This case study will aim to look at breastfeeding and growth and its impact on the mother and child. It will explore best practice and current initiatives and guidelines in line with the Department of Health (DH), National Institute of Clinical Excellence (NICE) and the local Primary Care Trust (PCT).
In order to maintain confidentiality in line with The Code (NMC 2008), pseudonyms have been used to protect the mother and baby from being identified.
I first met Eve when we went out to do baby Adam’s first contact visit at 14 days old (DH 2004b). Eve is a 28 year old lady who is a first time mother who lives with her partner. As part of the initial assessment Adam was weighed. Adam was born at 38+ weeks gestation by caesarean section after mother failed to dilate past 5cm and baby went into distress. His birth weight was six pound two ounces (2.78kg). Adam was a relatively small baby but not classed as low birth weight which often classified as 2.5kg or less (Bonellie et al 2008). When we weighed Adam and his weight was entered onto his centile chart it was noted he had lost 4oz. It is reported that most babies will lose 5%-7% of their birth weigh in the first weeks, usually regaining the weight by week three (La Leche League 1997).
With the consent of mum, Adam was checked over physically to see if there was any medical reason why he was not feeding. Mouth ulcers, sores, teeth and thrush can often be painful for the baby when feeding which in turn may cause them to reject the breast (Eiger and Olds, 1999). Tongue tie and poor latching are also associated with poor feeding.
When Eve let us observe her breastfeeding it was noted that he wasn’t latching onto his mother’s breast correctly to feed. An extensive history of their daily routine was taken, documenting the times that Adam was feeding, how long for and what position he would feed from. Eve gave a good account of when and what time of the day he was feeding and also for how long he would feed for, telling us which breast he preferred and what he was like latching on. Eve then began to get upset and disclosed she was finding it difficult to feed Adam and because he had lost some weight, she was prepared to give up breastfeeding altogether and bottle feed him. She was also feeling extremely tired from all the day and night feeds.
Breastfeeding initiation rates in the UK are among the lowest in Europe (DH 2008 p16). Breast milk has been identified in several studies to be the only form of nutrition needed for al least the first six months of a babies life (DH 2004a, DH 2007, WHO 2001), containing nutritional value and immunity to certain diseases (Who 2003) and exclusive breastfeeding is recommended for the first six months (26 weeks) of an infant’s life.
Breast milk is full of all the nutrients a baby needs, it also contains natural antibodies which help develop a natural immune system making the baby less prone to infections and viruses as breast milk is high in white blood cells. Not only does breast milk have all of the above but it also contains vital fats and protein which helps the babies growth and development (Eiger and Olds, 1999).
After observing Eve feed Adam, advice was given on different feeding positions and techniques. We got eve to get into a comfortable position for both her and Adam and then got them to try several different positions including slide over hold, rugby ball hold, the cradle and cross cradle hold for feeding till she found one which she felt at ease with. If a baby is correctly positioned and latched it will stimulate the breast supply with less effort making it easy for the baby to suckle and less stressful for mother (Le Leche, 1997). Eve found that the rugby ball hold felt the must comfortable using pillow to support Adam’s weight. The rugby ball hold favours a pillow for support for the baby whilst allowing it to be kept at the height of mother’s breast for a period of time. Mother can also look down to baby and engage in eye contact at the same providing a closer bond of attachment (Le Leche, 1997).
At all times supportive advice and reassurance was given at mothers pace and at her level of understanding free from jargon. Advice given to a mother needs to be practical and given in a language the mother can understand, without making her overpowered (Inch and Fisher, 1999)
Due to mothers concern over baby’s weight gain we agreed to weigh Adam in two weeks look at his weight and then weigh him again after two weeks at baby days, formally known as baby clinic. Sachs (2006) and Sachs et al (2005) as cited by Deshpande (2008) does not recommend weighing frequently as it can increases mothers anxiety causing them to fixate on the baby gaining weight. Monthly weighing is sufficient (Sachs, 2006) and babies with normal growth should only be weighed at immunisation and routine contacts (Wright, 2000). Weekly weighing lowers a mother’s self esteem causing them to blame themselve’s for the poor weight gain which in turn makes them feel a failure, leading to them supplementing feeds (Despande, 2008).
Recent studies (Bonellie et al 2008) show British birth rates have increased in the last few decades. Present centile charts in use date back to studies from the 1950’s based on the average infants weight of that era meaning centile charts now may not accurately reflect the average progression of growth in today’s infant. This can cause anxieties in parents when they see that the child does not follow along the ‘normal’ line of the centile line (Bonellie et al 2008). This needs careful explanation from the health visitor when weighing occurs.
Contact was arranged with mother’s consent for the nursery nurse to go in once a week to offer extra support in the early weeks, we also encouraged Eve to attended the breastfeeding support groups drop in sessions on a regular basis to help maintain her with the breast feeding. It would also give her chance to meet with other mothers who often experience the same anxieties.
Extra advice and support was offered from the health visiting team and its service’s inviting to Eve to attend a weekly breastfeeding workshop which provides support and advise from health visitors, nursery nurses and peer support from other mothers who were either breastfeeding or had breastfeed.
As part of the health surveillance screening we arrange a twelve to sixteen routine follow up screening visit (DH 2004b). As part of this visit we discuss weaning. Eva and Adams visit took place at fifteen weeks. We discusses weaning and at three an a half months old Eve noticed that Adam was starting to suck at his thumb and fingers more frequently, which led her to believing he wasn’t get enough to eat. She disclosed that again she had been tempted to give him some baby rice.
We revisited Adam’s feeding patterns and how milk supply ‘settles down’ when established feeding is in place, and how the breast produces its supply as need arises (Marvin 1999). We discussed weaning and Department of Health’s guidelines about best practice and weaning at six month (DH 2007).
Because breast milk changes in taste depending on mother’s diet, breastfed babies are exposed to a variety of different tastes and flavours preparing them for weaning. It is thought (Eiger and Olds, 1999) that breastfed babies are more likely to take to weaning and eating vegetables far easier than bottle fed babies. This is because formula milk never varies in taste making weaning more challenging when new tastes are introduced.
Reports show (Acheson 1998) a mother is more likely to bottle feed if she lacks confidence, has an unsupportive partner or family and where is also a lack of education and knowledge around breastfeeding. Bottle feeding is also more likely to occur in young women from deprived low income areas, they are less likely to breastfeed or follow breastfeeding guidelines correctly (DH 2007, Dh 2008). Babies born to mothers from deprived low income areas are more likely to be smaller than average weighing up to 130 grams lower than babies born to higher social classes (Acheson, 1998)
Recommendations from DH (2008, p19) suggest that, ‘all health professionals who come into contact with mothers and babies should have some form of breastfeeding management training’. The trust in which I am practicing encourages all staff to undertake the La Lesha training to provide that extra support to mums. The trust also train the peer support councillors on how to give correct advice and support to mums.
Benefits of breastfeeding for the baby are; a greater survival rate of breastfed babies (Eiger and Olds, 1999), less hospital admissions for diarrhoea and sickness, viruses and gastrointestinal problems (Inch and Fisher 1999). Breastfeeding also reduces the risk of nappy rash as breast milk is easier to digest than formula milk making less waste for the baby to pass (Biancuzzo, 1999). Breast milk has clear long term benefits as studies by Horta et al (2007) show that breastfed babies are more likely to have lower blood pressure, cholesterol, type 2 diabetes and be less likely to be obese it later life.
Benefits of breastfeeding for mother are; better bonding and attachment, a decreased risk of breast cancer and ovarian cancer. Womb shrinks back to size quicker regaining figure back quicker. (Biancuzzo,1999)
As well as the above benefits breastfeeding is convenient as it is always there, you don’t have to sterilize equipment or wait for the feed to cool. It saves money on equipment, bottles, formula and electricity (Eiger and Olds, 1999).
Benefits of formula feeding include, anyone can give a formula feed it doesn’t have to be mother and increases father/baby bond giving father a greater role to play, For those living in low income households buying formula can take up to 30% of the house hold income (Palmer, 1993) this can lead to mothers diluting the feed to last longer causing malnutrition and vitamin deficiency.
At World breastfeeding week the government announced that an extra 2 million pounds will be given to help promote breastfeeding as the UK has the lowest rate of breastfeeding in Europe. This money is to help improve the services of hospitals in deprived areas (Unicef, 2008). At present it hasn’t been decides how this money will be spent.
With all this in mind the local PCT within the area of practice has no recorded data on breastfeeding percentages for either those wholly breastfeeding or those partially breastfeeding at the 6-8week check for the first quarter or 2008. This was either due to inaccurate data given or records submitted. However it was recorded that initiating breastfeeding rates had been increasing with a 3.1% rise from 37.2% in 2004/2005- 40.3% in 2007/2008. For the first quarter of this year 2008/2009 the figures look promising for the year as the percentage rate is at 42.1%. Hopefully this will continue to increase as the year goes on. (Local Delivery plan Healthcare Commission Indicator 2008). The PCT’s aim is to increase the rate of breastfeeding by 2% a year by appointing specialist practitioners to over see this project. At present only 1% of mother’s breastfed their baby exclusively for the full six month.
From the evidence and literature I have read and researched it still seems a great deal of resources still need to be put it place to educate and allow mothers and potential mother who live in my practice area to make a more informed choices in the reasons as to why they to choose to breastfeed or bottle feed their child. Hopefully in the next five years we will have seen an increase in mother who chose to breastfeed.