PUBLIC HEALTH & BREASTFEEDING General Practice Training 2011

DH RECOMMENDATION “As a global public health recommendation, infants should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health.” WHO 2001 Breastfeeding mothers are now a "protected characteristic" under the Equality Act 2010.

The Lancet, 1994 Immunisation is preventative medicine par excellence. If a new vaccine became available that could prevent 1 million or more child deaths a year and that was moreover, cheap, safe, administered orally and required no cold chain, it would become an immediate public health imperative. Breastfeeding could do all this and more, but it requires its own ‘warm chain’ of support that is skilled care for mothers to build their confidence and show them what to do, and protect them from harmful practices.

Evidence Base Healthy Weight, Healthy Lives (2008) Scientific Advisory Committee on Nutrition (2008) Child Health Promotion Programme (2008) Infant and Maternal Nutrition Guidelines NICE(2008) Ip S et al 2007(research based benefits of breastfeeding)

Public Health Breastfeeding has a major role within public health. It promotes health and prevents disease in both the short and long term for mother and baby Exclusive breastfeeding for around 6 months, and then continued breastfeeding alongside the introduction of solids for the first year,achieves the greatest benefits 90% of women stop breastfeeding long before they had planned (Infant Feeding Survey 2005) 90% of women who stop breastfeeding before their infant is 6 weeks do not want to. They experience problems, and/or lack of up to date information and support to continue.

Potential savings Breastfed babies have 15% fewer GP consultations during the first 6 months of life than formula-fed babies Reduction in common childhood illnesses and long-term health problems means: Improved public health Money saved - £35 million on hospital admission Gastroenteritis (DH) Reduced workload for GP’s

UNICEF BABY FRIENDLY INITIATIVE Provides a framework for the implementation of best practise for NHS Trusts and other health care facilities Within the community the seven point plan for the Protection, Promotion and Support of Breastfeeding in the Community

Implementing Baby Friendly Seven point plan for community settings Antenatal information Effective support and appropriate referral Appropriate prescribing Care with advertising

The Seven Point Plan for the Promotion, Protection and Support of Breastfeeding 1. Policy 2. Staff training 3. Information for pregnant women 4. Support to breastfeed 5. Exclusive breastfeeding 6. A welcoming atmosphere 7. Support groups

Incidence of breastfeeding 1990 - 2005

Local statistics for breastfeeding initiation and duration at birth & six weeks     Initiation: Q1 – 79%, Q2 – 78%, Q3 – 77%, Q4 – 77% 6-8 weeks: Q1 – 45.19%, Q2 – 48.84%, Q£ - 51.23%, Q4 – 53.38%    

Why breastfeed? Risks of formula feeding to babies Increased incidence of gastroenteritis Increased incidence of ear, chest infections and wheeze Higher risk of diabetes Increased risk of obesity Increased risk eczema and allergies Increased risk of childhood cancers Ip S et al 2007(research based benefits of breastfeeding)

Risks of not breastfeeding - for mothers Increased risk of pre & post menopausal breast cancer Increased risk of ovarian cancer Increased incidence of osteoporosis Delayed involution of the uterus

Infant Feeding Survey 2005 Most common reported problem in the first two weeks is sore breasts/nipples or perceived insufficient milk supply Approximately less than 2% of women have a true milk insufficiency Most milk insufficiency is perceived due to unrealistic expectations or mismanagement of breastfeeding

Common Problems Sore nipples Mastitis / breast abscess Thrush - topical and ductal Low weight gain

SORE NIPPLES- mostly associated with poor attachment Review positioning and attachment with midwife / health visitor / breastfeeding counsellor Moist wound healing, do not allow nipples to become dry Other causes: Eczema, bacterial infection, thrush, Tongue-tie or high arched palate in baby, Raynauds syndrome etc

MASTITIS Inflammatory condition of the breast which may/may not be accompanied by infection Reported incidence of <10% of lactating women Majority of cases in the first 12 weeks Only approximately 1/3rd are infected

Treatment IT IS VITAL THAT BREASTFEEDING IS NOT INTERRUPTED optimise attachment frequent feeding hand expressing if required begin feeds on affected breast all fours feeding position as this prevents drainage of the breast and may worsen the symptoms position the tongue and chin in line with the inflammation warm compress before feeding cold compress after feeds bed rest analgesia/anti-inflammatory (Ibuprofen) refer to breast feeding policy

Antibiotics – where appropriate Flucloxacillin 250mg qds Amoxycillin 250-500mgs tds If allergic to penicillin Erythromycin 250-500mgs qds Cephalexin 250-500mg qds Most antibiotics are safe in lactation, loose stools etc possible but not clinically important, may cause static weight gain. Beware of Thrush!

Breast Abscess Unusual, can be caused by mismanagement of blocked duct/mastitis May require aspiration or surgical drainage In most cases, breastfeeding can continue, if mother wishes, depending on the location of the abscess Breastfeeding can continue on the non affected side

Thrush – Topical Signs in mother Nipple may be super sensitive, red, shiny and itchy May be blanching of the nipple Pain while feeding not improved by correct positioning and attachment Nipple trauma Previous antibiotic treatment

Thrush - Ductal Intense breast pain when, previously, breastfeeding has been pain-free No relief from altered position/attachment Pain experienced deep within the breast and continues after feed Healed nipple trauma Antibiotic treatment

Signs in baby Baby may show one or more of the following symptoms or none Pulling off the breast, fussy feeder White plaques on the oral mucosa Windy, fretful or difficult to settle Nappy rash

Treatment of Thrush Treat the mother and baby simultaneously Mother: Miconazole cream apply a smear to the nipple after each feed Baby: Miconazole oral gel (not licensed for babies under 4 months, but can be prescribed) Education on correct application of cream & oral gel needed Refer for extra help with breastfeeding

Ductal Thrush Treatment Fluconozole 150 – 300 mgs load dose 50 -100 mgs BD x 10 days. NB Not licensed for lactating women (WHO recognise as compatible with breastfeeding) 0.6mg/kg/day the amount that gets through in breast milk 6.0mg/kg/day is the amount that can be given to a baby within licence (Thomas Hale – “Medication in Mothers Milk”)

Poor Weight Gain If no medical reason diagnosed: Improve milk transfer through correct positioning and attachment Encourage more frequent feeding (2 hourly) Breast compression while feeding Use both breasts at each feed Expressing and supplementing with expressed breast milk, by cup Encourage contact with practitioner trained to support breastfeeding and peer support network to build mothers confidence

The Dilemma of Prescribing “ Recommendations for the lactating mother are probably over-cautious and mothers who need treatment should not be prevented from breastfeeding if the drug is likely to be safe”. Wendy Jones PhD MRPharmS

Prescribing during breastfeeding BNF cautious in pregnancy and breastfeeding Thomas Hale – assesses risk Breastfeeding Network - Wendy Jones, Pharmacist Ideally breastfeed immediately before medication and should be avoided for 1 – 2 hours after any dose of medication( the time of highest plasma concentrations) Consider alternatives

Recommended booklist Medications and Mothers’ Milk 14th edition 2010, Thomas Hale PhD - ISBN – 978-0-9823379-9-8 Breastfeeding Answers Made Simple - Nancy Mohrbacher, IBCLC, FILCA - ISBN-13: 978-0-9845039-0-2 Breastfeeding & Human Lactation, Jan Riordan – ISBN – 0-7637-4585-5 Textbook of Human Lactation, Thomas Hale & Peter Hartmann – ISBN - 978-0-9772268-9-4 Breastfeeding a Guide for Medical Profession, Ruth & Robert Lawrence – ISBN 0-8151-2615-8 The Breastfeeding Atlas, Barbara Wilson-Clay & Kay Hoover – ISBN – 0-9672758-1-4

Useful links UNICEF Baby Friendly - www.babyfriendly.org.uk Lactation Consultants GB – www.lcgb.org ABM – www.abm.me.uk La Leche – www.laleche.org NCT – www.nctpregnancyandbabycare.com Online training for GPs – http://www.cks.nhs.uk/breastfeeding_problems www.breastfeedingnetwork.org.uk E-Groups: Lacthelpers - groups.yahoo.com/subscribe/lact-helpers-UK