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

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.

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

Midwife, Infant Feeding Coordinator, IBCLC

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

Paediatrician

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

Paediatric Nurse

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!

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.

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

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.

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”

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.

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:

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?

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

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.

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.

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.

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.

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.