JULY 2022

Advocating for breastfeeding training amongst paediatricians and paediatric trainees

THE SITUATION

For the World Breastfeeding Week, Young EAP and EAP would like to promote the importance of breastfeeding training amongst healthcare professionals, particularly paediatricians and paediatric trainees, with the aim of improving breastfeeding rates.

How does this affect children and young people across Europe?

On a global basis, WHO and UNICEF recommend exclusive breastfeeding for the first six months of babies’ lives, and in combination with other food and drinks for up to two years and beyond. In Europe, introduction of complementary feeding at the age of about 4-6 months is recommended along with breastfeeding, because this was shown to reduce the risk of developing food allergies (1) while there is no appreciable risk increase of infectious disease morbidity in Europe associated with introducing complementary feeding prior to the age of 6 months. Breastfeeding has shown to have huge public health benefits for both children and mothers. However, the WHO European region has some of the lowest breastfeeding rates when compared to other parts of the world [2].

Protecting and promoting breastfeeding is a public health priority. Increasing breastfeeding rates to a near universal level may prevent 823 000 annual deaths in children younger than 5 years in low- and medium income countries with a high burden of infant diarrhoea and respiratory infections, and 20 000 annual deaths from breast cancer [3]. Paediatricians and healthcare professionals working with mothers and babies have an important role and responsibility in promoting, protecting and supporting breastfeeding.

Breastfeeding is not always the norm in many countries. This is due to many reasons at different levels, which include cultural attitudes and values, different healthcare policies, women working conditions and parental leave. The best breastfeeding outcomes are achieved when many interventions are implemented through multiple channels [4,5]. Even if improving staff training and knowledge on its own might not sufficiently improve breastfeeding rates [6], education and training of healthcare professionals is one crucial component in breastfeeding support strategies. Implementation of the 10 Ten Steps to Successful Breastfeeding in maternity wards was been shown to effectively improve breastfeeding outcomes [7]. The Baby-Friendly Hospital Initiative (BFHI) promotes implementation of the Ten Steps in maternity and newborn services [8]. Step 2 states: ‘Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding’ while Step 5 states: ‘Support mothers to initiate and maintain breastfeeding and manage common difficulties.’ This will include checking position, latch and suckling, giving practical breastfeeding support and help mothers with breastfeeding problems [8]. BFHI certification are scattered across Europe. Only around 35% of births in the WHO European Region occur in BFHI-certified services; however, there are large differences between countries, with one third of countries in the WHO European region having no BFHI-certified facilities [2].

It is commonly reported by mothers that doctors may give contradictory advice about breastfeeding which creates confusion and undermines mothers’ confidence in persevering when they face difficulties[9,10]. Various studies have revealed inadequacies in breastfeeding education during paediatric training and have shown the efficacy of breastfeeding training in improving physician knowledge and confidence in providing care for breastfed babies and their mothers [9–13]. Interestingly, a targeted breastfeeding curriculum for paediatric, family medicine and obs&gynae trainees in US also improved rates of infants exclusively breastfeeding in the institutions where the intervention was implemented[11].

Our recommendations

Young EAP and EAP emphasize the importance of breastfeeding training amongst healthcare professionals. It is particularly important to increase knowledge on support and assessment of effective feeding, including correct mode of attachment to the breast, signs of effective feeding including milk transfer and physiological feeding patterns in babies. Healthcare professionals caring for mother and babies should be aware of common breastfeeding problems, how to offer further support depending on the local services, and how to maintain maternal milk supply when introducing formula milk and awaiting further breastfeeding assessment. Genuine, insufficient breast milk supply is rare. Adequate support from healthcare professionals with experience on breastfeeding will enable most women to provide an adequate amount of breast milk to support their baby’s growth [9]. 

Various accredited organisations including UNICEF provide good resources including breastfeeding assessment tools [14], guidance for antenatal and postnatal conversations [15] and training packages for healthcare professionals with evidence-based resources.

REFERENCES

1. Halken, S., A. Muraro, D. de Silva, E. Khaleva, E. Angier, S. Arasi, H. Arshad, H. T. Bahnson, K. Beyer, R. Boyle, G. du Toit, M. Ebisawa, P. Eigenmann, K. Grimshaw, A. Hoest, C. Jones, G. Lack, K. Nadeau, L. O’Mahony, H. Szajewska, C. Venter, V. Verhasselt, G. W. K. Wong, G. Roberts, A. European Academy of, A. Clinical Immunology Food and G. Anaphylaxis Guidelines (2021). “EAACI guideline: Preventing the development of food allergy in infants and young children (2020 update).” Pediatr Allergy Immunol.
2. Theurich MA, Davanzo R, Busck-Rasmussen M, et al. Breastfeeding rates and programs in europe: A survey of 11 national breastfeeding committees and representatives. Journal of Pediatric Gastroenterology and Nutrition 2019;68:400–7. doi:10.1097/MPG.0000000000002234
3. Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387:475–90. doi:10.1016/S0140-6736(15)01024-7
4. Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016;387:491–504. doi:10.1016/S0140-6736(15)01044-2
5. Sinha B, Chowdhury R, Sankar MJ, et al. Interventions to improve breastfeeding outcomes: A systematic review and meta-analysis. Acta Paediatrica, International Journal of Paediatrics 2015;104:114–35. doi:10.1111/APA.13127
6. Gavine A, MacGillivray S, Renfrew MJ, et al. Education and training of healthcare staff in the knowledge, attitudes and skills needed to work effectively with breastfeeding women: A systematic review. International Breastfeeding Journal 2017;12:1–10. doi:10.1186/S13006-016-0097-2/TABLES/2
7. Organization WH. Evidence for the ten steps to successful breastfeeding. 1998. https://apps.who.int/iris/bitstream/handle/10665/43633/9241591544_eng.pdf (accessed 1 Jul 2022).
8. Nutrition and Food Safety. https://www.who.int/teams/nutrition-and-food-safety/food-and-nutrition-actions-in-health-systems/ten-steps-to-successful-breastfeeding (accessed 22 Jun 2022).
9. Cleugh F, Langseth A. Fifteen-minute consultation on the healthy child: breast feeding. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/ARCHDISCHILD-2016-311456
10. Eisenberg SR, Bair-Merritt MH, Colson ER, et al. Maternal Report of Advice Received for Infant Care. Pediatrics 2015;136:e315–22. doi:10.1542/PEDS.2015-0551
11. Feldman-Winter L, Barone L, Milcarek B, et al. Residency Curriculum Improves Breastfeeding Care. Pediatrics 2010;126:289–97. doi:10.1542/PEDS.2009-3250
12. Ercole LJ, McCoy K, Mandlik N. Increasing the Supply of Breastfeeding Knowledge. Pediatrics 2021;147:321–2. doi:10.1542/PEDS.147.3MA4.321
13. Sabella J, Williams TS. Developing Breastfeeding Champions: A Quality Improvement Project to Increase Provider Knowledge, Skills and Comfort with Supporting Exclusive Breastfeeding in the Pediatric Office. Pediatrics 2019;144:257–257. doi:10.1542/PEDS.144.2MA3.257
14. Breastfeeding Assessment Tools – Baby Friendly Initiative. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/breastfeeding-assessment-tools/ (accessed 6 Jul 2022).
15. Guidance for antenatal and postnatal conversations – Baby Friendly Initiative. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/guidance-for-antenatal-and-postnatal-conversations/ (accessed 6 Jul 2022).

About the authors:

Lead author: Dr Francesca Seregni. Paediatric Trainee ST6, mother of two children and passionate about breastfeeding promotion.
Author: Dr Sian Copley, Paediatric Gastroenterology, Hepatology and Nutrition subspeciality trainee.

Reviewed by:

Berthold Koletzko is a Prof. of Paediatrics at the Ludwig-Maximilians-University of Munich (LMU), a paediatrician at the Children’s Hospital and Children clinic of the Dr. von Hauner Children’s Hospital, and a EAP member.