UNICEF Baby Friendly Conference

Round up of information from UNICEF UK Baby Friendly Initiative Conference November 2009. Siega Benwell

I was lucky enough to receive a funded place from the Department of Health South West to attend both days of last years conference in Bournemouth, and thought I’d write a short synopsis of what I heard there.

Sue Ashmore, Programme Director for UNICEF UK Baby Friendly Initative, opened the conference; she gave an update and overview of the initiatives activities last year including information of new documents available to those trying to implement the initiative. She ended with plans for the next year, which included support for those caring for high-risk babies, i.e. those in neonatal units.

Next spoke Professor Peter Bundred, he is a recently retired Paediatrician and Senior Lecturer at the university of Liverpool. Over the last ten years he has carried out research into the epidemiology of childhood obesity. His presentation was titled ‘ The effect of breastfeeding on obesity.’ And the full presentation is available to view on www.babyfriendly.org.uk/page.asp?page=8.

Professor Bundred stated there is now strong evidence that nutrition in early life is a major contributory factor to the development of adult obesity. He stated early life nutrition starts in the first trimester of pregnancy, sub-optimal nutrition at this stage in development leads to programming of the foetus and neonate for increased weight gain. He then gave details of papers that supported his claims.

Next he gave details of evidence that supports the idea that breastfeeding has a positive effect on the incidence of obesity and three hypothesis for the mechanisms as to why this should be so. They were the following: behaviour explanations, nutritional explanations and the growth acceleration hypothesis. Full details of these are available in his slides accessible with the mentioned link. Professor Bundred’s presentation continued with its focus on the growth acceleration hypothesis. This is the idea that rapid weight (crossing 2 centiles of the UK90 charts) gained in the last trimester of pregnancy and in the first seven days of life programmes obesity into childhood and then adult life. Breastfed babies are more likely than formula fed babies to lose weight or have such rapid weight gain during this period and therefore breastfeeding decreases the incidence of obesity. There were details of various studies to support this claim including a very large study (over 16,000 babies) in the Wirral.

The next speaker was Magda Sachs, whom in 2008 joined the UK-WHO Growth chart group, funded by the Department of Health and organised by the Royal College of Paediatrics and Child Health, this group had responsibility for the design of the new UK growth charts. Her presentation titled, ‘Weighing babies, the new growth charts and supporting breastfeeding’ is available to view on  www.babyfriendly.org.uk/page.asp?page=8.

Magda began her presentation with information about why new growth charts were designed, that breastfed babies growth was observed to be different from babies fed in other ways and that there were concerns that routine weighing was undermining breastfeeding. We then heard details of how the information for the charts was collected, the sampled groups were all non-deprived mothers that were also non-smokers and sample groups were taken from six different countries. Some of the main differences were then described; the growth described in the charts is optimal rather than average growth. There are no centiles for the first two weeks as percentage weight loss is more relevant than centiles at this time. The fiftieth centile is no longer bold. There is a separate pre term section.

Magda then described the process through which the production and implementation of the new growth charts had followed. Details are in Magda’s full presentation but the following were included, parent group consultations and professional focus groups, these informed both the format of the charts and the educational materials used with their implementation.

The speaker then gave us information on when weighing of babies/children should take place as recommend by the growth chart group. Again full details are in her slides but it’s now suggested that weighing should be around the time immunisations are due, i.e 8, 12 and 16 weeks. If closer observation is required weighing should not occur more than once a month for the first six months, once per two months for between 6 and 12 months and once per 3 moths over the age of one year.

The next speaker was due to give a presentation on the presence of stem like cells in breastmilk, but he was unwell and unable to attend.

Following lunch Dr Kathleen Kendall-Tackett, a heath psychologist, a lactation consultant, and an associate professor of paediatrics at the TexasTech University School of Medicine gave a presentation titled ‘ Breastfeeding made simple: seven natural laws for new mothers.’ This is available to view at  www.babyfriendly.org.uk/page.asp?page=8. Dr Kathleen was unable to cover all the 7 natural laws in her 45-minute presentation, so my notes are limited to what she was able to cover. She has a website with this presentation and others  www.uppitysciencechick.com (!!) She was a really funny and fascinating speaker and her website is well worth a look.

Dr Kathleen began by giving us some statistics about breastfeeding rates in the United States, the breastfeeding rates are similar to those we have in the UK. 77% initiation rate and by 42 days 61% doing any breastfeeding. At 7 days 59% exclusively breastfeeding and by 42 days 49% exclusively breastfeeding. She then hypothesised that it wasn’t a lack of mothers having access to information about breastfeeding but the way in which the information was given, leading to the basic concepts being unclear, mothers missing key information and receiving conflicting advice together with bottle feeding norms that caused the early weaning from the breast of so many mothers in the U.S. Dr Kathleen then suggested that instead of giving more information, those helping in breastfeeding tap into strengths and abilities the mothers already have and that are built-in to the breastfeeding relationship. This she believes will enable mothers to really understand how breastfeeding works and also underlying reasons for newborn behaviour.

Natural law 1. Babies are hard wired to breastfeed. They know how to do so if we let them. Mothers do not breastfeed, babies breastfeed. There are releasing stimuli for the babies instinctive feeding behaviours. Mothers receiving left- brained instructions, mother led feeding and an unstable hold of the baby all lead to breastfeeding difficulties. We then heard details of how the left- brain works; logical, verbal, practical, sequential, analytical, objective, focuses on parts and detail orientated. The right side of the brain is emotional, intuitive, creative, subjective, ‘big picture’ orientated and uses symbols and images. Mothers are, post natally in right brain mode, while those helping them breastfeed are in left-brain mode. We use technical words that the right brain mode doesn’t ‘get’ and breastfeeding seems complicated and confusing. Dr Kathleen suggested that the reason why mothers are in the right brain mode is because it facilitates emotional attachment between mother and baby. When a baby is ready to feed, he will show early feeding cues, he will be calm and emotionally open to interacting. If the baby’s torso is skin to skin with the mother, vertical between her breasts, this will trigger breast-seeking behaviours. The mother encourages instinctive behaviours as she strokes, talks and makes eye contact as needed she helps support and align the baby.

Natural law 2. The mother’s body is the baby’s natural habitat. We then heard details of how kangaroo care had benefits for babies not only pre term but term as well. In a variety of places around the world including those where the baby’s survival depended upon being in such close contact with its mother. We had details of one study in pre term infants, which concluded that those babies receiving kangaroo care had improved oxygen saturation rates, stabilised temperature and respiration, heart rates lowered by 3-5 beats a minute, the babies also cried less and slept more and higher rates of breastfeeding occurred. Mothers reported amongst other things that they felt more confident in handling their babies.

Studies which showed those mothers giving kangaroo care were more receptive to their babies cues at six months and that their infants scored higher on developmental scores were also shown. Dr Kathleen moved on to co- sleeping giving details of findings that when co sleeping, mothers and babies sleep/arousal cycles are synchronised, this leads to babies spending less time in deep stages of sleep.

Dr Kathleen then ran out of time, her other 5 natural laws are; Law 3. Better feel and flow happen in the comfort zone, looking at how the baby goes to the breast to achieve a comfortable feed for the mother and effective feeding for the baby.

Law 4. More breastfeeding at first means more milk later. Law 5. Every breastfeeding couple has their own rhythm, looking at feeding frequency and length. Law 6. More milk out equals more milk made, including information on storage capacity. Law 7. Children wean naturally.

Next spoke Jo Orgles and Janette Westman both professional officers with the Baby Friendly Initiative with backgrounds in midwifery and infant feeding. Their presentation was titled, ‘ Supporting informed decision making: the health professional’s role.’ The whole presentation is available on www.babyfriendly.org.uk/page.asp?page=8.

This presentation gave information on the underlying principle of Baby Friendly initiative that women should be given sufficient information to enable them to make informed choices and that they are then empowered to feed their babies however they choose to, for as long as they wish. The focus was on how to give information, building on knowledge the women already knows was described as best practice, asking what she knows already about breastfeeding and building on that. Considering circumstances for the women, offering information about benefits, risks and alternatives and meeting individual need all need to aimed for. The availability of leaflets, posters and a DVD to back up the 1:1 information sharing session was discussed.

The final speaker for day one was Steven Johnson from the Social Marketing agency ‘The Hub’. The presentation titled ‘ Unlocking the power of social marketing- a case study approach.’ Is available to view in it’s entirety at  www.babyfriendly.org.uk/page.asp?page=8.

Steven began by explaining to us what exactly social marketing is, that is not health promotion, social advertising or social media marketing. Social marketing is a process that applies marketing principles and techniques to create, communicate, and deliver in order to influence target audience behaviours that benefit society as well as the target audience. It’s not just about engagement and information, it’s about empowerment and inspiration. It’s about taking action as well as giving advice- changing lives not just changing minds.

We then heard how social marketing is a five-stepped systematic and phased process. Steven then introduced the ‘Be a star’ initiative that ‘The Hub’ created and took us through the five steps followed during the process of creating the initiative. We heard how this initiative was aimed at 15 to 25 year old mothers to increase breastfeeding initiation rates in the Lancashire, Bolton and Blackburn area. Young mothers asked about breastfeeding gave the following as barriers to breastfed; it’s tying, I don’t want to show my boobs in public, my Mum didn’t do it, my partner wants to share feeding, my partner says my boobs are his, it’s weird. A big message that was heard during the process was ‘it’s not for me’. The way of offsetting the barriers/ competition was to make the desired behaviour more attractive and easier to execute, with emotional incentives and relevant support. Full details are in his slides but posters were created with local mothers who were breastfeeding looking very glamorous with the words, ‘she’s not a model/actress/- she’s a star: be a star- breastfeed’ some posters showed babies at the breast, with the words ‘how I feed my baby without showing my boobs’ Peer support was available at home and also in hospital. 24-hour phone help lines as well as SMS text support service were also provided. We then heard some of the results of the ‘Be a Star’ initiative, including a 13% increase in breastfeeding initiation in the first 6 months.

The following day the first speaker was again Dr Kathleen Kendall-Tackett, her presentation was titled ‘A new paradigm for depression in new mothers.’ this is available in full from www.babyfriendly.org.uk/page.asp?page=8.

This was a very science based presentation looking at the psychonueroimmunology and stress and how they impact on the pregnant and postpartum women. I’ll try and give details that are the most relevant to our working area, but it’s well worth looking at the presentation online to get a full picture and all the information. Proinflammatory cytokines, similar to CRP, rise during the last trimester of pregnancy, a women’s risk of depression increases in the last trimester of pregnancy and the levels of cytokines remain elevated postpartum. There are increased cytokines in depressed and stressed mothers, some cytokines ripen the cervix, levels increase in pre-eclampisa and infection therefore leading the speaker to conclude that depression and anxiety increase the risk of preterm birth.

Dr Kathleen then spoke about pain, reporting that women with nipple pain had higher rates of depression than those without, and that mood returned to normal once pain was resolved. Cytokines are stimulated by Substance P, substance P is a neuropeptide present in pain, pain increases the inflammation and inflammation increases the pain.

We then heard about sleep, Dr Kathleen reported that tired mothers had higher levels of an inflammatory cytokine at 4-6 weeks than mothers who were less fatigued.

The presentation then looked at trauma. We then moved on to how to breastfeeding can impact on depression. Dr Kathleen stated that breastfeeding protects maternal mood by lowering maternal stress, but that breastfeeding difficulties can increase inflammation, possibly leading to a lowering of mood. In a study of women who were both breastfeeding and bottle-feeding found that when they breastfed it decreases their negative mood and that when they bottle-fed it increased their negative mood. Breastfeeding caused a lowering of cortisol and other stress related hormones. We then saw findings on the interaction depressed mothers had with their babies, those breastfeeding touched, stroked and looked at their babies more than those not breastfeeding. Finally we heard about how the treatments for depression lower inflammation, be that exercise, drug treatments such as SSRI’, these have such an effective effect on inflammation that some are using then for the treatment of asthma, herbal remedies such as St John’s Wort, or dietary treatment. Specifically Omega 3’s such Eicosapentaenoic Acid EPA and Docosahexaenoic Acid DHA, many women in the western world are deficient in EPA and DHA during pregnancy and post natally, with pregnancy further depleting stores. Studies found higher Omega 3’s related to lower inflammatory cytokines.

The next speaker was Kerstin Hedberg Nyqvist, Kerstin’s presentation titled ‘Kangaroo Mother Care – Aspects of Neonatal care and breastfeeding beyond your imagination’ is available on www.babyfriendly.org.uk/page.asp?page=8.

Kerstin in a nurse at the NICU at the University Hospital, Uppsala, Sweden. She is also an associate professor in Paediatric nursing at the Department of women’s and children’s health of Uppsala University.

To begin we heard some of the effects on the infant of separation being; higher heart rates, higher cortisol levels and lower levels of growth hormone levels. We then heard details of effects on the parents and more on their babies of separation. Kerstin then told us of the European Association for Children in Hospital charter based on UNICEF convention on the rights of the child, which states; that ‘children in hospital shall have the right to have parents or a parent substitute with them at all times’. Kerstin then proposed that what was needed was opportunities for parents 24 hour presence, a family friendly environment, family friendly care giving policies and practices and optimal breastfeeding support and that evidence showed that a model of care that covered those components was kangaroo mother care (KMC).

She then defined KMC as; early, continuous and prolonged skin-to-skin contact (24 hours and day, 7 days a week) Between a mother and low birth weight infant (Less than 2,500g) exclusive breastfeeding (ideally) and early discharge with adequate follow up. The World Health Organisation recommends this for all levels of care for babies from 29 weeks of gestation as long as weight is 1,500g or greater. (Kerstin stated, I haven’t checked!!)

We then heard details of how things are done in the NICU in Uppsala. There are no visiting hours, and parents have 24-hour access. The parents decide who can visit their baby with the nurses providing screening for any possible infections. Siblings can stay overnight in the family/ co-care room when required for the mothers’ presence. Fathers have no restriction on their visiting time; they are the mothers’ main supporter as well as the infants’ caregiver. This means that in the Uppsala NICU babies have can have at least one parent present 24 hours a day, with all levels of care.

With intermediate care, this is provided in the co-care rooms with the parents being present 24 hours a day giving the baby’s care. Intensive care nurseries have beds in each space along side the incubator and all other necessary medical equipment. Each space has dividing walls with half height windows present; this provides privacy as well as safety. The rooms are situated around a central nurses station, with monitoring available via telemetry, blinds are available for the extra privacy when appropriate/desired. The space has a decibel-reading device and Kerstin reported the space gave a quiet, comfortable environment for parents and their babies. In one picture we saw 2 beds with Mum and Dad in them providing KMC for their twins!

For intermediate care, mother and father/or substitute room in from birth or as early as possible, we saw photos of the co-care rooms, which were lovely. Each room had a sofa bed, television, comfy chairs, and bathroom and were very spacious, more like little flats than rooms. There is also a large parents kitchen and dining room/ lounge and a fantastic playroom for siblings.

KMC is the only way care is provided.

The postnatal ward has no cots! Parents are given an information leaflet before birth or very soon afterwards describing the way KMC is given and why. Kerstin had to go very soon after her presentation so there was no way of asking how they manage those babies who’s parents may not be able to provide such a level a care without a lot of support. If Mums are unwell Dads step in to give the KMC until Mum is well enough.

We then heard practical details of how KMC is given in Uppsala, after birth all babies are put on mums’ chest where an initial medical assessment is made, if possible the baby is stabilized in this position and transported to the NICU with portable monitoring in situ and the mother in a wheel chair or on a bed.

The policy for giving KMC is; infants born at 32 weeks or more have KMC 24 hours a day 7 days a week from birth if possible. This is the norm. Those born at 28 –31 weeks, have KMC 24 hrs, if possible. If not they should have KMC wherever possible and only go to another place of care when necessary. For those babies born at 27 weeks or less, for the first week of life it is an individual decision based on physiological stability, temperature, fluid and electrolyte balance. KMC for these babies has to be prescribed by a neonatalogist. If a baby is requiring an incubator temperature of 35 degrees or greater KMC is difficult. However even for babies of this gestation the norm is that they have KMC for at least 2 hours a day. After the first week the policy is the same for those at 28 weeks.

Babies are removed from KMC to have nappy changes, umbilical care, routine assessment and assessment for other reasons. Phototherapy is not an obstacle.

The parents hold their babies in place by using a ‘binder’, Kerstin demonstrated at the beginning of her talk what this was by placing a doll in one she was wearing and continuing her talk with the doll still in place! It was a sort of ‘boob tube’ that is made of a fabric that supports the baby but is comfortable for the parents, some mothers has special tops that can over the top or just wear their usual clothes. Ensuring access to the babies is easy at all time.

We saw photos of ventilated babies and those receiving CPAP in KMC. Kerstin described that the same high tech monitoring and care are given but in a different place. This change from the norm embraces the believe that the parents’ chest is the natural and optimal place for the infants’ growth and care, as well as a change in professional attitudes and roles.

Kerstin then spoke about breastfeeding, arguing the belief that babies were unable to coordinate swallowing, sucking and breathing before 34 weeks was untrue. That preterm babies have dysfunctional swallowing behaviour, that may need intervention was also untrue. Stating these common assumptions lead to mothers and their babies being deprived of optimal opportunities to establish breastfeeding, and mothers believing something is wrong with their babies. Kerstin then gave details of some evidence backing up her observations.

We then heard of the breastfeeding policy followed at the NICU in Uppsala. All babies are initially on a 2 hourly feeding schedule, with the introduction of breastfeeding from birth, if gestation 28 weeks or greater. If respiratory support has been required once the baby has had one day off CPAP and remained stable.

At signs that the baby is taking milk from the breast, the feeding schedule moves to semi – demand. There is a prescription of the total daily intake milk volume. Mothers offer the breast at any time the baby looks interested in feeding, as well as actively offering the breast after a time interval of 2-3 hours and giving supplementation by tube or cup to ensure total intake is met. Cup feeding is the first choice for supplementation, offered from 29 weeks gestation. Supplementation is in addition to breastfeeding, not routine to supplement after each time of breastfeeding. Tube feeding is done if the baby is tired or if the parents don’t want to cup feed. If the baby is awake and the parent is absent nursing staff will cup feed. When tube feeding is done, a tube is inserted each time a feed is given, unless the baby is sensitive during insertion or the parents don’t wish to cup feed.

To reduce supplementation mothers are offered 2 strategies and they decide which one they follow, they can test weigh pre and post feed plus daily weighs, or just daily weighs. Test weighing is only used if it increases the mothers’ confidence and doesn’t increase her stress. Kerstin noted that ‘starving’ doesn’t help.

We then heard details of the discharge procedure at the NICU in Uppsala, planning starts when the infant first comes to the unit; parents are given the opportunity to give care early on and there is a gradual process where the parents become the primary care givers. The pace is individual and there is no pressure. Parents are able to do nearly all that nurses do. Early discharge involves home care by parents, there is an open door policy, babies have to be 34 weeks with no signs of illness, there has to be some oral feeding with parents able to tube and /or cup feed. The baby has to maintain their temperature with KMC or clothes and bedding, the parents have to be willing/ able to participate in follow up care.

Unfortunately I had been poisoned by either the conference catering or ASK the following evening!! I stayed for the next two speakers but didn’t make notes and left at lunchtime before the final 2 speakers, as with all the presentations there are available on  www.babyfriendly.org.uk/page.asp?page=8 subjects covered were; Effects of Baby Friendly training on health visitors breastfeeding attitudes, knowledge and confidence. Turning training into improved practice. Breastfeeding support for women of Bangladeshi origin and Nurturing: Why love is not enough.

Many thanks for your time; I hope this round up has been of some interest to you! The ‘binders’ that ease the KMC in such preterm babies are available from www.kamcaredesign@se.