Abstract: We found 10 trials (23 reports) of education and support for breastfeeding that included women with twins or higher order multiples. The quality of evidence was mixed, and the risk of bias was mostly high or unclear. It is difficult to blind women or staff to group allocation for this intervention, so in all studies there was high risk of performance and high or unclear risk of detection bias. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial); of these, data were available from two studies for 42 women with twins or higher order multiples. None of the interventions were specifically designed for women with more than one infant, and the outcomes for multiples were not reported separately for each infant. Due to the scarcity of evidence and the format in which data were reported, a narrative description of the data is presented, no analyses are presented in this review, and we were unable to GRADE the evidence. The two trials with data for women with multiple births compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). The number of women who initiated breastfeeding was reported (all 15 women in one study, 25 out of 27 women in one study). Stopping any breastfeeding before four to six weeks postpartum, stopping exclusive breastfeeding before four to six weeks postpartum, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, and there were insufficient data to draw any meaningful conclusions from survival data. Stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported. Measures ofmaternal satisfaction were reported in one study of 15 women, but there were insufficient data to draw any conclusions; no other secondary outcomes were reported for women with multiple births in either study. No adverse events were reported. We found no evidence from randomised controlled trials about the effectiveness of breastfeeding education and support for women with twins or higher order multiples, or the most effective way to provide education and support . There was no evidence about the best way to deliver the intervention, the timing of care, or the best person to deliver the care. There is a need for well-designed, adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.

Plain-language summary: We searched for randomised controlled trials on 30 June 2016 and 1 July 2016 and found 10 studies (23 reports) to include in our review. All the studies were of education and support for all mothers, not just those giving birth to more than one baby, which introduced methodological issues for looking specifically at multiple births. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial). The number of babies from multiple pregnancies was small and none of the studies had sufficient numbers to provide information about how interventions worked for mothers of multiples. There were several problems with how the studies had been done, including women knowing if they were in the group getting support. The authors of two of the studies sent us their findings for women with multiple births (42 women in total). The trials compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). They looked at the number of women stopping any or exclusive breastfeeding before four weeks after giving birth and before six months, without any clear improvements provided by the intervention. All 15 women in one study and 25 out of 27 women in the other had started breastfeeding. There was no information on breast milk expression. Other outcome measures were reported, including a measure of maternal satisfaction in one study of 15 women, but there were not sufficient numbers to allow us to draw any conclusions. No adverse events were reported. We could not draw conclusions from the evidence available from randomised controlled trials about whether education and support helps mothers of multiples to breastfeed. None of the studies were designed to offer tailored support or education to women who give birth to more than one baby. More research is needed to find out what types of education and support could help mothers of multiples to breastfeed their babies. Data from these studies should be presented and analysed in an appropriate way for multiple babies.