Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Breastfeeding: evidence, targets and resources may lead to cultural change
- D. Graham Mackenzie, Michele McCoy, Alison K. McCallum (16 February 2009)
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Sad facts and bad graphics
- Helena Jopling (16 February 2009)
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breast feeding policy . A disaster
- Anne Savage (17 February 2009)
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Has this study really 'disproved' the benefits of peer support?
- Anna Storrs, Trisha Greenhalgh (20 February 2009)
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Hypernatraemic dehydration in exclusively breast fed babies
- Geeta Subramanian, Sanjay Wazir, Jeewan Rawal (25 March 2009)
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D. Graham Mackenzie, Consultant in Public Health Department of Public Health and Health Policy, NHS Lothian, Deaconess House, Edinburgh, EH8 9RS, Michele McCoy, Alison K. McCallum
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The recent BMJ issue featuring breastfeeding (14 February 2009) provides useful evidence and advice about approaches to improving breastfeeding rates. Hoddinott et al’s study identified no apparent effect of breastfeeding groups on breastfeeding rates at 6-8 weeks,1 while MacArthur et al’s Birmingham study found no improvement in initiation rates with antenatal peer support.2 Cattaneo’s editorial provides a balanced interpretation and concludes that only a “multifaceted programme” will produce the substantial increase in breastfeeding rates required.3
For over a decade Dr. Pat Hoddinott has written on this topic in the BMJ, starting with a letter in 1997 questioning the merit of breastfeeding targets.4 It is interesting to note therefore that there is a new Scottish Government health improvement target to increase the proportion of newborn children exclusively breastfed at 6-8 weeks from 26.6% in 2006/07 to 33.3% in 2010/11 (a 25% increase).5 While this target may seem unrealistic in light of these two new studies,1,2 the important difference from previous rounds of target setting is that this time huge resources are attached: Ł19m Scottish Government funding available over the same 3 year period to improve the nutrition of women of childbearing age, pregnant women and children under five, with a very welcome focus on disadvantaged areas.5 These resources provide a once in a generation opportunity to support the cultural change required to encourage women to breastfeed and should enable the development of carefully designed, well evaluated complex interventions that systematically address the barriers to initiating and continuing breastfeeding that many women face. Graham Mackenzie, Consultant in Public Health, Department of Public Health and Health Policy, NHS Lothian Michele McCoy, Specialist in Public Health, Department of Public Health and Health Policy, NHS Lothian Alison McCallum, Director of Public Health, Department of Public Health and Health Policy, NHS Lothian References 1) Hoddinott P, Britten J, Prescott GJ et al. Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial. BMJ 2009;338:a3026 2) MacArthur C, Jolly K, Ingram L et al. Antenatal peer support workers and initiation of breast feeding: cluster randomised controlled trial. BMJ 2009;338:b131 3) Cattaneo A. Promoting breast feeding in the community. BMJ 2009;338:a2657 4) Hoddinott P. Setting target rates for breast feeding would probably be a waste of resources. BMJ 1997;315:313. 5) Nutrition of women of childbearing age, pregnant women and children under five in disadvantaged areas - funding allocation 2008 – 2011. Scottish Government (2008). www.sehd.scot.nhs.uk/mels/CEL2008_36.pdf accessed 14 February 2009 Competing interests: None declared |
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Helena Jopling, FY2 Doctor, Obstetrics and Gynaecology West Suffolk Hospital, Bury St Edmunds, Suffolk, IP33 2QZ
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Hoddinott et al(1) suggest that resources for promoting and supporting breast feeding would be best directed to the early postnatal days when breast feeding rates drop dramatically. There is already a structure in place for this care to be provided: it is called the postnatal bay on the maternity ward and postnatal visits to the mother’s home. It is clear that the current service is systematically failing its clients. From my personal experience as a breast feeding mother and in posts in paediatrics, public health and obstetrics and gynaecology, the need for a multifaceted programme for breast feeding promotion(2) rings desperately true. A complete paradigm shift is required. Government, health authorities, health professionals, mothers, fathers, extended families, employers and baby-milk substitute manufacturers need finally to accept the truth that breast feeding is normal, natural, and the only way a mother should feed her baby. Only then will initiation and continuation rates start to increase and the overarching benefits of breast feeding, not just to mother and baby but to the community at large, be felt. One considerable step towards this goal would be the destruction of the belief that a baby’s milk comes in a bottle. With this in mind, perhaps the BMJ’s editorial team should have exercised rather more thought about the graphics used on this week’s front cover. 1 Hoddinott P, Britten J, Prescott GJ, Tappin DM, Ludbrook A, Godden DJ. Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial. BMJ 2009;338:a3026 2 Cattaneo A. Promoting breast feeding in the community. BMJ 2009;338:a2657 Competing interests: I am a grateful member of La Leche League Cambridge, a mother-to-mother breast feeding support group. |
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Anne Savage, Retired NW3 5RA
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As a student in the early 1950s we visited the Lying-In Hospital and I still remember the miserable rows of women forced to bathe their breasts with hot and cold water and swallow pints of water to make sure they breast fed. Not the best way to bond with your baby. The academic outcomes of this tyranny are dubious; no one can tell,later in life, which child has been breast and which bottle fed. The personal misery is evident in the number of mothers suffering from cracked nipples, feelings of guilt and crying and underfed babies. But if British women suffer that is nothing to the damage done to the developing world. 'Teacher's child' we would say, in a mixture of despair and compassion as we admitted yet another miserable scrawny baby to our African hospital. Our teachers got two weeks maternity leave and then the baby was left in the care of a relative, frequently an older child. They(the teachers)were intelligent, lived in comfortable houses and kept themselves and their children clean. Yet they were considered, by distant academics, too stupid to learn safe bottle feeding. Educated women make the best mothers, working women can afford books and uniforms for school but developing countries cannot afford to pay two people to do one job so Maternity Leave is minimal. Colonial attitudes should go. Competing interests: None declared |
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Anna Storrs, Medical Student University College London, Trisha Greenhalgh
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One of us (AS) is a medical student who has received no formal training in breast feeding apart from lectures on its physiology and endocrinology. An ex breast feeding counsellor, she is now undertaking a BSc project on barriers to breast feeding. Her experience and research findings support the above responses and those in the linked editorial - that breastfeeding is an intimate, personal and sometimes difficult task and that women’s attitudes to it are influenced by their own experiences, that of their relatives and peers, and media images. The comedy programme Little Britain and documentaries such as ‘Other people’s breast milk’ have focused attention on the minority of women who push the social boundaries of breastfeeding beyond what many would see as ‘natural’. These messages set the stage for ambivalent attitudes. We were struck by the mismatch between an earlier qualitative study (1) and the pilot phase of this latest study (which both suggested that breastfeeding peer support would be beneficial) and the main study (which suggested that it would not). There is a telling statement hidden in the discussion: “The preliminary study used action research methods, compared with a distant research team running a trial, and partnership working between midwives, health visitors, and women was less evident in the trial.” (2) Perhaps it is time to question the status of the randomised trial as the ‘gold standard’ in evaluating the impact of policies that are likely to depend heavily on building a positive institutional context within which the core intervention can be embedded. TG is currently writing up a study of peer support in diabetes which showed great popularity and promise in an action research phase (3) but which produced largely (though not entirely) negative results in the randomised trial phase. As in Hoddinott et al’s study, the mismatch between action research and trial findings may have been due partly to a distinct fall in staff enthusiasm when they were required to take on a position of clinical equipoise in relation to an intervention they had already invested in emotionally and professionally. (1) Hoddinott P, Pill R. Qualitative study of decisions about infant feeding among women in east end of London. BMJ 1999; 318:30-34 (2) Hoddinott P, et al. Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial. BMJ 2009;338:a3026 (3) Greenhalgh T, Collard A, Begum N. Sharing stories: complex intervention for diabetes education in minority ethnic groups who do not speak English. BMJ 2005; 330: 628-34. Competing interests: AS worked as a breastfeeding counsellor before studying medicine. TG breast fed two children. |
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Geeta Subramanian, Consultant Paediatrician Queens Hospital, Rom Valley Road, Romford, RM7 0AG, Sanjay Wazir, Jeewan Rawal
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We read with interest recent publications in the BMJ on promotion of breast feeding (1,2). The advantages of breast feeding are compelling, when there is breast milk but consequences of its failure are serious. Hypernatraemic dehydration in exclusively breast fed neonates and receiving insufficient breast milk is a well established clinical entity and possibly rising in incidence. A local audit at our institution for 12 months (2008/2009) adds another 3 cases, the worst of which was a 9 day old neonate with serum sodium of 185 mmol/l and weight loss of 28% . It is a preventable cause of neonatal morbidity and mortality 3.Well recognised complications are cerebral oedema, intracranial haemorrhage, hydrocephalus, seizures, neurological deficits, limb gangrene , DIC, renal venous thrombosis, renal failure etc (4,5) A number of UK policy documents and guidelines (6,7,8) have been published within the last 2-3 years. We reviewed the NICE guidelines on Promotion of breast feeding, Routine postnatal care , Maternal and Child Nutrition etc. We found that in these documents there is valuable discussion for education and support but little to address this problem. There is reference to this condition under research recommendations, the argument being that there is debate about the benefits and harm of weighing these neonates, the opponents arguing that weighing may cause harm by interefering with exclusive breast feeding(8).But what about the potentially serious, irreversible harm to the neonate? There is acknowledgedly much more to supporting breast feeding babies and mums, than just weight assessment of the baby but it is an objective component of the assessment of adequacy of nutrition (9,10,11,12). We quote the authors of an article entitled ‘ Prevention of Breast Feeding Tragedies’ -‘Potential catastrophic infant outcomes can occur when enthusiastic promotion of breastfeeding outpaces necessary support services and management’. ‘Those who enthusiastically promote breastfeeding for its many health benefits must confront the reality of breast feeding failure and implement necessary changes in medical education and support services to foster successful outcomes in breast fed infants(13). While, evidence for best practice, to prevent this neonatal malnutrition, may be accruing, some interim debate and policy is required now. Ref: 1.Hoddinott P, Britten J, Prescott GJ, Tappin DM, Ludbrook A, Godden DJ. Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial. BMJ 2009;338:a3026 2.MacArthur C, Jolly K, Ingram L, Freemantle N, Dennis C-L, Hamburger R, et al. Antenatal peer support workers and breastfeeding initiation: cluster randomised controlled trial. BMJ 2009;338:b131. 3.Kaplan J, Siegler R, Schmunk, Gregory A. Fatal Hypernatremic Dehydration in Exclusively Breast-Fed Newborn Infants Due To Maternal Lactation Failure. The American Journal of Forensic Medicine and Pathology March1998;19;1;19-22 4.Arboits JM, Gildengers E. Breast-feeding and hypernatremia. J Paediatr 1980;97;335-6 5.Cooper WO, Atherton H, Kahana M, Kotagal RU. Increased Incidence of Severe Breastfeeding Malnutrition and Hypernatremia in a Metropolitan Area PEDIATRICS 1995;96;5;957-960 6.NICE Guidance : Maternal and Child Nutrition; Mar 2008 7.NICE Guidance :Promotion of Breast feeding initiation and duration :Evidence into practice briefing; July 2006 8.NICE Guidance CG37: Routine Postnatal Care of Women and their babies;July 2006 9.Iyer NP, Srinivasan R, Evans K, Ward L,Cheung W-Y, Mathews JA. Impact of early weighing policy on neonatal hypernataemic dehydration and breast feeding Arch.Dis.Child 2008; 93;297-299 10.Kudumula V,Ashokkumar A,Akinsoji O,Babu S. Breast feeding Malnutrition in Neonates: a step towards controlling the problem.ADC 2009:94:206 11.Mackie A, Young D, MacDonald P D : Does monitoring weight discourage breast feeding ADC 2006;91;44-46. 12.AAP Policy Statement of Breast feeding and the Use of humam Milk Pediatrics 2005;2;115 13.Neifert M : Prevention of Breast feeding tragedies Pediatric Clinics of North America 2001;48(2) Competing interests: None declared |
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