Part 1 - Open to the Public
ITEM NO.A1
__________________________________________________________________
JOINT REPORT OF THE SALFORD PCT AND THE LEAD MEMBER FOR
CHILDREN’S SERVICES
__________________________________________________________________
To
Cabinet
14 September ,2010
__________________________________________________________________
TITLE: INFANT FEEDING STRATEGY
__________________________________________________________________
RECOMMENDATIONS:
THAT Cabinet approves the implementation of the Infant Feeding
Strategy
__________________________________________________________________
EXECUTIVE SUMMARY:
The aims of the Infant Feeding Strategy are:
To increase the prevalence of breastfeeding
To increase the percentage of babies who receive appropriately timed healthy
weaning foods.
This will require changes to services and the local culture.
Documents:
Breastfeeding and Healthy Weaning: an Infant Feeding Strategy for Salford
2010-2013 (attached)
A series of presentations has been made to groups in the City as part of the
process of Strategy agreement. The document attached outlines the
comments made and the response that has been incorporated into the
strategy.
__________________________________________________________________
KEY DECISION:
YES
__________________________________________________________________
DETAILS:
1
This is a key decision in terms of its potential to impact on Salford’s Health
inequalities and the preventative effects of good infant feeding practices on
lifelong health.
__________________________________________________________________
KEY COUNCIL POLICIES:
Health Inequalities Strategy
Healthy Weight Strategy
__________________________________________________________________
EQUALITY IMPACT ASSESSMENT AND IMPLICATIONS:
An equality impact assessment will be carried out as part of the Strategic
Action Plan. The Department of Health has identified the potential for
increased, sustained breastfeeding support to impact on health inequalities.
Infant feeding practices are influenced by culture, so there is a need to
provide services which are sensitive to local cultures, including all minority
ethnic families.
__________________________________________________________________
ASSESSMENT OF RISK:
The strategy sets out a comprehensive approach to improving infant feeding
practices across Salford. Infant feeding is a preventative approach to health
problems over the life course. The risk and impact of not implementing a
Salford-wide approach is high.
__________________________________________________________________
SOURCE OF FUNDING:
NHS Salford has submitted a business case that has been agreed for funding
peer infant feeding support across Salford.
A successful bid for monies from the Department of Health (2009) will allow
investment in:
 implementing Baby Friendly practices across Salford Children’s Centres as
well as Salford Community Health, through staff training and a time limited
post to manage the process of working toward Baby Friendly accreditation
 a time limited post to support the new paid infant feeding peer team
Salford Royal Foundation Trust has received Baby Friendly accreditation.
Maintaining this standard is part of standard practice.
___________________________________________________________________________
LEGAL IMPLICATIONS Supplied by: to be clarified
___________________________________________________________________________
FINANCIAL IMPLICATIONS Supplied by:
The costs associated with the implementation of the strategy have partly been
determined through a business case submitted to NHS Salford.
Additional funds have been secured through a successful bid to the Department of
Health in respect of funds for breastfeeding and health inequalities
Other elements of the strategy are likely to represent changes in practice which have
no funding implication. Any further funding needs will identified through the strategy
action plan and appropriate business cases developed.
2
OTHER DIRECTORATES CONSULTED:
Several discussions with Paul Greenaway (Children’s Commissioning)
Presentation and discussion at Health and Well-Being Board, Feb 2010 (see attached
document which lists comments of all boards consulted)
___________________________________________________________________________
CONTACT OFFICER:
Magda Sachs
TEL NO: 0161 212 4924
___________________________________________________________________________
WARD(S) TO WHICH REPORT RELATE(S):
All Wards
3
BREASTFEEDING AND HEALTHY WEANING:
An Infant Feeding Strategy for Salford 2010-2013
4
Contents
Page
1.
Introduction
3
2.
Salford’s Infant Feeding Strategy – a summary
4
3.
Salford’s Pledges on Infant Feeding
7
4.
The Importance of Infant Feeding Practices
9
5.
Infant feeding in Salford
13
6.
What Works to Support Improved Infant Feeding Practices
18
7.
Current Delivery – 2009
20
8.
Gaps in Current Provision
23
9.
Financial Requirements
27
10.
Commissioning for Breast and Infant Feeding
28
11.
References
30
5
1
Introduction
1.1
The health of both babies and women is affected by choices in infant feeding,
with a substantial positive impact made by breastfeeding. The purpose of this
strategy is to set out our commitment to ensuring the health and wellbeing of
Salford’s children through sound infant feeding practices. This will require
significant changes for services and in local culture.
1.2
The national priority given to infant feeding is shown by its inclusion in the
Public Service Delivery Agreement 12: Improve the health and wellbeing of
children and young people (2008 -11) and as one of the national indicators for
infant health and inequalities (1). This has been supported by the National
Service Framework for Children, Young People and Maternity Services and
more recently through The Healthy Child Programme and Healthy lives, brighter
futures. The Healthy Child Programme emphasises breastfeeding as an
essential part of an integrated programme for child health and parenting
support (2, 3, 4).
1.3
Investing in services to support infant feeding will form part of Salford’s Children
and Young People’s Health and Wellbeing Strategy. This document is based on
needs assessment and consultation with services and parents, to identify the
priorities and strategic objectives for Salford’s partnership and to progress into
efficiently commissioned services which will be monitored and reviewed.
1.4
Breastfeeding is a key health factor in reducing infant mortality and our health
inequalities. There are differences in infant feeding practices with young, white,
poor British
women with low educational attainment least likely to
breastfeed, sustain
breastfeeding and follow the recommendations on
introducing solid foods. Reducing this gap in practice is important as a
preventative which will help
assure the health and wellbeing of children in
need and from disadvantaged groups and areas. This is integral to this
strategy.
1.5
To achieve the ambitions of the strategy, it will be crucial to have the
engagement and commitment of all clinical and community partners. The Infant
Feeding Strategy for Salford sets out a clear vision of how partners in Salford
can support infant feeding. Improvement is monitored through the Local Area
Agreement, NHS Vital Signs and by the Care Quality Commission.
The
strategy will align with other local plans such as Salford’s Children and Young
People’s Health and Wellbeing strategy, Healthy Weight Strategy and Teenage
Pregnancy and Parenting Strategy.
1.6
Not just strategic partners but everyone in Salford can have a part in creating a
community in which families are supported to feed their babies in a way that will
promote health and wellbeing. This means more than just telling pregnant
women that ‘breast is best’. It will involve creating a normative environment for
breastfeeding. The actions outlined in this strategy aim to provide a plan for the
way forward to meet these challenges.
6
Salford’s Infant Feeding Strategy – A Summary
2.
2.1
This section sets out the strategic objectives of this strategy and the actions
which will deliver these objectives.
2.2
In response to Salford’s current position and the national
recommendations, Salford has identified the following as the strategic
objectives for 2010 – 2013.
2.3
The ambition for Salford is not only to achieve the national targets but to make
a step change in further achievement. An action from the strategic plan will be
to consult on and seek agreement on a stretch target for Salford which will
ensure that sufficient progress is being made on infant feeding to reduce health
inequalities and embed good practice for infant feeding for the city.
Our vision is to give Salford’s children a healthy beginning through good feeding
practices. We aim:


To increase the prevalence of breastfeeding.
And
To increase the percentage of babies who receive appropriately timed
healthy weaning foods.
We will build the environment and culture in which this can happen by:



2.4
Creating a culture that supports good practice in infant feeding across
Salford, so that breastfeeding is normalised and children are weaned onto a
healthy family diet.
Reducing health inequalities by targeting groups where breastfeeding is
unlikely to be the norm and where additional support may needed on healthy
weaning.
Changing services to make sure that we can deliver.
This section describes the actions that will deliver the strategic objectives of this
strategy. They are based on the evidence outlined in section 6, and have been
shaped in the knowledge of the gaps currently in Salford. Together these will
ensure that Salford’s children have a healthy beginning.
Create a culture that supports good practice in infant feeding across Salford,
so that breastfeeding is normalised and children are weaned onto a healthy
family diet.



Work towards and achieve Baby Friendly accreditation across Salford
Children’s Trust while maintaining the standard at Salford Royal Foundation
Trust.
Work with Children’s Centres to ensure services for parents support best
practice in infant feeding.
Engage with local media and use social marketing insight to motivate culture
and behaviour change.
7
Objective: reduce health inequalities by targeting groups where
breastfeeding is unlikely to be the norm and where additional support may
needed on healthy weaning.



Commission delivery to target disadvantaged groups where breast feeding is
unlikely to be the norm.
In our target communities, provide to all breastfeeding mothers, as soon as
possible after birth, access to accredited Infant Feeding Peer Supporters.
Review current practices and assess the need regarding the introduction of
weaning foods in Salford and set local targets for improvement.
Review and where necessary, redesign our services that support the delivery
of infant feeding.









2.5
Provide all pregnant women and their families with appropriate and relevant
information on breast feeding during antenatal contacts.
Ensure that all women who initiate breast feeding have access to peer and
specialist support where this is assessed as being needed.
Create robust data and performance management systems and audit to
improve performance monitoring of outcomes.
Build a competent and confident workforce to support mothers and families
with breastfeeding through a programme of UNICEF Baby Friendly standard
training.
Train and support the primary care workforce to provide consistent advice
and support to mothers and fathers on breastfeeding and healthy weaning.
Encourage and actively support all women giving birth to initiate breast
feeding.
Promote the uptake of Healthy Start vitamins for all babies and breastfeeding
women in Salford.
Promote practices that make formula as safe as possible for babies who
receive formula milk.
Ensure that all information on formula and bottle feeding is independent of
commercial influence.
Primary and secondary drivers for change:
The diagram on the following page depicts the primary drivers for change.
These show how changes in infant feeding need to be influenced. The
secondary drivers are the programmes and initiatives which will contribute to
the achievement of the primary drivers. By ensuring that these are delivered,
we can track and measure impact at programme level and monitor change.
8
Objective
Primary Drivers
Give children a healthy start
through good feeding practices
Increase the prevalence
of breastfeeding
Improve weaning practices
MEASURABLE?
Create a supportive
culture
Ensure Healthy Start vitamins are available
in all areas
yes
Children’s Centres support best practices in
infant feeding
yes
yes
Audit and assess current
practices across Salford
Progress to Baby Friendly
accreditation across community
yes
Set local targets for
improvement
Provide all pregnant women and their
families with information on
breastfeeding
yes
Standardise information
given to families
yes
Promote best practice in formula feeding for
all babies receiving formula
Train and support workforce
to deliver good practice
yes
Ensure all information on products is
independent of commercial influence
Ensure all breastfeeding women
have access to peer support
yes
Ensure all breastfeeding women
have access to specialist support
where needed
Ensure Infant Peer supporters offer
contact to all breastfeeding women
soon after birth
yes
Encourage all schools to include
breastfeeding in the curriculum at
appropriate points
yes
MEASURABLE?
Maintain robust data monitoring systems
yes
Develop commissioning systems to
deliver strategic aims
yes
Encourage all employers to have policies
and facilities for employees returning to
work to continue breastfeeding
Work to influence provision of facilities for
women to feed babies in public spaces
yes
MEASURABLE?
Ensure information to mothers and
families is consistent
Regular audit of services is conducted
by trained team
yes
Engage with local media to normalise
breastfeeding and weaning onto a healthy
family diet
Providers of services
accountable for delivering
good practice in infant
feeding
Train workforce in Breastfeeding
Management to Baby Friendly standard
Reduce health
inequalities
MEASURABLE?
MEASURABLE?
Maintain Baby Friendly accreditation
in hospital
All women encouraged and
supported to breastfeed at birth
Secondary Drivers
Ensure services can
deliver
yes
Commission delivery to target groups where
breastfeeding is unlikely to be the norm
yes
Ensure infant feeding peer supporters work
in targeted communities antenatally
Collect intelligence on health inequalities in
weaning
Ensure access to fruit and vegetables in
deprived communities through Healthy Start
yes
9
3.
Salford’s Pledges on Infant Feeding
3.1
When we make the changes outlined in this strategy, this is what people can
expect in Salford:
3.2
All mothers will have:
 An offer of a one-to-one discussion on breastfeeding including benefits and
practical information on how to start and continue.
 An invitation to antenatal sessions on breastfeeding.
 Information on breastfeeding support groups locally.
 Easy access to the full Healthy Start allocation, where they qualify, including
vitamins for themselves and their baby.
3.3
All breastfeeding mothers will have:
 An offer of contact from a peer worker who can give information and support
about breastfeeding.
 On going contact from peer support worker if desired.
 Help from members of the midwifery and health visiting teams with any
breastfeeding difficulties.
 Access to specialist help if more complex difficulties arise with feeding.
3.4
All fathers will have:
 The opportunity to ask questions of staff about feeding, before and after the
birth.
3.5
All parents who decide to use formula after the birth of their baby will have:
 The offer of information on how to make up a bottle.
 Support with questions around formula feeding.
3.6
All parents will:
 Be offered information on introducing foods to their baby through a one-toone visit from their health visitor.
 Be sent an invitation to attend a weaning session where they can learn
more.
 Have their choices supported.
 Be encouraged to continue with milk-only feeding until their baby is six
months old.
3.7
Parents will be able to access support:
 From the midwifery team in hospital and in the early days at home.
 From health visiting teams.
 From peer infant feeding supporters for breastfeeding.
 From volunteer breastfeeding peer supporters at breastfeeding support
groups.
 At children’s centres from children’s centre staff.
3.8
All public facilities will:
 Offer a place to feed babies if mothers wish to do this in private.
 Will be free of information and products from companies which manufacture
formula milks.
 Will be Baby Friendly accredited or working toward Baby Friendly.
10
3.9
All Children’s Centres will:
 Support breastfeeding as a normal way to feed a baby.
 Support the timely introduction of appropriate foods.
 Offer a place to feed babies if mothers wish to do this in private.
 Provide facilities for breastfeeding support group and weaning groups if this
is suitable in the local area.
3.10 All staff will:
 Receive training on breastfeeding appropriate to their role.
 Work in accordance with the breastfeeding policy for their organisation.
 Know where they can refer a mother for further feeding help if needed.
 Have access to facilities to express breast milk if they wish to do this on
returning to work after having a baby.
3.11 The PCT, Salford Royal NHS Foundation Trust and Salford City Council will:
 Actively promote a supportive culture and environment for parents who
choose for their baby to be breast fed.
 Provide employees who return from maternity leave with suitable facilities to
express and store their milk.
3.12 Parents’ views will be sought and welcomed and will inform any update of this
strategy.
3.13 And… Babies will have their healthy start in life supported by feeding in
their first year.
3.14 Seeing the change:
The diagram below shows how breastfeeding support will be organised once all
the changes envisioned in the strategy have taken place.
Supporting best practice in breastfeeding IN SALFORD
UNIVERSAL
All women
receive info
about
breastfeeding
in pregnancy
All women
receive skinto-skin
contact and
help with first
feed
All women
receive support
with early feeds
Peer support
and family
provide positive
social support
All
breastfeeding
women
receive offer
of peer
support
All
breastfeeding
women access
to
breastfeeding
group
All Children’s
Centres
supportive
SPECIALIST
All staff able
to help with
everyday
issues
All staff know
referral
pathway
Peer team
provides
ongoing
support
Specialist
lactation
support
GPs
prescribe
effectively
Midwifery
and Health
Visiting
teams help
with more
complicated
issues
Special care and
children’s ward
staff support
Specialist
paediatric
care
Breast
surgery
support
Teenage team
support
This depicts the services
we expect to see when the
strategy is implemented
11
4.
The Importance of Infant Feeding Practices
There is no finer investment for any community than
putting milk into babies.” Winston Churchill
4.1
Feeding in the first year of life impacts on lifelong health and development.
Sustained breastfeeding and the timely introduction of appropriate weaning
foods can make a substantial contribution both to public health and a reduction
in infant mortality (6).
4.2
In addition to nutritional and physical health outcomes, feeding a baby has
important relational aspects. Successful feeding is important for parents to feel
they have established successful parenting, and for forming bonds between
parents and their children. The goal of successful infant feeding is not just
nutrition, but involves babies joining in with the eating culture of their families
and wider social group.
4.3
Reasons for women’s choices in infant feeding are complex, multifaceted and
multi-layered.
Influences range from over-arching social and cultural
expectations of women and babies, through family and community norms, and
are influenced by the organisation of health services, including the lack of
effective support for the physical process of breastfeeding. Personal aspiration,
body confidence and self-image as well as the attitudes of partners are also
important.
Breastfeeding
4.4
Breastfeeding impacts on babies’ health, and is also important for maternal
health outcomes.
4.5
Many outcomes from breastfeeding are dose dependent, meaning that
exclusive breastfeeding (where the baby receives just breast milk and no water,
other milks or foods) sustained for six months provides better health outcomes
than when breastfeeding is only partial (mixed with formula) or ceases early.
4.6
Breastfeeding contributes to the reduction of health inequalities, mitigating
some effects of other environmental constraints (7, 8). Initiating and sustaining
breastfeeding is strongly associated with higher maternal age, social-economic
status and educational attainment. In 2005, 88% of women from non-manual
classes initiated breastfeeding, in comparison with 65% from the manual class.
White women in deprived circumstances with low educational attainment are
least likely to breastfeed, but have a higher incidence of low birth weight infants
and their children experience higher incidences of childhood infectious disease
(9). The cyclical, cumulative effect of poor infant feeding practices over
generations deepens health inequalities. Increasing breastfeeding initiation
rates for women in disadvantaged communities where breastfeeding is not the
norm offers great potential health gains.
12
Reducing inequalities in outcomes for families, mothers and children
Infant Mortality National Support Team
Identifiable Actions to Reduce the 2002-04 Gap
in Infant Mortality
What would work
What would work
Impact on the 2002-04 gap
(percentage points)
Reducing conceptions in under 18s in the
R&M group by 44% to meet the target
1.0
1.4
Targeted interventions to prevent SUDI by
10% in the R&M group
1.4
2.0
Reducing the prevalence of obesity in the
R&M group to 23%
Increasing the rate of breastfeeding initiation
in the R&M group to those of the non-R&M
group from 67% to 83%
Immediate actions
Optimising preconception care
Early booking
Access to culturally sensitive healthcare
Reducing maternal and infant infections
Reducing overcrowding in the R&M group,
through its effect on SUDI
Reducing the rate of smoking in pregnancy by
two percentage points by 2010
2.8
3.0
Meeting the child poverty strategy
4.0
Achieve UNICEF Baby Friendly Accreditation in
Hospital and Community settings.
Long-term actions
Improving maternal educational attainment
1
Key: R&M = Routine and Manual
SUDI = sudden unexplained death of an infant
Source: The Infant Mortality National Support Team, 2009
4.7
In the past, health outcomes associated with breastfeeding were summed up by
the slogan ‘breast is best’. This may suggest breastfeeding is aspirational,
implying that formula feeding is adequate. It is like saying ‘a Rolls Royce is
best’ – while we all know that driving a Ford will be perfectly adequate.
Breastfeeding is biologically normal and provides adequate infant nutrition, and
formula feeding is the emergency replacement, similar to artificial insulin for
diabetics.
4.8
At the start of the twentieth century, breastfeeding rates in England began to
decline, with a low reached in the 1960’s, and the creation of a ‘bottle feeding
culture’. This trend has since reversed, and an increasing percentage of
women have initiated breastfeeding with longer duration rates (9). In 2001, the
World Health Organisation revised its guidance to recommend exclusive
breastfeeding for the first six months of life. The Department of Health adopted
this recommendation in 2003 (10). However, rates of initiating breastfeeding in
the UK remain among the lowest in Western Europe.
4.9
Along with other aspects of parenting, breastfeeding is a learnt behaviour and
requires a variety of skills, knowledge and techniques. Many mothers
experience a “generation gap” in family and social support, as women who
became mothers during the decades of low breastfeeding initiation become
grandmothers. Today’s mothers, as well as their family members, may have
had little opportunity to see a baby at the breast. Women are thus more reliant
on health professionals or dedicated voluntary support for accurate information
on all aspects of breastfeeding.
4.10 Health professionals as members of society are affected by wider social trends,
and many will have personal experience of choosing not to breastfeed or
13
experiencing breastfeeding difficulties. Our bottle feeding culture has also led
to a loss of professional skills in supporting women to initiate and sustain
breastfeeding. Institutional and organisational practices, such as separation of
mothers and babies and set feeding routines, which undermine breastfeeding
were common for decades. Marketing of formula, bottles and teats has
strengthened the perception that bottle feeding is an inevitable part and normal
progression of infant feeding.
Formula feeding
4.11 When infants are not breastfed they are at higher risk of poor health outcomes.
However, any woman who chooses to formula feed her baby, after having clear
information, must be allowed that choice without prejudice or bias. Indeed, her
need for support is important, due to her baby’s increased risk.
4.12 Some of the poor health outcomes associated with formula feeding are inherent
to the use of non-human milk. Poor formula preparation and feeding practices
can increase infant illness and the risk of obesity. Department of Health
information provides guidance (11). In 2005 of mothers using formula in the
early weeks, only three in ten followed recommendations (9).
4.13 Companies who make formula have sophisticated marketing operations.
Information from companies is promotional rather than informational.
4.14 The cultural perception remains that formula feeding from a bottle is
unproblematic. This needs to be challenged in order to ensure that women
and families make choices about initiating or continuing breastfeeding in a
realistic context.
Health differences between breastfed and formula fed
babies
Health impact on
women:
Babies who are not breastfed are at greater risk of:
 gastro-intestinal infection
 respiratory disease
 necrotising enterocolitis (NEC) in premature babies
 urinary tract infections
 allergic disease (eczema, asthma and wheezing)
 ear infections
 childhood leukaemia
Women who breastfeed
are at lower risk of:
 pre-menopausal
breast cancer
 ovarian cancer
 hip fractures
 low bone density
 osteoporosis
 rheumatoid
arthritis.
Breastfed babies have lower incidence of important childhood
diseases such as:
 obesity and overweight
 juvenile-onset insulin dependent diabetes mellitus
 raised blood pressure.
Breastfeeding also
increases the likelihood
of a return to prepregnancy weight.
Breastfed babies have lower incidence of diseases in later life
such as:
 atopic diseases
 raised blood pressure
 Reduced risk of coronary heart disease (CHD)
throughout life and have lower average blood pressure in
later life.
14
Weaning or the introduction of first foods
4.15 Weaning, or the introduction of food other than milk, is an important transition
for all babies and influences lifelong eating habits. The Department of Health
recommends that food, of appropriate types and in appropriate amounts, is
introduced at six months (10).
4.16 The introduction of any food other than milk should be a gradual process,
introducing a baby to a variety of home prepared foods, with an increasing
variety of texture, flavour, aroma and appearance. The COMA report of 1994,
remains current guidance, alongside the changed recommendation as to age of
introduction to foods (12, 10).
4.17 The actual age at introduction of solid food has gradually increased in the UK,
from a mean of 15 weeks in 2000 to 19 weeks in 2005. However, fewer than
2% of babies receive 6 months of milk-only feeding. Women with lower
educational levels and in lower social classes tend to introduce solids earlier: as
noted, these babies are more likely to be formula fed (9).
4.18 A baby’s first experiences of food will influence lifelong eating patterns. Parents
who are concerned to get a certain amount of food into their baby may override
the baby’s satiety mechanisms. First foods are important in terms of the
provision of a number of micronutrients, but milk remains the main source of
nutrition for babies for at least the first year of life.
4.19 Babies given solids between 4 to 6 months are more likely to receive
commercially prepared rather than home-prepared foods (9). Marketing of
convenience baby foods has helped create the perception that they are
necessary. Reliance on commercial foods and a desire to move babies quickly
onto solids may have contributed to the obesogenic trend affecting children in
the UK.
4.20 Babies who are born pre-term should be weaned according to their individual
needs, and advice should be sought from a dietician and the medical team.
Healthy Start
4.21 The government replaced the Welfare Foods Scheme with Healthy Start, a
programme which provides vouchers for fruits, vegetables or formula milk as
well as vitamin supplements for women and children. This programme
supports the nutrition of children in their first year of life.
4.22 The following sections of the Strategy (4-7) provide an analysis of the current
position in Salford through scrutiny of the breastfeeding initiation and
prevalence data against national averages and variation within Salford. It
provides an overview of the evidence base, outlining effective practice and what
the current service delivery is providing. Using this information and the
outcomes from a range of consultations, a number of gaps have been identified
in section 7.
15
5.
5.1
Infant Feeding in Salford
The North West region has one of the lowest rates of breastfeeding initiation
and of prevalence at six months in England (9). Salford’s rates are below
regional averages reflecting patterns of deprivation and high rates of teenage
pregnancy. Early introduction of solid foods is the norm. In many families there
may be a lack of cooking skills and poor understanding of what constitutes a
healthy family diet. In order to change the perceptions of women so that they
consider breastfeeding as a realistic feeding choice, and to highlight the
importance of a timely, appropriate weaning diet, there will need to be a social
shift to mobilise the support of grandparents, partners and also social peers.
Current position in Salford
Breastfeeding initiation:
5.2
Initiating breastfeeding is defined as a mother putting the baby to the breast or
the baby receiving some of the mother’s milk within the first 48 hours after birth.
The chart below compares national survey data for the percentage of women
who initiate breastfeeding in England & Wales and available data for Salford.
Salford remained 20% below the national average in 2005 despite an increase
of 30% in breastfeeding at birth since 1990.
Infant feeding survey, 1980-2005
England & Wales
Salford
90
77
80
Percentage of babies breastfed at birth
71
70
67
68
65
64
60
56
50
40
30
38
38
1995
2000
26
20
10
0
1980
1985
1990
2005
Year
Source: Department of Health Infant Feeding survey 1980-2005 and Salford PCT
Initiation rates have risen since 2005; however, more recent figures demonstrate that
this earlier upward trend is not being maintained. An ambitious local target has been
set of 75% initiation, this will require targeting of effort in areas such as Little Hulton
and Ordsall, where rates are considerably lower than the Salford average.
16
Breastfeeding at Initiation (Prevalence)
Trajectory
Actual
DH Trajectory
Prevalence at Initiation (%)
70
65
60
55
50
Q1
Q2
Q3
Q4
2007/08
Q1
Q2
Q3
Q4
Q1
2008/09
Q2
Q3
2009/10
Q4
Q1
Q2
Q3
Q4
2010/11
Month/Year
Source: NHS Salford
5.4 Levels of breastfeeding prevalence at birth vary by ward. Areas with low rates
are most often areas of deprivation, as indicated in map below, although this does
not account for all observed variation. To bring areas with the lowest rates to a level
that is comparable with the best, would require a 100% increase in prevalence.
17
Prevalence of Breastfeeding at 6-8 weeks:
5.5
All PCTs are required to collect information on this indicator. In Salford, data
collection became robust (89% coverage) by Quarter 4 of 2008-09, with
coverage over 90% for 2009-10. Prevalence has been revealed as relatively
static, with just over 30% of Salford babies receiving any breast milk by 6-8
weeks.
18
VSB11 - Breastfeeding at 6-8 Weeks (Prevalence)
Trajectory
Actual
Prevalence at 6-8 weeks (%)
45
40
35
30
25
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Month
Source: NHS Salford
As with initiation, there are variations in sustaining breastfeeding across the
city. For example, in Little Hulton 13% of babies were breastfed at 6-8 weeks
in Quarter 4 of 2009-10, while in Eccles 73% were.
19
NHS Salford Information Department
5.6
Salford communities are changing, with an increasing percentage of births to
non-white women. In addition to the long-standing Jewish community, which
has demonstrated a high level of commitment to and support for breastfeeding,
new Europeans have moved into the area, bringing their infant feeding
traditions.
This has introduced complexity into understanding the infant
feeding needs of parents in Salford.
Costs of infant feeding
5.7
In 2009 it was estimated that a 10% increase in prevalence of breastfeeding in
the UK would provide the following annual savings in treatment costs (14):






5.8
Otitis media -- £0.5 million
Gastroenteritis -- £2.3 million
Asthma -- £2.6 million
Lower respiratory tract infection – £0.8 million
Beast Cancer -- £0.9 million
Total saving -- £7.1 million
If all UK infants were exclusively breastfed, it is estimated the hospitalisation
each month with diarrhoea would be halved, and with respiratory infections
20
would be cut by a quarter (15). A further impact of child illness is parental
absence from work.
5.9
There are environmental impacts of formula feeding such as increased use of
land for pasturage, the impact of milk processing and the use of resources for
packaging and landfill for waste. Packaging and the impact of industrial
production methods are also results of a reliance on commercial baby foods.
5.10 Breastfeeding affects family relationships. A recent study found a strong
positive association of breastfeeding on parenting behaviours; this appeared
particularly important for single and lower income mothers (16). Another study
found correlations between lower levels of maternal neglect and longer
durations of breastfeeding (17).
Consultation
5.11 An early draft of this strategy was circulated to parents at Salford’s Children’s
Centres and in support groups in 2009. These responses generally supported
the aims of the strategy, but there were a number of comments which could be
summed up in one mother’s words: “Give support to mums who decide to
bottlefeed, too”. The current strategy includes infant formula feeding to a
greater extent.
5.12 There were also comments which reflected on how support for breastfeeding is
given, which asked that professionals “offer support, not preach” and one
mother commented: “I would like the support workers to also tell you that
breastfeeding does sometimes hurt and maybe be truthful with the downsides”.
5.13 When asked how they would like support to be given, one respondant asked for
“perhaps a buddy system, someone to talk over the phone”. Meeting this need
will be part of the remit of the Infant Feeding Peer Support Team.
5.14 The development of the strategy has benefited from consultation with members
of the Infant Feeding Operational Group, which brings together practitioners
from SRFT, SCH, the Health Improvement Team and Salford’s Children’s
Centres. This group was instrumental in the development of the strategic aims
and in understanding the current gaps in service. The strategy has also
benefited from comments of the Children’s Divisional Board from SCH.
21
6.
What Works to Support Improved Infant Feeding Practices
International Recommendations
6.1
The World Health Organisation published the Global Strategy for Infant and
Young Child Feeding in 2003 (18). This strategic document is based on the
best available scientific evidence. Governments are recommended to develop
a comprehensive policy on infant and young child feeding, ensuring that all
mothers have access to skilled support for initiating and sustaining exclusive
breastfeeding for six months, and ensuring the timely introduction of adequate
and safe complementary foods, with continued breastfeeding up to two years or
beyond.
The provisions of the 1981 WHO/UNICEF Code of Marketing of
Breast Milk Substitutes should be adequately legislated and enforced (19).
6.2
Other recommendations include renewed commitment to implementing the
UNICEF Baby Friendly Initiative, and the provision of community based
networks offering mother-to-mother breastfeeding support.
National recommendations
National Institute for Health and Clinical Excellence (NICE) guidance and
UNICEF Baby Friendly Initiative (BFI)
6.3
NICE has produced two sets of recommendations in the area of maternal and
infant nutrition (20, 21). A key recommendation is the implementation of the
UNICEF Baby Friendly Initiative in both hospital and community settings.
Through adopting best practice standards and training staff in delivering care,
the Baby Friendly programme ensures that staff are able to support parents in
making informed decisions about infant feeding and carrying them through, and
that institutional practices do not undermine breastfeeding.
6.4
In the community, working toward Baby Friendly accreditation should include
Children’s Centres, which provide a range of services in local communities. It
is vital to ensure these Centres are integrated in the delivery of antenatal and
postnatal care and that they are equal partners in the development of all
initiatives.
6.5
Other public buildings and areas may also be designated baby friendly through
local schemes – this is important as a major barrier to breastfeeding is a fear of
embarrassment when feeding outside the home; the restrictions this places on
everyday life can be considerable.
Healthy Start
6.6
Healthy Start is a national Department of Health programme providing food and
vitamins for pregnant and breastfeeding women and children under 4
particularly targeting low income and disadvantaged families. Vitamins are
recommended as young children may not get enough vitamin A, C and D from
their food and pregnant and breastfeeding women may not get enough vitamin
D or folic acid which may harm their baby. Vitamins should be offered to
breastfed babies from 6 months of age, and to formula fed babies having less
than 500ml of formula a day. Families need ready access to vitamins and
foods under the scheme.
22
Department of Health recommendations
6.7
The Department of Health has produced a set of clear priorities for action to
support breastfeeding (14). These provide a consistent template of activities
which should be considered as a minimum provision.
6.8
The Department of Health has further disseminated recommendations for
preparation of formula feeding to ensure babies receiving this are protected
(11). Further guidance is available on the timing of the introduction of foods as
well as guidelines for suitable first foods (23).
6.9
Local services will require joint commissioning, and implementation.
Templates for this process are provided through World Class Commissioning.
Regional recommendations
6.10 In 2008, A North West Breastfeeding Framework for Action was published,
which reiterates national and international goals as appropriate across the
Northwest region (24). The commitment at regional level to these initiatives
gives access to colleagues working in similar communities so that practice and
ideas can be shared to support Salford.
23
7.
Current Delivery - 2009
Current Provision
7.1
Over the past decade there has been a concerted effort by partners to improve
the breastfeeding support that is available to Salford families. However more
remains to be done. As new initiatives and service developments are planned,
commissioned and implemented, it is vital that they are integrated into existing
delivery systems where these can demonstrate effectiveness.
7.2
The transition to strategic planning and commissioning through Children’s Trust
arrangements involves coordination through a delivery system across a range
of provider organisations. This strategy reflects the complexity of this for the
infant feeding issue and this section maps out the current provision up to year
end 2009.
Strategic
theme
Provider
services
Salford Royal
Foundation
Trust (SRFT)
Improving
breastfeeding
prevalence,
and reducing
health
inequalities
SCH: Health
Visiting Service
SCH (SRFT):
Specialist
support
Salford City
Council:
Children’s
Centres
Breastfeeding
support groups
Breast Mates
Formula
Feeding
SRFT & SCH:
Midwifery and
Health Visiting
Activity
Antenatal one-to-one discussion on infant feeding
offered to every mother as part of standard package
of care.
Antenatal sessions on breastfeeding are offered to
all pregnant women.
As of October, 2009, free formula has been
withdrawn from the maternity wards. Parents must
supply their own ready-to-feed formula.
SRFT supports its staff who wish to continue
breastfeeding when they return to work with flexible
breaks and suitable facilities.
Breastfeeding support is offered one-to-one during
home visits and at clinics.
Two sessions a week are available in the
community. These are covered by one midwife
Lactation
Consultant
(IBCLC),
and by a
Breastfeeding Specialist (who also holds the IBCLC
qualification). Women can self-refer or be referred
by another professional.
Children’s Centres offer breastfeeding support
groups on site and signpost. Signage supports
breastfeeding within centres.
There are breastfeeding support groups at many of
the Children’s Centres.
Salford’s team of volunteer peer breastfeeding
supporters (Breast Mates) has been in place for 7
years and supporting breastfeeding groups and
providing telephone support.
New Breast Mate training sessions were run in 2009.
Department of Health leaflet is given to all women
who use formula milk in the hospital.
24
service
Healthy
Start
Programme
Infant
Weaning
SRFT & SCH:
Midwifery and
Health Visiting
service
Healthy Start information available via midwifery and
Health Visiting teams; uptake poor.
Not known how many women not eligible for Healthy
Start give their babies vitamin supplements.
SCH: Health
visiting service
A weaning home visit is offered by Health Visitors to
mothers when their babies are around 12 weeks old
– not currently happening uniformly across Salford.
Many localities have weaning sessions on offer to
parents. These may be delivered Health Visiting
team, Health Improvement Teams.
Where Food Workers offer sessions, these
emphasise a healthy family diet and cooking skills.
Each area has its own session format.
Weaning
sessions: SCH:
Health Visiting
service; Health
Improvement
Workers and
Community
Food Workers
Salford Royal
Foundation
Trust
Organisation
of services
and
monitoring
of progress
Other hospitals
offering
maternity care
to Salford
women
SCH: Health
Visiting service
Policy
Data gathering
and monitoring
of rates
SRFT attained the Baby Friendly Hospital award in
2006, and was reaccredited in 2008. The care
offered to women and training of staff conforms to
the ‘Ten Steps to Successful Breastfeeding’.
Regular audits are conducted to assess staff
knowledge.
Two midwives are International Board Certified
Lactation Consultants and provide guidance for
fellow staff and specialist support to women with
more complex breastfeeding issues.
All midwifery staff receive training in breastfeeding
management.
Three hospitals provide most of the maternity care
for the one quarter of Salford women who do not
attend SRFT. One has achieved BFI status, while
the other two have declared their commitment to
gaining this.
During the past few years, training using the La
Leche League programme was offered to all
members of Health Visiting teams. Most Nursery
Nurses and Staff Nurses and some Health Visitors
who support new mothers completed the training and
update sessions are arranged on a regular basis.
Health Visiting teams are supported by SCH
Breastfeeding Specialist, who is an IBCLC.
Training has been given to most Health Visitors on
the use of the new UK-WHO growth charts.
A breastfeeding policy which covers both hospital
and community is in place and has been regularly
updated to reflect changes at SRFT; work has begun
to update the community sections.
During 2008-09 NHS Salford has worked to improve
the collection of data and to keep this consistent.
Over the year the quality of data collected and the
sophistication of how we investigate the data to
25
understand what it can reveal has increased. This
has reflected a commitment on the part of health
visiting teams and this commitment is ongoing, as is
demonstrated in the 2010-11 Service Specification.
Meeting of
professionals
Wider
Community
Social
Marketing
Gateway
centres
The infant feeding operational group meets regularly.
Members represent Midwifery, Salford Community
Health, Health Improvement team and Children’s
Centres. Meetings monitor progress and issues and
provide feedback.
The Be a Star social marketing campaign has been
running in Salford since June 2009. This aims to
engage younger mothers, through the presentation
of glamorous breastfeeding images using young
local mothers.
All have baby feeding rooms for mothers using the
building.
Planned Initiatives
7.3
In October 2009, NHS Salford was successful in securing money from the
Department of Health for breastfeeding and inequalities. The funding is
designed to enable Salford to make accelerated progress toward Baby Friendly
accreditation in the community. Funding will be used to:
 Train a team of professionals as trainers who can deliver Baby Friendly
accredited ‘Breastfeeding Management’ training to staff.
 Train a team of auditors to conduct regular audits to ensure sustained
progress toward accreditation.
 A two-year post of Baby Friendly Manager to oversee and ensure progress
 A one-year post of Infant Feeding Peer Coordinator to develop a team of
peer supporters (see below).
 Meet Baby Friendly accreditation costs for Salford Community Health and
Salford’s Children’s Centres (this includes visits from the Baby Friendly
team).
 Increase capacity to support breastfeeding at SRFT.
The Department of Health will require reporting and monitor progress closely.
7.4
NHS Salford has resourced a new peer Infant Feeding Support team. As
recommended by NICE, peer support can be crucial in enabling women to
tackle the social barriers and constraints to breastfeeding and appropriate
weaning. This may be particularly important for women in communities where it
is unlikely for them to breastfeed.
7.5
These posts are funded recurrently and the team will work within Salford’s
Health Improvement Teams, ensuring that support is local. Children’s Centres
have been involved in this development..
7.6
A North West Healthy School Breast Feeding Task and Finish Group is
developing guidance for schools. The guidance will map out how
breastfeeding and its benefits can be included in the school curriculum for all
key stages. This guidance will be used in Salford to also promote breastfeeding through Extended Services.
26
8.
Gaps in Current Provision
8.1
As shown in the section on Infant Feeding in Salford (section 4) parents’
practices often do not reflect national recommendations and services are not
effectively supporting parents to make and sustain healthy infant feeding
choices. An initial review of the current position for Salford against national
targets and current delivery has identified a number of gaps in service delivery
which will inform the strategic objectives of this strategy.
8.2
This analysis of gaps is organised into themes though these are interrelated in
terms of delivery.
8.3
Changing the Culture

Salford’s general culture continues to expect babies to be bottlefed, with
breastfeeding as an unusual option. Any breastfeeding is expected to last
only for the early weeks. Bottle feeding is regarded as uncontroversial. The
transition to solid foods is understood to require a period of spoon-feeding
when the baby is passively fed with special foods.
 Many Salford families have diets that are not suitable for sharing with
babies and young children, which is a contributory factor to our health
inequalities

8.4
Education through Schools

8.5
For partners in Salford, there is recognition that infant feeding is important,
particularly with regard to Salford’s Healthy Weight Strategy and strategic
objectives. Partnership between NHS Salford, Salford Community Health
and Children’s Centres is ongoing, but may not always be well disseminated
or visible.
Some schools incorporate breastfeeding and feeding young children into
parts of the curriculum. Guidance on how to include information appropriate
to all stages of the curriculum is currently awaited from the North West
Regional Breastfeeding Task and Finish Group.
UNICEF Baby Friendly Initiative

Salford Royal Foundation Trust received the Baby Friendly accreditation in
2006, and has received recertification in 2008. Baby Friendly Audit is
conducted every six months.

Salford Community Health signed the letter of intent, taking the first step
toward Baby Friendly Accreditation in October 2009.

Children’s Centres are committed to working toward the standards, but
need to work in tandem with SCH: Baby Friendly accredits community
facilities as an integrated whole.
27
8.6
8.7
8.8
Antenatal provision

More staff time is needed during antenatal period to motivate women to
breastfeed and to provide more comprehensive information, including the
risks of formula feeding.

Women intending to use formula need more information about preparation
of feeds and hazards of storing.

Front line clinicians (Midwifery, Health Visiting and General Practice) need
to understand the rationale and actively promote breastfeeding.

Frontline clinicians are not actively promoting Healthy Start to eligible
women.
Integrated service provision

The handover from hospital midwives to community midwives and, later,
from midwifery to health visitor care sometimes interrupts what should be a
coordinated continuum of care for women. They are unsure who to ask for
help with feeding questions. A robust referral structure is not in place.

Professionals in Health Visiting Teams and General Practice are not always
aware of service provisions such as support groups and specialist services.
Referral is uneven and women may lose the chance to access available
services.

Some of the breastfeeding support groups held in Children’s Centres
meet criteria for suitability. Others do not. Provision of groups changes
frequently, making accurate information difficult to provide.

Current provision of weaning classes across the city is patchy and uneven.
A variety of professionals are involved in delivery and information included
varies. Some staff do not feel confident to support parents who wish to start
with finger foods only.

Three quarters of Salford mothers currently deliver at SRFT. As part of the
Making it Better consultation on maternity services for Manchester, the
maternity unit is scheduled to close in 2012. Currently NHS Salford
commissioners do not engage regularly with the three main units which are
expected to provide maternity care for Salford women.
Healthy Start

Midwives advise women about women’s vitamins antenatally. There is no
Salford wide system for ensuring access to Healthy Start children’s vitamins
for eligible families, with some Health Visitor teams distributing them, and
others not. Distribution at Children’s Centres for both women’s and
children’s vitamins offers the potential to widen uptake and raise the profile.
This needs to be established.
28
8.9
Workforce

Staff in midwifery teams have received training in Breastfeeding
Management to UNICEF Baby Friendly standards. In the Health Visiting
teams few have received this (in-service training has been provided). This
results in conflicting information to women and families.

Initial training for all staff across the health economy needs to be supported
by a programme of updates.

Children’s Centre staff are eager to support breastfeeding, but have not
received training in how they can do this most effectively.

Salford’s volunteer peer supporters, the Breast Mates, support
breastfeeding groups and offer telephone support. Boundaries of the role
are not always clear.
In some areas, good relationships exist with
professional teams, but in other areas, there is little coordinated working.
8.10
Wider Community

Most public buildings in Salford do not have a recognised feeding room for
parents who may be present and request it.

For women returning to work, there may be provision for expressing breast
milk. However some public service employers and companies do not have
a policy in this area and some with a policy do not act on this so that women
are actually enabled to do this.
8.11
Data management, quality and performance management

Recently, previous improvement in the percentage of women initiating
breastfeeding has not been sustained. New ways of building on previous
achievements in this area need to be identified.

Data collection for the 6-8 week indicator meets current Department of
Health quality requirements. However, there are issues in particular
localities and concerns about the long-term sustainability of the current
method of collection.

SRFT conducts regular audit of infant feeding practices and support issues,
using the Baby Friendly Initiative hospital audit tool. No audit has been
conducted for the community. A programme of regular audit could help in
the evaluation and improvement of services.

Currently no data exists on the age of the introduction of solid foods for
Salford babies. The kinds of first foods used and difficulties parents have
are poorly understood.

Currently fewer than 1% of children eligible for free vitamins under the
Healthy Start scheme appear to receive these.

There is currently no local measure for monitoring health inequalities in
infant feeding.
29
8.12
Information and communication

Women do not receive consistent information about the importance of
exclusive breastfeeding and its role in delivering health outcomes.

Breastfeeding mothers who use formula supplements to address a
breastfeeding difficulty may not receive clear help and information about
transitioning off supplements.

Some staff members access formula company information in order to help
parents. They accept promotional gifts such as pens and diary covers.
8.13 Gaps summary

It can be seen that although services in Salford meet some national
recommendations, there are areas which require work to meet the currently
understood minimum level of care.

We have made and are making progress in understanding local infant
feeding practices. However, particularly in the area of weaning, there is a
lack of locally gathered information to inform services, planning and
commissioning. Commitment to supporting breastfeeding has been evident
in the attainment and maintenance of the Baby Friendly award at SRFT.
This now needs to be replicated across the community, while ensuring
integration so that women experience a coordinated continuum of care.
30
9.
9.1
Financial Requirements
Financial Requirements of the Strategy
Existing services for breastfeeding and weaning are provided by the midwifery unit at Salford Royal Foundation Trust and by Salford
Community Health’s Health Visiting team, as such these services form part of the contracts NHS Salford has with these organisations and
are reflected in service specifications. Salford City Council’s Children’s Centres provide breastfeeding support groups and NHS Salford’s
Health Improvement Teams provide weaning support.
9.2
Many of the actions identified in this strategy will require no further financial investment and will be achieved through development of
service specifications and performance management of existing services, ensuring consistent messages and uniform services are
provided.
9.3
There are three areas where further investment is required and the funding for these has already been identified. A fourth area may
require funding but further work is required to establish a complete picture of the current provision. Details of each of the four areas are
provided in the table below.
Programme
UNICEF Baby Friendly
accreditation in the community
Activity
Train Trainers and implement
training programme for staff;
train auditors and conduct
regular audits every 6 months;
BFI manager post (with SCH)
Peer Infant feeding Support
Peer team sitting with Health
Team
Improvement Team, offering
community support
Coordination with partners to
Peer Coordinator
ensure effective working of team
Motivate culture and behaviour
Engage with local media and
change
use social marketing insight
Promote uptake of Healthy Start Ensure all clinics are engaged in
vitamins for all babies and
the promotion of Healthy Start
breastfeeding women in Salford vitamins
Funding required
Costs of accreditation
2 year BFI manager post
Training trainers
Backfill for training staff
Audit training
Costs of 8 wte post holders
Source of funding
Department of Health bid, October
2009
Salford Children’s Centres
Costs for post holder
Department of Health bid
Costs of media campaigns and social
marketing projects
Potentially the cost of vitamins, but
can be paid for by individuals or
reclaimed from the DoH where
families are on benefits
A business case will be developed to
take this work forward
Should be achievable within current
delivery of services
PCT Infant Feeding Business Case
(September 2009)
31
10.
Commissioning for Breast and Infant Feeding
10.1 Commissioning for breast and infant feeding will be through Children’s Trust
arrangements which will provide the opportunities for strengthening integrated
services to support parents and infants in these early years. The NHS
component of the services is incorporated into services specifications with NHS
providers, the two current key providers being Salford Royal Foundation Trust
and Salford Community Health.
10.2 NHS Salford is responsible for inclusion of appropriate indicators in the relevant
contractual arrangements and performance managing these throughout the
year to ensure achievement of quality and outcomes which will result in:
 an improvement in the health and wellbeing of mothers and infants;
 a reduction in health inequalities;
 achievement of
targets which are current in Salford’s Local Area
Agreement and NHS Operating Plan, and are part of the Comprehensive
Area Assessment and Care Quality Commission assurance processes.
10.3 Governance Arrangements
 Salford’s Infant Feeding Strategy will be accountable to the Children and
Young People’s Partnership Board via the Children’s Health and
Wellbeing Strategy Group.

Progress on the Strategy will also report to Salford’s Health and Well
Being Board through the Think Healthy Living Group, specifically on its
contribution to reducing health inequalities.

There are links into the Healthy Weight Strategy, Teenage Pregnancy
Strategy and infant feeding outcomes are supportive of the Oral Health
Strategy. Infant feeding will also be an element of the forthcoming Health
Inequalities Strategy.
10.4 Action Plan
 The action plan for delivery of the strategic objectives accompanies the
Infant Feeding Strategy and will provide the requirements for commissioning
of future services and contract performance management arrangements.

Progress reporting on implementation of the action plan will be through
quarterly reports to the Children’s Health and Wellbeing Strategy Group
which will include a risk assessment against the actions.

A formal annual progress report will be made to the Children and Young
People’s Partnership Board and Children’s Health and Wellbeing Strategy
Group.
32
Salford’s Health
and Well Being
Board
Children and Young Peoples
Partnership Board (CYPPB)
(including Children’s Trust
Board)
Children’s Health and
Wellbeing Strategy Group
Health Inequalities
Strategy
Infant Feeding Strategy
Oral Health
Strategy
Teenage
Pregnancy
Strategy
Healthy
Weight
Strategy
33
11.
References
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