WBTi’s Twelve Days of Christmas: part 1

WBTi’s Twelve Days of Christmas: part 1

This blog explores links that can be made between the gifts described in “The Twelve Days of Christmas” song and the World Breastfeeding Trends Initiative 2016 report

Day 1 – a partridge in a pear tree

Just as a partridge can find support and protection in the branches of a pear tree, each breastfeeding dyad needs a society that provides a supportive structure; to achieve this needs  coordination at national level through having a national policy, a strategic plan and effective implementation of that plan (WBTi Indicator 1). 

Jeremy Hunt, when Secretary of State for Health, declared that 

“The government is implementing the vision set out in the WBTi UK report. The Maternity Transformation Programme seeks to achieve the vision set out in the report by bringing together a wide range of organisations to work in nine areas… this includes promoting the benefits of breastfeeding by

  • Providing national leadership for breastfeeding celebration week;
  • Publishing breastfeeding initiation data;
  • Publishing breastfeeding profiles; and
  • Improving the quality of data on breastfeeding prevalence at 6-8 weeks after birth.”

A national assessment of UK breastfeeding policies and programmes, “Becoming Breastfeeding Friendly,” has now begun across England, Scotland, and Wales, led by the national governments and public health agencies and the University of Kent. Importantly, this initiative requires government commitment to implementing the resulting recommendations.

Another positive development since the WBTi report in 2016 is that in April 2018 Public Health England created a one-year Midwifery Adviser post for a seconded health professional whose responsibilities include breastfeeding, funded by the National Maternity Transformation Programme.

Day 2 – two turtle doves

This fits very well with Indicator 2 as it assesses the extent to which maternity-related services are Baby-Friendly accredited and the standards support loving relationships. Since the WBTi report, percentages of UK accreditations have increased as follows (2016 figure in brackets):

  • maternity services  62% (58%)
  • health visiting services  67% (62%)
  • universities: 43% (36%) midwifery and 17% (15%) of health visiting courses
  • childrens’ centres  16 (0)
  • neonatal units   6 (0)

Births taking place in fully accredited hospitals:

The WBTi recommendations call for “implementation and maintenance of Baby Friendly standards in all healthcare settings” in England and Wales. New maternity plans in December 2018 from the Department for Health and Social Care include “asking all maternity services to deliver an accredited, evidence-based infant feeding programme in 2019 to 2020, such as the UNICEF Baby Friendly initiative.” 
We would urge the government to extend the expectation of Unicef Baby Friendly accreditation as a minimum in community settings and Health Visiting Services, in neonatal units, and in midwifery and health visitor training programmes.

Day 3 – three French hens

The French hens are believed to symbolise the virtues of faith, hope and charity. Indicator 3 assesses the extent of implementation of the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions. There is faith, that incorporating the Code and resolutions in a country’s laws improves protection for all babies from commercial interests, as the experiences of individual countries like Brazil shows. There is hope that the Code and Resolutions will one day be implemented in UK law. Charity includes helping the vulnerable, such as babies.

Relatively recent changes include the World Health Assembly passing resolution 69.9 in May 2016, welcoming the new World Health Organisation 2016 guidance which clarifies that the Code applies to all milks and commercially produced foods marketed as suitable for infants and young children up to 36 months. A new Implementation Manual for this WHO guidance is also available.

The charity, Save the Children Fund, published its report Don’t Push It: Why the formula milk industry must clean up its act in February 2018.

The Changing Markets Foundation has published two recent exposés of formula company marketing tactics: Milking It and Busting the Myth of Science-Based Formula

The First Steps Nutrition Trust has published numerous reports and statements on topics around the marketing and nutritional composition of infant formula and baby foods 

In addition, the First Steps Nutrition Trust is now taking on the role of secretariat to the Baby Feeding Law Group (BFLG), a coalition of UK organisations working in maternal and infant health who work to bring UK law into compliance with the International Code. The WBTi UK Steering team is a member of the BFLG.

Day 4 – four calling birds

Indicator 4 assesses the protection and support provided by workplaces for employees who are breastfeeding. Four organisations helping to improve the situation include:

Since the publication of the WBTi report, tribunal fees were abolished in 2017

Day 5 – five gold rings

Gold is associated with precious things, and colostrum is known as “liquid gold.”

Indicator 5 assesses both the extent to which care providers are trained in infant and young child feeding and how supportive health service policies are. There are five professions which work most closely with mothers, infants and young children: midwives, obstetricians, paediatricians, health visitors and GPs. If they value breastfeeding and have the training to support mothers effectively they can serve as a golden chain of support.

 However, the WBTi report showed that there are gaps in health professional pre-registration standards in relation to the WHO Education checklist for topics they need to know about. Part 2 of the WBTi report contains further details for each health profession. In 2016, the General Medical Council published its revised Generic Professional Capabilities Framework, which all postgraduate medical curricula must fit. This includes a domain covering capabilities in health promotion and illness prevention. Medical curricula have to be revised to fit the framework and the RCPCH training for paediatricians now includes more about infant feeding at Level 2 (p.31)  Also, the RCPCH made a detailed policy statement on breastfeeding in 2017  and the RCGP developed a position statement on breastfeeding in 2018

The midwifery standards are currently undergoing a thorough review and there will be a consultation in February 2019. 

Members of the WBTi team have been supporting the work of revising and updating professional standards, and a working group led by Unicef Baby Friendly has now formed to take this work forward.

Day 6  – six geese a-laying

In the song the geese symbolise the six days of creation. 

Indicator 6 covers community-based support. So many mothers stop breastfeeding before they want to that it is really important to create an integrated system of support to avoid mothers falling into gaps between services. Six key aspects are:

  • Basic support: Health visitors and other health workers trained to a minimum Baby Friendly standard provide basic but universal help with feeding.
  • Additional: A peer support programme with trained peer supporters provides ongoing social support.
  • Specialist: For more challenging situations, mothers need to be able to access specialist help, for example from certified lactation consultants and breastfeeding counsellors.
  • Ready access to a tongue-tie division service where appropriate.
  • Good data collection is needed to underpin all these services.
  • Families must receive clear information about the services available.

WBTi Indicators 7-12 are covered in part 2

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  • Images from WBTi UK Report and Microsoft ClipArt

Breastfeeding and the First 1000 Days: the foundation of life

Breastfeeding and the First 1000 Days: the foundation of life

Breastfeeding: The Foundation of Life

The First 1000 Days of Life (from conception to the age of two years) are a critical window in a baby’s development. The 1000 Days concept was first widely used by the World Health Organisation and UNICEF, and there are currently numerous campaigns building on that theme.*

There is currently an inquiry into the First 1000 Days by the UK Parliamentary Select Committee on Health and Social Care. This blog brings together a few of the key concepts and resources on the importance of breastfeeding during the First 1000 days.

A joint supplement on the importance of breastfeeding in the first 1001 Days was produced by the UK breastfeeding organisations in 2015, which summarises much of the evidence.

A focused briefing on the the role of breastfeeding on infant brain growth and emotional development can be found here.

 

Breastfeeding: cornerstone of the First 1000 Days

Human babies are born extremely immature compared to other mammals; they are completely dependent on their mothers for milk, comfort and warmth.

  • “A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts, and security in the knowledge of her presence. Breastfeeding satisfies all three.” ~ Grantly Dick-Read

Scientific research has continued to underscore the vital role that breastfeeding and breastmilk play in the development of the human infant. See our WBTi blog series for this year’s World Breastfeeding Week, from 31st July – 7th August 2018 for a review of the myriad ways that breastfeeding influences human development.

 

Breastfeeding: more than just food

This is the title of a series of blogs by Dr Jenny Thomas which focuses on some of the ways that breastfeeding contributes to immune development and more. Beyond physical health and development, however, breastfeeding also plays a key role in the healthy mental and emotional development of the infant. Breastfeeding provides optimal nutrition for the first months and years of life, alongside suitable complementary food after six months, but it also supports the development of the child’s immune system and protects against a number of non-communicable diseases in later life as well.

The World Health Organization commissioned high level reviews on a range of health and cognitive outcomes which were published in a special issue of Acta Paediatrica in 2015; these formed the foundation of the Lancet Series on Breastfeeding  which was published in 2016.

 

The impact of breastfeeding on maternal and infant mental health and wellbeing.

Breastfeeding can help strengthen mother and baby’s resilience against adversity, and can protect infants even when their mothers suffer from postnatal depression. It supports optimal brain growth and cognitive development. Unfortunately, if mothers don’t receive the support they need with breastfeeding, this can significantly increase their risk of postnatal depression. A summary of evidence can be found here.

The role of breastfeeding in protecting maternal and infant mental health is often poorly understood – mothers who are struggling need skilled support to resolve breastfeeding problems if they wish to continue breastfeeding

 

What does the future hold?

It is essential that policy makers, commissioners, and researchers understand the evidence and importance of breastfeeding, so that women who want to breastfeed get any support they need. The WBTI report outlines major policies and programmes that national infant feeding strategies need to include; other research on the psychological and cultural influences on mothers’ infant feeding decisions will help policy makers to develop sensitive and sound policies and programmes to support all families.

In the end, it will be essential that families themselves are heard, in order to create the support systems that our society needs.

 

 

*Unfortunately a number of infant milk and baby food companies have jumped on the “1000 Days” bandwagon too, despite the fact that breastfeeding is the centrepiece of the original 1000 Days concept, and replacing breastmilk with formula or baby food actually removes that fundamental building block from a baby’s development.

 

 

 

Helen Gray IBCLC photoHelen Gray MPhil IBCLC is Joint Coordinator of the World Breastfeeding Trends Initiative (WBTi) UK Working Group. She is on the national committee of Lactation Consultants of Great Britain, and is also an accredited La Leche League Leader. She is a founding member of National Maternity Voices. She represents LLLGB on the UK Baby Feeding Law Group, and serves on the La Leche League International special committee on the International Code.

What does your doctor know about breastfeeding?

What does your doctor know about breastfeeding?

‘I’m still not convinced breastfeeding 4 year olds should be considered normal!’ – feedback from final year medical student after teaching session

‘Most [UK] pre-registration training for healthcare practitioners who work with mothers, children and young infants has many gaps in the high-level standards and curricula…’ World Breastfeeding Trends Initiative report 2016

 

As a consultant paediatrician, I deliver a one hour seminar to our medical students several times a term. I have the coveted before-home time slot for ‘essentials of paediatric nutrition’, which aims to encompass the investigation and management of faltering growth, the aetiology and treatment of obesity, and all infant feeding issues. Luckily I talk fast.

Of course, I’m joking.  Covering the syllabus in that time means focusing on key points, and one way I try to do this is encourage the students to set the agenda. At the start of the seminar, I plot out on a whiteboard what they want to get from the session. The students always ask me to cover the different types of formula. In fact, their syllabus emphasises breastfeeding, but their preoccupation is with learning components of, and indications for, breastmilk substitutes. This is manageable rote learning, standard in undergraduate education, easy to put on a flashcard and commit to memory for exams. It also connects to the overwhelming societal perception that formula is the default feed for babies. It is much harder to open up a discussion about breastfeeding and accept that we, as doctors, know almost nothing about it because we aren’t seeing it or learning about it at medical school. Of the twenty or so students in each session, often only one or two have seen a baby breastfed at all. Usually no one in the room has seen a child over the age of one nursing.

The ignorance around breastfeeding continues into our postgraduate curriculum. The ‘breast is best’ message is emphasised (although that has been superseded elsewhere by the ‘breast is normal’ message) but without the backup of grounding in lactation physiology and how our profession contributes to what I think of as ‘iatrogenic low milk supply’ – medical practices such as separating mother and baby, delaying the first feed, not respecting the importance of skin to skin, feeding on an artificial schedule,  wrongly assuming that maternal and infant medical conditions and medication preclude breastfeeding…  Without understanding the science, doctors will always resort to what they have seen before, are comfortable with, and believe to be normal. At the moment, that is usually formula feeding.

Screen Shot 2017 wbti ind 5 full slide

 

The World Breastfeeding Trends Initiative report flags up the holes in training for healthcare practitioners – illustrated here, the universal minimum pre-registration standards set by the GMC, the NMC and the BDA – and my experience echoes that (see Indicator 5, in Part 1 and Part 2, online). Our doctors need to realise what they don’t know about breastfeeding before they can start to learn. Recognising this is the first step on a very long road, but it is at least a step forward.

Victoria Thomas

 

Dr Vicky Thomas is a consultant paediatrician at the Great North Children’s Hospital in Newcastle upon Tyne. A generalist at heart, she has developed an interest in growth and nutrition and is passionate about the role of breastfeeding in optimising child health.

Who knows breast: GPs, Midwives, Health Visitors, Paediatricians, Obstetricians, Friends, Family?

Who knows breast: GPs, Midwives, Health Visitors, Paediatricians, Obstetricians, Friends, Family?

By Kate Butler

Peer Supporter, West Hertfordshire Hospitals NHS Trust

As a mum embarking on a new breastfeeding journey with their baby, who could she turn to for support and advice that she can trust? How would she know that what she’s doing is “right”, that her baby’s behaviour is “normal”? Her midwife? GP? Obstetrician? Paediatrician? Health Visitor? Surely the advice and support you get from a qualified and trained healthcare professional can be trusted? The findings from the World Breastfeeding Trends Initiative (WBTi) UK 2016 Report (published November 2016) may surprise you.

Screen Shot 2017 wbti ind 5

Health professional training in the UK

The WBTi UK Report (WBTi UK 2016) was based on the WBTi toolkit developed by the International Baby Food Action Network (IBFAN) to help countries evaluate breastfeeding policies and practices in a systematic way. One area that the report focuses on is health professional training and subsequent impact on breastfeeding initiation and continuation rates across the UK. Worryingly the report highlights many gaps in the pre-registration training of some healthcare professions in the area of infant and young child feeding, particularly in the practical aspects of enabling mothers to initiate and continue breastfeeding. Following qualification, healthcare professionals are then expected to undertake in-service training in infant and young child feeding. The WBTi UK Report reveals that provision and uptake of these courses is limited.

So what does this mean? The very healthcare professionals our new mums ought to be able to trust to give them the right advice may not be the right source of information to enable a mum to breastfeed successfully. It’s through no fault of the healthcare professional, but rather the fault of how their initial training and ongoing training is structured. Therefore their advice and support might often based on personal experiences and/or out of date practices. Not only that but our healthcare professionals also have to work in line with their own NHS trust policies. These differ between trusts and are based not only on NICE guidelines but also considerations such as the skill set of staff and trust finances.

Breastfeeding rates are dropping off drastically after birth

The issue with all this? Published in November 2012, the 2010 Infant Feeding Survey showed that the initial breastfeeding rate in the U.K. was 81%. Across the UK, at three months, the number of mothers breastfeeding exclusively was 17% and at four months, it was 12% (Infant Feeding Survey 2010). However, exclusive breastfeeding at six months is only around 1%. But with the infant feeding survey being cancelled last year and lack of any national leadership or strategy in infant feeding, what hope do we have to improve these figures? What hope do we have of changing the way our health professionals are trained and how their on-going training is structured?

Some people might ask what’s wrong with these figures presented above. In doing so, they reflect a society, our society, in which formula feeding has become normalised. Where friends and family see formula as “just as good” as breastmilk and don’t have their own personal experiences of breastfeeding in order to support new mothers. The World Health Organisation recommends exclusive breastfeeding up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond. It is not within the scope of this post to explore the reasons behind this recommendation, more this article is to raise the issue that breastfeeding families have a dwindling pool of resources from which to obtain support during their breastfeeding journeys. Breastfeeding families are unlikely to be able to rely on advice from healthcare professionals, friends or family. That’s a lonely existence.

How can we change society and health care for new mothers and babies?

All is not lost though. The Unicef Baby Friendly Initiative, launched in the U.K. in 1995 (Unicef UK Baby Friendly Initiative 1995), is based on a global accreditation programme of UNICEF and the World Health Organisation. It is designed to support breastfeeding and parent infant relationships by working with public services to improve standards of care. Maternity units and community facilities have the option to become Baby Friendly accredited and in order to do so are required to provide training for its midwives and health visitors. While the majority of maternity units (91%) and health-visiting services (83%) have achieved or are working towards Baby Friendly status, the remainder have not commenced the process. Therefore new breastfeeding mums can hope that the situation is improving and healthcare professionals that have undergone Baby Friendly training will start to provide the trusted information that mums deserve. But this will require quite a culture shift change within the NHS and this will take time.

There is also lots to be done with the image of, and marketing of infant milk so that “normal infant feeding” moves away from formula and focusses on breastfeeding.

Our society needs educating and this will also need the support and investment from the government.

wbti-ind-5-gaps-recs.png

For further information on how mums can find the most appropriate support right now for their breastfeeding journey, visit http://www.lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/

 

Kate ButlerKate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 1 and 3) day and night. She trained as a breastfeeding 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. This post was first published on Kate’s blog, The Instinctive Parent (www.theinstictiveparent.org), which she started to share knowledge and help further educate parents to help them make properly informed decisions and choices in how they choose to parent.

 

References

Infant Feeding Survey 2010 [ONLINE] Available at: http://www.content.digital.nhs.uk/catalogue/PUB08694/Infant-Feeding-Survey-2010-Consolidated-Report.pdf [Accessed 30/13/16]

UNICEF Baby Friendly Initiative 1995 [ONLINE]  https://www.unicef.org.uk/babyfriendly/what-is-baby-friendly/ [Accessed 30/12/16]

WBTi UK Report 2016 [ONLINE] Available at: https://ukbreastfeedingtrends.files.wordpress.com/2016/12/wbti-uk-report-2016-part-1-11-12-16.pdf [Accessed 30/12/16]

World Health Organisation [ONLINE] Available at: http://www.who.int/topics/breastfeeding/en/ [Accessed 30/12/16]

Supporting mothers to breastfeed – more on Indicators 5 & 6

baby-holding-hand

74 percent of mothers initiated breastfeeding
44 percent of mothers were still breastfeeding at 6–8 weeks

– Public Health Outcomes Framework (England) 2014/15

90 percent of women who stop breastfeeding in the first six weeks report giving up before they wanted to

– David Bull, Executive Director UNICEF UK

Most mothers in the UK want to breastfeed, yet most mothers stop breastfeeding before they want to. Why?

The fact is that while breastfeeding is natural, mothers need skilled support to be able to breastfeed. Yet many of the health professionals who work with mothers and babies do not have the knowledge or skills to help them.

Indicator 5 of the WBTi examines how well healthcare systems support breastfeeding. It looks in detail at the training of all health professionals who interact with mothers and babies – midwives, health visitors, GPs, paediatricians, lactation consultants and others – both before and after they qualify in their profession. You can see the full education checklist here.

It also asks whether health workers understand their responsibilities under the International Code of Marketing of Breast-milk Substitutes, and whether mothers and babies are able to stay together when one of them is sick.

Support for mothers comes from many sources, not just health professionals. It can come from family, friends, the community at large, and particularly breastfeeding peer-support groups. In the UK, these are run by organisations like the Association of Breastfeeding Mothers, Breastfeeding Network, La Leche League, NCT, as well as by the NHS itself. Mothers who have breastfed their own babies – and who have received training to provide breastfeeding support – are able to provide valuable help to new mothers.

In the UK, just 1 percent of babies are exclusively breastfed for the recommended six months. Common reasons that mothers give for stopping breastfeeding include:

  • finding breastfeeding painful
  • concerns about their milk supply
  • conflicting advice from health professionals
  • lack of support

LLL Mother support group
Trained support is needed at all levels, from peer supporters to lactation consultants. Click here for details of the different roles.

Peer supporters are “informed friends” who can help mothers understand what’s normal and help with many common breastfeeding concerns. They offer a compassionate and empathetic ear to new mothers.

This importance of this community-level support is recognised in Indicator 6 of the WBTi, which looks in detail at access to skilled mother support and community outreach. Good peer-support programmes can increase the length of time that mothers exclusively breastfeed their babies. In other words, they can help mothers who want to breastfeed to carry on for as long they choose.