I was asked to deliver a 15-minute talk at the Institute of Health Visiting and Royal Society of Public Health conference in April, entitled: The role of the infant feeding specialist. The following is a synopsis.

I started by sharing the story of a client whose journey will sound familiar to many IBCLCs – a first time mum who gave birth in a fully accredited Baby Friendly hospital, but struggled to breastfeed from the beginning. After receiving support with skin to skin, basic positioning, hand expressing and cup feeding, the mother went home exclusively pumping and supplementing with formula. She received a lot of support from midwives, health visitors and peer supporters, but by 10 weeks had still never had a successful breastfeed.

What the mother needed was specialist breastfeeding input, which she eventually found, to resolve her complex issues, and she continues to breastfeed, exclusively, to this day.

While most mothers begin breastfeeding, the sharp decline in the number of mothers still breastfeeding is staggering in the first 2-6 weeks. Many of the problems that women encounter are basic challenges which are solvable with the correct support.

The issue is not whether most health professionals are doing a good job, but whether  every mother can access the level of support that she requires. That may be “basic” infant feeding training such as BFI trained midwives and health visitors; or it may be “additional” support from a network of trained peer supporters, or in some complex cases, where the basic and additional levels of care have not solved the mothers’ problems, access to “specialist” infant feeding care may be required (see below). It is an equity issue that there is not access in every area to trained specialist care for complex cases.

Guidance

Basics of breastfeeding support are fundamental, and  NICE guidance states that Baby Friendly Initiative (BFI) accreditation should be the basic minimum standard across all maternity and community settings in the UK.

Relevant guidance from NICE, PHE and BFI are summarised in this “Guide to the Guidance” from Better Breastfeeding, outlining three recommended levels of support:

1) Basic support: A universal service with health professionals with BFI standard training in infant feeding 

2) Additional  support: Social and trained peer support

3) Specialist  support: access to a referral pathway to specialist support for complex cases.

The recommendations from the WBTi report and BFI both agree that for some mothers, access to specialist breastfeeding support should be available and readily accessible.

While most mothers only require routine care, with the adjunct of drop in groups, peer support and telephone helplines, some mothers will require a more thorough and specialised level of care in order to overcome their breastfeeding challenge and continue to breastfeed for as long as they wanted to.

The problem is how that service is provided. The BFI provide guidelines on the person specification of the Infant feeding lead . Many of these individuals are very experienced, skilled, hard-working and dedicated. But the fact remains that there is no set of core competencies, and no requirement for the infant feeding lead to have an infant feeding qualification. This makes the skill set of the infant feeding lead a vulnerability in itself .

In many cases, the infant feeding lead is required to achieve an enormous amount, encompassing audit, training, logistical management, liaising with key partners and commissioners, as well as provide a clinical service. This role is usually undertaken on a part time basis, often supplemented with countless hours of unpaid overtime in order to fulfill the requirements of the post.

Specialist infant feeding support: a team effort

Ideally, in order to provide the best service for families, and achieve sustainability, infant feeding support should be the responsibility of a team. Appropriately trained professionals should work together to deliver a service, so that it is not the sole responsibility of one overworked individual. These teams should include medical input from paediatricians, alongside dietetic and speech and language specialist support. Health visitors, midwives, community nursery nurses, and specialist breastfeeding support from an extensively trained member of staff, such as an IBCLC or accredited breastfeeding counsellor, should also make up the team.

For women and babies with complex feeding problems, the infant feeding specialist service should be readily accessible, timely, and high quality, with a clear referral pathway as recommended by the BFI. But importantly, this service needs to seamlessly transfer families back into routine care and follow up support. This would free up the specialist service and reduce the likelihood that the other health professionals providing routine and additional care become de-skilled.

Research indicates that delayed, inaccurate and inappropriate advice can reduce maternal confidence and self-efficacy, and leads to frustration, confusion and ultimately reduces the duration and exclusivity of breastfeeding.

Specialist skills and knowledge

The value of the infant feeding specialist is that their advanced skills and training provides them with expert listening and problem-solving skills. Infant feeding specialists such as IBCLCs possess the necessary clinical skills and training to accurately assess a problem and make an individualised plan: keeping the baby fed, protecting the maternal milk supply, and ultimately tackling the underlying cause of the problem (ILCA, 2011).

Having initially trained as a paediatric nurse, and later as a health visitor, I quickly realised that to be an effective practitioner, competent and confident to take on the management of more complex breastfeeding challenges, I needed some additional training. IBCLCs are required to not only have more than 1000 clinical practice hours, but also study an extensive curriculum, to equip them to understand and support mothers and babies with a whole range of breastfeeding problems. Moreover, we are required to keep our skills and knowledge sharp by completing 15 hours of CPD in advanced lactation and ethics every year, and by resitting our exam every ten years. I have now been an IBCLC for over 7 years, and though I still feel like a ‘junior’ compared to many of my IBCLC colleagues for whom I have a great deal of respect, my training and experience has helped me to feel capable of handling both entrenched and complex breastfeeding problems, and also to be a resource for the wider healthcare team.

Faulkner and Finch’s 2016 research found that many IBCLCs already hold infant feeding lead posts, or work in the voluntary sector. Other infant feeding leads have accessed further skills and training that equips them to run a specialist service.

Challenges

However, there are challenges. Firstly, many infant feeding leads are swamped with administrative and managerial tasks which detract from their clinical and educational role. Secondly, many infant leads are working in isolation, and simply do not have any cover when they are sick, take holiday or are overloaded. Thirdly, some infant feeding leads do not have enough access to advanced training to equip them to run specialist services, or do not have the time to be able to disseminate best practice to their team. Finally, many third sector services have been cut, which leads to services becoming overwhelmed, or women simply not having anywhere to turn when challenges crop up.

A successful specialist infant feeding referral service should be free, accessible, well-resourced, seamlessly linked with routine and additional care, and multi-disciplinary. Professionals should know where to access further training and be able to signpost families to quality sources of information. IBCLCs are well-placed to run these NHS services, and in many case they already are, but a greater emphasis on training of the entire infant feeding team would strengthen the approach and ultimately make the service more sustainable.

Lyndsey is an experienced Paediatric Nurse, Health Visitor, International Board Certified Lactation Consultant, Holistic Sleep Coach and Birth Trauma Recovery Practitioner, with almost 20 years experience working with infants, children and families in hospitals, clinics, and the community.

Lyndsey runs a busy practice offering one-to-one specialist breastfeeding, bottle feeding, sleep, eating, behaviour and parenting support to families in the UK and Internationally. Lyndsey is the author of Holistic Sleep Coaching and has published a number of articles in academic journals, as well as parenting magazines regarding breastfeeding, caring for premature babies and sleep issues in children. She regularly teaches health and childcare professionals, lectures as an independent speaker, and hopes to begin her PhD later this year.

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

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.

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

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

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.

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

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 10^th 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 4^th 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

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).

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

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