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ABM  guide for GPs on breastfeeding past infancy

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ABM  guide for GPs on breastfeeding past infancy

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Breastfeeding until at least 2 years old is recommended by the World Health Organization because of the benefits for both child and mother. This includes developed countries such as the UK. Although there are estimates that less than 1% of UK children are still breastfed by their first birthday, the exact figure is unknown. For those families who do continue to breastfeed, it has a significant value that goes beyond nutritional or health benefits. Children allowed to continue breastfeeding will typically self-wean between the ages of 2 and 7 (natural term). A breastfed child eats normal solid foods alongside breastmilk, and they do not require any other mammalian milk (e.g. cow's milk). There is no evidence of harm to children or mothers who breastfeed to natural term. Breastfeeding beyond infancy is biologically normal: it should be celebrated and encouraged in mothers who wish to do so. It has health, economic and environmental benefits for the individuals involved as well as wider society; yet British culture is not generally supportive of natural term breastfeeding. Few GPs receive high quality lactation education, and thus may be inadequately informed to support families achieve longer term breastfeeding. This guide summarises the evidence available and how GPs can help. Effects on maternal and child health
Most GPs are aware of the vast array of benefits of breastfeeding babies (1), but may mistakenly believe that these benefits are time-limited. Breastmilk remains rich in vitamins, minerals and fats through toddlerhood and beyond (2,3), and immune components unique to human milk actually increase as the child ages (4). Children who are breastfed beyond 1 year have a reduced risk of acute otitis media (5), type 2 diabetes (6) and obesity (7). Breastfeeding beyond infancy may have psychological benefits for the child (8) and is an important source of comfort for young children. Many mothers find breastfeeding an invaluable parenting tool, by soothing a tired, injured or frustrated toddler and helping to promote sleep. Continued breastfeeding can prevent dehydration and malnourishment in unwell or hospitalised children, and is an ideal source of nutrition for 'fussy eaters'; parental attempts to increase solid foods in these situations can lead to displacement of nutrient-rich breastmilk (9). Breastmilk is particularly important for children with cow's milk protein allergy, as ready-made soya, oat, coconut or other milk substitutes are unsuitable under 2 years of age (10). There are also numerous benefits for mothers, but it should be noted that few (if any) mothers continue to breastfeed beyond 12 months solely for their own benefit. Benefits include a reduction in the risk of breast cancer (11), endometrial cancer (12) ovarian cancer (13), cardiovascular disease (14) and type 2 diabetes (15). Indeed, the UK government estimates savings of over £31 million for each annual cohort of new mothers through reduction of maternal breast cancer, if more women breastfed and did so for longer (16). There is no evidence in the literature of harm to either mother or child from natural term breastfeeding, including tooth decay (17). Production of toddler 'follow-on milks', which in ordinary circumstances are not proven to be necessary (18), undermine the International Code of Marketing of Breast-milk Substitutes and contribute to environmental impact (19).
Considerations for GPs

Mothers who breastfeed any age of child(ren) do not require any specific dietary adjustment or supplement apart from 10mcg Vitamin D daily (20).

It is very rarely necessary for a mother to stop breastfeeding in order to take medication (21). Many mothers will opt to delay treatment if a breastfeeding compatible medication is not prioritised. The BNF alone is an inadequate reference for safety in lactation, and GPs should check additional sources for more comprehensive information (22): we recommend UK Drugs In Lactation Advisory Service (NHS service) or The Breastfeeding Network.

Lactational Amenorrhoea Method of contraception is only suitable for use if the baby is under 6 months and has several strict criteria, as detailed by FSRH (23). Beyond 6 weeks of age, all hormonal forms of contraception (including COCP) are categorised as UKMEC 1 or 2 (24), however this is a complex area. Breastfeeding professionals frequently see mothers reporting a decrease in milk supply with all types of hormonal contraception, and GPs should be prepared to counsel women fully, including a discussion of the risks (25).

Women breastfeeding a baby or child of any age may develop sore nipples, engorgement, blocked ducts, mastitis or thrush and should be supported appropriately - see GP Infant Feeding Network for detailed information (26).

Supporting Breastfeeding
Breastfeeding is not always easy, and families who have reached 12 months may have overcome many challenges (27). Whilst many mothers report they receive good breastfeeding support in the early months, this reduces as their baby gets older (28). Lactation-specific education is scarce in UK medical schools and postgraduate training programmes, leaving many GPs ill-prepared to support natural term breastfeeding. Unsolicited advice to wean, unsupportive personal opinions or inaccurate information are all unhelpful to families who trust their GP, and may damage the doctor-patient relationship (29). US research has shown that even a very brief educational programme can improve doctors' attitude and knowledge towards breastfeeding beyond infancy (30). A doctor's personal experience of breastfeeding can affect their breastfeeding advocacy (31). Therefore, GPs who have had a negative personal experience of breastfeeding should ensure that any advice they give is evidence-based rather than anecdotal. Mothers who fear ridicule may choose to hide the fact that they breastfeed (32). But breastfeeding in public in the UK is protected by law, and there is no upper age limit to this (33). Mothers returning to work can successfully continue breastfeeding with appropriate support, and there is no need to wean unless she or the child wish to (34).

Nursing aversion (intense unpleasant emotions experienced whilst breastfeeding) may affect mothers, particularly of older children (35). Some mothers persevere for the benefit of their child; others may wish to wean. In either case, mothers benefit from their GP asking them about their wishes and then providing appropriate signposting to achieve this. Weaning from the breast may be mother-led or child-led (or a combination): natural child-led weaning is a gradual and gentle process and all children will eventually wean (36). Families should avoid abrupt weaning due to the risk of breast engorgement, mastitis and emotional distress for both mother and child. Some mothers fall pregnant whilst breastfeeding, and may continue to breastfeed their older child throughout their pregnancy and once their baby is born (tandem nursing). There is no evidence that breastfeeding during a normal pregnancy causes miscarriage or premature labour (37).

Mothers seeking breastfeeding support can contact the National Breastfeeding Helpline on 0300 100 0212, or can seek face to face support from Peer/Mother Supporters, Breastfeeding Counsellors or International Board Certified Lactation Consultants. IBCLCs are recognised as the gold standard in breastfeeding support and are available throughout the UK (38). GPs who wish to learn more about breastfeeding can do so via Unicef's e-learning package (39) or RCGP's e-learning course (40), which is free to College members. The ABM also offers their Breastfeeding Support Training Foundation Module (41), an online course suitable for healthcare professionals. Finally an online book for doctors has recently been published and is free to access (42).
Conclusions
In summary, GPs have an important role to play in helping to normalise and support breastfeeding beyond infancy. Breastfeeding mothers have a right to ongoing high standards of evidence-based healthcare for as long as they choose to continue. Breastfeeding beyond infancy benefits mothers, children and the NHS and thus should be actively supported by all GPs.
Dr Naomi Dow (GP) naomi.dow@nhs.net Emma Pickett (International Board Certified Lactation Consultant, Chair of Association of Breastfeeding Mothers) Dr Vicky Thomas (Consultant Paediatrician with special interest in growth and nutrition)
Whilst we have used the terms 'mother', 'woman' and 'breastfeeding', we recognise that not all families use this terminology. We encourage GPs to use the terminology preferred by each parent or family.

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Breastfeeding Beyond Infancy a GP Guide - ABM

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Breastfeeding until at least 2 years old is recommended by the World Health Organization because of the benefits for both child and mother. This includes developed countries such as the UK. Although there are estimates that less than 1% of UK children are still breastfed by their first birthday, the exact figure is unknown.

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Breastmilk continues to be a valuable source of nutrients even when your child is eating a varied diet. Find out the benefits of breastfeed an older baby.

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Your baby will also continue to be protected by the antibodies in your breastmilk for as long as he or she is getting any breastmilk: "Breastfeeding toddlers between the ages of one and three have been found to have fewer illnesses, illnesses of shorter duration, and lower mortality rates  (Mølbak 1994, van den Bogaard  1991, Gulick 1986).”

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Your baby will also continue to be protected by the antibodies in your breastmilk for as long as he or she is getting any breastmilk: "Breastfeeding toddlers between the ages of one and three have been found to have fewer illnesses, illnesses of shorter duration, and lower mortality rates  (Mølbak 1994, van den Bogaard  1991, Gulick 1986).”

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There are also massive health advantages to mothers of continuing to breastfeed past 6 months. The protection again all the ‘female’ cancers is dose-related, so the longer you breastfeed, the more protected you are. And breastfeeding protects women against type 2 diabetes, osteoporosis and heart disease : 

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There are also massive health advantages to mothers of continuing to breastfeed past 6 months. The protection again all the ‘female’ cancers is dose-related, so the longer you breastfeed, the more protected you are. And breastfeeding protects women against type 2 diabetes, osteoporosis and heart disease : 

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E. Bimla Schwarz, a women's health expert and scholar of evidence-based data, sheds new light on the maternal health benefits of breastfeeding. "There is a simple and natural way to spare tens of thousands of women from having heart attacks each year... yet less than 8% of hospitals are fully promoting this approach." - E. Bimla Schwarz

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How mothers can nurse themselves healthy

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E. Bimla Schwarz, a women's health expert and scholar of evidence-based data, sheds new light on the maternal health benefits of breastfeeding. "There is a simple and natural way to spare tens of thousands of women from having heart attacks each year... yet less than 8% of hospitals are fully promoting this approach."

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One good reason, of many, for continuing to breastfeed past 1 year (alongside giving solid food, of course) is the evidence that infants who are breastfed into their 2nd year have higher IQs. At around a year, when babies are experiencing a period of rapid brain growth, the fat content in breastmilk increases. A lot of that fat is in the form of triglycerides, and it's triglycerides that form the main ingredient in myelin, the fatty sheath that coats the axon of a neuron and speeds up the transmission of messages from one neuron to another. 

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One good reason, of many, for continuing to breastfeed past 1 year (alongside giving solid food, of course) is the evidence that infants who are breastfed into their 2nd year have higher IQs. At around a year, when babies are experiencing a period of rapid brain growth, the fat content in breastmilk increases. A lot of that fat is in the form of triglycerides, and it's triglycerides that form the main ingredient in myelin, the fatty sheath that coats the axon of a neuron and speeds up the transmission of messages from one neuron to another. 

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Here’s an important new study from Brazil linking duration of breastfeeding with IQ: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)70002-1/abstract

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Some interesting links on continued breastfeeding 

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Some interesting links on continued breastfeeding 

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http://kellymom.com/ages/older-infant/ebf-benefits/

http://kellymom.com/bf/normal/toddlernursing/

http://whale.to/a/newman.html

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I'm attaching some information on the advantages of continuing to breastfeed past 6 months. Continued Breastfeeding (From BfN website):

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I'm attaching some information on the advantages of continuing to breastfeed past 6 months. Continued Breastfeeding (From BfN website):

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Breastfeeding continues to be important for children’s nutrition, development and care after the first 6 months of life. On average, breastfed babies of 6-8 months obtain 75% of their energy needs from breastmilk, this falls to around 55% at 9-11 months, and 40% at 12-23 months. When breastfeeding is well established, it can contribute an even larger percentage to energy and nutrient requirements. Breastmilk is also a major provider of protein, vitamins, minerals, essential fatty acids and protective factors. It provides more calories and nutrients per ml than most of the other foods, and much more than the soft cereals, baby rice or pureed vegetables that are typically some of the first foods given to older babies. If babies’ stomachs are filled with nutritionally poor foods, they will take less breastmilk and their overall diet and health will be inferior. The contribution of breastmilk is often overlooked in the enthusiasm to get complementary feeding started. The challenge is how to feed other foods so that they add to the nutritional contribution of breastmilk, rather than replace it.

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Have a look at this chart detailing what's actually in breastmilk. It's mind-blowing:

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Have a look at this chart detailing what's actually in breastmilk. It's mind-blowing:

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I wanted to mention how brilliant it is that you are still breastfeeding. Only 34% of mothers in the UK are still doing any breastfeeding at 6 months, only 17% of mothers are exclusively breastfeeding at 3 months, only 12% are exclusively breastfeeding at 4 months, and fewer than 1% are exclusively breastfeeding at 6 months, so you deserve to feel very proud. 

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I wanted to mention how brilliant it is that you are still breastfeeding. Only 34% of mothers in the UK are still doing any breastfeeding at 6 months, only 17% of mothers are exclusively breastfeeding at 3 months, only 12% are exclusively breastfeeding at 4 months, and fewer than 1% are exclusively breastfeeding at 6 months, so you deserve to feel very proud. 