It had been announced at the Baby Friendly conference in 2018 that learning outcomes and resources were being produced.
The WBTi report in 2016 (see Indicator 5 in Part 1 of the WBTi UK report for the above table, and Indicator 5 in Part 2 for the detailed findings for each UK health profession) showed that for most health professions in the UK, the coverage of infant feeding in pre-registration training was inadequate. In some case only broad standards are given and the individual universities develop their own curricula.
The infant feeding learning outcomes launched by BFI are for a range of newly qualified health professionals so they ‘articulate the minimum knowledge and understanding of infant feeding that it would be reasonable to expect from a health practitioner at the point of qualification’. There are slightly different ones for the following five groups:
maternity support workers/nursery nurses.
For each of these professional groups the learning outcomes are grouped into three broad themes:
The value of human milk and breastfeeding.
Supporting infant feeding.
Infant feeding in context, which includes understanding the importance of the International Code.
They are intended as ‘a stimulus to universities and others to start to consider what should be covered in relevant curricula and training, and then to take action to make that a reality.’
One useful recommendation is that ‘A mapping exercise can help the university to assess how far the topics are already covered and assessed in the curriculum, and to identify and plan for any additions to modules or design alternations needed.’ Plans for the resources ‘include a slide pack to help lecturers deliver the content to students, e-learning for students and assessment examples’.
Specific learning outcomes like these, provided they are taken on board by the training institutions, will surely help to achieve a higher and consistent level of knowledge and skills within and between health professions.
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.
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.
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.
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.
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.
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.
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.
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.
Sign up HERE for WBTi’s email list, and don’t forget to sign up to follow our blog!