Postnatal Interventions for Infants Under Six Months: A Systematic Review

Early life growth faltering (also referred to as failure to thrive) and malnutrition are major global public health problems. Infants aged under six months with growth faltering are a particularly vulnerable group. These first six months of life are a period of rapid maturation and development with unique dietary needs. The mother or carer thus plays a critical role in fulfilling the child’s nutritional requirements. 

To inform the updated World Health Organization (WHO) guidelines on the prevention and management of growth faltering among infants under six months, this review examined the effectiveness of postnatal maternal or caregiver interventions on seven domains. Anthropometric recovery, child development, anthropometric outcomes, mortality, readmission, relapse, and non-response among infants aged under six months were all considered.

A total of 13 studies with preterm and/or low birth weight infants contributed to the final synthesis, which assessed the effects of breastfeeding counselling or education (n = 8), maternal nutrition supplementation (n = 2), mental health (n = 1), relaxation therapy (n = 1), and cash transfer (n = 1) interventions. Overall, the evidence from these studies had serious indirectness and a high risk of bias. 

The evidence was limited in scope and primarily ranged from 'low' to 'very low' certainty. Breastfeeding counselling or education compared to standard care might increase infant weight at one month, weight at two months, and length at one month, but with very uncertain evidence (very low quality). Maternal nutrition supplementation, in comparison to standard care, may not result in increased infant weight at 36 weeks postmenstrual age and may not reduce infant mortality by 36 weeks postmenstrual age (low quality). 

Moreover, interventions for maternal mental health compared to standard care might not increase infant weight, length, and head circumference at two months, with the evidence ranging from low to very low quality. The effects of relaxation therapy versus standard care on infant weight, length, and head circumference at three months are highly uncertain (very low quality). Lastly, the evidence regarding cash transfers compared to standard care on child development scores at three months, changes in weight and head circumference z-score from birth to three months post-discharge, and readmission by three months remains highly uncertain, with very low-quality evidence.

Based on review findings, strong new WHO recommendations for maternal interventions for infants under six months with growth faltering will be challenging to make because these need a more secure underpinning evidence base. The WHO guidelines of 2013 and 2023 both recommend providing counselling and support, including mental health support, to mothers or caregivers of infants with severe malnutrition, both for inpatient and outpatient care. Given that the 2023 guidelines are still based on ‘low’ to ‘very low’ quality evidence, with little change since 2013, the authors urged the need for well-designed, well-targeted future trials assessing postnatal maternal or caregiver interventions on infants aged under six months with growth faltering, stating that this is more urgent than ever.