Breastfeeding: why nurses need to encourage and support mothers with babies in hospital
The RCNs latest guidance offers advice on promoting breastfeeding in childrens wards and departments
Emma Hobden, a deputy sister on a childrens ward, was admitted to hospital with dangerously high blood pressure when her son was three weeks old.
She had postpartum pre-eclampsia, which left her body swollen with excess fluid and, still recovering from a caesarean section, she had to fight to keep her son with her so she could feed him.Emma Hobden and child
Apart from one male doctor, who was great, no one could understand why I wanted to keep my baby with me and breastfeed him, she recalls.
Breastfeeding was so important to me and it had been going well. As a nurse I had a
The RCN’s latest guidance offers advice on promoting breastfeeding in children’s wards and departments
Emma Hobden, a deputy sister on a children’s ward, was admitted to hospital with dangerously high blood pressure when her son was three weeks old.
She had postpartum pre-eclampsia, which left her body swollen with excess fluid and, still recovering from a caesarean section, she had to fight to keep her son with her so she could feed him.
‘Apart from one male doctor, who was great, no one could understand why I wanted to keep my baby with me and breastfeed him,’ she recalls.
‘Breastfeeding was so important to me and it had been going well. As a nurse I had a voice and I stood my ground. But it was frightening and horrible. Someone else in the same situation may not have been able to fight for it.’
After successfully maintaining feeding despite the hospital stay, she is still feeding her son 19 months on.
Parents can get conflicting advice and little encouragement
Ms Hobden’s experience prompted her to think about how breastfeeding friendly children’s wards are.
‘Parents can get conflicting advice from different members of staff and there is not much encouragement,’ she says.
‘Doctors especially work with figures and want to know exactly how many millimetres a baby has had, so they move quickly to bottle feeding. Or babies are given big formula top-ups after a breastfeed, and then they sleep through their next breastfeed because they are so full.’
‘Breastfeeding was so important to me and it had been going well. As a nurse I had a voice and I stood my ground. But it was frightening and horrible. Someone else in the same situation may not have been able to fight for it’
Emma Hobden, deputy sister on a children’s ward
The guidance stresses women are likely to be vulnerable when their child has been admitted to a ward, and need access to breastfeeding support.
Straightforward practical steps, including the easy availability of equipment, such as pumps and a fridge, can make a big difference.
What do breastfeeding mothers on children’s wards need?
- A supply of snacks and meals as well as sufficient drinks to maintain milk supply
- A breast pump and fridge to store milk should be easy available. Fridges used to store expressed breast milk should be labelled as such and posters or advice leaflets on safe storage instructions provided. Fridges where expressed breast milk is stored need to be appropriately secured to prevent unwarranted access
- Private spaces for expressing or feeding
- Non-emergency nursing care or intervention should be planned to avoid disturbance to breastfeeding
- Staff should carry out any patient care required with minimal disturbance to the mother and breastfeeding infant
- Mothers should be given relevant information and education to sustain breastfeeding
- All staff need to be aware of and adhere to the World Health Organization’s 1981 International Code of Marketing Breast-milk Substitutes and avoid using documentation and items such as literature that promotes the use of breast milk substitutes
Adapted from RCN (2021)
Rates of breastfeeding in the UK are low
The World Health Organization (WHO) says babies should be exclusively breastfed for the first six months. Breastmilk is the ideal food for infants, as it is safe, clean and contains antibodies, which help protect against many common childhood illnesses.
Breastmilk provides all the energy and nutrients that an infant needs for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs during the second half of the first year.
Despite this, rates of breastfeeding in the UK are not high, with 2010 figures suggesting just 1% of babies are exclusively breastfed at six months in line with WHO recommendations.
There are many reasons for a breastfeeding woman to be in hospital:
- Her breastfed child is a patient.
- She could be supporting another family member receiving care.
- A sibling of her breastfed child is in need of care.
- She could be a patient herself.
The RCN guidance is clear that the approach of nursing staff is important. ‘The attitude of staff in supporting breastfeeding is absolutely critical,’ it says.
‘It must be clearly understood that there is no equivalence between breast milk and formula milk.’
Every children’s unit should have a written infant feeding policy that is routinely communicated to staff and patients.
‘Some evidence suggests that just staying a night or two on a ward with a baby with bronchiolitis is highly likely to alter that mother’s breastfeeding journey’
Lyndsey Hookway, children’s nurse and international board certified lactation consultant
Mothers need to be provided with the environment and facilities which meets their needs for privacy, information and appropriate nutrition, the guidance says.
This means suitable snacks, plenty of fluid and a private room if needed, and these facilities should be available in every area of a hospital, from outpatients to X-ray, the RCN says.
Offer access to private areas, pumps, storage facilities and breastfeeding counsellors
Mothers should be offered prompt access to trained staff or breastfeeding counsellors, who can help them with any difficulties they are encountering. Written information should also be available, and in different languages.
Women who need to express need a private, comfortable area, access to pumps, a fridge to store milk in, as well as storage pots and labels to mark their name and when the milk was expressed.
But nurses say access to even basic equipment can be tricky, with children’s ward staff often calling round maternity and neonatal units in search of a pump.
Difficulties faced by breastfeeding women on children’s wards are supported by research carried out by Lyndsey Hookway, a children’s nurse, international board certified lactation consultant, and a member of Lactation Consultants of Great Britain.
She has found widespread anecdotal reports of lack of support, inconsistent or inaccurate advice, and a sense by parents of feeling let down and discouraged to persevere with breastfeeding.
Ms Hookway has been conducting research for her PhD into the barriers for breastfeeding for medically complex children.
Even a brief hospital stay can have an effect on breastfeeding
She says that small studies have suggested that even the briefest hospital stay can have a serious effect on breastfeeding.
‘Some evidence suggests that just staying a night or two on a ward with a baby with bronchiolitis is highly likely to alter that mother’s breastfeeding journey.
‘That is all it takes for feeding to be disrupted. Any length of stay can have a negative impact, which is frustrating and upsetting because we know that when parents do not meet their feeding goals, they can experience grief and disappointment.’
One difficulty staff can face when looking after a child who is breastfed is that care can take longer, which can be a major challenge on overstretched, understaffed wards.
There is also a sense that doctors, in particular, struggle with the uncertainty of how much a breastfed baby has consumed.
‘Often nurses are fully signed up for the mother and baby dyad, but doctors less so. Supporting breastfeeding is a multidisciplinary skill’
Doreen Crawford, nurse adviser who worked on the RCN guidance
COVID-19 is also having an impact. It is harder to keep mother and babies together in adult wards, and harder for children’s wards to keep families together due to restrictions to limit the spread of the virus.
All nurses should have training on the importance and benefits of breastfeeding
Nurse adviser and consultant editor of Nursing Children and Young People, Doreen Crawford, who worked on the RCN guidance, says: ‘Often wards are under pressure, short of staff and keen to turn patients round quickly so they are after a quick fix, and it is a longer fix with a child on the breast.
‘The mother and baby dyad needs to be nursed through it, and this takes extra time and skill. So sustaining or reinstating breastfeeding becomes a luxury. Often nurses are fully signed up to it, but doctors less so. Supporting breastfeeding is a multidisciplinary skill.’
Lack of training, which gives nurses the tools and confidence to promote breastfeeding, are also problems, Ms Crawford says.
The RCN guidance says that all nurses should have training on the importance and benefits of breastfeeding and breast milk feeding for the mother and her baby and all aspects of lactation management, positioning and attachment, at a level relevant for each professional group.
There should also be training on methods of and equipment for expressing milk and all mothers should be shown how to hand express.
Staff on children’s wards in particular can find this tricky, as they care for patients from a few days or weeks old to the age of 17, nurses deal less frequently with breastfeeding – and training may be less up to date.
Unicef baby friendly neonatal standards
Supporting breastfeeding has always been a high priority in the neonatal unit at Evelina London Children’s Hospital, part of Guy’s and St Thomas’ NHS Foundation Trust , but working through Unicef’s Baby Friendly Neonatal Standards has brought an even greater focus.
All nursing staff have had training on supporting breastfeeding women, receive an annual update, and all new starters receive a day’s training on the standards.
Neonatal sister Elaine Wood says this training means all staff can provide immediate bedside help and advice to women. She is one of a number of staff who have received extra lactation consultancy training when more complex or in-depth support is needed.
The unit is working towards the final stage 3 assessment level of the standards.
‘Our staff use these skills every day, and can provide advice at the bedside,’ Ms Wood says.
‘This can be on expressing or, as their baby becomes more able to feed by mouth, supporting the feeding that the parents want to use.’
The unit has:
- 25 hospital grade electric breast pumps
- Some smaller electric pumps to lend to new mothers to use at home
- Comfortable reclining chairs beside the 46 beds to provide comfort during breastfeeding or expressing
- A private room for expressing
Positive approach means 90% of infants receive breast milk when they go home
Conversations about supporting breastfeeding with women are started as soon as possible, Ms Wood says. ‘It is so important to discuss and answer questions for mums about breastfeeding straight away.
‘There are so many things that parents whose babies are here worry about, and this is one aspect we can help mums with.’
The unit’s positive approach is working, with about 90% of infants receiving breast milk when they go home, compared to nearly 50% a decade ago.
For other nurses’ keen to embrace Unicef’s standards, Ms Wood says it is important to get the senior team on board with the value of breastfeeding at the beginning.
‘This will provide the opportunity and resources to be able to transfer that into support for families and patients.’
Neonatal and maternity services are able to draw on Unicef’s United Kingdom Baby Friendly Initiative, which is focused on helping public services to better support families with feeding and developing close, loving relationships.
The charity provides an evidence-based, staged accreditation programme, with a strong focus on staff training on breastfeeding.
This approach is recommended by the National Institute for Health and Care Excellence, and the majority of maternity units (91%) and health visiting services (89%) across the UK are now working towards Unicef’s Baby Friendly accreditation.
Standards are currently being developed for children’s hospitals.
Another source of support for acute staff is the Hospital Infant Feeding Network, established in 2018 for healthcare professionals.
Breastfeeding provides nutritional benefits and essential comfort for infants
When it comes to the care of a seriously ill child, there can be more barriers to negotiate, but in many cases it doesn’t mean that breastfeeding can’t continue, Ms Hookway says.
Alongside the nutritional benefits, breastfeeding can provide a much-needed sense of control during a traumatic time for parents, and for the infant it can provide essential comfort.
The RCN guidance says that resident mothers of sick children need to be provided with relevant information and education to sustain breastfeeding.
Ms Hookway, who breastfed her young daughter through successful cancer treatment, says parents are rarely given the encouragement to continue. She supports hundreds of families who are breastfeeding sick children, and many have shared their negative experiences.
‘When a baby with cancer is admitted, who will need chemotherapy, sadly, staff sometimes assume that breastfeeding will be impossible, as a young child on chemotherapy will often lose weight and they may need a nasogastric tube,’ she says.
‘But rather than giving a parent the support they need to maintain breastfeeding, the mother is often encouraged to stop straightaway in favour of high-calorie formula. This can be a real loss to the mother and child.’
- Hospital Feeding Network
- Lactation Consultants of Great Britain
- RCN (2021) Promoting Optimal Breastfeeding in Children’s Wards and Departments
- World Health Organization (1981) International Code of Marketing of Breast-milk Substitutes
- Unicef – United Kingdom Baby Friendly Initiative
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