Enabling women to breast feed

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1570 (Published 25 September 2008) Cite this as: BMJ 2008;337:a1570
  1. Mary Renfrew, professor and director 1,
  2. David Hall, emeritus professor of community paediatrics2
  1. 1Mother and Infant Research Unit, University of York, Department of Health Sciences, York YO10 5DD
  2. 2Institute of General Practice, University of Sheffield, Sheffield S5 7AU
  1. mjr505{at}york.ac.uk

    Is a challenge for the health professions

    Breast feeding improves infant and maternal health and cognitive development in both developed and developing countries, and it is the single most important preventive approach for saving children’s lives.1 2 Yet most infants in developed countries are formula fed within the first three months of birth, either exclusively or partially,3 and in many developing countries exclusive breast feeding (no additional fluids, cereal, or other foods) is rare. In the United Kingdom, the women most likely to formula feed are young, white, and from low socioeconomic backgrounds. This poses a major public health and inequalities challenge.

    Despite national and international policy initiatives, neither the duration of breast feeding nor the exclusivity of breast feeding up to six months of age have improved in the UK; 40% of women who start to breast feed discontinue by the time their baby is 6 weeks old, and only 20% of infants are exclusively breast fed at six weeks. The reasons women give for discontinuation are consistent over time and internationally; they think that they do not have enough milk, breast feeding is painful, and they have problems getting the baby to feed.4 These distressing problems could mostly be prevented.

    Comparative international data show that rates of breast feeding are related to sociocultural factors and support rather than to clinical problems. In Norway, where the incidence of breast feeding fell in the early 20th century—as it did in many developed countries—mother to mother support and policy interventions resulted in it returning to over 90% within 25 years.5 Other countries, including Canada and Australia, have introduced changes in policy and practice with positive results in recent years.

    These problems were the subject of a symposium at the annual conference of the Royal College of Paediatrics and Child Health (RCPCH). A compelling account of one woman’s struggle to breast feed, which was only resolved when she finally met a midwife who understood positioning and attachment, provoked several paediatricians in the audience to admit that they did not know the basic skill of helping mothers to position the baby so that feeding was effective and pain free. This supported recent evidence that health professionals, especially doctors, are not adequately trained in breast feeding and that changes are needed in professional education.6 Evidence also exists for the fundamental role of support for women, the need to avoid harmful interventions such as restricting the frequency and duration of feeding, and the important role of the United Nations (International) Children’s (Emergency) Fund (Unicef) baby friendly initiative.7 8 9

    Recent studies on the extent and range of weight loss in the first 10 days of life illuminate the contribution of weighing to avoiding potentially serious dehydration and confirm that this can be achieved without increasing maternal anxiety.10 The growth trajectory of healthy breastfed babies differs from that of formula fed infants, and this sometimes worries mothers if not explained. Charts based on the growth of healthy breastfed infants have now been developed, although training will be needed for them to be used effectively. Staff also need to be well informed about topics and controversies that, if not sensibly managed, can lead to anxiety and even discontinuation of breast feeding; for example, the role of ankyloglossia (tongue tie) as a cause of breastfeeding problems,11 and the management of the infant suspected of having breast milk associated jaundice.12

    For breast feeding to become the norm in developed countries, real and sustained changes are needed in policy, practice, and education. Implementation of the baby friendly initiative in hospital and community settings has been recommended by the National Institute for Health and Clinical Excellence.9 Accreditation in this initiative covers the core problems of training staff, supporting mothers, removing inappropriate interventions, defining strategy, coordinating change, and mainstreaming improved practice. These measures increase the rates of initiating breast feeding, the rates of exclusive breast feeding up to six months, and the duration of breast feeding, even in women in low income groups. However, the proportion of NHS trusts with such accreditation in England is much lower than in other UK countries, which poses a challenge for the relevant health professionals and managers.

    Changes in the provision of health services are unlikely to succeed without changes in society that would enable women to breast feed in public, to have their employment protected when breast feeding, and to be protected from misleading advertising regarding formula milk. Children also need to be taught that breast feeding is the norm. A national strategy to tackle the large scale changes is needed. Such changes are advocated by the national breastfeeding manifesto, which is supported by the relevant royal colleges and voluntary groups.

    Doctors, midwives, and health visitors should support such changes but need not wait until they are in place. Women and infants need their doctors to advocate breast feeding, to learn the basic skills, to revise protocols for weight monitoring to ensure that breast feeding is protected, and to support their colleagues who are working to promote and protect breast feeding. Helping women to breast feed will avoid discontinuation and distress and encourage other women to breast feed. It’s not rocket science, but the effect on health outcomes will be profound and long lasting.


    Cite this as: BMJ 2008;337:a1570


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.


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