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Breastfeeding in the early days and beyond

Key learning points

- Breastfeeding has benefits for mother and baby both in developing countries and in developed European countries such as the UK

 - Social factors rather than biological have the most impact upon women's ability to breastfeed

 - Health visitors are well placed to prevent problems in the early days and to support mothers in feeding for as long as they wish

The work of health visitors is currently centred on children aged 0-5 years, and much of the health promotion carried out by health visitors focuses on diet and nutrition. How a baby is fed in the first year of life has a major impact upon physical health in both the long and short term, and is increasingly found to have an influence upon emotional and mental health in both the mother and child. Healthy nutrition in the first year of life 'sets the scene' for later eating behaviours, and has an impact upon family attitudes towards food. The World Health Organization (WHO)1 currently recommends exclusive breastfeeding for six months followed by weaning onto complementary foods at around six months and continued breastfeeding to two years. The Department of Health recommends exclusive breastfeeding for six months and continued breastfeeding for one year and beyond.2 

The benefits of breastfeeding are well evidenced in scientific literature. Two landmark papers have demonstrated that breastfeeding has benefits over formula feeding, not only in developing countries where facilities are often not available to safely make up formula feeds, but also in developed European countries such as the UK.3,4 Evidence shows that babies who are artificially fed have an increased risk of infections in the first year of life (gastrointestinal, respiratory, ear and urinary tract), eczema, asthma and wheezing, childhood leukaemia, sudden infant death syndrome (SIDs) and of being obese.5 This reduced risk of obesity for breastfed babies is particularly important in view of rising levels of childhood obesity in the UK. Benefits of breastfeeding for mothers include reduced risk of breast and ovarian cancer, and higher bone density in later life. 

Despite these impressive benefits, rates of breastfeeding in the UK are among the lowest in Europe. The 2010 Infant Feeding Survey shows that while 81% of UK babies are breastfed at birth, 55% are breastfed at six weeks and by six months only 34% of babies receive any breast milk at all. Just 1% of UK mothers follow the recommendation to exclusively breastfed to six months. The most common reasons given by mothers for stopping breastfeeding are problems with latching the baby on, having painful breasts or nipples and feeling that they have 'not enough milk' (31%).6 Of the mothers who stopped breastfeeding, more than three in five (63%) said that they would have liked to have breastfed for longer. These figures suggest that there is much health professionals can do to prevent problems in the early days and to support mothers in feeding for as long as they wish. 

Success in breastfeeding varies widely between different socio-economic groups and between countries. Among the white British population, the women most likely to breastfeed are professional women who live in the least deprived areas and are most highly educated.6 Ethnicity also has a major influence on breastfeeding with over 90% initiation rates among Chinese, Black and Asian mothers, and high rates of continued breastfeeding. Many countries have made changes in policy and practice to improve their breastfeeding rates. From a low level of breastfeeding in the 1970s, Norway now has a 99% initiation rate, with 70% of mothers still exclusively breastfeeding at three months.7 Policies introduced to facilitate continued breastfeeding include generous parental leave, additional childcare leave and rights to nursing breaks. In addition, 80% of hospitals in Norway are now 'baby friendly' and law has been passed surrounding the marketing of formula milks. This variation in rates between different social and ethnic groups, and between countries, indicates that social factors rather than biological have the most impact upon women's ability to breastfeed. 

As breastfeeding is causally linked to the prevention of mortality and morbidity in the first year of life, and ill health in later life, interventions to promote and support breastfeeding are highly cost effective. Such interventions are not limited to the clinical environment. Service providers and commissioners can support practitioners with their breastfeeding role by providing appropriate training for all professionals working with pregnant or new mothers. It is recommended that Unicef's Baby Friendly Initiative is commissioned and implemented as a minimum standard in as many environments as possible in order to support an organisational culture where breastfeeding is encouraged and valued. A structured, audited and publicised breastfeeding policy underpins all practice, providing best practice and research evidence upon which professionals can confidently base their practice8. 

So what can nurses and health visitors do to support mothers to breastfeed for as long as they wish? Health visitors have the skills to establish a relationship that is sensitive to the needs of the individual family context, and can work in partnership with other agencies and third sector organisations in order to promote and support breastfeeding. Much research has been done into the best ways of supporting mothers to initiate and continue breastfeeding which is summarised below.

Promoting breastfeeding ante-natally 

 

The Healthy Child Programme2 emphasises the importance of discussing infant feeding ante-natally. Dyson et al9 suggest that informal education, repeated over several sessions and based on the needs of the individual, is most effective in promoting breastfeeding. Thus an antenatal visit from the health visitor where infant feeding plans can be discussed at home in a relaxed atmosphere with other family members present may be preferable to a formal antenatal class. The health visitor should be able to provide clear information on positioning and attachment, and on how to recognise that the baby is feeding well.8 Signs of feeding well include the baby being calm and relaxed during feeds, taking eight feeds or more per 24 hours, having wet and dirty nappies and breastfeeding being comfortable.5 The health visitor should also discuss skin-to-skin contact at birth, as mothers of babies who experience this are more likely to initiate breastfeeding.6 

Supporting breastfeeding in the early days and beyond 

The importance of a mother's confidence at her ability to breastfeed should also not be underestimated. Commitment to make breastfeeding a success, despite the challenges and a belief in the value of the process were identified as influential factors in sustained breastfeeding.10 In order to increase the duration of breastfeeding, setting achievable incremental goals is the key, but a woman or family centred approach is more effective than focusing solely on breastfeeding in contacts with families.11 Parents appreciate professionals who are encouraging, non-judgmental and acknowledge that every family has different needs.12 With good support and well-informed advice on positioning and attachment, problems such as sore nipples and poor milk supply can be prevented. Specific advice is available from the Unicef website which contains up-to-date information for both parents and professionals about how to deal with common problems.5 

Peer support schemes have the potential to prolong the duration of breastfeeding13 but key to their success is making sure that supporters are well informed, have opportunities to update and work closely with a health professional. Face-to-face support is most likely to be effective; support visits should be scheduled so that the mother can plan when support will be available - expecting the mother to contact a peer supporter or health professional means the intervention is less likely to succeed. Of particular significance is the availability of link workers or peer supporters whose first language is not English.8 Not only can these supporters relate to the needs of minority groups but can also encourage migrants to continue with the good feeding habits that they may have brought from their original culture.

Breastfeeding is a high impact area of public health, with the potential to improve outcomes for babies and their mothers. Health visitors are well placed to support families both ante-natally and postnatally as part of their universal child health promotion work. It is therefore important for health visitors to undergo training such as that provided by the Unicef Baby Friendly Initiative in order to ensure that they are up to date and well informed. Perhaps more importantly it is vital that health visitors form warm and supportive relationships with families, within which breastfeeding can be encouraged as part of a holistic health promotion framework. 

 

Don't miss the Nursing in Practice Health Visitor Supplement included with this issue for more articles on infant health.

 

Resources

UNICEF UK (for health professionals)

NHS Choices (for parents) 

References 

1. World Health Organisation Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organisation, 2003.

2. DH. The Healthy Child Programme: Pregnancy and the first five years of life. 

3. Ip S, et al. Breastfeeding and Maternal Health Outcomes in Developed Countries. AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

4. Horta B, et al. Evidence on the long term effects of breastfeeding. Geneva: World Health Organisation; 2007.

5. UNICEF 2014 Research.

6. Health and Social Care Information Centre Infant Feeding Survey - UK 2010. HSCIC, 2012.

7. Save the Children State of the World's Mothers Report: Nutrition in the first 1000 days, Save the Children 2012.

8. NICE. Maternal and child nutrition: NICE public health guidance 11, London: NICE; 2008. 

9. Dyson L, et al. Interventions for promoting the initiation of breastfeeding (Review). The Cochrane Collaboration: John Wiley & Sons, Ltd; 2012.

10. Avery A, Zimmermann K, Underwood PW, Magnus JH. Confident commitment is a key factor for sustained breastfeeding. Birth 2002:36;141-8.

11. Hoddinott P, Craig LCA, Britten J, McInnes RM. A serial qualitative interview study of infant feeding experiences: idealism meets realism. BMJ Open 2012;2:e000504 doi:10.1136/bmjopen-2011-00050412. 

12. McInnes RJ, et al. Supporting breastfeeding mothers: qualitative synthesis. Journal of Advanced Nursing 2008;62(4):

407-27.

13. Renfrew MJ, et al Support for healthy breastfeeding mothers with healthy term babies (Review). The Cochrane Collaboration: John Wiley & Sons, Ltd; 2012.