Chester Clinic

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Section 1. The Introduction and Overview
1.1 Strategic Aims 1.2 Reducing Health Inequalities 1.3 Philosophy and Principles of Change 1.4 Engaging with Communities 1.5 Partnership Working 1.6 Responsibility for Achieving the Strategy Aims and Objectives 1.7 The Role of Glasgow and Clyde NHS Board 1.8 The Objectives of the Strategy 1.9 How are we doing so far? • Breastfeeding • Formula Feeding • Introduction and Establishment Of Complementary Foods (Weaning) 1.10 Strategy Prioritisation Overview Section 2. The Evidence for the Action Plans
2.1. Antenatal Care: – Information for Pregnant Women 2.2 Information and Support for New Mothers in Hospital 2.3 Information and Support for Mothers in the Community 2.4 Information and Support for mothers and babies in Paediatric and Neonatal Units 2.5 Supporting Mothers who choose to formula feed or who cannot breastfeed. 2.6 Introduction and Establishment of Complementary foods (weaning) Section 3. The Action Plans
3.1 Policy and Guideline Implementation and Staff training – for all areas 3.2 Audit and data collection –for all areas 3.3 Care in Hospital and by Community Midwives at Home –for Maternity Units 3.4 Information and Support for Mothers in the Community- for Community Health Partnerships 3.5 Information and Support For infants in Neonatal Units and Paediatric Section 4. The Role of the Infant Feeding Team and Work plans
4.1 The team's commitment to Services 4.2 The team objectives and priorities 4.3 The Appendices including the UNICEF UK Baby Friendly Standards and the Staff Training Plan 4.4 The References 127001.indd Sec1:1 127001.indd Sec1:1 The Foreword
The Scottish Government and NHS Greater Glasgow and Clyde (NHSGGC) are committed to ensuring that every child has the best possible start in life and is able to reach their full potential. Experiences and influences in childhood will have far-reaching and profound effects in adulthood and later life. Efforts to tackle key health and social problems common in the Scottish population must begin in the early years and continue throughout the primary school years and adolescence. Improving child health, welfare and opportunity, particularly for our most disadvantaged children and young people, is a priority across all Government and Board portfolios and departments. Good nutrition, particularly amongst 0-2 year olds, is a foundation for future health and has a major role to play in promoting public health and reducing inequalities. This period is critical for infants and the immediate consequences of poor nutrition at this time can include illness and death. It can also cause delayed mental and motor development, impaired intellectual performance and future work capacity1. Optimal nutrition is exclusive breastfeeding for around 6 months and then continued for 2 years and beyond with the appropriate introduction of nutritious weaning foods. Breastfeeding can make a major contribution to an infant's health and development and it is associated with better health outcomes for the mother; reducing her incidence of breast and ovarian cancer, osteoporosis and obesity and its associated diseases (diabetes, hypertension and heart disease). It has long term health benefits for the child including; reduced incidence of gastroenteritis, otitis media, urinary tract infections, obesity, eczema, asthma and diabetes2'3 The Scottish Government has set a H.E.A.T (Health, Efficiency, and Access Target) for Breastfeeding in Scotland of
33.1% of babies being exclusively breastfed a 6-8 weeks by 2011. The NHSGGC target has been set at 30% (currently
the rate is only 24.1%). Implementation of this Strategy and its Action Plans is the mechanism by which NHSGGC can
work towards achieving this target and the wider nutrition aims for all our children.
The NHSGGC Infant Feeding Strategy has been through a systematic process of public consultation, including focus group and user responses which have greatly influenced the final document. Users were very clear that their priority was to be supported by professionals with skill and knowledge and who could impart this to them effectively. It was evident that further staff training is vital along with adherence to a few basic standards. During the focus groups mothers made simple suggestions for improving breastfeeding outcomes, including, "having someone to sit with them for one whole breastfeed and teach them how to feed their baby rather than doing it for them".
The Strategy and its objectives will run from 2008 -2012. However the Action plans will be updated in 2010. This will enable new evidence, effective interventions and new tools to be incorporated. During 2008 we will concentrate on communicating the objectives, planning the implementation of the action plans and initiating the evaluation tools. NHS GGC Infant Feeding Strategy Group
Chair Rosslyn Crocket Public Health Consultant Dr Maggie Lachlan Head of Maternity Services Eleanor Stenhouse Professor of Human Nutrition Professor Lawrence Weaver Head of Dietetics Anne MacLean at Yorkhill Representing CHPS Health Improvement & Planning Fiona Mackay Partnership Rona Agnew (RCN) Infant Feeding Coordinator NHS GGC Linda Wolfson 127001.indd Sec1:2 127001.indd Sec1:2 Section 1. The Introduction and Overview
1.1 Strategic Aims
The Aim of the Infant Feeding Strategy is to Promote and Support Optimal
Nutrition for all Babies and Infants in the 0-2 Year Range.
• To increase breastfeeding initiation and maintenance rates at all time points.
• To increase the incidence of exclusive milk feeding until around 6 months.
• To improve practices associated with formula feeding and use of suitable milks.
• To increase the incidence of continued optimal nutrition for all infants when introducing solid foods and establishing lifelong healthy eating habits • To increase the incidence of appropriate vitamin supplementation.
• To reduce health inequalities 1.2 Reducing Health Inequalities
It has been clearly demonstrated that even children from the most affluent families who are formula fed are less
healthy as teenagers and show worrying markers of poor, long term health than children from the poorest families
who are breastfed1.
The philosophy of this strategy is "Health for all19". "Health for all" is an internationally recognised framework which
highlights the need to develop health policy based on equity and to close the health gap within countries.
Gakidou et al defined health inequality as the variations in health status across individuals in a population3. In Scotland,
between 2001-06, while 66.4% of babies from SIMD quintile 1 were breastfed, only 24.8% of those born into SIMD
quintile 5 were breastfed20.
Glasgow and Clyde has a poor health record and suboptimal nutrition clearly contributes to variations in health status
within its population. In 2006, only 40% of babies in NHSGGC were being breastfed at all at 6-8 weeks. Within
NHSGG&C, because inequalities are so widespread there is the potential for an exclusively population-based approach
to infant feeding to contribute to an increase in health inequalities. Thus the Strategy will balance a population-based
approach with targeted interventions for specific vulnerable groups.
The Infant Feeding Strategy is aligned to the program's four themes:
• Supporting families, mothers and children• Engaging communities and individuals• Preventing illness and providing effective treatment and care• Addressing the underlying determinants of health The themes are underpinned by five principles that will guide how health inequalities are tackled in practice: • Preventing health inequalities getting worse by reducing exposure to risks and addressing the underlying causes of ill health.
• Working through the mainstream by making services more responsive to the needs of disadvantaged • Targeting specific interventions through new ways of meeting need, particularly in areas resistant to • Supporting action from the centre by clear policies effectively managed.
• Delivering at a local level and meeting national standards through diversity of provision.
127001.indd Sec1:3 127001.indd Sec1:3 1.3 The Principles of the model of Change
The UNICEF UK Baby Friendly Initiative will target all families. It will be the main vehicle for increasing staff capacity
and capability, and the main driver for delivering this Strategy. The wider social and nutritional and early year's agenda
can then build on this to achieve optimal continued nutrition. The Strategy also includes more targeted interventions
to support infant nutrition. These include peer support in areas with low breastfeeding rates to develop social capital;
specialist support for mothers with breastfeeding problems and multiple interventions for the most vulnerable sick and
premature babies. These infants often come from areas of high social deprivation. Combining approaches will improve
the nutrition and health outcomes amongst these children and contribute to reducing inequalities. In this way, allocation
of resource will relate to and reflect the greater concentration of need. Resulting from disadvantage, whether social of
physical.
Health for All in the 21st century, advocates creating more sustainable health through health promoting physical,
economic, social and cultural environments for people21. The strategy recognises the importance of cultural change in
improving infant nutrition and therefore includes components highlighting the role of CHCPs, partner agencies and local
communities in developing public acceptability programmes of work.
The principles of the model of change described in the Ottawa charter more than 20 years ago5 are still applicable and can inform the way we improve health in the following areas:- Building Healthy Public Policy; Boards and Councils need to take responsibility for ensuring that policy protects breastfeeding, other food provision and environmental factors which contribute to a suboptimal nutrition risk. It can support women by limiting advertising of breast milk substitutes, protecting maternity leave and rights to continue to breastfeed or express milk for working mothers. Any policy or strategy which may have an impact on children's nutrition should collaborate and promote cross working to ensure appropriate pathways, i.e. Hall 4 and the review of Maternity Services and the new Maternity Care Pathways Creating Supportive Environments for Health; The community needs to create environments which make healthy choices easier, supporting public acceptability of breastfeeding feeding in public and awareness of breastfeeding's role in reducing the obesogenic environment.
Strengthen Community Action for Health; Developing social capital through local support groups and peer counselors and with local women promoting breastfeeding at community events, postnatal groups promoting diet and exercise programs which support healthy lifestyles and optimal nutrition for children.
Developing Personal Skills for Health; facilitating mothers' ability to maximise their families' health, to interact effectively with health services and to become active partners. Promoting self efficacy amongst young adults to enable appropriate decision making, to make healthy choices and develop effective parenting skills is vital.
Reorientation of Health Services; Services should be fit for purpose, increasing opportunities for health promotion, parenting and nutrition programs for expectant parents, whilst also tackling professionals lack of knowledge and skills and inappropriate personal attitudes to nutrition, particularly breastfeeding.
1.4 Engaging with Communities
The main focus for this will be local action within CH(C)Ps, supported by NHSGG&C Children and Families network,
and they will have a key role.
The Strategy emphasises, that creating sustainable change requires the support, enthusiasm and commitment of local
people working in partnership with a wide range of local statutory and voluntary organisations.
• Local people should be involved in the planning and development of local services and set priorities within national plans and targets.
• CH(S)Ps could commission voluntary and community organisations to deliver services to tackle specific inequalities relating to infant nutrition. They need to work together to develop Local Strategic Partnerships to encourage community involvement and ensure that action on health inequalities is relevant to local need, engaging with the philosophies of Hall 4, social justice and narrowing the inequalities gap. 127001.indd Sec1:4 127001.indd Sec1:4

This Strategy fits with the three-year cross-government plan to tackle health inequalities, establishing the foundations
required to reach the national health inequalities targets. It commits to actions across different geographical areas,
between genders and different ethnic communities, as well as between different economic and social groups. The program
draws on evidence from the Acheson Report (Independent Inquiry into Inequalities in Health, 1998).
There remains a great deal of work to do towards reducing the gradient in health inequalities but improving child nutrition
would be a step in the right direction. Over the last decade Glasgow and Clyde has been proactive in implementing
successful Breastfeeding Strategies. This new strategy will continue much of this work but also expand the remit to all
nutrition for children in the 0-2 year range.
1.5 Partnership Working
Whilst a great deal of this Strategy is orientated towards the health sector as the primary contact and support network for
new parents there is a clear recognition that there are many agencies and interventions, both upstream and down stream
which can contribute towards a shift in cultural orientation towards optimal nutrition. It is clear that the health services
need to be prepared to support and protect nutrition, acknowledging the biological norm of exclusive breastfeeding as
optimum nutrition for around the first 6 months of life.
The main structure for partnership working will be the new CHC(S) P structure. There are also opportunities for
partnership working within the strategy sub groups The Infant Feeding Strategy is not just for health but for education,
business, the media, the voluntary sector, communities and the public to work together to improve the health of our
children. Parents will require coordinated support from a range of agencies that have differing but complementary roles.
1.6 The Responsibility and accountability for implementing the Infant Feeding Strategy is clearly
• Directors of CHP's, Director of Mental Health Partnership, Director of Women & Children's Directorate, Board Nurse Director and Director of Public Health.
• Health care staff and managers across the Board area e.g. midwives, health visitors, dieticians, pharmacists, GP's, paediatricians, neonatologists, nurses, support staff, social workers, mental health, addictions staff and dentists. • Leads for pre registration and under graduate Health Professional Education 1.7 The Role of Glasgow and Clyde NHS Board
The Board has appointed an Infant Feeding Coordinator and team of Advisors to facilitate the delivery of this Strategy
and enable partners to implement the objectives. The team of Advisors will use their expertise to advise local teams on the
implementation of the action plans and setting local targets. Each service will have a named link Advisor.
• This team will work towards increasing staff capacity and capability and improving processes and • There are core services that require expertise which this team will provide i.e. staff training, audit, policy and guideline development and expert support at breastfeeding clinics. • The team will carry out some of the project work of the strategy sub groups and dissemination of good However the ultimate responsibility for achieving these objectives lies with the directors and clinical leads within each service.
127001.indd Sec1:5 127001.indd Sec1:5 1.8 The Objectives of the Strategy;
1. To increase the capacity and capability of health professionals to promote optimal nutrition for all babies and all
infants and to help establish lifelong healthy eating habits 2. To develop a centrally coordinated, standardised system of collecting and disseminating infant feeding data, quality outcomes and practice audit 3. To promote and enhance cultural acceptability of and positive public and professional attitudes towards breastfeeding.
a. To Increase the Capacity and Capability of Health Professionals;
• By designing processes that deliver a service that can promote optimal nutrition for infants and improve the patient journey to that end.
• By implementing, achieving accreditation and maintaining the UNICEF UK Baby Friendly Initiative6 standards for maternity Units7, Community8 Health Partnerships Education9 providers and Neonatal Units10. (see appendices 1, 2 and3) • By continuing to develop and review service policies and procedures to ensure that they actively support breastfeeding and optimal nutrition.
• By educating professionals and providing infant feeding training for all staff that have contact with pregnant women and or new mothers at an appropriate level for each staff group. There will be a consistent approach and standard across the board, and this will be regularly evaluated, reviewed and updated. (see appendix 4 –the Training Plan) • By developing and supporting staff to be able to provide evidence based information. • To provide skilled clinical and positive emotional support for parents whilst initiating milk feeding and throughout the establishment of healthy lifelong eating habits11.
b. To Develop a Centrally Coordinated, Standardised System of Collecting and Disseminating Infant Feeding
Data, Quality Outcomes and Practice Audit;
• By collecting data about breastfeeding initiation and maintenance, formula feeding and weaning practices through a centrally coordinated system. • By collecting information on the quality of the patient experience using measurable quality indicators and identifying risk.
• By providing comprehensive information throughout the board area to inform and direct future action plans and resources.
c. To Promote and Enhance Cultural and Public Acceptability and positive attitudes towards Breastfeeding;
• By developing initiatives which increase social capital, e.g. by targeting resources into areas with low breastfeeding rates with a view to facilitating peer volunteer support networks, peer support groups and community involvement.
• By developing and implementing a multi-agency approach to all services; working together to promote and • By developing and implementing educational tools for schools and nurseries to promote the benefits of breastfeeding and public acceptability of breastfeeding as the norm.
• By implementing programs which raise public awareness of the benefits and public acceptability of • By further developing and implementing human resources policies and suitable facilities for staff who return to work whilst breastfeeding within the public and private sector.
127001.indd Sec1:6 127001.indd Sec1:6 1.9 How are we doing so far? - Breastfeeding -
Best Practice; It is recommended that mothers exclusively breastfeed for around 6 months and then
continue breastfeeding for two years and beyond.
Glasgow and Clyde has exclusive breastfeeding rates at 6-8 weeks of 24.6% (2006). This reduced initiation and maintenance of breastfeeding is of growing concern especially in disadvantaged groups and is a prime example of the gap in health inequalities. % Exclusive breastfeeding at 5- 7 days
(Guthrie card data by Maternity Unit)
Inverclyde Royal Hospital, Greenock
The Princess Royal Maternity The Queen Mother's Hospital, Royal Alexandra Hospital, Paisley The Southern General Hospital, Vale of Leven, Dumbarton * Data is not available as less than 100 deliveries
% Breastfeeding Rates (exclusive)
at 6-8 weeks by CHCP12
East Dunbartonshire CHP
East Glasgow CHCP East Renfrewshire CHCP North Glasgow CHCP Renfrewshire CHP South West Glasgow CHCP South East Glasgow CHCP West Dunbartonshire CHP West Glasgow CHCP NHSGGC Any Breastfeeding NHSGGC Exclusive Breastfeeding
Why are breastfeeding rates so low? – Comments from mothers and peer volunteers during the
consultation process.
• We have a formula and bottle feeding culture• Health professionals attitudes are not aligned to optimal nutrition, they are not adequately trained and best practice is not being sufficiently implemented • There are widespread cultural issues, unsupportive and obstructive practices & misinformation• Changes in social infrastructures have eroded social capital and support mechanisms which favoured • Patterns of employment, maternity leave and work environments are unsupportive.
The reasons for not initiating breastfeeding are multifaceted and include the influence of society and cultural norms. Mothers do not maintain it for the same reasons but also because of clinical problems13. The organisation of health and social services and the lack of consistent and effective support for breastfeeding can cause or exacerbate these issues. To improve breastfeeding rates a sustainable, coordinated approach is needed, requiring effective partnerships between statutory, voluntary and community services14. This strategy highlights a vision of the multi-agency action that is required to promote and protect breastfeeding in Glasgow and Clyde. It is based on the best available current evidence.
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Formula feeding
Best Practice; Where parents choose not to breastfeed or it is not possible then exclusive whey based
formula milk is recommended for the first 6 months. They should continue with the whey based
formula milk and weaning foods until the baby is a year old. Whole cows milk is then adequate for the
majority of babies.
We do not have precise data for local formula feeding practices, however the Infant Feeding Survey 200515 said; • Three-quarters of all mothers had given their baby milk other than breast milk by the age of six weeks, this proportion rising to 92% by six months. • About half of all mothers had given their baby casein based follow-on milks. • Just under half of all mothers who had prepared powdered infant formula in the last seven days had not followed the key recommendations for preparing formula.
• Locally health professionals are reporting the common use of casein based milks and increasingly associated referrals to dietetic services and "constipation" clinics. The practice of larger, less frequent feeds can lead to over feeding, lack of appetite control and subsequently obesity. The Introduction of Complementary foods (weaning)10
Best Practice; Weaning foods should be introduced at around 6 months. Additional vitamin
supplements should be given according to current recommendations. Healthy eating patterns and
appropriate food and drinks should be established during the weaning process and continued into
childhood to meet changing nutritional and developmental needs.
The Infant Feeding Survey 200512 said; that there has been a marked trend towards mothers introducing solid foods later. In 2000 85% of mothers had introduced solid foods too early (by four months) but by 2005 this figure had fallen to 51%. Only a negligible proportion of mothers (2%) were delaying weaning onto solids until six months.
• Later introduction of solids tended to be guided by professional advice such as the health visitor and written sources. The decision for earlier weaning was likely to be based on informal advice from friends, family and subjective criteria such as whether the baby seems satisfied with milk feeds and the mother's previous experience.
• There is some local data but no Infant Feeding Survey results for vitamin Supplements; Each year a significant number of children show evidence of rickets in Glasgow and Clyde. Work is currently under way to identify the causes. Although some of the children had major underlying illnesses, some were healthy term infants. The guideline around vitamin supplements requires to be more closely complied with and the mechanisms for distribution clarified.
127001.indd Sec1:8 127001.indd Sec1:8 1.10 Strategy Prioritisation Overview
Short –term actions / priorities
Medium-term actions /priorities
Long-term actions / priorities
Jan 2008 –Dec 2008 Dec 2008 – Dec 2010 Dec 2010 –Dec 20 12 • Infant Feeding Strategy Group, • Strategy sub groups to be • Review of membership, structure, Implementation and Monitoring developing from implementers workload and effectiveness of groups Group and Sub Groups to of best practice standards to a • Review achievements in light of the oversee and develop the research and development phase 2010 Infant Feeding Survey implementation of the Strategy where new evidence is created.
(with appropriate membership, • Review Strategy Action Plans chairpersons, remit, in line with the National Infant communication mechanisms, Feeding Strategy (when available).
objectives, time scales and reporting frameworks).
• Roll out Strategy & align health services to the aims and objectives.
• Link members of the Infant • Action plans within services and • Health services partners to complete Feeding advisor team to support clinical teams /CHP's, progressing action plans and achieve all objectives with objectives and achieving and non NHS to be progressing with • Roll out action plans to services action plans.
and clinical teams / CHP's etc • Update action plans.
• Health services to all have achieved and to carry out self assessment of • Develop partnership working with maintaining UNICEF UK accreditation. progress within action plans.
nurseries, schools, universities • Accreditation to be sustainable.
• Health services to plan actions and the public sector to develop for prioritised objectives of appropriate action plans, implementing standards and • Advisors to assist the teaching tools for these groups.
implementation of these objectives, including the UNICEF UK Baby Friendly Standards and WHO International Code compliance (includes the cessation of artificial milk promotion within the health service. • Update, coordinate and deliver • Completion of training for • Training for staff that provide secondary training for staff with clinical staff who have primary clinical clinical responsibility responsibility for Infant feeding responsibility for feeding • Evaluate the models of peer • Rolling out peer support into • Peer support equitably available and support available and promote all maternity units, the RHSC, the appropriate model(s) support groups and community (effective, acceptable and sustainable) to individual CHP's.
• Service providers to agree • Local rates and quality targets to • Review of outcomes, effectiveness and uniform data and quality be set and audit of action plans evidence for actions and re-write of indicator collection, risk Strategy Action Plans.
management tools and • Data, quality indicators and action • Groups to contribute to further setting standardised audit tools.
plans to be formed into Clinical of local and Board targets and future Effectiveness Reports, to inform structure of the Clinical Effectiveness providers and strategy group of progress and reported annually to the Strategy Group and the Health Board.
127001.indd Sec1:9 127001.indd Sec1:9 How will things get better for mothers and
How will we know things are better?
All mothers will have access; Breastfeeding rates will increase at all time • to a suitable professional who will offer a points and be measured; one to one discussion on the benefits and management of breastfeeding.
• on discharge from hospital • to effective antenatal classes which prepare them for breastfeeding.
• to antenatal input that is adapted to best suit • to breastfeeding promotion in a number of There will be improved rates of exclusive areas, particularly within schools. breastfeeding at all stages All health professionals who advise parents More Formula feeding mothers will report; • that they are following recommendations for • promote optimal nutrition and be informed, preparing formula and are choosing more knowledgeable, skilled and appropriately appropriate milks. • a reduced incidence of vomiting, colic and • provide standards based on the UNICEF UK Baby Friendly Initiative • adhere to the Health Board policy and Whilst introducing solids more mothers will guidelines which will be evidence based, support optimal nutrition and effective care.
• that they are waiting until nearer 6 months to • provide formula feeding mothers with care based on the Boards standards • that the incidence of appropriate vitamin use • participate in the local audit of standards and is increasing and the incidence, particularly in act on discrepancies.
healthy term infants of rickets is decreasing, Parents who encounter feeding difficulties and Mothers' comments and audits will report challenging situations; improved standards of care; • will be fully supported by the board staff and • more UNICEF Baby Friendly accreditations given consistent information.
• improved audit results • will be appropriately referred to the most • reduced incidence of breastfeeding problems appropriate service • higher satisfaction levels and less complaints • access to relevant expertise will be provided • improved rates of exclusive breastfeeding at • parents views and insight into their experiences will be actively sought • reduced incidence of high risk events Parents will have access to community based nutritional support;• from trained health professionals and specialist services • at breastfeeding workshops• at breastfeeding support groups• from peer support volunteers (target groups)• at weaning fares 127001.indd Sec1:10 127001.indd Sec1:10 Section 2. The Evidence for the Action Plans
2.1. Antenatal Care: – Information for Pregnant Women 2.2 Information and Support for New Mothers in Hospital2.3 Information and Support for Mothers in the Community2.4 Information and Support for mothers and babies in Paediatric and Neonatal Units2.5 Supporting Mothers who choose to formula feed or who cannot breastfeed.
2.6 Introduction and Establishment of Complementary foods (weaning) 127001.indd Sec1:11 127001.indd Sec1:11 2.1 Antenatal Care: – Information for Pregnant Women
The Evidence - Effective action recommendations to increase breastfeeding initiation rates (N.I.C.E 200610)
• One-to-one needs-based breastfeeding education and peer support programmes should provide information and counseling support in the antenatal period combined with postnatal support to low income women. • Informal, practical breastfeeding education in the antenatal period should be delivered in combination with peer support programmes to all women. • A single session of informal, small group and discursive breastfeeding education should include topics like avoiding and resolving nipple pain and trauma, particularly targeting women from minority ethnic groups.
• Breastfeeding education and support from one professional should be targeted to women on low incomes. What do the mothers say? Infant Feeding Survey (200512)
• First-time mothers, second-time mothers who had breastfed their previous child for six weeks or more, mothers who had been breastfed themselves as infants, and mothers who had friends who breastfed were the most likely to intend to breastfeed. Mothers who intended to breastfeed exclusively fed for longer than mothers who intended to mix breast and formula feeding.
• 80% of mothers had received some advice during their pregnancy about the health benefits of breastfeeding, with midwives being the most common source of such advice. Mothers who had information were more likely than mothers who had not to initiate breastfeeding. • About a third of mothers had attended antenatal classes and first-time mothers and mothers from managerial and professional occupations were the most likely to attend. Mothers who had attended antenatal classes where feeding was discussed or where they were taught how to position the baby were more likely to intend to breastfeed. Where are the gaps at present? • Health Education classes and breastfeeding workshops are generally provided in hospitals and in the community by midwives and a few health visitors. Few are needs based, attendance is low and often not reaching target groups. • Peer volunteer intervention, on a one to one basis, in pregnancy is available in some areas but it is not provided equitably for all women for whom it may benefit. Mothers in areas where it is available are recruited from deprivation category 5, 6 and 7 and offered input form peer volunteers. The recruitment process is resource intensive but could be refined to more accurately target the appropriate mothers. Other staff groups could assist by referring appropriate mothers.
• There is limited input from peer volunteers into local or hospital antenatal groups.
• One to one additional professional input for target mothers is variable.
2.2 Information and Support for New Mothers in Hospital
Evidence; -Effective action recommendations to increase breastfeeding maintenance in hospital (N.I.C.E 200610)
Most of the recommendations could be achieved by implementing the UNICEF UK Baby Friendly Standards4
Hospital practices – to be adopted (these practices have the greatest evidence that they support successful
breastfeeding)
• Unrestricted breastfeeding from birth onwards and unrestricted mother-baby contact during the postnatal stay, for all women. Encouraging rooming in and early initiation of breastfeeding.
• Provision of additional, breastfeeding-specific, practical and problem solving support from a health professional should be delivered in the early postnatal period for all women.
• Changes in hospital policies to ensure that discharge packs are free from promotion for artificial feeding.
127001.indd Sec1:12 127001.indd Sec1:12 • A review of educational materials and approaches• Professional training should be undertaken for hospital staff to teach positioning and attachment using a predominantly "hands off" approach in the early postpartum period.
• One-to-one needs-based breastfeeding education in the antenatal period combined with postnatal support through the first year should be available to low income women Hospital practices – to be abandoned (these practices have the strongest evidence that they are harmful to the
establishment of successful breastfeeding.
• Routine supplemental feeds given in addition to breast feeds • Restriction of the timing and/or frequency of breastfeeds • Restriction of mother-baby contact from birth onwards during immediate postnatal care.
• The provision of hospital discharge packs containing formula • Separating healthy babies from their mothers for the treatment of jaundice What do the mothers say? Infant Feeding Survey (200512) – Key findings
The most common time for mothers to stop breastfeeding is in the first 72 hours (14%). In Scotland an increase
in prevalence was seen at birth but the proportion still breastfeeding at six weeks and six months fell in 2005. 38% of
mothers who breastfed initially had stopped breastfeeding at six weeks.
Breastfeeding and the birth/experience in hospital; the type of delivery did not have a significant effect on
breastfeeding duration. Initiation of breastfeeding was higher for mothers who had early skin-to-skin contact than those
who had no such contact after the birth. Babies spending a few days in special care after the birth were less likely than
average to be successfully breastfed. Long-term admissions did better.
A third of breastfed babies had received additional feeds in the form of formula, water or glucose while in hospital.
This practice was particularly associated with low birth weight babies and those starting life in special care. In about a
third of cases, additional feeds had been given because the mother wanted this rather than because this had been advised.
Help in hospital; Only 70% of mothers' breastfeeding in hospital had been shown how to put their baby to the breast in
the first few days. Mothers who had received help or advice found this most useful if the helper stayed until the baby had
fed.
The problems experienced in hospital; Problems encountered in the very early days by breastfeeding mothers were
mainly centered on problems with attachment or failure to feed followed by breast or nipple discomfort. These still
featured as problems for mothers after leaving hospital. Mothers introducing or switching to formula milk commented
that the babies were not satisfied (24%) or had a medical need for top-ups of formula (18%).
Most Common reasons mothers give up breastfeeding in hospital12;
1. Reluctant Feeders 2. Difficult attachment 6. Admission to PD > 2 days 3. Formula supplement given 4. Skin Contact, none or <3o minutes 8. Wt loss > 10% Where are the gaps at present?
The breastfeeding cessation and incidence of mixed feeding occurs most often in the first 72 hours (14%). Many of the interventions need to be preventative. More effective support needs to be targeted into this period e.g. more intensive input from Midwives, Infant Feeding Advisors, Peer Support Volunteers and Lay Counselors. 5 of the 6 local maternity units are accredited as UNICEF UK Baby Friendly and many of the core principles should be in place. It is clear that these standards are not being met all of the time. The additional support for auditing, maintaining and improving the standards is inequitable across the services. 127001.indd Sec1:13 127001.indd Sec1:13 The likely hood of success is increased by avoiding problems4;
• Skin Contact at birth and an early feed
• Effectively teaching positioning and attachment and particularly observing a full breastfeed
• All staff able to effectively teach parents how to understand feeding cues, demand feeding, offer both
breasts and rooming in.
• Avoiding Supplements• Previous successful breastfeeding, > 6 weeks is predictive of future success– so ensure prim gravid have an optimal experience 2.3 Information and Support for Mothers in the Community
Evidence; -Effective action recommendations to increase breastfeeding maintenance in the community (N.I.C.E
200610) (these practices have the greatest evidence that they support successful breastfeeding)
• Peer support or volunteer counselor support should be delivered by telephone to complement face-to-face support in the early postnatal period to women who want to breastfeed. • Additional health professional, breastfeeding-specific, practical and problem solving support should be delivered in the early postnatal period for all women.
• Regular breast drainage and continued breastfeeding should be implemented as routine practice for breastfeeding women experiencing mastitis. • The combination of supportive care, teaching breastfeeding technique, rest and reassurance should be routine practice for breastfeeding women with ‘insufficient milk'.
What do the mothers say? Infant Feeding Survey (200512) – Key findings
Problems feeding the baby in the early weeks; A third of breastfeeding mothers had experienced some kind of feeding
problem either in hospital or in the early weeks after leaving. The highest levels of problems were experienced by mothers
who used a combination of breast and formula (around half of all mixed feeding mothers experienced problems). Mothers
who did not receive help for these problems were more likely to have stopped breastfeeding within two weeks than those
who did.
Prevalence and duration of exclusive breastfeeding; At six months the prevalence of exclusive breastfeeding was
negligible (<1%). The prevalence and duration of exclusive breastfeeding was higher at all ages up to four months among
mothers from managerial & professional occupations, aged 30 or over and highest education level.
The most common reasons mothers stop breastfeeding in the community12;
1. Wouldn't suck/latch on/poor attachment2. Baby still hungry/not satisfied3. Needed (top-ups of) formula4. Baby fed too slowly/ falling asleep/ distracted / Baby not feeding properly/ enough/ not interested5. Baby vomiting/reflux / Colic/wind6. Breast milk dried up/not enough / not gaining enough/ lost weight7. Breastfeeding painful (incl. sore breasts/nipples/ mastitis) Where are the gaps at present?
Many of the interventions need to be preventative but more effective support needs to be targeted into the early period of establishing breastfeeding e.g. more intensive input from Midwives, Infant Feeding Advisors, Health Visitors, Peer Support Volunteers and Lay Counselors.
127001.indd Sec1:14 127001.indd Sec1:14 There are 3 UNICEF Baby Friendly accreditations in the community5 areas of Glasgow and Clyde. These standards need to be achieved for all areas. The additional support for auditing, maintaining and improving the standards is inequitable across the services. This needs to be addressed locally by the CHP's and within the Boards Infant Feeding Team.
The likely hood of success is increased by avoiding problems5;
• Skin to skin contact in hospital and home.
• All staff able to effectively teach positioning and attachment
• All staff able to effectively teach parents how to understand feeding cues, demand feeding, offer both
breasts and rooming in.
• Guidelines and monitoring of supplements, Staff skilled around issues which avoid parental choice to • Targeting high risk groups e.g. by providing peer support input and or additional professional led groups and interventions. 2.4 Information and Support for Mothers and Babies in Neonatal Units and Paediatric Hospitals
Evidence; Recommendations to increase breastfeeding initiation and maintenance amongst sick and premature
babies.
Effective action recommendations; Breastfeeding in Neonatal Units: A review of publications McInnes R & Chambers
J16 (2005).
WHO (2007) Optimal feeding of low-birth-weight infants: technical review / Karen Edmond, Rajiv Bahl.
There are many reasons that can cause a young baby or child to be admitted to a neonatal or paediatric facility including genetic or structural abnormalities, sepsis and birth complications but low birth weight and prematurity are amongst the most common. These children are frequently born to families in NHSGGC's most deprived communities. Improving their nutrition will greatly reduce the burden of ill health and the length and quality of life. This most vulnerable group are one of the Boards target high risk groups.
Low birth weight (LBW) has been defined by the World Health Organization (WHO) as a weight at birth less than 2500 grams. In Europe this affects approximately 6.4% of newborns. Low birth weight can be a consequence of pre-term birth (i.e. before 37 completed weeks of gestation), or due to small size for gestational age (SGA, defined as weight for gestation <10th percentile). It is generally recognised that being born with a low birth weight is a disadvantage for the infant. Pre-term birth is a directcause of 27% of the 4 million neonatal deaths that occur globally every year. Pre-term birth and SGA are also important indirect causes of neonatal deaths. Low birth weight directly or indirectly may contribute up to 60–80% of all neonatal deaths. LBW infants are at higher risk of early growth retardation, infectious disease, developmental delay and death during infancy and childhood. Countries can substantially reduce their infant mortality rates by improving the care of low birth weight infants. Experience from both developed and developing countries has clearly shown that appropriate care of LBW infants,
including feeding, temperature maintenance, hygienic cord and skin care, and early detection and treatment of infections
can substantially reduce mortality in this highly vulnerable group. Interventions to improve feeding are likely to
improve the immediate and longer-term health and wellbeing of the individual infant and to have a significant
impact on neonatal and infant mortality levels in the population. Better feeding of pre-term babies was one of the first
interventions in the 1960s in the UK and was associated with reduced case fatality for pre-term babies in hospitals before
the advent of intensive care.
127001.indd Sec1:15 127001.indd Sec1:15 Summary of the findings from the reviews;
Choice of milk
Breastfeeding or mother's own expressed milk (EBM). There is strong and consistent evidence that feeding mother's
own milk to pre-term infants of any gestation is associated with a lower incidence of infections and necrotising
enterocolitis, and improved neurodevelopmental outcome compared with formula feeding. Feeding unsupplemented
mother's own milk to pre-term infants <1500 g resulted in slower weight and length gains, but the implications of this
slower growth are unclear and there is not enough evidence to assess if it increased the risk of malnutrition. Long-term
beneficial effects of breastfeeding on blood pressure, serum lipid profile or pro-insulin levels have also been reported for
pre-term infants. There is limited data on most outcomes in term LBW infants; the available data suggest that improved
infection and neurodevelopmental outcomes associated with feeding mother's milk in pre-term infants is also seen in this
group.
Methods of Expressing Breast Milk; hand expressing is recommended, starting as soon after the birth as possible,
expressing at least 6-8 times in 24 hours including at least once at night. When the breasts begin to fill, at around 3-5 days
after delivery the mother can continue to hand express and or use an electric or hand breast pump. She should continue
to use a massage technique prior to and during expressing to increase hormone release. Double pumping is preferred
to sequential pumping (electric pumps). Even though hand pumps are preferred by some mothers the purchase or hire
requires motivation and has cost implications and it may not convey a sense of necessity or medical support to express
amongst some parents. Therefore units should be cautious about a move to recommending hand pump for all parents.
Donor human milk. The available data indicate that feeding with donor human milk rather than standard or pre-term
infant formula to LBW infants of <32 weeks gestation reduces the incidence of necrotising enterocolitis. The data is
insufficient to conclude if there are neurodevelopmental advantages. Growth is slower in the short term in the infants fed
donor human milk, but there are insufficient data to assess the effects on long-term growth outcomes. It should be noted
that many of the identified studies used drip milk (i.e. breastmilk that drips from the opposite breast while breastfeeding)
rather than the recommended expressed donor milk. Although there is limited evidence, it can be assumed that the
findings are similar in infants of 32–36 weeks gestation. There are no data on outcomes in the subgroup of term LBW
infants.
Pre-term infant formula. Infants of <32 weeks gestational age who were fed preterm infant formula had higher
psychomotor developmental scores at 18 months of age than those fed standard infant formula. Although there was no
overall effect observed in these children at 7½–8 years of age, the verbal intelligence quotient (IQ) scores were higher
in the pre-term infant formula group among boys. Pre-term formula increases growth during the neonatal period but
this is not sustained during later infancy and childhood. No long-term benefits (e.g. blood pressure, serum lipid profile
or pro-insulin) have been found. There is insufficient data to draw any conclusions for pre-term infants of 32–36 weeks
gestational age or for term LBW infants.
Optimal duration of exclusive breastfeeding. Overall there is no evidence to recommend a different duration of exclusive
breastfeeding for pre-term or term LBW infants than for infants who are not low birth weight. Limited available data from
industrialised countries suggest that early supplementation of breastfeeding (at about 3 months of age) with a high calorie
diet in pre-term infants may marginally increase linear growth and haemoglobin levels. No data are available for other
key outcomes. Among term LBW infants, the available evidence from two trials suggests that exclusive breastfeeding for
6 months, compared with 4 months had no deleterious impact on neurodevelopment, growth, or haemoglobin levels, if it
was accompanied by iron supplementation.
Human milk supplementation
Vitamin D; There is some evidence of reduced linear growth and increased risk of rickets in babies with a birth weight
<1500 g fed unsupplemented human milk. There seems to be no consistent benefit of increasing the intake of vitamin D
from the usually recommended 400 IU per day. There are no clinical trial data on the effect of vitamin D on key clinical
outcomes in infants with a birth weight >1500 g.
Phosphorus and calcium; There is some evidence that phosphorus and calcium supplementation reduces the risk of
metabolic bone disease in pre-term infants and leads to short-term increases in bone mineralization in infants with a birth
weight of <1500 g. There are no data on the effect of phosphorus and calcium supplementation on key clinical outcomes
in infants with a birth weight >1500 g.
127001.indd Sec1:16 127001.indd Sec1:16 Iron; Iron supplementation, started at 6–8 weeks of age in LBW infants, is effective in preventing anaemia during
infancy. There is some evidence that anaemia is common in LBW infants fed unsupplemented human milk even at 8
weeks of age. There is also some evidence to suggest that iron supplementation, started at 2 weeks of age, may prevent
this early anaemia in infants with birth weights <1500 g. However, there are insufficient data on the safety of iron
supplementation during the first two months of life. There are no data on the effects of iron supplementation on mortality,
common childhood illnesses or neurodevelopment in LBW infants.
Vitamin A; No conclusions can be made about the benefits of early vitamin A supplementation of LBW infants. Findings
from one large trial suggests that vitamin A (50,000 IU in one or two divided doses) during the first days of life may have
a survival advantage, particularly in infants with birth weights <2000g.
Zinc; There are no data on the effect of zinc on key clinical outcomes in pre-term infants. Data from two trials in
developing countries suggest that term LBW infants in developing countries may have lower mortality and morbidity if
they receive zinc supplementation. There seems to be little evidence that zinc supplementation in these infants improves
neurodevelopment or affects growth.
Multicomponent fortifier; In infants of <32 weeks gestation, there is evidence that use of multicomponent fortifier leads
to short-term increases in weight gain, linear growth, head growth and bone mineralization. There is insufficient data
to evaluate the long-term neurodevelopmental and growth outcomes, although there appears to be no effect on growth
beyond one year of age. Use of multicomponent fortifiers does not appear to be associated with increased risk of mortality
or necrotizing enterocolitis, although the small number of infants and the large amount of missing data in the studies
reduce confidence in this conclusion. Also, in the largest trial undertaken there was a significant increase in the incidence
of infection among infants receiving the fortifier. There is no data examining the efficacy of multicomponent fortifier in
infants of 32–36 weeks gestation or in term LBW infants.
Parents views on Fortifiers v Preterm Formulae; Parents preferred powder additives and infants who had powder
additives tended to be breastfed for longer. Parents were more satisfied with growth with liquid supplements (although
weights were not statistically significant and may be driven by professional attitudes). Current fortification practice is
generally driven by individual paediatricians or units preferences. A balance needs to be struck between the many benefits
of breastmilk use and the likelihood of increasing breastfeeding duration without increasing infection rates.
Cup feeding compared with bottle feeding; In pre-term infants, cup feeding leads to higher rates of full (exclusive or
predominant) breastfeeding, compared with bottle feeding at the time of discharge from hospital. Cup feeding was also
associated with greater physiological stability, e.g. lower risk of bradycardia or desaturation, than bottle feeding. No data
are available for term LBW infants. When cup feeding is correctly done, i.e. with the infant upright and the milk is not
poured into the mouth, there is no evidence that there is an increased risk of aspiration.
Nasogastric compared with orogastric feeding; Physiological data show that nasogastric tubes increase airway
impedance and the work of breathing in very preterm infants, which is supported by clinical data showing an increased
incidence of apnoea and desaturation.
Bolus compared with continuous intragastric feeding; Bolus feeding refers to a calculated amount of feed given
intermittently every 1–4 hours by a nasogastric or orogastric tube. In infants of <32 weeks gestation, there is some
evidence that bolus feeding can reduce the time to full enteral feeding, but no conclusions can be made about other
advantages or disadvantages. A disadvantage of continuous feeding of expressed breastmilk is that fat can separate
and stick to the syringe and tubes. There is physiological data which shows that duodenal motor responses and gastric
emptying is enhanced in infants of 32–35 weeks gestation given continuous intragastric feeding. There is no trial data
comparing clinical outcomes associated with continuous or bolus intragastric feeding in infants of 32–36 weeks gestation
or in term LBW infants.
Trophic feedings or minimal enteral nutrition; Trophic feeding or minimal enteral nutrition refers to intragastric milk
feeds in the first few days of life in sub-nutritional quantities, e.g. 5–10 ml/kg/day on the first day of life. A systematic
review and Meta analysis of 10 randomized controlled trials (RCTs) indicate that trophic feedings in infants of <32 weeks
gestation is associated with a shorter time to reach full enteral feeds and shorter duration of hospitalisation. There was
127001.indd Sec1:17 127001.indd Sec1:17 no significant increase in the risk of necrotising enterocolitis although the findings do not exclude an important effect. Trophic feeding is not relevant for infants of >32 weeks gestation because they usually tolerate maintenance enteral feeding from the first day of life.
Initiation of ‘maintenance' enteral feeding; Data is available only from two controlled studies conducted in the 1960s.
One of these studies showed that infants <2250 g at birth had higher mortality if given full maintenance enteral fluids
starting within 2 hours of birth as compared to those given small enteral feeds starting 12–16 hours after birth. Findings
from the other study in infants of <32 weeks gestation indicated that infants given IV fluids on the first day of life had
lower mortality than those who received nasogastric feeds of glucose in water or those who received no feeds or fluids.
No firm conclusions can be drawn from these studies. However, it appears that very pre-term infants may benefit from
avoidance of full enteral feeds on the first day of life.
Progression of enteral feeding; In infants of <32 weeks gestation, faster rates of increase in feeding volumes (20–35
ml/kg/day compared with 10–20 ml/kg/day) may decrease the time to full enteral feeds and may increase weight gain.
There is limited information regarding safety (broad confidence intervals for incidence of necrotising enterocolitis)
and the effect on length of hospital stay. There is limited data from which to draw any conclusions about fast rates of
advancement of feeding rates in infants with 32–36 weeks gestation or in term LBW infants. However, these infants are
more likely to tolerate rapid feeding regimens even better than smaller more immature infants.
Demand or scheduled feeding; Demand feeding may be feasible for some infants with 32–36 weeks gestation and may
reduce the length of hospitalisation. No data are available for infants of <32 weeks gestation and term LBW infants.
Maternal involvement in care and feeding of LBW infants; Substantial benefits in terms of improved breastfeeding rates
and early discharge from hospital were reported when mothers participated in the care and feeding of their LBW infants
in neonatal units.
Time of discharge from hospital; Several RCTs indicate that there are no adverse outcomes of early discharge, including
no differences in weight gain, short-term complications and hospital readmissions, if the infants are discharged when the
following criteria are met: the infant can breastfeed and maintain body temperature in an open crib, shows no evidence of
clinical illness and is not losing weight, and the mother demonstrates satisfactory care-giving skills.
Kangaroo mother care (KMC); In clinically stable pre-term infants with a birth weight of <2000 g, there is evidence
that KMC is at least as effective as conventional care in reducing mortality. KMC may reduce infections and improve
exclusive breastfeeding rates and weight gain. There are insufficient data regarding the effect of KMC in infants
with birth weights <1500 g because many of these infants were excluded from the available studies as they were not
considered to be clinically stable. There is preliminary evidence from resource-poor settings that KMC may be effective
even in clinically unstable LBW infants including those with birth weights <1500 g. There are no data regarding the effect
of KMC in term LBW infants.
Non-nutritive sucking; Non-nutritive sucking may decrease the length of hospital stay in pre-term infants but has no
effect on growth outcomes in preterm infants who weigh less than 1800 g at birth. Encouraging the infant to suck on the
‘emptied' breast, after expression of breast milk, may result in improved breastfeeding rates at discharge and at follow-up.
Breastfeeding counselling; There is little data on the effect of breastfeeding counselling among pre-term infants of <32
weeks gestation. Among pre-term infants of 32–36 weeks gestation and term LBW infants, breastfeeding counselling
improves the rates of exclusive breastfeeding at 3 months. This finding is consistent with the results of a meta-analysis of
20 intervention trials in term normal birth weight infants.
Drug therapy for enhancing lactation; The available evidence suggests that domperidone increases breastmilk volume in
mothers of infants of <32 weeks gestation, particularly those who were having difficulty in maintaining milk production.
There are no data regarding efficacy in the mothers of infants of 32–36 weeks gestation or for term LBW infants.
Growth monitoring; There is evidence that exact mimicry of fetal growth is not possible even in well-resourced neonatal
care units in developed countries. Catch-up growth occurs after very discrepant rates of neonatal growth and is less likely
to be complete in the smallest infants. The optimal timing of catch-up growth is uncertain. It is unclear if lack of rapid
catch-up is associated with a higher malnutrition risk. Rapid catch-up does not appear to improve neurodevelopment. On
the other hand, rapid catch-up after the first year of life may be associated with increased cardiovascular risk in later life.
127001.indd Sec1:18 127001.indd Sec1:18 Although monitoring the growth of LBW infants is considered essential for appropriate management, there are no data examining the effects of growth monitoring on key clinical outcomes of LBW infants. Breastfeeding is associated with significant health advantages for the low birth weight infant and the mother; however, they are less likely to be breastfed than their term counterparts. The evidence base for practices that support breastfeeding in the neonatal unit is more limited than the term evidence base and as preterm or sick babies experience different feeding challenges it may not be helpful to extrapolate findings to them. Food, Fluid and Nutritional Care in Hospitals17
The effective delivery of food and fluid, and the provision of high quality nutritional care, are crucial for the wellbeing of patients in all hospitals. The NHS Quality Improvement Scotland (NHS QIS) Food, Fluid and Nutritional Care in Hospitals Project Group developed six standards which bring together the patient at all stages in the journey of care, with the processes of planning, preparing and delivering food and fluid. The overall performance assessment statements are underpinned by criteria that are mapped directly from each standard. • Standard 1 - Policy and Strategy; Each NHS Board has a policy, and a strategic and co-ordinated
approach, to ensure that all patients in hospitals have food and fluid delivered effectively and receive a high quality of nutritional care.
• Standard 2 - Assessment, Screening and Care Planning; Processes and procedures for assessment,
screening and care planning are being implemented and monitored fully, and there is a cycle of continuous monitoring of implementation and impact on patient care throughout the Board area. When a person is admitted to hospital, an assessment is carried out. Screening for risk of under nutrition is undertaken, both on admission and on an ongoing basis. A care plan is developed, implemented and evaluated.
• Standard 3 - Planning and Delivery of Food and Fluid; There are formalised structures and processes in
place to plan the provision and delivery of food and fluid. There are formalised structures and processes in place to plan the provision and delivery of food and fluid.
• Standard 4 - Provision of Food and Fluid to Patients; Food and fluid are provided in a way that is
acceptable to patients.
• Standard 5 - Patient Information and Communication; Patients have the opportunity to discuss, and
are given information about, their nutritional care, food and fluid. Patient views are sought and inform decisions made about the nutritional care, food and fluid provided.
• Standard 6 - Education and Training for Staff; A Board nutrition awareness, education and training
programme is being implemented and monitored fully, and there is a cycle of continuous monitoring of implementation and impact on patient care throughout the Board area.
Where are the gaps in Neonatal Services at present?
• The UNICEF UK Neonatal Standards are available; however they cannot be externally assessed and accredited as yet. There has been less awareness raising amongst staff although the neonatal units have many of these standards in place because of the similar maternity standards. The Paediatric sites are the acute area that needs most attention. The additional support for auditing, maintaining and improving the standards has not been available consistently. This needs to be addressed by the individual services.
• Many of the interventions need to be proactive and more effective support needs to be targeted into the early period of establishing lactation then breastfeeding e.g. more intensive input from midwives, Infant Feeding Advisors, Health Visitors, peer support volunteers and lay counselors.
• The Food, fluid and nutrition standards are being implemented but much work is still required for all of the standards to be met.
127001.indd Sec1:19 127001.indd Sec1:19 2.5 Supporting Mothers who choose to formula feed or who cannot breastfeed.
What do the mothers say? Infant Feeding Survey (200512) – Key findings
• Formula milk use; Three-quarters of all mothers had given their baby milk other than breast milk by the
age of six weeks, this proportion rising to 92% by six months. Mothers from managerial and professional occupations and older mothers were the most likely to introduce milk other than breast milk at a later age, which reflects the higher levels of breastfeeding amongst these babies. About half of all mothers had given their baby follow-on milk. Mothers from routine and manual occupations, mothers who had never worked, and mothers with the lowest education level were more likely than average to say they had given their baby follow-on at an earlier age.
• Preparation of feeds; Just under half of all mothers who had prepared powdered infant formula in the last
seven days had not followed the key recommendations for preparing formula: either by not always using boiled water that had cooled for less than 30 minutes or not always adding the water to the bottle before the powder. About a third of mothers did not follow the recommendations for preparing formula when away from the home, either by not keeping pre-prepared formula chilled or by using cold or cooled water when making up feeds.
• Formula-feeding mothers with problems; These mothers were particularly likely to mention that the baby
fed too slowly (30% compared with around one in ten mothers breast or mixed feeing) or that the baby suffered from vomiting/reflux (15% compared with 1% breastfeeding and 2% mixed feeding).
• After leaving hospital, the main problems experienced by mothers formula-feeding were related to the
health of the baby: vomiting (27% compared with 4% of breastfeeding babies and 6% for mixed feeding) and colic/wind (27% compared with 8% breastfeeding & 6% mixed feeding).
Preventing Formula Feeding Problems
• Many of the interventions need to be preventative and support needs to be most available in the early days • Promoting breastfeeding in the antenatal period• Recommending skin contact and an early feed• Teaching how to bottle feed, choosing appropriate teats and bottles and winding the baby effectively. Explaining demand feeding and avoiding overfeeding • Demonstrating how to sterilise equipment, make up feeds correctly and discussion on appropriate milk Where are the gaps at present?
• Without precise local data and practice audit it is difficult to determine where we are. From reports in a variety of areas, there are comments that professionals remain very unclear about giving correct information to parents. Many feel that access to formula milk companies has reduced this. The Infant Feeding Policy and Guidelines15 have a nutrition sub group which has been providing accurate information since 2003 but staff awareness of this is limited. A more proactive approach to information dissemination, awareness raising and staff training is required.
127001.indd Sec1:20 127001.indd Sec1:20 2.6 Introduction and Establishment of Complementary foods (weaning)
Introducing solids -What do the mothers say? Infant Feeding Survey (200512) – Key findings
• Age of introducing solid foods; There has been a marked trend towards mothers introducing solid foods
later in 2005. For example, in 2000 85% of mothers had introduced solid foods by four months, but by 2005 this figure had fallen to 51%. Only a negligible proportion of mothers (2%) were following Department of Health guidelines in accordance with their precise interpretation - that is to delay weaning onto solids until six months. Later introduction of solids tended to be guided by professional advice such as the health visitor and written sources, whilst the decision for earlier weaning was likely to be based on informal advice from friends, family and subjective criteria such as whether the baby seems satisfied with milk feeds and the mother's experience.
• Solid foods given and avoided; When babies were four to six months, mothers giving solids were much
more likely to provide commercially-prepared foods than home-prepared foods in their babies' daily diets. Compared with 2000, higher proportions of mothers in 2005 said they avoided the use of salt, nuts and honey in their babies' diets. A greater awareness of food allergies in 2005 was one of the key reasons behind these shifts • Local guidance on establishing healthy eating habits for life (See Glasgow and Clyde Infant Feeding
Policy and Guidelines18). There is no clear evidence on local progress towards the objectives. By 12 months the diet of infants should have a variety of foods with appropriate textures, quantity, frequency and variety to meet changing nutritional and developmental needs. In the second year of life self feeding should be established in a family mealtime setting offering home prepared, nutritious foods, limiting high fat, high sugar and convenience foods and drinks. • Preventing ongoing feeding problems requires interventions which are support good practice. Support
needs to be available prior to the period of likely introduction of solids and again proactively to chart progress towards family foods and lifetime eating habits; By promoting 6 months exclusive milk feeding in the antenatal and postnatal period and by teaching how to make and offer nutritious and appropriate foods at different stages. Parents need education on the basic nutritional principles and how to avoid overfeeding, faddy diets and unhealthy eating habits.
• Vitamin Supplements; There is some local data but no Infant Feeding Survey results for vitamin
Supplements; Each year a significant number of children show evidence of rickets in Glasgow and Clyde. Work is currently under way to identify the causes. Although some of the children had major underlying illnesses, some were healthy term infants. The guideline around vitamin supplements requires to be more closely complied with and the mechanisms for distribution clarified. Where are the gaps at present?
• Without precise local data and practice audit it is difficult to determine where we are. From professionals in a variety of areas, there are reports that staff remains unclear about giving correct information to parents. The Infant Feeding Policy and Guidelines have nutrition sub group have been providing accurate information since 2003 but staff awareness of this is limited. A more proactive approach to information dissemination, awareness raising and staff training is required.
127001.indd Sec1:21 127001.indd Sec1:21 Section 3. The Action Plans
3.1 Policy and Guideline Implementation and Staff training – for all areas3.2 Audit and data collection –for all areas3.3 Care in Hospital and by Community Midwives at Home –for Maternity Units3.4 Information and Support for Mothers in the Community- for Community Health 3.5 Information and Support For infants in Neonatal Units and Paediatric Hospitals Each action plan relates to a particular aspect of the parents journey. It is
recommended that individual services work with the appropriate action plan or
plans relating to the care they provide.
• The plans require to be localised according to local needs and are designed to be dynamic, to be developed and to evolve with time.
• Action plans include all of the elements which will lead to readiness for UNICEF Baby Friendly assessment and accreditation. This is the Board's priority recommendation.
• The Board Infant Feeding Advisors are available to assist services to complete self assessments, develop the action plans and assist with the implementation. UNICEF requires an action plan to be completed as part of the staged approach to accreditation. As a board we can apply for some of these stages as a whole board or in groups (much more likely as many areas are at different stages). UNICEF can provide an action planning visit and your local attached advisor can work with your team to complete this. The UNICEF action plan will only cover the points in the action plans which relate to the UNICEF standards.
• There are a number of core services provided by the Board team to enable a simpler, more coordinated and effective implementation of the action plans objectives including;• Staff training packages and delivery of training.
• A Board wide Infant Feeding Policy and Guidelines• Audit tools and audit training for local staff• Standardised implementation tools, data collection and analysis 127001.indd Sec1:22 127001.indd Sec1:22 Action Plan 1 and 2 – For all areas
• Actions designed to Increase Capacity and Capability of Health Professionals across the Board area
• Actions designed to provide Evidence of Improved Outcomes and Standards of Care
1. Policy and Guideline Implementation and Staff training
Standards and Criteria Actions to be undertaken Required for the
a. Form a local Action planning group implementation of the
UNICEF UK Baby
Friendly Initiative (BFI)
b. Complete a baseline action plan in conjunction with the Standards (see appendix
Board Infant Feeding Advisor (and UNICEF advisor).
c. Complete a baseline audit of practice to ensure that action 1.1 Action Planning
plan is accurate in terms of addressing areas of weakness.
• Complete local action plan for implementation d. Action plan to be reviewed with regard to audit results and amended as necessary.
e. Action plane to be finalised & submitted to the Infant Feeding Strategy Group annually.
1.2 Application for
a. Stage 1 submission form to be completed and submitted, UNICEF UK BFI
together with required documents (Board Advisor will provide centralised materials).
• Submission for Stage 1. b. Baby Friendly Initiative office to be contacted to arrange assessment once audit findings indicate required standards are met.
• Application for Stage 2 c. Stage 2 assessment to be arranged based on satisfactory audit results and within 2 years of achievement of Stage 1.
• Application for Stage 3 assessment Stage 3 assessment d. Stage 3 assessment to be arranged based on satisfactory audit results and within 2 years of achievement of Stage 2.
1.3 Policy
a. An NHSGGC Infant Feeding policy exists but it requires (Step 1 /point 1.)
to be checked prior to submission for Stage 1 of the UNICEF accreditation process particularly if it has • Infant Feeding policy been updated/amended since award of Certificate of which covers best practice standards b. Laminated copies of the parents' guide to the policy are • Display of policy in available and should be prominently displayed in all all areas which serve premises/ areas which serve pregnant and new mothers.
mothers and babies (in different languages, large text, braille, audio if required) c. Each clinical area should be able to provide full policy copies of the Infant Feeding Policy and Guidelines for users on request.
127001.indd Sec1:23 127001.indd Sec1:23 • Mechanism for d. Each GP surgery, clinic, ward etc to have a nominated orientation of new health person to be responsible for ensuring that the parents' visiting and support staff guide is displayed and that a full copy of the policy is available for any member of the public wishing to view it.
• Mechanism for e. Develop & implement a written curriculum for orientation orientation of new of new staff (including new medical staff) to the Infant medical staff to the Feeding Policy and Guidelines. f. Ensure a formal mechanism for orientation to the policy • Mechanism for exists. A copy of the infant feeding policy should be orientation of other contained within the induction pack and new staff staff (e.g. Receptionists, meets with a nominated mentor on commencement of Practice Nurses) to the g. Consideration to be given to the introduction of a form to confirm that new health visiting and support staff have read and understood the policy. Forms could then be collected and stored by the clinical lead.
h. All staff to be orientated to the policy based on the 1.4. Staff Training (Step
Basic Infant Feeding Training 2 /point 2.) (See the
a. A written training curriculum which covers the Ten Steps, the Seven Points Plan and Neonatal Standards exists and a Board-wide mandatory education program for all relevant • Written curriculum for staff is available. The training program will be provided mandatory education as a core board service and will be updated according to program for health recommendations and evidence. The written curriculum visitors and support staff has been reviewed to ensure that all aspects listed in the – to include clinical skills Baby Friendly Initiative curriculum guidance document are training and updates covered. The standard program is available to all staff and the public for comment. Training will be evaluated at least • Plan for delivery of annually. (Training to reflect an understanding of impact of mandatory education for inequalities, equality and diversity sensitivities) clinical and support staff agreed b. Agreement to be reached with managers to enable staff to be released for training within 6 months of commencement • Written curriculum for of employment.
mandatory education program for medical staff c. Staff to be booked to have the appropriate mandatory Infant Feeding. Staff who have not yet attended the training to do • Plan for delivery of so at the next available date. mandatory education for medical staff agreed d. Training of appropriate clinical staff (those with primary responsibility for supporting mothers to establish feeding to • Mechanism for record have mentored Supervised Clinical Practice (SCP) within keeping of mandatory 6 months of starting a new post. Workbook should also be completed within this 6 month period.
e. All medical staff to be scheduled to attend/ uptake 127001.indd Sec1:24 127001.indd Sec1:24 To support classroom teaching;f. Consideration to be given to the development of a group of key local health visitors to act as mentors in the provision of supervised clinical practices for colleagues.
g. Key Workers to be educated to facilitate Supervised Clinical Practice (SCP), policy orientation and short education sessions. h. Key workers to be available in each clinical area which serves pregnant mothers and new parents.
i. Key workers to carry out clinical practices* **with staff in their allocated areas. Key workers to have an ongoing, updating programme.
* The provision of skills training is required for for all midwives, neonatal nurses, health visitors and support is necessary to support mothers with positioning and attachment and hand expression of breastmilk. ** Professional training should be undertaken for staff to teach positioning and attachment using a predominantly "hands off" approach with women in the early postpartum period with all women.
Updating staffj. Update sessions to be arranged should any additional learning needs be identified as a result of audit k. Develop a schedule for staff to be updated at least every 3 years and complete SCP in workbook again. l. Staff updates to be locally based on audit discrepancies. Keeping Recordsm. All staff orientation, training and SCP should be recorded in central record /database.
n. Records to be maintained and made available for 1.5 International Code
a. A Board-wide nutrition group exists and formula company Compliance
representatives are invited to inform the group bi-annually of new / relevant information in relation to their products.
• No promotion of breastmilk substitutes, bottles, teats or dummies b. Compliance with the Code is monitored locally and by the NHS GGC Clinical Practice Group.
• No sale of formula milk on facility premises or by its staff 127001.indd Sec1:25 127001.indd Sec1:25 c. Information about new/ relevant information about artificial milks to be disseminated to all relevant staff working within area. d. Appropriate staff, i.e. practice managers to be consulted regarding ways to ensure no innapropriate promotional materials are displayed.
e. Check all areas and written materials including Bounty (or other commercial packs) pack 4-6 weekly to ensure that they are WHO International Code compliant.
f. Ensure only appropriate formula feeding information is g. No sale of formula milk on health service facilities premises or by its staff.
Additional to the UNICEF a. Training programme will be provided as a core board
BFI Standards
service but will be updated according to recommendations and evidence. Training will support exclusive milk feeding 1.6. Mandatory staff
for around 6 months. Standard programme will be available training to support;
to all staff and the public for comment. Training will be evaluated at least annually. • Formula feeding for babies and children with whose mothers cannot or b. Staff to be booked to have the appropriate mandatory Infant choose not to or who stop Feeding Training within 6 months of starting a new post. c. Complete a schedule for staff who has already received • Community and training to ensure they are updated at least every 3 years. children's hospital based Staff updates to be locally based on audit discrepancies.
staff to support weaning and establishment of healthy eating habits. • For children's hospital based staff to support the Food, fluid and Nutrition standards 127001.indd Sec1:26 127001.indd Sec1:26 2. Total Quality Improvement - Audit and data collection
Required for the
a. Standardised feeding statistics to be available for each implementation of the
clinical area every 3 months; UNICEF UK Baby
• Antenatal checklist completion Friendly Initiative (BFI)
Standards (see appendix
• Feeding at birth, Feeding at discharge from hospital 1,2 & 3) and additional
• Feeding at 1st Health visitor visit, 6- 8weeks, and 26 weeks standards to the UNICEF
• Breastfeeding - supplementation rates.
2.1 Data Collection
b. Staff completion rates of statistical tools / compliance to be monitored locally.
• Maintenance of standardised feeding c. Results to influence local action plans and HEAT targets.
2.2 Audit
a. Implement routine face to face /telephone audit tool to measure standard implementation. Audit tool should cover • Mechanism for auditing all of the UNICEF UK BFI standards at least annually.
b. Infant Feeding Advisors to support local teams to complete • Audit to contribute to annual face to face audit, feedback to local staff on staff development standards of antenatal information giving, staff skills & postnatal support.
c. Consideration to be given to enabling key health visitors to attend audit training to enable effective use of the audit tool. 2.3 Quality Indicators
a. Quality Indicators to be developed, board wide, based on the DOH Infant Feeding Survey and updated after each • Maintenance of data on 5 yearly survey. Data collection tool to be developed standards and outcomes centrally. (may require additional interpreter support for b. Monitor quality indicators and re-train staff to improve clinical outcomes (staff updates to be designed to meet deficiencies).
2.5 Risk management
c. Develop strategies to identify and monitor problems and risk e.g. via feed charts & audit tools or an incident • Maintenance of data on monitoring system.
high risk incidents and poor outcomes d. Develop a mechanism for provision of debriefing for parents who have difficult feeding experiences. Improve • Management of Risk feedback for parents e. Development of a peer review system for staff to examine/ explore poor feeding outcomes.
f. Input into the Strategy annual clinical effectiveness report (results from audits, risk assessment, quality monitoring and incident reporting).
g. Staff development to be influenced by Clinical Effectiveness reports 127001.indd Sec1:27 127001.indd Sec1:27 Action Plan 3. – For Maternity Units
a. Antenatal actions designed to increase the initiation of and prepare parents for the reality of breastfeedingb. Postnatal actions designed to increase the initiation and maintenance of breastfeeding rates within c. Postnatal actions designed to improve the care provided for formula feeding families within maternity units 3.1. Antenatal Care: – Information for Pregnant Women
Standards and Criteria Actions to be undertaken Implement the UNICEF
a. Health professionals to have a discussion on a 1:1 basis UK Baby Friendly
with all mothers on the benefits and management of Initiative (BFI) Standards
breastfeeding prior to 32 weeks gestation. (appendix 1,2 & 3) ; Step
(may need information in different formats & languages) 3/ point 3
3.1.1 Provision of
b. Design standards for information giving sessions.
information on
health benefits and
management of
c. Implement written standards for antenatal information breastfeeding to all
giving Agreed written information should be given.
d. An antenatal infant feeding checklist based on the UNICEF • Written description of the checklist exists and forms an integral part of the maternity minimum information hand-held records (SWMR).
provided to all pregnant women e. An antenatal checklist should be completed for all mothers.
• Effectiveness and accuracy of written f. Professionals to further target those mothers greatest need. g. Peer support volunteers to target appropriate groups.
• Ensure Effectiveness and accuracy of written materials and WHO h. Checks to be carried out as part of audit cycle to confirm International Code that any changes to materials do not compromise effectiveness or accuracy.
i. Review resources locally and at Board level.
3.1.2 Ensure all
a. Ensure the appropriate teaching is within the standard Infant Feeding Curriculum for all staff that has who provide
responsibility for provision of this information.
this antenatal
care; midwives,
obstetricians,
b. Design updates for staff who deliver antenatal care. students & support
staff have had
specific training
to enable them
to deliver this
effectively.
127001.indd Sec1:28 127001.indd Sec1:28 3.1.3 Develop a
a. At action planning stage discuss and decide who will coordinated
take the lead in providing / or ensuring this information is approach between
health professionals
to ensure a
mechanism exists
b. Develop a collaborative approach to ensure that pregnant o ensure that
women receive all necessary information to be employed pregnant women
between CHCP staff and local maternity unit staff.
receive all necessary
information
c. CHCP health visiting staff and GPs to be made aware of the importance of opportunistic information-giving in the • Provision of information antenatal period and provide information opportunistically.
on the health benefits and management of breastfeeding to all d. Review situations where this information could be Additional to the UNICEF a. Infant Feeding Advisors to carry out a city wide review of
BFI Standards
provision of antenatal information giving.
3.1.4 Review provision
of antenatal
b. Review equity and accessibility of service provision and uptake i.e. consider combining midwifery, health visiting and peer volunteers to provide workshops in each CHCP.
3.1.5 Review provision of
a. Provide a written description of the minimum information antenatal education
provided for pregnant women at antenatal visits, classes & needs of specific
b. Consider specific additional needs based provision for target groups, i.e. young pregnant mothers, ethnic groups, partners, families and supporters, pregnant diabetics, multiple pregnancy & fetal abnormality, c. Develop needs based provision for these groups. Consider developing programs in conjunction with other agencies which may be more acceptable to particular groups. d. Develop informal, practical breastfeeding education in the antenatal period to be delivered in combination with peer support volunteer programs e. Extend invitations to pregnant mothers to attend postnatal breastfeeding support groups.
Evidence from the
a. Type of analgesia used in labour and at delivery and NICE Review (2006)
it's potential effect on breastfeeding outcome should be discussed with parents 3.1.6 Preparation for Birth
127001.indd Sec1:29 127001.indd Sec1:29 3.2 Postnatal Care in Hospital and by Community Midwives at Home
Implement the UNICEF
a. Ensure the place of delivery is supportive and conducive UK Baby Friendly
to unhurried, supported skin contact Standards: (appendix
1.); Step 4. & 7
b. Provide the opportunity for all mothers to have skin- 3.2.1 Mother and baby
to-skin contact with their babies in an unhurried, uninterrupted environment after delivery c. Ensure that the skin contact period is safe and observations of the mother and baby are made.
d. Keep mothers and babies together at all times including at night time unless the mother or baby's condition prevents this.
e. Offer of help with a first breastfeed for all mother when the baby is ready to feed.
Implement the UNICEF
a. NHGGC postnatal checklist to be incorporated into 3.2.2 Mechanism to
records for use by staff and all topics are included in ensure that mothers
postnatal checklist receive all necessary
information and
b. All relevant staff to be orientated in the appropriate support to breastfeed
use of the checklist at professional forums and during effectively and help
orientation period and education programs.
given to breastfeeding
mothers; Information
and support to
c. Staff to sign postnatal checklist when care is provided including; support with positioning and attachment and when they have taught a mother how to hand express • Demonstration/teaching for all breastfeeding mothers on how to position and attach their babies for d. Breastfeeding progress to be discussed at each contact with breastfeeding mothers and this to be recorded in the appropriate records • Demonstration/teaching for all breastfeeding mothers e. Offer of further assistance for mothers within six hours on how to hand express f. Provide effective teaching for all breastfeeding • Provision of information mothers on how to position and attach their babies for for all breastfeeding breastfeeding (hands off technique) mothers on the following issues: g. All breastfeeding mothers should have at least one full breastfeed observed, commented on and documented in • Maintaining closeness the first 72 hours after the birth.
of mother and baby and rooming-in* 127001.indd Sec1:30 127001.indd Sec1:30 • Baby-led feeding h. Provide a demonstration/teaching for all breastfeeding mothers on how to hand express breastmilk • Avoiding the use of teats and dummies for breastfed i. Staff to be encouraged to use written information, pictures and other props to reinforce teaching Encourage baby-led feeding, ensuring all mothers fully understand its importance and how to do it.
• Exclusive breastfeeding until around 6 months*Continued j. Ensure staff fully supports the keeping of mothers and breastfeeding for at least a babies together at all times including at night time and that staff and mother understand its vital importance.
* These topics are also to k. Ensure staff understand and support the importance of be discussed with mothers avoiding the use of teats and dummies for breastfed who are artificially feeding babies and provide information on this for parents.
their babies. Exclusive formula feeding for the l. Provide mothers information on the benefits of exclusive first six months should breastfeeding for 6 months and continued breastfeeding be discussed with these for the 1st year and beyond.
mothers rather than exclusive breastfeeding m. Ensure effectiveness, consistency& continuity of information giving including accuracy of written materials n. Discharge packs are free from promotion for artificial feeding and to encourage rooming in and early initiation of breastfeeding.
3.2.4 Supplementation of
a. Ensuring appropriate supplementation of breastfed breastfed babies
babies for clinical indication only.
b. Clinical indications should be evidence and needs based and recommended by appropriately trained staff.
c. Address supplementation of babies for non-clinical reasons and ensure this choice is fully informed.
d. All Policies and Guidelines should support exclusive and continued breastfeeding and balance the need for safety.
e. Timing of discussion with mothers regarding appropriate introduction of complementary foods at 6 months to be discussed and decision to be disseminated to health visitors 127001.indd Sec1:31 127001.indd Sec1:31 3.2.5 Provision of
a. Written information listing contact details for both health contact number(s)
professionals, support groups and voluntary groups to be for health visitor/
given to all breastfeeding mothers professional support
and local/national
breastfeeding
b. Professionals should ensure that mothers have received and understood these contact details and discussion documented on the postnatal checklist 3.2.6 Support for
Premature and Sick Babies
continued
a. Provide support to continue breastfeeding /expressing breastmilk and maintain contact with the baby when for difficult
mothers and babies are separated if the baby is unwell or circumstances and
premature (see neonatal and paediatric action plan).(to be when complications
included as part of mandatory education programme) • Provision of information b. Ensure expressing is encouraged as soon as possible for mothers separated from following birth and at least 6-8 times in a 24-hour period, their babies to enable them including once at night to establish and maintain lactation c. Staff to ensure that mothers are able to express both by hand and by pump (including offering details of how a pump may be obtained/loaned).
d. Mothers to be encouraged to visit their babies frequently and to have skin contact whenever possible Sick mothers
e. Provide support to continue breastfeeding /expressing
breastmilk and maintain contact with the baby when the mother is sick. Breastfeeding difficulties
f. Provide additional, breastfeeding-specific, practical and
problem solving support from a trained professional in the early postnatal period for women who are identified "at risk." and provide specialist intervention if needed. including those observed to be ineffectively feeding in the first 72 hours.
g. Provide contact number(s) for professional specialist support for feeding problems and refer to breastfeeding clinics.
Additional to the UNICEF
a. One-to-one needs-based peer support should be available to women in hospital who have been identified as target groups 3.2.7 Peer Support
b. Include mothers and peer supporters views and ideas in the development of services within maternity units.
c. Ensure peer supporters reflect target groups.
127001.indd Sec1:32 127001.indd Sec1:32 3.2.8 Encourage
a. Recommending skin contact and an early feed and appropriate formula
continued closeness feeding for babies and
children with whose
mothers cannot or
b. Ensure mothers receive all necessary information and choose not to or who
support to formula feeding as safely as possible.
Provision of information for all formula feeding mothers on the following issues: • Exclusive milk feeding until around 6 months• Appropriate whey based formula milk feeding for at least a • Provide teaching on how to bottle feed, choosing appropriate teats and bottles and winding the baby effectively.
• Explaining demand feeding –avoiding overfeeding• Demonstrating how to sterilise equipment and make up c. Ensure adequate provision of, effectiveness and accuracy of written materials 127001.indd Sec1:33 127001.indd Sec1:33 Action Plan 4. – For Community Health Partnerships
• Antenatal actions designed to increase the initiation of and prepare parents for the reality of breastfeeding• Actions designed to increase the maintenance of breastfeeding rates within the community• Actions designed to improve the care provided for formula feeding families within the community• Actions designed to improve the care families who are establishing a healthy eating life style for their 4.1 Antenatal Care: – Information for Pregnant Women
Standards and Criteria Actions to be undertaken Implement the UNICEF
a. Health professionals to have a discussion on a 1:1 basis UK Baby Friendly
with all mothers on the benefits and management of Initiative (BFI) Standards
breastfeeding prior to 32 weeks gestation. (see appendix 1,2 & 3) ;
Step 3/ point 3
c. Design standards for information giving sessions.
4.1.1 Provision of
information on
d. Implement written standards for antenatal information health benefits and
giving Agreed written information should be given.
management of
breastfeeding to all
e. An antenatal infant feeding checklist based on the UNICEF checklist exists and forms an integral part of the maternity hand-held records • Written description of the minimum information f. An antenatal checklist should be completed for all mothers provided to all pregnant women g. Professionals to further target those mothers greatest need. • Effectiveness and accuracy of written h. Peer support volunteers to target appropriate groups i. Checks to be carried out as part of audit cycle to confirm that any changes to materials do not compromise • Ensure Effectiveness effectiveness or accuracy and accuracy of written materials and WHO International Code j. Review resources locally and at Board level 4.1.2 Ensure all
a. Ensure the appropriate teaching is within the standard Infant Feeding Curriculum for all staff that has who provide this
responsibility for provision of this information.
antenatal care;
GP's, Health
Visitor, midwives,
b. Design updates for staff who deliver antenatal care. obstetricians,
students & support
staff have had
specific training
to enable them
to deliver this
effectively.
127001.indd Sec1:34 127001.indd Sec1:34 4.1.3 Develop a
a. At action planning stage discuss and decide who will coordinated
take the lead in providing / or ensuring this information is approach between
health professionals
to ensure a
b. A collaborative approach to ensure that pregnant women mechanism exists
receive all necessary information to be employed between to ensure that
CHCP staff and local maternity unit staff.
pregnant women
receive all necessary
information
c. CHCP health visiting staff and GPs to be made aware of the importance of opportunistic information-giving in the • Provision of information antenatal period and provide information opportunistically.
on the health benefits and management of breastfeeding to all d. Review situations where this information could be • Provide a written description of the minimum information provided for pregnant women at antenatal visits, classes & workshops Additional to the UNICEF a. Infant Feeding Advisors to carry out a city wide review of
BFI Standards
4.1.4 Review provision
b. Review equity and accessibility of service provision and of antenatal
uptake i.e. consider combining midwifery, health visiting and peer volunteers to provide workshops in each CHCP.
4.1.5 Ensure Effectiveness
a. Review resources locally and at Board level and accuracy of
written materials
and WHO
b. Checks to be carried out as part of audit cycle to confirm International Code
that any changes to materials do not compromise effectiveness or accuracy 4.1.6 Review provision of
a. Consider specific additional needs based provision for antenatal education
target groups, i.e. young pregnant mothers, ethnic groups, needs of specific
partners, families and supporters, pregnant diabetics, multiple pregnancy & fetal abnormality.
b. Develop needs based provision for these groups. Consider developing programs in conjunction with other agencies which may be more acceptable to particular groups. c. Develop informal, practical breastfeeding education in the antenatal period to be delivered in combination with peer support volunteer programs.
d. Extend invitations to pregnant mothers to attend postnatal breastfeeding support groups.
127001.indd Sec1:35 127001.indd Sec1:35 4.2 Information and Support for Mothers in the Community
Implement the UNICEF
a. Breastfeeding to be welcomed in all CHCP premises UK Baby Friendly
which serve mothers and babies. Practice managers to Standards (appendix 2.);
be consulted in order to establish how this can best be facilitated 4.2.1 Display of welcome-
to-breastfeed notice
in all areas which
b. Quiet/private areas to be identified in all CHCP premises to serve mothers and
enable mothers to breastfeed in privacy should they request (Point 6)
c. Reception/administrative staff working within each of the CHCP premises to be aware of this welcome to breastfeed in all public areas and of the identified quiet/private areas for those women who prefer privacy d. Either local or existing Board-wide welcome posters to be laminated and made available for prominent display in all CHCP premises e. Each GP surgery and clinic to have a nominated health visitor who will collaborate with practice managers/clinic administrators to ensure that the welcome posters remain prominently displayed 4.2.2 Mechanism for
a. NHS Greater Glasgow postnatal checklist to be ensuring that
incorporated into records for use by staff.
mothers receive
all necessary
information and
b. All relevant staff to be orientated in the appropriate use of support to breastfeed
the checklist at professional forums and during orientation and education programs 4.2.3 Mechanism for
a. Handover of care form to be standardised and an effort effective handover of
made to ensure that the form does not get lost in the mother's home.
(Point 7)
b. Updates for all relevant staff to be arranged on effective handover of care and routine use of the standardised form 4.2.4 Provision of
Provision of information on;
information for
a. Ensure all topics are included in postnatal checklist all breastfeeding
mothers
b. Breastfeeding progress to be discussed at each contact with breastfeeding mothers and this to be recorded in the appropriate records • How to position and attach their babies for breastfeeding and on how to hand express their breastmilk • Maintaining closeness of mother and baby and rooming-in • Baby-led feeding 127001.indd Sec1:36 127001.indd Sec1:36 • Avoiding the use of teats and dummies for breastfed babies • Promote exclusive breastfeeding until around 6 months* • Promote continued breastfeeding for at least a year • Provide information for all mothers of the benefits of and contra-indications to bed sharing c. The provision of local contact number(s) for health visitor/ professional support and local/national breastfeeding support groups d. Ensure effectiveness and accuracy of written materials 4.2.5 Help given to
a. Provide effective teaching for all breastfeeding mothers on how to position and attach their babies for breastfeeding mothers;
(hands off technique) Information and
support to breastfeed
effectively
b. All breastfeeding mothers should have at least one full (Point 4 &5)
breastfeed observed when difficulties are suspected. • Demonstration/teaching c. Provide a demonstration/teaching for all breastfeeding for all breastfeeding mothers on how to hand express breastmilk mothers on how to position and attach their babies for breastfeeding d. Staff to be encouraged to use written information, pictures and other props to reinforce teaching for mothers • Demonstration/teaching for all breastfeeding e. Staff to be encouraged to use written information, pictures mothers on how to hand and other props to reinforce teaching express their breastmilk f. Encourage baby-led feeding, ensuring all mothers fully • Provision of information understand its importance and how to do it.
for all breastfeeding mothers on the following issues: g. Ensure staff fully support the keeping of mothers and babies together at all times including at night time and that staff and mother understand its vital importance.
* These topics are also to be discussed with mothers h. Ensure staff understand and support the importance of who are artificially avoiding the use of teats and dummies for breastfed babies feeding their babies. and provide information on this for parents.
Exclusive formula feeding for the first six months should be i. Provide mothers information on the benefits of exclusive discussed with these breastfeeding for 6 months* and continued breastfeeding mothers rather than for the 1st year and beyond. j. Ensure effectiveness, consistency& continuity of information giving including accuracy of written materials Discharge packs are free from promotion for artificial feeding and to encourage rooming in and early initiation of breastfeeding.
127001.indd Sec1:37 127001.indd Sec1:37 4.2.6 Support for
Returning to Work
a. All mothers to be offered the opportunity to discuss in difficult
breastfeeding and return to work if they plan to return to circumstances and
when complications
occur
b. An individual plan to be developed with each mother a. Provision of information for mothers separated from their babies to When mothers or babies are unwell
enable them to establish c. Provide support to continue breastfeeding /expressing and maintain lactation breastmilk and maintain contact with the baby when mothers and babies are separated if the baby is unwell or premature (see neonatal and paediatric action plan).
b. Support for mothers to continue breastfeeding on return to work d. Expressing to be encouraged as soon as possible following birth and at least 6-8 times in a 24-hour period, including once at night if the mother or baby is unwell and cannot breastfeeding is difficult e. Staff to ensure that mothers are able to express both by f. Support to be available to enable mothers to express by pump by offering details of how a pump may be obtained/loaned g. Mothers to be encouraged to visit their babies frequently and to have skin contact whenever possible h. Provide support to continue breastfeeding /expressing breastmilk and maintain contact with the baby when the mother is sick.
When breastfeeding difficulties occur
i. Provide additional, breastfeeding-specific, practical and
problem solving support from a trained professional in the early postnatal period for women who are identified "at risk." and provide specialist intervention if needed. (including those observed to be ineffectively feeding) Provide contact number(s) for professional specialist support for feeding problems and refer to breastfeeding clinics.
4.2.7 Supplementation of
a. Ensuring appropriate supplementation of breastfed babies for clinical indication only. (Point 5)
b. Clinical indications should be evidence and needs based and recommended by appropriately trained staff.
c. Address supplementation of babies for non-clinical reasons and ensure this choice is fully informed.
127001.indd Sec1:38 127001.indd Sec1:38 d. All Policies and Guidelines should support exclusive and continued breastfeeding and balance the need for safety.
e. Timing of discussion with mothers regarding appropriate introduction of complementary foods at 6 months to be discussed and decision to be disseminated to health visitors 4.2.8 Provision of
a. Bed sharing issues to be discussed and written information information for
given to all families all mothers on the
benefits of and
contra-indications to
b. Individual risks to be highlighted to each family.
bed sharing
c. The discussion and parents responses to be documented on the postnatal checklist 4.2.9 Ongoing Support
a. Written information listing contact details for both health for Breastfeeding
professionals, support groups and voluntary groups to be given to all breastfeeding mothers • Provision of contact number(s) for health b. Professionals should ensure that mothers have received visitor/professional and understood these contact details and discussion support and local/national documented on the postnatal checklist breastfeeding support groups c. Ensure adequate provision of suitable, accessible, acceptable support groups within each locality.
d. Ensure such groups are based on effective, evidence bases (BIG trial) models that best suit local needs –board advisors will enable localities to investigate such models i.e. professional supported groups, ‘The Baby Café; model and or peer volunteer of counsellor supported (NCT, La Leche League, BFN or ABM).
e. Group facilitators should be suitably trained in breastfeeding support skills and group facilitation skills and be able to refer appropriately when difficulties occur.
Reducing Inequalities,
a. Target appropriate women for peer volunteer support increasing Social
Capital, supporting
b. Volunteer support should be based on a model that is cultural acceptability
effective, safe, acceptable, affordable, and sustainable.
of breastfeeding and
developing partnership
working.
c. Peer models should enable volunteers to engage with the general public, mothers in the antenatal and postnatal 4.2.10 Peer Support
period to provide information and give basic clinical and emotional support.
d. Peer supports should reflect the target groups, areas of deprivation, young mothers and a variety of ethnic and religious groups.
127001.indd Sec1:39 127001.indd Sec1:39 d. Peer support models should be localised to suit the needs of their local peers and have a core function of focusing on community involvement and development e.g. at breastfeeding support groups, community events with a local health focus including breastfeeding awareness week.
e. Models should be equitably available across each CHCP and for all CHCP's 4.2.11 Working with
a. Provide training for organisations /companies to implement Education
the "Breastfeeding welcome" award.
Other actions have still to be determined 4.2.12 Working with
These actions have still to be determined Social Work
4.2.13 Working with
a. Provide training for childcare provider to implement the "Breastfeeding friendly nursery award".
Other actions have still to be determined 4.2.14 Working with
a. Support employers to develop return to work policies and supportive environments for breastfeeding mothers who return to work.
Other actions have still to be determined Support for Formula
a. Recommending skin contact and an early feed and continued closeness 4.2.15 Encourage
b. Ensure mothers receive all necessary information and appropriate
support to formula feeding as safely as possible.
formula feeding for
babies and children
with whose mothers c. Provision of information for all formula feeding mothers
cannot or choose
on the following issues: not to or who stop
breastfeeding
• Exclusive milk feeding until around 6 months • Appropriate whey based formula milk feeding for at least a • Provide teaching on how to bottle feed, choosing appropriate teats and bottles and winding the baby effectively.
• Explaining demand feeding, small frequent feeds and avoiding overfeeding • Demonstrating how to sterilise equipment and make up d. Ensure adequate provision of, effectiveness and accuracy of written materials 127001.indd Sec1:40 127001.indd Sec1:40 4.2.16 Support for
a. Ensure all staff, including Dieticians and Oral Health nutrition beyond
Promoters are involved in the development of and milk feeding and
provision of services which are aligned to this strategy and developing healthy
the NHSGGC Infant Feeding Policy and Guidelines. lifelong eating
habits.
b. Ensure that all staff have appropriate training to provide appropriate information and support. • Encourage appropriate introduction of complimentary food c. Develop a mechanism for ensuring that mothers receive all necessary information and support to enable mothers to introduce solid foods appropriately and confidently.
• Use of appropriate vitamins for babies and children d. Provide demonstration/teaching for all mothers on how to effectively introduce solids and on how to make nutritious foods • Infants requiring special e. Develop a suitable mechanism for the provision of vitamins as per guidelines for appropriate mothers and • Working in partnership with Dieticians and Oral Health Promoters and the Oral Health Strategy f. Board wide evaluation of weaning fares and development of a standard curriculum.
g. Provide ongoing professional support towards the establishment of healthy eating habits h. Ensure effectiveness and accuracy of written materials i. Implement policies and guidelines for infants requiring special foods (to be developed by dieticians).
j. Provision of contact number(s) for health visitor/ professional support for feeding problems, e.g. allergies, vegan /vegetarian, premature and unwell babies, growth faltering and fussy eaters.
127001.indd Sec1:41 127001.indd Sec1:41 Action Plan 5. – For Sick and Premature Babies and Infants in Hospital
• Actions designed to increase the maintenance of breastfeeding rates • Actions designed to improve the care provided for formula feeding families within hospital• Actions designed to improve the care of infants (0-2 years) who are establishing a healthy eating life styles• Actions designed to ensure the effective delivery of food and fluid, and the provision of high quality nutritional care in all Neonatal and Paediatric hospitals (NHS QIS).
5.1 Information and Support For infants in Neonatal Units and Paediatric Hospitals
Standards and Criteria Actions to be undertaken Implement the UNICEF
a. Inform all parents of the benefits of breastmilk and UK Baby Friendly
breastfeeding for babies in the neonatal unit Neonatal Standards
(appendix 3);
b. Any parent whose baby is admitted, or is likely to be admitted, to the neonatal or paediatric unit should have a one to one 5.1.1 Mechanism for
discussion with a suitably qualified health professional about ensuring that
the crucial importance of breastmilk for the preterm and mothers receive
ill infant. This discussion, along with the parents' decision, all necessary
should be documented in the baby's records information and
support to breastfeed
effectively
5.1.2 Support mothers
a. All mothers with a baby on the children's' ward or neonatal to initiate and
unit should be encouraged to initiate lactation as soon as maintain lactation
possible after delivery through expression of b. All mothers whose babies cannot breastfeed or take full
feeds from the breast should be taught how to express their milk by hand and pump c. Frequent expression of breastmilk should be encouraged at least 6-8 times in 24 hours including at night. Emphasis should be on frequent expressing rather than regular intervals between expressing.
d. Mothers should be encouraged to use a massage technique prior to and during expressing to increase hormone release. e. Double pumping increases milk supply (electric pumps).
f. Well maintained and sterile equipment for the safe expression of breastmilk should be available at all times. g. Facilities should be available to allow mothers to express breastmilk in comfort either near their baby or in private if preferred h. Instruction should be provided on the safe handling and storage of breastmilk in line with locally or nationally agreed guidelines 127001.indd Sec1:42 127001.indd Sec1:42 i. A system for the provision of breast pumps for home use should also be in place. (Even though hand pumps are preferred by some mothers the purchase or hire of pumps requires motivation and has cost implications which may be exclude some mothers and may not convey a sense of necessity or medical support to express amongst some parents.) 5.1.3 Encourage skin to
a. The benefits of skin to skin contact should be discussed skin contact and
with all parents at an appropriate time to allow informed Kangaroo Mother
Care between
mother and baby
b. Skin to skin contact between mother and baby should be initiated in an unhurried environment as soon as the baby's condition allows c. Skin to skin contact should continue to be offered at least on a daily basis or whenever the mother is available and the baby's condition allows 5.1.4 Support mothers
a. All breastfeeding mothers should be offered help with a to establish
first breastfeed as soon their baby's condition permits. and maintain
Breastfeeding mothers should receive information, help and support to achieve correct positioning and attachment • Demonstration/teaching b. When the baby is not yet able to take a full feed from for all breastfeeding the breast, mothers should be encouraged to practice mothers on how to positioning techniques position and attach their babies for breastfeeding c. Parents should be given information on the importance of baby-led feeding (as soon as appropriate) for the continuation of breastfeeding. They should be taught to recognise feeding cues and be encouraged to use all available opportunities to initiate breastfeeds d. The unit should have a policy of open visiting for parents. e. Facilities for rooming-in should be available and where possible parents and babies should be enabled to room-in together when the baby is well enough. It is recognised that rooming-in may not be available for all breastfeeding mothers. Priority should be given to mothers establishing breastfeeding prior to the baby's discharge home.
f. All written materials on infant feeding provided for parents should be accurate and effective. g. It is recognised that some mothers may not wish to breastfeed, but may decide to continue expressing breastmilk. In this circumstance the mothers should be supported to continue providing breastmilk and given an informed choice regarding the short and long term benefits to baby of feeding directly from the breast.
127001.indd Sec1:43 127001.indd Sec1:43 5.1.5 Provision of
a. Exclusive breastfeeding until around 6 months (may information for
vary for some premature or sick babies) and continued all breastfeeding
breastfeeding for the first years and beyond.
mothers on the
following issues:
b. Staff should provide contact number(s) for health visitor/ professional support and local/national breastfeeding support groups c. Ensure the effectiveness and accuracy of written materials Staff should recommend 5.1.6 Avoid the use of
a. Breastfed babies should be fed breastmilk by tube, syringe teats or dummies
or cup, appropriate to the baby's ability. for breastfed babies
unless clinically
indicated
b. Parents wishing to breastfeed who request that their baby be fed by teat must have the potential risks discussed and alternatives offered. Cup feeding has no significant risks and may offer advantages in terms of physiological stability c. Dummy use should be limited to when there is a clear clinical indication. Indiscriminate dummy use should be discouraged for breastfed babies.
d. The use of dummies for Non Nutritive Sucking; there is little evidence base for their use for preterm infants but currently there is no evidence of an associated adverse effect on breastfeeding duration. e. Parents should have a discussion and receive written information on any benefits and known potential risks of dummies /non nutritive sucking devices.
f. Skin to skin contact and breastfeeding/ breastmilk should be promoted for comforting babies and relieving pain during minor procedures such as heel pricks. g. Feeding and comforting methods appropriate to the baby's condition, and with reference to the presence or absence of the parents at any given time, should be discussed.
h. Discussion should be evidence based and include all potential benefits, risks and alternatives to allow informed decision making. The discussion and the parent's choice should be recorded in the baby's notes or care plan. i. The impact nipple shields on preterm breastfeeding have not been adequately determined and therefore should not be advised.
127001.indd Sec1:44 127001.indd Sec1:44 5.1.7 Support when
a. All mothers should be provided with the contact details mothers and babies
of midwives, health visitors, community neonatal nurses (where these exist), breastfeeding support networks and organisations which support parents of ill and premature • Promote breastfeeding babies for help with breastfeeding on admission to a support through local and neonatal unit and on discharge of the baby from the national networks b. A formal mechanism should exist to ensure that information on breastfeeding progress is passed on during handover of care from the neonatal unit to the community health care team. 5.1.8 Encourage exclusive
a. No food or drink other than breastmilk should be given to babies who are being breastfed or receiving breastmilk unless this is medically indicated or the result of a fully informed parental decision. b. Mother's own breastmilk is the first choice for infant feeding. Where mother's own milk is not available the use of donor milk should be considered and where possible obtained. c. When mothers are separated from their babies, mechanisms should exist to enable the regular transportation of the mother's milk to the facility caring for the baby. d. No promotion for breastmilk substitutes, feeding bottles, teats or dummies, should be displayed or distributed to parents or staff in the facility 5.1.9 Policies and
a. Protocols which protect exclusive breastfeeding should be developed where there is hypoglycaemia, jaundice requiring phototherapy or slow weight gain. Breastmilk should only be fortified / supplemented where there is a clear medical indication, for example for very low birth weight (less than 1500g) babies when a biochemical assessment indicates a need.
b. Guidelines for; cup feeding, dummies and teats, hypoglycaemia screening, early large weight loss and slow weight gain and supplementation of premature babies (Fortifiers v Preterm Formulae) should be developed and implemented.
5.1.10 Donor milk
a. Develop a service which ensures equity of provision across the Boards Neonatal areas.
b. Implement all UKAMB and Scottish Government regulations and recommendations 127001.indd Sec1:45 127001.indd Sec1:45 5.1.11 Support for
a. Provide support to maintain lactation when mothers and babies are separated in difficult
circumstances and
b. Implement policies and guidelines for infants requiring when complications
c. Provide contact number(s) for health visitor/professional support for feeding problems d. Provide mothers with referral to additional, breastfeeding- specific, practical and problem solving support at breastfeeding clinics.
e. Board Infant Feeding Advisors to develop an accessible service equitably across the board area.
5.1.12 Peer Support
a. Target appropriate women for volunteer support b. Provide volunteer support based on a model that is effective, safe, acceptable, affordable, and sustainable.
c. Peer models should enable volunteers to engage with the general public, mothers in neonatal units and at home to provide information and give basic clinical and emotional support.
d. Peer support models should be localised to suit the needs of their local peers and have a core function of focusing on community involvement and development in appropriate settings (i.e. cleft lip and palate association) e. Models should be equitably available across neonatal and 5.1.13 Encourage
a. Recommending skin contact and an early feed and appropriate formula
continued closeness feeding for babies
and children with
b. Ensure mothers receive all necessary information and whose mothers
support to formula feeding as safely as possible.
cannot or choose
not to or who stop
c. Provision of information for all formula feeding mothers on the following issues: • Exclusive milk feeding until around 6 months• Appropriate whey based formula milk feeding for at least a • Provide teaching on how to bottle feed, choosing appropriate teats and bottles and winding the baby effectively.
• Explaining demand feeding, small frequent feeds and avoiding overfeeding • Demonstrating how to sterilise equipment and make up feeds d. Ensure adequate provision of, effectiveness and accuracy of written materials 127001.indd Sec1:46 127001.indd Sec1:46 5.1.14 Encourage
a. Mechanism for ensuring that mothers receive all necessary appropriate
information and support to enable mothers to introduce introduction of
foods appropriately. complimentary food
b. Provide demonstration/teaching for all mothers on how to and vitamins for
effectively introduce solids and on how to make nutritious babies and children
c. Evaluate the provision of weaning information and development of a standard curriculum.
d. Ensure effectiveness and accuracy of written materials 5.1.15 Implement the Food, Fluid and Nutritional Care in Hospitals14 (NHS QIS) Standards
Standard 1 – Policy and
1.1 Each NHS Board has a policy on nutritional care and a strategic plan to improve the provision of nutritional Each NHS Board has a care, food and fluid. These : policy, and a strategic and are patient-focused, follow the patient journey of care co-ordinated approach, to and ensure that a comprehensive and co-ordinated ensure that all patients in nutritional care service is provided; hospitals have food and fluid delivered effectively are based on a health population needs assessment, and receive a high quality of which considers local ethnic, religious and cultural nutritional care.
patterns and which recognises the need for equity of access; iii) recognise patient groups with particular needs, e.g. iv) are risk-assessed and managed;v) are discussed annually at NHS Board level to evaluate progress and produce a plan for further action, based on: vi) reports from operational nutritional care group(s);vii) any need for re-design; andviii) the need for managing change of attitude and behaviour;ix) include a financial framework to underpin the implementation of the action plan; and are published in a format easily understood by and accessible to the public.
1.2 Each NHS Board area has at least one operational nutritional care group responsible to the NHS Board for overseeing the implementation of: NHS Quality Improvement Scotland standards for food, fluid and nutritional care in hospitals; and the NHS Board's strategic plan.
The nutritional care group produces an annual written report, detailing progress made and action taken/required.
iii) The core membership of this group includes a senior manager reporting to the chief executive, a senior dietician or dietetic manager, a lead doctor appointed by the medical director, a senior nurse appointed by the nursing director, a catering manager, a dentist, lay representation and co-opted specialist expertise appropriate for the population.
127001.indd Sec1:47 127001.indd Sec1:47 1.3 Where complex nutritional techniques are employed, the patient has access to the services of a clinical nutritional support team responsible for the clinical aspects of intravenous and enteral tube feeding.
The core membership of this team includes a doctor, a dietitian, a specialist nutrition nurse and a pharmacist. Clinicians should be part of the Scottish Managed Clinical Network for Home Parenteral Nutrition Standard 2 – Assessment,
Screening and Care When a person is admitted to hospital as an in-patient, the Planning Processes and following are identified and recorded within 1 day as part of
procedures for assessment, the medical/nursing assessment : screening and care planning • height and weight; are being implemented and monitored fully, • eating and drinking likes/dislikes; and there is a cycle of • food allergies and need for a therapeutic diet; continuous monitoring of • cultural/ethnic/religious requirements; implementation and impact on patient care throughout • social/environmental mealtime requirements; the Board area.
• physical difficulties with eating and drinking; and • The need for equipment to help with eating and drinking.
The initial assessment includes screening for risk of under nutrition. This screening is carried out using a validated tool appropriate to the patient population, and which includes criteria and scores that indicate action to be taken.
Repeat screenings are undertaken in accordance with clinical need and at a frequency determined by the outcome of the initial and subsequent screenings.
iii) The outcome of screening is recorded in the medical iv) The assessment process identifies the need for referral to specialist services, e.g. dietetic, dental.
Patients have access to specialist services : • within agreed timescales; and • 7 days a week for urgent cases.
Essential
2.7 A multidisciplinary care plan is followed, reviewed and
refined, and includes the : outcomes of the initial assessment; outcomes of the screening for risk of under nutrition; When a person is admitted iii) frequency/dates for repeat screenings; and to hospital, an assessment iv) actions taken as a consequence of repeat screenings.
is carried out. Screening for risk of under nutrition 2.8 The discharge plan is developed with the patient and, is undertaken, both on where appropriate, carer, and admission and on an ongoing basis. A care plan includes information about : is developed, implemented the patient's nutritional status; and Evaluated.
special dietary requirements; and iii) the arrangements made for any follow-up required on nutritional issues.
Desirable 2.9 Patients referred to the dietetic service are seen
within 2 days.
127001.indd Sec1:48 127001.indd Sec1:48 STANDARD 3 Planning
and Delivery of Food and
3.1 There is a planning group responsible for the implementation of a local protocol or protocols for the provision of food and fluid for patients. The core There are formalised
membership of this group includes a senior member of structures and processes
catering staff, a senior nurse, a doctor, a senior dietician in place to plan the
and allied health professionals and patient representation. provision and delivery of
The group will also have others appropriate to patient food and fluid.
groups (as identified in the population assessment) and to the food delivery system.
3.2 The planning group is responsible for:i) overseeing a local assessment of need; ii) producing a local ‘food chain' protocol/protocols;iii) menu planning, including the use of standard recipes;iv) ensuring the food and fluid provided meets the requirements of the individual, the v) catering specification is appetising, and is presented with vi) setting main mealtimes appropriate for patient groups;vii) setting mealtimes such that if the evening meal and breakfast are more than 14 hours viii) apart, a substantial snack is available;ix) ensuring there is appropriate food and fluid available out with main mealtimes; x) ongoing monitoring and review of the food and fluid provided for patients; and xi) reporting to, and implementing issues devolved from, the Nutritional Care Group.
3.3 All dishes and menus are analysed for nutritional content by a state-registered dietician at the planning stage.
3.4 Patient groups are consulted about new menus/dishes before they are introduced.
3.5 There is a procedure :for the delivery of the correct meals/dishes to the ward; • for responding when an incorrect meal/dish is provided; • to ensure that when a patient misses a meal he/she is then provided with a meal that meets his/her needs There are formalised
structures and processes
3.6 The nurse with responsibility for the ward is responsible in place to plan the
for having in place a protocol which ensures that : provision and delivery of
• correct meals/dishes are received on the ward; food and fluid.
• meals are delivered to the correct patients at the correct • there is adequate time for patients to eat or drink;• staff assist and support patients as required; and • Patients' intake of food and fluid is monitored, and the necessary action is taken if this intake is inadequate.
127001.indd Sec1:49 127001.indd Sec1:49 3.7 All non-essential staff activity (clinical and non-clinical) is stopped during patient mealtimes.
3.8 There is an adequate number of staff available at mealtimes to provide food and fluid to patients and, where necessary, to provide individual assistance with eating and drinking. 3.9 There is a protocol for the provision of all therapeutic diets, including oral nutritional supplements, and for high-energy and high- protein food and fluid.
3.10 There is a protocol for the provision of any requirement out with the planned menu, e.g. vegan meals STANDARD 4 Provision Essential
of Food and Fluid to
Patients
4.1 Patients are given a choice for all food and fluid options Food and fluid are provided provided, including therapeutic and texture-modified diets. in a way that is acceptable There is a choice of portion size for all main courses.
to patients.
4.2 Patients are given the opportunity to choose their own food and fluid. Where required, they are given help in doing so from a member of staff who is aware of their nutritional needs and preferences.
4.3 Patients select their menu choice as close to the serving of the meal as possible and no more than two meals in advance.
4.4 Food and fluid are provided to patients at the correct temperature and texture. Where required, patients are given assistance with eating/drinking while the food/fluid is at the correct temperature.
4.5 Meals/dishes provided for patients are appetising. Consideration is given to presentation, including the colour balance of dishes and when different courses are provided.
4.6 Patients are provided with the equipment/utensils for eating/drinking that meet their individual needs.
4.7 Accompaniments/condiments are available for patient use.
4.8 Where clinically appropriate, patients have access to fresh drinking water at all times.
Desirable
4.9 Where clinically appropriate, patients are given the
opportunity to choose whether to eat/drink at or away from their bed.
127001.indd Sec1:50 127001.indd Sec1:50 Standard 5 Patient
Information and
5.1 On, or prior to, admission to hospital, patients are provided with information on : Patients have the opportunity to discuss, and how to order their meals; are given information about, ii) mealtimes;their nutritional care, food iii) the content of meals and choices available; and fluid. Patient views are iv) facilities available for eating meals, and where meals are sought and inform decisions made about the nutritional v) the opportunities available for preparing/consuming care, food and fluid vi) assistance with eating and drinking if required;vii) special equipment/utensils for eating and drinking if viii) the procedure for obtaining a meal if one is missed; andix) how to make a comment or compliment about the nutritional care, food and fluid provided.
5.2 Patients and, where appropriate, carers, are given information about the : food and fluid that relatives and carers can provide for them; and ii) patient's nutritional needs, including any food/fluid to 5.3 Patients are encouraged to give their views on the food and fluid provided. These views are collected and trends are reported regularly to the relevant planning group.
Standard 6 – Education
and Training for Staff
6.1 All staff should be aware of the importance of A Board nutrition nutritional care for the patients' health and quality of awareness, education and life. Staff in contact with patients at any point in the training program is being ‘food chain' are aware of : implemented and monitored fully, and there is a cycle of the local protocol/s or processes for ordering and continuous monitoring of delivering food/fluid; implementation and impact ii) meal and snack times; and on patient care throughout iii) procedures for ordering missed meals.
the Board area.
6.2 All staff in contact with patients and their food and fluid receive training in health and safety issues and food hygiene commensurate with their duties.
6.3 There is a programme of nutrition education for staff, commensurate with their duties, which ensures that all staff with a specific responsibility at any point in the ‘food chain' are given appropriate guidance and training, e.g. in the preparation of texture-modified diets, in the use of the screening tool and appropriate alternative measures, and in the recognition of physical difficulties with eating and drinking 127001.indd Sec1:51 127001.indd Sec1:51 Section 4. The Role of the Infant Feeding Team and Team
Work plan
4.1 Team commitment to Services4.2 Team objectives and priorities4.3 Appendices4.4 References 4.1 Team commitment to Services
The Board has appointed an Infant Feeding Coordinator and team of Advisors to facilitate the delivery of this Strategy and enable partners to implement the objectives. The team of Advisors will use their expertise to advise local teams on the implementation of the action plans and setting local targets. Each service will have a named link Advisor. The team will work towards increasing staff capacity and capability, improving processes and flow. • This team will work towards increasing staff capacity and capability and improving processes and communication. • There are core services that require expertise which this team will provide i.e. staff training, audit, policy and guideline development and expert support at breastfeeding clinics. • The team will carry out some of the project work of the strategy sub groups and dissemination of good practice. However the ultimate responsibility for achieving these objectives lies with the
directors and clinical leads within each service.
127001.indd Sec1:52 127001.indd Sec1:52 4.2 Infant Feeding Team Objectives and Priorities
Standards and Criteria Actions to be undertaken 1. Strategic
To develop a
• To set priorities, objectives and targets based on comprehensive Strategy
comprehensive local needs. Use evidence, audit, Health and Action Plans and
Impact Assessment to Prioritise action plans, objectives and integrate them into
to set HEAT targets.
overall health policies and
strategies
Management
• To ensure continuity of the coordinator's and committee's
• To establish an Implementation and monitoring group with sub groups to progress the aims and objectives of the Strategy, regularly monitor progress and evaluate results of the local and Board plans.
Financing
• To find /assign adequate human and financial resources for
the implementation and monitoring of the Strategy. Actions need to be prioritised within budget constraints and finance allocated to achieve "best value" and greatest positive "Health Impact". • To ensure that planning, implementation, monitoring and evaluation of activities are carried out 2. Best Practice Standards Policy and BFI Accreditation
• Policies should reflect the requirements of the WHO /UNICEF standards and partners should achieve and maintain accreditation.
• The Maternity "Ten Steps to Successful Breastfeeding".
• The Community "Seven Point Plan".
• The UNICEF UK Neonatal Standards• The UNICEF UK Pre Registration Education Standards• Adopt and monitor adherence to the WHO Code on Marketing of Breast milk substitutes & WHA resolutions Infant Feeding policy and guidelines (2006)
• To ensure professional groups implement policy
recommendations and practice guidelines and require their members to follow them.
• The Infant feeding policy and guidelines will be updated every 3 years to ensure it covers best practice standards • The "Parents Guide to the Policy" will be on display in all Board areas which serve mothers and babies 127001.indd Sec1:53 127001.indd Sec1:53 3. Increasing capacity and
• All new staff in all Board areas which serve mothers and babies including medical staff will be orientated to the policy on commencement of employment. There will See Training Plan
be orientation of other staff (e.g. Receptionists, Practice Nurses) to the policy Ensure appropriate training • To develop, or review if existing, a minimum (contents,
of NHS staff to enable them
methods, time) standard for pre- and post-graduate to implementation objectives
curricula and competency on infant feeding and lactation of Strategy and Action Plans
management for relevant health workers • To develop, or review if existing, course textbooks and training materials in line with the updated standard curricula and recommended policies and practices • Education for all staff in skills necessary to support mothers with positioning and attachment and hand expression of breastmilk • Record keeping of student's education in infant feeding.
• Development of an education programme for trained and support staff including written curriculum • To offer continuing interdisciplinary education based on WHO/UNICEF or other evidence-based courses on infant feeding and lactation management, as part of induction and in-service education for all relevant health care staff, with particular emphasis on staff in frontline maternity and child care areas • To develop, or review if existing, training materials to be used for such interdisciplinary continuing education, ensuring that materials and courses are not influenced by manufacturers and distributors of products under the scope of the International Code • To encourage relevant health care workers to attend accredited advanced lactation management courses and to acquire certification shown to meet best practice criteria for competence.
• To encourage Infant Feeding Advisors to attend accredited advanced lactation management, nutrition and practice educator courses and to acquire certification shown to meet best practice criteria for competence.
• To encourage e-networking amongst professionals in order to increase knowledge and skills • Develop a record keeping of mandatory staff education• Develop / Implement training for Pharmacists, Dieticians, Oral Health Action Teams 4. Provide a Specialist
• Ensure an equitable, accessible, effective provision of Service for mothers
specialist services for mothers experiencing feeding experiencing breastfeeding
problems within the maternity, paediatric services and at problems or challenging
• Increase capacity and capability across the service for the management of feeding problems.
• Ensure breastfeeding clinics effectiveness and acceptability are evaluated, lessons learned are shared.
• Ensure services are integrated and can make appropriate direct referrals. 127001.indd Sec1:54 127001.indd Sec1:54 5. Develop public
• Peer Support; Evaluate current provision and models and acceptability and promotion
secure funding to proliferate suitable model(s) across the acute and maternity/paediatric services. • Work with CHP's to establish / maintain / fund peer supporters. Review volunteer activity and develop their capability and capacity. Safe, secure support for volunteers.
• Support Groups; Evaluate provision and effectiveness of existing groups, identifying gaps in accessibility, acceptability, suitability and effectiveness.
• Lay Support Organisations; Make links with local networks and involve and integrate in development of services.
• Breastfeeding in Public Award; • Nurseries Award, Child minding, Education Curriculum• Support breastfeeding in the workplace policies for NHS and public sector 6. Develop ways of
• Improve the patient journey to achieve improved measuring the patient
• Collection of breastfeeding statistics• Use of audit tools and increase local team capacity to effectively audit standards.
• Development and monitoring of Quality Indicators• Risk Management• Investigate methods of developing improved systems 7. Support the further
• Use appropriate methods and organisations (professional, development of the
peer or other partners) programmes which reach
• Develop / maintain /evaluate appropriate models of target families
education and support.
• Target groups; areas of deprivation, young mothers below 25, smokers, low educational attainment groups, mothers who did not breastfed previous children or fed for less than 6 weeks.
• Mothers with medical problems, e.g. diabetes• High risk (ill, premature) neonates• Ethnics groups with specific issues 8. Innovation and
• Work with researchers • Commission / carry out new research, evaluation & audit• Encourage innovation and creative thinking. 127001.indd Sec1:55 127001.indd Sec1:55 4.3 Appendices
Appendix 1.
UNICEF/UK Baby Friendly initiative
The Ten Steps to Successful Breastfeeding in the Maternity Services
1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
2. Train all healthcare staff in the skills necessary to implement the breastfeeding policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding soon after birth.
5. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their babies.
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7. Practice rooming-in, allowing mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or dummies to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Appendix 2.
UNICEF/UK Baby Friendly initiative
The Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care
Settings
1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
2. Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Support mothers to initiate and maintain breastfeeding5. Encourage exclusive and continued breastfeeding, with appropriately-timed introduction of complementary 6. Provide a welcoming atmosphere for breastfeeding families.
7. Promote co-operation between healthcare staff, breastfeeding support groups and the local community.
Appendix 3.
UNICEF/UK Baby Friendly initiative
Best practice standards for neonatal units
1. Have a written neonatal unit breastfeeding policy, which is routinely communicated to all staff. 2. Educate all health care staff in the skills necessary to implement the policy3. Inform all parents of the benefits of breastmilk and breastfeeding for babies in the neonatal unit4. Encourage skin to skin contact (Kangaroo care) between mother and baby 5. Support mothers to initiate and maintain lactation through expression of breastmilk6. Support mothers to establish and maintain breastfeeding7. Encourage exclusive breastmilk feeding8. Avoid the use of teats or dummies for breastfed babies unless clinically indicated. 9. Promote breastfeeding support through local and national networks.
127001.indd Sec1:56 127001.indd Sec1:56 Appendix 4. The Staff Training Plan
Midwives
2 day revised Mandatory Infant Health Visitors /Public health
Feeding training and Supervised Within 6 months of Advisors and Clinical Practices Paediatric / Special Care Baby /
Ongoing seminar/updates as As identified in Child branch nurses / Nursery
identified in audit/ training needs nurses / Health visiting staff
assessment. Mandatory 1 day 3 Advisors, partners, key workers and mentors Board infant feeding policy and UNICEF 10 step plan/ Neonatal StandardsManagement of problems Board infant feeding policy and Advisors to liaise GP's and GP trainees
UNICEF 7 step plan, Potential CHCP's, maternity and
paediatric facilities
Board infant feeding policy and agreed to enable Advisors to liaise Nursing and non nursing staff
staff to complete with local trainer who have contact with pregnant
Welcome for breastfeeding mothers Within 6 months of School nurses / Auxiliaries GP
receptionists
Practice nurses
Student Midwives, Health
2 day revised Mandatory Infant Visitors /Public Health Nursing
Feeding training and Supervised and Child Branch Nursing
Clinical Practices to meet UNICEF By the end of Education Standards Updates as identified in training Still to be determined To be determined To be determined by clinical practice clinical practice Dieticians and students
2 day revised Mandatory Infant Pharmacists and students
Feeding training and Supervised Clinical Practices to meet UNICEF Education StandardsHealth Scotland e-learning tool Still to be determined by public acceptability sub group 127001.indd Sec1:57 127001.indd Sec1:57 4.4 References
1. Michaelsen K., Weaver L., Branca F., Robertson A. ( 2000) Feeding and Nutrition of Infants and Young Children, WHO Regional Publications, European series no 87, Copenhagen 2. Wilson AC, Forsyth JS, Greene SA et.al. (1998) Relation of infant diet to childhood health: seven year follow up cohort of children in Dundee infant feeding study. British Medical Journal 316: 21-25 3. W H Oddy, P D Sly, N H de Klerk, L I Landau, G E Kendall, P G Holt and F J Stanley (2003) Breast feeding and respiratory morbidity in infancy: a birth cohort study, Archives of Disease in Childhood 2003;88:224-228 4. http://www.scotland.gov.uk/consultations/health/hfac-02.asp5. WHO (1986) The Ottawa Charter www.who.int (accessed 7/2/08)6. www.unicef.org.uk (accessed 20/7/07)7. WHO/UNICEF (1989) Protecting, Promoting and Supporting Breastfeeding.-The Special Role of Maternity Services, A joint WHO/ UNICEF Statement, WHO, Geneva 8. UNICEF (1998) The Seven Point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings 9. http://www.babyfriendly.org.uk/page.asp?page=79 (20/7/07)10. http://www.babyfriendly.org.uk/page.asp?page=128 (20/7/07)11. http://www.who.int/child-adolescent-health/publications/NUTRITION/Report_CF.htm (20/7/07)12. ISD (2006) http://www.isdscotland.org/isd/1764.html (20/7/07)13. N.I.C.E (2005) The Effectiveness of Public Health Interventions to promote the duration of breastfeeding – a systematic review. www.nice.org.uk (20/7/07) 14. European Commission (2004) EU Project on Promotion of breastfeeding in Europe, Protection, promotion and support of breastfeeding in Europe: a blueprint for action., Directorate of Public Health and risk assessment, Luxembourg, 15. DOH (2005) The Infant Feeding Survey, DOH, London 16. McInnes R & Chambers J (2005) Effective action recommendations Breastfeeding in Neonatal Units: A review of 17. The NHS Quality Improvement Scotland (NHS QIS) Food, Fluid and Nutrition Policy 18. Glasgow and Clyde NHS Board (2006) The Infant Feeding Policy and Guidelines19 The Health for All policy framework for the WHO European Region: 2005 update http://www.euro.who.int/ 20 Gakidou EE, Murray CJL, Frenk J (2007). Defining and measuring health inequality: an approach based on the distribution on health expectancy, in Measuring Socio-Economic Inequalities in health: a practical guide, ScotPHO 21 WHO (2005) - Health for All in the 21st Century, http://www.euro.who.int/document/EHFA5-E.pdf 127001.indd Sec1:58 127001.indd Sec1:58 127001.indd Sec1:59 127001.indd Sec1:59 127001.indd Sec1:60 127001.indd Sec1:60 127001.indd Sec1:61 127001.indd Sec1:61 127001.indd Sec1:62 127001.indd Sec1:62

Source: http://www.researchoffice.co.uk/Office_for_Psychosocial_Research/Projects/Entries/2010/9/15_Qualitative_Evaluation__NHS_GG&C_Infant_Feeding_Strategy_files/NHS%20GG%26C%20Infant%20Feeding%20Strategy.pdf