Weight monitoring of breastfed babies in the United Kingdom--interpreting, explaining and intervening

A big-data approach to producing descriptive anthropometric references: a feasibility and validation study of paediatric growth charts

BACKGROUND

Both national and WHO growth charts have been found to be poorly calibrated with the physical growth of children in many countries. We aimed to generate new national growth charts for French children in the context of huge datasets of physical growth measurements routinely collected by office-based health practitioners.

METHODS

We recruited 32 randomly sampled primary care paediatricians and ten volunteer general practitioners from across the French metropolitan territory who used the same electronic medical records software, from which we extracted all physical growth data for the paediatric patients, with anonymisation. We included measurements from all children born from Jan 1, 1990, and aged 1 month to 18 years by Feb 8, 2018, with birthweight greater than 2500 g, to which an automated process of data cleaning developed to detect and delete measurement or transcription errors was applied. Growth charts for weight and height were derived by using generalised additive models for location, scale, and shape with the Box-Cox power exponential distribution. We compared the new charts to WHO growth charts and existing French national growth charts, and validated our charts using growth data from recent national cross-sectional surveys.

FINDINGS

After data cleaning, we included 1 458 468 height and 1 690 340 weight measurements from 238 102 children. When compared with the existing French national and WHO growth charts, all height SD and weight percentile curves for the new growth charts were distinctly above those for the existing French national growth charts, as early as age 1 month, with an average difference of -0·75 SD for height and -0·50 SD for weight for both sexes. Comparison with national cross-sectional surveys showed satisfactory calibration, with generally good fit for children aged 5-6 years and 10-11 years in height and weight and small differences at age 14-15 years.

INTERPRETATION

We successfully produced calibrated paediatric growth charts by using a novel big-data approach applied to data routinely collected in clinical practice that could be used in many fields other than anthropometry.

FUNDING

The French Ministry of Health; Laboratoires Guigoz-General Pediatrics section of the French Society of Pediatrics-Pediatric Epidemiological Research Group; and the French Association for Ambulatory Pediatrics.

Parents' views on childhood obesity: qualitative analysis of discussion board postings

BACKGROUND

Childhood obesity is an increasing concern for parents and health professionals alike. Parents' perception of obesity as a current health issue for their children is important for the everyday parenting and health choices parents make. As parents are frequently going online to seek and exchange information about parenting and child health, asynchronous online discussion forums provide an opportunity to investigate their perceptions and concerns. Understanding parents' perceptions, beliefs and attitudes is important in any childhood obesity prevention and intervention.

AIM

To explore parents' perceptions, perspectives and concerns regarding childhood obesity expressed on asynchronous online discussion forums.

METHODS

A qualitative descriptive approach using template analysis to analyse a novel data collection strategy of 34 purposefully sampled threads from two Australian-based asynchronous online discussion forums.

RESULTS

Parents on the discussion forum displayed an understanding of childhood obesity as a public health concern, the discussion incorporated issues such as providing a healthy diet and lifestyle for children. Parents shared their own opinions and experiences that challenged or conceded to the status quo of the discussion. Parents discussed the role of health professionals in obesity prevention. There were varied opinions on the relevance of health professionals, particularly nurses, monitoring of growth and risk of obesity.

CONCLUSION

This exploratory study highlights that parents perceive childhood obesity as an important public health concern, and that they understand the key public health messages of prevention and intervention. Yet, for many it is difficult to successfully implement these messages into their everyday lives. Health professionals need to play a key role in providing non-judgemental, innovative support and advice to parents to successfully implement prevention and intervention strategies.

Health staff understanding, application, and interpretation of growth charts in Nigeria

We aimed to compare plotting accuracy and interpretation of weight gain patterns in average and small infants on road-to-health (RTH) and the new World Health Organization (WHO) growth charts in Enugu, Nigeria. Child health staff plotted standard weights on both formats. Twelve plotted charts were created, permutating three different weight trajectories (fast, steady, and slow) ending at two attained weights (average and small), with each plotted on both chart formats. Respondents were shown four of these charts and asked to describe the weight gain pattern shown and what action this pattern would prompt. There were 222 respondents, of whom 78% were hospital based; 54% were nurses, 32% medical doctors, and 13% nutritionists. Plotting accuracy was good on both the WHO and RTH charts, but rating of weight gain was generally poor. On the RTH chart, slow weight gain was correctly recognized in only 19% average and 35% small infants, and responses were not significantly associated with the pattern shown. On the WHO charts, slow weight gain was correctly recognized in 40% average and 65% small infants (p = .002 and <.001), but they were also more likely to rate small children with normal growth as slow weight gain. In a logistic regression model, final weight predicted a slow weight gain rating more strongly (OR = 2.4; 1.8-3.2) than an actual slow weight gain pattern (OR 1.8; 1.1-1.6). Health staff seemed unable to recognize slow weight gain and were influenced more by current weight than actual weight gain pattern, though the new WHO format improved recognition.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Health organisations recommend exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries. Recently, research has suggested that introducing solid food at around four months of age while the baby continues to breastfeed is more protective against developing food allergies compared to exclusive breastfeeding for six months. Other studies have shown that the risks associated with non-exclusive breastfeeding are dependent on the type of additional food or fluid given. Given this background we felt it was important to update the previous version of this review to incorporate the latest findings from studies examining exclusive compared to non-exclusive breastfeeding.

OBJECTIVES

To assess the benefits and harms of additional food or fluid for full-term healthy breastfeeding infants and to examine the timing and type of additional food or fluid.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2016) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 trials (2542 randomised infants/mothers). Nine trials (2226 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one primary (breastfeeding duration) and one secondary (weight change) outcome. None of the trials reported on physiological jaundice. Infant mortality was only reported in one trial.For the majority of older trials, the description of study methods was inadequate to assess the risk of bias. Most studies that we could assess showed a high risk of other biases and over half were at high risk of selection bias.Providing breastfeeding infants with artifical milk, compared to exclusive breastfeeding, did not affect rates of breastfeeding at hospital discharge (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.97 to 1.08; one trial, 100 infants; low-quality evidence). At three months, breastfeeding infants who were provided with artificial milk had higher rates of any breastfeeding compared to exclusively breastfeeding infants (RR 1.21, 95% CI 1.05 to 1.41; two trials, 137 infants; low-quality evidence). Infants who were given artifical milk in the first few days after birth before breastfeeding, had less "obvious or probable symptoms" of allergy compared to exclusively breastfeeding infants (RR 0.56, 95% CI 0.35 to 0.91; one trial, 207 infants; very low-quality evidence). No difference was found in maternal confidence when comparing non-exclusive breastfeeding infants who were provided with artificial milk with exclusive breastfeeding infants (mean difference (MD) 0.10, 95% CI -0.34 to 0.54; one study, 39 infants; low-quality evidence). Rates of breastfeeding were lower in the non-exclusive breastfeeding group compared to the exclusive breastfeeding group at four, eight, 12 (RR 0.68, 95% CI 0.53 to 0.87; one trial, 170 infants; low-quality evidence), 16 and 20 weeks.The addition of glucose water resulted in fewer episodes of hypoglycaemia (below 2.2 mmol/L) compared to the exclusive breastfeeding group, reported at 12 hours (RR 0.07, 95% CI 0.00 to 1.20; one trial, 170 infants; very low-quality evidence), but no significant difference at 24 hours (RR 1.57, 95% CI 0.27 to 9.17; one trial, 170 infants; very low-quality evidence). Weight loss was lower for infants who received additional glucose water (one trial, 170 infants) at six, 12, 24 and 48 hours of life (MD -32.50 g, 95% CI -52.09 to -12.91; low-quality evidence) compared to the exclusively breastfeeding infants but no difference between groups was observed at 72 hours of life (MD 3.00 g, 95% CI -20.83 to 26.83; very low-quality evidence). In another trial with the water and glucose water arms combined (one trial, 47 infants), we found no significant difference in weight loss between the additional fluid group and the exclusively breastfeeding group on either day three or day five (MD -1.03%, 95% CI -2.24 to 0.18; very low-quality evidence) and (MD -0.20%, 95% CI -0.86 to 0.46; very low-quality evidence).Infant mortality was reported in one trial with no deaths occurring in either group (1162 infants). The early introduction of potentially allergenic foods, compared to exclusively breastfeeding, did not reduce the risk of "food allergy" to one or more of these foods between one to three years of age (RR 0.80, 95% CI 0.51 to 1.25; 1162 children), visible eczema at 12 months stratified by visible eczema at enrolment (RR 0.86, 95% CI 0.51 to 1.44; 284 children), or food protein-induced enterocolitis syndrome reactions (RR 2.00, 95% CI 0.18 to 22.04; 1303 children) (all moderate-quality evidence). Breastfeeding infants receiving additional foods from four months showed no difference in infant weight gain (g) from 16 to 26 weeks compared to exclusive breastfeeding to six months (MD -39.48, 95% CI -128.43 to 49.48; two trials, 260 children; low-quality evidence) or weight z-scores (MD -0.01, 95% CI -0.15 to 0.13; one trial, 100 children; moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence of benefit to newborn infants on the duration of breastfeeding from the brief use of additional water or glucose water. The quality of the evidence on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. The majority of studies showed high risk of other bias and most outcomes were based on low-quality evidence which meant that we were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence to disagree with the current international recommendation that healthy infants exclusively breastfeed for the first six months.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers - a review of the scientific evidence

Natural processes do not always function perfectly. In breastfeeding, problems are encountered in up to 80% of mother-infant dyads. Altogether, in Western societies, the difficulties reduce the breastfeeding rate within the first months drastically. To deal with the problems of breastfeeding efficiently requires a profound understanding of its physiology, as well as of its psychological and social determinants. This review focuses on the current knowledge of breastfeeding physiology, only touching the psychosocial factors, which are included in the promotion strategies. Subsequently, it scrutinizes definitions, incidences, prevention, and treatment of breastfeeding problems faced most frequently by nursing mothers and their consultants. Not all measures used in counseling mothers and not all treatments for the most common medical problems withstand a careful evaluation on the basis of current scientific data. However, applying proven prevention strategies will significantly improve the well being of mothers and their infants, and may contribute to an affective attitude that increases the success, frequency, and duration of breastfeeding.

Bland-White-Garland syndrome - a rare and serious cause of failure to thrive

Patient: Male, 0

Final Diagnosis: Bland-White-Garland syndrome

Symptoms: Cardiomegaly, feeding problems

Medication: —

Clinical Procedure: Reimplantation of the left coronary artery to the aorta

Specialty: Pediatrics and Neonatology

'Now I understand': consulting parents on chart design and parental information for the UK-WHO child growth charts

BACKGROUND

Regular assessment of growth is an important part of child health surveillance in the UK and most parents are very interested in their child's growth. UK parents are given a personal child health record (PCHR), including growth charts, which are plotted during baby clinic visits. Parents were consulted as part of the process of designing new UK charts to incorporate the World Health Organization growth standard. This paper describes the main themes that emerged and how they influenced the final design.

METHOD

Three sets of consultations with 47 parents were conducted to collect preliminary information, and to evaluate proposed chart designs, instructions and written information for parents.

RESULTS

  At every consultation, the impact of the depiction of the 50th centile line in bold was mentioned spontaneously by parents. They also found aspects of the charts unclear, including the implications of a recorded weight on any particular centile, the difficulty of understanding existing text about charts in the PCHR, their preference for using pounds and ounces rather than metric weights and confusion about how frequently babies should be weighed. This led to the production of parental information including explanation of these issues which were then tested in two further sets of focus groups.

CONCLUSION

Involving parents in the process of designing growth charts and information influenced the finished design and the text in the PCHR. Ensuring information meets parents' needs is important to ensure successful growth monitoring.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However the addition of other fluids or foods before six months is common practice in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials; three extracted data and assessed risk of bias.

MAIN RESULTS

We included six trials (814 infants). Two trials in the early days after birth that reported data did not indicate that giving additional fluids was beneficial. For duration of breastfeeding, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), indicating that supplements may contribute to reducing the duration.For infant morbidity (three trials), one newborn trial found a statistically, but not clinically, significant difference in temperature at 72 hours (MD 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24mmol/l, 95% CI -0.51 to 0.03). Two trials with four- to six-month-old infants did not indicate any benefit to supplemented infants to 26 weeks nor any risks related to morbidity or weight change.None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation .We found no benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water. For infants at four to six months, we found no benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer term effects on infants and mothers, though randomising infants to receive supplements without medical need may be considered unethical.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Parental distress around supplementing breastfed babies using nasogastric tubes on the post-natal ward: a theme from an ethnographic study

There is abundant evidence of the benefits of breastfeeding. In the UK, supplementation in hospital has consistently been shown to be associated with shortened duration of breastfeeding. This paper reports on a subset of the data from an ethnographic study that explored the expectations, beliefs and experiences of mothers and health professionals concerning supplementation, using a variety of methods, of breastfed babies in an English maternity unit in 2002. This paper aims to describe the expectations, beliefs and experiences of mothers and health professionals concerning supplementation by nasogastric (NG) tube on the post-natal ward. Participant observation was carried out on day and night shifts and at weekends over 9 months. Mothers, midwives, neonatal nurses, health care assistants and senior paediatricians were interviewed. Categories and themes were generated. The researchers' constructs of 'the essential method', when the tube was the method needed for medical reasons, and 'the chosen method', when other methods of oral feeding should have been possible, emerged. The latter included time pressures and the avoidance of any form of oral activity that might perhaps make return to the breast more difficult. The data concerning the use of NG tubes for supplementation yielded the specific theme of parental distress. In the absence of evidence that supplementation by NG tube on the post-natal ward is associated with greater breastfeeding success than other methods, the use of the tube to avoid any form of 'oral confusion' should be discontinued. Its use primarily to save time should not be considered acceptable.

Reconfiguring insufficient breast milk as a sociosomatic problem: mothers of premature babies using the kangaroo method in Brazil

This study focuses on Brazilian mothers who gave birth to premature babies who were discharged from hospital using the Kangaroo Mother Care Method. While mothers left the hospital breastfeeding exclusively, once back at home, they abandoned exclusive breastfeeding because of insufficient breast milk (IBM). In this project we explored how IBM was interpreted by mothers within their social context. Participatory research using the Creative Sensitive Method was done in the homes of mothers with family members and neighbours. We described the conflicting social discourse that influenced the mothers' perception of IBM and explored their sources of distress. At the hospital and Kangaroo ward, mothers considered that clinicians recognized they were experiencing IBM and thus supported them to overcome this problem. Back at home and in their community, other sources of stress generated anxiety such as: the lack of outpatient clinical support, and conflicting local norms to care and feed premature babies. These difficulties combined with economic constraints and discontinuity in models of health care led mothers to lose confidence in their breastfeeding capacity. Mothers, thus, rapidly replaced exclusive breastfeeding by mixed feeding or formula feeding. Our analysis suggests that IBM in our sample was the result of a socio-somatic process. Recommendations are proposed to help overcome IBM and corresponding contextual barriers to exclusive breastfeeding.

Breast feeding practices and views among diabetic women: A retrospective cohort study

OBJECTIVE

to explore the pattern and experiences of breast-feeding practices among diabetic women.

DESIGN

retrospective cohort study using maternal records and postal questionnaires in a Baby-Friendly hospital.

PARTICIPANTS

diabetic mothers including women with gestational diabetes, and type 1 and 2 diabetes mellitus.

FINDINGS

from the total group of respondents, 81.9% intended to breast feed. The actual breast feeding rates were 81.9% at birth, 68.1% at 2 weeks and 28.7% at 6 months postpartum. Major themes that were identified from women's experiences included information and advice, support vs. pressure, classification and labelling, and expectations.

CONCLUSIONS

more than two-thirds of the diabetic women intended to breast feed and actually did breast feed in this study. For both the total study population and the type 1 and 2 diabetics alone, more than half were still breast feeding at 2 weeks postpartum, and approximately one-third were still breast feeding at 6 months postpartum.

IMPLICATIONS FOR PRACTICE

structured support, provided for women through Baby-Friendly initiatives, was appreciated by the diabetic women in this study. The extent to which this support influenced the highly successful breast feeding practices in this group of women needs focused investigation. The need for a delicate balancing act between pressure and advice in order to prevent coercion was noted.

Feeding by numbers: an ethnographic study of how breastfeeding women understand their babies' weight charts

BACKGROUND

Weighing breastfed babies has been the subject of some controversy as the previous international growth chart was largely based on data from infants fed infant formula. The concern that professionals may be misled by the charts into suggesting to mothers that they supplement unnecessarily was a major impetus for the World Health Organization's investment in a new growth chart. Evidence of interpretation in practice has been scant.

METHODS

An ethnographic study was conducted in a town in the Northwest of England to investigate this issue. In the first phase, women and health visitors were observed in the well-child clinic during clinic sessions and breastfeeding group meetings. In the second phase, longitudinal interviews with 14 women were conducted. Each woman was interviewed up to three times in the first six months after the birth of her baby, with a total of 35 interviews.

RESULTS

Mothers and health visitors focussed on weight gain with frequent weighing and attention to even minor fluctuations of the plotted line being evident. Women felt it important to ensure their baby's weight followed a centile, and preferred for this to be the fiftieth centile. Interventions included giving infant formula and solids as well as changing what the mother ate and drank. Women also described how they worried about their baby's weight. Little effective support by health professionals with breastfeeding technique was observed.

CONCLUSION

Babies were weighed more often than officially recommended, with weighing and plotting being at the core of each clinic visit. The plotted weight chart exerted a powerful influence on both women's and health visitors' understanding of the adequacy of breastfeeding. They appeared to rate the regular progression of weight gains along the chart centiles more highly than continued or exclusive breastfeeding. Thus weighing and visual charting of weight constituted a form of surveillance under the medical gaze, with mothers actively participating in self monitoring of their babies. Interventions, by mothers and health visitors, were targeted towards increasing weight gain rather than improving breastfeeding effectiveness. Improvements in training are needed for health visitors in weighing techniques, assessing growth patterns--particularly of breastfed babies--and in giving information to women, if the practice of routine weight monitoring is to support rather than undermine breastfeeding.

Breastfeeding support for adolescent mothers: similarities and differences in the approach of midwives and qualified breastfeeding supporters

BACKGROUND

The protection, promotion and support of breastfeeding are now major public health priorities. It is well established that skilled support, voluntary or professional, proactively offered to women who want to breastfeed, can increase the initiation and/or duration of breastfeeding. Low levels of breastfeeding uptake and continuation amongst adolescent mothers in industrialised countries suggest that this is a group that is in particular need of breastfeeding support. Using qualitative methods, the present study aimed to investigate the similarities and differences in the approaches of midwives and qualified breastfeeding supporters (the Breastfeeding Network (BfN)) in supporting breastfeeding adolescent mothers.

METHODS

The study was conducted in the North West of England between September 2001 and October 2002. The supportive approaches of 12 midwives and 12 BfN supporters were evaluated using vignettes, short descriptions of an event designed to obtain specific information from participants about their knowledge, perceptions and attitudes to a particular situation. Responses to vignettes were analysed using thematic networks analysis, involving the extraction of basic themes by analysing each script line by line. The basic themes were then grouped to form organising themes and finally central global themes. Discussion and consensus was reached related to the systematic development of the three levels of theme.

RESULTS

Five components of support were identified: emotional, esteem, instrumental, informational and network support. Whilst the supportive approaches of both groups incorporated elements of each of the five components of support, BfN supporters placed greater emphasis upon providing emotional and esteem support and highlighted the need to elicit the mothers' existing knowledge, checking understanding through use of open questions and utilising more tentative language. Midwives were more directive and gave more examples of closed questions. These differences could reflect the considerable emphasis upon person-centred approaches within the BfN curriculum and, in the case of midwives, the bureaucratic and institutional constraints upon them making it difficult, if not impossible, to take time and touch base with women.

CONCLUSION

Follow up ethnographic work is required to assess the differences in the supportive approaches of BfN supporters and midwives in the practice areas. Such research, which specifically focuses upon how the different approaches are received and experienced by parents, is required before meaningful policy and practice recommendations can be made.

Weight monitoring of breastfed babies in the UK - centile charts, scales and weighing frequency

Weighing infants during their first 6 months is an important focus of growth monitoring and a common activity of child health care services worldwide. In these same months, health workers provide support for breastfeeding and promote continued exclusive breastfeeding. The literature on the practice of weighing breastfed babies is reviewed, as it applies to the United Kingdom. The shape of the growth curves for breastfed babies differs from that of formula-fed infants and also from centile charts previously in use. The World Health Organization commitment to the production of a new growth reference has generated discussion of the implications of charts in use. The country-specific charts in use in the UK are examined and the data used to construct them discussed with reference to clinical use for breastfed infants. Recent UK discussions on charts, as well as on the frequency of routine weighing for babies in the community are considered, and the available evidence on the accuracy of weighing in practice is noted. The choices made in constructing different charts; the physical condition of scales and their use in practice have implications for plotted growth. This paper aims to present a wide range of evidence available in this area in order to encourage debate on practice. A companion paper will discuss issues of interpretation, conveying information to parents, and interventions.