Breastfeeding promotion in early learning settings

The Queen’s Nursing Institute Scotland (QNIS) offers funding programmes for projects led by a community nurse.

Elizabeth Smith,
Breastfeeding Advocacy Lead for Scotland and Queen’s Nurse 

Sarah Edwards,
Scottish Programme Manager, The Breastfeeding Network

Amy Bryson,
Community Peer Support Co-ordinator, The Breastfeeding Network


The Queen’s Nursing Institute Scotland (QNIS) offers funding programmes for projects led by a community nurse. Working for NHS Ayrshire and Arran in an area where breastfeeding rates are amongst the lowest in Scotland, the authors decided to apply to undertake a project which would introduce breastfeeding to nursery children and promote it to young people in school. The bid was successful and the project was carried out from September 2017 until June 2018. The focus of this article will be the Early Learning and Childcare work.


Breastfeeding rates remain low both nationally in Scotland and globally. The health benefits of breastfeeding are well recognised, yet many mothers do not initiate breastfeeding. Younger mothers are less likely to breastfeed and breastfeeding initiation rates in areas of deprivation are much lower than those in less deprived areas. This means that vulnerable infants are further disadvantaged (NHS National Services - Information Services Division). Levels of breastfeeding fall over the first days, weeks and months, and continuation of breastfeeding at six months nationally does not come close to meeting the WHO target of 50%. Policy at national and international level has sought to address these issues and there is good evidence that interventions can improve breastfeeding rates. However, innovations to shift public attitudes have been limited and the growth and reach of the breastmilk substitute industry undermine efforts to improve breastfeeding (Victora et al., 2016).

Messages from breastfeeding research

A literature review was undertaken to assess the factors which could impact on breastfeeding attitudes, particularly in areas with low breastfeeding rates.

Midwifery and health visiting teams are tasked with encouraging mothers to breastfeed and to provide or to signpost to local services for advice and support to enable mothers to continue. Yet there is evidence that some professionals feel they have little influence on mothers’ choice of feeding method; they also report anxiety around the tension between breastfeeding promotion and coercion, and about making mothers who formula feed feel guilty (Marks & O’Connor, 2015).

Bartle and Harvey (2017) asked first-time mothers at an antenatal clinic in South East England to complete a questionnaire rating:

  • their infant feeding experiences (especially formula feeding)
  • self-efficacy (personal confidence in being able to breastfeed)
  • attitude to breastfeeding
  • subjective norm (if close family and friends had chosen to breastfeed or to formula feed).

Analysis of the data suggested that mothers who had experience of seeing babies formula feeding were more likely to give up breastfeeding when they experienced problems, as they already had more positive attitudes towards formula feeding. These mothers were living in an embedded formula feeding culture; formula feeding was the social norm and therefore the easy choice. Bailey et al. (2001) described a ‘give it a go’ breastfeeding culture among low-income mothers. In these studies, the reason many mothers discontinued was because they had a feeling that it would be difficult and expected to fail. The mothers lacked breastfeeding knowledge and support for breastfeeding in the family. Where the family had expertise and confidence in formula feeding, the mother was more likely to stop breastfeeding and formula feed.

The infant feeding survey (NHS Digital, 2010) gives an insight into the importance of role models. The results for the UK reported that 26% of mothers who were surrounded by friends who were formula feeding gave up breastfeeding in the first two weeks compared to only 6% of mothers who were surrounded by friends who were mainly breastfeeding.

The Scottish Infant Feeding Survey (2017) reported that around a quarter of mothers had not breastfed in a particular venue as they believed breastfeeding would not be welcomed. This is despite the legislation in place to support breastfeeding in public (Breastfeeding etc. (Scotland) Act, 2005). Scottish mothers were found to be much less likely to breastfeed in public than Swedish mothers, where breastfeeding in public is the social norm. Scott et al. (2015) found an association between perception of acceptability of public breastfeeding and breastfeeding practice; mothers with a negative attitude towards breastfeeding in public were more likely to stop breastfeeding earlier. Johnson-Robledo et al., (2007) suggest that the sexualisation of the breast is the reason why breastfeeding in public is contentious.

There is little research around the portrayal of breastfeeding in the media, but representation of breastfeeding could affect social norms if women were repeatedly exposed to positive images of breastfeeding. Yet while infant feeding is often mentioned in women’s magazines, formula feeding is portrayed more often than breastfeeding (O’Brien et al., 2017).

The available evidence suggests that:

  • Midwives and health visitors need societal support to promote and support breastfeeding.
  • Experience of formula feeding (that of the mother and those close to her) is highly influential. If formula feeding is the mother’s primary experience, positive attitudes to formula feeding are formed.
  • If there are no family/friends who have experience and knowledge of breastfeeding, mothers are more likely to stop breastfeeding if they experience problems.
  • Positive breastfeeding role models are important and prolong breastfeeding practice.
  • Mothers are concerned about breastfeeding when out and about, feeling they will meet with disapproval if they breastfeed in public.
  • Breastfeeding is not well represented in the media; formula feeding receives more representation.

Aims of the project

We felt that breastfeeding needs to be normalised in our communities and that the presence of positive role models is important. We recognised that we could change perceptions of breastfeeding by starting before attitudes around infant feeding are firmly developed, especially in areas where breastfeeding rates are low. Our project was delivered in an area of North Ayrshire where breastfeeding rates are critically low, with only 17% of women exclusively breastfeeding at 6-8 weeks compared to the Scottish average of 26.8%.

We therefore planned to introduce the concept of breastfeeding to children as soon as they started in education (aged 3 years) and to continue to broaden knowledge as they progressed through primary and secondary school.

How we approached the early learning and childcare staff

Working in partnership with the Community Infant Feeding Nurse and Breastfeeding Network (BfN) Peer Supporters, relationships were established with two schools in North Ayrshire:- St Matthew’s Academy and Glencairn Primary School and Early Years Centre. The schools were enthusiastic about the pilot project and staff welcomed the idea of early intervention to promote healthy lifestyles, positive attachment and parenting, and decrease the obesity rate in the area. Our work around breastfeeding complemented an existing project in the Primary School and Early Years Centre looking at healthy weight for children and their parents.

Content of the session

The session devised for the Early Years children was based on ‘How Mammals Feed Their Young’. It followed the style of learning used in Early Years settings: - interactive, learning through play and not as structured as sessions delivered for older children. Children were welcome to play at the table where the Peer Supporter sat with toy animals and a matching jigsaw of mammals and their young.

How the children were engaged

Children were engaged through the use of toys and animals, familiar items in the Early Years setting. The Peer Supporter facilitated conversations about mammals and how humans are mammals and have a lot in common with other mammals, including feeding our young with our milk. The Peer Supporter had a jigsaw available for the children that involved pairing mum and baby mammals. This led to conversations about what all the animals in the jigsaw had in common (all mammals). The Peer Supporter talked about how one of the factors that links mammals is that they all produce milk to feed their babies. With older nursery children, we extended this work by talking about the correct names for each mum and baby animal, for example a vixen and a cub for the fox pair. We also asked the question, ‘Where do all the mum animals get the milk to feed their babies?’ Although mammals such as a lion and a whale were in the jigsaw, we often got the answer from the children that milk to feed the baby came ‘from a cow’. This led to some interesting discussions about how a lion or a whale might get milk from a cow or buy milk from a shop! All of these discussions were led by the children, so they were different discussions every time, but with the same aim of getting across that all female mammals make milk specifically for their babies and that human mums are just the same.

We also used interesting facts about each mammal to engage the children; for example, whales’ milk is thick like toothpaste so that the calf can get every last drop if it escapes into the water. We demonstrated this by having two glasses of water and inviting the children to put small amounts of cow’s milk into one and small amounts of toothpaste into the other to see how each behaved in the water. We also talked about how bats can breastfeed their babies whilst flying, which seemed to interest the boys especially! The children also interacted with a baby doll and wanted to put the baby in the sling (like a mother kangaroo); this prompted conversations about the importance of caring for babies and responding to their needs.

Feedback from parents/carers

Staff were initially concerned that parents/carers would disapprove of the sessions and that some families might not see breastfeeding as an appropriate topic to discuss with young children. To help with this, it was suggested that an information stall be set up in the reception area during the Early Years Centre’s pick-up and drop-off times so that parents/carers could be informed about the content of the sessions and reassured of the importance of talking about infant feeding at an early age. All parents/carers were positive and supportive, with some asking for support with their own breastfeeding experiences from the Peer Supporters.

Raising staff’s awareness of breastfeeding

We were also keen to work with staff so that
the simple activities around infant feeding that we were using could be embedded within the early years setting once the project had finished. To help with this, the Peer Supporters delivered a short (1 hour) breastfeeding awareness session, developed by the Breastfeeding Network, called ‘First Milk Matters’. This is designed to raise knowledge and awareness around breastfeeding and can be tailored to the specific audience.
We used the accredited IOWA Infant Feeding Attitudes Assessment Scale to measure the change in attitudes in staff before and after the session and saw a shift to their being more positive about breastfeeding. During the session, there were lots of opportunities for staff to share their experiences and thoughts around breastfeeding, if they wished, giving them a chance to debrief their own experiences, especially if these were negative so that they could talk about breastfeeding in a more positive way. There were lots of discussions about how staff could introduce the topic of breastfeeding with the children. Staff identified a topic area that they already covered each year (Spring and Baby Animals) that could easily be adapted to include a discussion about mammals feeding their babies without adding extra work for staff. Some staff volunteered that after the training, they felt confident to start conversations about breastfeeding with children in the ‘home corner’ when they were role playing feeding a baby. They said that before the training, they wouldn’t have known how to start such a conversation.

IOWA Infant Feeding Attitudes
Assessment Scale*

This scale measures maternal attitudes toward infant feeding methods (e.g., breast-feeding, formula-feeding).  The scale includes questions about the costs of infant feeding, nutrition, convenience and infant bonding.
*de la Mora, Russell, Dungy, Losch, & Dusdieker, 1998

Conclusions

There are a few areas in Scotland where Breastfeeding Friendly nursery schemes are currently delivered. The Scottish Government has provided increased funding for breastfeeding support and included in this are national advocacy and culture change activities. It is hoped that Breastfeeding Friendly Scotland Early Learning and Schools schemes can be designed and delivered across Scotland. This will ensure that children are introduced to breastfeeding at age 3 to 4 years and that this information can be built on through primary and secondary school. The consequent increase in breastfeeding knowledge may result in more positive attitudes towards breastfeeding and increased initiation rates.

Acknowledgement

The author wishes to acknowledge funding from the Queen’s Nursing Institute Scotland Catalyst for Change Programme which allowed this project to take place.

References

Bartle, N.C., Harvey, K. (2017) Explaining infant feeding: The role of previous personal and vicarious experience on attitudes, subjective norms, self-efficacy, and breastfeeding outcomes. British Journal of Health Psychology, 22(4):763-785.

Bailey, C., Pain, R. (2001) Geographies of infant feeding and access to primary health-care. Health & Social Care in the Community, 9(5):309-317.

de la Mora, A., Russell, D.W., Dungy, C.I., Losch, M., Dusdieker, L. (1999) The Iowa Infant Feeding Attitude Scale:  Analysis of reliability and validity.  Journal of Applied Social Psychology 29(11):2362-2380.

Johnston Robledo, I., Wares, S., Fricker, J., Pasek, L. (2007) Indecent exposure: Self-objectification and young women’s attitudes toward breastfeeding. Sex Roles, 56(7-8):429-437.

Marks, D., O’Connor, R. (2015) Health professionals’ attitudes towards the promotion of breastfeeding. British Journal of Midwifery, 23(1):50-58.

McAndrew, F., Thompson, J., Fellows, L., Large, A., Speed, M. et al. (2015) Infant feeding survey 2010. NHS The Information Centre. Available at: https://sp.ukdataservice.ac.uk/doc/7281/mrdoc/pdf/7281_ifs-uk-2010_report.pdf <accessed 06 November, 2019>

NHS National Services Scotland - Information Services Division, Available at:  https://www.isdscotland.org/ <accessed 06 November, 2019>

O’Brien, E., Myles, P., Pritchard, C. (2017) The portrayal of infant feeding in British women’s magazines: A qualitative and quantitative content analysis. Journal of Public Health, 39(2):221-226.

Scott, J.A., Kwok, Y.Y., Synnott, K., Bogue, J., Amarri, S. et al. (2015) A comparison of maternal attitudes to breastfeeding in public and the association with breastfeeding duration in four European countries: Results of a cohort study. Birth: Issues in Perinatal Care, 42(1):78-85.

The Scottish Government (2018) Scottish Maternal and Infant Nutrition Survey 2017 , Available at: https://www.gov.scot/publications/scottish-maternal-infant-nutrition-survey-2017/ <accessed 06 November, 2019>

The Scottish Government. (2005) Breastfeeding etc. (Scotland) Act. Available at:  http://www.legislation.gov.uk/asp/2005/1/contents <accessed 06 November, 2019>

Victora, C.G., Bahl, R., Barros, A.J.D., França, G.V.A. et al. (2016) Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017):475-490.

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