS

Criteria for considering studies for this review

Types of studies We considered studies if they met the following inclusion criteria: randomized controlled trials (RCTs) evaluating structured forms of postnatal education provided to individual parents or groups of parents; random allocation to treatment and control groups; violations of allocated management insufficient to materially affect outcomes; and loss to follow-up insufficient to materially affect outcomes. We considered studies that involved individual- or cluster randomization eligible for inclusion. We excluded crossover trials and quasi-RCTs.

Types of participants We included studies of one or both parents of a living infant. We excluded studies of educational interventions for parents of infants in a neonatal intensive care unit and parents less than 20 years old, because the needs of these families differ substantially from those of other families.

Types of interventions We included studies of any structured educational intervention (using a variety of methods/media), offered either in hospital or elsewhere within the first two months post birth to individuals or groups by an educator (nurse, nurse practitioner, midwife, physician, or other), related to the general health or care of an infant or to parent-infant relationships. We excluded studies of interventions that were primarily support-based.

Types of outcome measures General infant health, infant care, or parent-infant relationship factors, as measured by the researchers, that could be affected by postnatal education.

Primary outcomes

1. Infant growth and development; 2. infant crying; 3. infant sleeping;

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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4. infant preventive care (e.g., infant positioning, infant car seat use, smoke detector use, infant vaccination).

Selection of studies The first and second review authors independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any disagreement through discussion.

Secondary outcomes

1. 2. 3. 4.

Maternal/paternal knowledge acquisition; maternal/paternal care confidence; maternal/paternal-infant interaction; maternal/paternal stress/anxiety.

Search methods for identification of studies

Data extraction and management We used an adaptation of ’The Cochrane Pregnancy Childbirth Group Data Extraction Template’ to extract data. For eligible studies, both review authors extracted the data using the adapted template. We resolved discrepancies through discussion. We entered data into Review Manager software (RevMan 2012) and checked them for accuracy. The first author attempted to contact two authors of the original reports to secure useable data. One did not respond and the other chose not to provide the data.

Electronic searches We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Trials Search Co-ordinator (31 March 2013). The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); 2. weekly searches of MEDLINE; 3. weekly searches of Embase; 4. handsearches of 30 journals and the proceedings of major conferences; 5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts. Details of the search strategies for CENTRAL, MEDLINE and Embase, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group. Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords. For details of the search strategies used in the previous version of this review, see Appendix 1.

Data collection and analysis For the methods used when assessing the trials identified in the previous version of this review, see Bryanton 2010. For this update we used the following methods when assessing the reports identified by the updated search.

Assessment of risk of bias in included studies Two review authors independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion.

(1) Random sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups. We assessed the method as: • low risk of bias (any truly random process, e.g., random number table; computer random number generator); • high risk of bias (any non-random process, e.g., odd or even date of birth; hospital or clinic record number); • unclear risk of bias.

(2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal allocation to interventions prior to assignment and assessed whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment. We assessed the methods as: • low risk of bias (e.g., telephone or central randomization; consecutively numbered sealed opaque envelopes); • high risk of bias (open random allocation; unsealed or nonopaque envelopes, alternation; date of birth); • unclear risk of bias.

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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(3.1) Blinding of participants and personnel (checking for possible performance bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered that studies were at low risk of bias if they were blinded, or if we judged that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes. We assessed the methods as: • low, high or unclear risk of bias for participants; • low, high or unclear risk of bias for personnel. (3.2) Blinding of outcome assessment (checking for possible detection bias)

We described for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We assessed blinding separately for different outcomes or classes of outcomes. We assessed methods used to blind outcome assessment as: • low, high or unclear risk of bias. (4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomized participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. We assessed methods as: • low risk of bias (e.g., no missing outcome data; < 20% missing outcome data; missing outcome data balanced across groups); • high risk of bias (e.g., > 20% missing outcome data; numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomization); • unclear risk of bias. (5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found. We assessed the methods as: • low risk of bias (where it is clear that all of the study’s prespecified outcomes and all expected outcomes of interest to the review have been reported); • high risk of bias (where not all the study’s pre-specified outcomes have been reported; one or more reported primary

outcomes were not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported); • unclear risk of bias. (6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

We described for each included study any important concerns we had about other possible sources of bias. We assessed whether each study was free of other problems that could put it at risk of bias: • low risk of other bias; • high risk of other bias; • unclear whether there is risk of other bias. (7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Cochrane Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it is likely to impact on the findings. We explored the impact of the level of bias through undertaking sensitivity analyses when feasible. Measures of treatment effect

Dichotomous data

For dichotomous data, we presented results as summary risk ratios with 95% confidence intervals.

Continuous data

For continuous data, we used the mean difference if outcomes were measured in the same way between trials. We planned to use the standardized mean difference to combine trials that measured the same outcome, but used different methods. We used the generic inverse variance method when original studies provided estimates of the intervention effect (mean differences) and standard errors rather than the means for each group. Unit of analysis issues

Cluster-randomized trials

We identified no cluster-randomized trials for inclusion in this review. Cluster-randomized trials would have been included in the analyses along with individually-randomized trials. We planned

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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to adjust their sample sizes using the methods described in the Cochrane Handbook (section 16.3.4) using an estimate of the intracluster correlation co-efficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we used ICCs from other sources, we planned to report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identified both cluster-randomized trials and individually-randomized trials, we planned to synthesize the relevant information. We would consider it reasonable to combine the results from both if there was little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomization unit was considered to be unlikely. We planned to acknowledge heterogeneity in the randomization unit and perform sensitivity analyses to investigate the effects of the randomization unit.

Cross-over trials

Cross-over trials were not eligible for inclusion in this review due to the nature of the intervention. Dealing with missing data For included studies, we noted levels of attrition. We explored the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis when feasible. For all outcomes, we carried out analyses using available case analysis. Assessment of heterogeneity We assessed statistical heterogeneity in each meta-analysis using the Tau², I² and Chi² statistics. We regarded heterogeneity as substantial if an I² was greater than 30% and either a Tau² was greater than zero, or there was a low P value (less than 0.10) in the Chi² test for heterogeneity.

and methods were judged sufficiently similar. When substantial heterogeneity was identified in a fixed-effect meta-analysis, we repeated the analysis using a random-effects method and compared the results. Subgroup analysis and investigation of heterogeneity We planned to carry out the following subgroup analyses: 1. specific class content (e.g., childcare, parenthood); 2. specific teaching approaches (e.g., didactic, experiential); 3. format of interventions (e.g., one-to-one in hospital/home, telephone, information line, outpatient clinic, group); 4. age of infant at time of intervention; 5. effects in specific populations (e.g., low income, multiethnic). We planned to use the following outcomes in subgroup analysis: 1. infant growth and development; 2. infant crying; 3. infant sleeping; 4. infant preventive care (e.g., infant positioning, infant car seat use, smoke detector use, infant vaccination). We planned to assess subgroup differences by interaction tests available within RevMan (RevMan 2012). We planned to report the results of subgroup analyses quoting the Chi² statistic and P value and the interaction test I² value. Sensitivity analysis We carried out sensitivity analyses to explore the effects of trial quality and outcomes with statistical heterogeneity.

RESULTS

Description of studies Assessment of reporting biases There were no meta-analyses with 10 or more studies. If there had been 10 or more studies in the meta-analysis, we planned to investigate reporting biases (such as publication bias) using funnel plots. We would have assessed funnel plot asymmetry visually. If asymmetry was suggested by a visual assessment, we planned to perform exploratory analyses to investigate it. Data synthesis We carried out statistical analysis using the Review Manager software (RevMan 2012). We used fixed-effect meta-analysis for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect: i.e., where trials were examining the same intervention and the trials’ populations

Results of the search The search was updated and four new studies were included (Issler 2009; McRury 2010; Paradis 2011; Paul 2011). Twenty-three studies were excluded. One study was left in awaiting classification; it had no English translation so we were unable to assess if it was a RCT (Kim 2004). One study was left in ongoing studies as it was a study protocol and was not completed (Cook 2012). Eligibilty criteria were reviewed and clarified. Two studies were excluded from the original review because they included an antenatal education component that could not be separated from the postnatal one and upon clarification of eligibility criteria, they were deemed not eligible (Doherty 2006; Wolfson 1992). Outcomes were reviewed and clarified. Maternal/paternal infant care

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competence was deleted because it overlapped infant preventive care and maternal/paternal care confidence. It was replaced by maternal/paternal stress/anxiety.

ing education relative to general infant care, four testing education relative to infant safety. Excluded studies We excluded a total of 39 studies in this update.

Included studies In this update, a total of 27 trials, involving 3949 mothers and 579 fathers, met the study inclusion criteria; however only 15 of these (2922 mothers and 388 fathers) reported useable data on outcomes of interest. Twenty-one studies were conducted in the United States, two in Brazil, and one each in Australia, Canada, Nepal, and the United Kingdom. Trials directed towards women or couples included: five testing education relative to sleep enhancement, 12 testing education relative to infant behaviour, three testing education relative to general post-birth health, three test-

Risk of bias in included studies The vast majority of the included studies were of uncertain quality, since details of the randomization procedure, allocation concealment, blinding of outcome assessors or participant accrual/loss, or both, were often not reported or were unclear. Many studies had substantial attrition (greater than 20%). See Figure 1 and Figure 2 for a summary of ’Risk of bias’ assessments.

Figure 1. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2. ’Risk of bias’ summary: review authors’ judgements about each risk of bias item for each included study.

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Allocation Forty-four per cent (n = 12) of studies reported random sequence generation; whereas for 56% (n = 15) the risk of selection bias was unclear. Twenty-six per cent (n = 7) described allocation concealment; however the risk of selection bias was unclear for 70% (n = 19) of studies and high for 4% (n = 1).

Blinding In 15% (n = 4) of studies, there was blinding of participants and or personnel; whereas the risk of performance bias was unclear for 66% (n = 18) of studies and high in 19% (n = 5). Fourty-four per cent (n = 12) of studies reported blinding of outcome assessment; however 37% (n = 10) of studies had an unclear risk of detection bias and 19% (n = 5) were judged to have a high risk of bias.

presented outcome data on two primary outcomes and one secondary outcome using four outcome measures, with infants from a few days to six weeks, three months, and six months of age. Studies measured the effects of education on all primary outcomes (infant growth and development, infant crying, infant sleeping, and infant preventive care) as well as all secondary outcomes (parental knowledge acquisition, parental care confidence, parental-infant interaction, and parental stress/anxiety) using 40 different outcome measures at many different times postpartum. Only 13 outcomes were measured similarly enough by more than one study to be combined in meta-analyses. Of these 13, we found only four to have a low enough level of heterogeneity to provide a reliable overall estimate of effect.

1. Education on sleep enhancement versus usual care Incomplete outcome data Thirty per cent (n = 8) of studies reported complete outcome data; whereas 44% (n = 12) had an unclear risk of attrition bias and 26% (n = 7) had a high risk due to incomplete outcome data.

Selective reporting In 63% (n = 17) of studies there was complete reporting on all outcomes; however there was an unclear risk of reporting bias in 15% (n = 4) of studies and a high risk in 22% (n = 6).

Other potential sources of bias The majority of studies (63%; n = 17) were deemed as having a low risk of other sources of bias; whereas in 30% (n = 8) there was an unclear risk and in 7% (n = 2) there was a high risk.

Effects of interventions Of the 15 trials that presented useable data, outcomes differed considerably from one to the next. Four trials testing education relative to sleep enhancement presented data on two primary outcomes and one secondary outcome using 20 different outcome measures; these included assessments of infants at four, six, eight, and 12 weeks. The five studies testing education relative to infant behaviour presented outcome data on the four secondary outcomes using eight outcome measures; these with infants aged one to four days and four weeks. The two studies testing education relative to general infant post-birth health or care presented data on two primary outcomes and one secondary outcome using eight different outcome measures; these included infants aged up to six months. The four studies testing education relative to infant safety

Primary outcomes

Infant sleeping was measured in four studies in a total of 12 different ways. Education on sleep enhancement resulted in a mean difference (MD) of 29 more night-time minutes of sleep in 24 hours (95% confidence interval (CI) 18.53 to 39.73) at six weeks of age than usual care (Analysis 1.3.1). It should be noted, however, that the size of the two studies (Stremler 2006; Symon 2005) differed considerably, so that over 90% of the weighted results in this metaanalysis are due to the Symon 2005 study. This study had greater than 20% attrition. Symon 2005 also found a beneficial effect of the intervention on total infant sleep greater than or equal to 15 hours per 24 hours (risk ratio (RR) at six weeks 1.72; 95% CI 1.56 to 1.90; and at 12 weeks RR 1.73; 95% CI 1.54 to 1.95) (Analysis 1.1). Stremler 2006 reported that at six weeks, infants in the intervention group had significantly fewer night-time awakenings (MD 4.40; 95% CI 1.40 to 7.60) and longer maximum lengths of uninterrupted night-time sleep (MD 46 minutes; 95% CI 4.51 to 87.49) (Analysis 1.4.1). Two additional studies (McRury 2010; St James-Roberts 2001) did not find any meaningful or statistically significant effect of a sleep enhancement educational intervention on any of the infant sleep outcome measures at any period of time. A second primary outcome measured in an educational intervention on sleep enhancement resulted in no significant difference in the mean crying time in 24 hours at six weeks (MD 4.36 minutes; 95% CI -6.44 to 15.16) (Analysis 1.7.2) and at 12 weeks (MD 0.55 minutes; 95% CI -8.38 to 9.47) (Analysis 1.7.4). The size of these two studies (McRury 2010; Symon 2005) differed considerably with 95% and 99% of the weighted results of this metaanalysis due to Symon 2005. Both studies had greater than 20% attrition. Symon 2005, McRury 2010, and St James-Roberts 2001 did not find any statistically significant effect of a sleep enhance-

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ment educational intervention on any of the seven infant crying outcome measures at any of the time periods.

Secondary outcomes

McRury 2010 examined the effect of a sleep enhancement intervention on maternal stress at six and 12 weeks. There were no differences between groups at six weeks and at 12 weeks the intervention group had significantly higher stress sores than the control (MD 36.40; 95%CI 15.38 to 57.42) (Analysis 1.20.2).

3. Education on general post-birth infant health or care

Primary outcomes

An educational intervention about general post-birth infant health and care was examined with respect to its effect on infant growth and development in a single study (Bolam 1998), using infant weight, length, and head circumference as measures. Infant preventive care, represented by appropriate immunization, was also assessed in this study. No differences were found between groups on either primary outcome as a result of the intervention.

2. Education on infant behaviour versus usual care Secondary outcomes

Primary outcomes

No primary outcomes were assessed by interventions related to education on infant behaviour.

Four measures of maternal knowledge acquisition were used in two studies (Bolam 1998; Regan 1995) to test the effects of educational interventions related to post-birth infant health and care. No significant differences were found in either study on any of the measures.

4. Education on infant safety versus usual care Secondary outcomes

Five studies testing education related to infant behaviour examined the four secondary outcomes in eight different ways. Education about infant behaviour resulted in an increase in maternal knowledge acquisition of infant behaviour at four weeks postpartum by a mean difference in score of 2.85 points (95% CI 1.78 to 3.91) (Analysis 2.1.2). The weighted results of the two studies in this meta-analysis were comparable (Golas 1986; Myers 1982). Myers 1982 reported a mean difference in score on maternal knowledge of infant behaviour of 2.50 points (95% CI 1.01 to 3.99); whereas Golas 1986 found a mean difference of 3.20 points (95% CI 1.68 to 4.72). Myers 1982 also reported a significant difference in knowledge for mothers (MD 4.60 points; 95% CI 2.60 to 6.60) (Analysis 2.1.1) and for fathers (MD 6.50 points; 95% CI 4.88 to 8.12) (Analysis 2.1.3) at one to four days postpartum, and for fathers at four weeks postpartum (MD 3.70 points; 95% CI 1.93 to 5.47) (Analysis 2.1.4). Maternal/paternal infant care confidence was measured by maternal confidence in interpreting infant behaviour by Golas 1986, with no significant difference noted between the intervention and control group. Another study (Wendland-Carro 1999) related to education about infant behaviour, found beneficial effects on maternal responsiveness at one month postpartum. Maternal visual and vocal synchronous co-occurrences during free play were significantly greater in the intervention group (MD 10.10; 95% CI 5.96 to 14.24) (Analysis 2.5) and (MD 6.73; 95% CI 3.64 to 9.82) (Analysis 2.6), respectively. Two other studies did not find any significant effect of education related to infant behaviour on any outcomes (Flagler 1988; Hall 1980).

Primary outcomes

Infant preventive care was measured three different ways in four studies testing education related to infant safety. Education related to prevention of tap water burns was effective in the single study that examined this (Shapiro 1987) (RR for greater use of temperature testing 1.76; 95% CI 1.43 to 2.17) (Analysis 4.3). Issler 2009 reported that an educational session for mothers on infant sleep position significantly increased the prevalence of supine position for infant sleep at three months (RR 1.79; 95% CI 1.17 to 2.72) (Analysis 4.4.3) and at six months post-birth (RR 2.18; 95% CI 1.35 to 3.53) (Analysis 4.4.4). Goetter 2005 also found a significant effect on sleep position at one week post-birth (RR 1.31; 95% CI 1.00 to 1.72) (Analysis 4.4.1) but found no effect at six weeks. Beneficial effects were reported in the one study that examined education regarding car seat safety. Christophersen 1982 found that the intervention parents used greater infant car seat restraint by a lap belt on hospital discharge (RR 21.00; 95%, CI 1.34 to 328.86) (Analysis 4.1.1) than the control parents. This effect was no longer significant at four to six weeks.

Secondary outcomes

Maternal knowledge acquisition was measured in one study related to infant safety (Shapiro 1987). Education related to prevention of tap water burns was effective in increasing post-hospitalization awareness of tap water burns (RR 1.07; 95% CI 1.04 to 1.11) (Analysis 4.2).

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Subgroup analyses These could not be carried out due to an insufficient number of comparable trials.

Sensitivity analyses For the nine meta-analyses having high statistical heterogeneity (I² greater than 30%), we carried out sensitivity analyses exploring the differences between fixed-effect and random-effects methods; for four of these, the overall estimate of effect changed from being significant to non-significant. The other five that were non-significant did not change. Other sensitivity analyses were carried out on one meta-analysis of three studies (See Outcome 1.2.2: Total minutes of infant sleep in 24 hours at six weeks). Two studies that had greater than 20% attrition (McRury 2010; Symon 2005) were removed from the meta-analysis one at a time. When McRury 2010 was removed, high statistical heterogeneity remained. When Symon 2005 was removed, the heterogeneity was reduced to I² = 0%; however the overall estimate of effect changed from being significant to non-significant.

Overall completeness and applicability of evidence The usual benefit of meta-analyses for increasing statistical power by combining small studies was not achieved, since, with the exception of six studies (Golas 1986; McRury 2010; Myers 1982; St James-Roberts 2001; Stremler 2006; Symon 2005), the remaining nine studies were testing the effect of an intervention on one or more different outcomes at different lengths of time post-birth. This extensive heterogeneity of study outcomes permitted us to perform limited sensitivity analyses to test the effects of including studies of varying methodological quality. We were also unable to perform subgroup analyses to examine the effects of: specific class content, teaching approaches, interventions formats, age of infant at time of intervention, or effects in specific population groups.

Quality of the evidence The trials were of small to moderate size. The vast majority of the included studies were of uncertain quality, since details of the randomization procedure, allocation concealment, blinding of outcome assessors or participant accrual/loss, or both, were often not reported or unclear. Many studies had substantial attrition (greater than 20%).

DISCUSSION Potential biases in the review process Summary of main results Of the 27 trials (3949 mothers and 579 fathers) that met the inclusion criteria, only 15 (2922 mothers and 388 fathers) reported useable data. Educational interventions included: five on infant sleep enhancement, 12 on infant behaviour, three on general postbirth health, three on infant care, and four on infant safety. Of the outcomes analyzed, only 13 were measured similarly enough by more than one study to be combined in meta-analyses. Of these 13 meta-analyses, only four were found to have a low enough level of heterogeneity to provide an overall estimate of effect. Education about sleep enhancement resulted in a mean difference of 29 more night-time minutes of infant sleep in 24 hours at six weeks of age (95% CI 18.53 to 39.73) than usual care. However, it had no significant effect on the mean difference in minutes of crying time in 24 hours at six weeks and 12 weeks of age. Education related to infant behaviour increased maternal knowledge of infant behaviour by a mean difference of 2.85 points (95% CI 1.78 to 3.91). With the exception of these four meta-analyses, the benefits of educational programs to participants and their newborn infants remain unclear. Interestingly, only four of the 15 studies reporting useable data assessed whether additional knowledge was acquired as a result of an educational intervention, and of these, only two found an effect.

The review authors are not aware of any potential biases in the review process. We clarified inclusion criteria, as well as outcomes, which helped to create a more consistent result with respect to the study objective and time frame for the educational intervention.

Agreements and disagreements with other studies or reviews The review authors are not aware of other systematic reviews related to postnatal education with the same focus on interventions, outcomes, and time frame as the current review. Individual RCTs have found beneficial effects of postnatal parental education on infant sleep (Stremler 2006; Symon 2005); maternal knowledge (Golas 1986; Myers 1982); and infant safety (Christophersen 1982; Goetter 2005; Issler 2009; Shapiro 1987) as reported in this review; whereas others have shown no beneficial effect. The most consistent evidence appears to be related to the positive effect of education on infant safety early postnatally; however, we were unable to confirm this finding through meta-analyses. There also appears to be little effect of education on infant crying. Other studies of various postnatal educational interventions using various designs have demonstrated that they have been effective in improving parenting and infant outcomes such as: maternal-infant interaction; infant language development; parental attitudes

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and knowledge (Mercer 2006); paternal competence in parenting, including fostering infant cognitive growth and sensitivity to infant cues (Magill-Evans 2007). Many studies have investigated parental education that transitions from the antenatal period into the postnatal period and were excluded from this review as it is difficult to isolate the effect of postnatal education alone in these studies (e.g., Cupples 2011; Doherty 2006; Petch 2012; Wolfson 1992).

grams can be determined. Programs should include an assessment of whether they have been successful in teaching participants. Researchers should ensure that outcomes to be measured include those defined as important by both the consumers of this education and those providing new parents with this education. Conducting such trials will be challenging due to the large amount of information needed by new parents to respond to their infants’ needs. Measurement of education received in the ’usual care’ arm may be the most difficult to capture but would be key in ensuring clarity of comparisons.

AUTHORS’ CONCLUSIONS Implications for practice

ACKNOWLEDGEMENTS

No recommendations for practice changes can be made at this time, since there exists insufficient evidence to determine the effects of postnatal parental education for optimizing infant general health and care and parent-infant relationships.

Implications for research Postnatal education occurs on a regular basis in many post-birth settings worldwide. This suggests the need for large, well-designed clinical trials to answer the question of effectiveness on several key aspects of information retention and knowledge gained, together with consequent infant health intermediate outcomes and endpoints. Common outcome measures across different parent education programs are critical so that the general usefulness of such pro-

Anita Gagnon served as first author on the original review and the protocol. Laurie Barkun served as co-author on the published protocol. Hilary Elkins and Diane Habbouche provided editorial and practical support for the original review. Sharon Grant, Medical Librarian, McGill University verified the search strategies of the original review. Dawn Hooper, Data and Research Services Librarian, University of Prince Edward Island, transferred the original Ovid search strategies to Ebscohost and CSA interfaces and updated additional searches for the previous review. The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Pregnancy and Childbirth Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

REFERENCES

References to studies included in this review Anderson 1981 {published data only} Anderson CJ. Enhancing reciprocity between mother and neonate. Nursing Research 1981;30(2):89–93. Bolam 1998 {published data only} ∗ Bolam A, Manandhar DS, Shrestha P, Ellis M, Costello AM. The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial. BMJ 1998;316(7134):805–11. Stangroom C, Appleby A. Postnatal health education in Nepal study cannot be generalised [letter; comment]. BMJ 1998;317(7156):477; discussion 478.

Gibson 1995 {published data only} Gibson L. Patient education: effects of two teaching methods upon parental retention of infant feeding practices. Pediatric Nursing 1995;21(1):78–80. Goetter 2005 {published data only} Goetter MC, Flanders Stepans MB. First-time mothers’ selection of infant supine sleep positioning. Journal of Perinatal Education 2005;14(4):16–23. Golas 1986 {published data only} Golas GA, Parks P. Effect of early postpartum teaching on primiparas’ knowledge of infant behavior and degree of confidence. Research in Nursing & Health 1986;9(3): 209–14.

Christophersen 1982 {published data only} Christophersen ER, Sullivan MA. Increasing the protection of newborn infants in cars. Pediatrics 1982;70(1):21–5.

Hall 1980 {published data only} Hall LA. Effect of teaching on primiparas’ perceptions of their newborn. Nursing Research 1980;29(5):317–22.

Flagler 1988 {published data only} Flagler S. Maternal role competence. Western Journal of Nursing Research 1988;10(3):274–90.

Issler 2009 {published data only} Issler RM, Marostica PJ, Giugliani ER. Infant sleep position: a randomized clinical trial of an educational intervention in

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the maternity ward in Porto Alegre, Brazil. Birth 2009;36 (2):115–21. Jones 1977 {unpublished data only} ∗ Jones F. Maternal attachment to infants during postnatal period: effects of additional infant-mother contact and information about infant competency [thesis]. Oklahoma: Oklahoma State University, 1977. Jones FA, Green V, Krauss DR. Maternal responsiveness of primiparous mothers during the postpartum period: age differences. Pediatrics 1980;65(3):579–84. Keefe 2005 {published data only} Keefe MR, Barbosa GA, Froese-Fretz A, Kotzer AM, Lobo M. An intervention program for families with irritable infants. American Journal of Maternal Child Nursing 2005; 30(4):230–6. Liptak 1983 {published data only} Liptak GS, Keller BB, Feldman AW, Chamberlin RW. Enhancing infant development and parent-practitioner interaction with the Brazelton Neonatal Assessment Scale. Pediatrics 1983;72(1):71–8. McRury 2010 {published data only} McRury JM, Zolotor AJ. A randomized, controlled trial of a behavioral intervention to reduce crying among infants. Journal of the American Board of Family Medicine: JABFM 2010;23(3):315–22. Moore 1987 {published data only} Moore L. Effects of mediated instruction, the cesarean experience, and infant characteristics on maternal attachment behavior. Journal of Obstetric Gynecologic and Neonatal Nursing 1987;6:366. Myers 1982 {published data only} Myers BJ. Early intervention using Brazelton training with middle-class mothers and fathers of newborns. Child Development 1982;53(2):462–71. Paradis 2011 {published data only} ∗ Paradis HA, Conn KM, Gewirtz JR, Halterman JS. Innovative delivery of newborn anticipatory guidance: a randomized, controlled trial incorporating media-based learning into primary care. Academic Pediatrics 2011;11(1): 27–33. Paradis HA, Conn KM, Haltermann JS. Innovative delivery of newborn anticipatory guidance: a RCT incorporating media-based learning into primary care. Pediatric Academic Societies’ 2010 Annual Meeting; 2010 May 1-4; Vancouver, Canada. 2010. Paul 2011 {published data only} Paul IM, Beiler JS, Schaefer EW, Hollenbeak CS, Alleman N, Sturgis SA. A randomized trial of nurse home visits vs. office-based care after nursery/maternity discharge. Pediatric Academic Societies and Asian Society for Pediatric Research Joint Meeting; 2011 April 30-May 3; Denver, Colorado, USA. 2011:2300.6. ∗ Paul IM, Savage JS, Anzman SL, Beiler JS, Marini ME, Stokes JL, et al. Preventing obesity during infancy: a pilot study. Obesity (Silver Spring, Md.) 2011;19(2):353–61.

Petrowski 1981 {published data only} Petrowski DD. Effectiveness of prenatal and postnatal instruction in postpartum care. Journal of Obstetric, Gynecologic and Neonatal Nursing 1981;10(5):386–9. Regan 1995 {published data only} Regan RE, Lydon-Rochelle MT. Research exchange. Effectiveness of postpartum education received by certified nurse-midwives’ clients at a university hospital. Journal of Nurse-Midwifery 1995;40(1):31–5. Riesch 1984 {published data only} Riesch SK, Munns SK. Promoting awareness: the mother and her baby. Nursing Research 1984;33(5):271–6. Shapiro 1987 {published data only} Shapiro M, Katcher M. Injury-prevention education during postpartum hospitalization. American Journal of Diseases of Children 1987;141:382. St James-Roberts 2001 {published data only} St James-Roberts I, Sleep J, Morris S, Owen C, Gillham P. Use of a behavioural programme in the first 3 months to prevent infant crying and sleeping problems. Journal of Paediatrics & Child Health 2001;37(3):289–97. Stremler 2006 {published data only} Stremler R, Hodnett E, Lee K, MacMillan S, Mill C, Ongcangco L, et al. A behavioral-educational intervention to promote maternal and infant sleep: a pilot randomized, controlled trial. Sleep 2006;29(12):1609–15. Sullivan 1980 {published data only} Sullivan LD, Leake D. Significant effect of the Brazelton Neonatal Behavioral assessment scale (BNBAS) in maternal training. Pediatric Research 1980;14:439. Symon 2005 {published data only} Symon BG, Marley JE, Martin AJ, Norman ER. Effect of a consultation teaching behaviour modification on sleep performance in infants: a randomised controlled trial. Medical Journal of Australia 2005;182(5):215–8. Wendland-Carro 1999 {published data only} Wendland-Carro J, Piccinini CA, Millar WS. The role of an early intervention on enhancing the quality of motherinfant interaction. Child Development 1999;70(3):713–21. Worobey 1982 {published data only} Worobey J, Belsky J. Employing the Brazelton scale to influence mothering: an experimental comparison of three strategies. Developmental Psychology 1982;18(5):736–43.

References to studies excluded from this review Adam 1985 {published data only} Adam HM, Stern EK, Stein REK. Anticipatory guidance: a modest intervention in the nursery. Pediatrics 1985;76: 781–6. Akai 2008 {published data only} Akai CE, Guttentag CL, Baggett, KM, Willard Noria CC. Enhancing parenting practices of at-risk mothers. Journal of Primary Prevention 2008;29(3):223–42.

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Baqui 2008 {published data only} Baqui AH, Arifeen SE, Rosen HE, Mannan I, Rahman SM, Al-Mahmud AB, et al. Community-based validation of assessment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh. Tropical Medicine and International Health 2009;14(12):1448–56. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 2008;371 (9628):1936–44. Barlow 2013 {published data only} Barlow A, Mullany B, Neault N, Compton S, Carter A, Hastings R, et al. Effect of a paraprofessional home-visiting intervention on American Indian teen mothers’ and infants’ behavioral risks: A randomized controlled trial. American Journal of Psychiatry 2013;170(1):83–93. Barr 2009 {published data only} Barr RG, Rivara FP, Barr M, Cummings P, Taylor J, Lengua LJ, et al. Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial. Pediatrics 2009;123(3): 972–80. Bashour 2008 {published data only} Bashour HN, Kharouf MH, Abdulsalam AA, El Asmar K, Tabbaa MA, Cheikha SA. Effect of postnatal home visits on maternal/infant outcomes in Syria: a randomized controlled trial. Public Health Nursing 2008;25(2):115–25. Beal 1989 {published data only} Beal JA. The effect on father-infant interaction of demonstrating the neonatal behavioral assessment scale. Birth 1989;16(1):18–22. Beiler 2011 {published data only} Beiler JS, Schaefer EW, Alleman N, Paul IM. Newborn anticipatory guidance delivered at office-based vs. home nurse visits. Pediatric Academic Societies and Asian Society for Pediatric Research Joint Meeting; 2011 April 30-May 3; Denver, Colorado, USA. 2011. Bristor 1984 {published data only} Bristor MW, Helfer RE, Coy KB. Effects of perinatal coaching on mother-infant interaction. American Journal of Diseases of Children 1984;138:254–7. Cevasco 2008 {published data only} Cevasco AM. The effects of mothers’ singing on full-term and preterm infants and maternal emotional responses. Journal of Music Therapy 2008;45(3):273–306. Cohen 1980 {published data only} Cohen S. Postpartum teaching and the subsequent use of milk supplements. Birth and the Family Journal 1980;7(3): 163–7. Cupples 2011 {published data only} Cupples ME, Stewart MC, Percy A, Hepper P, Murphy C, Halliday HL. A RCT of peer-mentoring for first-time

mothers in socially disadvantaged areas (the MOMENTS Study). Archives of Disease in Childhood 2011;96(3):252–8. Dihigo 1998 {published data only} Dihigo SK. New strategies for the treatment of colic: modifying the parent/infant interaction. Journal of Pediatric Health Care 1998;12(5):256–62. Doherty 2006 {published data only} Doherty WJ, Erickson MF, LaRossa R. An intervention to increase father involvement and skills with infants during the transition to parenthood. Journal of Family Psychology 2006;20(3):438–47. French 2012 {published data only} French GM, Nicholson L, Skybo T, Klein EG, Schwirian PM, Murray-Johnson L, et al. An evaluation of mothercentered anticipatory guidance to reduce obesogenic infant feeding behaviors. Pediatrics 2012;130(3):e507–17. Glazebrook 2007 {published data only} Glazebrook C, Marlow N, Israel C, Croudace T, Johnson S, White IR, et al. Randomised trial of a parenting intervention during neonatal intensive care. Archives of Disease in Childhood. Fetal and Neonatal Edition 2007;92 (6):F438–F443. Goyal 2009 {published data only} Goyal D, Gay C, Lee K. Fragmented maternal sleep is more strongly correlated with depressive symptoms than infant temperament at three months postpartum. Archives of Women’s Mental Health 2009;12(4):229–37. Hansen 1990 {published data only} Hansen BW. A randomized controlled trial on the effect of an information booklet for young families in Denmark. Patient Education & Counseling 1990;16(2):147–50. Hawkins 2008 {published data only} Hawkins AJ, Lovejoy KR, Holmes EK, Blanchard VL, Fawcett E. Increasing fathers’ involvement in child care with a couple-focused intervention during the transition to parenthood. Family Relations 2008;57:49–59. Ho 2009 {published data only} Ho S-M, Heh S-S, Jevitt CM, Huang L-H, Fu Y-Y, Wang L-L. Effectiveness of a discharge education program in reducing the severity of postpartum depression. A randomized controlled evaluation study. Patient Education and Counseling 2009;77(1):68–71. Kabakian-Khasholian 2005 {published data only} Kabakian-Khasholian T, Campbell OM. Impact of written information on women’s use of postpartum services: a randomised controlled trial. Acta Obstetricia et Gynecologica Scandinavica 2007;86:793–8. Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG: an International Journal of Obstetrics & Gynaecology 2005;112(9):1315–21. Kemp 2011 {published data only} Kemp L, Harris E, McMahon C, Matthey S, Impani GV, Anderson T, et al. Child and family outcomes of a longterm nurse home visitation programme: a randomised

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controlled trial. Archives of Disease in Childhood 2011;96 (6):533–40. Kistin 2011 {published data only} Kistin C, Barrero-Castillero A, Lewis S, Hoch R, Philipp BL, Wang J. The impact of maternal note taking on the effectiveness of newborn anticipatory guidance: a randomized controlled trial. Pediatric Academic Societies and Asian Society for Pediatric Research Joint Meeting; 2011 April 30-May 3; Denver, Colorado, USA. 2011: 4505.147. Lee 2012 {published data only} Lee JT, Tsai J L. Transtheoretical model-based postpartum sexual health education program improves women’s sexual behaviors and sexual health. Journal of Sexual Medicine 2012;9(4):986–96. Leff 1988 {published data only} Leff EW. Comparison of the effectiveness of videotape versus live group infant care classes. Journal of Obstetric Gynecologic and Neonatal Nursing 1988;17(5):338–44. Morrell 2000 {published data only} ∗ Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and benefits of community postnatal support workers: a randomised controlled trial. Health Technology Assessment 2000;4(6):1–100. Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321(7261):593–8. Niccols 2008 {published data only} Niccols A. ’Right from the Start’: randomized trial comparing an attachment group intervention to supportive home visiting. Journal of Child Psychology and Psychiatry and Allied Disciplines 2008;49(7):754–64. Petch 2012 {published data only} Petch JF, Halford WK, Creedy DK, Gamble J. A randomized controlled trial of a couple relationship and coparenting program (Couple CARE for Parents) for high- and low-risk new parents. Journal of Consulting & Clinical Psychology 2012;80(4):662–73. Reich 2010 {published data only} Reich SM, Bickman L, Saville BR, Alvarez J. The effectiveness of baby books for providing pediatric anticipatory guidance to new mothers. Pediatrics 2010;125 (5):997–1002. Reich SM, Penner EK, Duncan GJ. Using baby books to increase new mothers’ safety practices. Academic Pediatrics 2011;11(1):34–43. Reich SM, Penner EK, Duncan GJ, Auger A. Using baby books to change new mothers’ attitudes about corporal punishment. Child Abuse & Neglect 2012;36(2):108–17. Rotheram-Borus 2011 {published data only} Rotheram-Borus MJ, le Roux IM, Tomlinson M, Mbewu N, Comulada WS, le Roux K, et al. Philani Plus (+): a Mentor Mother community health worker home visiting program to improve maternal and infants’ outcomes. Prevention Science 2011;12(4):372–88.

Santelices 2011 {published data only} Santelices MP, Guzman GM, Aracena M, Farkas C, Armijo I, Perez-Salas CP, et al. Promoting secure attachment: evaluation of the effectiveness of an early intervention pilot programme with mother-infant dyads in Santiago, Chile. Child: Care, Health & Development 2011;37(2):203–10. Scott 1990 {published data only} Scott G, Richards MP. Night waking in infants: effects of providing advice and support for parents. Journal of Child Psychology & Psychiatry & Allied Disciplines 1990;31(4): 551–67. Shapiro 2011 {published data only} Shapiro AF, Nahm EY, Gottman JM, Content K. Bringing baby home together: examining the impact of a couplefocused intervention on the dynamics within family play. American Journal of Orthopsychiatry 2011;81(3):337–50. Simons 2001 {published data only} Simons J, Reynolds J, Morison L. Randomised controlled trial of training health visitors to identify and help couples with relationship problems following a birth. British Journal of General Practice 2001;51(471):793–9. Spigelblatt 1991 {published data only} Spigelblatt L, Laine-Ammara G, Arsenault L, Zvagulis I, Pless IB. Influence of follow-up education of mothers about too early introduction of solid food to infants. Pediatrie 1991;46(5):475–9. Wagner 1999 {published data only} Wagner MM, Clayton SL. The Parents as Teachers Program: results from two demonstrations. Future of Children 1999;9 (1):91–115. Waterston 2009 {published data only} Waterston T, Welsh B. What are the benefits of a parenting newsletter?. Community Practitioner 2007;80(8):32–5. ∗ Waterston T, Welsh B, Keane B, Cook M, Hammal D, Parker L, et al. Improving early relationships: a randomized, controlled trial of an age-paced parenting newsletter. Pediatrics 2009;123(1):241–7. Wen 2011 {published data only} Wen LM, Baur LA, Simpson JM, Rissel C, Flood VM. Effectiveness of an early intervention on infant feeding practices and “tummy time”: A randomized controlled trial. Archives of Pediatrics and Adolescent Medicine 2011;165(8): 701–7. Wen LM, Baur LA, Simpson JM, Rissel C, Wardle K, Flood VM. Effectiveness of home based early intervention on children’s BMI at age 2: Randomised controlled trial. BMJ (Online) 2012;345(7865):e3732. Wolfson 1992 {published data only} Wolfson A, Lacks P, Futterman A. Effects of parent training on infant sleeping patterns, parents’ stress, and perceived parental competence. Journal of Consulting and Clinical Psychology 1992;60(1):41–8.

References to studies awaiting assessment

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Kim 2004 {published data only} Kim MY, Jang GJ, Kim SH. [Effects of sensory stimulation program conducted by primipara on the physical growth and mother-infant feeding interaction for full term infant]. [Korean]. Daehan Ganho Haghoeji 2004; Vol. 34, issue 5: 820–8.

References to ongoing studies Cook 2012 {published data only} Cook F, Bayer J, Le HND, Mensah F, Cann W, Hiscock H. Baby Business: A randomised controlled trial of a universal parenting program that aims to prevent early infant sleep and cry problems and associated parental depression. BMC Pediatrics 2012;12:13.

March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org. Maas 2012 Maas A, Vreeswijk C, de Cock E, Rijk C, van Bakel H. “Expectant parents”: Study protocol of a longitudinal study concerning prenatal (risk) factors and postnatal infant development, parenting, and parent-infant relationships. BMC Pregnancy & Childbirth 2012;12(1):46–53. Magill-Evans 2007 Magill-Evans J, Harrison M, Benzies K, Gierl M, Kimak C. Effects of parenting education on first-time fathers’ skills in interactions with their infants. Fathering 2007;5(1):42–57.

Additional references

McCain 2011 McCain M, Mustard F. Early Years Study 3. Toronto: Margaret & Wallace McCain Family Foundation, 2011.

Bandura 1989 Bandura A. Regulation of cognitive processes through perceived self-efficacy. Developmental Psychology 1989;25: 729–35.

Mercer 2006 Mercer R, Walker L. A review of nursing interventions to foster becoming a mother. Journal of Obstetric, Gynecologic & Neonatal Nursing 2006;35(5):568–82.

Bornstein 2002 Bornstein MH. Parenting infants. Handbook of Parenting. 2nd Edition. Mahwah, NJ: Lawrence Erlbaum Associates, 2002:3–43.

Murray 2010 Murray S, McKinney E. Foundations of Maternal-Newborn Nursing. 5th Edition. St. Louis, MO: Saunders, 2010.

Brown 2006 Brown S. Tender Beginnings Program: an educational continuum for the maternity patient. Journal of Perinatal and Neonatal Nursing 2006;20(3):210–9. CCCF 2001 Canadian Child Care Federation. What We Know About the Brain. Ottawa: Canadian Institute of Child Health, 2001. de Montigny 2008 de Montigny F, Lacharite C. Modeling parents’ and nurses’ relationships. Western Journal of Nursing Research 2008;30 (6):734–58. Dusing 2012 Dusing SCM, Brown SE. Instituting parent education practices in the neonatal intensive care unit: An administrative case report of practice evaluation and statewide action. Physical Therapy 2012;92(7):967–75. El-Mohandes 2003 El-Mohandes A, Katz K, El-Khorazaty N, McNeelyJohnson D, Sharps P, Jarrett M, et al. The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study. Pediatrics 2003; 111(6):1324–33. Higgins 2011 Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated

Mustard 2008 Mustard F. Investing in the Early Years: Closing the Gap Between What We Know and What We Do. South Australia: Government of South Australia, 2008. RevMan 2012 [Computer program] The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012. Wilkins 2006 Wilkins C. A qualitative study exploring the support needs of first-time mothers on their journey towards intuitive parenting. Midwifery 2006;22(2):169–80.

References to other published versions of this review Bryanton 2010 Bryanton J, Beck C. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD004068.pub3] Gagnon 2009 Gagnon AJ, Bryanton J. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD004068.pub2] ∗ Indicates the major publication for the study

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CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID] Anderson 1981 Methods

Randomization to 3 groups: 1 control and 2 intervention. Method of randomization not stated. Blinding of outcome assessors. Single-centre trial.

Participants

Included 30 mothers and newborns. Inclusion criteria were: primiparas having uncomplicated pregnancies, labours, and births, local or regional anaesthesia, full term, healthy, female newborns, no post-birth complications. All breastfeeding. Trial conducted in a 500-bed community hospital likely in Chicago, Illinois, USA

Interventions

Group 1 (Control) received no instruction. Brazelton Assessment performed in nursery with mom not present, no feedback to moms, offered a class on infant furnishings during postpartum hospital stay. Group 2 (Explanation only) Brazelton Assessment performed in the nursery without mom present. Following assessment the investigator met with the mother in her postpartum room and explained the assessment done, her infant’s performance and positive aspects of performance stressed. Group 3 (Demonstration and Explanation) Investigator met with mother in her room, performed the Brazelton Assessment in the mother’s presence and gave an explanation of the assessment throughout. 10 dyads randomized per group

Outcomes

An independent assessor (graduate student) assessed mother-infant dyads observed during a feeding at 24-48 hours (pre-test) and 10 to 12 days postpartum (post-test) (not clear where data were collected at 10 days). Measured Maternal Reciprocity (13 items) , Infant Reciprocity (5 items) and Maternal-Infant Interaction (3 items). Items scored 1 to 5 with 1 representing low reciprocity and 5 representing high reciprocity.

Notes

Small sample, no power analysis noted. No useable data.

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not stated.

Allocation concealment (selection bias)

Allocation concealment not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Low risk bias) All outcomes

Blinding of outcome assessor.

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Anderson 1981

(Continued)

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

No losses discussed.

Selective reporting (reporting bias)

High risk

Findings reported but no data on maternalinfant interaction. Infant reciprocity data incomplete for Group 3

Other bias

Low risk

Groups equivalent at baseline.

Bolam 1998 Methods

Block randomization to 4 groups: 3 intervention and 1 control. Blinding of outcome assessors (different assessors at 3 and 6 months). Single-centre trial

Participants

Included 540 Nepalese participants, all pregnant women admitted to Prasute Griha Hospital. Exclusion criteria were: women who had stillbirths or discharged from hospital before randomization occurred

Interventions

Included 1-on-1 teaching for mothers in treatment groups. None for control (Group A - teaching at birth and 3 months, Group B - birth only, Group C - 3 months only, Group D - none) (n = 135 women randomized to each group). Intervention occurred in hospital and at home and included topics such as breastfeeding, treatment of diarrhoea, recognition of and response to upper respiratory tract infections, immunization, and family planning

Outcomes

Mothers’ knowledge of pneumonia, indrawing, tachypnoea; knowledge of diarrhoea; give rehydration solution; immunized infant. Infants’ weight gain, length, and head circumference. Comparisons presented in analyses are for Group B vs Group D as only these groups met review inclusion criteria of 2 months post-birth

Notes

May have included teens and mothers of NICU babies. Power analysis on all outcomes

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Block randomization using blocks of 20, random ordering of numbers from 0 to 19. Numbers 0-4, 5-9, 10-14, and 15-19 were assigned to groups A to D respectively

Allocation concealment (selection bias)

Sequentially numbered, sealed, opaque envelopes. Generator of assignment was not involved in execution of allocation

Low risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

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Bolam 1998

(Continued)

Blinding of outcome assessment (detection Low risk bias) All outcomes

Single blinding of outcome assessors (different assessors at 3 and 6 months)

Incomplete outcome data (attrition bias) All outcomes

High risk

Reported losses for all groups at 3 and 6 months due to stillbirth, infant death, and loss to follow-up. Total losses Group A (30%), Group B (22%) Group C (29%), Group D (27%). No imbalance across outcomes. No intention to treat. Greater than 20% attrition

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

Low risk

Groups equivalent at baseline except 15% difference in illiteracy between groups B and C

Christophersen 1982 Methods

Mothers were selected sequentially from the obstetrics ward and randomly assigned by coin toss, in pairs to either the restraint seat group or usual care. There was no blinding of patients, caregivers, or outcome assessors. Single-centre trial

Participants

Included 30 mothers who gave birth at Shawnee Mission Medical Center, a private nonprofit hospital in suburban Kansas City, USA to a single live infant with baby’s doctor practising within a 10-mile radius

Interventions

Intervention (restraint seat): mothers (n = 15) were approached in their rooms prior to discharge by trained staff and offered a demonstration of the proper placement of the infant in the infant restraint seat, how to carry the seat with the infant in it, and the correct restraining of the seat with the automobile lap belt. They also placed the infant in the seat and securely in the car. Control group mothers (n = 15) were discharged in the usual manner

Outcomes

Correct use of infant restraint seat at discharge and at 4 to 6 week follow-up

Notes

Mothers were not asked to participate in the study; however their obstetricians, paediatricians, and family practitioners were asked for informed consent to observe their patients. The study was reviewed by the Medical Center Committee on human subjects. Interobserver reliability 100% at both times. Although education was given in the experimental group, the intervention included placing the newborn correctly in the car. Thus the observed outcome was either the result of the parents physically removing the infant or the staff member putting the infant in correctly

Risk of bias Bias

Authors’ judgement

Support for judgement

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Christophersen 1982

(Continued)

Random sequence generation (selection Low risk bias)

Randomly assigned by coin toss to “restraint seat” or “no restraint seat” group

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Low risk (performance bias) All outcomes

Participants were not aware they were in a study so they were essentially blinded

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

Low risk

At discharge no loss. At 4 to 6 weeks, .5% loss in treatment (n = 1) and 1% in control (n = 2). No intention-to-treat

Selective reporting (reporting bias)

Low risk

Main outcome reported for both groups at both times.

Other bias

High risk

No baseline data collected so unclear if groups equivalent at baseline

Flagler 1988 Methods

Randomization to intervention and control group. Method of randomization not stated. No blinding. Likely a single-centre trial

Participants

Included 74 American participants. Inclusion criteria were: vaginal birth, primipara, 2030 years of age, living with father, normal full-term infant, and uncomplicated postpartum.Trial conducted in San Francisco, CA, USA

Interventions

A 20-minute Brazelton assessment, individual demonstration of normal newborn behaviour with mother on second or third day postpartum in mother’s room. Nothing stated regarding control group. The article did not state the number of participants randomized to each group (at analysis n = 31 in intervention n = 30 in control)

Outcomes

Included maternal role competence as measured by: (1) the mother’s perception of herself as a mother as compared against an ideal mother (15 items on a 7-point scale), with smaller distances between the 2 indicating greater role competence; (2) mutuality - the mother’s ability to perceive her infant’s cues, using the 10-item Issue One Subscale of the Maternal Attitude Scale; and (3) maternal anxiety related to child-rearing using the 14-item MAS subscale - a higher score reflects less anxiety. Data collection occurred at baseline and in the home 4 to 6 weeks’ postpartum

Notes Risk of bias Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Flagler 1988

(Continued)

Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not stated.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel High risk (performance bias) All outcomes

No blinding.

Blinding of outcome assessment (detection High risk bias) All outcomes

No blinding.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

Numbers not given for initial randomization to groups. 13 lost to follow-up (18%) but not stated which group. No intentionto-treat

Selective reporting (reporting bias)

Low risk

Reported on all outcomes

Other bias

Low risk

Groups at baseline comparable except for gender of infant.

Gibson 1995 Methods

Randomization done by having mother select a number from a box that contained numbered wooden squares. Mothers selecting even numbered squares were placed in the intervention groups and those selecting odd-numbered squares were placed in the control group. No blinding evident. Single-centre trial

Participants

Included 40 mothers on the postpartum unit of a metropolitan hospital in Arlington, Texas, USA. Inclusion criteria were not stated but all newborns were full term and were in the normal newborn nursery.

Interventions

The control group (n = 20) received 20 minutes of education related to first year infant feeding practices. The intervention group (n = 20) received the same 20 minutes of education as well as an additional 10 minutes of teaching with the same information in the form of a video but condensed (50% over learning beyond the mastery level). Teaching was done in group format on the postpartum unit. Did not state number of days postpartum. 4 lost to follow-up at 2 weeks

Outcomes

Included maternal knowledge of infant feeding practices measured by the Infant Feeding Questionnaire which contained 16 multiple choice and 8 true and false questions. Pretest given to all mothers. If scored less than 95% (less than mastery), they were given correct answers and brief explanation. Then they answered questions they missed and process repeated until they had 95% or above. Post-test at 2 weeks during a visit to paediatrician

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Gibson 1995

(Continued)

or home visit Notes

Content validity and internal consistency of instrument satisfactory. Ratings done by 2 nurses on similarity between verbal directions and film (4.6 and 4.8 on a scale of 5). No useable data

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Randomization done by having mother select a number from a box that contained numbered wooden squares

Allocation concealment (selection bias)

No allocation concealment.

High risk

Blinding of participants and personnel High risk (performance bias) All outcomes

No blinding evident.

Blinding of outcome assessment (detection High risk bias) All outcomes

No blinding evident.

Incomplete outcome data (attrition bias) All outcomes

Low risk

4 lost to follow-up at 2 weeks were not included in analysis

Selective reporting (reporting bias)

Low risk

Outcomes reported but data not useable as only reported t-test and P values

Other bias

Low risk

Stated extraneous variables controlled by randomization but no baseline characteristics reported

Goetter 2005 Methods

Randomization to intervention and control group. Method of randomization not stated and no blinding occurred. Single-centre trial

Participants

Included 61 American participants. Inclusion criteria were: primiparas, 18-35, Englishspeaking. Exclusion criteria were: NICU infants and women who knew researcher. Trial conducted in a mountain community hospital, possibly Wyoming

Interventions

Intervention (n = 32) included positioning for SIDS prevention, individual instruction with mother in hospital postpartum, explanation and demonstration of positioning, and how to maintain position, definition and causes of SIDS. Control (n = 29) received usual care (inconsistent individual or group teaching SIDS might or might not be mentioned)

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Goetter 2005

(Continued)

Outcomes

Included first week positioning (supine/not supine). Also, at 6 weeks, current position, last night’s position, and today’s nap position

Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not stated.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel High risk (performance bias) All outcomes

No blinding.

Blinding of outcome assessment (detection High risk bias) All outcomes

No blinding.

Incomplete outcome data (attrition bias) All outcomes

Low risk

No losses to follow-up.

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

Unclear risk

Groups not equivalent at baseline. Intervention group was older and included more Caucasians than the control group

Golas 1986 Methods

Randomization to intervention, contrast, and control groups. Method of randomization not described. Groups equivalent at baseline. No blinding. Single-centre trial

Participants

Included 54 mothers and newborns. Inclusion criteria were: primiparas, uncomplicated births, newborns received examinations by private paediatrician group practice, term infants, no congenital anomalies or medical complications in first 2 weeks of life. Exclusion criterion was: multiple births. Mothers were well educated, adults, married, white, middle-class Americans from Baltimore, MD, USA

Interventions

19 mother-infant dyads randomized to intervention: n = 19 to contrast and n = 16 to control group. Intervention included individual 2-hour session by nurse practitioner with each mother-infant dyad within 5 days of newborn being 2 weeks old. Setting: examination room of paediatrician’s office. Teaching plan with specific goals but delivered in a flexible order based on infant behaviour and mother’s responses and questions. (1) viewed a 25-minute film (The Amazing Newborn); (2) oral and visual presentation of

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Golas 1986

(Continued)

different states of infant behaviour and appropriate maternal response; (3) demonstration of selected items from BNBAS and return demonstration by mothers, individually based on newborn. Control received no contact with paediatric nurse practitioner at 2 weeks. Contrast received no contact with nurse practitioner at 2 weeks. Completed Newborn Information Checklist at 2 weeks. Teaching provided to control and contrast mothers following study Outcomes

Measurements taken at 4 weeks postpartum lasting 20-25 minutes. Included (1) maternal knowledge of newborn characteristics and capabilities from birth to 4 weeks: consolability; interpretation of physical cues, crying, visual auditory responses. 20 items worth 1 point. Total score 0-20; (2) maternal confidence in interpreting infant behaviour. 12 items rated 1-5. Total score 12-60; (3) maternal satisfaction with teaching interventionmean response (only intervention group).

Notes

Small sample. No mention of power analysis.

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not discussed.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel High risk (performance bias) All outcomes

No blinding.

Blinding of outcome assessment (detection High risk bias) All outcomes

Researcher conducted intervention and collected data.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

Overall a 14.8% loss (10.5% intervention; 15.8% contrast; 18.8% control). 5 withdrew after randomization (n = 2 intervention, n = 1 contrast, n = 2 control), and 3 were excluded from analysis because 1 had twins and 2 were enrolled in a similar class (n = 2 contrast and n = 1 control). Did not use intention-to-treat

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

Low risk

Chi2 analysis to rule out confounding by telephone information that was included in the teaching intervention given to mothers across groups. No significant difference in occurrence of calls to office between

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Golas 1986

(Continued)

groups. Groups were comparable at baseline Hall 1980 Methods

Randomization to intervention and control group. Method of randomization not stated and no blinding was described. Single-centre trial

Participants

Included 30 participants recruited in the US, possibly in South Carolina. Inclusion criteria were: 18-30 years, primiparas, married, no chronic disease, an uncomplicated pregnancy, vaginal birth, full-term, no complications during birth and postpartum

Interventions

Included individual teaching for mothers at home in 1 session 2 to 4 days postpartum. They were assessed individually based on learning needs, taught normal newborn behaviour, crying, feeding, spitting up, elimination, and predictability. 15 each randomized to intervention and control group. No mention if control received usual care

Outcomes

Data collected at 1 month and included perception of infant and mean scores on neonatal perception. Results are presented as differences between the average baby and the mother’s baby; lower values indicate more positive perceptions

Notes

Sample chosen deliberately. No power analysis mentioned.

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not discussed.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

No mention of losses. Sample sizes at analysis were not given

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

Low risk

Groups similar at baseline.

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Issler 2009 Methods

Block randomization Monday to Friday (excluded weekends to prevent contamination between groups). Blocks of 4 consecutive weeks at a time. Outcome assessor blinded. Single-centre trial

Participants

Included 228 mother-infant pairs “living in a previously selected area of Porto Alegre” from September 2005 to September 2006. Pairs were excluded if mothers had a “severe physical handicap or mental health problems” such as “profound depression or overt schizophrenia”. Study took place on the maternity ward of a large teaching hospital in a large city in Brazil

Interventions

Intervention: 112 mothers received a 1-on-1 oral orientation and demonstration using a baby doll model regarding sleep position. They were also given a folder with information about infant sleep positioning and received the routine oral orientation from hospital personnel. The education occurred in the mother’s hospital room. Control: 116 mothers received usual care which included routine oral orientation from hospital personnel

Outcomes

Infant sleep position at 3 and 6 months observed by an interviewer in the home or demonstrated by the mother if infant was awake during visit

Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Tossed a coin to randomize in blocks of 4 consecutive weeks. Women giving birth on weekends were not included but this should not result in a selection bias

Allocation concealment (selection bias)

All women who gave birth during the week assigned by randomization were eligible. All received the same condition for that week with no recruitment to minimize possible contamination effects

Low risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

Not clear if women were blinded to study hypotheses. Otherwise clinicians nor mothers were blinded

Blinding of outcome assessment (detection Low risk bias) All outcomes

Outcome assessors were blinded to group assignment. Once initial data were collected, group assignment was sealed in an envelope and not opened until the study was completed

Incomplete outcome data (attrition bias) All outcomes

Following randomization, loss to follow-up in intervention group n = 21 (2 refused to participate, 10 moved to another town, 9

High risk

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Issler 2009

(Continued)

were not found at the stated address) and n = 16 in the control group (1 refused to participate, 8 moved to another town, 7 were not found at the stated address). The control group lost another 6 by 6 months. Attrition was comparable in both groups. (Intervention = 19% and control = 14% at 3 months and 19% for both at 6 months). No intention-to-treat analysis. At 3 months 91 were analyzed in the intervention group and 100 in the control and at 6 months 91 and 94 were analyzed respectively Selective reporting (reporting bias)

Low risk

2 outcomes reported.

Other bias

Low risk

Baseline equivalence except for marital status. In intervention group more women were married or living with a partner. This was not associated with sleeping position in bivariate analysis

Jones 1977 Methods

Randomization to 4 groups: 3 intervention and 1 control group. Method of randomization not stated. Experimenter and outcome assessor blinded. No other blinding mentioned. Single-centre trial

Participants

Included 40 mothers from Oklahoma, USA. Inclusion criteria were: well, primiparous women of a clinic population of 1 hospital who had a vaginal birth and planned to keep their infants; well, term infants without evidence of IUGR or anomalies, with a 1minute Apgar greater than 4 and a 5-minute Apgar greater than 7. Exclusion criterion was: multiple births

Interventions

Intervention and data collection occurred on the postpartum unit of 1 hospital. 10 mothers received “Additional Information (AI)” by the neonatologist within 24 hours post-birth. They were informed about sensory capabilities of newborns and encouraged to be aware of their infant’s capabilities. 10 mothers received “Additional Contact (AC) ”. They were instructed by a nurse within 24 hours of birth to stroke their nude infants for 10 minutes, dress and hold or rock their infants for 5 minutes after 4 daily feedings. Benefits of skin to skin also given. 10 mothers received “Additional Contact and Additional Information (AI-AC). 10 control mothers received traditional contact which was a glimpse of the infant after birth, brief contact at 6 to 12 hours and visits of 20 to 30 minutes every 4 hours for feeding. Data collection occurred before discharge in the nursery on days 3 to 6

Outcomes

Maternal behaviours were observed from video-taped sessions of mothers watching their infants during the discharge exam (distance from infant, questions about care, questions about condition, contact with infant, behavioural responsiveness, verbal responsiveness

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Jones 1977

(Continued)

to infant, verbal responsiveness to physician, distress of infant) and during a feeding (enface position, lateral trunk contact, fondling of infant, vocalizations). Behaviours were given a total score representing the presence of the behaviour at any time within a 30second film clip summed over a series of 5 film clips. Left Sided Preference to Hold Infant presented from midline also observed. Notes

Inter-rater reliability 70% to 100% on 10 observations with an average of 91.6%. 10% refusal rate. Teenagers included in sample. No useable data

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not stated.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

Experimenter blinded, otherwise not discussed.

Blinding of outcome assessment (detection Low risk bias) All outcomes

Outcome assessor blinded.

Incomplete outcome data (attrition bias) All outcomes

Low risk

3 moms discharged before data collected were replaced by next eligible subject assigned to condition

Selective reporting (reporting bias)

High risk

All outcomes discussed but ANOVA tables for each outcome present only mean square and f ratio and data not useable

Other bias

Low risk

Groups equivalent at baseline.

Keefe 2005 Methods

Randomized by project co-ordinator using central computer randomization. 3 groups: intervention, control, and post-test only group. Post-test only group not randomized (used to compare to control on outcome data to illustrate any changes due to attention from evaluation team or developmental changes alone). Evaluation team blinded, separate from intervention team. 2 centres

Participants

Included 180 newborns and their parents. Inclusion criteria were: healthy, full-term, low risk infants between 2 to 6 weeks of age, living within a 2-hour radius of the city, and having unexplained crying more than 2.5 hours per day over the past week. Conducted in Charleston, South Carolina and Denver, Colorado, USA

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Keefe 2005

(Continued)

Interventions

Control group received routine care (not described). 121 in intervention and control. Doesn’t state number per group except 43 in non-randomized post-test only. Intervention parents received REST program. Intervention nurses formed specific recommendations and care plans for each infant. 4 home visits, 1 per week. Both parents received individual instruction, demonstration, written material, video in the home over the 4 visits. 16 lost to follow-up, not included in analysis

Outcomes

Included hours of infant crying using a crying log and infant fussiness using Fussiness Rating Scale (Likert-type scale). Collected at baseline, 4 weeks and 8 weeks

Notes

Power analysis done. No useable data.

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Randomized by project coordinator using central computer randomization

Allocation concealment (selection bias)

Adequate concealment.

Low risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Low risk bias) All outcomes

Evaluation team blinded, separate from intervention team.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

16 withdrew or were lost to follow-up after randomization not included in analysis. Not explicit about numbers per group and losses per group not clear. States no differences between those who left and completed. No intention-to-treat

Selective reporting (reporting bias)

Unclear risk

All outcomes reported but not able to use data as unable to determine numbers per group and only P values or percentages given

Other bias

Low risk

No baseline data given but states groups are comparable on race, gender, birth outcome, parental characteristics

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Liptak 1983 Methods

Infants randomly assigned following Brazelton Assessment to 1 intervention and 2 control groups. Method of randomization not stated. Blinding of outcome assessor. Singlecentre trial

Participants

Included 75 mother-infant dyads. Inclusion criteria were: full term, first-born, healthy, white newborns of English speaking, middle class parents from Strong Memorial Hospital, Rochester, New York, USA

Interventions

Control Group 1 infants received usual care. Physical exams were performed in the absence of parents. Mothers were visited by 1 of the researchers every day and any concerns raised by the mothers were addressed. Routine anticipatory guidance given. Control Group 2 infants received the same as Group 1 but in addition received complete physical exams in front of the mothers on the morning of discharge from hospital as well as a discussion of normal findings. This group was selected to control for the Hawthorne effect of an investigator intervention. Intervention Group 3 infants received the same care as those in Control Group 1 but also had parts of the Brazelton Neonatal Assessment Scale demonstrated to their mothers on the morning of discharge approximately 30 minutes following a feeding. A 20-minute semi-structured discussion, modified for the individuality of each infant, was held with the mother. Number randomized to each group not given; however it may have been 25 per group. 3 lost to follow-up; 2 before the first home visit and 1 after. Did not report on which group losses occurred

Outcomes

Outcomes measured at 1 and 3 months postpartum on home visits. Included observations and measurement of (1) gross physical contact, (2) feeding additional food, (3) positive contact, (4) overall Ainsworth rating, (5) mothers asking developmentally related questions, (6) mothers continuing to seek medical advice as well as self-reports of degree of bother, infant temperament. Following feeding, 35- and 45-minute observations during play. Observer recorded infant and maternal behaviour every 15 seconds using a behaviour checklist. After leaving home, observers rated mother-infant interactions using 21 9-point interaction scales by Ainsworth. At 1 month completed Broussard Perception Inventory and modified Degree of Bother Scale, and Carey Infant Questionnaire at 3 months.

Notes

Power analysis done. Inter-rater reliabilities ranged from 83% to 96%. No useable data

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

No method of randomization discussed.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

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Liptak 1983

(Continued)

Blinding of outcome assessment (detection Low risk bias) All outcomes

Blinding of outcome assessor.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

3 lost to follow-up but do not state to which group. No intention-to-treat

Selective reporting (reporting bias)

High risk

All outcomes addressed but they do not give the number randomized per group. Not able to use data because of this as only percentages and P values reported

Other bias

Unclear risk

Demographic baseline characteristics appear comparable although not discussed

McRury 2010 Methods

Basic randomized design. Mother-infant dyads assigned using a random numbers table. Outcome assessor blinded. Single-centre trial

Participants

Included 51 mother-infant dyads. Infants were singletons, 37-41 weeks’ gestation, and admitted to the normal newborn nursery. Mothers were required to have resources to view VHS tape. Exclusion criteria: mothers who did not speak English or were unable to fill out a diary. Conducted in Columbus, Ohio in a large community hospital

Interventions

Intervention: 27 mothers were given a 30-minute video to view in hospital and then take home to view as well. Specific instructions about 5 steps to use to soothe infant during crying. Control: 24 mothers watched a 30-minute video “Begin with Love” that was offered on the newborn channel with standard anticipatory guidance about infant needs and care. Both groups received a lightweight blanket for swaddling

Outcomes

Mothers documented sleep and crying in a diary 3 days per week during the 1st, 4th, 6th, 8th, and 12th week. Diaries were analyzed as 1) mean hours of total infant crying per day (time fussing, crying, inconsolable was calculated for each day; the mean of the daily sums at each time was calculated) and 2) mean daily total sleep time was calculated similarly to crying time. “Diary data that had more than 3 hours not recorded or recorded as ’can’t remember’ were excluded from the analysis”. 3) Mother’s level of stress was measured by the Parenting Stress Index at 6 and 12 weeks. “Total stress scores can range from 131 to 320 (less stress to more), with a score of 222 being the 50th percentile”

Notes

1408 flyers distributed and 51 recruited. Nothing mentioned re validity or reliability of instrument but stated that it was “scored according to the manual”. Sample small and under powered. Needed 42 per group to “detect a minimally intense intervention to reduce crying time by 40%”

Risk of bias

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McRury 2010

(Continued)

Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Random numbers table used.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Low risk (performance bias) All outcomes

Mothers blinded. Given an unmarked jacket on video so did not know which video they received

Blinding of outcome assessment (detection Low risk bias) All outcomes

Research assistant was blinded during baseline data collection but not during followup data collection as intervention fidelity was assessed

Incomplete outcome data (attrition bias) All outcomes

High risk

9 pairs were lost to the intervention group (33%) and 7 to the control group (29%) . Lower levels of education in those who left but about the same number in each group. No intention-to-treat. 18 analyzed in intervention group and 17 in control. Some diaries were incomplete

Selective reporting (reporting bias)

Low risk

Appears to have provided data on all outcomes.

Other bias

Low risk

Both groups equivalent at baseline.

Moore 1987 Methods

Randomization to intervention and control group. Method of randomization not stated. No mention of blinding. May have been a multi-centre trial

Participants

Included 159 mothers who gave birth at the University of Texas Medical Branch Hospitals, Galveston Texas, USA. Inclusion criteria were: mothers who had a cesarean birth, were literate, spoke English, 17 years of age or older and singleton infants born after 37 weeks. Also, mother had to be able to hold and feed infant in her room

Interventions

On the third postpartum day, mothers in intervention group saw a video focusing on the manner in which infants from birth to 9 months exhibit multi-sensory capabilities for communication and how with interaction these capabilities can be enhanced. No mention if intervention was individual or group. No description of control group given. Number randomized to each group not stated

Outcomes

Maternal behaviour was assessed on the fourth postpartum day during a feeding. Maternal attachment behaviour assessment total and composite factor scores (e.g., maternal attentiveness, tactile response, body contact) were used.

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Moore 1987

(Continued)

Notes

No useable data.

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

No method of randomization discussed.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

No mention of losses. Number per group not given.

Selective reporting (reporting bias)

High risk

Abstract only. No data presented.

Other bias

Unclear risk

No baseline equivalence discussed.

Myers 1982 Methods

Randomization to 3 groups: (1) mother intervention, none for father, (2) father intervention, none for mother, (3) control was made post recruitment by the throw of a die. Single-centre trial

Participants

Included 42 middle-class married couples in the US who had just had their first baby. No inclusion/exclusion criteria were specified

Interventions

The 2 intervention groups (n = 14 fathers in 1 group and n = 14 mothers in another) were taught individually how to administer most of the items of the Brazelton exam. Throughout the session, the experimenter gave information about infant development related to the infant’s performance. The experimenter aimed at being supportive. Information learned was encouraged to be given to the other partner and to be used at home. The intervention was given after second day post-birth but before departure for home at day 4. Sessions were held in mother’s room for the mothers and in a small room near the nursery for the fathers. Sessions lasted 45-60 minutes

Outcomes

Included (1) knowledge of infant behaviour as measured by a set of 15 multiple choice factual questions related to infants’ physical capacities, including reflexes and senses (higher scores out of a maximum of 15 indicate more knowledge); (2) feelings of confidence as a caregiver; (3) feeling of affection and satisfaction with the infant; (4) behaviour

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Myers 1982

(Continued)

with the infant. Measures were made greater than 6 hours after intervention Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Random assignment by the throw of a die.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

Not discussed.

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

Unclear risk

Acceptance rates post randomization were about 66% overall but greater (no % given) in father intervention and control groups. Timing of outcome assessment an issue, since some were tested as soon as 6 hours after the intervention but no data are presented by group on this issue. No data on group comparisons at baseline were given

Paradis 2011 Methods

Block randomization using random numbers table to 1 intervention and 1 control group. Randomization occurred by week in blocks of 8 weeks to account for seasonal variation in birth rate. Blinding of outcome assessors. Single-centre trial

Participants

Included 126 mothers and 11 fathers who were: 18 years of age or older, able to read and speak English, had access to a working telephone, and whose infant was less than 1 month old. Exclusion criteria: parents of premature or medically complex infants. Trial conducted in Rochester, New York, USA in a large hospital with a hospital-based primary care paediatric practice

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Paradis 2011

(Continued)

Interventions

Intervention: a media-based learning intervention of a 15 minute locally produced DVD was given to 70 parents during the baby’s first visit to the paediatrician’s office. The video depicted basic aspects of newborn care that were endorsed by the American Academy of Pediatrics and Brighter Futures guidelines. Content included: normal newborn breathing patterns, bathing, feeding, safe sleep, dealing with crying, promoting development. A staff member started the DVD in the exam room and it was stopped if it was still running when the provider came in. The DVD was then given to parent to take home. Control: 67 parents received an enhanced standard of care. They were given a packet of written handouts (written at the 4th grade reading level) that were already available at the clinic and covered similar but not identical material to the DVD. Parents were given the packet during the first clinic visit

Outcomes

Parent: 1) knowledge of infant development using 14 questions from a 58-item Knowledge of Infant Development Inventory (chose questions pertaining most to newborns, answered agree, disagree, not sure); 2) self-efficacy using 20 items from a 52 item Infant Care Survey (rated on a 5-point scale from 1 (little confidence) to 5 (quite a lot of confidence); 3) problem solving competence using the How I Deal with Problem Regarding Care of My Baby Questionnaire (rated from 1 (never) to 9 (always) for a maximum score of 90). 3 scales administered at baseline and at 2 weeks post visit by telephone. Did not separate out mothers and fathers. Infant: health care utilization for infant assessed by chart review at 2 months. Utilization included: parent initiated clinic visits, phone calls, emergency department visits

Notes

No validity or reliability information was given on the 2 adapted scales. Stated the third scale was validated but no further information. No useable data. Attempted to contact author with no response

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

“Randomization occurred by week (rather than by subject) to simplify administration of the intervention for the nursing staff ”. “Used a random-numbers table to generate the assignment of weeks to treatment or control in blocks of 8 to account for seasonal variations in birthrate”

Allocation concealment (selection bias)

“At the beginning of each week, the principal investigator informed the nursing staff of whether” it was a treatment or control week. It is unlikely that a parent would not come for a visit knowing it was a control week or a treatment week

Low risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

Not clear if participants were blinded. Personnal were not blinded. Recruiter was blinded

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Paradis 2011

(Continued)

Blinding of outcome assessment (detection Low risk bias) All outcomes

“Outcomes were assessed by research associates who were blinded to group allocation”

Incomplete outcome data (attrition bias) All outcomes

Low risk

Loss of 6 participants, 3 per group: 1 refused and 2 lost to follow-up per group. Intervention = 4.3% loss and control = 4.4% loss. Performed an intention-to-treat analysis

Selective reporting (reporting bias)

Low risk

Described findings for primary and secondary outcomes.No useable data, as data are reported in pre- and post-mean withingroup differences

Other bias

Unclear risk

Intervention group had more mothers and infants of Hispanic ethnicity and control group had more babies born outside hospital and being exclusively breastfed. Control group had better knowledge of infant development. Researchers adjusted for these baseline differences in analyses

Paul 2011 Methods

Stratified, randomized factorial 2X2 design. Mother baby dyad unit of randomization. Randomization method not described. Single-centre trial. It appears no blinding was used

Participants

Full study included 160 mother baby dyads. Focus for this review is 80 mother baby dyads: 39 in intervention and 41 in control. Infants were included if they were singleton, 34 weeks’ gestation or greater, without morbidities that would affect sleeping or feeding. Mothers were English speaking primiparas, who intended to breastfeed and followup care with a university affiliated primary care provider. Pairs were excluded if either newborn or mother had a hospital stay 7days or more and if mothers had a major preexisting morbidity or condition that would affect postpartum care or study participation such as cancer, MS, or lupus. Study took place in Hershey, Pennsylvania, USA

Interventions

The “Soothe/Sleep” intervention was delivered by nurses during the first home visit at 2 to 3 weeks. Intervention included 1-on-1 verbal information, an instructional handout, and a commercially prepared video. Parents were taught “alternative strategies to feeding as an indiscriminate first response to infant distress” in an attempt to have parents understand the difference between crying from hunger versus other causes of crying. The video included strategies to calm and soothe the infant during the day and night when it was time for sleep. They also received a standard infant parenting book. The control parents received the standard infant parenting book. All parents had their questions answered

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Paul 2011

(Continued)

Outcomes

Included: infant weight-for-length percentile at 1 year; total daily crying and fussing; total daily sleep; total nocturnal sleep from 9pm to 6 am; timing and content of feedings measured by 96 hour diary cards at 3, 4, 8, 16, 24, 36, and 48 weeks post-birth. These were detailed at 15-minute intervals. Relative percentage of breast milk versus formula was documented using a visual analogue scale

Notes

May have included infants in NICU. No useable data. Contacted author who chose not to provide data

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Not addressed other than being stratified based on maternal prepregnancy BMI < 25 or >= 25

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel High risk (performance bias) All outcomes

Appears no blinding was used. Nurses providing the intervention could not be blinded

Blinding of outcome assessment (detection High risk bias) All outcomes

Nurses measuring infants were not blinded.

Incomplete outcome data (attrition bias) All outcomes

High risk

Greater than 20% loss to follow-up in both groups. Losses equal across groups. Mothers not completing were significantly younger, less educated, single, non-white, and medicaid insured. No intention-totreat for those who were randomized but did not receive the intervention. Some for non-completers who had growth data from second home visit

Selective reporting (reporting bias)

Low risk

Appears to have reported on all outcomes but data not useable

Other bias

Low risk

Baseline equivalence across all groups.

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Petrowski 1981 Methods

Randomization to 4 groups: 3 intervention and 1 control. No method of randomization stated. No blinding noted. 2 hospital sites

Participants

Included 56 mothers. Inclusion criteria were: primiparas who were staff patients of 2 inner-city hospital clinics in Washington, DC, USA, were educated in the USA, and who gave birth to healthy, normal newborns not less than 5 pounds

Interventions

Group 1 (n = 10) received the Instructional Package Form 1 in the last trimester of pregnancy. (Instructional Package included 4 cassette recordings: Care of the Umbilical Cord and Navel, Burping or Bubbling a Baby, Perineal Care, and Rest, Activity, and Exercise. Each tape accompanied by 13 pictures. 2 alternate forms). This group was also re-instructed postpartum in hospital using Form 2. Group 2 (n = 10) received the Instructional Package Form 1 in the last trimester of pregnancy. Group 3 (n = 10) received the Instructional Package, Form 1, from the first to fourth day postpartum in hospital. Group 4 (n = 10) (control group) received no instruction unless they requested it after the outcome measure was taken.

Outcomes

Included maternal acquisition of knowledge related to newborn and postpartum care measured using a multiple choice test of 20 questions based on the information in the package. Data were collected in the home from the fifth to thirteenth day postpartum

Notes

Antenatal and postpartum intervention for Group 1 and antenatal only for Group 2. Initially wanted sample size of 56 and then reduced it to 40. No mention of power analysis or basis for reduction. Controlled for participants’ educational level. Content validity of instructional packages assessed. No useable data

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

No method of randomization described.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

20 of initial 56 randomized lost to followup (36%). No reasons given. Did not give losses per group. Recruited 4 new participants after initial randomization. No intention-to-treat

High risk

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Petrowski 1981

(Continued)

Selective reporting (reporting bias)

Unclear risk

Outcome reported for all groups but data not useable, as no means or standard deviations presented

Other bias

Unclear risk

No mention of baseline equivalence of groups.

Regan 1995 Methods

Randomization to intervention and control group was performed using a table of random numbers. Groups were similar on age and education but differed on ’other ethnicity’. Single-centre trial

Participants

Included 100 women who were included in the caseloads of CNMs at the University of New Mexico Hospital (USA). Inclusion criteria were: English-speaking primiparas providing written consent

Interventions

Both groups attended a daily nurse-conducted class and received a packet of handouts of postpartum information. The experimental group (n = 45) also received individual education by the CNM. The content and length of intervention not given. Average age of baby was 17.6 hours at intervention. The control group (n = 55) did not receive individual education

Outcomes

Knowledge of postpartum mother-infant care based on written instructions developed by nurse-midwives and measured by a 20-item true/false instrument developed by the researchers; maximum score was 20

Notes

To control for the confounding variable of nurses’ teaching, the post-test was administered prior to the usual daily nurse-conducted postpartum class

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Randomization using a table of random numbers.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

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Regan 1995

(Continued)

Incomplete outcome data (attrition bias) All outcomes

Low risk

No losses.

Selective reporting (reporting bias)

Low risk

Reported on outcome.

Other bias

Unclear risk

Groups were similar on age and education but differed on ethnicity

Riesch 1984 Methods

Randomization to intervention and control group. Method of randomization not stated. No blinding mentioned. 2 hospital sites

Participants

2 studies were described. The first study included 108 mother-infant dyads. Inclusion criteria were: term, infants and women from 2 urban medical centres in a mid-western city, USA. The second study included 32 mother-infant dyads. Inclusion criteria were: preterm infants (34 to 37 weeks’ gestation), singleton births, absence of physical malformations, absence of serious medical complications at 72 hours of age such as RDS, sepsis, convulsions, severe acid base imbalance and women from 2 urban medical centres in a mid-western city, USA. Exclusion criteria were: high-risk or ill mothers or infants including mothers with chronic illnesses, teen mothers, or mothers who required a cesarean birth

Interventions

Term study: 54 participants in intervention and control groups. Preterm study: 16 participants in both groups. The intervention groups received an audiotape with accompanying text which the mother listened to in her own room during a time mutually agreed upon. Visitors, calls, etc. were postponed during the listening period. The tape described neonate’s ability to demonstrate protective reflexes; to habituate to sound, light or motion; to self quiet; and to attend to objects. Appropriate maternal actions were described. Printed text was left with mother. In the term study the intervention occurred within 48 hours of infant’s birth. In the preterm study the intervention occurred within 5 days post-birth. The control groups received usual care (e.g., physical care, infant feeding, bathing)

Outcomes

A 10-minute continuous observation using a checklist of 22 neonatal social behaviours and 16 maternal social behaviours, designed by researchers. Maternal self-report of her own and infant behaviours. Term study: maternal-infant interaction during an evening feeding, in hospital 24 to 72 hours post-birth. Preterm study: maternal-infant interaction during a feeding, in the home 2 to 4 days after discharge

Notes

Inter-rater reliability .96 to 1.00. Content validity of instrument. No useable data

Risk of bias Bias

Authors’ judgement

Random sequence generation (selection Unclear risk bias)

Support for judgement Method of randomization not described.

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Riesch 1984

(Continued)

Allocation concealment (selection bias)

Unclear risk

Not discussed.

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

No losses described.

Selective reporting (reporting bias)

Unclear risk

Outcomes reported but no usable data.

Other bias

Low risk

Groups equivalent at baseline for both studies.

Shapiro 1987 Methods

Randomization to intervention and control group. Method of randomization not stated. No blinding described. Multi-centre study

Participants

Included 696 women admitted to 3 maternity wards in US hospitals

Interventions

Both groups received a pamphlet about burns from hot water taps and a thermometer for testing maximum water temperature. The intervention group (n = 302 at analysis) also received a 1-minute verbal summary of the dangers of hot tap water, calling the pamphlet and thermometer to their attention. The control group (n = 302 at analysis) did not receive the verbal summary. The intervention was provided on the postpartum unit. Numbers randomized to both groups were not given

Outcomes

Maternal awareness of tap water burns and greater use of temperature testing; reported as percentages

Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not described.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

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Shapiro 1987

(Continued)

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

92 participants were lost post randomization (13%); however, no information was given on numbers lost per group. No intention-to-treat

Selective reporting (reporting bias)

Low risk

Appears that all outcomes are reported.

Other bias

Low risk

Stated major socio-demographic attributes of the 2 groups were comparable but no data given

St James-Roberts 2001 Methods

Randomization to 2 intervention and 1 control group was determined by a computergenerated randomization schedule and placed in a sealed envelope, which was opened between days 8 and 14 in their homes. No blinding described. Single-centre trial

Participants

Included 610 consenting women who consecutively gave birth to a live singleton infant of greater than 37 weeks’ gestation on postnatal wards of a large general hospital in the UK. Exclusion criteria were: non-fluency in English, no telephone, infants with congenital anomalies or admitted to the NICU

Interventions

Behavioural group (n = 205) received a leaflet describing a 9-point program. The educational intervention (n = 202) consisted of a 10-page guide to baby crying and sleeping that was developed with local health professionals and a telephone number for CRYSIS (a voluntary organization for parents with young babies). Guide included a question and answer section on common problems and how to deal with them and a step-by-step guide to preventing crying and sleeping problems. This highlighted the need for a regular and structured approach to care that emphasized day-night differences, recommended settling baby in a crib or other designated place and sanctioned leaving baby to fret for a few moments when judged to be suitable. It did not prescribe a focal feed. It provided written advice and suggestions that could be adapted (not prescriptions, as was the case in the behavioural intervention). The control group (n = 203) received “normal services” (also received by 2 other groups greater than 1 home visit by a health visitor nurse, clinic visits, and access to a family doctor)

Outcomes

Infant crying and sleeping measured using 24-hour behaviour diaries which gave a continuous record of starting time, end time, and duration of each behaviour. These were completed at 1 week of age (baseline) and at 3, 6, 9 and 12 weeks of age

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St James-Roberts 2001

(Continued)

Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

A computer-generated randomization schedule was used for allocation to groups

Allocation concealment (selection bias)

Group assignment was placed in a sealed envelope, which was opened between days 8 and 14 in their homes

Low risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

Incomplete outcome data (attrition bias) All outcomes

High risk

At 1 week, losses were 3%, 2% and 6% respectively for diary completion. At 12 weeks, losses were 21%, 19%, and 22% respectively for diary completion. At 9 months, there was a 19% loss in behavioural group, 18% in educational group, and 19% in control group for questionnaire completion. Intention to treat not mentioned

Selective reporting (reporting bias)

High risk

Specific comparisons of sleeping and fuss/ crying not reported for 1 week and 9 months “because of large numbers of measures collected”; however no significant differences noted at these times

Other bias

Low risk

Groups comparable on demographics at baseline.

Stremler 2006 Methods

Randomization centrally by computer-generated random number sequence.The groups appear comparable at baseline.The outcome assessor was blinded. Single-centre trial

Participants

Included 30 Canadian primiparous women who had a healthy singleton baby born greater than or equal to 37 weeks’ gestation, lived in greater Toronto area, planning to provide care to their infant for first 6 weeks postdischarge. Exclusion criteria were: experienced complications requiring lengthy hospital stay, previous stillbirth/neonatal

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Stremler 2006

(Continued)

death, chronic poorly controlled maternal illness, mother used medications affecting sleep, history of drug/alcohol abuse, diagnosed sleep disorder, mother’s partner worked night shifts, mother unable to read or understand English, no telephone Interventions

Intervention group (n = 15) received TIPS (Tips for Infant and Parent Sleep). The sleep intervention included a 45-minute meeting with a nurse to discuss sleep information and strategies, an 11-page booklet, and weekly phone contact to reinforce information and problem solve. The control group (n = 15) received a 10-minute meeting during which only maternal sleep hygiene and basic information about infant sleep were discussed, a 1-page pamphlet, and calls at weeks 3 and 5 to maintain contact without provision of advice

Outcomes

Included 6 infant sleep measurements determined by sleep diaries and Actigraph at 6 weeks. The Actigraph detects and records continuous motion data by use of a microprocessor. Detected movements are translated into digital counts across investigator-designated recording parameters. Brief movements in the middle of sleep periods are recorded as sleep, and brief periods of no activity within time intervals of extensive wakeful movement are recorded as awake

Notes

Same research nurse provided both TIPS and control intervention. Pilot study limited to 6 weeks. Small sample. Only 6 randomized per week due to limited number of Actigraphs

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Randomization of groups was done using a computer-generated random-number sequence

Allocation concealment (selection bias)

Low risk

Random-number sequence was held by a research associate outside of the immediate research team

Blinding of participants and personnel Low risk (performance bias) All outcomes

Contamination between groups was unlikely because “women were randomly assigned before discharge with little opportunity to share information before discharge”. Also 1 woman per room was enrolled at a time

Blinding of outcome assessment (detection Low risk bias) All outcomes

The outcome assessor was blinded.

Incomplete outcome data (attrition bias) All outcomes

Low risk

No losses.

Selective reporting (reporting bias)

Low risk

All outcomes reported.

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Stremler 2006

(Continued)

Other bias

Low risk

Groups were similar at baseline.

Sullivan 1980 Methods

Randomization to 4 groups: 3 intervention and 1 control. Method of randomization not stated. Outcome assessors blinded. Likely single-centre trial although not clear.

Participants

Included 53 mother-infant dyads. Inclusion criteria were: mothers were healthy, had a vaginal birth of their first or second infant. Infants were healthy and full-term. Trial conducted in Torrance, California, USA.

Interventions

Intervention Group 1 (n = 14) received 30 minutes of unstructured early contact during the second hour postpartum plus 30 minutes of special training in infant care based on BNBAS results for their infant during the postpartum period. Intervention Group 2 (n = 12) had early contact but not training. Intervention Group 3 (n = 14) had training without early contact. Control Group mothers (n = 13) had neither early contact nor training. Intervention occurred in hospital but not clear where training was provided

Outcomes

Included (1) levels of attachment behaviour, (2) self-confidence, (3) competency, and (4) mutuality of interaction at 1 and 2 months based on infant physical exam, 2 structured interviews, and scoring by independent raters of videotaped feelings and interactions. Not stated where data collection occurred

Notes

No useable data.

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

No method of randomization stated.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Low risk bias) All outcomes

Outcome assessors blinded.

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

No mention of losses.

Selective reporting (reporting bias)

High risk

Not all outcomes reported. Only P values presented. Abstract only

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Sullivan 1980

(Continued)

Other bias

Unclear risk

No baseline equivalence mentioned.

Symon 2005 Methods

Blind, randomization to intervention and control groups within block sizes of 8 was performed by a specific staff member. Single-centre trial

Participants

Included 346 families recruited from birth notification published in the only South Australian newspaper with contact details from the telephone directory. They were contacted by telephone within 2 weeks of birth. Inclusion criteria were: gave birth at 36-42 weeks’ gestation; English speaking; mother planning to provide full-time care to infant for greater than 12 weeks post-birth. Exclusion criteria were: infant was admitted to the NICU within the first 2 weeks post-birth

Interventions

Intervention group (n = 171 families) received usual care plus both parents were invited to attend a 45-minute consultation with a nurse at 2 to 3 weeks on normal sleep patterns in newborn infants and a 50-page book reinforcing the information. If infant weight gain was less than 30g/d, parents were encouraged to see their usual postnatal care provider. Control care (n = 175 families) not described

Outcomes

Included greater than or equal to 15 hours of total sleep per 24 hours as per sleep diary for 7 consecutive days at 6 and 12 weeks, reported as percentages. Group differences in mean number of hours for sleep time were also reported at 6 and 12 weeks, as well as mean crying time per 24 hours

Notes Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Low risk bias)

Blind, randomization to intervention and control groups within block sizes of 8 was performed by a specific staff member. Actual method not stated

Allocation concealment (selection bias)

Blind, randomization was performed by a specific staff member

Low risk

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Unclear risk bias) All outcomes

No blinding discussed.

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Symon 2005

(Continued)

Incomplete outcome data (attrition bias) All outcomes

High risk

Loss at 6 weeks was 23% in intervention group and 31% in control group. At 12 weeks, loss was 36% and 39%, respectively. Losses greater than 20%. Intention-to-treat

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

High risk

High refusal rate before randomization (65%).Groups appear similar on the only baseline information provided: infant sex and the socio-economic status of families

Wendland-Carro 1999 Methods

Randomization to intervention and control groups. Method of randomization not stated. Outcome coders were blind to objectives and group assignment. Single-centre trial

Participants

Included 38 primiparous mothers and infants from Poxto Alegre, Brazil. Inclusion/ exclusion criteria not given

Interventions

The intervention (n = 17) was designed to enhance the mother-infant interaction. On day 2 or 3 postpartum, a video covering 5 areas was viewed and discussed with the mother individually to determine what she knew, whether she had seen these infant behaviours, and what her expectations were vis-a-vis her own infant. The investigator directed the mother’s attention toward the infant’s potential to interact as well as the importance of affectionate handling and sensitivity toward the infant and discovering the infant’s individuality. A written list describing each of these items was then given and they were encouraged to identify the behaviours in their infants. The video lasted 15 minutes, the session lasted 50 minutes. 19 dyads participated in the control group and received an intervention that emphasized basic care giving skills

Outcomes

Included sensitive maternal responsiveness to the infant at the end of the first month. Video tapes during free play and bathing were used to capture this. Subsequently coded as synchronous (i.e., responsiveness to the behaviour of the other in the dyad). 13 categories used. Each observation period was divided into 15-second intervals and co-occurrence of synchronous categories were determined. Reported as mean frequency of co-occurrences

Notes

Small sample. Intercoder reliabilities exceeded 80% for all categories

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not described.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

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Wendland-Carro 1999

(Continued)

Blinding of participants and personnel Unclear risk (performance bias) All outcomes

No blinding discussed.

Blinding of outcome assessment (detection Low risk bias) All outcomes

Outcome coders were blinded to objectives and group assignment

Incomplete outcome data (attrition bias) All outcomes

Low risk

2 mothers (11%) dropped out of the intervention group after being randomized, no loss from control group. No intention-totreat

Selective reporting (reporting bias)

Low risk

All outcomes reported.

Other bias

Low risk

Groups comparable at baseline except more control fathers had unskilled occupations

Worobey 1982 Methods

Randomization to 3 groups: intervention, contrast, and control. Method of randomization not described. Mothers were blinded to the hypotheses. Outcome assessors blinded to experimental design and purpose of study. Single-centre trial

Participants

Included 48 mother-infant dyads from the Centre Community Hospital, State College, Pennsylvania, USA. Inclusion criteria were: healthy, full-term newborns

Interventions

16 dyads randomized per group. The 1-on-1 intervention consisted of 3 methods of relaying information from BNBAS. The control group (minimal information through auditory feedback) received usual care which consisted of a verbal description of their newborn’s performance on the BNBAS immediately following the assessment lasting approximately 15 minutes. The contrast group (passive observation with auditory and visual feedback) watched the examiner administer the BNBAS on their infants and received a verbal description of their infant behaviour as well as a 1-page summary 2 days later. The assessment lasted approximately 45 minutes. It occurred on the second or third day post-birth. The intervention group (active information through auditory, visual, and tactile interaction) were guided through an interaction with their newborns in which they administered the BNBAS. The facilitator did not touch the infant but rather guided the mother through the procedure. The intervention lasted approximately 45 minutes on the infant’s second or third day. These mothers also received a 1-page summary

Outcomes

At 4 to 6 weeks post-birth, dyads were observed for an hour in the home before, during, and after a bathing session. Maternal-infant behaviours were observed and documented on a pre-coded check list each time a behaviour from 16 behaviour categories occurred in a 15-second period. 5 a priori clusters of behaviours were used to create scores: (1) contingent interaction, (2) embellished maternal involvement, (3) simple maternal attention, (4) basic maternal care, and (5) infant behaviour.

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Worobey 1982

(Continued)

Notes

Inter-rater reliability between observers .87 to .99. No useable data

Risk of bias Bias

Authors’ judgement

Support for judgement

Random sequence generation (selection Unclear risk bias)

Method of randomization not described.

Allocation concealment (selection bias)

Not discussed.

Unclear risk

Blinding of participants and personnel Low risk (performance bias) All outcomes

Mothers were blinded to the hypotheses.

Blinding of outcome assessment (detection Low risk bias) All outcomes

Outcome assessors blinded to experimental design and purpose of study

Incomplete outcome data (attrition bias) All outcomes

Unclear risk

No mention of losses.

Selective reporting (reporting bias)

Unclear risk

All outcomes reported but no useable data.

Other bias

Low risk

Groups equivalent at baseline

BMI: body mass index BNBAS: Brazelton Neonatal Behavioral Assessment Scale CNM: certified nurse midwives IUGR: intrauterine growth restriction MAS: Maternal Attitude Scale MS: multiple sclerosis NICU: neonatal intensive care unit RDS: respiratory distress syndrome REST: Regulation, Entrainment, Structure, and Touch SIDS: sudden infant death syndrome vs: versus

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Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Adam 1985

Study is not a RCT.

Akai 2008

Not a structured form of postnatal education. Home-based support program. On average infants were 4.3 months old at start of intervention. Mother-infant dyads participated for about 4.5 months and then outcomes measured when infants were approximately 9 months of age

Baqui 2008

Part of an antenatal education and postnatal preventative and curative newborn care intervention for community health workers not parents

Barlow 2013

Study of teen parents.

Barr 2009

Not a structured form of postnatal education. Study is not exclusively a postpartum intervention. Education started prenatally

Bashour 2008

Home visitation program, not a clear structured educational intervention

Beal 1989

Study is not a RCT - alteration of assignment to groups, no random start

Beiler 2011

Not a structured form of postnatal education. Office-based versus home-nurse visits

Bristor 1984

Study is not a RCT, no randomization of groups.

Cevasco 2008

Singing songs is not a structured form of postnatal education

Cohen 1980

Study is not a RCT, although the abstract indicated it was.

Cupples 2011

Study is not exclusively a postpartum intervention. Education began twice monthly during pregnancy

Dihigo 1998

Study is not a RCT - randomization to 2 treatment groups only, not control group

Doherty 2006

Study is not exclusively a postpartum intervention and results were not presented separately

French 2012

5 time periods for intervention up to 12 months postpartum. Not able to separate out the 2-week and 2-month interventions

Glazebrook 2007

Parents of infants in NICU.

Goyal 2009

Not a RCT. Also not an educational intervention. Support for postpartum depression

Hansen 1990

Study is not exclusively a postpartum intervention and results were not presented separately for intervention received at 0 to 2 months

Hawkins 2008

Couples had already enrolled in Welcome Baby program prior to being randomly assigned to 1 of the 2 treatment groups. Assignment to control group was not randomized. First 40 couples who were not interested in Welcome Baby program but were interested in being in study were enrolled in control

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(Continued)

group. Postnatal education did not start until 3 months after birth. Data collected for post-tests at 45 months and again 9-10 months postpartum Ho 2009

A support-based intervention for postpartum depression not a structured form of postnatal education

Kabakian-Khasholian 2005

Study outcomes were related to women’s use of postpartum services

Kemp 2011

Not a structured form of postnatal education. A home-based support intervention. Started in the prenatal period

Kistin 2011

Not a structured form of postnatal education.

Lee 2012

Intervention not related to infant health/care or infant-parent relationships. Intervention related to women’s postpartum sexual health behaviours

Leff 1988

Study is not a RCT - 2 intervention groups and no control group

Morrell 2000

Study does not test an educational intervention.

Niccols 2008

Parenting program not within 2 months postpartum; infants from 1-24 months

Petch 2012

Study is not exclusively a postpartum intervention. Education began in the prenatal period

Reich 2010

Not a structured form of postnatal education. Study is not exclusively a postpartum intervention. Education began in the third trimester of pregnancy

Rotheram-Borus 2011

Not a structured form of postnatal education. Study is not exclusively a postpartum intervention. Home-based support program, intervention began with 4 antenatal visits

Santelices 2011

Study is not exclusively a postpartum intervention. There were 6 prenatal group sessions

Scott 1990

Infants recruited at less than 18 months; no data presented separately for infants receiving the intervention prior to 2 months old

Shapiro 2011

Study is not exclusively a postpartum intervention. Workshop was completed during pregnancy

Simons 2001

Study is not a structured teaching intervention and effect of education not isolated from other intervention components

Spigelblatt 1991

Study is not a RCT although the study title indicated that it was

Wagner 1999

Study does not focus on infants less than 2 months old.

Waterston 2009

Postnatal education was beyond 2 months postpartum. The newsletter went through the first 12 months postpartum

Wen 2011

Home-based support program, intervention started in the prenatal period

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(Continued)

Wolfson 1992

Study is not exclusively a postpartum intervention. Education started prenatally

NICU: neonatal intensive care unit RCT: randomized controlled trial

Characteristics of studies awaiting assessment [ordered by study ID] Kim 2004 Methods

Not clear if this study is a RCT. It is written in Korean except for the tables. Attemping to secure a translation

Participants

35 mothers and their infants.

Interventions

Education related to sensory stimulation administered twice a day

Outcomes

Infant growth, mother-infant interaction.

Notes RCT: randomized controlled trial

Characteristics of ongoing studies [ordered by study ID] Cook 2012 Trial name or title

Baby business: A randomized controlled trial of a universal parenting program that aims to prevent early infant sleep and cry problems and associated parental depression

Methods

RCT

Participants

750 English speaking parents in Australia with healthy newborns greater than 32 weeks’ gestation

Interventions

Experimental group receives Baby Business program providing information to parents about infant sleep and crying via DVD and booklet mailed soon after birth and telephone consultation at 6-8 weeks postpartum. Control groups receives usual care

Outcomes

Parent report of infant night time sleep as a problem at 4 months, parent report of infant day time sleep or crying as a problem, mean duration of infant sleep and crying/24 hours, parental depression symptoms, parent sleep quality and quantity and health service use

Starting date

2011

Contact information

Fallon Cook at [email protected]

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Cook 2012

(Continued)

Notes RCT: randomized controlled trial

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DATA AND ANALYSES

Comparison 1. Education on sleep enhancement versus usual care

Outcome or subgroup title 1 Total infant sleep >= 15 hrs per 24 hrs 1.1 At 6 weeks 1.2 At 12 weeks 2 Total minutes of infant sleep in 24 hrs (mean diff ) 2.1 At 4 weeks 2.2 At 6 weeks 2.3 At 8 weeks 2.4 At 12 weeks 3 Night-time minutes of infant sleep in 24 hrs (mean diff ) 3.1 At 6 weeks 3.2 At 12 weeks 4 Longest uninterrupted night-time minutes of infant sleep in 24 hrs (mean diff ) 4.1 At 6 weeks 4.2 At 12 weeks 5 Day-time minutes of infant sleep in 24 hrs (mean diff ) 5.1 At 6 weeks 5.2 At 12 weeks 6 Longest uninterrupted day-time minutes of infant sleep in 24 hrs (mean diff ) 6.1 At 6 weeks 6.2 At 12 weeks 7 Infant crying time in 24 hrs (mean diff ) 7.1 At 4 weeks 7.2 At 6 weeks 7.3 At 8 weeks 7.4 At 12 weeks 8 Night-time minutes of infant sleep in 24 hrs 8.1 At 12 weeks 9 Longest uninterrupted night-time minutes of infant sleep in 24 hrs 9.1 At 12 weeks

No. of studies

No. of participants

1

Statistical method

Effect size

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean difference (Fixed, 95% CI)

1.72 [1.56, 1.90] 1.73 [1.54, 1.95] Subtotals only

1

Mean difference (Fixed, 95% CI)

3 1

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI)

2 3

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI)

60.0 [-24.02, 144. 02] 62.08 [42.88, 81.29] -12.0 [-78.58, 54. 58] 61.41 [28.08, 94.73] Subtotals only

2 2 3

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI)

29.13 [18.53, 39.73] 16.18 [4.41, 27.95] Subtotals only

2 2 3

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI)

13.74 [-1.11, 28.58] 11.45 [-5.40, 28.30] Subtotals only

2 2 3

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI)

39.59 [25.01, 54.17] 9.92 [-1.83, 21.66] Subtotals only

2 2 2

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI)

5.57 [-2.31, 13.45] 0.60 [-3.89, 5.09] Subtotals only

1 2 1 2 1

Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean difference (Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

18.0 [-25.63, 61.63] 4.36 [-6.44, 15.16] 42.0 [-6.41, 90.41] 0.55 [-8.38, 9.47] Subtotals only

1 1 3

1749 1497

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

6.0 [-8.21, 20.21] Subtotals only

1

316

Mean Difference (IV, Fixed, 95% CI)

-5.0 [-27.66, 17.66]

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10 No. of infant night-time sleeping episodes 10.1 At 12 weeks 11 Day-time minutes of infant sleep in 24 hrs 11.1 At 12 weeks 12 Longest uninterrupted day-time minutes of infant sleep in 24 hrs 12.1 At 12 weeks 13 No. of infant day-time sleeping episodes 13.1 At 12 weeks 14 Night-time minutes of infant fussing/crying in 24 hrs 14.1 At 12 weeks 15 Longest uninterrupted night-time minutes of infant fuss/cry in 24 hrs 15.1 At 12 weeks 16 No. of infant night-time fussing/crying episodes 16.1 At 12 weeks 17 Day-time minutes of infant fussing/crying in 24 hrs 17.1 At 12 weeks 18 Longest uninterrupted day-time minutes of infant fuss/cry in 24 hrs 18.1 At 12 weeks 19 No. of infant day-time fussing/crying episodes 19.1 At 12 weeks 20 Maternal stress score 20.1 At 6 weeks postpartum 20.2 At 12 weeks postpartum

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.10 [-0.18, 0.38] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-5.0 [-19.86, 9.86] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-5.0 [-11.40, 1.40] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.10 [-0.12, 0.32] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

2.0 [-2.24, 6.24] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.0 [-2.24, 2.24] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.20 [-0.08, 0.48] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

3.0 [-4.07, 10.07] Subtotals only

1 1

316

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-1.0 [-3.24, 1.24] Subtotals only

1 1 1 1

316 70 35 35

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.40 [-0.10, 0.90] 30.31 [15.20, 45.41] 23.80 [2.08, 45.52] 36.40 [15.38, 57.42]

Comparison 2. Education on infant behaviour versus usual care

Outcome or subgroup title 1 Knowledge of infant behaviour 1.1 Maternal at 1-4 days postpartum 1.2 Maternal at 4 weeks postpartum 1.3 Paternal at 1-4 days postpartum

No. of studies

No. of participants

2 1

28

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

Subtotals only 4.6 [2.60, 6.60]

2

56

Mean Difference (IV, Fixed, 95% CI)

2.85 [1.78, 3.91]

1

28

Mean Difference (IV, Fixed, 95% CI)

6.5 [4.88, 8.12]

Statistical method

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Effect size

55

1.4 Paternal at 4 weeks postpartum 2 Child-rearing anxiety 3 Mother distance 4 Mutuality 5 Synchronous co-occurrences during free play - visual 6 Synchronous co-occurrences during free play - vocal 7 Mothers’ perception of their infants 7.1 At 1 month postpartum 8 Maternal confidence interpreting infant behaviour 8.1 At 4 weeks postpartum

1

26

Mean Difference (IV, Fixed, 95% CI)

3.70 [1.93, 5.47]

1 1 1 1

61 61 61 36

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

3.70 [-1.33, 8.73] 0.20 [-0.11, 0.51] 1.10 [-3.07, 5.27] 10.10 [5.96, 14.24]

1

36

Mean Difference (IV, Fixed, 95% CI)

6.73 [3.64, 9.82]

1

30

Mean Difference (IV, Fixed, 95% CI)

0.66 [-8.44, 9.76]

1 1

30 30

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.66 [-8.44, 9.76] 3.70 [-1.16, 8.56]

1

30

Mean Difference (IV, Fixed, 95% CI)

3.70 [-1.16, 8.56]

Comparison 3. Education on general post-birth infant health or care versus usual care

Outcome or subgroup title 1 Maternal general post-birth knowledge score (mean) 2 Maternal general post-birth knowledge score (per cent correct) 3 Infant weight (kg) 3.1 At 6 months post-birth 4 Infant length (cm) 4.1 At 6 months post-birth 5 Head circumference (cm) 5.1 At 6 months post-birth 6 Appropriate immunization 6.1 At 6 months post-birth 7 Knowledge of signs of infant pneumonia 7.1 Indrawing 7.2 Tachypnea 8 Knowledge of action to take in the case of infant diarrhoea 8.1 Continue breastfeeding 8.2 Give oral rehydration solution

No. of studies

No. of participants

1

100

Mean Difference (IV, Fixed, 95% CI)

0.40 [-0.27, 1.07]

1

100

Risk Ratio (M-H, Fixed, 95% CI)

1.07 [0.92, 1.23]

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only 0.10 [-0.19, 0.39] Subtotals only 0.30 [-0.88, 1.48] Subtotals only -0.20 [-0.76, 0.36] Subtotals only 1.04 [0.97, 1.11] Subtotals only

1 1 1 1 1 1 1 1 1

203 202 203 202

Statistical method

Effect size

1 1 1

203 203

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

1.21 [0.73, 2.03] 1.19 [0.90, 1.58] Subtotals only

1 1

203 203

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

0.99 [0.75, 1.31] 1.00 [0.92, 1.08]

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Comparison 4. Education on infant safety versus usual care

Outcome or subgroup title

No. of studies

1 Infant restraint seat fastened by lap belt 1.1 At hospital discharge 1.2 At 4-6 weeks 2 Post-hospitalization awareness of tap water burns 3 Greater use of temperature testing 4 Supine infant sleep position 4.1 At 1 week 4.2 At 6 weeks 4.3 At 3 months 4.4 At 6 months

No. of participants

1

Statistical method

Effect size

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

1 1 1

30 27 604

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

21.0 [1.34, 328.86] 1.24 [0.34, 4.51] 1.07 [1.04, 1.11]

1

604

Risk Ratio (M-H, Fixed, 95% CI)

1.76 [1.43, 2.17]

2 1 1 1 1

61 61 191 185

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only 1.31 [1.00, 1.72] 1.21 [0.85, 1.71] 1.79 [1.17, 2.72] 2.18 [1.35, 3.53]

Analysis 1.1. Comparison 1 Education on sleep enhancement versus usual care, Outcome 1 Total infant sleep >= 15 hrs per 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 1 Total infant sleep >= 15 hrs per 24 hrs

Study or subgroup

Sleep intervention

Usual care

n/N

n/N

Risk Ratio

Weight

599/913

318/836

100.0 %

1.72 [ 1.56, 1.90 ]

913

836

100.0 %

1.72 [ 1.56, 1.90 ]

432/752

247/745

100.0 %

1.73 [ 1.54, 1.95 ]

752

745

100.0 %

1.73 [ 1.54, 1.95 ]

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 At 6 weeks Symon 2005

Subtotal (95% CI)

Total events: 599 (Sleep intervention), 318 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 10.85 (P < 0.00001) 2 At 12 weeks Symon 2005

Subtotal (95% CI)

Total events: 432 (Sleep intervention), 247 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 9.05 (P < 0.00001)

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

57

Analysis 1.2. Comparison 1 Education on sleep enhancement versus usual care, Outcome 2 Total minutes of infant sleep in 24 hrs (mean diff). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 2 Total minutes of infant sleep in 24 hrs (mean diff)

Study or subgroup

Mean difference

Mean difference (SE)

Weight

IV,Fixed,95% CI

Mean difference IV,Fixed,95% CI

1 At 4 weeks McRury 2010

60 (42.87)

Subtotal (95% CI)

100.0 %

60.00 [ -24.02, 144.02 ]

100.0 %

60.00 [ -24.02, 144.02 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.40 (P = 0.16) 2 At 6 weeks McRury 2010

-6 (35.9)

7.4 %

-6.00 [ -76.36, 64.36 ]

Stremler 2006

-31 (32.91)

8.9 %

-31.00 [ -95.50, 33.50 ]

78 (10.71)

83.7 %

78.00 [ 57.01, 98.99 ]

100.0 %

62.08 [ 42.88, 81.29 ]

100.0 %

-12.00 [ -78.58, 54.58 ]

100.0 %

-12.00 [ -78.58, 54.58 ]

-6 (45.06)

14.2 %

-6.00 [ -94.32, 82.32 ]

72.6 (18.36)

85.8 %

72.60 [ 36.62, 108.58 ]

100.0 %

61.41 [ 28.08, 94.73 ]

Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 13.81, df = 2 (P = 0.001); I2 =86% Test for overall effect: Z = 6.34 (P < 0.00001) 3 At 8 weeks McRury 2010

-12 (33.97)

Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 0.35 (P = 0.72) 4 At 12 weeks McRury 2010 Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 2.61, df = 1 (P = 0.11); I2 =62% Test for overall effect: Z = 3.61 (P = 0.00030)

-100

-50

Favours usual care

0

50

100

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

58

Analysis 1.3. Comparison 1 Education on sleep enhancement versus usual care, Outcome 3 Night-time minutes of infant sleep in 24 hrs (mean diff). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 3 Night-time minutes of infant sleep in 24 hrs (mean diff)

Study or subgroup

Mean difference

Mean difference (SE)

Weight

IV,Fixed,95% CI

Mean difference IV,Fixed,95% CI

1 At 6 weeks Stremler 2006 Symon 2005

20 (18.37)

8.7 %

20.00 [ -16.00, 56.00 ]

30 (5.66)

91.3 %

30.00 [ 18.91, 41.09 ]

100.0 %

29.13 [ 18.53, 39.73 ]

6 (7.25)

68.6 %

6.00 [ -8.21, 20.21 ]

38.4 (10.71)

31.4 %

38.40 [ 17.41, 59.39 ]

100.0 %

16.18 [ 4.41, 27.95 ]

Subtotal (95% CI) Heterogeneity: Chi2 = 0.27, df = 1 (P = 0.60); I2 =0.0% Test for overall effect: Z = 5.39 (P < 0.00001) 2 At 12 weeks St James-Roberts 2001 Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 6.28, df = 1 (P = 0.01); I2 =84% Test for overall effect: Z = 2.70 (P = 0.0070) Test for subgroup differences: Chi2 = 2.57, df = 1 (P = 0.11), I2 =61%

-100

-50

Favours usual care

0

50

100

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.4. Comparison 1 Education on sleep enhancement versus usual care, Outcome 4 Longest uninterrupted night-time minutes of infant sleep in 24 hrs (mean diff). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 4 Longest uninterrupted night-time minutes of infant sleep in 24 hrs (mean diff)

Study or subgroup

Mean difference

Mean difference (SE)

Weight

IV,Fixed,95% CI

Mean difference IV,Fixed,95% CI

1 At 6 weeks Stremler 2006 Symon 2005

46 (21.17)

12.8 %

46.00 [ 4.51, 87.49 ]

9 (8.11)

87.2 %

9.00 [ -6.90, 24.90 ]

100.0 %

13.74 [ -1.11, 28.58 ]

-5 (11.56)

55.3 %

-5.00 [ -27.66, 17.66 ]

31.8 (12.86)

44.7 %

31.80 [ 6.59, 57.01 ]

100.0 %

11.45 [ -5.40, 28.30 ]

Subtotal (95% CI) Heterogeneity: Chi2 = 2.66, df = 1 (P = 0.10); I2 =62% Test for overall effect: Z = 1.81 (P = 0.070) 2 At 12 weeks St James-Roberts 2001 Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 4.53, df = 1 (P = 0.03); I2 =78% Test for overall effect: Z = 1.33 (P = 0.18)

-100

-50

Favours usual care

0

50

100

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

60

Analysis 1.5. Comparison 1 Education on sleep enhancement versus usual care, Outcome 5 Day-time minutes of infant sleep in 24 hrs (mean diff). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 5 Day-time minutes of infant sleep in 24 hrs (mean diff)

Study or subgroup

Mean difference

Mean difference (SE)

Weight

IV,Fixed,95% CI

Mean difference IV,Fixed,95% CI

1 At 6 weeks Stremler 2006 Symon 2005

-45 (24.74)

9.0 %

-45.00 [ -93.49, 3.49 ]

48 (7.8)

91.0 %

48.00 [ 32.71, 63.29 ]

100.0 %

39.59 [ 25.01, 54.17 ]

-5 (7.58)

62.5 %

-5.00 [ -19.86, 9.86 ]

34.8 (9.79)

37.5 %

34.80 [ 15.61, 53.99 ]

100.0 %

9.92 [ -1.83, 21.66 ]

Subtotal (95% CI) Heterogeneity: Chi2 = 12.85, df = 1 (P = 0.00034); I2 =92% Test for overall effect: Z = 5.32 (P < 0.00001) 2 At 12 weeks St James-Roberts 2001 Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 10.33, df = 1 (P = 0.001); I2 =90% Test for overall effect: Z = 1.65 (P = 0.098)

-100

-50

Favours usual care

0

50

100

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

61

Analysis 1.6. Comparison 1 Education on sleep enhancement versus usual care, Outcome 6 Longest uninterrupted day-time minutes of infant sleep in 24 hrs (mean diff). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 6 Longest uninterrupted day-time minutes of infant sleep in 24 hrs (mean diff)

Study or subgroup

Mean difference

Mean difference (SE)

Weight

IV,Fixed,95% CI

Mean difference IV,Fixed,95% CI

1 At 6 weeks Stremler 2006

-24 (17.6)

5.2 %

-24.00 [ -58.50, 10.50 ]

Symon 2005

7.2 (4.13)

94.8 %

7.20 [ -0.89, 15.29 ]

100.0 %

5.57 [ -2.31, 13.45 ]

-5 (3.27)

49.1 %

-5.00 [ -11.41, 1.41 ]

6 (3.21)

50.9 %

6.00 [ -0.29, 12.29 ]

100.0 %

0.60 [ -3.89, 5.09 ]

Subtotal (95% CI) Heterogeneity: Chi2 = 2.98, df = 1 (P = 0.08); I2 =66% Test for overall effect: Z = 1.39 (P = 0.17) 2 At 12 weeks St James-Roberts 2001 Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 5.76, df = 1 (P = 0.02); I2 =83% Test for overall effect: Z = 0.26 (P = 0.79)

-100

-50

Favours usual care

0

50

100

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.7. Comparison 1 Education on sleep enhancement versus usual care, Outcome 7 Infant crying time in 24 hrs (mean diff). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 7 Infant crying time in 24 hrs (mean diff)

Study or subgroup

Mean difference

Mean difference (SE)

Weight

IV,Fixed,95% CI

Mean difference IV,Fixed,95% CI

1 At 4 weeks McRury 2010

18 (22.26)

Subtotal (95% CI)

100.0 %

18.00 [ -25.63, 61.63 ]

100.0 %

18.00 [ -25.63, 61.63 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.81 (P = 0.42) 2 At 6 weeks McRury 2010

18 (24.02)

5.3 %

18.00 [ -29.08, 65.08 ]

Symon 2005

3.6 (5.66)

94.7 %

3.60 [ -7.49, 14.69 ]

100.0 %

4.36 [ -6.44, 15.16 ]

100.0 %

42.00 [ -6.41, 90.41 ]

100.0 %

42.00 [ -6.41, 90.41 ]

36 (36.94)

1.5 %

36.00 [ -36.40, 108.40 ]

0 (4.59)

98.5 %

0.0 [ -9.00, 9.00 ]

100.0 %

0.55 [ -8.38, 9.47 ]

Subtotal (95% CI) Heterogeneity: Chi2 = 0.34, df = 1 (P = 0.56); I2 =0.0% Test for overall effect: Z = 0.79 (P = 0.43) 3 At 8 weeks McRury 2010

42 (24.7)

Subtotal (95% CI) Heterogeneity: not applicable Test for overall effect: Z = 1.70 (P = 0.089) 4 At 12 weeks McRury 2010 Symon 2005

Subtotal (95% CI) Heterogeneity: Chi2 = 0.94, df = 1 (P = 0.33); I2 =0.0% Test for overall effect: Z = 0.12 (P = 0.90) Test for subgroup differences: Chi2 = 3.29, df = 3 (P = 0.35), I2 =9%

-100

-50

Favours sleep treatment

0

50

100

Favours usual care

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

63

Analysis 1.8. Comparison 1 Education on sleep enhancement versus usual care, Outcome 8 Night-time minutes of infant sleep in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 8 Night-time minutes of infant sleep in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

566 (58.77)

152

560 (69.19)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

6.00 [ -8.21, 20.21 ]

100.0 % 6.00 [ -8.21, 20.21 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.83 (P = 0.41) Test for subgroup differences: Not applicable

-50

-25

0

Favours usual care

25

50

Favours sleep treatment

Analysis 1.9. Comparison 1 Education on sleep enhancement versus usual care, Outcome 9 Longest uninterrupted night-time minutes of infant sleep in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 9 Longest uninterrupted night-time minutes of infant sleep in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual Care

N

Mean(SD)

164

226 (97.95)

N

Mean(SD)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

152 231 (106.93)

100.0 %

-5.00 [ -27.66, 17.66 ]

100.0 % -5.00 [ -27.66, 17.66 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.43 (P = 0.67) Test for subgroup differences: Not applicable

-50

-25

Favours usual care

0

25

50

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.10. Comparison 1 Education on sleep enhancement versus usual care, Outcome 10 No. of infant night-time sleeping episodes. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 10 No. of infant night-time sleeping episodes

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

3 (1.31)

152

2.9 (1.26)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

152

0.10 [ -0.18, 0.38 ]

100.0 % 0.10 [ -0.18, 0.38 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.69 (P = 0.49) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

65

Analysis 1.11. Comparison 1 Education on sleep enhancement versus usual care, Outcome 11 Day-time minutes of infant sleep in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 11 Day-time minutes of infant sleep in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

278 (65.3)

152

283 (69.19)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

-5.00 [ -19.86, 9.86 ]

100.0 % -5.00 [ -19.86, 9.86 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.66 (P = 0.51) Test for subgroup differences: Not applicable

-20

-10

0

Favours usual care

10

20

Favours sleep treatment

Analysis 1.12. Comparison 1 Education on sleep enhancement versus usual care, Outcome 12 Longest uninterrupted day-time minutes of infant sleep in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 12 Longest uninterrupted day-time minutes of infant sleep in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

68 (26.12)

152

73 (31.45)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

-5.00 [ -11.40, 1.40 ]

100.0 % -5.00 [ -11.40, 1.40 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 1.53 (P = 0.13) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.13. Comparison 1 Education on sleep enhancement versus usual care, Outcome 13 No. of infant day-time sleeping episodes. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 13 No. of infant day-time sleeping episodes

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

4 (0.65)

152

3.9 (1.26)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

152

0.10 [ -0.12, 0.32 ]

100.0 % 0.10 [ -0.12, 0.32 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.88 (P = 0.38) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours sleep treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

67

Analysis 1.14. Comparison 1 Education on sleep enhancement versus usual care, Outcome 14 Night-time minutes of infant fussing/crying in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 14 Night-time minutes of infant fussing/crying in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

22 (19.59)

152

20 (18.87)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

2.00 [ -2.24, 6.24 ]

100.0 % 2.00 [ -2.24, 6.24 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.92 (P = 0.36) Test for subgroup differences: Not applicable

-10

-5

0

5

Favours sleep treatment

10

Favours usual care

Analysis 1.15. Comparison 1 Education on sleep enhancement versus usual care, Outcome 15 Longest uninterrupted night-time minutes of infant fuss/cry in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 15 Longest uninterrupted night-time minutes of infant fuss/cry in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

11 (6.53)

152

11 (12.58)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

0.0 [ -2.24, 2.24 ]

100.0 % 0.0 [ -2.24, 2.24 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.0 (P = 1.0) Test for subgroup differences: Not applicable

-10

-5

Favours sleep treatment

0

5

10

Favours usual care

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.16. Comparison 1 Education on sleep enhancement versus usual care, Outcome 16 No. of infant night-time fussing/crying episodes. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 16 No. of infant night-time fussing/crying episodes

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

2 (1.31)

152

1.8 (1.26)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

152

0.20 [ -0.08, 0.48 ]

100.0 % 0.20 [ -0.08, 0.48 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.38 (P = 0.17) Test for subgroup differences: Not applicable

-10

-5

Favours sleep treatment

0

5

10

Favours usual care

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.17. Comparison 1 Education on sleep enhancement versus usual care, Outcome 17 Day-time minutes of infant fussing/crying in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 17 Day-time minutes of infant fussing/crying in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

43 (32.65)

152

40 (31.45)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

3.00 [ -4.07, 10.07 ]

100.0 % 3.00 [ -4.07, 10.07 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.83 (P = 0.41) Test for subgroup differences: Not applicable

-10

-5

0

Favours sleep treatment

5

10

Favours usual care

Analysis 1.18. Comparison 1 Education on sleep enhancement versus usual care, Outcome 18 Longest uninterrupted day-time minutes of infant fuss/cry in 24 hrs. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 18 Longest uninterrupted day-time minutes of infant fuss/cry in 24 hrs

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

11 (6.53)

152

12 (12.58)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

-1.00 [ -3.24, 1.24 ]

100.0 % -1.00 [ -3.24, 1.24 ]

152

Heterogeneity: not applicable Test for overall effect: Z = 0.88 (P = 0.38) Test for subgroup differences: Not applicable

-10

-5

Favours sleep treatment

0

5

10

Favours usual care

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.19. Comparison 1 Education on sleep enhancement versus usual care, Outcome 19 No. of infant day-time fussing/crying episodes. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 19 No. of infant day-time fussing/crying episodes

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

164

4 (1.96)

152

3.6 (2.52)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 12 weeks St James-Roberts 2001

Subtotal (95% CI)

164

100.0 %

152

0.40 [ -0.10, 0.90 ]

100.0 % 0.40 [ -0.10, 0.90 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.57 (P = 0.12) Test for subgroup differences: Not applicable

-10

-5

Favours sleep treatment

0

5

10

Favours usual care

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 1.20. Comparison 1 Education on sleep enhancement versus usual care, Outcome 20 Maternal stress score. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 1 Education on sleep enhancement versus usual care Outcome: 20 Maternal stress score

Study or subgroup

Sleep intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

18

220.1 (38.8)

17

196.3 (25.8)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 6 weeks postpartum McRury 2010

Subtotal (95% CI)

18

17

48.4 %

23.80 [ 2.08, 45.52 ]

48.4 %

23.80 [ 2.08, 45.52 ]

51.6 %

36.40 [ 15.38, 57.42 ]

Heterogeneity: not applicable Test for overall effect: Z = 2.15 (P = 0.032) 2 At 12 weeks postpartum McRury 2010

Subtotal (95% CI)

18

225.3 (35.3)

18

17

188.9 (27.9)

17

51.6 % 36.40 [ 15.38, 57.42 ]

34

100.0 % 30.31 [ 15.20, 45.41 ]

Heterogeneity: not applicable Test for overall effect: Z = 3.39 (P = 0.00069)

Total (95% CI)

36

Heterogeneity: Chi2 = 0.67, df = 1 (P = 0.41); I2 =0.0% Test for overall effect: Z = 3.93 (P = 0.000084) Test for subgroup differences: Chi2 = 0.67, df = 1 (P = 0.41), I2 =0.0%

-100

-50

Favours sleep treatment

0

50

100

Favours usual care

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Analysis 2.1. Comparison 2 Education on infant behaviour versus usual care, Outcome 1 Knowledge of infant behaviour. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 1 Knowledge of infant behaviour

Study or subgroup

Infant behaviour interven

Mean Difference

Usual Care

N

Mean(SD)

N

Mean(SD)

14

12.6 (2.1)

14

8 (3.2)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 Maternal at 1-4 days postpartum Myers 1982

Subtotal (95% CI)

14

14

100.0 %

4.60 [ 2.60, 6.60 ]

100.0 %

4.60 [ 2.60, 6.60 ]

Heterogeneity: not applicable Test for overall effect: Z = 4.50 (P < 0.00001) 2 Maternal at 4 weeks postpartum Golas 1986

17

16.6 (1.8)

13

13.4 (2.3)

49.3 %

3.20 [ 1.68, 4.72 ]

Myers 1982

14

10.8 (1.4)

12

8.3 (2.3)

50.7 %

2.50 [ 1.01, 3.99 ]

100.0 %

2.85 [ 1.78, 3.91 ]

100.0 %

6.50 [ 4.88, 8.12 ]

100.0 %

6.50 [ 4.88, 8.12 ]

100.0 %

3.70 [ 1.93, 5.47 ]

100.0 %

3.70 [ 1.93, 5.47 ]

Subtotal (95% CI)

31

25

Heterogeneity: Chi2 = 0.42, df = 1 (P = 0.52); I2 =0.0% Test for overall effect: Z = 5.24 (P < 0.00001) 3 Paternal at 1-4 days postpartum Myers 1982

Subtotal (95% CI)

14

13.1 (1.5)

14

14

6.6 (2.7)

14

Heterogeneity: not applicable Test for overall effect: Z = 7.87 (P < 0.00001) 4 Paternal at 4 weeks postpartum Myers 1982

Subtotal (95% CI)

14

14

10.4 (2.5)

12

6.7 (2.1)

12

Heterogeneity: not applicable Test for overall effect: Z = 4.10 (P = 0.000041) Test for subgroup differences: Chi2 = 14.16, df = 3 (P = 0.00), I2 =79%

-100

-50

Favours usual care

0

50

100

Favours behaviour treat

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Analysis 2.2. Comparison 2 Education on infant behaviour versus usual care, Outcome 2 Child-rearing anxiety. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 2 Child-rearing anxiety

Study or subgroup

Infant behaviour interven

Flagler 1988

Total (95% CI)

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

31

58.7 (9)

30

55 (10.9)

31

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

30

100.0 %

3.70 [ -1.33, 8.73 ]

100.0 %

3.70 [ -1.33, 8.73 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.44 (P = 0.15) Test for subgroup differences: Not applicable

-10

-5

0

Favours behaviour treat

5

10

Favours usual care

Analysis 2.3. Comparison 2 Education on infant behaviour versus usual care, Outcome 3 Mother distance. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 3 Mother distance

Study or subgroup

Infant behaviour interven

Flagler 1988

Total (95% CI)

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

31

1.4 (0.5)

30

1.2 (0.7)

31

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

30

100.0 %

0.20 [ -0.11, 0.51 ]

100.0 %

0.20 [ -0.11, 0.51 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.28 (P = 0.20) Test for subgroup differences: Not applicable

-10

-5

Favours behaviour treat

0

5

10

Favours usual care

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Analysis 2.4. Comparison 2 Education on infant behaviour versus usual care, Outcome 4 Mutuality. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 4 Mutuality

Study or subgroup

Infant behaviour interven

Flagler 1988

Total (95% CI)

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

31

47.1 (8.2)

30

46 (8.4)

31

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

30

100.0 %

1.10 [ -3.07, 5.27 ]

100.0 %

1.10 [ -3.07, 5.27 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.52 (P = 0.60) Test for subgroup differences: Not applicable

-10

-5

0

Favours usual care

5

10

Favours behaviour treat

Analysis 2.5. Comparison 2 Education on infant behaviour versus usual care, Outcome 5 Synchronous cooccurrences during free play - visual. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 5 Synchronous co-occurrences during free play - visual

Study or subgroup

Wendland-Carro 1999

Total (95% CI)

Infant behaviour interven

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

17

17.41 (6.34)

19

7.31 (6.3)

17

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

100.0 %

19

10.10 [ 5.96, 14.24 ]

100.0 % 10.10 [ 5.96, 14.24 ]

Heterogeneity: not applicable Test for overall effect: Z = 4.79 (P < 0.00001) Test for subgroup differences: Not applicable

-20

-10

Favours behaviour treat

0

10

20

Favours usual care

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Analysis 2.6. Comparison 2 Education on infant behaviour versus usual care, Outcome 6 Synchronous cooccurrences during free play - vocal. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 6 Synchronous co-occurrences during free play - vocal

Infant behaviour interven

Study or subgroup

Wendland-Carro 1999

Total (95% CI)

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

17

11.47 (5.34)

19

4.74 (3.9)

17

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

19

100.0 %

6.73 [ 3.64, 9.82 ]

100.0 %

6.73 [ 3.64, 9.82 ]

Heterogeneity: not applicable Test for overall effect: Z = 4.28 (P = 0.000019) Test for subgroup differences: Not applicable

-10

-5

0

Favours behaviour treat

5

10

Favours usual care

Analysis 2.7. Comparison 2 Education on infant behaviour versus usual care, Outcome 7 Mothers’ perception of their infants. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 7 Mothers’ perception of their infants

Study or subgroup

Infant behaviour interven

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

15

2.8 (9.72)

15

2.14 (15.14)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 1 month postpartum Hall 1980

Total (95% CI)

15

15

100.0 %

0.66 [ -8.44, 9.76 ]

100.0 %

0.66 [ -8.44, 9.76 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.14 (P = 0.89) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours behaviour treat

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Analysis 2.8. Comparison 2 Education on infant behaviour versus usual care, Outcome 8 Maternal confidence interpreting infant behaviour. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 2 Education on infant behaviour versus usual care Outcome: 8 Maternal confidence interpreting infant behaviour

Study or subgroup

Infant behaviour interven

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

17

49.9 (5.4)

13

46.2 (7.6)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 4 weeks postpartum Golas 1986

Total (95% CI)

17

13

100.0 %

3.70 [ -1.16, 8.56 ]

100.0 %

3.70 [ -1.16, 8.56 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.49 (P = 0.14) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours behaviour treat

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Analysis 3.1. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 1 Maternal general post-birth knowledge score (mean). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 1 Maternal general post-birth knowledge score (mean)

Study or subgroup

Health/care intervention

Regan 1995

Total (95% CI)

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

45

18.3 (1.56)

55

17.9 (1.87)

45

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

55

100.0 %

0.40 [ -0.27, 1.07 ]

100.0 %

0.40 [ -0.27, 1.07 ]

Heterogeneity: not applicable Test for overall effect: Z = 1.17 (P = 0.24) Test for subgroup differences: Not applicable

-10

-5

0

Favours usual care

5

10

Favours health treatment

Analysis 3.2. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 2 Maternal general post-birth knowledge score (per cent correct). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 2 Maternal general post-birth knowledge score (per cent correct)

Study or subgroup

Regan 1995

Total (95% CI)

Health/care intervention

Usual care

n/N

n/N

41/45

47/55

100.0 %

1.07 [ 0.92, 1.23 ]

45

55

100.0 %

1.07 [ 0.92, 1.23 ]

Risk Ratio

Weight

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

Total events: 41 (Health/care intervention), 47 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 0.88 (P = 0.38) Test for subgroup differences: Not applicable

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours health treatment

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Analysis 3.3. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 3 Infant weight (kg). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 3 Infant weight (kg)

Study or subgroup

Health/care intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

105

7.3 (1)

98

7.2 (1.1)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 6 months post-birth Bolam 1998

Subtotal (95% CI)

105

98

100.0 %

0.10 [ -0.19, 0.39 ]

100.0 %

0.10 [ -0.19, 0.39 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.68 (P = 0.50) Test for subgroup differences: Not applicable

-10

-5

0

Favours usual care

5

10

Favours health treatment

Analysis 3.4. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 4 Infant length (cm). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 4 Infant length (cm)

Study or subgroup

Health/care intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

104

63.2 (4)

98

62.9 (4.5)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 6 months post-birth Bolam 1998

Subtotal (95% CI)

104

98

100.0 %

0.30 [ -0.88, 1.48 ]

100.0 %

0.30 [ -0.88, 1.48 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.50 (P = 0.62) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours health treatment

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Analysis 3.5. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 5 Head circumference (cm). Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 5 Head circumference (cm)

Study or subgroup

Health/care intervention

Mean Difference

Usual care

N

Mean(SD)

N

Mean(SD)

105

42.4 (2)

98

42.6 (2.1)

Weight

IV,Fixed,95% CI

Mean Difference IV,Fixed,95% CI

1 At 6 months post-birth Bolam 1998

Subtotal (95% CI)

105

98

100.0 %

-0.20 [ -0.76, 0.36 ]

100.0 %

-0.20 [ -0.76, 0.36 ]

Heterogeneity: not applicable Test for overall effect: Z = 0.69 (P = 0.49) Test for subgroup differences: Not applicable

-10

-5

Favours usual care

0

5

10

Favours health treatment

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Analysis 3.6. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 6 Appropriate immunization. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 6 Appropriate immunization

Study or subgroup

Health/care intervention

Usual care

n/N

n/N

100/104

91/98

100.0 %

1.04 [ 0.97, 1.11 ]

104

98

100.0 %

1.04 [ 0.97, 1.11 ]

Risk Ratio

Weight

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 At 6 months post-birth Bolam 1998

Subtotal (95% CI)

Total events: 100 (Health/care intervention), 91 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 1.02 (P = 0.31)

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours health treatment

Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 3.7. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 7 Knowledge of signs of infant pneumonia. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 7 Knowledge of signs of infant pneumonia

Study or subgroup

Health/care intervention

Usual care

n/N

n/N

26/105

20/98

100.0 %

1.21 [ 0.73, 2.03 ]

105

98

100.0 %

1.21 [ 0.73, 2.03 ]

56/105

44/98

100.0 %

1.19 [ 0.90, 1.58 ]

105

98

100.0 %

1.19 [ 0.90, 1.58 ]

Risk Ratio

Weight

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 Indrawing Bolam 1998

Subtotal (95% CI)

Total events: 26 (Health/care intervention), 20 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 0.74 (P = 0.46) 2 Tachypnea Bolam 1998

Subtotal (95% CI)

Total events: 56 (Health/care intervention), 44 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 1.19 (P = 0.23)

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours health treatment

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Analysis 3.8. Comparison 3 Education on general post-birth infant health or care versus usual care, Outcome 8 Knowledge of action to take in the case of infant diarrhoea. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 3 Education on general post-birth infant health or care versus usual care Outcome: 8 Knowledge of action to take in the case of infant diarrhoea

Study or subgroup

Health/care intervention

Usual care

n/N

n/N

51/105

48/98

100.0 %

0.99 [ 0.75, 1.31 ]

105

98

100.0 %

0.99 [ 0.75, 1.31 ]

96/105

90/98

100.0 %

1.00 [ 0.92, 1.08 ]

105

98

100.0 %

1.00 [ 0.92, 1.08 ]

Risk Ratio

Weight

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 Continue breastfeeding Bolam 1998

Subtotal (95% CI)

Total events: 51 (Health/care intervention), 48 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 0.06 (P = 0.95) 2 Give oral rehydration solution Bolam 1998

Subtotal (95% CI)

Total events: 96 (Health/care intervention), 90 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 0.10 (P = 0.92)

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours health treatment

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Analysis 4.1. Comparison 4 Education on infant safety versus usual care, Outcome 1 Infant restraint seat fastened by lap belt. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 4 Education on infant safety versus usual care Outcome: 1 Infant restraint seat fastened by lap belt

Study or subgroup

Safety intervention

Usual care

n/N

n/N

Risk Ratio

Weight

Christophersen 1982

10/15

0/15

100.0 %

21.00 [ 1.34, 328.86 ]

Subtotal (95% CI)

15

15

100.0 %

21.00 [ 1.34, 328.86 ]

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 At hospital discharge

Total events: 10 (Safety intervention), 0 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 2.17 (P = 0.030) 2 At 4-6 weeks Christophersen 1982

4/14

3/13

100.0 %

1.24 [ 0.34, 4.51 ]

Subtotal (95% CI)

14

13

100.0 %

1.24 [ 0.34, 4.51 ]

Total events: 4 (Safety intervention), 3 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 0.32 (P = 0.75)

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours safety treatment

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Analysis 4.2. Comparison 4 Education on infant safety versus usual care, Outcome 2 Post-hospitalization awareness of tap water burns. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 4 Education on infant safety versus usual care Outcome: 2 Post-hospitalization awareness of tap water burns

Study or subgroup

Shapiro 1987

Total (95% CI)

Safety intervention

Usual care

n/N

n/N

Risk Ratio

Weight

299/302

279/302

100.0 %

1.07 [ 1.04, 1.11 ]

302

302

100.0 %

1.07 [ 1.04, 1.11 ]

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

Total events: 299 (Safety intervention), 279 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 3.96 (P = 0.000076) Test for subgroup differences: Not applicable

0.1 0.2

0.5

1

Favours usual care

2

5

10

Favours safety treatment

Analysis 4.3. Comparison 4 Education on infant safety versus usual care, Outcome 3 Greater use of temperature testing. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 4 Education on infant safety versus usual care Outcome: 3 Greater use of temperature testing

Study or subgroup

Shapiro 1987

Total (95% CI)

Safety intervention

Usual care

n/N

n/N

Risk Ratio

Weight

155/302

88/302

100.0 %

1.76 [ 1.43, 2.17 ]

302

302

100.0 %

1.76 [ 1.43, 2.17 ]

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

Total events: 155 (Safety intervention), 88 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 5.35 (P < 0.00001) Test for subgroup differences: Not applicable

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours safety treatment

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Analysis 4.4. Comparison 4 Education on infant safety versus usual care, Outcome 4 Supine infant sleep position. Review:

Postnatal parental education for optimizing infant general health and parent-infant relationships

Comparison: 4 Education on infant safety versus usual care Outcome: 4 Supine infant sleep position

Study or subgroup

Safety intervention

Usual care

n/N

n/N

Risk Ratio

Weight

29/32

20/29

100.0 %

1.31 [ 1.00, 1.72 ]

32

29

100.0 %

1.31 [ 1.00, 1.72 ]

24/32

18/29

100.0 %

1.21 [ 0.85, 1.71 ]

32

29

100.0 %

1.21 [ 0.85, 1.71 ]

39/91

24/100

100.0 %

1.79 [ 1.17, 2.72 ]

91

100

100.0 %

1.79 [ 1.17, 2.72 ]

38/91

18/94

100.0 %

2.18 [ 1.35, 3.53 ]

91

94

100.0 %

2.18 [ 1.35, 3.53 ]

M-H,Fixed,95% CI

Risk Ratio M-H,Fixed,95% CI

1 At 1 week Goetter 2005

Subtotal (95% CI)

Total events: 29 (Safety intervention), 20 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 1.99 (P = 0.046) 2 At 6 weeks Goetter 2005

Subtotal (95% CI)

Total events: 24 (Safety intervention), 18 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 1.07 (P = 0.29) 3 At 3 months Issler 2009

Subtotal (95% CI)

Total events: 39 (Safety intervention), 24 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 2.69 (P = 0.0071) 4 At 6 months Issler 2009

Subtotal (95% CI)

Total events: 38 (Safety intervention), 18 (Usual care) Heterogeneity: not applicable Test for overall effect: Z = 3.18 (P = 0.0015)

0.1 0.2

0.5

Favours usual care

1

2

5

10

Favours safety treatment

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APPENDICES Appendix 1. Search methods used in previous version 2009

Search methods for identification of studies

Electronic searches We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Trials Search Co-ordinator (30 April 2009). The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 1. quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); 2. weekly searches of MEDLINE; 3. handsearches of 30 journals and the proceedings of major conferences; 4. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts. Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group. Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Coordinator searches the register for each review using the topic list rather than keywords. In addition, we searched CINAHL (1982 to July 2009), ERIC (1966 to July 2009), HealthSTAR (1966 to July 2009), PsycINFO (1806 to July 2009), Sociological Abstracts (1974 to July 2009), ClinicalTrials.gov (August 2009), Current Controlled Trials (August 2009), Trialscentral.org (August 2009), using the search strategies detailed in below. We did not apply any language restrictions. Database: CINAHL: September 2007 to July 2009 (Ebscohost) (1)MH postnatal period+ or postnatal (2)MH parents+ or MH parenting+ or (parent or parents or parenting) (3)MH breast feeding+ or breastfeeding or breast feeding (4)MH depression, postpartum+ or postpartum N5 depression (5)S1 or S2 or S3 or S4 (6)MH postnatal care+ or postnatal care (7)MH patient education or patient education (8)MH community health nursing+ or community health nursing (9)MH parenting education or parenting education or health education (10)S6 or S7 or S8 or S9 (11)S5 and S10 (12)S11 and (clinical trial or PT clinical trial or controlled trial) Database: ERIC: September 2007 to July 2009 (Ebscohost) (1)DE birth or birth or DE pregnancy or pregnancy (2)DE early parenthood or DE obstetrics or DE perinatal influences (3)(DE adult learning or didactic) or (class or course) or DE teaching methods+ or DE educational research+ (4)DE parenthood education or preparation or (postpartum N5 education) or (postnatal N5 education) (5)S1or S2 (6)S3 or S4 (7)S5 and S6 (8)S7 and (trial or trials) Database: HealthSTAR: September 2007 to July 2009 (Ovid) (1) exp puerperium/ or puerperium.ti,ab,sh. or post partum.ti,ab,sh. or postpartum.ti,ab,sh. (2) exp parents/ or parenting/ or (parent$ or mother$ or father$).ti,ab,sh. (3) exp breastfeeding/ or (breastfeeding or breast feeding or breast fed or breastfed).ti,ab,sh. Postnatal parental education for optimizing infant general health and parent-infant relationships (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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(4) exp depression, postpartum/ or depression, postpartum.ti,ab,sh. (5) or/1-4 (6) exp postnatal care/ or postnatal care.ti,ab,sh. (7) exp health education/ or health education.ti,ab,sh. (8) preventive health service$.ti,ab,sh. (9) exp community health nursing/ or community health nurs$.ti,ab,sh. (10) (educat$ or teach$ or learn$).ti,ab,sh. (11) or/6-10 (12) 5 and 11 (13) limit 12 to nonmedline Database: PsycINFO: September 2007 to July 2009 (Ebscohost) (1)DE birth+ or DE pregnancy or postpartum or postnatal (2)DE postpartum depression + or postpartum depression (3)DE education or preparation (4)S1 or S2 (5)S3 and S4 (6)S5 and (trial or trials) Limit: Population Group: Human Database: Sociological Abstracts: 2007 to July 2009 (CSA Illumina) (1)birth or de=birth (2)pregnancy or exp pregnancy (3)postpartum or postnatal (4)#1 or #2 or #3 (5)parent* or exp parent (6)education or de=education or de=health education (7)parent training or de=parent training (8)#6 or #7 (9)#4 and #5 and #8 (10)#9 and (trial or trials) Unpublished, planned or ongoing trials databases (all searched August 2009) Clinical Trials.gov Current Controlled Trials Trialscentral.org (postpartum OR postnatal) AND (parent OR parents OR parenting)

WHAT’S NEW Last assessed as up-to-date: 17 September 2013.

Date

Event

Description

17 September 2013

New citation required but conclusions have not Four new studies were included: (Issler 2009; McRury changed 2010; Paradis 2011; Paul 2011). Two studies originally included (Doherty 2006; Wolfson 1992) were excluded because upon clarification of eligibility criteria, they were deemed not eligible

31 March 2013

New search has been performed

Search updated. Eligibilty criteria reviewed and clarified. Outcomes reviewed and clarified. Methods and Background sections updated

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HISTORY Protocol first published: Issue 1, 2003 Review first published: Issue 1, 2009

Date

Event

Description

11 October 2010

Amended

We have corrected an error in the text. Stremler 2006 did not measure either infant crying or parent confidence. Thank you to Robyn Stremler for bringing this to our attention

31 August 2009

New citation required but conclusions have not New review team updated the review. changed

31 August 2009

New search has been performed

Search updated: one new study included (Golas 1986); nine new studies excluded. One additional meta-analysis conducted and risk of bias tables completed for all included studies. Ten studies excluded in original review due to lack of useable data moved to included studies and tables completed

31 August 2009

Amended

Converted to new review format.

CONTRIBUTIONS OF AUTHORS For the 2013 update, Janet Bryanton and Cheryl Tatano Beck collaborated to review and assess the literature, enter the data into RevMan 2012, draft all sections of the updated and amended review, and approve the final version of the review. William Montelpare acted as an advisor for the data analysis.

DECLARATIONS OF INTEREST None known.

SOURCES OF SUPPORT Internal sources • McGill University, Canada. • McGill University Health Centre - Royal Victoria Hospital Site, Canada. • University of Prince Edward Island, Canada.

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External sources • Le Fonds de la recherche en santé du Québec (FRSQ), Canada. • Canadian Cochrane Network - McGill University Site, Canada. • Groupe de recherche interuniversitaire en soins infirmiers de Montreal (GRISIM), Canada.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW We have: • changed the title from ’Postnatal parental education for improving family health’ to ’Postnatal parental education for optimizing infant general health and parent-infant relationships’, as we believe this reflects the scope of our review more accurately; • updated the Methods section in line with the Cochrane Pregnancy and Childbirth Group’s guidelines; • reviewed and clarified outcomes. Maternal/paternal infant care competence was deleted because it overlapped infant preventive care and maternal/paternal care confidence. It was replaced by maternal/paternal stress/anxiety; • presented all the results for dichotomous data as risk ratios (RR) with 95% confidence intervals - in previous versions of this review a mix of risk ratios (RR) and odds ratios(OR) had been used.

INDEX TERMS Medical Subject Headings (MeSH) ∗ Health

Behavior; ∗ Infant Care; ∗ Infant Welfare; ∗ Parent-Child Relations; ∗ Parenting; Child Development; Parents [education]; Postpartum Period; Randomized Controlled Trials as Topic; Sleep [physiology]

MeSH check words Adult; Female; Humans; Infant, Newborn; Male

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Postnatal parental education for optimizing infant general health and parent-infant relationships.

Many learning needs arise in the early postpartum period, and it is important to examine interventions used to educate new parents about caring for th...
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