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Department of Health West Midlands
Quality, Innovation, Productivity & Prevention
Breastfeeding & Infant Feeding
1.
INTRODUCTION/OVERVIEW OF WEST MIDLANDS
There is clear evidence that breastfeeding has positive health benefits for both
mother and baby in the short and longer-term (beyond the period of breastfeeding)1.
Breast milk is the best form of nutrition for infants and exclusive breastfeeding is
recommended for the first six months of an infant’s life. Thereafter, breastfeeding
should continue for as long as the mother and baby wish, while gradually
introducing a more varied diet.
Babies who are not breast-fed are many times more likely to acquire illnesses such
as gastroenteritis and respiratory infections in the first year 2. In addition, there is
some evidence that babies who are not breast-fed are more likely to become obese
in later childhood3,4. Mothers who do not breastfeed have an increased risk of
breast and ovarian cancers and may find it more difficult to return to their
pre-pregnancy weight5.
Within the West Midlands, breastfeeding initiation rates have risen from 53.0% in
2005/06 to 66.6% in 2009/106.
The Public Health White Paper also emphasises that public health evaluation and
research will be critical in enabling public health practice to develop into the future
and address key challenges and opportunities, such as how to handle the wider
determinants of health and how to use behaviour change science to support better
more cost effective practice. This is supported by the setting up of a new School for
Public Health Research and a Policy Research Unit on Behaviour and Health.
Public Health England, the new service that will be part of the Department of
Health, will be expected to properly resource research into interventions happening
outside the NHS. Public Health England and others will work together to identify
research priorities and use the best evidence and evaluation and will support
innovative and cost effective approaches to behaviour change.
2.
OVERALL RECOMMENDATIONS
Infants
Babies who are not breast-fed are many times more likely to acquire illnesses such
as gastroenteritis and respiratory infections in the first year7. There is some
evidence that babies who are not breastfed are more likely to become obese in later
childhood8,9.
Mothers
Mothers who do not breastfeed have an increased risk of breast and ovarian
cancers and may find it more difficult to return to their pre-pregnancy weight10.
Breastfeeding can protect mothers against breast cancer; the relative risk of
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cancers decreases by 4.3% for every 12 months of breastfeeding. This can lead to
145 few cases every year11.
NICE uses a threshold of £20,000 - £30,000 per QALY to assess cost
effectiveness. Even if the scheme has a net cost, it would still be cost effective if the
QALY gain from a reduction in infection and breast cancer is achieved at less than
£20,000 - £30,000 per QALY.
Enhanced staff contact (which was additional skilled professional support in
hospital) was found to be more effective and less costly than normal staff contact,
both in the base case and the sensitivity only scenarios.
3.
EVIDENCE ON SPECIFIC INTERVENTIONS
The Baby Friendly Initiative (BFI), produced by WHO and UNICEF, accredits
maternity and community healthcare facilities that have implemented best practice
for breastfeeding and have passed an external assessment12. It has been endorsed
by NICE as the minimum standard for breast feeding management 13. Below are
components of BFI as well as other initiatives for the promotion of breastfeeding.
BFI Step 1: Have a written breastfeeding policy that is routinely communicated to
all healthcare staff14
There are few studies that have looked specifically at the effectiveness of a
breastfeeding policy on breastfeeding rates. However, the studies included in this
review seem to indicate that breastfeeding policies do appreciably improve
breastfeeding rates although this has not been definitively demonstrated. Taken in
combination with the other steps of the BFI, a breastfeeding policy is an important
starting point and can be used to implement the other steps of the BFI.
BFI Step 2: Train all healthcare staff in the skills necessary to implement the
breastfeeding policy
There is a paucity of data on the individual effect of training healthcare staff on
breastfeeding policy. The one non-randomised controlled quasi-experimental study
included in this review15 demonstrated a markedly positive effect on breastfeeding
rates of training in several steps of the BFI in a developing country. Training of
healthcare staff will be a pre-requisite to implementing the other steps of the BFI.
BFI Step 3: Inform all pregnant women about the benefits and management of
breastfeeding16
Individual educational interventions appear to be variably effective in
socio-economically deprived populations. Group discursive educational sessions on
breastfeeding, however, however appear to be effective in low-income and minority
groups17. There is also some evidence that showing mothers how to breastfeed and
express breast milk improves exclusive breastfeeding rates18.
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BFI Step 4: Help mothers initiate breastfeeding soon after birth19
This component appears to have a positive effect on breastfeeding rates including
in socio-economically deprived populations. Early breastfeeding initiation and
skin-to-skin contact should be encouraged.
BFI Step 6: Give newborn infants no food or drink other than breast milk, unless
medically indicated20
The majority of evidence points towards routine nutritional supplementation
reducing breastfeeding rates. Exclusive breastfeeding should therefore be
encouraged unless medically indicated.
BFI Step 7: Practice rooming-in, allowing mothers and infants to remain together
24 hours a day21
Although the evidence around rooming-in remains weak, it does point towards a
positive effect on breastfeeding rates and should therefore be encouraged.
BFI Step 8: Encourage breastfeeding on demand22
A weak evidence base suggests breastfeeding on demand improves breastfeeding
rates beyond one month23,24. This is likely to be more feasible when rooming-in is
practiced.
BFI Step 9: Give no artificial teats or dummies to breastfeeding infants25
The evidence around the harms of artificial teats is ambiguous but several
observational studies indicate that they may reduce breastfeeding rates in both high
and low income settings26,27,28. It therefore seems reasonable to avoid provision of
artificial teats and pacifiers to breastfeeding infants.
Do not provide commercial discharge packs promoting formula milk
Two meta-analyses29,30 suggest that provision of commercial discharge packs with
formula milk is detrimental to breastfeeding rates and should therefore be
prevented.
BFI Step 10: Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital or clinic31
This was the only aspect of the BFI for which economic data was available.
Jacklin’s (2007) economic analysis showed that peer support groups fall within the
NICE threshold for cost effectiveness. A systematic review by NICE32 showed that
breastfeeding support from both peers and professionals is effective at increasing
any breastfeeding among women who plan to breastfeed. Its effect on exclusive
breastfeeding among socially disadvantaged women however is weak.
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BFI
This combined intervention has been demonstrated to improve breastfeeding rates
in one large cluster RCT33 by 36.9% at 3 months following 12 to 16 months of
implementation in Belarus and two before-after studies34,35. Similar findings were
also observed in Gateshead, UK36. The marked findings of these studies suggest a
synergistic effect of the multiple components of the BFI and that complete
implementation may be more effective than isolated interventions. See Appendix 1
- Evidence for Breastfeeding Initiatives for full results and references, prepared by
Shamil Haroon, Sandwell PCT.
4.
COSTS AND COST EFFECTIVENESS
Breastfeeding Benefits to Infants and Mothers:
Cumulative Annual Savings in NHS Treatment Costs37
An increase of 10 percentage points in prevalence at 6 months means that 60,000
extra infants are breast-fed every year, providing estimated annual savings to the
NHS in treatment costs as follows38,39. See also the Financial Benefits of Improving
Health of Low Income Households (Appendix 2).
Otitis Meida
Gastroenteritis
Asthma
Lower Respiratory Tract Infection
Breast Cancer
Total Annual Savings
5.
£0.5 million
£2.3 million
£2.6 million
£0.8 million
£0.9 million
---------------£7.1 million
FURTHER READING
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NICE Public Health Guidance 11: Maternal and Child Health – ‘Improving the
Nutrition of pregnant and breastfeeding mothers in low income households &
NICE Public Health Guidance 11: Costing Statement Maternal and Child
Nutrition: http://guidance.nice.org.uk/PH11/guidance/pdf/English
NICE Clinical Guidance 37, “Routine Postnatal Care of Women and Their
Babies”, includes clear recommendations and a costing report template to
support implementation and calculating national and local costs and savings
including costs in relations to implementing Breastfeeding Initiative:
http://www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf
Increasingly breastfeeding prevalence contributes to reduction in health service
costs. NICE Costing Template, NICE 37, 2006: “Postnatal Care: Routine
Postnatal Care of Women and their Babies Costing Report: Implementing Nice
Guidance in England”:
http://www.nice.org.uk/nicemedia/pdf/implementation_tools/cg37costingreport.d
oc
Appendix 3 - obesity and breastfeeding - a review of the evidence
Financial Benefits Associated with Breastfeeding © UNICEF UK/Jill Jennings
2006: www.babyfreindly.org.uk (see Appendix 2)
Department of Health: Commissioning Local Breastfeeding Support Services:
consolidates the case for breastfeeding care and support as an integral part of
local strategies to improve child health and reduce health inequalities and
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signposts commissioners to sources of policy, practice and evidence.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic
yAndGuidance/DH_106501
Breastfeeding Promotion for Infants in Neonatal Units: A systematic review and
economic analysis, Health Technology Assessment-National Institute for Health
Research 2009: Vol 13: No 40 DOI:10.3310/hta13400. HMSO ISSN 1366-5278:
www.hta.ac.uk/project/1611.asp
Modeling the Cost Effectiveness of Interventions to Promote Breastfeeding,
September 2007. National Collaboration Centre for Women’s and Child Health
for NICE: www.nice.org.uk/nicemedia/live/11677/34695/34695.pdf
Support for Breastfeeding Mothers (Review), The Cochrane Library 2009,
Issue 4,
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001141/frame.html
Public Health Guidance 11, Maternal and Child Nutrition
http://www.nice.org.uk/nicemedia/pdf/ph011quickrefguide.pdf
Appendix 4 - West Midlands Breastfeeding CQUINs (updated September 2010)
A literature review (Appendix 5) was undertaken on preventing obesity in
children aged <5. The review confirms that there is limited and immature
evidence and a lack of comprehensive evidence on effective strategies to
prevent obesity in younger children. There are some interesting individual
studies that enhance and support recent NICE guidance around activity, familybased interventions and breast-feeding. The need remains for structured,
focused and systematic research on child obesity prevention. Well-designed
studies examining a range of interventions remain a priority. The findings in this
review support the recommendations in the National Institute for Health and
Clinical Excellence (NICE) guidelines on obesity.
http://jpubhealth.oxfordjournals.org/content/29/4/368.full.pdf+html
5
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APPENDICES
Appendix 1
Summary of Evidence for Breastfeeding Initiatives
Adobe Acrobat
Document
Appendix 2
Financial benefits and improving health of low income households
Adobe Acrobat
Document
Appendix 3
Obesity and Breastfeeding – A Review of the Evidence
Adobe Acrobat
Document
Appendix 4
West Midlands Breastfeeding CQUINs
Adobe Acrobat
Document
Appendix 5
Literature Review – Preventing Obesity in Children Aged <5
I:\Pbhealth\Health
Strategy Unit (JB AO JD)\Julie Davis 2011\OBESITY - QIPP FINAL DOCS FROM ALEX - AMENDED\Infant Feeding - App KS.pdf
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8