Breastfeeding and maternal care – What’s new?

Early results from the 2010 Infant Feeding Survey (IFS) carried out on behalf of the NHS Information Centre by the IFF Research in partnership with Professor Mary Renfrew in the Mother and Infant Research Unit at the University of York, show that Breastfeeding Initiation Rates (BIR) across the UK have risen by as much as 5% since the last survey in 2005 and by 12% since 2000. Average BIR for the UK is now 81%, but the highest recorded initiation rate in England was 83%.

The statement from the Director of UNICEF Baby Friendly Initiative, Sue Ashmore, in June of this year observes that the effort put into Breastfeeding support by NHS staff in the form of staff training and knowledge and policies that are proven to increase breastfeeding rates, have been rewarded with this rise in breastfeeding rates. Over the past 10 years the number of maternity hospitals gaining UNICEF Baby Friendly Accreditation has almost tripled.

The IFS showed as well that primagravida mothers tended to initiate breastfeeding slightly more than after subsequent deliveries: 84% compared to 78%. The incidence of breastfeeding remains highest amongst mothers in managerial and professional occupations, however rates increased across all socio-economic groups. As with previous studys, mothers who left full-time education after the age of 18 had a higher prevalence of breastfeeding whilst mothers under the age of 20 continue to have the lowest rate of initiation.

It would appear then that the incentives that are being used across the country are working in improving the breastfeeding Initiation rate across the UK. The Scientific Advisory Committee on Nutrition Report 2011 has reviewed the evidence and concluded that early life nutrition exerts long term effects and influences the risk of chronic disease in adults.The increasing body of research evidence shows that Breastfeeding can help protect not only the mother and child but the child as it develops into an adult from these illnesses. Children who are breastfed in infancy demonstrate a characteristic pattern of growth associated with better health than observed in infants who are fed artificial milk. Infants who are not breastfed tend to eventually have higher blood pressures and raised serum cholesterol as adult, and may be at risk of type 2 diabetes, as are more likely to be obese.

We know that breastmilk contains living cells which provide a unique immunological benefit to babies and has the ability to change and adapt to the growing needs of the infant, changing the amount of proteins, carbohydrates and fats as required. Work being carried out at the University of Western Australia is also focussing on cells within breast milk that seem to resemble stem cells.

The Millennium Cohort Study (MCS) showed that babies who are breastfed are less likely to eventually develop behavioural problems at the age of five years compared to children who are formula fed [4% v 16%]. This trial looked at 10,000 pairs who were from a white ethnic background between 2000-2007 from Oxford, Essex and York. This study also showed that not only were the babies born at term struggling to be breastfed until six months- 29% at four months, but that with prematurity it is even less likely- 21% at four months. It is believed that in pre term infants, breastmilk can reduce the risk of necrotizing enterocolitis by as much as four fold.

The MCS also identified a link between the essential fatty acids found in breastmilk and the improved role in development and function of the brain and central nervous system, this coupled with the increased neuro-psychological interaction between the mother and infant pairs may have a bearing on the babies subsequent intellectual quotient.

Breastfeeding has a huge role in protecting children’s health, and the reduction in hospital admissions for gastroenteritis, ear and urine infections. The Royal College of Paediatric Child Health (RCPCH) new position paper on Breastfeeding (2011) encourages mothers to breastfeed. For example, if all babies born in the UK were breastfed until the age of six months admissions to hospital due to diarrhoea would be reduced by 50%.This has to be significant not only for the mothers and babies but also has implications on the financial benefits to the National Health Service.

The RCPCH is also supportive of the UINICEF Baby Friendly Initiative and feels that a collaborative and multi disciplinary team approach is important to allow health professionals and families to work together towards increasing both the initiation rate and maintenance rate of breastfeeding.

A recent study of bone marker turnover at six months by a Danish cohort found that participants who were breastfed and were followed up until the age of 17 years appear to have a positive age-expected correlation of the lumber spine bone mass.

Maternal depression has been associated with a number of adverse outcomes in children. A small study looked at mothers of 12 day old infants who had reported a depressed mood and anxiety.The study found that maternal depression is associated with less weight gain in infants, poor attachment to the breast and less sensitive positioning at the breast by the mother. It is an important point that if mothers were showing a depressed mood then greater breastfeeding support should be given.

In many areas of the country staff are being asked to work more efficiently, including considering reducing the number of visits that a new mother gets in the initial post partum period. How might we identify these mothers who are feeling low and are we then going to be able to give them the increased support this evidence suggests is required? If this is the route professionals have to address, then should we be looking to alternative support mechanisms to give support to these mothers and their infants.

During the World Breastfeeding Week UNICEF stated that no other preventative intervention is more cost effective than breastfeeding in reducing the number of children who die before their fifth birthday. It is also remarkable that the Cancer Research Foundation lists breastfeeding as one of only ten preventative measures in reducing your risk of developing cancer along side reducing obesity and increasing physical activity.

We need to look at any scope for improving upon the rise in UK breastfeeding initiation rates. We also need to ensure there are strategies in place to promote, protect and support exclusive breastfeeding. Some of these are summarised in Table 1.

Table 1. Strategies for supporting exclusive breastfeeding.

In some babies with significant ankylaglossia (tongue-tie), frenulotomy appears to immediately improve both breastfeeding and maternal nipple pain. There may be some value to this controversial procedure.

Lots of trusts, PCTs and SHAs are also working closely alongside the voluntary sector or social enterprise. It may be worthwhile to consider introducing peer support alongside more conventional support from health professionals for breastfeeding. Peer supporters who meet mothers in the antenatal period are able to offer support with breastfeeding when the baby is subsequently born. Such peer supporters and baby feeding coordinators have been trained by the charity The Breast Feeding Network. They come onto the maternity ward and meet mums to offer support at home, this ranges from a telephone call/text at 48hrs to home visiting and on going support for up to six weeks. Peer supporters may be paid or voluntary, but some use a mixture of both. Some local charities run support groups around the country and are developing a network of café’s, restaurants and public places were mothers are welcome to breastfeed their infants: stickers will be displayed for families to look out for.

Other parts of the country are paying to bring in social marketing groups who will appoint peer supporters from the local area and managers to coordinate the program locally. This can be very expensive for trusts. From the NICE guidelines however, achieving baby friendly accreditation is the basic support that trusts should be offering to mothers.

Our peer supporters will also signpost mums to other support groups, either locally or nationally. These include the National Child birth Trust, the Le Leche League and Association of Breast Feeding Mothers. Many of these organisations now use social networking sites to promote and share information via Facebook, Twitter etc.

To conclude, we as health professionals should reassure our mothers that breastfeeding is the right thing to do and that it is normal. A few years down the line, we might be able to tell them that it really is the best.

Some useful websites:

• www.abm.me.uk
• www.babyfriendly.org.uk/
• www.breastfeedingnetwork.org.uk/
• www.breastfeedingsupporters.org.uk/
• www.cls.ioe.ac.uk/mcs/ Millennium Cohort Study
• www.llli.org
• www.nct.org.uk

References

• Infant Feeding Survey 2010: Early Results. UK Health and Social Care Information Centre.
• Scientific Advisory Committee on Nutrition SCAN 2011
• Molgaard C, Larnkjaer A, Budek A et al (2011). Are early growth and nutrition related to bone health in adolescence? The Copenhagen Cohort Study of infant nutrition and growth. Am J Clin Nutr. (2011), 10.3945/ajcn.110.001214
• MA Quigley, C Hockley, C Carson, Y Kelly, MJ Renfrew, and A Sacker. Breastfeeding is associated with Improved Child Cognitive Development: A Population-Based Cohort Study. J Pediatr 10 Aug 2011.
• Sybil L. Hart, Shera C. Jackson, and L. Mallory Boylan. Compromised weight gain, milk intake, and feeding behavior in breastfed newborns of depressive mothers. J. Pediatr. Psychol. (2011) 36(8): 942-950.
• http://www.ncchta.org/project/1611.asp Breastmilk/Breastfeeding in Neonatal units
• Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial.. Pediatrics. July 2011, 10.1542/peds.2011-0077.

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