Northern England Strategic Clinical Network Conference 15th May 2015 1001 Critical Days The importance of the conception to age 2 period

1001 Critical Days Everyone’s business The nature of the day to day relationship between the child and primary care giver is crucial The physical and mental wellbeing of the mother during pregnancy can have lifelong impacts on the child

The 1001 Critical Days cross party manifesto highlights the importance of acting early to enhance the outcomes for children. With a forward by the Chief Medical Officer (CMO), the manifesto calls for interventions that are evidence based and economically sound, have an emphasis on training of staff, and focus on prevention and early intervention.

The Age of Opportunity Overwhelming international evidence from all the relevant fields has brightly illuminated the path we should travel. It shows that primary prevention coupled with robust, effective support for mothers, fathers and/or carers during the first 1,001 days offer the best chance to break the cycle of inequality. Taken from Scottish coalition document 11/14

The 6 High Impact Areas (DOH 2014) Transition to Parenthood and the Early Weeks Maternal Mental Health (Perinatal Depression) Breastfeeding (Initiation and Duration) Healthy Weight, Healthy Nutrition (to include Physical Activity) Managing Minor Illness and Reducing Accidents (Reducing Hospital Attendance/Admissions) Health, Wellbeing and Development of the Child Age 2 – Two year old review (integrated review) and support to be ‘ready for school’ Why have these Six High Impact Area documents been developed? The Early Years High Impact Area documents have been developed to support the transition of commissioning to Local Authorities and to help inform decisions around the commissioning of the health visiting service and integrated children’s early years services. The purpose of the High Impact Area documents is to articulate the contribution of health visitors to the 0-5 agenda and describe areas where health visitors have a significant impact on health and wellbeing and improving outcomes for children, families and communities. The six High Impact Areas are: Transition to Parenthood and the Early Weeks Maternal Mental Health (Perinatal Depression) Breastfeeding (Initiation and Duration) Healthy Weight, Healthy Nutrition (to include Physical Activity) Managing Minor Illness and Reducing Accidents (Reducing Hospital Attendance/Admissions) Health, Wellbeing and Development of the Child Age 2 – Two year old review (integrated review) and support to be ‘ready for school’ Policy Drivers Early intervention Giving every child a better start DH 2013 Promote mother infant attachment Focus on multi-agency working Troubled Families Agenda DH 2012 Vulnerable Child priorities Chief Medical Officer guidance on physical activity DH 2011 No Health without Mental Health DH 2011 Foundation Years Conception to Age 2 – The Age of opportunity – Department for Education/WAVE Trust 1001 Critical Days – cross party manifesto 2014

Early Years High Impact Area 2 Maternal Mental Health Taken together, perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK. This is equivalent to a cost of just under £10,000 for every single birth in the country. Nearly three-quarters (72%) of this cost relates to adverse impacts on the child rather than the mother. The children are at higher risk of poor outcomes, emotional, social and educational. (Centre for Mental Health LSE 2014)

Breastfeeding and Attachment Breastfeeding has long been linked to mother and child attachment. Recent studies which appear to corroborate this include -

Does breastfeeding impact upon parenting capability? (Gutman LM 2009). Does breastfeeding have an effect upon child behaviour? (Heikkila 2011). Breastfeeding may have an effect on child and adolescent mental health (Oddy et al 2009). Breastfeeding and it’s effect on child maltreatment (Strathearn L 2009). Parenting capability – this was carried out to establish why parenting is important in the early years. Researches examined how a Cohort of 1,136 mothers interacted with their child at 1 and 5 years old, findings showed that breastfeeding had a positive association regardless of marital status or income level - It appeared however to be particularly important for single and lower income mothers. Heikila This prospective millennium cohort study to establish whether BF is associated with behavioural development in children aged 5 yrs 10,000 mother and infant pairs Findings suggest that in term children longer duration of BF > 4 months was ass with fewer parent related behavioural problems, even when taking into accont other factors ie socio economic Oddy Cohort 2900 pregnant women Mental health of their child was assessed using a validated tool at 2,6,8,10 and 14 yrs, maternal confounders ie age, education, family income were taken into account Findings BF for less that 6 months compared with 6 months or more was an independent predictor of mental health problems such as anxiety, depression and aggressive behaviour (child) Strathearn Prospectie s , monitored over 15 yrs maltreatment was confirmed on the basis of substantiated reportslongerpairs with the aim of establishing whether there was a protective effect on maternally perpetrated child mal treatment study of 7223 mother and infant A large prospective study in Australia was carried out with the aim of establishing whether there was a protective effect of breastfeeding on maternally perpetrated child maltreatment. A total of 7223 Australian mother-infant pairs were monitored over 15 years and maltreatment was confirmed on the basis of substantiated reports by the child protection agency. In 6621 (91.7%) cases, the duration of breastfeeding was analysed with respect to child maltreatment (including neglect, physical abuse, and emotional abuse) whilst factors which may confound results were taken into account (e.g. sociodemographic factors, whether the pregnancy was wanted, substance abuse during pregnancy, postpartum employment, attitudes regarding infant care giving, and symptoms of anxiety or depression). Of 512 children with substantiated maltreatment reports, the odds ratio for maternal maltreatment increased as breastfeeding duration decreased. After adjustment for the above confounding variables, the odds for maltreatment for non-breastfed infants remained 2.6 times higher. Maternal neglect was the only type of maltreatment associated independently with breastfeeding duration. The authors conclude that breastfeeding, among other factors, may help to protect children against maltreatment by their mother, particularly child neglect Findings after adjustment for confounding variables the odds for maltreatment for non breastfed infants remained 2.6 times higher than infants who had been breastfed for 4 months or

Oxytocin and Cortisol Oxytocin - fertiliser for the brain Cortisol – prunes back brain growth A simple visual image to show importance of oxytocin and impact of cortisol, an look at the scan photo Options for use Good to get participants to think about how nature sets it up that mothers fall in love with their babies so that they will protect and care for them and not abandon them in order to ensure survival of the species. However this is only part of the story and the advances in neuroscience have shown that a baby who grows up in a loving and nurturing environment has the best chance to grow into a well adjusted adult who will contribute positively to society.

Facilitating attachment During breastfeeding women become more peaceful and develop deep bonds with their baby Breastfeeding makes the mother more interested in close relationships, The more spikes in oxytocin content in her blood, the more open to attachment and bonding she becomes Women who have symptoms of anxiety and OCD often have a reduction of symptoms during breastfeeding Breastfeeding induces social memory and calmness in the infant Moberg 2003 Women become more peaceful and develop deep bonds with their babies Could this be a reason why a lot of women develop life long friendships at this life stage?

The breastfeeding state of mind facilitates the womans ability to calm her baby and she is potentially more able to calm his stress response and ensure his cortisol levels remain low leading to the formation of fewer cortisol receptors (Gerhardt 2004) The breastfeeding state of mind facilitates the womans ability to calm her baby and she is potentially more able to calm his stress response and ensure his cortisol levels remain low leading to the formation of fewer cortisol receptors (Gerhardt 2004)

In Practice Meaningful antenatal discussions for all families Timely face to face support for women who are breastfeeding, particularly in areas of low prevalence Encouraging women who are formula feeding to hold their baby close during feeds, and to limit number of caregivers Dads produce oxytocin too

Strategic Clinical Network Task and Finish Groups Building Happy Babies Infant Feeding Perinatal mental health Task and finish groups are working to produce regional best practice guidance with regard to Building Happy Babies and Infant feeding, possibly using a “care bundle” approach

Everyone’s business GPs- every woman of a certain age is potentially pre conceptual Community midwives Health Visitors Obstetricians Paediatricians Educational establishments Sure Start

THANK YOU Lives in one of the most deprived wards in the country, poor education exp, never worked, much older partner, has had custodial prison sentence, was her voice. no contact with mother, sees father regularly First baby at 16yrs formula fed, smoker Second baby, 20yrs continued smoking, booked at 30 wks gest, FTA several an opds,BF d/w mw and BF support in clinic, not keen to BF but consider 1st feed (leaflet) Normal del at term,SGA but ? Gest, formula fed after first feed then decided to BF at 10/7, proactive support from MW, HV and BF support worker. Initial slow weight gain, specialist support started gaining,. Met at BF group by familiar person (along sidedness) began to visibly grow in confidence, smoking cessation. Invited to join volunteer BF peer support training Completed this and DBS etc, now volunteers in the area and has applied to do further education