Breastfeeding update

1. Breastfeeding update 2008

2. Session content • Review of breastfeeding guidance • Research roundup • Review of teaching skills for positioning and attachment • Talking about breastfeeding • Discussion/Q & A

3. NICE guidance • Healthcare professionals should have sufficient time, as a priority, to give support to a woman and baby during initiation and continuation of breastfeeding • Women who leave hospital soon after birth should be reassured that this should not impact on breastfeeding duration • Initiation of breastfeeding should be encouraged as soon as possible after the birth, ideally within 1 hour

4. Separation of a woman and her baby within the first hour of the birth for routine postnatal procedures, for example weighing, measuring and bathing, should be avoided unless these measurements are requested by the woman, or are necessary for the immediate care of the baby • Women should be encouraged to have skin-to-skin contact with their babies as soon as possible after the birth • It is not recommended that women are asked about their proposed method of feeding until after the first skin-to-skin contact

5. Continuing Successful Breastfeeding • Unrestricted breastfeeding frequency and duration should be encouraged • Women should be advised that babies generally stop feeding when they are satisfied, which may follow a feed from only one breast. Babies should be offered the second breast if they do not appear to be satisfied following a feed from one breast • Women should be advised of the indicators of good attachment, positioning and successful feeding

6. Indicators of good attachment and positioning: • mouth wide open • • less areola visible underneath the chin than above the nipple • • chin touching the breast, lower lip rolled down, and nose free • • no pain •

7. Indicators of successful feeding in babies: • • audible and visible swallowing • • sustained rhythmic suck • • relaxed arms and hands • • moist mouth • • regular soaked/heavy nappies • • Indicators of successful breastfeeding in women: • • breast softening • • no compression of the nipple at the end of the feed • • woman feels relaxed and sleepy •

8. Remember, happiness is a round nipple and a yellow poo

9. Women should be given information about local breastfeeding support groups • If an insufficiency of milk is perceived by the woman, attachment and positioning should be reviewed and her baby’s health should be evaluated. Reassurance should be offered to support the woman to gain confidence in her ability to produce enough milk for her baby • If the baby is not taking sufficient milk directly from the breast and supplementary feeds are necessary, expressed breast milk should be given by a cup or bottle • Supplementation with fluids other than breast milk is not recommended.

10. All breastfeeding women should be shown how to hand express their colostrum or breast milk and advised on how to correctly store and freeze it.

12. Preventing, identifying and treating breastfeeding concerns • Women should be advised that if their nipples are painful or cracked, it is probably due to incorrect attachment • If nipple pain persists after repositioning and re-attachment, assessment for thrush should be considered • Breast engorgement should be treated with: • frequent unlimited breastfeeding including prolonged feeding from the affected breast • breast massage and, if necessary, hand expression • analgesia.

13. Mastitis • Women should be advised to report any signs and symptoms of mastitis including flu like symptoms, red, tender and painful breasts to their healthcare professional urgently • Women with signs and symptoms of mastitis should be offered assistance with positioning and attachment and advised to: • continue breastfeeding and/or hand expression to ensure effective milk removal; if necessary, this should be with gentle massaging of the breast to overcome any blockage • take analgesia compatible with breastfeeding, for example paracetamol • increase fluid intake.

14. Mastitis • If signs and symptoms of mastitis continue for more than a few hours of self management, a woman should be advised to contact her healthcare professional again (urgent action) • If the signs and symptoms of mastitis have not eased, the woman should be evaluated as she may need antibiotic therapy (urgent action)

15. Special Situations • Women with inverted nipples should receive extra support and care to ensure successful breastfeeding • Evaluation for ankyloglossia should be made if breastfeeding concerns persist after a review of positioning and attachment by a skilled healthcare professional or peer counsellor • Babies who appear to have ankyloglossia should be evaluated further (non-urgent action) • IPG149 Division of ankyloglossia for breastfeeding - guidance

16. Tongue Tie

17. More relevant guidance • The National Institute for Health and Clinical Excellence (NICE) has published new Public Health Guidance on improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. There are six key priorities for implementation • Adoption of a multifaceted approach to increasing breastfeeding, including implementation of the Baby Friendly Initiative; • Training for health professionals and support workers, including in breastfeeding, using the Baby Friendly Initiative training as a minimum standard; • The implementation of peer support programmes; • Promotion of the Healthy Start Scheme; • Vitamin D supplementation for pregnant women and breastfeeding mothers; • This guidance concurs with the 2006 NICE Postnatal Care Guidelines which also recommend the implementation of the Baby Friendly Initiative as a clinically and cost effective method of improving breastfeeding rates

18. SACN • The Scientific Advisory Committee on Nutrition (SACN) has reviewed the findings of the 2005 Infant Feeding Survey and made recommendations to improve infant feeding practice and inform policy. Recommendations include: • Implementation of the Baby Friendly Initiative in both hospital and community; • Health professional training in practical breastfeeding management; • Raising awareness of the health risks associated with not breastfeeding; • Addressing inequalities in access to antenatal and postnatal services, identifying women who are hard to reach and ensuring that the topic of breastfeeding is raised at antenatal visits; • Clear, independent professional advice on infant and follow-on formulae; • Appropriately tailored advice on formula feeding for mothers who have chosen to formula feed. • SACN is an advisory committee of independent experts that provides advice to the Food Standards Agency and Department of Health as well as other Government Agencies and Departments

19. Healthy weight, healthy lives: A cross-government Strategy for England • Healthy weight, healthy lives outlines the Government’s strategy for tackling obesity in England. Improving breastfeeding rates and delaying the introduction of solids until 6 months are identified as key interventions to tackle obesity. In order to achieve this, the Government commits to: • Encouraging maternity units to adopt the Baby Friendly Initiative; • Investing in an information campaign to promote the benefits of breastfeeding; • Supporting a National Breastfeeding Helpline for mothers; • Rolling out the new WHO Growth Standards

20. Proposals for a National Programme to Support Breastfeeding in Wales • The Welsh Assembly Government’s Breastfeeding Strategy, “Investing in A Better Start: Promoting Breastfeeding in Wales” makes recommendations for ways to support and encourage mothers and mothers-to-be in Wales to breastfeed their babies • Breastfeeding provides considerable health benefits for mothers and babies as well as economic benefits to the healthcare system. The factors that affect the intention, initiation and duration rates of breastfeeding are complex and therefore to address these factors, a multi-sectoral and collaborative approach is needed. Long term success and sustainability requires, among other things, a shift in culture and attitudes towards breastfeeding among both the public and those health professionals who support them • The 2005 UK Infant Feeding Survey provided breastfeeding rates for Wales for the first time and showed that two thirds of mothers initiated breastfeeding.  By six weeks, 37% of mothers were still breastfeeding and this number had fallen to 18% by six months of age.  These figures are all lower than in England and Scotland.  

21. Research Roundup

22. Breast-feeding Increases Sleep Duration of New Parents • As part of a randomized clinical trial, the study utilized infant feeding and sleep data at 3 months postpartum from 133 new mothers and fathers. Infant feeding type (breast milk or formula) was determined from parent diaries • Sleep was measured objectively using wrist actigraphy and subjectively using diaries. Lee's General Sleep Disturbance Scale was used to estimate perceived sleep disturbance

23. Results: Parents of infants who were breastfed in the evening and/or at night slept anaverage of 40-45 minutes more than parents of infants given formula • Parents of infantsgiven formula at night also self-reported more sleep disturbance than parents of infants who were exclusively breast-fed at night • Conclusions: Parents who supplement their infant feeding with formula under theimpression that they will get more sleep should be encouraged to continue breast-feedingbecause sleep loss of more than 30 minutes each night can begin to affect daytime functioning, particularly in those parents who return to work

24. Breast-feeding Increases Sleep Duration of New Parents • Journal of Perinatal & Neonatal Nursing. 21(3):200-206, July/September 2007.Doan, Therese RN, IBCLC; Gardiner, Annelise; Gay, Caryl L.; Lee, Kathryn A. PhD, RN, FAAN

25. Breastfeeding associated with a lower risk of being overweight at 7 years • Data on 2,347 Dutch children born in 1996–7 were collected. After adjustment for confounders, children breastfed for >16 weeks were found to have a lower BMI at 1 year of age than children who were not breastfed • a high BMI at 1 year of age was strongly associated with a high BMI between 1 and 7 years of age • The authors conclude that these findings suggest that the lower BMI and lower risk of overweight among breastfed children later in life are already achieved by 1 year of age

26. Scholtens S, Gehring U, Brunekreef B et al. Breastfeeding, weight gain in infancy, and overweight at seven years of age. • American Journal of Epidemiology 2007; doi:10.1093/aje/kwk083

27. Prolonged, Exclusive Breast-Feeding Raises IQ at Age 6.5 Years • Prolonged, exclusive breast-feeding improved cognitive development in what researchers described as the largest randomised trial ever conducted in human lactation • This benefit to the child’s cognitive development, as measured by IQ testing and teachers’ academic evaluations, was not related to the mother’s cognitive ability • Many observational studies have reported the same findings, but some in the medical community have been unconvinced because only randomised, controlled trials can show definitively whether breast-feeding improves cognition. However, it would be unfeasible, and unethical, to randomly assign mother-infant pairs to bottle-feeding in order to settle the question

28. PROBIT, which was developed by the World Health Organization and UNICEF, sidestepped this difficulty by randomly assigning subjects who said they intended to breast-feed to either a promotion intervention or a “usual care” control group, then performing an intention-to-treat analysis. The intervention was a programme that promoted prolonged breast-feeding through at least age 1 year and exclusive breast-feeding for as long as possible • The study subjects were 17,046 healthy infants enroled at 31 maternity hospitals and clinics in the Republic of Belarus, of whom 13,889 were assessed again at age 6.5 years • The intervention led to a substantial increase in both the prevalence and the duration of breast-feeding. At 3 months, the prevalence of exclusive breast-feeding was seven times higher in the intervention group (43%) than in the control group (6%)

29. At age 6.5 years, the intervention group had significantly higher scores on the Wechsler Abbreviated Scales of Intelligence, on all subtests of WASI, and on teacher assessments of academic performance in reading, writing, mathematics, and other subjects • It is unclear whether the cognitive benefits of breast-feeding result from some constituent of breast milk or from the physical, social, or emotional interactions that characterise nursing. It is possible that breast-feeding could lead to permanent physiologic changes that accelerate neurocognitive development or that the longer time required for breast-feeding may increase interactions between mother and infant, which in turn might stimulate cognitive development, the investigators said

30. Breastfeeding and Child Cognitive Development, Kramer, Frances et al • Arch. Gen. Psychiatry 2008;65:578-84

31. Formula Fed Babies more likely to die of Cot Death • babies who are at least partly breastfed are one-third less likely to die as a cot death than babies who were never breastfed • this advice was released on April 30th to launch FSID’s cot death awareness drive Save a Baby Month which runs from 1-31 May • USA Agency for Healthcare Research and Quality (AHRQ) performed a stringent meta-analysis incorporating 6 studies in which SIDS was rigorously defined and the duration of breastfeeding specified. They found that ever breastfeeding reduced the risk of SIDS compared with never breastfeeding, with an adjusted odds ratio of 0.64 (95% CI 0.51-0.81). It is therefore clear that breastfeeding should be recommended as a protective measure against SIDS, in addition to the other well known reasons for promoting the practice.

32. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence report/technology assessment No. 153 (prepared by Tufts-New England Medical Center Evidence-based Practice Center, under contract No. 290-02-0022) Agency for Healthcare Research and Quality; 2007. p. 1-186. http://www.ahrq.gov/clinic/tp/brfouttp.htm

33. Formula Fed Babies more likely to die of Cot Death • Actually, that information was sent out as a press release with the title “Breastfeeding reduces the risk of cot death” Discuss!