MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of completion: 7.7.97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


17. Infant Feeding

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

17.1 BREAST FEEDING  
The Statements The Evidence
17.1a. Breast feeding, compared with artificial feeding, has been clearly shown to protect against
  • gastrointestinal infection in the infant(i) and
  • necrotising enterocolitis among babies born at more than 30 weeks gestation(ii).

Breast feeding may also

  • enhance neurological development in the child (iii)
  • protect against allergy in neonates (of<1850g) with a family history of atopy (OR=3.6)(iv)
  • protect against breast cancer in premenopausal women (OR= 0.78) but not postmenopausal women(v), and
  • protect against ovarian cancer(vi)

(Cohrane health gain notation - 2 "likely to be beneficial")

i. Howie PW, Forsyth JS, Ogston SA, Clark A, duV Florey C. Protective effect of breast feeding against infection. British Medical Journal. 1990; 300: 11-16(Type IV evidence - prospective observational study over 2 years of 618 pairs of mothers and infants);
ii. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990; 336: 1519-1523.
(Type IV evidence - prospective multicentre study of 926 preterm infants);
iii. Statement of the Standing committee on Nutrition of the British Paediatric Association. Is breast feeding beneficial in the UK? Archives of disease in childhood. 1994; 71: 376-380
(Type IV evidence - observational studies);
iv. Lucas A, Brooke OG, Morley R, Cole TJ, Bamford MF. Early diet of preterm infants and development of allergic or atopic disease: randomised prospective study, BMJ 1990; 300: 837-840
(Type II evidence - randomised prospective study of 777 infants - 75 with a family history of atopy);
v. Newcomb PA, Storer BE, Longnecker MP et al. Lactation and a reduced risk of premenopausal breast cancer. New England Journal of Medicine. 1994; 330(2): 81-87
(Type IV evidence - case study of 5878 women with breast cancer and 8216 controls);
vi. Rosenblatt KA, Thomas DB. WHO collaborative study of neoplasia and steroid contraceptives. Lactation and the risk of epithelial ovarian cancer. International Journal of Epidemiology. 1993; 22(2): 192-197
(Type III evidence - case control study of 393 cases of ovarian cancer compared with 2565 age matched controls)
17.1b. The following are recommended in promoting successful breastfeeding:clearly beneficial in promoting successful breast feeding(i):
(Health gain notation - 2 "likely to be beneficial")
  • Consistency in advice and support;
  • Personal support from a knowledgable individual;
  • Unrestricted breastfeeding.
  • Encouragement of early feedingalthough there is no evidence of advantage of any particular time;
  • Skilled help with the first feed
  • Correct positioning of the baby;
  • Flexibility in feeding practices in both duration and frequency;
  • Well designed information about breast feeding.
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)

Top

17.1d. Oxytocin nasal spray to improve milk supply is of unknown benefit(i)

(Health gain notation - 4 "unknown")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.1e. The following practices are unlikely to be beneficial(i):
(Health gain notation - 5 "unlikely to be beneficial")
  • Antenatal breast or nipple care;
  • The use of nipple shields;
  • Switching breasts before baby spontaneously finishes feeding
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.1f. The following practices have been shown to be ineffective or harmful(i):
(Health gain notation - 6 "ineffective or harmful")
  • Antenatal breast shells for inverted nipples;
  • Routine supplementation of either water or formula milk for breast fed babies;
  • Pressing excess fluid intake (beyond the demands of thirst) to breast feeding mothers;
  • Test weighing of breast fed infants - both inaccurate and a major cause of maternal anxiety;
  • Free offers of formula feeds;
  • Nipple creams
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)

 

Top
17.2 BREAST ENGORGEMENT  
The Statements The Evidence
17.2a. Unrestricted access for the baby to the breast still appears to be the most effective way to prevent and treat breast engorgment(i)

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.2b. The effect of oral proteolytic enzymes or cabbage leaves for breast engorgement is unknown(i)

(Health gain notation - 4 "unknown")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.2c. In simple breast engorgement, antibiotics and oxytocin are unlikely to be beneficial(i)

(Health gain notation - 5 "unlikely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.2d. If mastitis does not rapidly resolve with good feeding practice and expression, then antibiotics ( and bacterial culture of milk) should be instituted(i).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)

Top

17.3 CONTRACEPTION AND BREAST FEEDING  
The Statements The Evidence
17.3a. Combined oestrogen-progestogen oral contraceptives should be avoided - as use increases the incidence of breast feeding failure(i)

(Health gain notation - 6 "ineffective or harmful")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)

 

17.4 LACTATION SUPPRESSION  
The Statements The Evidence
17.4a. Women may not breast feed for a variety of reasons, ranging from personal choice to stillbirth or neonatal death. For the majority of women who decide not to breast feed simple supportive methods (binding and fluid restriction) are effective in suppression of lactation and in reducing breast pain and engorgement. While associated with more discomfort than drug suppression in the short term, they appear to be at least as effective in the long term(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.4b. For those who have lost a baby or where simple supportive methods are unsuccessful then pharmacological suppression of lactation may be considered: Bromocryptine is effective in lactation suppression but rebound lactation is common(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
Carbergoline, compared with bromocryptine, is more effective and may be used as a single dose.
(Health gain notation - 2 "likely to be beneficial")
Further comparative trials including women’s views in any evaluation are needed.
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)

Top

17.4c. Oestrogen should not be used in lactation suppression - as it increases the risk of vaginal bleeding and of thrombo embolism(i)

(Health gain notation - 6 "ineffective or harmful")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 Chapters 21, 80, 81, 82.
(Review of types I-V evidence. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. Chapters 46 & 48. See also pp. 73-75 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992)
17.5 FORMULA FEEDING  
The Statements The Evidence
17.5a. Where formula feeds are used standard formulae based on modified cow’s milk with a protein concentration of 13-15 gl-1 provide the best nutritional source(i).
(Health gain notation - 2 "likely to be beneficial")
caveat: Additions to feeds of small molecular weight compounds which are known to be present in breast milk may be important for growth and development.
i. Atkinson, SA. Feeding the normal term infant: human milk and formula. Chapter 6, pp. 73-93 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992
(Type V evidence - expert opinion based on some descriptive studies and statistical information)
17.5b. Soy based formulas (lactulose free) may be useful in the short term for milk intolerance but long term effects on nutrition have not been established(i).

(Health gain notation - 4 "unknown")

i. Atkinson, SA. Feeding the normal term infant: human milk and formula. Chapter 6, pp. 73-93 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992
(Type V evidence - expert opinion based on some descriptive studies and statistical information)
17.5d. Whey or casein hydrolysate formulae may be appropriate for infants presenting with allergy to cow’s mild protein but their use in prophylaxis has not been established(i).

(Health gain notation - 4 "unknown")

i. Atkinson, SA. Feeding the normal term infant: human milk and formula. Chapter 6, pp. 73-93 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992
(Type V evidence - expert opinion based on some descriptive studies and statistical information)
17.5e. Current recommendations for supplemental iron are to supplement formula fed infants from birth and breast fed infants from 6 months of age(i).

(Health gain notation - 2 "likely to be beneficial")

i. Atkinson, SA. Feeding the normal term infant: human milk and formula. Chapter 6, pp. 73-93 in Sinclair JC, Bracken MB (eds.) Effective care of the newborn infant. Oxford: Oxford University Press, 1992
(Type V evidence - expert opinion based on some descriptive studies and statistical information)
Top

Contents Home

Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk