Health Visiting – Keeping Everyone Happy?

If you have read my recent posts about quality of health visiting advice and encouraging parents to provide feedback, you will know that I am keen to address the current perception of health visiting that I see on social media.  So many people, myself included, have had excellent health visitor support, but still there is a persistent theme on Facebook forums and on Twitter that HVs do not “know their stuff”.  Considering how much training HVs do, I personally don’t believe that as many health visitors are as mystified about parenting topics as social media would have us believe.  I feel there is a slightly different problem, and it is one of approach and goals rather than training.

When I met with David Munday of Unite before Christmas one thing that he said to me as part of our discussion really stuck with me.  He said something along the lines of “Health Visitors want to enable children to be the best they can be and to enable parents to enjoy the experience of parenting. Health Visitors will try to focus on a family’s strengths. Health Visitors want to give children the best future and they want families to have the best possible experience.”

Now I’m paraphrasing there, but the meaning was clear: Health Visitors want us to be happy. They want us to enjoy parenthood, to enjoy our children, to have a pleasant experience as a family. Sounds pretty good doesn’t it?

Well it does, and then again it doesn’t.  I was privileged to be able to explore this idea in an article for the March edition of Community Practitioner magazine, the journal of the Community Practitioners’ and Health Visitors’ Association.

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My argument was that it had never occurred to me that my happiness or enjoyment of the parenting experience has anything to do with my Health Visitor, and a number of members of my Facebook group felt the same. As parents, we are expecting HVs to give us up to date, evidence based, accurate information on the health aspects of parenting, and this includes infant feeding, bedsharing, introducing solid food, post natal depression, toddler behaviour, weight gain and development. Yet if the focus is on keeping parents happy it goes a long way to explaining where things might be going wrong.

The classic example here is of the breastfeeding mum who is advised to give formula top ups. I say classic, because it happens all the time. Any breastfeeding peer supporter, counsellor or lactation consultant will tell you that formula top ups are rarely required. Either the mother has a problem with her milk supply which requires resolution, the child has a health problem which requires investigation or (far more likely) the pair simply require some breastfeeding support. So why do Health Visitors so often resort to recommending top ups? I don’t believe it is because they are behind in their breastfeeding training, I know they are all well trained and informed about infant feeding. I wonder though whether it isn’t because, in the short term at least, they believe introducing some formula will make mum and baby happy, will take the stress out of their lives and will make everyone’s life easier?

Unfortunately I am not convinced that this is the approach that families want, and in my article I shared a number of comments from parents to that effect.

If Health Visitors are there to put mum’s happiness first, then they take on the role of friends, family and society which in turn will just perpetuate the beliefs and practices of that group, family or society…..They should be health professionals who provide accurate up to date information to help both babies and society to grow healthy.” (Julie, Yorkshire)

It is very easy nowadays for parents to discover that the advice they received from their health visitor was not the most up to date or the most evidence-based available. It doesn’t matter at that point what the intentions of the Health Visitor were, the parents lose faith in that professional. As an HV you may have made the decision to tell mum to try controlled crying because you could see that she was exhausted after nine months of broken sleep. But if you omitted to mention the body of evidence questioning that practice, or the evidence to suggest that sleeping through is not necessarily “normal” for a nine month old, please remember that she will find out that information for herself. And she will then wonder why you weren’t aware of it, and will hesitate to seek your advice again.

The Internet can be a minefield of dodgy information, but it is easy to find and follow trusted sites that spread from parent to parent via word of mouth and social media.  If these sites are providing more evidence-based information than our health visitors, or are providing more in depth analysis of parents’ options, we start to see this situation where some parents lose faith in the health visiting profession.  This is a huge problem, because health visitors play a vital role in supporting families, safeguarding public health and disseminating important messages.  Parents encouraging each other to disregard HV advice is a big concern to me, yet it is hard to turn this tide if evidence based information is not the norm.

I would not wish to suggest that the profession becomes a robotic, information and signposting service – the personal touch is vitally important.  The postnatal period is an extremely vulnerable time for mums, and many of us are eternally grateful for the emotional support and hand holding offered by our Health Visitors.  And of course HVs have to use their discretion and judgement when it comes to the approach to take with families. But I feel it’s important to remember that all families prefer to make their own decisions. Some might need information in written form, some might be happy to be directed to the Internet, some may need a good chat through the options, others may require signposting to local groups and classes. But very few will be happy to discover that a health visitor has made the decision for them and given them only that piece of advice which they have decided is in the family’s best interests.

Barbara Potter of HV Community of Practice Evidence Hub read my original article and has been in touch with me to look at ways parents and health visitors can work together to tackle the issue of evidence-based practice.

 HVECop

The Hub can be followed on Twitter @HVeCOP and works in partnership with the Institute of Health Visiting, the University of Hertfordshire and The Open University.  I have also been in touch with Elaine McInnes of the iHV who is keen to ensure that the resources available to parents on their site reflect current evidence and best practice.  How many health visitors are engaged with these communities?  How can we reach those who are not?  How else is new evidence communicated to a busy workforce?  As parents and health visitors, what are your favourite resources for information and advice?

As parents, we want to know that we will receive all of the information from our Health Visitor, and that it will be as accurate as possible. As professionals health visitors want what is best for families and children. We need to remember that they have the benefit of years of training, hard work and experience. They need to remember that, given the right information, we will know what is best for our family.

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Health Visiting – Tell Us About It

If you read my post on Health Visiting – Quality and Quantity you will know that the mothers in my Facebook group have plenty to say about health visiting services.  Good and bad, the feedback comes thick and fast every week, so much so that I contacted various senior health visitors to discuss the trends I was seeing.

But if I ask my group whether they have personally provided this feedback to their health visitors or trusts most of them will say no.  Why is this the case?  Sure, a lot of it will be the usual social media rants and whinges that we see all the time, and doesn’t actually warrant a call to a team leader.  But I frequently see posts where the health visiting team in question would really benefit from being told about the perceived problems, the poor quality of advice, the difficulties families are facing and so on.  Yet trying to convince mums to provide feedback is very difficult.  Why should this be the case?

Health Visitor Advisor to the Department of Health Andrea Johns asked me to find out from the group what they felt were the barriers to providing feedback.  I will give you a flavour here of their response:

“I didn’t complain about mine as I knew it would be likely I’d still see her at clinic. I didn’t want there to be any awkwardness / receive more negative attitude as a result of a complaint.”

“I think the problem is that no one really knows who you can complain to.”

“I complained about mine and was told there was nothing I could do as it would be recorded as a personality clash.  I can’t remember the exact wording of the conversation but I was essentially told my request would have to be referred to management (leaving a mark on the health visitor’s record) and would likely be put down as a personality clash. They just advised me to go to the baby clinic if I had questions.”

“Had it been any other service or an every day situation like being served in a restaurant I wouldn’t put up with poor service and would say something. But when it comes to HVs I found I suddenly lost my voice. It felt like questioning them would lead to questioning of you and you as a mother. If they had a very clear and well set out feedback system (for positive and negative feedback) that was highlighted from the beginning I think it would help to make the whole system seem more transparent and make it easier. Maybe even something online? It would also make it easier for people to quickly raise an issue without feeling they have to talk to the people involved directly themselves?”

“I haven’t complained as you’re stuck with them for 5 years so it would be quite embarrassing!”

“I realise that they are under staffed which I think stops me from complaining. Like others I depend on the internet for advice nowadays or the GP as I just find it’s less stressful.”

There is so much confusion about the role of health visitors and by whom they are supervised. It is even news to a lot of mums that HVs are registered nurses.  Of course, even when this is well known, a complaint to the NMC seems extreme!  But is it made clear to families how and where they can provide feedback on health visiting services – feedback in general and complaints specifically?

Fortunately I have absolutely no complaint about my health visiting team, and I have provided positive feedback to them directly on a number of occasions.  But let’s say I wanted to mention that I had been unhappy with something my HV had said to me.  Not even a complaint as such, just a concern.  Putting aside the contacts I have and the things I know now, where would I have looked as a first time mum?

Well, I may have Googled Sale Moor Health Visitors.  And if I had the top link would have been this

Sale Moor HV capture 1

This takes me to the Trafford Council website where I am told the following:

Sale Moor HV capture 2

Sale Moor HV capture 3

Now I know that Joan is the team leader.  But that is not made clear on this information.  And it is certainly not made clear that you could use her email address to provide feedback about the team.  But is this the webpage the team would like you to be directed to? Let’s see if there is a better link than the one at the top…..

No, there isn’t.  The other links are to news reports about awards the team has won, and to the local GP surgeries.  There might be something on the next page, but I don’t know of many people who search past one page of Google.  Added to this is the fact that when my eldest was born I didn’t know that my health visitor was from the Sale Moor team.  I only registered that information fairly recently.  So in all honesty I would have Googled Trafford Health Visitors.  And I would have got this:

Sale Moor HV capture 4

Even less informative.  Now I’m not suggesting that all health visiting teams should suddenly spend the huge amounts of time they don’t have building fantastic websites and employing search engine optimisation experts.  What I am saying is that if my team is typical it is not obvious to whom feedback should be addressed.

The second issue is of course what will happen if feedback is provided.  What will be the repercussions?  What is the standard procedure for dealing with feedback and complaints?  What if there is only one health visitor in your area?  And is the team leader likely to welcome feedback or will you just be creating problems for yourself in providing it?

The consensus on my group was that feedback should be gathered online, simply and anonymously.  This comment summarises the general feeling:

“I think a feedback survey, one that has one-word answers but also gives you the space to elaborate if you need to, but so that you can remain anonymous as well. And for them to be given at standard times throughout the age of your little ones, as I realise everyone differs in the amount of times they would see their HV.  So like once your little one is 1 month then 6 months etc. And to do it online, that way the NHS are saving costs with postage but also it’s a lot quicker for the parents to fill out. It personally takes me ages to get round to filling out a survey by hand and then posting it (will sit on my kitchen table for weeks!) But I think online you’re more likely to just do it when you’re having a browsing session.  Also make sure the survey would allow you to put the positives on there as well. Even though I’ve had negative experiences I also know there are a lot of good HVs out there as well.”

I know that some areas are piloting systems very like that described above and I hope these are rolled out nationwide.  In the meantime, it would be fantastic if every team could provide clear information about how to provide feedback (positive and negative), how to complain, and what the procedure will be if you do.  With health visitors working alone, certainly when it comes to home visits, there is not the informal peer supervision you get with so many other healthcare providers.  This is why gathering honest feedback from families is so crucial – and hopefully relatively simple to achieve.

Health Visiting – Quality and Quantity

I am starting a new series of blog posts today about health visiting and the relationship between health visitors and parents.  This is something that I became concerned about over a year ago, having seen numerous posts on my Facebook group about questionable advice from health visitors, HVs upsetting mothers, a lack of health visiting support and so on.  My family has been so fortunate in the wonderful support we have had from Anna Embleton and the Sale Moor health visiting team, it saddens me that this is not everyone’s experience.  It is also a concern, as if parents are losing faith in HVs then it will be that much harder for health visiting teams to communicate important public health messages and provide support to families.

This becomes even more of a concern when we consider the changes that are coming this October, when health visiting will start to be commissioned locally instead of nationally.  If families do not value their health visitors, will there be enough public pressure on local authorities to commission the services that communities need?

Health visitors currently work to what is termed the 4, 5, 6 model, which is 4 levels of service, 5 universal health reviews and 6 High Impact Areas.

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So what feedback have I received on social media about health visiting advice over the last year or so, particularly in relation to the areas covered by this model?

Universal Health Reviews

“Mine saw baby at 3 weeks and hasn’t seen her since – she’s now 7 months! Not even a phone call!”

“My little girl is 6 months old and I’ve only ever seen my HV once, and that was when she was 10 days old.” 

“My current HV told me she’d come out to see me at 6 weeks post birth – 6 weeks has been and gone and I’ve heard nothing. Good thing there are no issues!”

“I can’t even remember a thing about mine…..they stop coming at about 6 weeks don’t they? I vaguely remember having to be in for when someone was coming but can’t really remember what they did. Babies are 20 months now so it seems a long time ago.”

Transition to Parenthood

“My HV advised me not to go to any groups until my daughter had received her first set of injections. As I was new to it all I didn’t go to any groups until after the first jabs. Which was hard. When I did start going to groups the Children’s Centre were shocked and told me this wasn’t the case at all. I believe that the Children’s Centre were rather upset as they want to get as many mums & babies to the groups. It was reported to a higher power but I’m not sure whether the HV was advised of the correct procedure.”

“I had had an episiotomy and I asked whether the stitches would be checked at some point.  I’d had surgery / stitches on my foot prior to being pregnant which had had regular follow ups. I assumed, given the ‘vulnerability’ of the area in this case that someone at some point would want to make sure they were ok. Want to know what my HV said….?! ‘well not everyone wants to get on a table, spread their legs and show someone their vagina.’ “

“I find like any professional you get good and bad ones. What does annoy me is the inconsistent advice you get from them. I rarely see the same one at baby clinic and they all have a different opinion on things which just leaves me confused about what’s best for baby!”

“With my little girl we were seeing the doctor for weighing on a monthly basis due to her reflux. On the two times I visited the HV for weighing they didn’t listen to the reasons why she wasn’t putting on a massive amount of weight or that the doctor was seeing us. They made me feel stupid and like I wasn’t caring for my child by insisting that she needed to be seen by the GP straight away and that the GP’s recordings were wrong. I just stopped going. My daughter still hasn’t had her two year check and will be 3 in August.”

“Any HV I’ve ever come across has been very reluctant or unable to answer any questions directly.  Seemingly for fear of being blamed if something goes wrong based on their advice. One that I asked about the amount of milk needed at 8 months, and for tips on getting baby off the breast and onto a bottle, told me to go and talk to the breast-feeding counsellor instead about it..!  I’m a bit confused as to what their purpose is to be honest.  My mum’s friend is a retired HV and has said to me ‘Most babies are pretty sturdy and will grow anyway, so I just used to tell mothers what they want to hear.’ Pretty much sums up what I’ve found – except for the ones that are downright rude and make mums feel the worst ever.”

“In general I’ve been disappointed by my HV contacts, to date I’ve had 3 different staff and little support has been given. I’m not sure what I was expecting but on each occasion I’ve simply been given NHS standard literature on a variety of topics.” 

“My health visitor is a bit patronising if I’m honest; leaflets leaflets leaflets I hate the text book way they work – all babies are different. I think they should see you a lot more as well on your first baby. I don’t feel as though I see mine enough – luckily I have experience with babies but for people who don’t and it’s all new more support is needed definitely.”

“I’d like it to be a bit more personal & a little less textbook, when you’ve just had a baby you’re so worried about every single thing & health visitors (I doubt on purpose) don’t make that any easier.  I saw a post of a lady a few days ago saying she hoovered the entire house & even changed the bedding because her HV was coming round.  It’d be nice to have that reassurance that you don’t need to do that, even if it’s just a comment “oh wow you’re house is lovely considering you have such a small baby”, maybe this would mean mum is a little more relaxed on the next visit. Also a little more interest in your own baby rather than ‘all babies’ and just being given leaflets upon leaflets of how it should be done.  Mine couldn’t remember my daughter’s name once, she kept asking. I’d like to be able to have a nice chat and maybe even a bit of a laugh with the HV and I never felt comfortable enough to do that, it felt a bit like I was in an interview to be honest.” 

“I’m currently on health visitor number three. My little girl is 9 months and I met the first one once before she was born.  Only met the second one once too. The rest of the time it’s been another health visitor. Although they have all been helpful and supportive, it’s hard to build a relationship with them when you’re seeing a different one all the time.”

Maternal Mental Health

“I never had a home visit.  I got a letter when my baby was a few weeks old telling me they were busy and there weren’t enough to go round but if I wanted to see someone I could give them a ring or go to the drop in.”

“For the first 2 months my little girl would only sleep vertically, which meant that my partner and I slept and ate in shifts as she would only sleep on us – we tried everything – carrycot in cot, cot, Moses basket, swaddling – nothing worked. I was also breastfeeding. The Health Visitor was unmoving in her mantra of ‘baby must sleep in her own bed, baby must not sleep with us’. It was really stressful. I was sleep deprived. Terrified I was doing something wrong. Scared to admit to my depression as I thought they would think I was incapable etc etc. In the end, after weeks of this I straight out asked her what she would do and she couldn’t give me an answer.”

“Went today & had to fill out a questionnaire about post natal depression. I scored 12??? Whatever that means but I always feel they judge me. I’m absolutely fine & happy, but like any new mum have tough days. Going today has made me feel more down.”

Breastfeeding

“At the time, I couldn’t understand why the HVs I saw refused to give me any kind of support, or tell me where I could get it. Now, I realise that they had no idea what they were doing, were understaffed, under-trained, and trying to get through too many appointments. They were resentful of their working conditions and taking it out on the women they saw. Visits were purely about getting through the paperwork they needed to show they had done, and nothing else.  In my opinion they did my daughter and I a lot more harm than good, which is why I am going to give them one chance only to impress me this time.  In their favour, they didn’t put as much pressure on me to formula feed as the community midwives did, but only because they didn’t really say much at all.”

“I had mixed experiences. Judging by the huge number of moans on the many breastfeeding and parenting groups I am part of, in general people find their HVs to be unhelpful and giving inaccurate information. Of course, there are some great HVs, but wouldn’t it be good if they were all as good. With regards to breastfeeding, I believe that many HVs are not educated enough in the art of lactation! (The same goes for doctors, nurses and other health professionals.) They give wrong and misleading information. So many mums don’t get the help they should have and are failed by the health service. Many more would continue breastfeeding for longer if they just had some help. It is so often a regret for mums that they didn’t persevere and it is often not their fault. They just needed that support or help.

So why are HVs not trained by La Leche League or whoever to be lactation consultants? And why are they not giving out accurate and up-to-date information? Mums must of course have the choice whether or not to breastfeed, but I believe that we are not provided with all the information and the evidence about the benefits of breastfeeding and the problems with formula feeding. And then if us mums do have problems, why are we not helped by trained lactation consultants. So long as people are educated enough then they can choose to stop breastfeeding when they wish, but at the moment so many mums are being failed because they are not fully informed and so they are stopping prematurely. I truly believe that there will be a revolution at some stage against the multimillion pound advertising from the formula companies who are giving out inaccurate information about infant feeding. Once the health service starts to provide help and education, this revolution will start.”

“Definitely think HVs do not often have up to date breastfeeding info especially when baby has lost a little bit of weight; instead of suggesting upping feeds etc they are quick to suggest that your milk is not enough and they must have formula which then totally interferes with a mum’s supply often making things worse not better, and thus the downward spiral of an end to breastfeeding.”

“I am not sure why but my daughter was never an enthusiastic feeder. At the time, I felt I was being blamed for not producing enough milk. I did everything they said and even tried expressing, but I couldn’t produce any more. I fed on demand and she never wanted more. Her weight started to plateau at 5 months and we ended up having to wean her early. I broke down at a weighing session and thankfully there was an Early Years advisor there who was a breastfeeding specialist. She came and visited us at home the next day and was wonderful. For us though it was too late – I just couldn’t produce any more (tried super switching?? etc) and we decided to wean her early and use a mixture of bottle and bf when I went back to work when she was 6 months (I didn’t want to, circumstances dictated). I carried on breastfeeding for another 4 months after I went back to work full time (morning and evening). My little girl decided to stop at 11 months when she got her first cold.

I have discovered that I have seriously low levels of vitamin D, which wasn’t picked up until the end of last year. I don’t know if that had anything to do with it. I am still really upset (I am in tears just writing this down), 4 years later, that I couldn’t produce more milk, that I couldn’t encourage my daughter to take more and I didn’t get the support I really needed at the time. I really do feel like I failed her in that respect. I have no answers.  It’s still so raw.”

“I’ve actually just been to the self-weigh drop-in clinic and asked about nighttime feeding. Again I was given a leaflet and told that at the age of 34 weeks my baby doesn’t “need” food during the night and we should stop immediately and only give her water to satisfy her thirst!  I guess I was hoping for a little more support as a first-time mum.”

Healthy Weight

“The health visitor I used to see was lovely, very approachable, good with advice, kind and made you feel good about what you and baby had achieved together.  However one week I had a stand in … absolutely horrible woman. Had no time for my little boy or to listen to what I had to say. I said that I was concerned about him not eating a variety of foods and wanted advice. None was given other than ‘put him on the scales. I’ll see what his weight is like’.  Yes he had dropped a little as I had guessed and all I was told was “he’s underweight push more food”. I left feeling very upset and that I was failing as a first time mum. This put me off going to the health visitor unless I have to and also made me paranoid about the amount of food my boy eats”

“My health visitor was lovely, a very sweet woman with a gentle manner, but I have to say (not sure if politically correct to mention) that she was obviously clinically obese.  This did leave me to wonder how she managed to conduct her job with regards to advising on healthy lifestyle. She did comment that my 2 year old at the time had increased quite a lot on his centile (chunky and tall but not overweight!) and that I should really keep an eye on that!!?”

Managing Minor Illness and Accident Prevention

From the mother of a child with a Congenital Heart Defect: “My HV is a very nice person, but hasn’t a clue what to do with my little girl as she isn’t ‘normal’. We have seen her 3 times in 5 years but she has said if I need anything to ring her. When I have asked her for anything she has said ask the hospital as my daughter is under them! I just didn’t bother from then onwards.”

“I voiced my concerns to my HV regarding my little boy’s back and his lack of movement in his neck and she shrugged it off and said he was fine without a second look.  Didn’t even bother to make a note of it in his red book. Despite her advice I went to see my GP who made an instant referral. Then he was diagnosed with scoliosis and torticolis. Glad I followed my instincts! It has made me lose faith in my HV.”  

“My health visitor told me that because I am in a same sex relationship she didn’t need to worry about domestic violence, because only men beat up their female partners because they get jealous of new baby.”

Healthy 2 Year Olds and School Readiness

“Has anyone had to deal with a toddler head butting when they can’t get their own way? My little boy is 18 months and been head butting loads when he can’t get his own way. I spoke to the health visitor before Christmas and she told me to strap him in the pushchair when he is throwing a temper tantrum but I don’t want to be doing that.”

Institute of Health Visiting. Library Photography. Picture: Cleverbox / www.matthewwalkerphotography.com

Institute of Health Visiting. Library Photography. Picture: Cleverbox / http://www.matthewwalkerphotography.com

It is interesting that Infant Sleep is not one of the High Impact Areas, as it is certainly one of the areas with the highest impact on parents!  This comment is unfortunately not unusual, which is frustrating considering the evidence available on infant sleep and “sleep training”:

“My health visitors were awful, I only saw someone three times before opting out. 
The last time was when my little girl was about 5 weeks old and the HV told me I should let her “cry it out” to get her to sleep… She had colic… So no, I don’t think that health visitors are helpful in the slightest.” 

The above comments are a snapshot of what is a weekly if not daily subject on my group and other social media forums, and I felt that I needed to raise this with somebody.  Simply trying to find out online who is responsible for health visitors is a difficult task for a parent who does not work for the NHS and so doesn’t understand the hierarchies.  Should I speak to the Nursing & Midwifery Council?  Should I speak to NHS England?  Should I speak to individual trusts?  Who decides on training for health visitors?  Who can tackle perceived inadequacies?

In the end I wrote to two organisations: the Institute of Health Visiting and Unite.  I have since had a lot of contact with both organisations, and other senior health visitors working for the Department of Health, and the feedback from my group has been provided to quite a few people.  More of that another time.  The first discussion I had on all of this was with David Munday of Unite, when I met with him at their Salford offices in December 2014.

My meeting with David was helpful and productive.  He gave me some background to health visiting in the UK which goes a long way to explaining some of the issues families experience.  David explained that between 2000 and 2010 there was a dramatic decrease in the number of health visitors in the UK.  Caseloads in some areas went up to 1,000 families per health visitor.  As a result of some awful cases that hit the news, all political parties promised to increase the number of health visitors during the 2010 election campaign.  There has been an increase in the last 4/5 years, and the pledge was that there would be 4,200 more HVs by April 2015.

Click here to see #CPHVatt debating progress on the HV Plan on Twitter around the time that I met with David Munday.

So we have a situation where the profession lost a lot of experienced practitioners, and now 50% or more of HVs are newly qualified.  An exhausted profession is then being expected to train up a lot of novices.

Now, this does not excuse some of the things we as parents experience, and David did not offer it as an excuse, but it does explain why some health visitors do not have the time or inclination to keep as up-to-date as we would like them to be, or to be sunny and positive at every appointment.

Baby Friendly training is helping with regards to breastfeeding knowledge, although it will take time for the effects of this to be seen.  The impact of the closure of children’s centres is huge in David’s view – and I know that in my own borough, Trafford, all but 2 of 16 original centres have been closed over the last 3-4 years.  The Birth to 5 book is no longer available in hard copy, as a cost saving measure, hence the myriad leaflets with which HVs and families have to contend.

It is important to remember that health visitors have to deal with some awful situations (I know of HVs who have received death threats) and their primary concern is always the safety of a child.  The profession is over-stretched and lacking in resilience – something I see frequently on Twitter, where the passion and compassion of health visitors is being pushed to breaking point.  David referred to “going upstream” – when HVs are under pressure they focus on pulling out of the river the people who are drowning.  In an ideal world, they would be going upstream to find and tackle the causes of people being pushed into the river.

From the Institute of Health Visiting

From the Institute of Health Visiting

Since that initial meeting I have had many more discussions about health visiting quality and quantity and I will be discussing approaches, improvements and gathering feedback in later posts.  For now I wanted to leave you with the other side of the coin – the positive comments that have come from members of my group.  Because there are a great deal of fantastic, hard working health visitors out there doing their best for UK families:

“My HV has been fantastic, has always been very good at listening & answering any questions I have had. My little girl was the first baby she had seen with a heart defect & di George syndrome, so she spent a lot of time looking into it & getting ideas on what I could do to help my daughter.”

“I feel really lucky, mine have been good in all sorts of ways. If I’ve been worried that I’ve not heard from them when a check of any kind is due, I just phone and chase them up. We’re also very lucky to have a breastfeeding guru (not sure of her official title) in our area who is also qualified to deal with tongue ties and did so with my first son as soon as she had diagnosed it. When I did go over to formula they were also supportive and I didn’t feel judged or a failure. All good so far really!”

“Appreciate that she is one of thousands in the country, but I can only speak positively of my HV. She covers our village and the surrounding ones, so we always see the same person, she’s ready to answer any question however silly, is always at the end of the phone and willing to do home visits. She’s chased prescriptions and hospital appointments and arranged an eye test for my 2 year old immediately when I was concerned about a possible squint. Importantly, she always gives a balanced, common sense view….she has been in the job for a long time and seen lots of changes in guidance and policy….she will give the official advice and tell you why it is what it is, but also tailors her advice to the individual baby. I think if I had a young one who just took a “tick box” approach I would get very annoyed! So there are good ones out there!”

“My HV is lovely; unfortunately she has not managed to actually help much with my little boy because of his issues but she is always there to support me.  The last two times she hasn’t even come to see about him, she’s keeping her eye on me because of my recent problems with coping and depression.  She is very supportive of me and it’s lovely to have that from an ‘outsider’ so I have nothing but positive praise for my HV!”

“My HV was brilliant, as was the rest of the team. I was able to contact them whenever needed and when I first called up to ask for help because of suspected PND they kept me on the phone for an hour talking to me and discussing next steps to get through the night, until they could make a home visit the next day. So nice and friendly and really calmed me down and helped me. I asked her for plenty of advice on PND, baby sleep, baby eating, illness etc and she was able to provide really good advice as far as I’m concerned, it all worked at the end of the day and it’s advice I still pass on now to other mummies to make their own decisions. She was non judgmental as to our choices.  She seemed very comfortable around children, and had a no nonsense approach that may have put some off but I felt at ease with that as it exuded confidence and made me trust her.”

“I have to say that the health visitors in my area have been a mine of information and support for me. Particularly the breastfeeding support I had that came out for home visits and phoned me to see how I was doing till we were comfortable with it all. And a massive support from my sleep expert lady she has been my rock when I thought I was losing the plot. No complaints here.”

“My health visitors have all been great. Really supportive when my son didn’t put on much weight the first few months and supported my decision to exclusively breast feed even though I think they thought I should have topped up with formula. Also very supportive about sleep (or lack of), I have cried on them many times, and have had a few home visits from them about it and attended a talk. However I’ve realised they don’t have all the answers and sometimes have conflicting advice, but they always give me an idea of something else to try which I’m really grateful for. Having heard bad things about HVs before I had a baby I was worried, but I have felt really supported. My son is just over 11 months, we’ve just had his check and the HV was fab and really gave me confidence that I’m a good mum, which was exactly what I needed to hear.”

“Mine was fab, to be honest just what I needed when trying to breastfeed twins with tongue ties and never once did I feel under pressure to breastfeed. My HV even sorted out some HomeStart to help once a week which has been a godsend, also she arranged for a breastfeeding adviser to get in touch with me who in turn came out to see me a few times and was a major influence in me continuing to breastfeed as long as I did.”

“I must say I really like my HV, she’s really nice and approachable and I know if I needed to I could contact her and she would come and visit. She visited more often at first as I was having breastfeeding problems.  She referred me for an early days group at the local Sure Start for first time mums and she’s been really informative with advice. Last time she came was two weeks ago – it was supposed to be our last visit but I was quite tearful and emotional as I was tired and worn out as my daughter had started waking in the night again.  It was “just one of those days” but I think she could tell there was something wrong as she kept asking “are you sure everything is alright?” then I burst into tears, embarrassing! She stayed and chatted and reassured me that everything will settle and she arranged to come back to see me tomorrow to make sure I’m okay and to check things have settled.”

“I have no complaints with the health visitors I have met in Northwich or the ones that go to Cherubs in Winsford. I have found them all kind, supportive, caring and pleasant. I had breastfeeding support from them in my home in the early days. I had a trainee as well as my own HV, and whenever she sees me she knows my name and my little boy’s without a reminder which I think is lovely.”

“My second HV, Louise, was and is completely brilliant. She came round, asked how she could help and listened to me. She still filled in forms, but as part of a chat, so the form was incidental, rather than all-important.  When I was struggling with anxiety, she visited weekly and then monthly until I told her I was feeling better. When she visited and I was exhausted from breastfeeding through a growth spurt, she made me a cup of tea. Little things, but they all added up.  She also made it clear that she would help me access any services I needed to access. I didn’t need to take her up on it, but it was the reassurance that mattered.  Louise pretty much fulfils my idea of a perfect health visitor.”

Mental Health Awareness Week: Alert! Alert! Move away from the Online Debate

It’s Mental Health Awareness Week. Whenever there’s an “awareness” week afoot, you know that you are being asked to be more “aware” of other people’s struggles. And sometimes, depending on the week, you will be asking them to be aware of yours. Yet there is another side to this: being self aware. Where mental health is concerned this is both difficult and important.

The last week and a bit has been hard going. People who are passionate about politics have all been left feeling bruised, both by actual events and by the tone of the debate in person and online. As a result, a lot of people’s resilience is low. In those circumstances, it doesn’t take much to spark off disaster. If like me you spend a lot of time discussing issues on social media you will have found that there is a little less empathy. A little less holding back. A little more “sod it, I’m just going to say it”. A few more heated exchanges. One or two blazing rows.

Self awareness is undoubtedly important when you are dealing with other people, as you need to be mindful of how your language can come across to those who don’t share your passions, or who don’t understand your enthusiasm. It is always worth remembering

battle

When it comes to mental health, awareness of your own feelings is vital when you are heading into debates. Especially if those debates involve issues about which you have knowledge and a genuine desire for change. In those circumstances it is easy to feel got at, battered, attacked, demonised and worst of all misunderstood. To be spoken to as though you are uncaring or lacking in awareness when discussing a subject to which you are deeply committed is heartbreaking. And if you have a tendency towards anxiety, it can send that through the roof.

So be aware of how you are feeling. I know that some people prefer to simply stay out of arguments, but anyone who knows me will know that’s not be style! Get stuck in, stand up for your views, try to change things if you feel they need to be changed. But be aware. Watch out for those warning signs that your enthusiasm for the discussion is tipping over into defensiveness and lashing out. Do you feel backed into a corner, as though everyone is getting at you, as though nobody understands your point of view? It’s time to step away for a moment. Take a step back. However important the issue, you are certainly not going to change anyone’s mind, or effect meaningful change, if you are on the defensive. Chances are they have reached that stage too. That is a debate that has gone awry. Regroup. Try again another day.

It has taken me a long time to recognise the signs that I need to take a step back, and even longer to work out what to do about it. I now have two favourite tactics: Number one – call my best friend. There is no one like a best friend for agreeing with whatever crazy rubbish is important to you, pretending that it matters and bringing you a large cake. A good friend is worth so much.

Best Friend

Number two – a walk in the fresh air, preferably in the sunshine.

Now, unfortunately I cannot share my best friend with you. She has a big heart but she can’t take on everybody. But what I can do is take you on a virtual tour of my town, the places I walk when I need to get some perspective, when I need to clear my head. Sale is absolutely beautiful in the springtime, and it’s my pleasure to share it with you now. Take a step back. Take a breath. Come for a walk.

Then go back in there and kick ass.

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When #hospitalbreastfeeding met #WeNurses

I had the great privilege of hosting a #WeNurses Twitter chat on Thursday evening. For those of you unfamiliar with Twitter chats and the WeCommunities, more here.  The chat was based on #hospitalbreastfeeding, my campaign to improve support for families trying to breastfeed sick children in hospital.  The campaign is focused on children’s wards and children’s hospitals, as the support in these settings is often inferior to that found on maternity wards or in NICU.  For more on the campaign to date, please see my recent posts #hospitalbreastfeeding Part 1, Breast Isn’t Best, It’s Just Normal and #hospitalbreastfeeding Part 2.

Thursday night’s chat was fantastic – very lively and full of important discussions and debates – it was impossible to read everything and keep up!  In writing this post I have gone back over the hashtag and have seen lots of useful tweets that I would have liked to have responded to at the time, but it is great to see that nurses, paediatricians, lactation consultants, peer supporters and parents were all getting stuck in.  We had over 100 people taking part.

Those who contributed to the chat

Those who contributed to the chat

Word cloud from Thursday 7 May

Word cloud from Thursday 7 May

It is so tempting to rehash the entire discussion here as we touched upon so many important issues, but I will try to keep this to what I see as the key themes to have emerged from the evening.  To begin with though I will repeat the questions I asked and give you a flavour of some of the answers.

WeNurses Q1

To which nurse and mum Marie Batey replied “what training would be required?”  An excellent question and one that is pertinent to my first theme – levels of training and experience – on which more later.

Directorate lead nurse for children & neonatal services, ACCNUK vice chair

Directorate lead nurse for children & neonatal services, ACCNUK vice chair

Midwife, Infant Feeding Coordinator, IBCLC

Midwife, Infant Feeding Coordinator, IBCLC

Head of Patient Experience NHSEngland Children's Nurse, ACCNUK Member, Health Care Ambassador for Save The Children

Head of Patient Experience NHSEngland Children’s Nurse, ACCNUK Member, Health Care Ambassador for Save The Children

WeNurses Q1 response Sue2

Paediatrician

Paediatrician

Connecting, driving and supporting the Children & Young People nurse community

Connecting, driving and supporting the Children & Young People nurse community

WeNurses Q1 response CYPnurses2

Paediatric Nurse

WeNurses Q1 response CYPnurses3

NHS Breastfeeding support worker NNU/community, doula.

NHS Breastfeeding support worker NNU/community, doula.

To put all of this into context, let’s look at the training requirements for those volunteers and professionals who focus on breastfeeding.  To do this I will be quoting from this excellent article by Charlotte Young, IBCLC (aka Analytical Armadillo) who was kind enough to join the chat last Thursday.  Please read the whole thing if you get the chance, it’s really informative.

Breastfeeding Peer Supporters are women who have breastfed themselves who then train for up to 10 weeks.  Breastfeeding Counsellors are mums or health professionals who in addition to completing peer supporter training have breastfed their own baby for at least 6-9 months at the point of application (depending upon organisation).  A Counsellor undergoes 2-3 years part time training, Many then continue to work in a voluntary capacity, both in local areas running support groups, manning national help lines, occasionally on the hospital ward or teaching peer supporters.  

The term lactation consultant loosely refers to anyone who is working in the field of lactation, either as a volunteer or as a professional, but only the letters IBCLC after an individual’s name identifies that person with a recognized standard of independently measured competency in lactation.  

A certified lactation consultant has met the strict criteria to apply for and passed, the examination set by the International Board of Lactation Consultants Examiners (IBLCE). “The IBLCE’s mission statement is to certify, by means of an internationally recognised examination, individuals who demonstrate their competence to practice as International Board Certified Lactation Consultants, providing quality care to babies and mothers world-wide” (ICLA 1995).

Periodic re-certification is mandated by the IBLCE thus ensuring continuing competence and up-to-date information. Only successful candidates may use the title ‘International Board Certified Lactation Consultant’.

I made reference to IBCLCs early on in the chat and it became apparent that it is not a term paediatric nurses are necessarily aware of.  This is relevant to my second theme – signposting and collaborative working.  Stay tuned!

WeNurses IBCLC convo

WeNurses IBCLC extra

Emma Pickett (Breastfeeding Counsellor & Chair of the Association of Breastfeeding Mothers, IBCLC) went on to explain that it is considered good practice for specialist midwives and infant feeding coordinators to hold the IBCLC qualification.

WeNurses Q2

In terms of challenges, nurses and paediatricians mentioned monitoring fluid balance, how to quickly rehydrate a baby who has been admitted as failure to thrive, and the challenge of lack of breastfeeding education for staff.  We also heard from mothers who had wanted to breastfeed their children in hospital:

“mummy of Erin, our gorgeous daughter who only lived for 22 days, but who has changed our lives forever, and her little brother”

One third of @WeAHPs and mother to heart child

One third of @WeAHPs and mother to heart child

WeNurses PAVLIK

AHP CPD Lead – Senior Lecturer University of the West of England

This all led to lively discussions between healthcare professionals and IBCLCs around alternative ways of working and the clinical realities of caring for young children.

WeNurses Q3

Again, we heard from parents here as well as HCPs:

“Full-time mummy and blogger, treasuring every precious moment with my little heart miracle daughter and her heart-healthy sister”

WeNurses Q3 response Erin

WeNurses Q3 response Erin2

In my experience, most parents who say they were well supported to breastfeed their sick child do talk about access to breast pumps and help with expressing.  I have come across very few who were assisted to feed at the breast, or to transition their baby to the breast at the end of a hospital stay.  This is important, because exclusively expressing for a baby once you are at home, possibly with siblings to care for, is extremely hard work.  Many mums do it, but I would say it is far more likely that a breastfeeding journey will continue for months or years if that child is feeding at the breast rather than having only expressed breast milk.

WeNurses Q4

This was a very interesting one for me, as so many nurses said that they would “call the midwife”.  Firstly, midwives are only responsible for babies up to 28 days, so I am not sure whether a midwife would come to assist with breastfeeding for a hospitalised 3, 4, 5 month old baby.  Secondly, midwives are of course extremely busy themselves and might not be available.  Thirdly, children’s hospitals such as Alder Hey do not have maternity services on site.  A midwife might visit the entire hospital once, maybe twice a week.

Added to this, as many parents will tell you, midwives (and health visitors) do not always have particularly robust training in breastfeeding support, and certainly not usually in breastfeeding where the child is seriously ill.  This brings us back around to that training theme again…..

When it comes to signposting for breastfeeding information, there are many good resources available.  The Breastfeeding Network has an excellent website, Kellymom is extremely comprehensive and well researched, international expert Dr Jack Newman has a fantastic Facebook page as well as the website for his clinic.  Emma Pickett’s blog includes some invaluable posts about topics such as the digestive problems for babies caused by oversupply, how to encourage breastfeeding when a newborn is persistently reluctant to latch and how to correctly identify low milk supply.  These are just my pick for today, there are numerous other organisations and websites that provide superb breastfeeding information.  Families and nurses alike also have access to the following helplines:

Helplines

And of course there will be the Infant Feeding Coordinator for your area, and local IBCLCs.  Do those working in children’s hospitals have easy access to the contact details to their IFC and other local breastfeeding professionals?  If not, could these be displayed somewhere on wards?

WeNurses Q5

RCN guidelines

These guidelines can be found here, and are comprehensive and invaluable.  One of the authors, Lorraine Tinker, was kind enough to contribute to Thursday’s chat.  When I first read the guidelines last year I could not believe what I was reading – here was everything I was pushing for written down in the Royal College of Nursing’s own guidelines!  Unfortunately of course, policy and everyday working environments do not always go hand in hand.  I tried to find key areas of the document to quote in this post, but it is all so valuable I would urge you to read the whole thing – parents and professionals alike.

By this point in the chat the discussion was so lively that my last question didn’t get any direct responses.  It would be very interesting to know which wards/hospitals feel that they are closely following the guidelines.

KEY THEMES

So what are these themes that I would like to pick out from the energetic discussions that we had?  Well as I mentioned, the first is TRAINING. It is very difficult to get your point across with any nuance in 140 characters when you are chatting against the clock, so some of my tweets on Thursday came across as pretty disparaging towards the breastfeeding training that nurses have available to them.  This was not my intention.  They key idea I wanted to get across was “Know what you don’t know.”  As detailed above, breastfeeding knowledge takes time to build up, both in terms of training and in terms of personal breastfeeding experience.  And that is for healthy, term babies.  For neonates or seriously ill children, the skill set is even more specific.

This does not mean that I am demanding weeks and months of breastfeeding training for all paediatric staff – it is not realistic and it is not necessary.  What it does mean is that I am asking for staff to be self aware.  You feel that your ward is doing its best to support breastfeeding because all of the babies who are physically able to feed at the breast are doing so.  You feel that you are doing the best for the children in your care because all of the babies who cannot feed at the breast are receiving expressed breast milk.  You and your colleagues are satisfied that all the mothers on your ward who have chosen to breastfeed have been enabled to do so…..

Are you sure?

Has your training been enough to give you all of the tools to fully assess whether a baby can feed at the breast?  Has it given you all of the information with regards to options for enhanced weight gain and measuring fluid intake? Do you feel confident in assessing whether a mother has genuinely chosen not to breastfeed or whether she is simply afraid that she and her baby are not able to do so?  If you follow some of the pages and sites to which I signposted above, you will find huge amounts of information about circumstances where healthcare professionals feel breastfeeding is not possible but IBCLCs and other breastfeeding practitioners feel that a way can be found.

If you do not feel confident in these areas, please speak to someone who does.  Which brings me to my next theme:

WORKING TOGETHER

WeNurses collaboration

Interim Director of Clinical Governance, Registered Nurse

Supporting families to breastfeed their sick children is not a one team job.  Paediatricians may not have the time, nurses may not have the training, peer supporters may not have the clinical knowledge, midwives might not be available (or any combination of those professions and problems).  Collaboration is the key.  I realise that we are living in tough times, but allow me for a moment a glimpse of Utopia: I would love to see breastfeeding peer supporters in children’s hospitals.  I would love to see children’s wards working closely with neonates and maternity in terms of shared knowledge and resources.  I would love to see IBCLCs on the staff at our premier children’s hospitals, and I would love to see them on the speed-dial of consultants and ward managers.  This cuts both ways of course.  Those trained to support a breastfeeding relationship must respect clinical knowledge and medical contraindications to feeding at the breast.  But the more closely teams work together the more that mutual respect will grow – to the benefit of the families in everybody’s care.

WeNurses need for peer support

WeNurses peer supporters please

WeNurses peer supporters please 2

WeNurses peer supporters please 3

It goes back to my favourite reminder: Breastfeeding is more likely to be possible than impossible.  If you have a mother who WANTS to breastfeed her child, please do not bring that journey to an end before you have spoken to people with a different skillset to yours.  Mothers and babies deserve that much.

But how do you know who to speak to and what skillset they have?  This brings us to theme number 3:

IDENTIFYING THOSE WITH SKILLS AND EXPERIENCE

We have discussed above the various titles held by those with a breastfeeding qualification.  But that is not the whole picture.  Mothers who have breastfed their children have significant experience without necessarily being peer supporters.  (I should point out at this juncture that I hold no breastfeeding qualification whatsoever, but I have roughly 22 months’ experience.)  To gain an IBCLC qualification is expensive so not all healthcare professionals with fantastic skills and years of experience will be able to put those letters after their name.

WeNurses identifying skilled

The different titles can be confusing for parents and healthcare professionals alike.  It is hard for new mums to believe that a “peer supporter” can have more insight into her breastfeeding struggles than does her midwife, but that is often the case.  It is even harder for a consultant to have confidence that the breastfeeding suggestions offered by a “breastfeeding counsellor” will be safe and effective for her patient.  And of course breastfeeding specialists often forget that midwives, consultants, nurses and health visitors may all have breastfed their own children and so be significantly more experienced in the subject than their annual day of training might suggest.

So what is the answer? I had an idea at the beginning of this campaign that it would be wonderful to have a simple system for identifying everybody’s breastfeeding skills and experience.  Unfortunately I referred to it as “bandings” which was a mistake, as “bandings” are a real thing within the NHS and have connotations I don’t fully understand and probably didn’t mean to refer to.

Let’s talk instead about levels.  Or something better if you can suggest it?  The premise is simple though: everyone has the potential to have breastfeeding skills that they have learned in training, and experience they have gained as a parent.  This is regardless of their job title, role or place in the hierarchy.  Wouldn’t it be useful for that information to be simply displayed?

For instance (and this is very roughly thought out), I could be a level 1 because I have breastfed for over a year but I have no specific qualifications.  A nurse could also be a level 1 because although she has never personally breastfed a child she has done basic breastfeeding training.  A peer supporter might be a level 2.  A healthcare assistant could be a level 3 because not only has she had basic training but she has also breastfed two of her own children and supports breastfeeding on her ward.  One consultant might be a level 1 whereas his colleague could be a level 5 as they have an IBCLC qualification.

As I say, very roughly drawn, but you get the idea.  The important thing would be to include training AND experience when working out the levels, so that someone who has worked as an infant feeding coordinator for twenty years would obtain the level that deserves even though they may not have been able to afford the IBCLC course.

These levels could then be displayed on name badges or ward posters so that families, staff and volunteers alike can all see straight away who they should speak to, who has the competencies and who might need additional assistance where breastfeeding is concerned.

And that brings me to my final theme.  WHY?  Why does any of this even matter?  How is breastfeeding a key part of paediatric care?

For a full answer to that question, please see http://resources.heartmummy.co.uk/ and explore the links under the Guidance section.  My posters are available to download for free as jpeg and pdf so please do display them on your wards.

Nurses

Breastmilk is pain relief, it is protection against infection, it provides significant immune factors to the baby’s gut.  Feeding at the breast is comfort to the child and to the mother, it can help the child to sleep and it can ease the mother’s mental health.  Breastfed infants can have breastmilk up until at least 4 hours prior to surgery, if not closer.  Breastfeeding provides a mother with some protection against diseases including breast cancer.  And increasing breastfeeding rates across the UK will save money for the NHS.

Breastfeeding is the natural way that human babies are fed.  Breastmilk is created specifically for human children.  As such it has a hell of a lot to offer.

whats-in-breastmilk-poster-canada

For an easy to read version of this poster please click here.

Thank you to everyone who took part in Thursday’s chat, to everyone who is working tirelessly to support breastfeeding families, and a special thank you to all paediatric nurses.  An extremely special group of people.

#hospitalbreastfeeding Part 2

So this is my final blog post before I have the privilege of hosting a #WeNurses Twitter chat on Thursday 7 May (far more exciting than the general election!). In Part 1 I outlined the #hospitalbreastfeeding campaign to the end of 2014, and in my post last Friday I quoted from a couple of articles that have come out of the campaign.

Today I want to bring you up to date with developments from the start of this year.

First for the good news!  Liz Grady, Medela and Ronald McDonald House, Alder Hey, all came together to get a hospital grade breast pump for the use of families staying in “Mac House”.  This pump was donated by Medela and will make a huge difference to breastfeeding families, as they will no longer have to trek across to the hospital to express during the night.  I had the privilege of being there on the day the pump was officially handed over to Mac House Manager Lynne.

Liz Grady, Sioned of Medela, Manager Lynne and me!

Liz Grady, Sioned of Medela, Manager Lynne and me!

Liz has also done an audit of breastfeeding families in the hospital, and the results were mainly positive, with most of the 22 respondents being happy with the support they have received.  It is worth bearing in mind that of those respondents most had breastfed before and have not suffered any physical or mental illnesses since their baby was born, so are in a good place to breastfeed successfully, but still a positive outcome.

I was delighted to be able to introduce Liz to the lovely Kylie Hodges of Bliss North West, who is hoping to work with Alder Hey to introduce Bliss Champions to the wards.  Starting on neonatal, Kylie is going to seek out Bliss Champions who are also trained breastfeeding peer supporters, the combination of these two sets of training being ideal for the Alder Hey environment.  If this works out then similar volunteers could be introduced onto other wards in the hospital.

Whilst all this is going on, I am taking the #hospitalbreastfeeding message to a couple of events in June, as I am attending the Manchester Breastfeeding Festival and the annual conference of the Association of Breastfeeding Mothers.  Look out for my posters and information and come and say hi if you are attending!

Sadly, there is also bad news to share.  Liz Grady’s Health Promotions remit has changed, and she will now be providing far less breastfeeding support at Alder Hey.  It is not clear who, if anybody, will be taking over the oversight for breastfeeding support at the hospital.  I have written to Louise Shepherd, Alder Hey CEO, to express my concerns in this regard.  I have not yet had a response, although Louise has kindly acknowledged my email, so I will not share my thoughts just yet before Louise has had a chance to comment.

I would very much like to see Alder Hey one day reach Baby Friendly status as befits the North West’s premier paediatric hospital.  At the moment that day seems a very long way off.  Do you work in a children’s hospital?  How close does that day feel to you?

For more information on how supporting breastfeeding can help you in your role – and how you can be supported to help breastfeeding mothers – visit http://resources.heartmummy.co.uk/

#hospitalbreastfeeding Breast Isn’t Best – It’s Just Normal

In advance of the #WeNurses Twitter chat on 7 May I am doing a couple of posts to summarise my #hospitalbreastfeeding campaign to date.  Part 1 covered what I got up to in 2014, and Part 2 (hopefully coming out on Monday) will explain what has been happening so far this year.  In between, I wanted to give you a flavour of a couple of articles relating to the campaign, one that I had published and one that highlighted the issue.

Thanks to the support of Doreen Crawford, I had an article published in the December 2014 edition of Nursing Children and Young People, an RCN journal.  Doreen is one of the authors of the RCN’s “Guidance for good practice – Breastfeeding in children’s wards and departments“, and the consultant editor of Nursing Children and Young People.  The edition of the journal in which I appeared also had a CPD article on “Supporting the establishment and maintenance of lactation for mothers of sick infants” which is well worth a look.

December 2014 edition

December 2014 edition

In her editorial Doreen wrote “To support a breastfeeding mother takes time and expertise; sadly, time is in short supply and expertise is expensive.”

My article was entitled “Breast isn’t best, it’s just normal”, which was a quotation from the text that the editors had picked out.  The key theme I wanted to get across in the article is the perception of breastfeeding amongst children’s nurses and the realities of what it can mean for a mother and baby dyad.  I wrote:

The common perception of breastfeeding in our society can be summed up by the odious phrase “breast is best”.  The perception is that breastfeeding is an ideal.  A lifestyle choice.  A wonderful thing to do if everything is fantastic and straightforward in your life.

What effect does this perception have on the way the breastfeeding is viewed by some children’s nurses if you have a sick baby?  Well, of course, it is the last thing you want to be worrying about isn’t it?  You have enough stress in your life without putting yourself under pressure to breastfeed.  Far better to remove one area of stress and focus on other things.  When your baby is very ill, getting the ‘best’ food is not a priority, as long as they are eating something, right?

The problem with this perception is that breastfeeding is the biological norm, the way that humans have evolved to feed their children.  Hence the quote “breast is not ‘best’, it is normal”.  Thank goodness we have the option of formula feeding when necessary, but I would hope that we all know by now that formula does not offer anywhere near as much to a child as does breast milk.

How a family chooses to feed their baby, any baby, is entirely up to them, and it is a decision that takes into account far more information and circumstances than the benefits and risks of one feeding option versus another.  However, if families do choose to breastfeed they should be supported across the NHS, not least because an increase in breastfeeding rates would save the NHS money!  As I put in the article, why breastfeeding matters to sick babies in particular becomes clear when you consider the following key information:

  • Breast milk guards against infection
  • Feeding at the breast is a huge comfort to a child, the importance of which cannot be underestimated when the child is hospitalised
  • Some hospitals class breast milk as a ‘clear fluid’, which means that it can be taken far closer to the time of an anaesthetic than formula can
  • It is easy to digest and contains immune factors to protect a child’s gut
  • Breastfeeding and breast milk provide pain relief

For the evidence base for the above, please see the Guidance section of my website.

The second article featuring #hospitalbreastfeeding was written by Dominique Mylod of the Faculty of Health Sciences, University of Southampton.  Kath Evans had suggested that I provide a write up to Professor Alan Glasper of that university, and he kindly passed on the information to Dominique, who was published in “Issues in Comprehensive Pediatric Nursing” (of which Prof Glasper is the editor in chief).

Issues in Comprehensive Pediatric Nursing

Issues in Comprehensive Pediatric Nursing

In her article, Dominique writes “The known protective influence of breast milk in preventing the onset of disease in later life is of particular import for any sick infant, but the user voice as represented by Helen Calvert’s Twitter campaign @heartmummy #hospitalbreastfeeding has united service user and professional voices to call
for improved breastfeeding support in pediatric care.

She goes on to say “Although breastfeeding rates in industrialized countries drop markedly in the first 6 weeks, breastfed babies with cardiac conditions benefit from better oxygen saturations, faster weight gain, and shorter hospital stays.  Unwell babies are most in need of the benefits of breast milk. However, families and staff overcome physical barriers to the initiation and maintenance of breastfeeding, including lack of space, privacy, and separation of the maternal-infant dyad. Many women are motivated to breastfeed or express milk but are reluctant to approach health professionals for help and advice. Despite robust evidence and sound guidelines and policies, breastfeeding knowledge and experience amongst Child Health professionals is often inadequate and leaves them unable to support families.

Dominique ends her introduction with “Child Health strategy needs investment in young people’s long term health by increasing staff skills and focusing on breastfeeding as a core therapeutic intervention. Lactation Consultants could offer training, disseminate good
practice, and address the needs of breastfeeding families.

The full article explores the ways in which breastfeeding can be a key part of paediatric care, and looks in particular at the benefits to cardiac babies.  Dominique raises the issue of breastfeeding being “tiring” as I had been discussing on Twitter: “It is a common misconception that babies with cardiac conditions find breastfeeding more tiring.  In fact, they have better oxygen saturations than bottle fed babies. When unhampered by restrictive feeding practices, they gain weight faster than artificially-fed babies and have shorter hospital stays (Combs & Marino, 1993).”

I would urge anyone involved in paediatric care to seek out and read the whole article, not least because it has an impressive and useful selection of references.  The final paragraph I would like to quote for you is:

Wallis and Harper (2007a) identify that a mother-infant dyad with a cardiac condition falls anomalously between midwifery care and that of the pediatric nursing team. While each profession might focus on the care of ‘‘their’’ patient and scrupulously avoids trespassing on their colleagues’ territory, it may be argued there is no shared ideal or vision that supports mutual collaboration (Downe & Finlayson, 2011). Effective breastfeeding promotion and support in this most challenging of environments demands an absolute commitment by Child Health professionals to the principle and belief that breast milk is fundamental to a child’s short and long term health outcomes, and that this is auditable, achievable, and an asset to the clinicians’ practice and professional reputation.

If I was in any doubt as to the necessity for the #hospitalbreastfeeding campaign, Dominique’s article makes it clear that improvements to support for those breastfeeding a sick child are a must.  In our blog post for NHS Change Day, Emma Sasaru and I outlined some simple things that healthcare professionals can do to improve the support they offer day to day.  Of these the one that I wish all HCPs could remember is this:

Key quote

That doesn’t mean everyone can do it.  That doesn’t mean everyone wants to do it.  That doesn’t even mean that it is the right feeding choice for every child.  But if every paediatrician and CYP nurse started the day with that phrase in their minds, and a willingness to seek out the bounds of the possible, breastfeeding sick children would become that little bit easier.

For more information on how supporting breastfeeding can help you in your role – and how you can be supported to help breastfeeding mothers – visit http://resources.heartmummy.co.uk/