Doctors have an important role to play in supporting mothers who want to breastfeed.
A continuing theme of the WBTi UK work is improving medical training in infant feeding such that all, not just some, doctors have sufficient knowledge and understanding of breastfeeding to protect the decisions of mothers who want to breastfeed. Enabling more mothers to continue breastfeeding would improve infant and maternal health, reduce NHS costs (Renfrew et al) and reduce the number of GP appointments (Pokhrel et al, 2015).
Georgie BHS and Dani Phillipson from the Parenting Science Gang, which runs citizens’ science projects using mothers to collect evidence, spoke next. They described the breastfeeding and healthcare experiences project (inspired in part by the WBTi findings on health professional training) with its subsidiary small project of 8 interviews looking at healthcare professionals’ own experiences of breastfeeding on their professional practice. From the themes identified, PSG has produced MILK cards to guide health professionals:
Mothers’ voices matter
Investigate common issues, but also
Look for underlying causes§
Know where to find information
GP Dr. Terri Lovis (seen in banner photo above) described how the GP Infant Feeding Network (GPIFN), initiated by Dr. Louise Santhanam, was set up as a pharma free network to improve the quality of support in infant feeding with the work provided voluntarily. The website is a comprehensive educational resource for primary care and there is partnership with the Hospital Infant Feeding Network (HIFN). Additional achievements include working collaboratively with IMAP (International Milk Allergy in Primary Care Guidelines) to produce the 2019 version and bidding successfully with PHE and Surrey Heartlands to train Infant Feeding champions across Surrey (as Norwich already does).
The fascinating keynote presentation was by Dr. Natalie Shenker on Doctors and Breastmilk, and included the initiation of the Human Milk Foundation in 2017 and the work of the Hearts Milk Bank, which she co-founded with Gillian Weaver. The Milk Bank is involved in research as well as providing pasteurised donor milk.
The challenge is how to enable all medical students, trainees and qualified doctors to acquire an adequate minimum standard in infant feeding knowledge and skills. Yes, there is a huge amount that they need to know in total but being breastfed as an infant can make such a difference to the health of baby and mother (not to mention the environmental sustainability of breastfeeding!) that it is crucial to include. Some examples of what is already being done to help achieve this:
Imperial College Medical School is running a programme in which medical students are allocated to follow a mother from the end of pregnancy until the child is 3 years old.
Norwich CCG has a GP Champion in Infant Feeding scheme, which Surrey Heartlands is also rolling out, in which the champion receives training and disseminates the learning throughout the practice.
Imagine if all medical schools ran such a programme and all GP practices had a breastfeeding champion!
The new government needs to prioritise the first 1001 days of a child’s life, from conception to age two, to enable children to survive and thrive. How an infant is fed and nurtured strongly influences a child’s future life chances and emotional health. Importantly, if a woman breastfeeds there are substantial health benefits for her – having impacts onher future long after breastfeeding has stopped.
Independent, practical, evidence-based information and support is essential for every family. Supporting women with breastfeeding can go a long way to protecting children and mothers from a wide range of preventable ill health, including obesity and mental health problems.
This window of opportunity cannot be missed for the future health outcomes of mothers and the next generation. In addition to well documented health outcomes, supporting breastfeeding will also contribute to a stronger economy – potential annual savings to the NHS are estimated at about £40 million per year from just a moderate increase in breastfeeding rates.
Support for breastfeeding is also an environmental imperative and recognition of the contribution breastfeeding can make to avoiding environmental degradation should be a matter of increasing global and political attention.
In the UK, the majority of women start to breastfeed but breastfeeding rates drop rapidly – our continuation rates are some of the lowest in the world and are even lower amongst women living in deprived areas, where increasing rates could make a real difference to health inequalities. Support for all women, parents and families with breastfeeding falls short of what is wanted and needed.
Women tell us they encounter difficulties with the public perceptions of breastfeeding out of the home. Families tell us they are still regularly exposed to conflicting messaging and marketing for formula milks that drowns out advice from healthcare professionals.
Women tell us they receive little to no help with infant feeding and that their health visitors, midwives and doctors often have little training or knowledge about breastfeeding and limited time to support them.
Recent cuts in health visitor numbers and breastfeeding peer support services mean many women may be left without the support they need however they choose to feed their infants.
Despite robust evidence showing that investment in breastfeeding support and protection makes sense, politically breastfeeding has been viewed by governments as a lifestyle choice and so left to parents to work out for themselves. For too many women, trying to breastfeed without support, or stopping before they want to, is deeply upsetting and the situation is made worse by fragmented care, and poor and often conflicting advice from those they are seeking to support them. To ensure an increase in breastfeeding rates, to help reverse obesity rates and to reduce widening health inequalities will require significant investment in breastfeeding.
It is essential that our new government prioritises breastfeeding and invests in its support and protection.
We call on all political parties to commit to the following actions, if elected:
To appoint a permanent, multi-sectoral infant and young child feeding strategy group and develop, fund and implement a national strategy to improve infant and young child feeding practices.
To include actions to promote, protect and support breastfeeding in all policy areas where breastfeeding has an impact.
To implement the Unicef UK Baby Friendly Initiative across community and paediatric services, building on the recommendation for maternity services in the NHS Long Term Plan.
To protect babies from harmful commercial interests by bringing the full International Code of Marketing of Breastmilk Substitutes into UK law and enforcing this law.
To commission, and sustainably fund, universal breastfeeding support programmes delivered by specialist/lead midwives and health visitors or suitably qualified breastfeeding specialists, such as IBCLC lactation consultants and breastfeeding counsellors, alongside trained peer supporters with accredited qualifications.
To maintain and expand universal, accessible, affordable and confidential breastfeeding support through the National Breastfeeding Helpline and sustaining the Drugs in Breastmilk Service.
To deliver universal health visiting services and the Healthy Child Programme by linking in with local specialist and support services.
To establish/re-establish universal Children’s Centres with a focus on areas of deprivation, offering breastfeeding peer support.
To make it a statutory right of working mothers and those in education to work flexibly as required and to access a private space and paid breaks to breastfeed and/or express breastmilk and manage its safe storage.
To commit to resourcing for charitableorganisations who play a key role within the health agenda working at a national and local level to support families and communities with infant feeding.
To support the commitment to undertake an Infant Feeding Survey which builds on the data previously collected in the Infant Feeding Survey 2010 (now discontinued).
To implement the recommendations of the Becoming Breastfeeding Friendly (BBF) study.
A UNICEF reportstates that “no other health behaviour has such a broad-spectrum and long-lasting impact on public health. The good foundations and strong emotional bonds provided in the early postnatal period and through breastfeeding can affect a child’s subsequent life chances”.
Evidence has also demonstrated that a child from a low-income background who is breastfed is likely to have better health outcomes than a child from a more affluent background who is formula-fed. Breastfeeding provides one solution to the long-standing problem of health inequality.
Research into the extent of the burden of disease associated with low breastfeeding rates is hampered by data collection methods. This can be addressed by investment in good quality research.
2. Borra C, Iacovou M, Sevilla A (2015) Maternal Child Health Journal (4): 897-907. New evidence on breastfeeding and postpartum depression: the importance of understanding women’s intentions.
3. Brown, A, Rance J, Bennett, P (2015) Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing72 (2): 273-282
10. National Institute for Health and Care Excellence (2012) Improved access to peersupport NICE, London
11. Rollins N, Bhandari N, Hajeebhoy N, et al (2016) Why invest, and what it will take to improve breastfeeding practices? The Lancet387 491-504
12. Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. 1998 Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ. Jan 3;316(7124):21-5.
Doctors have an important role to play in supporting mothers who are breastfeeding, through providing encouragement, accurate information and signposting to sources of specialist and peer support. Their impact can be significant because doctors and their advice are held in such high regard, and this is particularly important in the UK, where a mother’s intention to breastfeed can so easily be undermined.
There are doctors who have made themselves really knowledgeable but sadly the UK universal standards for pre-registration medical training in breastfeeding have significant gaps, as shown by Indicator 5 of the WBTi 2016 report (see Part 1 for the summary table below, and Part 2 for the details of standards for different health professions)
However, there have been some positive changes since the publication of the WBTi UK report.
The WBTi UK team contributed to both curriculum consultations.
GP Infant Feeding Network and Hospital Infant Feeding Network
Dr. Louise Santhanam founded the GP Infant Feeding Network (GPIFN) in 2016 and in 2019 Drs Vicky Thomas and Ilana Levene launched the Hospital Infant Feeding Network (HIFN), which are valuable resources for medical professionals. See our series of three guest blogs from HIFN: Launch of HIFN, #DontStopLookItUp campaign on prescribing for breastfeeding women, and free posters on breastfeeding issues in the hospital setting.
New learning outcomes published by Unicef UK Baby Friendly Initiative
Doctors have a long training so there needs to be input at different stages of training and also encouragement for already qualified doctors to update. A group looking at this was initiated by the WBTi team and went on to be led by Unicef UK Baby Friendly Initiative, and chaired by paediatrician Charlotte Wright. Unicef UK Baby Friendly launched the resulting infant feeding learning outcomes in World Breastfeeding Week, with accompanying resources expected to follow soon (see our August 2019 blog). These are intended as a guide for training for various health professions from undergraduate courses through to the point of qualification.
New online book for trainee doctors
My book, Supporting mothers who breastfeed: a guide for trainee and qualified doctors, is primarily for trainee doctors but relevant to qualified doctors too. At the trainee stage they have specialised and are working clinically. The book provides a combination of factual knowledge about breastfeeding and an insight into mothers’ experiences. It includes some examples of good practice in responding to common situations and ends with a short quiz. It is available on the WBTi website (https://ukbreastfeeding.org/supporting-mothers-who-breastfeed-a-guide-for-trainee-and-qualified-doctors/) as a free PDF. Being electronic, it is easy to click on links to be taken to references and sources of further information, and can be updated more readily than a paper book.
I am very grateful to Charlotte Wright, who is Professor of Community Child Health at the University of Glasgow and a consultant paediatrician, for writing the foreword.
If you know any trainees or qualified doctors, perhaps you would pass the weblink to them.
It had been announced at the Baby Friendly conference in 2018 that learning outcomes and resources were being produced.
The WBTi report in 2016 (see Indicator 5 in Part 1 of the WBTi UK report for the above table, and Indicator 5 in Part 2 for the detailed findings for each UK health profession) showed that for most health professions in the UK, the coverage of infant feeding in pre-registration training was inadequate. In some case only broad standards are given and the individual universities develop their own curricula.
The infant feeding learning outcomes launched by BFI are for a range of newly qualified health professionals so they ‘articulate the minimum knowledge and understanding of infant feeding that it would be reasonable to expect from a health practitioner at the point of qualification’. There are slightly different ones for the following five groups:
maternity support workers/nursery nurses.
For each of these professional groups the learning outcomes are grouped into three broad themes:
The value of human milk and breastfeeding.
Supporting infant feeding.
Infant feeding in context, which includes understanding the importance of the International Code.
They are intended as ‘a stimulus to universities and others to start to consider what should be covered in relevant curricula and training, and then to take action to make that a reality.’
One useful recommendation is that ‘A mapping exercise can help the university to assess how far the topics are already covered and assessed in the curriculum, and to identify and plan for any additions to modules or design alternations needed.’ Plans for the resources ‘include a slide pack to help lecturers deliver the content to students, e-learning for students and assessment examples’.
Specific learning outcomes like these, provided they are taken on board by the training institutions, will surely help to achieve a higher and consistent level of knowledge and skills within and between health professions.
I’m a lactation consultant and writer who has just finished a Masters degree in Health Promotion at Leeds-Beckett University. This blog touches on some of the insights that my studies have given me, not least how data, like WBTi’s reports, can help health promoters create integrated, sustainable solutions that make health a resource to be shared by everyone.
In 1986, the World Health Organization (WHO) Ottawa Charter for Health Promotion defined Health Promotion as “the process of enabling people to increase control over, and to improve, their health.” Whether the focus be on breastfeeding, preventing obesity, supporting mental health or any of the complex (so called ‘wicked’) problems that challenge our societies, it is health promotion’s recognition of the social determinants of health that has most affected my thinking. All too often our society is quick to blame the individual for unhealthy behaviours; my increased awareness of the social determinants of health, that is, how socio-economic, cultural and environmental conditions determine individuals’ well-being, has changed my perception. It’s given me a heightened awareness of how prevailing political ideologies influence the way we think about society, and how this plays out into how likely (or not) individuals are to be able to make healthy choices throughout the course of their lives.
“This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements …and bad politics.” WHO
To give an example, indicator 6 of the WBTi looks at community-based support, so key to women continuing to breastfeed.In the UK, the recent NHS Long Term Plan’s recommendation of UNICEF UK Baby Friendly accreditation is cause for celebration and will boost the capacity of midwives and health visitors to support breastfeeding in the community.
However, cuts to peer-support services, and the closure of over 1000 Sure Start centres have disproportionately affected poorer members of society. If a mother in the community has persistent nipple pain, no car, no public transport, no money for a lactation consultant and her nearest breastfeeding group is 20 miles away, even with the support of the hard-working volunteers on the National Breastfeeding Helpline, her capacity to protect the health of her family through breastfeeding will be limited.
Incidentally, the discipline of Health Promotion, while focusing on the up-stream causes of health inequalities, is also focused on empowering communities to participate in the creation of healthier societies. The UK’s WBTi report, under Indicator 6, points out that in England and Wales there is often little coordination between NHS services and peer-supporters, who can offer so much to new mothers. It recommends a range of integrated postnatal services that include voluntary sector breastfeeding support, meet local needs and provide clear access to specialist support.
Integrated breastfeeding support is outlined in the criteria for UNICEF Baby Friendly accreditation for community services:
Basic: universal services such as midwives, health visitors, and support workers are trained to BFI standards
Additional: a network of trained local peer supporters and support groups
Specialist: a referral pathway to specialist help at IBCLC level, for complex cases that cant be resolved by “Basic” and “Additional” support
As an individual health promoter, the scale and complexity of the social determinants of health can feel overwhelming. Nonetheless, recognising them sets the challenge to health promoters (in all disciplines, not just those who work in traditional health services or policy) to work empathetically, creatively and collaboratively. After all, ‘Success in breastfeeding is not the sole responsibility of a woman – the promotion of breastfeeding is a collective societal responsibility’ (The Lancet).
Alice Allan is a lactation consultant, writer and communication specialist who has worked in Ethiopia and Uzbekistan on maternal and child health. Her novel, Open My Eyes, (Pinter and Martin) set in an Addis Ababa NICU, recently won The People’s book Prize for Fiction. She currently lives near London with her family and an Ethiopian street dog called Frank.
During World Breastfeeding Week #WBW2019, we are hosting a series of guest blogs exploring how the wider team of health professionals and community breastfeeding support can support breastfeeding families. The WBTi Report found numerous gaps in health professional training in infant feeding, and we are delighted to see a terrific range of resources being developed to address this.
In this blog, Wendy Jones MBE discusses gaps in the training of pharmacists (See Indicator 5 in Part 2 of the WBTi report for our detailed findings on pharmacist training) and introduces her new free online educational resources for pharmacists.
On a daily basis I hear that pharmacy staff have advised mothers not to breastfeed whilst taking medication or have refused to sell products such as antihistamines to lactating mothers. This is frustrating for families (and me!) and unnecessary.
We know that there are barriers around breastfeeding and medication:
The patient information leaflet – invariably it says that the product should not be used during lactation. This doesn’t imply risk usually rather that the manufacturer didn’t include breastfeeding when applying for marketing authorisation. For more information see this leaflet on the Breastfeeding Network website.
Understanding of the importance of breastfeeding for the future health of mother and child. Sadly breastfeeding, let alone understanding the pharmacokinetics of transfer of drugs into breastmilk, is not covered currently in most undergraduate training. Most knowledge relies on personal experience (Jones W 2000 Doctoral thesis University of Portsmouth. The role of community pharmacy is supporting mothers requiring medication).
Fear of litigation – to sell a medicine outside of its licence application entails taking responsibility. Pharmacists are concerned, rightly so if they do not access evidence-based information (Hale TW Medications and Mother’s Milk, Jones W Breastfeeding and Medication, LactMed , UKDILAS, Breastfeeding Network factsheets)
Time – frequently counter assistants rather than busy pharmacists are involved in sales of simple medications and do not discuss safety in breastfeeding unless asked by the mother.
Time limitations to consult expert sources.
Conflicts of interest
It has come to my attention recently that continued professional development (CPD) materials on infant feeding are being provided free of charge to make pharmacists and staff “Infant Feeding Champion”. Sadly, these are provided by the formula companies and the support of breastfeeding is considerably less than what I would describe as evidence based and full of advertisements for products ranging from nipple shields to nipple creams and specialist formulas.
New free training materials
I decided that I wanted to provide training materials for pharmacists and counter staff free of charge using the knowledge that I have gained over the past 31 years as a qualified, registered breastfeeding supporter as well as pharmacist with a specialist interest in the safety of drugs in breastmilk. The first module can be found here. More modules are underway looking at the pharmacokinetics of drug transfer and the treatment of common conditions.
In the meantime, my message is #DontSayStopLookItUp
I’m happy to be contacted:
by email at: email@example.com
Wendy was one of the founder members of a UK charity the Breastfeeding Network. In her employed life she was a community pharmacist and also worked in doctor surgeries supporting cost effective, evidence-based prescribing. She qualified as a pharmacist prescriber using her knowledge to reduce the risk of heart attacks and strokes in clinics to help patients stop smoking, weight optimisation and control of blood pressure and cholesterol. She feels she was best described as the conscience of the village. Her aim was to run clinics for breastfeeding mums needing medication but never managed it.
Wendy left paid work to concentrate on writing her book Breastfeeding and Medication (Routledge 2013, 2nd edition 2018), developing information and training material on drugs in breastmilk as well as setting up her own website http://www.breastfeeding-and-medication. She has also published Breastfeeding for Dads and Grandmas (Praeclarus Press) and Why Mothers Medication Matters (Pinter and Martin).
Wendy is known to many from her work on providing a service on the compatibility of drugs in breastmilk and has been a breastfeeding supporter for 30 years. She is passionate that breastfeeding should be valued by all and that medication should not be a barrier. She has 3 daughters and 5 grandchildren ranging in age from 6 years to 6 weeks. All her family seem as passionate about breastfeeding as she is and currently all 3 of her daughters are breastfeeding.
She was awarded a Points of Light award by the Prime Minister in May 2018 and was delighted to be nominated for an MBE in the New Year’s Honours List 2018 for services to mothers and babies. She received her award at Windsor Castle in May 2019 from Her Majesty the Queen.