Breastfeeding briefs

Breastfeeding Briefs

________________________________________________________________     N° 44-45, OCTOBER 2008__

The new BFHI training package
The Baby Friendly Hospital Initiative (BFHI) was launched in 1991. Since then, more than 15,000 facilities in 134 countries have been awarded Baby-Friendly status. However, after the initial exponential growth in the number of designated hospitals, progress slowed down everywhere after 1996, with notable differences between and within countries. Based on the figures reported by UNICEF, since 1991 less than seven hospitals per country have been designated Baby Friendly each year. Weighed against the global number of hospitals and of births taking place in hospitals, this rate is low. Moreover, there are no figures on the proportion of Baby Friendly hospitals reassessed to verify whether they maintain their standard over time. To revitalize the BFHI in both quantitative and qualitative terms, WHO and UNICEF have developed a new package, based on a revised 20-hour course for maternity staff. In the revised package: • Step 4 is re-formulated as to “place babies in skin-to-skin contact with their mother immediately following birth for at least an hour and encourage mothers to recognize when their baby is ready to breastfeed, offering help if needed”. Step 10 is updated to emphasize the importance of early support (preferably 2-4 days after birth and again the second week) at the facility or in the community by a skilled breastfeeding support person, if possible a peer counsellor associated with a mother-to-mother support group. New criteria are introduced for the assessment of compliance with the International Code. Optional alternative criteria are given for areas with high prevalence of HIV/AIDS. Additional optional criteria are specified for Mother Friendly care during labour and childbirth. To fulfil Step 2 of the BFHI, the goal is to train at least 80% of the clinical staff members that are in contact with mothers and/or infants and that have been employed 6 months or more. This is quite a challenge! A never ending activity to be planned twice a year, given the turnover of staff and the inadequate and outdated breastfeeding knowledge and skills that most health professionals acquire during their pre-service training. By the time they graduate from health schools, most doctors, nurses and midwives have been flooded with hi-tech diagnostic and treatment approaches, and are primed to address disease with a purely medical approach. Few learn to deal with pregnancy and childbirth as a physiological event, and to communicate with people and counsel them. Moreover, it is not uncommon, even during pre-service training, to be exposed to promotional material and activities provided by manufacturers of breastmilk substitutes, with the consequent bias as to the knowledge and attitude towards infant and young child feeding. It is extremely difficult to change the attitude and practice of these health professionals, and to train them in the basics of the BFHI: to protect breastfeeding as normal and natural throughout pregnancy and after birth, to promote early skin-to-skin contact, to avoid unnecessary separation of the mother from her newborn infant, to prevent the unnecessary use of bottles, teats and breastmilk substitutes, etc. Will it be possible to revitalize the BFHI and return to the enthusiasm of the early days? Will the revised BFHI package, centred on the in-service training of professionals, increase the rate of Baby Friendly hospital certification. We believe that applying the revised package and training materials alone will not bring about the changes needed to accelerate the progress of the BFHI, currently static in many countries. In addition, we would suggest the following: • Give priority to large teaching hospitals. These play an important role in the training of doctors, nurses and midwives. Only by learning the good practices in a Baby Friendly teaching hospital will these health professionals be able to replicate them when they are posted in other hospitals. Include the scientific bases of the 10 Steps and the risks of not breastfeeding in the curriculum of health schools. Include as well the International Code and knowledge of some of the commonmarketing practices of manufacturers of breastmilk substitutes. Promote the use of active teaching methods in BFHI courses and health schools. These methods should be based on adult learning theory that uses trainee knowledge and experience as the basis for successful acquisition and practice of new knowledge and skills.                                                             1 Four sections of the package are downloadable from Breastfeeding why
Kuhn L, Sinkala M, Kankasa C et al. High uptake of exclusive breastfeeding and reduced early post-natal Human Immunodeficiency Virus (HIV)
Becquet R, Ekouevi DK, Menan H et al. Early mixed To test the hypothesis that exclusive breastfeeding feeding and breastfeeding beyond 6 months increase the is associated with a lower risk of postnatal HIV risk of postnatal HIV transmission: ANRS 1201/1202 transmission than non-exclusive breastfeeding, 958 Ditrame Plus, Abidjan, Côte d'Ivoire. Preventive HIV-infected women and their infants were recruited in Lusaka, Zambia, as part of a randomized trial of early weaning; all were In 2001-2003, HIV-infected pregnant women encouraged to breastfeed exclusively to 4 months. received peri-partum antiretroviral prophylaxis and Single-dose nevirapine was provided to prevent were counselled antenatally regarding infant transmission of HIV. Uptake of exclusive feeding options: formula feeding or exclusive breastfeeding was high with 84% of women breastfeeding with early cessation from 4 months reporting only exclusive breastfeeding cumulatively to 4 of age. Of 622 live-born infants who were HIV months. Postnatal HIV transmission before 4 uninfected at or after 30 days, 15 were infected months was significantly lower among exclusively post-natally, 13/324 among breastfed, and 2/298 breastfed (4%; 2.4% to 5.5%) than non-exclusively breastfed infants (10.2%; 4.7% to 15.7%). There probability of remaining free from HIV infection were no significant differences in the severity of was respectively 95% (92–97%) and 99% (97– disease between exclusive and non-exclusive breast- 100%) in the breastfeeding and formula-feeding feeding mothers and the association remained groups. In adjusted analysis, breastfeeding for significant after adjusting for maternal CD4 count, more than 6 months and mixed feeding during the plasma viral load, syphilis screening results and first month of life were independently associated low birth weight. Programmes to support exclusive with a 7.5- (2.0–28.2) and a 6.3- (1.1–36.4) fold breastfeeding should be expanded universally in low increase of postnatal transmission among breastfed resource settings. Exclusive breastfeeding is an children. Mixed feeding during the first month of affordable, feasible, acceptable, safe and sus- life and breastfeeding beyond 6 months should be tainable practice that reduces HIV transmission, avoided when replacement feeding after breastfeeding thus providing HIV-infected women with a means cessation can be safely and sustainably provided. Piwoz EG, Humphrey JH, Tavengwa NV et al. The Leroy V, Ekouevi DK, Becquet R et al, for the ANRS impact of safer breastfeeding practices on postnatal 1201/1202 DITRAME PLUS Study Group. 18-month HIV-1 transmission in Zimbabwe. Am J Public Health effectiveness of short-course antiretroviral regimens combined with alternatives to breastfeeding to prevent This study assessed the association between HIV mother-to-child transmission. PloS One 2008;3:e1645 exposure to an educational intervention that The 18-month effectiveness of short-course emphasized safer breastfeeding practices and antiretroviral peripartum regimens  combined with postnatal HIV transmission among 437 HIV- alternatives to prolonged breastfeeding to prevent positive mothers in Zimbabwe, 365 of whom did mother-to-child transmission of HIV was assessed not know their infection status. Mothers were in Abidjan, Côte d'Ivoire. HIV-infected pregnant tested for HIV and were  encouraged, but not women received from 32-36 weeks of gestation required, to learn their HIV  status. Cumulative short-course zidovudine, with or without lamivudine, and postnatal HIV transmission was 8.2%; each with or without single-dose nevirapine at delivery; additional intervention contact was associated with neonates received single-dose nevirapine plus 7-day a 38% reduction in postnatal HIV transmission. zidovudine prophylaxis. Two infant-feeding interventions HIV-positive mothers who were exposed to both were systematically offered free of charge: formula- print and video materials were 79% less likely to feeding or exclusive breastfeeding with early transmit HIV to their infants compared with cessation at 4 months. The control group was an mothers who had no exposure. These findings were earlier cohort of pregnant women exposed to short- similar for mothers who did not know their HIV course zidovudine from 36 weeks, then to status. This article provides an important new prolonged breastfeeding. Among 926 live-born insight in the area of HIV and infant feeding and children enrolled, 107 (11.6%) were HIV-infected concludes that the promotion of exclusive at 18 months. Cumulative transmission risks were breastfeeding has the potential to reduce postnatal 22.3% (16–30%) in the 238 children of the control HIV transmission among women who do not know group, 15.9% (10–27%) in the 169 of the zidovudine + nevirapine breastfed group, 9.4% (6–14%) in the 195 of the zidovudine + nevirapine formula-fed Coutsoudis A, Coovadia HM, Wilfert CM. HIV, infant group, 6.8% (4–11%) in the 198 of the zidovudine feeding and more perils for poor people: new WHO + lamivudine + nevirapine breastfed group, and guidelines encourage review of formula milk policies. 5.6% (2–10%) in the 126 of the zidovudine + Bull World Health Organization 2008;86:210–14 lamivudine + nevirapine formula-fed group. Each This paper explores infant feeding policies in combination had a significantly higher effectiveness relation to broader socioeconomic issues in the than the control group except for the zidovudine + light of the new WHO guidelines on HIV and infant nevirapine breastfed children, ranging from 51% (20- feeding (2006). In order to accumulate evidence on 70%) for the zidovudine + nevirapine formula fed the increase in rates of malnutrition, morbidity and children to 63% (40-80%) for the zidovudine + mortality associated with the avoidance or early lamivudine + nevirapine breastfed children, after cessation of breastfeeding by HIV-infected adjustment for various factors. It is concluded that mothers, and the unanticipated hazards of formula substantial reductions of the risk of mother-to-child feeding, it is necessary to better assess the transmission are reachable in Africa, even in short- measures leading to optimum policies on infant term breastfed children, with long-term benefits and child nutrition and the reduction of poverty. until age 18 months and without increasing Piecemeal interventions that increase resources directed at only a fraction of a family’s impoverishment, Chopra M, Rollins N. Infant feeding in the time of HIV: such as basic materials for preparation of hygienic rapid assessment of infant feeding policy and programmes formula feeds and making flawed decisions on in four African countries scaling up prevention of choice of infant feeding, are bound to fail. Providing mother to child transmission programmes. Arch Dis formula to poor populations with high HIV prevalence is justified neither by evidence, humanitarian considerations, respect for local To assess the infant feeding components of traditions or economic outcomes. Exclusive prevention of mother-to-child HIV transmission breastfeeding – even threatened by the HIV programmes, an assessment was performed in all epidemic – remains an unfailing anchor of child health facilities of 29 randomly selected rural and urban districts of Botswana, Kenya, Malawi and Uganda. The facility level manager and the senior nurse in charge of maternal care were interviewed; _____________________________________
334 randomly selected health workers completed Child mortality
self-administered questionnaires; 640 counselling observations were carried out; and 34 focus groups Jakobsen MS, Sodemann M, Biai S et al. Promotion of exclusive breastfeeding is not likely to be cost effective Irrespective of exposure to training, most health in West Africa. A randomized intervention study from workers (234/334, 70%) were unable to estimate Guinea-Bissau. Acta Paediatr 2008;97:68-75 correctly the transmission risks of breastfeeding. Infant feeding options were mentioned in 307 of In order to evaluate the impact of health education the 640 (48%) observations of counselling sessions, on infant health in a region characterised by high and in only 35 (6%) of these were infant feeding mortality rates, widely practised breastfeeding and issues discussed in any depth. Moreover, of these low exclusive breastfeeding rates, the 1,721 infants 35, 19 (54%) were rated as poor. Several health of a birth cohort were randomized and their mothers were workers also reported receiving free samples of informed about the benefits of exclusive breastfeeding infant formula – in contravention with the International for the first 4-6 months. All children were followed Code. National HIV managers stated they were from birth to 6 months. Introduction of both water unsure about infant feeding policy in the context of and weaning food was significantly delayed in the intervention group (IG). There was no reduction in mortality in the IG compared with the control Finally, almost all participants believed that an HIV-positive mother who breastfeeds will always significantly lower in the IG (7.10 vs 7.25 kg). infect her child and that a mother who intentionally There was no difference in diarrhoea morbidity avoids to breastfeed indicates that she is HIV- and hospitalization rates. Although mothers wanted positive. These findings underline the need to to follow the new breastfeeding recommendations, implement and support systematic infant feeding these had no beneficial impact on infant health in policies and programme responses in the context of this society with traditional, intensive breastfeeding. Edmond KM, Kirkwood BR, Amenga-Etego S et al. Greer FR, Sicherer SH, Wesley Burks A and the Effect of early infant feeding practices on infection- Committee on Nutrition and Section on Allergy and specific neonatal mortality: an investigation of the Immunology. Effects of early nutritional interventions causal links with observational data from rural Ghana. pediatric care on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, This study assessed the effect of different early and hydrolyzed formulas. Pediatrics 2008;121:183-91 infant feeding practices (delayed breastfeeding initiation, prelacteal feeding, established neonatal This report of the American Academy of Pediatrics breastfeeding) on infection-specific neonatal mortality. A reviews the nutritional options during pregnancy, cohort of 10,942 breastfed singleton neonates born in lactation, and the first year of life that may affect Ghana between 1 July 2003 and 30 June 2004 and the development of atopic disease (atopic who survived to day 2, was examined. Verbal dermatitis, asthma, food allergy) in early life. The autopsies ascertained the cause of death. Of the documented benefits of nutritional intervention 140 neonates that died from days 2-28, 93 died of that may prevent or delay the onset of atopic infection and 47 of non-infectious causes. The risk disease are largely limited to infants at high risk of of death as a result of infection increased in developing allergy (i.e., infants with at least one parallel to the delay in initiation of breastfeeding first-degree relative with allergic disease). Current from hour 1 to day 7. Overall late initiation (after evidence does not support a major role for day 1) was associated with a 2.6-fold risk of death maternal dietary restrictions during pregnancy or (1.68-4.04). Partial breastfeeding was associated lactation. There is evidence that breastfeeding for with a 5.7-fold risk of death (2.75-11.91) as a re- at least 4 months – compared with feeding formula sult of infectious disease. No obvious associations made with intact cow milk protein – prevents or were noted between these feeding practices and delays the occurrence of atopic dermatitis, cow non-infection-specific mortality. This study milk allergy, and wheezing in early childhood. In provides the first epidemiologic evidence of a studies of infants at high risk of atopy and who are causal association between early breastfeeding and not exclusively breastfed for 4 to 6 months, there is reduced infection-specific neonatal mortality. some evidence that the onset of atopic disease may _____________________________________
be delayed or prevented by hydrolyzed formula rather than formula made of intact cow milk protein. There is also some slight evidence that delaying the introduction of complementary foods Kramer MS, Matush L, Vanilovich I et al. Effect of beyond 4 to 6 months prevents the occurrence of prolonged and exclusive breastfeeding on risk of allergy atopic disease. At present, there is insufficient data and asthma: cluster randomised trial. BMJ to document the protective effect of any dietary intervention beyond 4 to 6 months of age for the In this cluster randomised trial, a total of 17,046 _____________________________________
mother-infant pairs, of whom 13,889 (81.5%) were examined again at age 6.5 years, were enrolled in 31 Belarusian maternity hospitals and their affiliated polyclinics to assess whether exclusive and prolonged MacArthur AC, McBride ML, Spinelli JJ et al. Risk of childhood leukemia associated with vaccination, breastfeeding reduce the risk of childhood asthma infection, and medication use in childhood: the Cross- and allergy. A breastfeeding promotion programme Canada Childhood Leukemia Study. Am J Epidemiol modelled on the Baby Friendly Hospital Initiative (BFHI) had previously been implemented in the intervention group of hospitals and polyclinics. The intervention led to a large increase in exclusive This study examined the effect of postnatal exposures breastfeeding at 3 months (44.3% vs 6.4%) and a known to affect early immune functioning - childhood significantly higher prevalence of any breastfeeding at all vaccinations, illness, medication and breastfeeding ages up to and including 12 months. The experimental patterns - on the risk of childhood leukemia. Children group of infants had no reduction in risks of allergic 0-15 years of age diagnosed from 1990 to 1994 symptoms and diagnoses or positive skin prick with leukemia, and residing in the principal cities tests. These results do not support conclusions of across Canada were eligible for inclusion. 399 some other studies regarding a protective effect of cases were ascertained at the time of diagnosis prolonged and exclusive breastfeeding on asthma through paediatric oncology centres and population- based cancer registries. For each case, an age-, gender-, and area-matched control was randomly selected from government health insurance rolls. Risk behaviour. Scales to measure the intelligence factor information was obtained through personal quotient (IQ) were applied to the same children. interviews with each child’s parents or guardians. Mothers also responded to questions concerning Use of immunosuppressant medication decreased their relationships to their partner, their child and the risk of leukemia by 63% (16-84%), while breastfeeding of children born subsequently. The vitamin intake increased it by 66% (18-133%). BFHI intervention led to a large increase in exclusive Breastfeeding for more than 6 months was also breastfeeding at 3 months (43.3% vs 6.4%) and a protective: milk supplements given more than 50% significantly higher prevalence of any breastfeeding at of the time to infants 7-12 months of age increased all ages up to and including 12 months. No significant effects of the intervention were observed on the mother or the teacher ratings of Ortega Garcia JA, Ferris Tortajada J, Torres Cantero total difficulties, emotional symptoms, problems of AM et al. Full breastfeeding and paediatric cancer. J conduct, hyperactivity, peer problems, or social behaviour. Nor was there evidence of effects on the This study investigated the association between parents’ marriage or on the mother’s satisfaction full breastfeeding and paediatric cancer in a case regarding her relationship with her partner or child. control study in Spain. Maternal reports of full The intervention group had higher averages on all breastfeeding, collected through personal interviews, the scales of intelligence measures, with mean compared 187 children of 6 months and more who had differences of +7.5 (+0.8 to +14.3) for verbal IQ, + paediatric cancer and 187 age-matched control 2.9 (-3.3 to +9.1) for performance IQ, and + 5.9 siblings. The mean duration of full breastfeeding (-1.0 to +12.8) for full-scale IQ. Teachers’ was 8.43 weeks for the first group (cases) and academic ratings were significantly higher in the 11.25 for the control group. Cases had 80% (10- intervention group for both reading and writing. 180%) more probability of bottle-feeding than These results, based on the largest randomized trial controls. Cases were also 50% (20-70%) less likely ever conducted in the area of human lactation, to have been breastfed for at least 2 and 4 months, provide strong evidence that prolonged and and for 24 weeks or more. To conclude, breastfeeding exclusive breastfeeding improves children’s cognitive was inversely associated with paediatric cancer, the protection increasing with the duration of full _____________________________
Breastfeeding how?
Child behaviour and cognitive development
Baby Friendly Hospital Initiative (BFHI)
Kramer MS, Fombonne E, Igumnov S et al. for the Promotion of Breastfeeding Intervention Trial Reassessment of Baby Friendly Hospitals in Brazil. J (PROBIT) Study Group. Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: evidence from a large, randomized trial. This cross-sectional study was conducted in 2002 to assess adherence to the Baby Friendly Hospital Initiative (BFHI) in the 172 hospitals that have Kramer MS, Aboud F, Mironova E et al. for the been certified in Brazil in the period from 1992 to Promotion of Breastfeeding Intervention Trial 2000. Of the 167 hospitals assessed, 137 (82%) of (PROBIT) Study Group. Breastfeeding and child hospitals met all ten steps of the Baby Friendly cognitive development: new evidence from a large randomized08;65:578-84 Hospital Initiative. Steps 2 and 3 presented the These two papers come from the PROBIT cluster respectively), followed by Steps 4, 5 and 10, with randomised trial carried out in Belarus, where 95% each. Steps 7 and 9 reflected the highest 17,046 healthy breastfeeding mother-infant pairs – adherence rate, at 99%. These findings suggest the enrolled in 31 maternity hospitals and affiliated need to intensify regular training programmes for polyclinics, half of which had a BFHI intervention professionals working in Baby Friendly Hospitals – were followed for several years with the aim to assess various outcomes. Approximately 82% of implementation of Steps 3 (inform all pregnant the mothers and children were assessed at age 6.5 years to examine child behaviour and cognitive community), to further promote and support development as well as maternal adjustment. Mothers breastfeeding before and after delivery. and teachers completed the questionnaire on Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ, Kronborg H, Vaeth M, Olsen J et al. Effect of early Crivelli-Kovach A. Impact of hospital policies on postnatal breastfeeding support: a cluster-randomized breastfeeding outcomes. Breastfeed Med 2008;3:110-6 community based trial. Acta Paediatr 2007;96:1064-70 This study explored the association between the Kronborg H, Vaeth M, Olsen J et al. Health visitors and breastfeeding support: influence of knowledge and self- Ten Steps of the BFHI and breastfeeding at 2 days efficacy. Eur J Public Health 2008;18:283-88 and 2 weeks in each of the 57 birthing hospitals in Oregon through a 65-question institutional survey. This community-based cluster randomized trial Breastfeeding outcomes were obtained from the was conducted in Western Denmark to assess the newborn metabolic screening forms. Overall hospital impact of a supportive intervention on the duration breastfeeding support scores ranged from 49.4 to 98.2 of exclusive breastfeeding to 6 months. Fifty-two (possible total score of 100). Hospital compliance health visitors and 781 mothers were allocated to with individual steps ranged from 5.3% for Step 2 the intervention group (IG), 57 health visitors and (staff training) to 93% for Step 4 (helping with 816 mothers to the comparison group (CG). In the breastfeeding initiation) and Step 8 (encouraging former, health visitors received an 18-hour course feeding on demand). After controlling for that addressed maternal psychosocial factors and institutional differences, increases in overall focused on knowledge about lactation and how to hospital breastfeeding support scores were guide the mother to learn the mechanisms of associated with increases in breastfeeding rates at 2 breastfeeding. Mothers in the IG had a 14% (1- days and at 2 weeks. In analyzing each step 25%) lower cessation rate; they received their first individually however, only the presence of a home visit earlier, and received more visits and written hospital policy was independently practical breastfeeding training within the first 5 associated with increases in breastfeeding rates. weeks; they also reported having received more This evaluation suggests that hospitals with support than mothers in the CG. Babies in the IG comprehensive breastfeeding policies are likely to were breastfed more frequently; fewer used have better breastfeeding support services and pacifiers; and their mothers reported being more confident about not knowing the exact amount of _____________________________________
milk their babies had received when being Training
breastfed. Health visitors in the IG demonstrated significantly higher scores regarding knowledge questions and reported significantly higher Bassichetto KC, Rea MF. Infant and young child feeding counseling: an intervention study. J Pediatr (Rio guidance self-efficacy in three out of five breastfeeding problems. It was concluded that home visits in the first 5 weeks following birth prolong the duration of exclusive breastfeeding. This randomized study, carried out in São Paulo, Postnatal support should focus on both the Brazil, aimed to evaluate the effectiveness of an psychosocial and the practical aspects of integrated infant and young child feeding counselling breastfeeding. An interactive course increased the training course. The study included 29 health health visitors’ knowledge of breastfeeding professionals in the intervention group (IG), and 27 practice and increased their self-efficacy in helping others in the control group (CG). Interviewers mothers with common breastfeeding problems. collected data from the professionals before and 2 months after the intervention. Regarding the Creedy DK, Cantrill RM, Cooke M. Assessing specific level of knowledge, the results showed midwives’ breastfeeding knowledge: properties of the significantly improved outcomes in the intervention Newborn Feeding Ability questionnaire and group for the overall questionnaire, as well as regarding Breastfeeding Initiation Practices scale. Int Breastfeed J specific questions on breastfeeding, HIV and infant and young child feeding, complementary feeding There are few reliable and valid tools to assess and counselling in infant and young child feeding. lactation and infant feeding knowledge and Also, in terms of performance, the professionals in practices. This study tested the properties of two the intervention group significantly improved the new scales, the Newborn Feeding Ability (NFA) way they took feeding histories. On the other hand questionnaire and the Breastfeeding Initiation there was no improvement in their counselling Practices (BIP) scale, to assess midwives’ breastfeeding knowledge and practices specific to breastfeeding initiation. The postal survey was conducted with 3,500 Australian midwives in October 2001. The response rate was about 32%. Five factors on the NFA questionnaire were Peer counsellors
congruent with knowledge about effects of skin-to- skin contact, physiological stability, newborn Curtis P, Woodhill R, Stapleton H. The peer-professional innate abilities, work practices and effective interface in a community-based, breastfeeding peer-support breastfeeding. The BIP revealed three factors related to observing pre-feeding behaviour, mother/baby care and attachment and positioning practices. Midwives with high knowledge scores were more likely to report best This study explored key elements of the peer/professional practice when assisting mothers to initiate breastfeeding. interface in a breastfeeding peer-support community Midwives with more personal breastfeeding experience project based in Doncaster, England. Data was scored higher on all scales. The questionnaires could generated from focus-group discussions with seven be used to identify individual learning needs and to volunteer peer supporters and nine health professionals (community midwives and health visitors). Both volunteers and health professionals highlighted the benefits associated with Lasarte Velillas JJ, Hernández-Aguilar MT, Pallás participating in the breastfeeding peer-support Alonso CR et al. A breastfeeding e-learning project scheme. Volunteers experienced enhanced social based on a web forum. Breastfeed Med 2007;2:219-28 support and increased self-esteem and personal development. Health professionals benefited from Internet has introduced new ways of learning that being able to “spread the load” of breastfeeding may complement medical training during the support; some also learned from the volunteers’ residency period. This paper describes the specialist experiential and cultural knowledge. On experience with a new method of e-learning for the other hand, health professionals were concerned training in human lactation and breastfeeding about volunteers “transgressing” boundaries; and counselling. Paediatric residents participated in the both volunteers and health professionals described “gate-keeping” activities and surveillance Spanish Paediatric Association Breastfeeding behaviours practised by health professionals as Committee, a site on the Internet where parents may efforts to control the volunteers’ access to, and write in for paediatric advice on breastfeeding. From work with, breastfeeding women. It became clear April 2005 to May 2006, 42 paediatric residents from that in order to reduce tension at the peer- four hospitals received a month of intensive professional interface, and optimise relationships theoretical training on breastfeeding. Afterward, between volunteers and health professionals, an they took weekly turns answering parents’ ongoing process of development involving both questions in the forum. Before and after the groups was essential. Such a process would need to experience, they completed a pre-post knowledge proactively identify and diffuse the concerns of test and an opinion post-experience questionnaire professionals while addressing both the vulnerabilities with open questions. The mean age of participants of the volunteers and their potential for semi- was 28.3 years; 88% were women, and 80% were autonomous development within and beyond the in their third or fourth year of residency. The percentage of correct answers was higher after _____________________________________
participation in the programme. The residents estimated that nearly half of their patients needed Neonatal weight loss

breastfeeding advice, and they thought that the programme improved their knowledge of breastfeeding Van Dommelen P, van Wouwe JP, Breuning-Boers JM and their communication skills with mothers. On et al. Reference chart for relative weight change to average, they spent 2.9 hours daily answering the detect hypernatraemic dehydration. Arch Dis Child questions. The learning experience was positively evaluated by the participants and contributed to increase their knowledge and skills in breastfeeding Neonatal hypernatraemic dehydration (NHD) in the first days of life is a rare but potentially serious condition. In otherwise healthy full-term breastfed _____________________________________
babies the cause is poor milk intake with consequent weight loss that must be detected early. The validity of the rule that infants may lose 10% of their weight in the first days after birth goes unproven. This study assessed the validity of this rule to detect breastfed infants with NHD. A reference chart for relative weight change obtained by a retrospective cohort study was constructed as markers for the maturation of oral feeding and used to analyse 1,544 healthy, exclusively muscles. Infants born at 26/27 and 28/29 weeks of breastfed infants born in the Netherlands. In all, gestational age were at similar postmenstrual ages there were 3,075 weight measurements and 83 when taking 1-2 and 6-8 oral feedings per day. cases of breastfed infants with NHD. The Over time, feeding efficiency and several skills sensitivity of the rule that infants may lose 10% of improved, while some others decreased and still their weight in the first days was 90.4%, its others remained unchanged. This study demonstrates specificity was 98.3% and its positive predictive that, despite similar oral feeding outcomes, differences value was 3.7%, because of too many false positive in functional stability of particular feeding skills results. A chart for relative weight change can be depend on gestational age rather than on Iyer NP, Srinivasan R, Evans K et al. Impact of an early Akerstrom S, Asplund I, Norman M. Successful weighing policy on neonatal hypernatraemic dehydration and breastfeeding after discharge of preterm and sick breastfeeding. Arch Dis Child 2008;93;297-9 newborn infants. Acta Paediatr 2007;96:1450-4 In Swansea, Wales, a policy of weighing infants at This hospital-based follow-up of 1,730 infants 72–96 hours was introduced from 1 July 2004. born in 1996, 2001 and 2004 in Sweden, and Two time periods – pre- and post-policy – of 18 studied from discharge to 6 months of post-natal months each, were studied to ascertain the effect of age, was carried out to determine the extent and early weighing on the detection and severity of duration of breastfeeding in preterm and sick NHD and on breastfeeding rates in the short and newborn infants. At discharge, 98% of term (n = medium term. Babies of 28 days of age referred to 945) and 92% of preterm (n = 785) infants were hospital because of plasma sodium concentrations e x c l u s i v e l y o r p a r t l y b r e a s t f ed . Exclusive 145 mmol/l or higher, were identified. Age, plasma breastfeeding increased at 2 months of corrected sodium concentration, percentage loss of body post-natal age and 78% of term infants were still weight at presentation, breastfeeding rates at exclusively or partly breastfed at 6 months of discharge and at 8 weeks, and complications due to corrected post-natal age. Duration of breastfeeding hypernatraemia or its management were compared among preterm infants was significantly shorter between the two periods. Sixty cases of NHD were than in term-born infants. However, even among identified: 23 before and 37 after introduction of extremely preterm infants with a gestational age the policy. After the policy, there was earlier <28 weeks, 41% were still breastfeeding, recognition of NHD (median 3 vs 6 days), lower exclusively or in part, at 6 months of post-natal percentage weight loss (11% vs 15%), lower age. There was no difference between 1996 and increase in sodium (147 vs 150 mmol/l), and 2004 in breastfeeding after intensive neonatal care. higher breastfeeding rates both at discharge (73% Moreover, the study showed that breastfeeding vs 22%) and at 8 weeks (57% vs 22%). There was after intensive neonatal care differed only slightly one death in the pre-policy group, and none in the from data concerning all infants in Sweden. post-policy group. Weighing babies early, coupled with appropriate lactation support, results in the Flacking R, Wallin L, Ewald U. Perinatal and early recognition of NHD, with less dehydration, less socioeconomic determinants of breastfeeding duration severe hypernatraemia, and higher breastfeeding rates in very preterm infants. Acta Paediatr 2007;96:1126-30 ____________________________________
This article describes the impact of prematurity, size at birth, neonatal disorders and the families’ Low birth weight infants
socioeconomic status (SES) on breastfeeding duration in mothers of very preterm infants in Amaizu N, Shulman RJ, Schanler RJ et al. Maturation Sweden. Data on breastfeeding, registered in two of oral feeding skills in preterm infants. Acta Paediatr Swedish counties in 1993-2001, were matched with data from two national registries. Mothers of 225 very preterm singleton infants were identified Safe and successful oral feeding requires proper and included. Seventy-nine percent of the mothers maturation of sucking, swallowing and respiration. breastfed at 2 months, 62% at 4 months, 45% at 6 To test the hypothesis that oral feeding difficulties months, 22% at 9 months and 12% at 12 months. may result from different temporal development of Prematurity, size at birth and neonatal disorders the muscles implicated in these functions, 16 stable did not show an effect on breastfeeding duration. preterm infants of 26 to 29 weeks’ gestational age Being adversely exposed to any of the SES factors were recruited. Specific feeding skills were monitored (maternal education, unemployment benefits, so- cial welfare and equivalent disposable income in for fewer than 10 weeks than women who had not the household) was significantly associated with received the packs. The distribution of commercial earlier weaning up to 6 months of the infant’s discharge packs to mothers is not allowed under postnatal age. This study shows that the duration of the International Code and should be banned breastfeeding in mothers of very preterm infants everywhere in light of its negative impact on was affected by SES, and highlights the need for improved support of socioeconomically disadvantaged mothers, during and after their hospital stay. McInnes RJ, Wright C, Haq S et al. Who’s keeping the code? Compliance with the International Code for the _____________________________________
marketing of breastmilk substitutes in Greater Glasgow. Maternal smoking
Public Health Nutrition 2007;10:719–25 To evaluate compliance with the International Code in primary health care in Glasgow, an audit Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics 2007;120:497-502 form was sent to all community-based health professionals with an infant feeding remit. Walking tours were conducted in a random sample This study sought to determine what effects of community care facilities. The results showed mother’s smoking had on the breastfed infant. that contact with company personnel was minimal, Fifteen mother-infant dyads were tested on two usually unsolicited and mainly to provide product different days, each separated by a one-week information. Free samples of breastmilk substitutes interval. Mothers smoked (in the absence of their or feeding equipment were rare, but child care or infant) on one test day and refrained from smoking parenting literature was more prevalent. One-third on the other. During the 3.5 hours that followed the of facilities were still displaying materials non- smoking episode, they breastfed their infant on compliant with the Code, such as weight conversion demand. Despite the taste change in the mothers’ charts and posters. Due to the high level of bottle- breastmilk, there was no significant difference in feeding in Glasgow, primary-care staff stated a breastmilk intake. On the other hand, the infants need for information about breastmilk substitutes. slept significantly less during the hours immediately _____________________________
following their mother’s smoking episode (53.4 minutes), than they did following the non-smoking Systematic reviews
day (84.5 minutes). The reduction was attributed to a shorter period of the longest sleep bout, and to a Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk reduction of time spent in both active and quiet versus infant formula for preterm infants: systematic review and sleep. In other words, less time was spent in active meta-analysis. Arch Dis Child Fetal Neonatal Ed 2007;92;169- sleep when greater doses of nicotine were delivered to the infant. It was concluded that acute episodes of smoking by lactating mothers alter infants’ sleep/wake This systematic review of trials and observational patterns. Concerns that their milk may taste like studies compared the effect in pre-term infants of cigarettes and their infant’s sleep patterns may be donor breastmilk with infant formula. The main disrupted may motivate lactating mothers to outcomes were death, necrotising enterocolitis (NEC), infection, growth and development. Seven _____________________________________
studies (including five randomised controlled International Code
trials), all from the 1970s and 1980s, fulfilled the inclusion criteria. All studies compared the effect Rosenberg KD, Eastham CA, Kasehagen LJ et al. of sole donor breastmilk with formula (combined n Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on = 471). One of these also compared the effect of breastfeeding. Am J Public Health 2008;98:290-5 donor breastmilk with formula given as a supplement to the mother’s own milk (n = 343). In the USA, commercial hospital discharge packs No studies examined fortified donor breast milk. A are commonly given to new mothers. This study, meta-analysis based on three studies found a 79% carried out in Oregon between 2000 and 2001, (24-94%) lower risk of NEC in infants receiving analyzed data from a survey of 3,895 postpartum donor breastmilk compared with formula. Donor women (response rate = 72%). Among women breastmilk was associated with slower growth in who had initiated breastfeeding, 67% reported the early postnatal period, but its long-term effect having received commercial hospital discharge was unclear. Further research is needed also to packs. Women who received these packs were measure the effect of fortified or supplemented about 40% more likely to exclusively breastfeed Flint A, New K, Davies MW. Cup feeding versus other scores, but no significant difference in the duration forms of supplemental enteral feeding for newborn of crying time and oxygen saturation change. To infants unable to fully breastfeed. Cochrane Database of conclude, in order to alleviate pain in neonates Systematic Reviews 2007, Issue 2. Art. No.: CD005092 undergoing painful procedures, breastfeeding or breastmilk, if available, should be preferred to Some newborn infants may not be able to fully placebo, positioning or no intervention. It should breastfeed and may therefore require supplemental also be noted that in this study, the administration feeding. Traditionally, bottles and nasogastric of glucose/sucrose had similar pain reduction tubes have been used for this purpose. This review was carried out to determine the effects of cup feeding versus other forms of supplemental feeding Hannula L, Kaunonen M, Tarkka MT. A systematic on weight gain and achievement of successful review of professional support interventions for breastfeeding. After searching several databases breastfeeding. J Clin Nurs 2008;17:1132-43 for randomised or quasi-randomised controlled The objectives of this systematic review were to trials, and after quality assessment, four studies describe how breastfeeding is professionally were eligible for inclusion. There was no significant supported during pregnancy, at maternity hospitals difference in the incidence of not breastfeeding at and during the postnatal period, and to find out hospital discharge and at 3 or 6 months. There was how effective interventions are in supporting a significant difference in not fully breastfeeding at breastfeeding. Several databases were searched and hospital discharge, but not at 3 and 6 months, in two reviewers independently analysed 36 articles. favour of cup feeding. There was no significant Interventions expanding from pregnancy to the difference in weight gain from one study that intrapartum period and throughout the postnatal reported this outcome. In the one study that period were more effective than interventions assessed it, there was a significantly increased concentrating on a shorter period. In addition, length of hospital stay in the cup fed infants. Time period were more effective than interventions to full breastfeeding was not assessed in any study. concentrating on a shorter period. In addition, It is concluded that cup feeding cannot be intervention packages using various methods of recommended over bottle feeding as a supplement to breastfeeding because it confers no significant professionals were more effective than interventions benefit in maintaining breastfeeding beyond concentrating on a single method. During hospital discharge and carries the unacceptable pregnancy, the effective interventions were inter- consequence of a longer stay in hospital. active, involving mothers in conversation. Postnatally effective were home visits, telephone Shah PS, Aliwalas L, Shah V. Breastfeeding or support and breastfeeding centres combined with breastmilk to alleviate procedural pain in neonates: a peer support. The BFHI programme is effective systematic review. Breastfeed Med 2007;2:74-82 and it would be wise to include the core components of the programme in breastfeeding promotion This systematic review and meta-analysis compares breastfeeding and breastmilk with various controls (placebo, no treatment, sucrose, Spiby H, McCormick F, Wallace L, Renfrew MJ, glucose, pacifiers, and positioning) to measure D’Souza L, Dyson L. A systematic review of education their effectiveness in reducing pain in neonates. and evidence-based practice interventions with health Eleven eligible randomized and quasi-randomized professionals and breastfeeding counsellors on duration trials were identified from electronic databases and of breastfeeding. Midwifery 2007 Epub ahead of print hand searches. There were marked differences in control intervention and pain assessment measures. To examine the effects of interventions (training, The breastfeeding group had a significantly lower education, practice change) with health professionals increase in heart rate, a reduced proportion of and lay breastfeeding educators and counsellors on crying time, and a reduced duration of crying duration of breastfeeding, this review selected compared to the swaddled and pacifier groups. from appropriate databases nine studies undertaken Infant pain scores were lower in the breastfeeding in high income countries and published between group when compared to the placebo group and the 1980 and 2003. All were before-and-after studies group placed in the mother’s arms, but were that included the education of health professionals; similar to the no-treatment and the glucose groups. no studies related to breastfeeding counsellors. In Compared to the placebo group, neonates in the six of the studies, the participants were working supplemental breastmilk group had a significantly with mothers and babies in hospitals (three in the lower increase in heart rate and facial coding UK, two in Italy and one in France); in three studies, the participants were working in Evidence from these studies was insufficient to community settings (Canada, Spain and the USA). draw conclusions about the overall benefit or harm Two UK studies and two non-UK studies (Spain associated with the interventions. From the studies identified, there seems to be no single way that disadvantaged areas. Most interventions aimed to consistently achieves changes in breastfeeding increase knowledge and change professional duration. From one of the more methodologically practice in support of breastfeeding. Many of the robust studies, it seems that the UNICEF/WHO studies reviewed had methodological limitations. BFHI training might have the potential to influence Study settings and contexts varied and lacked comparability. Prepared by the Geneva Infant Feeding Association (GIFA), an affiliate of the International Baby Food Action Network (IBFAN). Editors: Adriano Cattaneo, Marina Ferreira Rea. Elaine Petitat-Côté revised and edited the text. Hard copies of issues 1-43 of Breastfeeding Briefs will be sent upon request (GIFA, 11 Ave de la Paix, 1202 Geneva, Switzerland, Fax: +41-22-798 44 43, e-mail [email protected]). Issues from no 44 are available online: Available also in French, Spanish, Portuguese and Arabic. 


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