Breastfeeding: Foundation of Life

Breastfeeding: Foundation of Life

World Breastfeeding Week 2018 (link) ends today. Kate’s six daily blogs for it have helped to explore in a UK context the key themes of nutrition, food security and poverty reduction which underpin the strapline Breastfeeding: Foundation of Life.

Nutrition

Breastmilk is uniquely tailored to the needs of the baby receiving it. The most critical time for epigenetic changes is from in utero to age 3 years so gene expression may be significantly affected by the nutrition the baby receives. Early nutrition also influences the development of the gut microbiome; vaginal birth, particularly at home, skin-to-skin contact and breastmilk help to seed the infant’s gut microbiome from the mother’s microbiota, and oligosaccharides in breastmilk are food for beneficial bacterial species. A healthy gut microbiome helps to programme the immune system and lessen the chances of the person developing non-communicable diseases (NCDs).

Food security

Breastfeeding ensures food security, including in times of crisis, as even malnourished mothers can breastfeed and the baby thrive. There is no reliance on external supplies, equipment or hygienic conditions for preparation. Breastmilk is the most locally produced food possible.

Poverty reduction

Breastfeeding is a low-cost way of feeding babies. The mother may be hungrier and eat more so then there is an additional cost, but a minimal one compared to formula-feeding a baby, which in turn can increase poverty as there is less income available for the rest of the family.

In addition, and Kate has given details, not breastfeeding increases the health risks of both babies and mothers. This has consequences for society as it leads to increased healthcare costs.

WBW Objectives

The 4 objectives are to:

Inform people about the links between good nutrition, food security, poverty reduction and breastfeeding.

Kate described how she has incorporated it in her Year 7 teaching about reproduction and led a school assembly on it. Despite others’ misgivings, the reality was that the boys responded maturely.

Anchor breastfeeding as the foundation for life.

Engage with individuals and organisations for greater impact.

For example, in April 2018, the World Breastfeeding Trends Initiative (WBTi) UK Steering Group organised a conference with the iHV (Institute of Health Visiting) at the Royal Society for Public Health; the conference summary has just been published.

Galvanise action to advance breastfeeding as part of good nutrition, food security and poverty reduction.

This needs education about breastfeeding in schools, workplaces, health professional training, parliaments……, with practical actions to improve support for mothers wherever they are and to encourage people to be supportive. The WBTi UK report in 2016 identified specific gaps, and recommendations to address those gaps.

 

Feature photo credit: Adobe Stock

 

30. Photo for WBTi MAINN presentation

Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.

Breastfeeding and the impact on society

Breastfeeding and the impact on society

I recently had a very interesting conversation with a friend who breastfed in America. Her initial observations of breastfeeding in the UK is that it is a lot more open and society a lot more accepting of mothers doing it. It’s interesting because, despite our generous maternity leave in comparison to The States and the legal status that a mum can breastfeed everywhere (not in place in every state in the U.S.A!), our rates remain some of the lowest in the world. So what is it? There are many articles and books discussing the matter. But more often than not, the “blame” lies with society. Society’s perception that bottle feeding is the normal. Why does every baby doll kit come with a bottle?! Why are we instilling in our children from a young age what is not biologically normal? Not that we should be looking for who or what to blame. We should be looking for solutions to ensure that the parents of our children of the future world are able to make informed decisions about how to feed their child. There are several places where we should be focussing. For example with our government, ensuring that we follow the World Health Assembly International Code (WHO 1981) and subsequent resolutions.

An area of great interest to me is ensuring that the children of our current generation are fully informed and educated on the matter. Incorporating this into the national curriculum would be amazing. But until that time, I can take heart by teaching it in the year 7 reproduction topic that I teach. I can teach the whole school by doing an assembly on it. Which in fact was what I did with two of my esteemed colleagues, who are equally passionate about breastfeeding and supporting mothers. When I tell friends and family I did an assembly on breastfeeding, they were amazed and in awe of the “brave” activity I did. Brave because I teach in an all boys’ school. But why brave? Breastfeeding isn’t just a female topic. It isn’t just a mother topic. It is a whole society topic. The whole of society should be educated and care about it. Interestingly, the management at the school supported the idea that this was indeed a “very brave” things to do. In actual fact, the boys received the information very maturely and it led to some great conversations and learning around the topic.

If we could improve society’s perceptions of breastfeeding and improve our breastfeeding rates, what impact would this have on society? As we’ve seen in these WBW blogs, one of the key benefits of breastfeeding is a reduction in illness in both mother and baby. Also of importance is the economics of breastfeeding based on these improved health outcomes. They are quite eye-opening. A 2012 report commissioned by Unicef UK showed that investment to increase and sustain breastfeeding rates will provide a rapid financial return on investment (Unicef 2012).

Kate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 2 and 4) day and night. She trained as a Kate Butlerbreastfeeding peer supporter in 2013 and since then has set up local peer support meetings in her local area and joined the committee of West Herts Breastfeeders to support with fundraising and event management. West Herts Breastfeeders is a community based mum to mum peer support group that supports breastfeeding families with their breastfeeding journeys in the community and within West Hertfordshire Hospitals NHS Trust.

References

UNICEF 2012 [ONLINE] Available at: https://www.unicef.org.uk/wp-content/uploads/sites/2/2012/11/Preventing_disease_saving_resources.pdf [Accessed 26/07/2018]

WHO 1981 [ONLINE] Available at: http://www.who.int/nutrition/publications/code_english.pdf [Accessed 26/07/18]

Breastfeeding and the impact on mothers

Breastfeeding and the impact on mothers

End of the breastfeeding shaming: Midwives ordered not to judge new mothers who choose to bottle feed” (Daily Mail June 2018). Wow, that’s one way for the Daily Mail to have a grabbing headline and epitomise what is so wrong with society’s view on breastfeeding. So basically, if new mothers choose to bottle feed, they will be judged by their midwives. They will feel guilty. I think I’m pretty confident in knowing that as healthcare professionals, midwives would be some of the least judgemental of them all? They are faced with parents making all sorts of decisions day in and day out. Professional, medical judgement must be made, but not judgement to lead to new mums feeling guilty. I was absolutely shocked by this news headline. It is the midwives’ role, always has been, to support a mother, a family, through the decisions they make. If a mother chooses to breastfeed, she should be supported. If a mother chooses to formula feed, she should be supported.

What is happening a lot for new mums is that the support to breastfeed is not there. Midwives are stretched. They don’t have the time. Women may also find that their partner, family and friends do not know how to support them. Therefore many new mums are forced into formula feeding due to lack of support, not because they wanted to. This can have deep psychological consequences due to their own preconceptions of motherhood and their idealistic expectations of what it should be like (Borra 2015). Inevitably, these circumstances may lead some women to develop postnatal depression. This is sad. A sad state that our society has put them in.

Fundamentally, breastfeeding has huge benefits for mums. Those who do not breastfeed have been shown to be at higher risk of breast and ovarian cancer, and type 2 diabetes. There is an increased risk of postpartum depression with shorter duration of breastfeeding (Chowdhury 2015) and Borra (2015) highlights the complexity of the association with postnatal depression. It’s often an urban myth that breastfed children don’t sleep as well as formula-fed children and therefore breastfeeding mums are exhausted, which could contribute to postpartum depression. Research shows that formula-fed babies sleep deeper and for longer bouts earlier than breastfed babies, although the total amount of sleep is the same (ISIS 2015). In fact, many breastfeeding mums get more sleep as to settle a waking baby can often be quicker with a breastfeed than having to make up a bottle.

 

Feature photo credit: Sally Etheridge, Leicester Mammas CIC

 

Kate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 2 and 4) day and night. She trained as a Kate Butlerbreastfeeding peer supporter in 2013 and since then has set up local peer support meetings in her local area and joined the committee of West Herts Breastfeeders to support with fundraising and event management. West Herts Breastfeeders is a community based mum to mum peer support group that supports breastfeeding families with their breastfeeding journeys in the community and within West Hertfordshire Hospitals NHS Trust.

 

References

Borra C, Iacovou M and Sevilla A. New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal 2015; 19(4): 897–907.

Chowdhury R, Sinha B, Sankar MJ et al. Breastfeeding and maternal health outcomes: A systematic review and meta-analysis. Acta Paediatrica 2015; 104(Suppl. 467): 96–113.

ISIS 2015 [ONLINE] Available at: https://www.dur.ac.uk/resources/isis.online/ISIS_normal_2015.pdf [Accessed 26/07/2018]

Breastfeeding, Neurodevelopment and the Microbiome

Breastfeeding, Neurodevelopment and the Microbiome

Non-communicable diseases (NCDs) are currently responsible for 70% of deaths worldwide and include conditions such as cardiovascular disease, cancers, respiratory diseases and diabetes (West 2015). The gut microbiome can be described as the healthy intestinal flora (bacteria) and there is a growing amount of evidence that it can protect infants from developing these NCDs and can influence epigenetic changes (Rollins 2016). The healthy gut flora is largely determined in infancy, with vaginal homebirth and breastfeeding being the biggest contributors (Penders 2006). Therefore, by breastfeeding, it is highly possible that we might be able to reduce the incidence of these NCDs, reduce the suffering from them, on the individuals affected, their friends and family. Not forgetting the economic impact due to time off work which leads to further pressure and strain on families to try and meet the rising cost of living.

The microbiome has also been linked with neurodevelopment. Studies in animals have shown changes in emotional responses and the biochemistry of the brain when changes have been made to the gut flora (Tillisch 2013). An additional cross-sectional study looked at the development of the brain in exclusively breastfed, combination-fed and formula-fed children. The research showed that, by age 2, babies who had been breastfed exclusively for at least three months had enhanced development in key parts of the brain compared to children who were fed formula or combination-fed. The enhanced development was found in areas of the brain that are involved with language, emotional function and cognition (Deoni 2013). Could it be that breastfeeding might play a vital role in influencing children’s neural development? With the raised profile of mental health and the rise in mental health, this is certainly an interesting area for scientists to explore further.

Fig4_MicrobirthBreastvBottle5

Feature photo credit: PB2007

Kate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 2 and 4) day and night. She trained as a Kate Butlerbreastfeeding peer supporter in 2013 and since then has set up local peer support meetings in her local area and joined the committee of West Herts Breastfeeders to support with fundraising and event management. West Herts Breastfeeders is a community based mum to mum peer support group that supports breastfeeding families with their breastfeeding journeys in the community and within West Hertfordshire Hospitals NHS Trust.

 

References

Deoni S.C.L., Dean D.C., Piryatinsky I., O’Muircheartaigh J., Waskiewicz N., Lehman K. Han M., Dirks H. Breastfeeding and early white matter development: A cross-sectional study NeuroImage 2013, 82, 77-86.

Penders J, Thijs C, Vink C, et al. Factors influencing the composition of the intestinal microbiota in early infancy. Pediatrics 2006; 118: 511 –21

Rollins N, Bhandari N, Hajeebhoy N et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016; 387(10017): 491–504

Tillisch K, Labus J, Kilpatrick L, et al. Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology 2013; 144: 1394–401.

West C, Renz H, Jenmalm MC et al. The gut microbiota and inflammatory noncommunicable diseases: Associations and potentials for gut microbiota therapies. Journal of Allergy and Clinical Immunology 2015; 135(1): 3–13.

Health outcomes for baby

Health outcomes for baby

The health benefits of breastfeeding for the child are substantial (Grummer-Strawn 2015). They’re thrust at us at our first antenatal appointment and continue to do so throughout our pregnancy. Perhaps another reason that new mums are set up to fail. They are told the importance of why they should breastfeed but not effectively supported in how to breastfeed.

So what health benefits to a child does breastfeeding provide? Breastfed children have a lower risk of obesity (Horta 2015), and subsequently reduced risk of diabetes later in life (Rollins 2016), they have less asthma (Lodge 2015), reduced malocclusion (Peres 2015) – a condition in which the teeth can be seriously misaligned and lead to prolonged and painful treatment to rectify, a lower risk of lower respiratory infections, gastroenteritis, necrotising enterocolitis (the most common gastrointestinal emergency occurring in neonates), middle ear infections and tooth decay (Rollins 2016). More recently, this year, researchers found a beneficial link between the sugars found in breastmilk and their ability to slow the growth of group B Streptococcus – a very nasty bacterial infection that can cause preterm birth, stillbirth, and neonatal sepsis, and two further types of bacterial infection prevalent in children, one linked to MRSA (Ackerman 2018). Rather more concerning is that mortality rates are higher among infants never breastfed compared to those exclusively breastfed for the first 6months and continued to be breastfed beyond 6 months (Sankar 2015) and that the risk of sudden infant death is higher in formula fed infants (Rollins 2016).

This is a timely reminder that breastfeeding is the biological normal, so giving artificial milk actively increases the risk of the conditions stated above. That’s not to say that breastfeeding stops these conditions from happening 100% nor does it mean that if you give formula, the infant will get these. What it means is that if a child is fed artificial milk, they have a higher chance of suffering from these conditions than children who are not. It’s a fact and certainly not an opportunity to “bash” formula feeding mums who didn’t have any other option. But for some mums, during those appetite spurts, when their baby seems to be feeding non-stop, it can be all too easy to reach for the formula. Because they doubt their supply, they doubt their ability that they can do it, and then because their baby guzzles a bottle they can assume they must be starving their baby. But providing the knowledge of why not to give up on a bad day and educating mums on what is normal is what’s important. For a mum to know how to know that her breastfeeding is going just fine. That’s what we should focus on.

 

Feature photo credit: Adobe Stock

 

 

References

Ackerman D, Craft K, Doster R, Weitkamp J-H, Aronoff D, Gaddy J, Townsend S Antimicrobial and Antibiofilm Activity of Human Milk Oligosaccharides against Streptococcus agalactiae, Staphylococcus aureus, and Acinetobacter baumannii. ACS Infect.Dis., 2018, 4(3), pp 315-324

Grummer-Strawn, L., & Rollins, N. (2015). Summarising the health effects of breastfeeding. Acta Pediatrica, 104(S467), 1–2

Horta BL, de Mola CL, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure,and type-2 diabetes: a systematic review and meta-analysis. ActaPaediatr 2015; 104 (Suppl. 467): 30–7

Lodge CJ, Tan DJ, Lau M, Dai X, Tham R, Lowe AJ, et al. Breastfeeding and asthma and allergies: a systematic review and meta-analysis. Acta Paediatr 2015; 104 (Suppl. 467):38–53

Peres KG, Cascaes AM, Nascimento GG, Victora CG. Effect of breastfeeding on malocclusions: a systematic review and meta-analysis. Acta Paediatr 2015; 104 (Suppl. 467): 54–61

Rollins N, Bhandari N, Hajeebhoy N et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016; 387(10017): 491–504

Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S,Martines J, et al. Optimal breastfeeding practices and infant andchild mortality: a systematic review and meta-analysis. ActaPaediatr 2015; 104 (Suppl. 467): 3–13

Breastfeeding and Epigenetics

Breastfeeding and Epigenetics

This is an area of scientific research that absolutely fascinates me! Despite dating back to 1942, it’s a relatively new and exciting area of research! Excuse the little science lesson before I actually get to my key points…

It’s well-known that we inherit 50% of our DNA from our mum and 50% from our dad. Our DNA is our blueprint that, together with our environment, makes us who we are. Epigenetics, a phrase coined by Waddington in 1942, was derived from the Greek word “epigenesis” which originally described the influence of genetic processes on development (Waddington 1942). Our DNA is structured into chromosomes (46 in humans). A chromosome is a very long length of the DNA molecule. Our genes are short sections of the DNA and tell our cells what proteins to make. In different cells, different genes are switched on. For example in the cell of the iris in our eye, there will be a gene switched on to make the proteins that give the eye colour. In a stomach cell, this gene would be switched off, as we don’t need the protein for eye colour in the stomach. Whether a gene is switched on or off is known as gene expression. Epigenetics is the study of how changes in gene expression that are hereditary (i.e. are passed on to children and future generations) happen.

What is the link to breastfeeding? Epigenetic changes to our DNA can be made by environmental and lifestyle factors such as nutrition, chemicals, stress, and emotional experiences (Wilson n.d.). Although the expression of our genes could potentially be altered throughout a person’s lifetime, the most critical time for epigenetic changes is from in utero to age three. Therefore the environment to which a mother is exposed during pregnancy and the nutrition that an infant receives during that period can have significant effects on the expression of their genes. These epigenetic changes may alter and change the predisposition of infants to certain diseases developing and therefore affect their lifelong heath (Wilson, n.d.). On an even deeper level, the egg cell that formed 50% of who our children are or may be, was developing in us when our own mother was pregnant with us. Therefore the environment that she was exposed to may well have initiated epigenetic changes to the DNA in those developing egg cells that have become or may become our children. So what we expose ourselves to, what we expose our children to, doesn’t just affect us and our children, but our future generations. Amazing.

epigenetics

Artwork credit – Amy Haderer, The Mandala Journey

All the eggs a woman will ever carry form in her ovaries while she is a four-month-old foetus in the womb of her mother. This means our cellular life as an egg begins in the womb of our grandmother. Each of us spent five months in our grandmother’s womb, and she in turn formed in the womb of her grandmother. We vibrate to the rhythm of our mother’s blood before she herself is born, and this pulse is the thread of blood that runs all the way back through the grandmothers to the first mother.”

Layne Redmond When the Drummers were Women

 

Feature photo credit: www.harrowbabies.co.uk

Kate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 2 and 4) day and night. She trained as a Kate Butlerbreastfeeding peer supporter in 2013 and since then has set up local peer support meetings in her local area and joined the committee of West Herts Breastfeeders to support with fundraising and event management. West Herts Breastfeeders is a community based mum to mum peer support group that supports breastfeeding families with their breastfeeding journeys in the community and within West Hertfordshire Hospitals NHS Trust.

 

References

Waddington C.H. “The epigenotype”. Endeavour 1: 18–20 (1942)

Wilson, L. (n.d.). Nutrition and breastfeeding – the long-term impact of breastmilk on health. [ONLINE] Available at: http://motherjourney.com/uploads/3/5/3/1/35315324/epigenetics_and_breastfeeding_article.pdf [Accessed 26/07/2018]

World Breastfeeding Week 2018

World Breastfeeding Week 2018

I’ve just finished my 9th academic year of teaching secondary Biology (well 7 really, if you count my two maternity leaves…). It’s ironic, perhaps, that here I am writing a blog to celebrate World Breastfeeding Week (1st August-7th August) where the slogan is breastfeeding: foundation for life. Because you could say that education is also a foundation for life. The similarities are perhaps obvious. They both set you up for a successful future, however you might define success. They both need teachers to teach you how to succeed. They both need supporters, friends, family, to keep you on track and keep you going.

Perhaps the link goes deeper. Breastfeeding is in itself an education. Many would think that as we are mammals, we should know what we’re doing and find it easy. But the reality is that many new mums struggle. One of the key indicators of a successful teacher is one who teaches a learner how to learn. A key indicator of a successful teacher of breastfeeding is one who teaches a mother, teaches a breastfeeding family, how to breastfeed, to know how to know what is normal and what might not be. So that a breastfeeding mum, and her child, don’t “just” breastfeed, they learn the art of breastfeeding together. It’s a learning curve, often a very steep one, for everyone involved.

WBTi WBW pic 8

I’ve been a rather passionate advocate and supporter of breastfeeding for 5 years now. My passion began when I had my first child. I’ve undertaken breastfeeding peer supporter training, volunteered on my local maternity wards and run local mum to mum breastfeeding support groups. I’ve read countless books and articles on the topic. I’ve even dabbled in the politics of it all, taking on massive corporations and looked to influence our national curriculum in schools. Yet despite my experience and my knowledge, I’ve still got a lot to learn. I’m still absolutely aghast that only 1% of babies are still exclusively breastfed at 6 months (Rollins 2016) despite the the World Health Organisation (WHO) recommending exclusive breastfeeding up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond (WHO 2018). At 8 weeks, less than half of babies are fed any breastmilk. Most upsetting is that many mothers who started breastfeeding, and then stopped, wished they could have fed for longer (McAndrew 2010).

What I really struggle with is talking about breastfeeding to an audience where breastfeeding hasn’t happened. For whatever reason. And there are many, many, very valid reasons. In the wise words of Professor Amy Brown, stop blaming mums, let’s have a look at society (Brown 2018). What I struggle with is that the moment we become mothers, we are shrouded in mother guilt. Mothers who feed their babies formula very often feel they had no option. Sometimes that is very true. They can feel guilty and very angry that their opportunity to breastfeed is taken away from them. They can find it difficult when they are surrounded by messages such as “breast is best” and can feel personally attacked when breastfeeding is on the agenda for discussion. I find that very hard to overcome when talking to friends and family who might not have breastfed. Breastfeeding mums are often branded as “bottle bashers”, “breastapo”, “lactonazi”. Delightful. But all breastfeeding mums want to do is to help other mums to breastfeed, if it’s what the mum wants to do. Because they’ve been there. They know the challenges and they know what might help.

Professor Amy Brown is right. We need to look at society. It is no one mum’s fault. The lack of support from society, the lack of knowledge from the health professionals who should know (see the World Breastfeeding Trends initiative (WBTi) UK Report with its Indicators, Gaps and Recommendations), the marketing tactics from formula companies. Society sets up our mums to fail at breastfeeding. And fuel that guilt. By the way, breast isn’t best. Breastfeeding is the biological norm. What is best is that mothers are able to make a FULLY informed choice about how they feed their baby. Informed is best. Support is best. Sometimes, that choice is taken away from mothers for various medical reasons. And hallelujah that we have formula to ensure that child is fed and as healthy as possible. Parents who use formula, accurately called artificial milk, should be taught how to feed responsively, close and lovingly in the way that breastmilk is given. To allow the child to take the lead, to take the teat into their own mouth and allow them to control how much and how quickly they drink the milk. Paced feeding, as this is often described, allows parents to feed their child in the most natural of ways and support the closeness and bonding that should accompany feeding (Spiro 2017).

What I want to explore further in the blogs this week is to focus on some of the key reasons why breastfeeding is a foundation for life. Time and time again, the benefits of breastfeeding are thrust upon expectant mums and their families. However without the support infrastructure, too many mums are let down by “the system” and fail to achieve their breastfeeding goals. We’ve heard all too often that we should breastfeed. But why? Thankfully there is far more scientific research and evidence than ever before to support families to make a fully informed choice about how to feed their child. Grummer-Strawn (2015) raises a very valid point in the editorial. Despite the rigours of scientific research, it is important that the reader scrutinises the research to be clear on the strengths and weaknesses of that research so that they can draw informed conclusions. Several of the papers that Grummer-Strawn comments on, and several areas that I will share, demonstrate the major contribution that breastfeeding makes to the foundation for life.

 

Feature photo credit: Adobe Stock

 

Kate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 2 and 4) day and night. She trained as a Kate Butlerbreastfeeding peer supporter in 2013 and since then has set up local peer support meetings in her local area and joined the committee of West Herts Breastfeeders to support with fundraising and event management. West Herts Breastfeeders is a community based mum to mum peer support group that supports breastfeeding families with their breastfeeding journeys in the community and within West Hertfordshire Hospitals NHS Trust.

 

References

Brown A, Dispatches “Breastfeeding Uncovered” First shown July 20th 2018

Grummer-Strawn, L., & Rollins, N. (2015). Summarising the health effects of breastfeeding. Acta Pediatrica, 104(S467), 1–2

McAndrew F, Thompson J, Fellows L et al. Infant Feeding Survey 2010. [ONLINE] Available at: http://content.digital.nhs.uk/catalogue/ PUB08694/Infant-Feeding-Survey-2010- Consolidated-Report.pdf [Accessed 26/07/2018]

Rollins N, Bhandari N, Hajeebhoy N et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016; 387(10017): 491–504

Spiro A. The public health benefits of breastfeeding. Perspectives in Public Health 2017; 137 No 6:307-308

The World Breastfeeding Trends initiative (WBTi). UK Report Indicators, Gaps and Recommendations [ONLINE] Available at: https://ukbreastfeeding.org/wbtiuk2016/ [Accessed 26/07/2018]

WHO 2018 [ONLINE] Available at: http://www.who.int/topics/breastfeeding/en/ [Accessed 26/07/2018]