1. PUBLIC HEALTH & BREASTFEEDING
General Practice Training
2011

2. 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.

3. 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.

4. 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)

5. 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.

6. 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

7. 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

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

9. 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

10. Incidence of breastfeeding 1990 - 2005

11. 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£ %, Q4 – 53.38%

12. 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)

13. 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

14. 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

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

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Ductal Thrush Treatment
Fluconozole 150 – 300 mgs load dose
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”)

26. 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

27. 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

28. 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

29. Recommended booklist
Medications and Mothers’ Milk 14th edition 2010, Thomas Hale PhD - ISBN –
Breastfeeding Answers Made Simple - Nancy Mohrbacher, IBCLC, FILCA - ISBN-13:
Breastfeeding & Human Lactation, Jan Riordan – ISBN –
Textbook of Human Lactation, Thomas Hale & Peter Hartmann – ISBN
Breastfeeding a Guide for Medical Profession, Ruth & Robert Lawrence – ISBN
The Breastfeeding Atlas, Barbara Wilson-Clay & Kay Hoover – ISBN –

30. Useful links UNICEF Baby Friendly - www.babyfriendly.org.uk
Lactation Consultants GB –
ABM –
La Leche –
NCT –
Online training for GPs –
E-Groups:
Lacthelpers - groups.yahoo.com/subscribe/lact-helpers-UK