Breastfeeding: A Public Health Priority

Breastfeeding: A Public Health Priority

Conference hosted by the Institute for Health Visiting and the Royal Society for Public Health, with the WBTi UK team.

10.00 Opening Remarks Chair: Dr Cheryll Adams CBE, Executive Director, Institute of Health Visiting 

A public health view of breastfeeding 

10.10 Breastfeeding as mother and physician – Dr Louise Santhanam, GP and Chair, the GP Infant learning from experience and learning needs Feeding Network (UK) 

10.20 Why breastfeeding is important for everyone’s health Dr Russell Viner, Paediatrician and President, Royal College of Paediatrics and Child Health (from March 18) 

10.40 Strengthening the public’s health from the start, what roles for the Hearts Milk Bank?  – Dr Natalie Shenker, co-founder, Hearts Milk Bank

11:00 The importance of breastfeeding and early years Jonathan Ashworth MP, Shadow Secretary of State for Health 

11:15 Questions 

11:25 Refreshments 

Strengthening breastfeeding in the UK 

11.45 The WBTi findings and recommendations for the UK Helen Gray IBCLC and Clare Meynell IBCLC, Joint Coordinators, World Breastfeeding Trends Initiative (WBTi) UK 

12.05 Education and training of health visitors and other health professionals through the Baby Friendly Initiative Sue Ashmore, UNICEF, Baby Friendly Initiative

12.25 The impact of breastfeeding on mental health Professor Amy Brown, Associate Professor and maternal and infant health researcher, Swansea University

12:45 Questions 

13:00 Lunch 

Breastfeeding in the community – what works? 

Specific issues: 

14:00 The importance and challenges of peer support Dr Gill Thomson, Reader & Associate Professor in Perinatal Health, MAINN, UCLAN, and Louise Hunt, PhD student

14.15 The role of the infant feeding specialist Lyndsey Hookway, Paediatric nurse, HV and IBCLC 

14.30 Medway – A System Wide Strategic Approach Scott Elliott, Head of Health and Well-being Services, Public Health, Medway Council 

14.45 Discussion and questions 

15:00 National developments for breastfeeding Professor Viv Bennett CBE, Chief Nurse, Public Health England 

15.15 Refreshments 

Moving forward – national and local actions required to increase UK rates of breastfeeding 

15:35 National expert opinion and panel discussion Scott Elliott, Head of Health and Wellbeing Services, Public Health, Medway Council 

Shereen Fisher, CEO, The Breastfeeding Network 

Emma Pickett, IBCLC 

Alison Spiro, Specialist Health Visitor 

16.25 Chair’s closing remarks Dr Cheryll Adams CBE 

Breastfeeding: a public health priority 

Thursday 19 April 2018, 9.30am-4.30pm 28 Portland Place, London W1B 1LY

Save the Children Fund report on infant formula marketing

Save the Children Fund report on infant formula marketing

Indicator 3 of a WBTi assessment is about implementation and monitoring of the World Health Assembly International Code on the Marketing of Breastmilk Substitutes. UK Regulations only partly incorporate the International Code yet the regulations still get broken, as the WBTi UK report of 2016  illustrates with examples of idealising text and images on packaging, and price reductions.

Last month, Save the Children published a report called Don’t Push It: Why the formula milk industry must clean up its act. It emphasises that breastfeeding saves lives but that millions of children are at risk form the rapid growth in the infant formula market. The report looks at the activities of six multinational companies which have more than 50% of the market between them – Abbott, Kraft Heinz, Friesland Campina, Danone, Nestlé and RB. Responses from the companies are on the charity’s website, along with its replies to them.

The market has grown very rapidly, increasing five-fold in two decades, and it is estimated will be worth more than $70 billion by 2019. The companies spend far more promoting their products than is spent by public health budgets in supporting breastfeeding. Examples of recent company marketing in the UK that contravene the International Code, and in some cases break the law as well, are described in the monitoring report, Look What They’re Doing in the UK – 2017 .

Save the Children also carried out an investigation jointly with The Guardian in deprived areas of the Philippines and found contraventions of the Code such as gifts to health professionals, and that the companies had a constant presence in hospitals, resulting in mothers being exposed to formula promotion. https://www.theguardian.com/lifeandstyle/2018/feb/27/formula-milk-companies-target-poor-mothers-breastfeeding

In its report, Save the Children calls on the companies to commit publicly to upholding the Internation Code to protect children’s health as well as governments incorporating the Code fully into legislation. It is also calling on investors to hold companies to account to increase their compliance, stating “Business models that undermine the health and wealth of future generations pose a long-term financial threat to investors.”

With the widespread use of IT in business, why is it that retailers do not have systems that prevent illegal marketing such as price reductions? Instead, monitoring in the UK relies on volunteers. If you do find any reductions and inform the store manager, you might also like to ask why their electronic stock control system doesn’t include information to prevent such violations.

 

1Panama Canal 33. Miraflores locks
Panama Canal (photo credit: P Wise)

I was recently on holiday in Panama and went into a couple of supermarkets, where I noticed that baby foods were labelled as suitable from 6 months. On the basis of this small sample, I then wondered whether Panama has a strong law. Indeed, the International Code is fully integrated in national law although, as the committee on the rights of the Child reported in January 2018 , there is no monitoring or sanctioning mechanism.

 

Banner photo from WBTi UK 2016 Report

 

 

30. Photo for WBTi MAINN presentation

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

A story about homes

A story about homes

Once upon a time there was a town where the young people had two options available when they wanted a place of their own to start a family . They could either live in the town, in existing apartment blocks, or build their own home on the edge of the town. Some preferred the apartments because they were already built using a tried and tested construction by large companies or they had grown up in the area and would be close to friends and family who had also had the same experience and had similar views to their own.The apartments provided adequate accommodation but those who preferred to build their own home liked the fact that it was healthier to live away from the pollution of the town and they could have a garden.

Those who built their own houses found it was hard work at first as they learned the techniques of construction. Those who had known and watched other people building houses tended to find it easier than those who had not been given the opportunity to see or learn how a house was built.

Some people found professional builders who could advise them on tricky issues such as what a solid foundation looked like or guidance with more minor aspects of design. Some local builders even offered free services. Unfortunately, there was also a few rogue builders, who always charged a much higher price than the others yet gave poor advice.

General advice was offered by big construction companies who built apartments in towns throughout the land, including this town. Their information was always complimentary about self build construction but somehow always implied that young people would find it “much easier and more convenient” if they moved into an apartment.

Some young people found enough encouragement to continue with their project by knowing that other self builders were also finding it hard. Some benefited from the learning process that others had experienced and willingly shared with them during the early stages of the house building.

However, other young people were unaware there was any help available and struggled on without support. Some eventually completed their houses. Others lost confidence and decided to move into an apartment after all, especially if the building work seemed to be taking over their lives or friends and family members doubted their ability to finish. Some consoled themselves with focussing on the convenience of being close to those they knew well so could share the tasks. Others believed that the idea of building one’s own house was oversold and felt annoyed with those who had originally suggested it to them. Some felt guilty that, even though they had tried so hard to build their own house, their children would live in the more polluted town air.

Those who completed building their houses felt proud of their achievement, especially if they had overcome major difficulties at the beginning. They still had ups and downs with repairs and maintenance, but they were happy in knowing, as a result of their personal endeavours, that their children would have a healthy future. The shared feelings among the house builders helped to form a new supportive community for other house builders. However, they hesitated to mention their homes if they met someone from an apartment in case that family had suffered an unhappy experience trying to build their own house.

Although they were all citizens of the same town, mischiefmakers spread rumours that there was ill-feeling between the two groups. But then an enlightened town council was elected that realised the need for better information about all the options available for the young people. Education in building skills for those who wanted to construct their own house, with professional help available if needed, was made readily available. The council invested in these services and also improved the byelaws and monitoring, to protect the citizens by preventing the big commercial companies from disseminating misleading information and also to catch any rogue builders.

When Christmas came, all the young people of the town held a party, showing the other citizens that they had much more in common than the differences between how their homes were constructed.

 

 

 

30. Photo for WBTi MAINN presentation

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

Protecting Infants and Young Children: WBTi Forum on Planning for Emergencies in the UK

Protecting Infants and Young Children: WBTi Forum on Planning for Emergencies in the UK

On Tuesday 28th, Dr Ruth Stirton of the University of Sussex joined forces with the World Breastfeeding Trends Initiative (WBTi) Steering Group, along with Marie McGrath of the Emergency Nutrition Network, to present on the topic of safe provision for feeding infants and young children in emergencies in the UK. This WBTi UK first anniversary forum was hosted by Alison Thewliss MP, chair of the All Party Parliamentary Group on Infant Feeding and Inequalities, at the Houses of Parliament.

Participants included infant feeding specialists and policy makers, emergency planners, international academics, and third sector organisations such as UNICEF UK Baby Friendly Initiative and Save the Children.
We heard from Clare Meynell and Helen Gray (WBTi UK) on the findings, gaps and recommendations from the WBTi UK report surrounding infant feeding in emergencies. Ruth Stirton presented on the legal and regulatory framework and the minimal place of infants and young children in the current framework. Marie McGrath then described the recently published 2017 Operational Guidance on Infant Feeding in Emergencies, and explored how it might be adapted to the UK context.

WBTI Forum 2017 discussion mapping LCGB Faulkner

The audience engaged in lively group discussion, considering:

  • the issues in the immediate response phase
  • how best to support formula feeding families in emergency situations
  • mapping the existing local capabilities that emergency plans could call upon
  • issues surrounding communication with the public and front line responders about how best to support infants and young children in emergencies
  • the wider policy framework and how best to ensure that infants and young children are specifically provided for
  • issues for the longer term recovery phase after the emergency

A report will be published in 2018 making recommendations for improvements. If you would like to contribute written comments to the report, please look at the presentations and group materials and send comments by email to Ruth Stirton r.stirton@sussex.ac.uk

WBTi Forum 2017 and GPIFN THewliss
WBTI Steering Group Helen Gray, Patricia Wise, Alison Spiro, (Clare Meynell in absentia), with host Alison Thewliss MP, and Dr Louise Santhamum and Dr Rosemary Marsh (GP Infant Feeding Network) and Dr Ruth Stirton (University of Sussex Law School)

Ruth Stirton, University of Sussex

Helen Gray, WBTi UK

Clare Meynell, WBTi UK

Alison Spiro, WBTi UK

Patricia Wise, WBTi UK

 

References and resources:

Presentations and group discussion materials

Storify with tweets from the event at Parliament:

Operational Guidance on Infant Feeding in Emergencies 

World Health Assembly Resolution 63/23 

WBTi UK report

 

Blog posts:
Overview of WBTi Indicator 9, Infant Feeding in Emergencies

Our Guest blog on UNICEF UK Baby Friendly 

Safely Fed UK Facebook page and social media campaign 

 

 

WBTi UK report – first anniversary celebration – a Forum

WBTi UK report – first anniversary celebration – a Forum

It’s a year since the first WBTi UK report was launched in November 2016 at the Houses of Parliament, giving the first snapshot of the state of breastfeeding support in the UK across the indicators. The report has been used as a basis to advocate for improvements in legislation, in strategy, and in training. It has been shared with MPs, with government ministers, as well as shared widely throughout the breastfeeding community through our website.

During the year, we have hosted monthly blogs on our website, focussing on the various indicators in turn. We have an active social media planning group that publicises the WBTi findings, our blog and activities. The team have also produced numerous journal articles, posters and conference presentations in the UK and beyond. Our talented team of volunteers have also developed a video  about our findings. We continue to contribute to ongoing consultations about improving health professional training in infant feeding

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Policy Forum: Protecting Infants in UK Planning for Emergencies

On November 28th 2017, we will be holding a policy forum at the Houses of Parliament, in collaboration with Ruth Stirton of the University of Sussex and hosted by Alison Thewliss MP: “Protecting Infants in UK Planning for Emergencies.” This event both celebrates the anniversary of the report and aims to achieve change in Indicator 9, “Infant and young child feeding during emergencies,” which is the policy with the lowest scores across the UK. At present, there are no UK-wide or national strategies addressing the issue and it is not explicitly mentioned in local planning.

Unicef UK Baby Friendly Initiative

The jewel in the crown of breastfeeding support in the UK is the Unicef Baby Friendly Initiative. All maternity units in Scotland and Northern Ireland are accredited and most in England and Wales are working towards it. Many community NHS trusts and boards are also on the ladder towards accreditation. Some neonatal units, university midwifery and health visiting/specialist community public health nursing courses are also involved. All are helping to raise the standards of infant support provided by these health professionals.

Cuts to breastfeeding support around the country

Sadly, the WBTi assessment found that cuts in infant feeding lead posts, drop-ins and peer support programmes as well as specialist services were occurring and this has continued. For example, Blackpool’s service was decommissioned in June and the service in Kent is under threat. It appears that there is an assumption by some commissioners that health visitors can provide a sufficient service. Health visitors do have a responsibility to provide effective support with infant feeding, and should do so at statutory visits and other contacts. However, a significant number of mothers also require specialist support, which needs time as well as skill, and all mothers can benefit considerably from the social support that trained peer supporters can provide. It seems it is not well understood how challenging some breastfeeding situations are and the amount of training required to help effectively in those situations.

Ask YOUR MP to join the Call to Action!

These cuts in services for women and babies are likely to have a negative impact on Baby Friendly accreditations. Unicef UK is holding an event for MPs at the Houses of Parliament on December 5th, asking them to pledge their support for breastfeeding. How would it be if every current MP were contacted? Are you willing to contact your MP?

 

 

 

Using data to help all children reach their potential

Using data to help all children reach their potential

Indicator 10: Mechanisms of Monitoring and Evaluating Systems:

Are monitoring and evaluation data regularly collected and used to improved infant and young child feeding practices?

In last month’s blog Patricia Wise explained how monitoring and evaluating breastfeeding rates is the 10th and final indicator of any World Breastfeeding Trends Initiative report, including the UK one . This blog shows how the data can be used as a tool to inform decision-making, especially for commissioning services, to reduce inequalities in child health.

Public Health datasets

Public Health England Early Years Profiles  allow for measures of infant health based on International Classification of Diseases codes (ICD10) to be tracked over time and compared with statistically similar areas across England. It needs local knowledge to interpret findings as you are looking for patterns, or signals, in amongst the noise of coding and other errors. Decision-making is hard when there are gaps or significant errors in the data so it is worth spending time with all involved to improve the quality of the data.

As an example, Northumbria Healthcare NHS Foundation Trust recently received the first Health Visiting Baby Friendly Achieving Sustainability Gold Award, demonstrating a long term commitment to implementing the Unicef UK Baby Friendly Initiative. The Trust is in the 4th most deprived decile (a decile is 1/10 of the population) in England (IMD2010) so a good example of what can be achieved in communities with areas of disadvantage.

In the Northumberland PHE area (which includes Northumbria NHS Trust), breastfeeding prevalence rates at 6-8 weeks have increased 2 percentage points between 2010/11 and 2014/15. Opportunities for assessing wider measures of child health from the Early Years Profiles are limited so Northumberland is unusual in having data available for gastroenteritis hospital admissions for two consecutive years. These reduced from 29 per 1,000 babies under one in 2014/15 to 19 per 1,000 in 2015/16. Other factors will also contribute but there is good evidence that breastfeeding reduces the incidence of gastroenteritis  and associated NHS cost savings have been calculated .

Comparing Northumberland to neighbouring trusts in the graph below, its hospital admission rate for gastroenteritis sits on the regression line. Darlington and North Tyneside have more admissions (32/1,000 and 31/1,000) while Gateshead has similar admissions to Northumberland at 20/1,000. However, all these four areas have similar breastfeeding rates. Local knowledge is key though to trying to understanding differences as South Tyneside has a low admission rate at 11/1,000 with lower breastfeeding rates.

 

Breastfeeding prevalence at 6-8 weeks compared with hospital admissions for infants with gastroenteritis in the North East Region

Gastro_plain
Figure 1:
X axis =Breastfeeding prevalence at 6-8 weeks – previous method
Y axis = Admissions for gastroenteritis in infants under 1 year
https://fingertips.phe.org.uk/profile-group/child-health/profile/child-health-early-years/data#page/10/gid/1938132986/pat/6/par/E12000001/ati/102/are/E06000057/iid/20202/age/170/sex/4 [accessed 13 November 2017]
(Link defaults to A&E attendances so Y-axis needs resetting each time to ‘admissions for gastroenteritis under 1 year’. You can vary the Area on the interactive chart, as in the table below, to see each of them highlighted as a black diamond. Areas mentioned in the blog are highlighted in bold in the table.)

Using the Public Health England data

The graph on the PHE site is interactive. Comparing breastfeeding rates at 6-8 weeks with gastroenteritis rates for under 1 year olds shows the prevalence of gastroenteritis decreases as breastfeeding rates increase, as seen by the regression line. However, the variations in hospital admission rates also reduce and stabilise as the breastfeeding prevalence rates exceed approximately two thirds of the population. The reason for this is not clear. It could be an indication of a longer average duration of breastfeeding, or more exclusive breastfeeding within the population or other factors. The differences between similar communities indicate these admissions can be reduced. Since October 2015 the breastfeeding data have been obtained via interim reporting arrangements to collect health visiting activity at a local authority resident level. This new method is not comparable with the previous method so it will take some time to understand any future trends (PHE Definitions for indicator 2.02ii, Indicator ID 20202).

 

“In health care, geography is destiny”

Reducing these unnecessary variations in breastfeeding improves child health, helping to reduce inequalities (WBTi report p4). The impact of cuts to peer support, health visiting teams and Children’s Centres may be demonstrated within the PHE data through increasing demand for hospital services. Where children grow up influences their health.

“In health care, geography is destiny” (Wennberg, 2010).

 

 

North East Area Breastfeeding Prevalence Rate 6-8 weeks previous method (%) Admissions for gastroenteritis in infants under 1 year / per 10,000 Admissions for gastroenteritis in infants under 1 year / per 10,000
                 2014/15 2014/15 2015/16
County Durham 28.9 339.6 312.7
Darlington 34.2 515.0 316.8
Gateshead 37.2 227.2 204.3
Hartlepool 20.2 300.5 364.5
Newcastle 46.2 348.6 201.1
Northumberland 38 292.7 185.5
North Tyneside 38.5 393.3 307.6
South Tyneside 24.4 244.3 108.8
Stockton-on-Tees 29.6 230.6 300.5
Sunderland 26.2 355.3 259.8
*Middlesbrough and Redcar and Cleveland have been omitted from the table as the previous method of collecting breastfeeding data was not available.
Data on gastroenteritis and explanation on definitions available at
https://fingertips.phe.org.uk/profile-group/child-health/profile/child-health-early-years/data#page/4/gid/1938132994/pat/6/par/E12000001/ati/102/are/E06000003/iid/92517/age/170/sex/4

 

References

Renfrew, MJ, Pokhrel S, et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. Unicef UK BFI

https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2012/11/Preventing_disease_saving_resources.pdf

Accessed 16 November 2017-11-16.

Rollins N, Bhandari N et al (2016) ‘Why Invest, and What It Will Take to Improve Breastfeeding Practices?’ The Lancet 387: 491–504.

http://www.thelancet.com/series/breastfeeding

Accessed 15 November 2017

Victora CG, Bahl R et al (2016) ‘Breastfeeding in the 21st century: Epidemiology, Mechanisms, and Lifelong Effect’ The Lancet Series: Breastfeeding 1 387(10017): 475–490

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext

Accessed 15 November 2017

Wennberg, J. E. (2010). Tracking medicine: a researcher’s quest to understand health care, Oxford, Oxford University Press.

 

 

Phyll_photo_IMG_4794-1

Phyll Buchanan is a Breastfeeding Network Supporter, tutor and trustee.

Phyll has completed her MSc in Evidence-based Health Care.

Data matters: How do we know what’s happening with breastfeeding?

Data matters: How do we know what’s happening with breastfeeding?

Indicator 10 of any World Breastfeeding Trends Initiative report is about that country’s monitoring and evaluation systems. It may not seem an exciting topic but it’s essential to collect robust data on infant feeding to know what the breastfeeding rates are and how mothers are experiencing services. Without having monitoring data how can services be evaluated and then improvements planned?

For small projects, feedback from mothers may be the most effective evaluation but for larger projects and sizeable areas, the percentages of babies being breastfed (called prevalence) at particular ages help to monitor what is happening. Figures don’t capture the ripple effect of support, though, such as a mother who’s been helped on her breastfeeding journey then supporting friends or being more likely to breastfeed a subsequent baby or deciding to train as a peer supporter.

The WBTi UK report in 2016  found that data collection and analysis had reduced considerably since the ending of the 5-yearly infant feeding survey. There is variation between the four nations with England collecting the least data.

Changing systems in England

In England, record level data on infant feeding is currently submitted by service providers to NHS Digital as part of the Maternity Services Dataset (initiation/first milk feed) and the Children and Young People’s Health Services Dataset (6-8 weeks). Whilst these new datasets are reaching full maturity, NHS England and Public Health England are publishing official statistics on an interim basis for breastfeeding initiation and breastfeeding at 6-8 weeks respectively. Both sets of data are assembled from aggregate data submitted on a voluntary basis by service commissioners. These two breastfeeding indicators are included in the Health Improvement part of the Public Health Outcomes Framework (https://fingertips.phe.org.uk/profile/public-health-outcomes-framework).

Data on infant feeding at birth are submitted by maternity units. Babies were previously counted as breastfeeding if they went to the breast at least once in the first 48 hours. However, this is now changing to a record of the baby’s first milk feed. This is captured as part of the Maternity Services Dataset and NHS Digital publishes monthly reports on the statistics of all the indicators in the data set: as well as annual data.

Local authorities have responsibility for ensuring that their commissioned providers of the universal health visiting service submit infant feeding data for babies aged 6-8 weeks as part of the Children and Young People’s Health Services Dataset (which is about to be renamed the Community Services Dataset). As this data collection is not yet mature, aggregate infant feeding data is submitted to PHE on a quarterly basis. Official statistics are produced annually and quarterly

The Early Years part of PHOF, including these indicators, is maintained by the National Child and Maternal Health Intelligence Network.

In theory, the information at 6-8 weeks provides a picture of what is happening for the whole population but, disappointingly, there are quite a number of gaps. In most cases the local authority submits data to PHE but it cannot always be published as official statistics as a result of validation failures. This is most often due to too many records of ‘unknown’ breastfeeding status.

In one area, the health visiting service has found a solution to this by including a mandatory field on infant feeding in the electronic record of the questions about maternal mood at 6-8 weeks.

There needs to be information on at least 95% of the eligible population of babies (called coverage) to be valid and thus included. This results in some gaps in the published statistics even though the underlying data is available.

 

Try it yourself!

There is now a facility to compare different sets of the annual data, such as comparing gastrointestinal or respiratory infection rates with breastfeeding rates. §If there is sufficient correlation between two datasets, a red line appears. It doesn’t prove there’s a causal link though. You can try this for yourself here:
You select the Region, Area and Indicator you are interested in and then another Indicator for the Y-axis. You need to tick ‘add regression line’ to see if there is a correlation.

Using data to advocate for services

However, even if a service is well-evaluated, that does not guarantee its continued existence, as occurred with the Blackpool peer support Star Buddies programme, although this can be a useful tool in challenging actual or proposed cuts. Zoe Walsh, in her speech to Blackpool council (at 4mins 30s in the recording) in September 2017 used data as part of her clear explanation of why the service needs to be reinstated.

Data collection counts!

 

Cover photo credit: Paul Carter

30. Photo for WBTi MAINN presentation

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