A Guide to Supporting Breastfeeding for the Medical Profession

Amy Brown, Wendy Jones, Amy Brown, Wendy Jones

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429557767
• Edition: 1
• Topic: Medicina
• Subtopic: Infermieristica

This book is a practical guide for medical practitioners as they navigate through breastfeeding problems that occur in day-to-day practice.

If mothers have a breastfeeding complication they are often directed to their GP. In complex situations, medical staff will be making decisions around what treatment plan to follow and whether a mother can keep breastfeeding. In recent years there has been growing evidence that medical professionals often advise mothers to stop breastfeeding while undergoing treatment, when in reality this was not a necessary step. In a time when breastfeeding rates are decreasing, it is important that medical professionals give accurate advice and support a mother's choice to breastfeed if the situation allows it. A Guide to Supporting Breastfeeding for the Medical Profession includes contributions from a wide range of medical professionals and each chapter is written with the practitioner in mind. Contributors include GPs, paediatricians, neonatologists, lactation specialists and midwives.

Doctors have a vital role to play in supporting and facilitating breastfeeding, and without the appropriate knowledge they can often inadvertently sabotage it. This book will be of interest to GPs and paediatricians as well as nurse prescribers, midwives and health visitors.

1The role of primary care and the GP in supporting breastfeeding

Marie-Therese Lovis

The fact that you are reading this book suggests you are probably already convinced that the primary care team has a role in supporting breastfeeding.This chapter overviews

• the benefits of breastfeeding for mothers, babies and you;

• reassuring mothers about what is normal;

• strategies that you can put in place to help support breastfeeding;

• counselling mothers who want to stop breastfeeding.

Sometimes it is a lonely place convincing others that the primary care team should support breastfeeding. It is widely acknowledged that there is a significant learning need around infant feeding within primary and secondary care (Renfrew et al. 2006). In this chapter I will therefore focus on giving you some tools to change the environment of the surgery, surgery communications, engagement of clinicians and resources available. If you need a hook to get the attention of the most reluctant of colleagues, perhaps share with them that the Care Quality Commission looks favourably on practices that are breastfeeding-friendly. You could also share the data that show that if we were able to increase breastfeeding rates to enable those exclusively breastfeeding at 1 week to continue to 4 months, we could save 11 million NHS pounds. This saving includes a significant reduction in GP appointments through a reduction in common childhood respiratory and gastrointestinal infections (Pokhrel et al. 2015). I don’t know about your surgery, but I could do with an extra 15% of appointments to offer my patients!

I will approach the role of primary care by following the patient journey and all that could be done for that patient to support breastfeeding. Please note this is not about forcing mothers to breastfeed when they do not wish to but is about supporting every mother to breastfeed her child for as long as she wishes to.

When mothers, particularly first-time mothers, venture out after the birth of a baby, the concern about breastfeeding in public can be a real issue for some. A practice can do much to support mothers to breastfeed outside the home. A simple gesture of posters in the waiting room or on your waiting-room screens advising ‘you are welcome to breastfeed here’ can go a long way. Posters can be easily printed off from the Unicef Baby Friendly Initiative website.

Breastfeeding mothers are protected by the UK Equality Act 2010 which defines treating a woman unfavourably because she is breastfeeding as discrimination. A mother breastfeeding at a GP surgery is therefore protected by Equality Law (unless there are health and safety risks, e.g. you might legitimately ask a breastfeeding mother to move to an isolation room if she or her infant has chickenpox or measles). It is useful to share this legislation with your reception staff as they will be the mother’s first-line defence against members of the public who may wish to make abusive comments to the mother about feeding elsewhere or about her to staff or others. A simple statement from reception that the mother is entitled by law to feed her baby in the waiting room will support a mother. It is also important to educate all patient-facing staff about infant feeding as simple gestures such as offering a glass of water to a breastfeeding mother on a hot day can make her feel supported by your team. Educating the whole team can also help to stop staff giving anecdotal advice to mothers that is at odds with NHS guidance and evidence.

Some mothers do wish to breastfeed somewhere more private, particularly if they are having struggles to establish a good latch or just if the baby has got to an age where s/he is more interested in the surroundings than feeding. If space permits, it is useful to be able to offer a simple private area for mothers to breastfeed if they prefer, perhaps with a box of tissues and wipe-clean toys in a box for an accompanying toddler. Think about where this might be and about visibility from windows and accessibility with a buggy. If you do not have space for a designated breastfeeding area, it can be useful for reception to have an awareness of any rooms that may be unoccupied (and with desks clear of clinical and patient-identifying information) so that a mother can be shown to a room to feed. Think about the language you use to advertise this space to ensure that it does not imply that mothers must feed in a designated area.

When you call a mother into the clinical room, if you see that she is feeding you could offer to let her finish the feed and see your next patient first if she wishes. The language that we use can have wide-reaching impacts on a mother’s breastfeeding journey. The simple question, ‘Are you still breastfeeding?’ has a value statement embedded in it, and whether you internally are thinking, ‘That is great that she is still feeding’ or ‘Why is she bothering to breastfeed still?’ the patient may well hear the latter value judgement. I would urge you to be curious but simple in your questions. ‘Are you breastfeeding?’ will suffice. Nine out of ten women in one study reported that they stopped breastfeeding before they wanted to (Bolling et al. 2007). Some of the factors listed in their reasons for this were that they were advised to stop by a professional. As primary care clinicians we can have a profound impact on that mother’s breastfeeding journey.

Within the consultation there are so many instances when we can support rather than undermine the breastfeeding dyad as a GP/primary care clinician and these might include signposting to a feeding assessment for all mothers presenting with mastitis. Antibiotics are not first-line in the first 24 hours in an otherwise well mother, and improving latch may help prevent further episodes. At every contact, praise the mother for every drop of breast milk she gives to her baby, via whatever means. In our formula-feeding culture there are few cheerleaders out there for the breastfeeding mother. As a health professional your words carry significant weight in helping that mother feel that what she is doing is worthwhile.

Discussions with patients about a perceived need to stop breastfeeding

When mothers say to me, ‘I have to stop breastfeeding because I’m going back to work,’ I would first check, ‘Do you want to stop breastfeeding or would you prefer to continue if you could?’ If they say that they want to continue I share that I have returned to work from 7 months with my four children and have pumped at work. I have fed my children for a range of 7 months to 3 years for varying reasons according to what felt right for us at the time. ‘Would you like to know more about expressing breastmilk or tips for returning to work and continuing to breastfeed?’ then allows further discussion about the practicalities, which if you are not able to give you could then signpost to a resource such as a breastfeeding support phone line (e.g. National Breastfeeding Helpline: 03001000212, 9.30 a.m. to 9.30 p.m., which also has a web chat service).

It can also be useful to signpost to employment support in regard to their rights on return to work: https://maternityaction.org.uk/advice/continuing-to-breastfeed-when-you-return-to-work/. Whilst we are on this subject, are you aware that the NHS has clear guidelines on supporting employees returning to work breastfeeding? Do you have a practice policy on supporting your colleagues when they return to work? Do you discuss where and when they will have opportunities to express milk and offer safe storage of expressed milk until the end of their working day?

Some women think they need to stop breastfeeding either permanently or due to advice to ‘pump and dump’ due to medication that they are on. Ensure you are up to date in your advice. The LactMed app is useful to have on your phone for quick evidence around safety in breastfeeding. Online resources include the UK Drugs in Lactation Advisory Service (UKDILAS; www.sps.nhs.uk/articles/ukdilas/), an NHS prescribing advisory service and the Breastfeeding Network website (www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/), which has great patient information leaflets on a range of medications and their use in breastfeeding mothers. I find it useful to pre-empt queries from well-meaning community pharmacists by printing e.g. the metronidazole leaflet and giving it to the patient as I have found that, unhelpfully, the British National Formulary (BNF) flags it as unsuitable in breastfeeding and so pharmacists have on occasion refused to dispense. Furthermore, cite the leaflet in the medical notes so that colleagues who see the patient after you, and who may not be as versed as you in prescribing in breastfeeding, can be empowered to support rather than undermine your advice.

Recognising and reassuring regarding normality

Be clear about what is within the physiological norm and be empowered to reassure when that is so. Online forums may advise mum that baby clearly has reflux or cows’ milk allergy and that can make it difficult to have that conversation when the parents’ expectations are set at the start of the consultation. There is no denying the effects on parents of the sleepless nights, extra washing and general relentlessness that having a tiny human who vomits or cries a lot can bring. It is so important to check in with the mental health of both parents. Mental health issues can underlie a concern about infant feeding, reflux or crying; living with a baby who cries a lot can also impact on mental health. You may find the Royal College of General Practitioners’ perinatal mental health toolkit a useful resource for supporting both parents – www.rcgp.org.uk/clinical-and-research/resources/toolkits/perinatal-mental-health-toolkit.aspx. http://purplecrying.info/ is a useful website to reassure about the utterly normal, yet absolutely difficult, phase commonly known as ‘colic’. Sometimes just knowing that ‘this too shall pass’ can be helpful, as well as managing expectations regarding what they thought parenthood and breastfeeding might look like and the realities. This can include managing expectations of breastfeeding and the frequency with which infants do need to feed. In today’s society of instant responses and increased control over our lives, tiny humans can provoke confusion in their grown-ups as they regularly demonstrate that they have not read the memo regarding Western cultural expectations of them and remind us of their biologically driven need for warmth, physical contact, regular nutrition and regular sleep with regular wakenings that protect them from sudden infant death syndrome and a need via all of the above for assistance with regulation of homeostasis whilst their bodies develop.

Continuing the theme of normality, it is useful to be able to give evidence-based advice and support around sleep issues. www.basisonline.org.uk/ is a great resource for parents and professionals that can help arm parents against the onslaught of friendly advice that if they only give a bottle baby will sleep through the night (this myth is not supported by the evidence). Of note, in terms of ‘sleeping through the night’, in medical terms this is classed as 5 hours: this might help manage expectations.

First do no harm. It is of course important to diagnose cows’ milk protein allergy or gastro-oestophageal reflux disease where it is present and provide evidence-based treatment and support for the family. There are also real dangers to overdiagnosing medical conditions and to overprescribing. These dangers include risking the breastfeeding journey and all the subsequent risks of not breastfeeding, as outlined in the Lancet breastfeeding series 2016 (www.thelancet.com/series/breastfeeding), risks to baby from unnecessary exclusion diets or medication and risks to the mother, including risks to her mental health if she stops breastfeeding sooner than she had intended. Recent studies have shown concerns around a significant increase in fracture risk in children who received proton pump inhibitors and H2 antagonists in the first 6 months of life. Gaviscon is commonly found to cause constipation in infants and mothers report that it can be difficult to give to a breastfed baby.

If you do diagnose delayed cows’ milk protein allergy then it is important to encourage continued breastfeeding as per the 2019 iMAP guidelines, now hosted by the GP Infant Feeding Network website (https://gpifn.org.uk/imap/). One way that you can do this is to ensure the mother gets useful guidance regarding being dairy-free both for herself and for her infant, once family foods are introduced, via referral to a paediatric dietician at the point of diagnosis (there are often long waiting lists). You may wish to read the GPIFN article that links to a number of resources for supporting parents with a child with a cows’ milk allergy (Lovis, 2019). Some mothers find the site www.dylanandme.com useful in providing top tips on being dairy-free as a breastfeeding mother. First Steps Nutrition website (pharma-free!) (www.firststepsnutrition.org/) has a useful section on vegan diets for the under-5s which may be a useful resource. The app Food Maestro was developed at Guys’ and St Thomas’ Trust and is a useful aid to identifying foods in supermarkets and when eating out.

Back to the importance of language: simply supporting a mother in her choice to breastfeed and in encouraging her that it is entirely feasible on a dairy-free diet can make a real difference to her and her baby. Often women report that well-meaning family members or friends suggest she should stop breastfeeding as ‘it’s too much’ to continue breastfeeding whilst dairy-free. It is only too much if the mother herself feels it is too much, ideally after she has been made aware of all the information and practical advice she needs to help it work for her.

It has been identified that infant feeding issues can represent an unmet educational need for GPs and primary care staff (Renfrew 2006). Little time on it is often spent in both undergraduate and specialist training curricula. This means that you can make a huge impact by arranging infant feeding education for GPs or trainees and primary care staff in your locality. Norwich Clinical Commissioning Group (CCG) has invested in this training and has an excellent GP Champion in Infant Feeding scheme, and at the time of writing, Surrey Heartlands ICS are also rolling out a similar programme. Practices each have an infant feeding lead who attends training in infant feeding and then disseminates this learning throughout the practice. The practice also is then awarded breastfeeding-friendly status. Such a scheme is easily replicated across other areas. It is worth coordinating funding bids with Public Health England as improving breastfeeding rates for the UK is an important public health priority. When educating clinicians I find it useful to have a GP champion co-presenting with an infant feeding advisor as it helps to have a prescriber’s input and the perspective of a clinician in primary care.

There are many very useful resources available for GPs to help you to give evidence-based guidance. The GP Infant Feeding Network is a national network of GPs with an interest in infant feeding. The website www.gpifn.org.uk covers many infant feeding queries that present in primary care and has links to other useful resources for GPs. You may wish to consider developing or importing an infant feeding template for your IT system. For example, I use EMIS Web and have developed a template to support decision making for colleagues in caring for breastfeeding women and their children. The template includes tabs for the common infant feeding issues that present to primary care (mastitis, ‘reflux’, ‘cows’ milk allergy’, ‘poor milk supply’, ‘tongue tie’) and links to guidance for these topics as well as to guidance for prescribing in breastfeeding. Interventions like this can help the clinicians in your practice offer evidence-based advice and support even if they have very little experience of breastfeeding or training on the topic. Including local information resources on the template can particularly help locum staff who might not know where the nearest breastfeeding clinic is.

In summary, you are in a wonderful position as a GP to change a mother’s experience of breastfeeding from the moment she contacts the surgery and enters the building to the consultation and beyond. Interventions can be cheap and quick wins. Knowledge is power and by helping mothers to breastfeed for as long as they wish you can be part of improving rates of breastfeeding in this country and making a huge financial saving for the NHS, saving time...