World Breastfeeding Week 2020 Statement: Covid-19 exposes fragility of infant feeding support in the UK

With breastfeeding support under strain, service providers propose plan to tackle inequalities

This World Breastfeeding Week (1-7 August 2020), #WBW2020 and #GreenFeeding, we are calling on the UK government to address the fragility of breastfeeding support services.

Our organisations have seen first-hand how the Covid-19 crisis has exposed the fragility of infant feeding support available for women, parents and families.

Over the past few months, the need to support babies and families has escalated and support services have been stretched beyond anything in our experience.

Existing variations in provision for infant feeding support have increased as services have been cut, health visiting teams redeployed and provision moved online, leading to unknown outcomes on infant nutritional
health, worsening maternal mental health and widening health inequalities.

Tremendous efforts from the NHS and Third Sector organisations, including many volunteers on the National Breastfeeding Helpline and other charity-run helplines, along with swift adaptation to offer online support,
have provided many families with support but this is not sustainable without a longer term strategy.

Meanwhile, the need to protect infant and young child feeding in pandemic emergencies has not previously been considered and has been entirely missing from the Scientific Advisory Group for Emergencies’ reports.

Investing in the health of new families, including supporting and protecting breastfeeding and supporting safe and responsive formula or mixed feeding, enables children not just to survive, but to thrive.

Rebuilding infant feeding support for communities after Covid-19 and giving important attention to the needs of mothers and children from Black, Asian and minority ethnic backgrounds will help tackle inequalities.

Infant feeding is a critical component of first 1001 Days and Early Years Health

We welcome the appointment of Andrea Leadsom MP as the Government’s Early Years Health Adviser and the announcement of a review at a time when infant feeding support services for women, parents and families have been stretched to an unprecedented degree.

Protecting breastfeeding and ensuring safe and responsive formula and mixed feeding during those first 1001 days would make a significant contribution to reducing inequalities in health. As a result, it also upholds the work of the NHS and helps build a healthier population.

While COVID-19 has undoubtedly placed a strain on support systems, it has also highlighted a huge omission in UK policy on planning for the care and feeding of infants and young children in case of emergencies, leaving our youngest members of society vulnerable.

While the benefits of breastfeeding are well-evidenced, merely stating these benefits does not ensure breastfeeding is protected or supported. At a time of global health crisis, and increasing recognition of the impact of human behaviour on the health of our planet, support for breastfeeding is also an environmental imperative.

10-point Infant Feeding Action Plan to address Inequalities

We call on the UK government to adopt the following 10-point Infant Feeding Action Plan below which has a particular focus on working to reduce inequalities:

For the new Government Early Years Advisor to appoint a permanent, multi-sectoral maternal, infant and young child nutrition strategy group to implement a national strategy to support good nutrition across the first 1001 days.
To commission and sustainably fund universal, accessible, confidential breastfeeding support delivered by specialist/lead midwives, health visitors and suitably qualified breastfeeding specialists, recognising the role of charitable organisations and community groups and their strong links with communities.
To ensure there are children’s centres or family hubs, disproportionately located in areas of disadvantage, offering joined-up universal services that include breastfeeding peer support, guidance on the introduction of solids and eating well in the early years.
To ensure that health visiting services are properly funded and the number of health visitors increased to ensure consistent timely nutritional support for all families to support good maternal and infant mental and physical health.
To integrate planning to support infant and young child feeding in emergencies into legislation, the Civil Contingencies Act, and Local Resilience Forums across the country.
To recognise the importance of breastmilk for preterm and vulnerable babies and the need for equitable access to donor breastmilk for these babies through the establishment of a fully funded regional donor milk banking service.
To implement the Unicef UK Baby Friendly Initiative across community, hospital and neonatal services, building on the recommendation for all maternity services to be accredited in the NHS Long Term Plan.
To make it a statutory right of working mothers to access a private space and paid breaks to breastfeed and/or express breastmilk and manage its safe storage.
To support the commitment to re-instate the quintennial Infant Feeding Survey which builds on data previously collected every five years since 1975, most recently in 2010.
To protect babies from harmful commercial interests by bringing, as a minimum, the full World Health Organisation International Code of Marketing of Breastmilk Substitutes into UK law and enforcing this law.

For more information and references, please visit:
www.breastfeedingnetwork.org.uk/2020statement

For enquiries, please email CEO@breastfeedingnetwork.org.uk

The Breastfeeding Network
Association of Breastfeeding Mothers
NCT
La Leche League GB
HENRY
Institute of Health Visiting
Best Beginnings
Human Milk Foundation
Local Infant Feeding Information Board
Lactation Consultants of Great Britain
World Breastfeeding Trends Initiative UK
Hospital Infant Feeding Network
GP Infant Feeding Network
UK Association of Milk Banking
Diversity in Infant Feeding
Better Breastfeeding
Nursing Matters
Save Time Support Breastfeeding
Swansea University
Breastfeeding Twins and Triplets

World Breastfeeding Week 2020 #WBW2020 COVID-19

The year 2020 has seen us facing unprecedented multiple crises and emergencies:

COVID19
The Climate Emergency
A crisis propelling equity, racial and social justice to the forefront through #BlackLivesMatter

The global theme of World Breastfeeding Week 2020, #WBW2020 and #GreenFeeding, “Support breastfeeding for a healthier planet,” is a focus on the Climate Emergency, and the impact of infant feeding on our environment and the planet.

When the novel coronavirus hit it reminded us that we are all linked, one people on one planet.

Breastfeeding and COVID-19

Some of those people were breastfeeding mothers and babies. At first, medical protocols for isolating COVID+ patients dictated that some mothers and babies were separated. Slowly the evidence accumulated that breastmilk itself did not appear to transmit the virus, and in fact antibodies to COVID19 began to be found in mothers’ milk. Now there are even research projects investigating whether the antibodies to COVID-19 in breastmilk could be used to protect others!

In the UK, the Royal Colleges who work with mothers and babies, led by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) quickly began to produce joint guidance, updated weekly. This was hosted on the RCOG website and became a global point of reference.

The web page includes

Coronavirus (COVID19) infection and pregnancy: this clinical guidance contains their influential recommendations on keeping mothers and babies together in hospital after birth, whether or not the mother is COVID+, and their recommendation that staff support the mother to breastfeed or express her milk for her baby, unless the mother is too ill. These recommendations have influenced health policy around the world, keeping many mothers and babies together worldwide.

A useful Q&A page of information for women and their families, written in plain language.

Guidance for antenatal and postnatal services during the evolving coronavirus (COVID19) pandemic. This includes some information on the management of breastfeeding in the community, including the following : “Remote support by third-sector organisations will be invaluable to provide support for breastfeeding, mental health and early parenting advice.”

Unicef UK Baby Friendly Initiative has also been producing and regularly updating a suite of statements and resources, mainly for staff. https://www.unicef.org.uk/babyfriendly/COVID-19/

The World Health Organisation has produced a steady stream of updates and resources emphasising the importance of breastfeeding during the COVID crisis. This includes:

clinical guidance, for when coronavirus infection is suspected

a new scientific brief on breastfeeding and Covid-19

FAQs on breastfeeding and COVID-19 for health workers

infographics, and

a media briefing on the 12 June at which the Director-General stated:

“WHO has also carefully investigated the risks of women transmitting COVID-19 to their babies during breastfeeding.

We know that children are at relatively low-risk of COVID-19, but are at high risk of numerous other diseases and conditions that breastfeeding prevents.

Based on the available evidence, WHO’s advice is that the benefits of breastfeeding outweigh any potential risks of transmission of COVID-19.

Mothers with suspected or confirmed COVID-19 should be encouraged to initiate and continue breastfeeding and not be separated from their infants, unless the mother is too unwell.

WHO has detailed information in our clinical guidance about how to breastfeed safely.”

You can watch the media briefing here .

We recommend that mothers with suspected or confirmed COVID-19 should be encouraged to initiate and continue breastfeeding. From the available evidence, mothers should be counselled that the benefits of breast-feeding substantially outweigh the potential risks of transmission.

In the UK, breastfeeding services suffered as midwifery and health visiting staffing levels were reduced by illness and self isolation, some staff were redeployed to labour ward or public health, childrens’ centres and breastfeeding support groups were closed. Families were discharged with their new baby to go home to a changed world, isolated in their home. Most health professional contacts were now virtual, and there were few opportunities to have baby weighed or seen in person, so parents were left on their own to figure out if their baby was doing well.

In areas like Brighton, with a strong, integrated commissioned NHS breastfeeding support programme, with a well embedded, large trained peer support programme and where there is a specialist NHS IBCLC clinic for complex problems, all the NHS support simply moved online. Once the technical side of this was worked out, breastfeeding support was still there for those who needed it.

In other areas, that depended on health visitors alone to deliver all the breastfeeding support, where there was no peer support commissioned and no specialist clinic staff, once the childrens’ centres were closed and many health visitors redeployed to other public health roles during the COVID-19 crisis, there might be one infant feeding lead health visitor left in the whole community.

Across the country, breastfeeding organisations and breastfeeding supporters sprang into action. Calls to the National Breastfeeding Helpline rose significantly, and trained volunteers turned out in droves. NCT moved their antenatal classes online, La Leche League local groups and NCT breastfeeding support groups moved onto Zoom, and IBCLCs set up remote consultations. A new app was trialled through the NHSX TechForce19 competition, Peppy Baby, in collaboration with Lactation Consultants of Great Britain and NCT, providing free access to online support groups and even video consultations for specialist breastfeeding help and mental health support. Suddenly there was online breastfeeding support available somewhere, every day of the week.

This had some advantages: mothers could join a Zoom meeting with their baby, still in bed. No one had to travel to get help. But some families had complex situations that did need face to face support, and it could be a challenge to find a specialist who could provide face to face support, or a tongue tie clinic that was still open.

Some families were able “nest” in isolation, with both parents home and no visitors, and flourished. Others struggled without face to face contact, without weight checks for baby, or struggled with their mental health. It will be hard to unpick the outcomes, as in many areas the usual health visitor checks were no longer taking place in person, so there are many gaps in the data. For instance, in some areas, no-one collected breastfeeding rates at 6-8 weeks, so it will be difficult to see the impact of COVID-19 on breastfeeding there.

It is vital that we all call on our local authorities, our CCGs and our Local Maternity Systems to rebuild a stronger network of skilled breastfeeding support as we come out of this first COVID-19 crisis – we must be more prepared for the next one.

Author: Helen Gray

World Breastfeeding Week

This is the start of World Breastfeeding Week 2020, which runs from the 1^st to the 7^th August. WBW is a global campaign to raise awareness and galvanise action on themes related to breastfeeding and commemorates the 1990 Innocenti Declaration. Since 2016, WBW has been aligned with the United Nations’ Sustainable Development Goals.

This year the theme is Support Breastfeeding for a Healthier Planet. #WBW2020 and #GreenFeeding

Breastfeeding can be hard in the early weeks under normal circumstances, adjusting to meeting the needs of a vulnerable human being, including urgent frequent feeding, and the tiredness that results from being on call 24 hours a day, 7 days a week. If feeding is painful it feels even harder. That is why having skilled breastfeeding support readily available, for any mother that needs it, is so important. Breastfeeding usually becomes much easier and more enjoyable as the weeks pass, especially if worries about painful feeds or milk supply or difficulties due to causes like tongue-tie are resolved, and is helped by babies tending to have more spaced and shorter feeds.

This year Covid-19 lockdown has been an added complication, particularly for new families as they have minimal face-to-face contacts.

What have the challenges and highlights been for you? You can share your experiences using the Leave a Reply box below.

Author: Patricia Wise

How confident do medical students feel about supporting breastfeeding?

A new study by trainee doctor Kirsty Biggs and senior colleagues has shown that 97% of the 411 medical students who responded to a survey are uncertain of their practical skills to support new mothers with breastfeeding, such as helping with latch issues, although the overall benefits of breastfeeding were moderately well-known. Yet most students (93%) perceived doctors to have an important role in supporting breastfeeding and the same percentage requested further breastfeeding education.

Over 80% of the respondents had a career interest in obstetric and gynaecology, paediatrics and/or general. While the sample was only around 1% of UK medical students, and only one-quarter of the students responding were male, it’s a very clear message that breastfeeding education overall is not adequate.

Around 80% of the 32 UK medical schools eligible responded to their part of the survey and results indicate that only 70% of medical schools provide compulsory breastfeeding education.

WBTI’s findings and vision

The WBTi UK report in 2016 indicated that medical curricula have many gaps with regard to breastfeeding, and Biggs’ study confirms that the students themselves find it inadequate. WBTi UK’s vision is that all doctors have sufficient training in infant feeding to protect the decisions of mothers who want to breastfeed.

UK Health Professional training standards mapped against WHO educational checklist. From the WBTI UK report. See also Part 2 for details of individual specialisms

How can the situation be improved?
High level standards and Unicef BFI learning outcomes

The General Medical Council provides broad guidelines for undergraduate curricula in its Outcomes for Graduates document and each medical school devises its own curriculum to fit the guidelines. For example, the expectation under the Outcomes Health promotion and illness prevention section is: ‘Newly qualified doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and sustainable healthcare to medical practice’. Unicef UK Baby Friendly Initiative’s learning outcomes for several professions, including medical students, published in November 2019 are highly relevant to improving curricula and accompanying resources are being developed.

RCPCH curriculum – an encouraging sign

Medical training is long, with undergraduate, Foundation and then specialty training. The RCPCH (Royal College of Paediatrics and Child Health) states as part of its activity to promote breastfeeding: ‘The RCPCH training curriculum for General Paediatricians and all paediatric subspecialties requires training to understand the importance of breastfeeding and lactation physiology, be able to recognise common breastfeeding problems, have knowledge of formula and complementary feeding, and be able to advise mothers or refer for support.’

Resources available

Qualified doctors also benefit from improving and updating their skills and knowledge. RCGP’s (Royal College of General Practitioners) Breastfeeding Position Statement has a link in the first sentence to its online resource on breastfeeding.

I’m very pleased that my e-book Supporting Mothers Who Breastfeed: A guide for trainee and qualified doctors, which is particularly aimed at trainers and trainee doctors, has been included in the Postnatal care guidelines of RCGP Learning.

The GP Infant Feeding Network (GPIFN) and Hospital Infant Feeding Network (HIFN) websites contain extensive information for doctors.

Other resources include Amy Brown and Wendy Jones’ book A guide for the Medical Profession, published in December 2019.

Guidance to qualified doctors

Mentioning infant feeding in guidance to doctors to encourage including it in consultations is also important. GP Louise Santhanam (founder of GPIFN) is the lead author of Postnatal Maternal and Infant care during the COVID-19 Pandemic: a Guide for General Practice that was recently added to the RCGP website. This clarifies that 6-8 week checks need to continue despite the Covid-19 pandemic and that infant feeding should be a routine clinical consideration.

Postnatal Maternal and Infant Care during COVID-19: A Guide for GPs by Louise Santhanam

The challenge

Thus plenty of resources are available but doctors are busy people. While some really understand the importance of protecting breastfeeding, and know how to – such as signposting mothers to local skilled help – the challenge is how to bring this into every medical student’s training.

If you know anyone at medical school, it would be really useful if you can let them know about Kirsty Biggs’ study.

Banner photo from Freepic

Patricia Wise is an NCT Breastfeeding Counsellor, a member of the WBTi UK Steering Group, and the author of Supporting Mothers Who Breastfeed: A guide for trainee and qualified doctors

We want the new government to invest in the health of women and children by supporting and protecting breastfeeding.

The WBTi UK team are proud to be part of producing this joint statement calling for our next government to make breastfeeding a priority in setting the agenda to prioritise the early years of life.

Download the PDF HERE

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 charitable organisations 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.

CASE FOR ACTION

Breastfeeding benefits all babies, and studies have shown that just a small increase in breastfeeding rates could cut NHS expenditure considerably. It is vital to invest in breastfeeding support in the early months and this will reap rewards in the future that are likely to exceed the initial cash flows associated with putting proper support in place.
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.

References

1. Laurence M. Grummer‐Strawn Nigel Rollins, (2015), Impact of Breastfeeding on Maternal and Child Health. https://onlinelibrary.wiley.com/toc/16512227/2015/104/S467

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 Nursing 72 (2): 273-282

4. https://www.brunel.ac.uk/research/News-and-events/news/Breastfeeding-for-longer-could-save-the-NHS-40-million-a-year

5. Li R, Fein SB, Chen J, Grummer-Strawn LM, (2008) Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics 122: S60-S76

6. Support for breastfeeding is an environmental imperative. (2019) BMJ 2019;367:l5646 https://www.bmj.com/content/367/bmj.l5646

7. McAndrew F et al (2012) Infant Feeding Survey 2010

8. NHS (2019) NHS Long term Plan https://www.longtermplan.nhs.uk/

9. National Institute for Health and Care Excellence (2013) Postnatal Guideline NICE, London https://www.nice.org.uk/guidance/cg37

10. National Institute for Health and Care Excellence (2012) Improved access to peer support NICE, London

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

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.

13. Brown, A, Finch, G, Trickey, H, Hopkins, R (2019) ‘A Lifeline when no one else wants to give you an answer’ – An Evaluation of the BFN’s drugs in breastmilk service. https://breastfeedingnetwork.org.uk/wp-content/pdfs/BfN%20Final%20report%20.pdf

Don’t Say Stop Look it Up – A New Breastfeeding Campaign for HCPs (HIFN): 2

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.

For details of gaps in health professional training, see “Indicator 5” in Part 1 of the WBTi Report for the summary table above and in Part 2 for the detailed findings on each health profession.

Following on from yesterday’s blog about the launch of the Hospital Infant Feeding Network website, today we are looking in more detail at the joint GPIFN, Breastfeeding Network and HIFN campaign “Don’t Say Stop Look It Up”.

DontStopLookItUp

This campaign, started by the GP Infant Feeding Network in 2017, aims to make sure healthcare professionals know how to check whether specific medicines can be taken by breastfeeding women. Most healthcare professionals know that with regard to breastfeeding and medication they should check what the British National Formulary (BNF) says. The BNF is a phenomenal resource, respected around the world, with comprehensive information about medication doses, side effects and cautions. However, in some cases it takes a very cautious line on breastfeeding – for example, for the antidepressant sertraline, recommended by specialist services as a preferred option in breastfeeding, the BNF says “not known to be harmful but consider discontinuing breastfeeding”. For ibuprofen, accepted by specialist services as appropriate during lactation, the BNF says “use with caution during breastfeeding. Amount too small to be harmful but some manufacturers advise avoid”. It isn’t hard to see that well-meaning healthcare professionals are nervous about recommending medicines for breastfeeding women when seeing these descriptions in a trusted source of information, and why they may advise that breastfeeding should be stopped, or that the medication cannot be taken.

The #Don’tSayStopLookItUp campaign seeks to highlight the position of the National Institute for Health and Care Excellence (NICE), which states “Ensure health professionals who prescribe drugs to a breastfeeding mother… seek guidance from the UK Drugs in Lactation Advisory Service… the ‘British National Formulary’ should only be used as a guide as it does not contain quantitative data on which to base individual decisions… Health professionals should recognise that there may be adverse health consequences for both mother and baby if the mother does not breastfeed. They should also recognise that it may not be easy for the mother to stop breastfeeding abruptly – and that it is difficult to reverse”. The campaign poster set can be downloaded, and covers common classes of drugs such as antibiotics, antidepressants, painkillers and anaesthetics. The rest of the blog will cover in more detail how health professionals can effectively use the UK Drugs in Lactation Advisory Service (UKDILAS).

UKDILAS is an NHS service specifically set up to help health professionals make informed decisions about the use of medicines during breastfeeding. It is provided by a team of highly specialised pharmacists. The website is not the easiest one to navigate so we’ll go through the three particularly useful services they provide, step by step.

Using UKDILAS

Firstly, UKDILAS provides thorough lactation-specific information on individual medications. When a health professional wants to check a single medication, where they would normally look it up in the BNF, they can go to www.sps.nhs.uk (or Google UKDILAS) and use the search box at the top of the page:

Searching for codeine, for example, will bring up first the individual drug name and any lactation (and other specialist service) factsheets as well:

Clicking on the individual drug name codeine brings the reader to a long list of articles and other specialist information so the last step is to click on the “Lactation Safety Information” link under the medication name to go straight to the relevant section.

In this case, the final result is “Use when breastfeeding – No” with useful comments about how much data this is based on and what effects are seen. This will also link you through to any other relevant lactation safety information held about this medicine:

The other two UKDILAS services are the factsheets and the ability to ask specific questions. Question & Answer factsheets are available via a link from the UKDILAS part of the SPS website (www.sps.nhs.uk/ukdilas) and cover general topics like “which oral antihistamines are safe to use while breastfeeding?”. There are also general “safety in lactation” articles covering specific classes of medication – these will come up when you search for an individual medication, as shown above with codeine, which is an opioid analgesic.

To ask UKDILAS a specific question, health professionals can telephone (9am-5pm Mon to Fri) or email – full details are on the website. The team will answer any breastfeeding and medicine-related question, but particularly specialise in highly complex areas such as multiple medications and premature infants.

Other sources of information on drugs in breastmilk

As lactation professionals know, there are many other ways to access information about medications in lactation – for example the wonderful Drug Factsheets put together by Wendy Jones at the Breastfeeding Network, American national resource LactMed and textbooks such as Medications and Mothers’ Milk (Hale). This blog has focused on UKDILAS because it is an NHS source, which is reassuring to busy UK health professionals who may not have time to check the credentials of other sources.

So, in summary, health professionals naturally use the BNF to check information about lactation, but by using the Don’t Say Stop Look It Up campaign, we can help them find out about specialist sources of information to help families make informed decisions.

Ilana Levene is a paediatric doctor planning to sub-specialise in neonatal medicine and interested in research relating to neonatal nutrition. She lives in Oxford with her husband, an environmental consultant, and two children. She is a trustee of Oxfordshire Breastfeeding Support, a local grassroots network of free weekly breastfeeding drop-ins and online support. She likes cross-stitching and making patchwork quilts.

Strengthening breastfeeding support through a new hospital network (HIFN): 1

There is exciting progress to strengthen breastfeeding education and policy in a hospital setting in the UK, with the launch of a comprehensive website resource for hospital health professionals this week www.hifn.org. Co-chair Ilana Levene tells us more about the Hospital Infant Feeding Network (HIFN).

“HIFN was set up in 2018 and consists of a network of health professionals interested in supporting and facilitating breastfeeding in a hospital setting in the United Kingdom. I’m a paediatric trainee with a special interest in neonatal nutrition and my co-chair Vicky Thomas is a consultant paediatrician with a special interest in complex nutritional difficulties in infancy and childhood. Our steering committee includes a parent, a nurse practitioner, a dietitian and doctors from other specialities such as anaesthetics, endocrinology and emergency medicine. All health professionals and those who have a strong interest in hospital breastfeeding are welcome to become active within HIFN – if you would like to join, please search for the closed Facebook Group “Hospital Infant Feeding Network” and follow us on Twitter @HIFN12. To understand more about HIFN, just dive right into our new website www.hifn.org, launching this week to mark World Breastfeeding Week. It covers our principles and goals, general background issues of infant feeding in the UK and specific topics relevant to health professionals looking after both mothers and children in a hospital setting. If you’re not a hospital health professional, signpost those you know to the website as a source of expert, referenced, practical breastfeeding-friendly knowledge.

Why did we decide to form a new network for hospital health professionals? In 2016, the GP Infant Feeding Network (GPIFN) was set up in order to improve infant feeding support by General Practitioners, and this arena showed that there was a significant appetite and unmet need not only from GPs, but also hospital professionals. A recent survey of paediatric doctors in a large UK hospital found that 30% did not agree that breastfeeding is the most beneficial form of nutrition in the first 6 months of life, and over 50% felt inadequately trained to manage breastfeeding when they encounter it. WBTi has documented the many gaps in undergraduate and postgraduate training (see Indicator 5 in both Part 1 and Pat 2 of the WBTi report) , and sources like the parent-led Hospital Breastfeeding campaign have clearly shown the poor practice families experience on the ground every day as a result. With this pressing need in mind, a group of hospital professionals active in GPIFN decided to form a sister network. From the moment of inception, we have reached out to families, the lay organisations active in the breastfeeding field, and lactation professionals, in order to work in partnership.

Apart from working on our website content, HIFN has achieved major campaigning wins through advocacy with the Royal College of Paediatrics and Child Health, who recently announced they will no longer accept any funding from breastmilk substitute manufacturers. This has started to ripple out to other associated organisations such as the British Association of Perinatal Medicine. We re-launched a longstanding campaign related to medication in lactation, alongside GPIFN and the Breastfeeding Network, and with support from the UK Drugs in Lactation Advisory Service, called #dontsaystoplookitup. We provided poster resources for National Breastfeeding Celebration weeks – both of these sets of resources are available for download on the website www.hifn.org/dontsaystop and www.hifn.org/posters.

We look forward to continuing to serve UK families moving forward and welcome you to have a look at the new website and get more health professionals involved.”

#WBW2019: Empower parents, enable breastfeeding

The theme for World Breastfeeding Week this year is “Empower parents, enable breastfeeding,” which fits the philosophy of our WBTi work very well. The WBTi recommendations have been produced by a Core Group of 18 of the UK’s key government agencies, health professional organisations and charities working in infant and maternal health. The 46 recommendations, across ten areas of policy and programmes, parallel many of the recommendations of previous national breastfeeding initiatives such as the UNICEF Baby Friendly Call to Action, the Becoming Breastfeeding Friendly project (completed in Wales and Scotland so far), and the Breastfeeding Manifesto.

The WBTi assessment and recommendations for action are all about providing the structures, policies and programmes that families need in order to support mothers and infants to be able to breastfeed successfully. It is not a woman’s responsibility on her own, it is the responsibility of ALL of us, across society, to provide the support that mothers and babies need.

This has been echoed by the UN Human Rights experts, who have stated that breastfeeding is a human right of the breastfeeding dyad, and that states/ society is responsible for providing the structural support they need. Likewise this is the key message of the Lancet 2016 Series on Breastfeeding.

Gaps and barriers

Our UK report found many gaps and barriers in ten areas of policy and programmes across the UK:

Lack of national leadership and national strategy on infant feeding, except in Scotland.
Areas where maternity settings still do not meet the minimum UNICEF Baby Friendly standards, in particular in England.
Weak regulations governing marketing by baby milk companies, no regulations governing bottle and teat marketing, and little enforcement of existing provisions.
Lack of provisions to support new mothers to continue breastfeeding when they return to work.
Gaps in health care professional training in infant and young child feeding (See both Part 1 and Part 2 of the WBTi report for full details)
Cuts to peer support and other community breastfeeding support.
No national communications strategy on breastfeeding.
Lack of understanding of current guidance on breastfeeding for HIV+ mothers.
No national guidance on planning for the care of infants and young children in emergencies or disasters.
Poor data collection and monitoring of breastfeeding rates.

Highlights of progress

There are several bright spots, however, and in the two years since the WBTi report and recommendations were published, there have been improvements in several areas

National policy work: Scotland already had strong national policy leadership. Scotland, Wales and England have taken part in the Becoming Breastfeeding Friendly project on scaling up breastfeeding interventions, with a government commitment to act on recommendations.
With the latest NHS England Long Term Plan, all of the UK has now pledged to reach full UNICEF Baby Friendly accreditation in all maternity settings.
Increased awareness of International Code issues in the UK include a relaunch of the UK Baby Feeding Law Group, a coalition of UK organisations working in infant and maternal health, to advocate for implementation of the International Code in UK law.
The Alliance for Maternity Rights has included the protection of flexible breastfeeding/ expressing breaks and suitable facilities in their Action Plan.
Several health professional councils have begun to review their training standards on infant feeding, and a working group led be UNICEF Baby Friendly has launched a new set of learning outcomes for the training of medical students, paediatric nurses, dietitians, pharmacists and maternity support workers/ nursery nurses.
Continued cuts to local authority and public health budgets has continued to severely impact community breastfeeding support such as trained peer support. The WBTi team organised a conference on the public health impact of breastfeeding with the Institute for Health Visiting, exploring in particular the UNICEF Baby Friendly community requirements for “basic” health professional BFI training, “additional” local trained support such as peer support groups, and a “specialist” referral pathway at IBCLC level. The BFI, NICE and Public Health England guidance are clearly explained in the “Guide to the Guidance” by Better Breastfeeding. However there is potential for strengthening the commissioning of integrated breastfeeding services, through the increased profile of breastfeeding in England in the NHS Long Term Plan, breastfeeding representation now being included in the NHS England National Maternity Transformation Programme Stakeholder Group, and in Scotland and Wales with renewed national leadership and funding.
Although no national communication strategies on breastfeeding have been developed, the national governments and public health agencies have developed breastfeeding campaigns and have supported national breastfeeding weeks again across all four nations.
New guidance on infant feeding for HIV+ mothers from the British HIV Association has included detailed guidance on how to support mothers who wish to breastfeed (see also our guest blog from Pamela Morrison IBCLC explaining the new guidance here)
Infant feeding in emergencies is still not covered by national guidance or universally in local disaster resilience planning, however a national forum hosted by Alison Thewliss MP, and led by the UK WBTI team and Dr Ruth Stirton from the University of Sussex Law School has kick-started the discussion to improve awareness and standards.
Monitoring of breastfeeding rates remains uneven across the UK; Scotland has continued to conduct robust infant feeding surveys, while, in England, the PHE data on breastfeeding rates still have gaps in reporting. The UK government has now proposed to reinstate the national infant feeding survey in a new consultation on prevention. See also our blog by Patricia Wise on gaps and changes in our data (including how YOU can access the fingertips data), and guest blog by Phyll Buchanan MSc on how we can use the infant feeding data to reveal insights into health inequalities.

So we are in interesting times – we still face budgetary and cultural challenges, and families still face many barriers.

However change is clearly happening!

Coming up on the WBTi blog for #WBW2019

For World Breastfeeding Week, we are hosting a number of guest blogs detailing some exciting innovations:
The launch of the Hospital Infant Feeding Network, with a website and a collection of posters and resources for health professionals working with mothers, infants and young children in hospital.

A new set of educational resources on breastfeeding and medications for pharmacists, from the wonderful Wendy Jones.

And a blog looking at some of the public health issues around breastfeeding support in the community, from Alice Allan IBCLC MPH.

Helen Gray IBCLC is Joint Coordinator of the WBTi UK team, with a special interest in supporting families in emergencies.

Improving UK support for breastfeeding – using a river metaphor

I was very pleased to have the opportunity at the 9 May iHV conference to present the broad findings of the World Breastfeeding Trends Initiative (WBTi) 2016 UK assessment of the state of support for breastfeeding, using the metaphor of a river. The WBTi UK Steering Group is keen to raise awareness of its 2016 report so that the findings can be used locally and nationally for change. National Breastfeeding Celebration Week provides an opportunity to be proud of what has been achieved but it is also important to be mindful of what still needs improving in supporting and protecting breastfeeding.

Any efforts to improve a situation require a thorough assessment of the current situation first. A WBTi assessment considers ten policy and programme indicators, drawn from the 2003 WHO Global Strategy on Infant and Young Child Feeding. Each indicator is scored on how well it is implemented, and gaps and recommendations are identified. The Steering Group collaborates with a core group of representatives of relevant organisations, such as professional organisations, charities and government departments, to achieve consensus on the various elements of the report. Nearly 100 countries have carried out this process so far.

	Indicator name	UK score out of 10
1	National policy, programme and coordination	1
2	Baby Friendly Initiative	7.5
3	Implementation of the International Code of Marketing of Breastmilk Substitutes	6
4	Maternity Protection	6.5
5	Healthcare systems (primarily health professional training)	5.5
6	Community-based support	7
7	Information support	5.5
8	Infant feeding and HIV	6.5
9	Infant feeding during emergencies	0
10	Monitoring and evaluation system	5

In the metaphor, the mother’s breastfeeding journey is represented by stepping stones across the river. The stepping stones stand for the people who provide the mother with direct support, such as family and friends, midwives, maternity support workers, health visitors, peer supporters, breastfeeding counsellors, and lactation consultants. The Health Visitor’s role is crucial as the service is universal and she can both signpost as well as give direct support.

The river itself is the flow of intermingling influences on the mother’s infant feeding decisions – these start in her infancy at the head of the river and include the later factors categorised as the WBTi indicators. A dam represents the legal protections – in the UK these include protection from formula advertising for babies under 6 months (Indicator 3) and maternity leave and protected breastfeeding/ expressing rights at work (Indicator 5).

The riverbanks represent other Indicators, such as the extent of national leadership (Indicator 1), health professional training (Indicator 5) and data collection on breastfeeding rates (Indicator 10). A weak riverbank that looks stable is particularly risky and is like a trusted health professional with inadequate knowledge and skills.

Strengthening the dam and riverbanks would mean that the mother is much less likely to be knocked off the stepping stones, so much more likely to achieve her breastfeeding goals. To have greatest impact, there needs to be concurrent improvement on the different Indicators, otherwise there will still be too great a flow of negative influences over the stepping stones.

#CelebrateBreastfeeding

June 2019

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

International Women’s Day, March 8th

Today is International Women’s Day, which was first held in 1911. The idea had been proposed at the second International Conference of Working Women, held in Copenhagen in 1910. The Day symbolises the struggle for equality, particularly in the workplace, but is also an opportunity to celebrate women’s achievements. You can read more about its history here: https://www.internationalwomensday.com/About

The theme this year is #BalanceforBetter, summarising that a better world has a better gender balance. While considerable progress has been made (for example, it was only in 1948 that women at Cambridge were given formal recognition of their degrees, and the percentage of girls in primary school in the world has risen from 65% in 1970 to 90% in 2015*), there is still a gender pay gap and women are in the minority in business and politics.

Balance requires removing conscious and unconscious bias about people; bias that results from assumptions being made about their capabilities. Alongside removing bias there needs to be support to meet specific needs individuals may have so that opportunities really are accessible – practical support includes items such as ramps and particular computer software. Thus, on the one hand, it’s essential not to assume differences that don’t exist so that women, men and intersex people of equal merit have equal opportunities.

On the other hand, it is important to respect real differences such as biological differences. Female employees who are breastfeeding need breaks for expressing or feeding, a suitable place to do that and facilities such as a fridge for storing expressed milk. If those were a legal requirement in the UK employers would be expected to provide them. Indicator 4 of the World Breastfeeding Trends Initiative is about maternity protection and the 2016 UK report assessed how well the UK is doing and made recommendations.

We’ve also had several blogs focussing on the issue, a blog on breastfeeding and Shared Parental Leave from Ros Bragg at Maternity Action, and a summary of the issue from our own Helen Gray.

With regard to achievements, every mother who nourishes her baby with her own milk is doing something ordinary that millions of women have done before her yet is also extraordinary.

* Rosling H (2018) Factfulness Stodder & Houghton

Photo: iStock.com/Jonas Unruh

Breastfeeding trends (UK)

Working together to improve breastfeeding in the UK

Category: Uncategorized