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5 Why do we need a strategy?

5.1 Earlier we identified key areas for action and this section expands on why these are important:

To provide optimal maternal nutrition

5.2 Good nutrition and the maintenance of a healthy body mass index are vital for a long and healthy life. This is not only affected by the food choices we make for ourselves, but those made by parents prior to becoming pregnant, during pregnancy, our parents' infant feeding choices, and how we are fed throughout childhood. There is increasing evidence that poor maternal nutrition and obesity prior to and during pregnancy can impact negatively on foetal and infant health resulting in conditions such as spina bifida, growth retardation in the womb, low birth-weight and health deficits in childhood and later life.

To increase initiation and duration of breastfeeding

5.3 A large body of published evidence demonstrates the benefits of breastfeeding for mothers and children. Breastmilk can protect infant health, ensure optimal nutrition and stimulate the growth of the infant's neurological, hormonal, gastrointestinal and immune systems. Some of these benefits last into childhood and beyond.

5.4 Breastfed babies are less likely to suffer from conditions including vomiting and diarrhoea, chest infections, urinary tract infections, ear infections, diabetes in childhood and childhood obesity. For some of these conditions the longer a baby is breastfed the greater the protection gained or the more positive the impact on long-term health. Pre-term babies that are breastfed are likely to have better eyesight and brain development than those who are not.

5.5 Mothers who breastfeed have a reduced risk of some cancers (ovarian and breast), and hip fracture in later life, caused by osteoporosis. In addition, breastfeeding creates a special emotional bond between mother and child, which may have a positive impact on future mental health. It can contribute to mothers' feelings of satisfaction or self-esteem. It can help women return to pre-pregnancy weight and contribute to maintaining their iron levels. It can have a contraceptive effect in specific circumstances.

5.6 Breastfeeding offers complete nutrition for most babies for the first six months of life. It requires no preparation and does not cost anything - although some mothers may purchase items which they feel make breastfeeding easier.

To minimise risks of formula feeding

5.7 Although evidence shows that breastfeeding is undoubtedly the healthiest way in which to feed a baby, particularly in the earliest months, there are some mothers who, for physical, social or psychological reasons, cannot or choose not to breastfeed. Evidence suggests that true lactation failure occurs in as few as 1% - 2% of breastfeeding mothers. It is essential that mothers are not judged or discriminated against for choosing to formula feed their babies and should be supported in their chosen mode of infant feeding.

5.8 Powdered formula milk is not sterile and does not contain any of the protective antimicrobial components found in breastmilk. It is also a growth medium for harmful bacteria. It is therefore essential to ensure that parents, who choose to formula feed are shown how to prepare and use infant formula as safely as possible. Other family members or carers should also be aware of how to prepare and use infant formula.

Support timely and appropriate weaning practices

5.9 In Scotland, weaning is taken to mean the gradual introduction of solid foods along with the usual milk feeds (breast or formula) to an infant's diet. The term 'weaning' has the same meaning as complementary feeding and introduction of solids.

5.10 On average, by the age of six months, a child's nutritional needs begin to exceed that which can be fulfilled by milk alone and for some infants this may be slightly earlier. However, many women decide to introduce solids based on the perception that their child is hungry or not satisfied with liquid feeds. They may also be highly influenced by friends, family and peers who can tend to make assessments on the basis of tradition or intuition rather than based on evidence. However, the main influences on the timing of introduction of solids are social deprivation, maternal knowledge and prior feeding experiences.

5.11 Inappropriate weaning is known to increase the risk of gastrointestinal illness if started too early. It is vital that solids are not introduced before four months as this increases the risk of intolerance to elements such as gluten, and the incidence of respiratory illness and gastrointestinal illness compared to those weaned at a later stage. For example, colic in newborn babies is very common and may be caused by intolerance to lactose in formula milk. The introduction of solids should happen alongside existing breast or formula feeds from six months.

To support informed choice

5.12 The decision of how to feed a child falls ultimately to the parent but it is important that they are fully aware of the choices available, understand the options and know the benefits and risks. During pregnancy parents receive a huge amount of information and it is important that it is useful and not overwhelming. Information on infant feeding has to compete with information on a host of other issues, much of which may seem more pertinent prior to birth, however it is important that feeding choice is discussed as early as possible and made available in a variety of forms.

To increase public knowledge and acceptance of breastfeeding

5.13 The health benefits of breastfeeding both for mother and baby are universally accepted and supported by a wealth of research. However, the clinical and cultural shift from breastfeeding to bottle-feeding in the latter part of the 20th century means that this natural interaction is still not regarded as the norm for newborn babies. This is not helped by the over-sexualisation of women's breasts by the media.

5.14 There is anecdotal evidence that women have been and are put off breastfeeding purely by others' opinions and attitudes. The Breastfeeding (Scotland) Act in 2005 made a huge step toward raising the profile of breastfeeding and has legislated to protect the right to breastfeed in public. The breastfeeding advertising campaign in 2004/05 placed cultural change at the centre and made a direct challenge to attitudes but more needs to be done.

Raise awareness of needs of vulnerable babies

5.15 As referred to earlier breastfeeding has particular benefits for pre-term babies and can protect them from neonatal necrotising enterocolitis (a life threatening inflammatory bowel condition) and improve eyesight and brain development.

Raise awareness of legal rights pertaining to infant feeding

5.16 Scotland has been at the forefront of legislative protection for breastfeeding which resulted in the Breastfeeding (Scotland) Act 2005, the first national legislation of its kind in the world. However, there are many other legal rights that can pertain to breastfeeding including Health and Safety Regulations, Sex Discrimination and Parental Rights.

To highlight the evidence on effective support for breastfeeding

5.17 It is only in recent years that research has begun to identify interventions which promote the initiation of breastfeeding. Effectiveness reviews have begun to inform health sector initiatives, health promotion and education activities, health professional training, social support, peer and group support and media campaigns. However, multifaceted interventions are the most likely to work.

5.18 A recent systematic review found that breastfeeding initiation and duration rates in the UK were amongst the lowest in Europe, particularly amongst lower socio-economic groups. The reasons given for these findings included the influence of society and cultural norms as well as clinical problems, organisation of health services and the lack of preparation of health professionals and others to support breastfeeding effectively.

5.19 Evidence from the Early Years Learning Network Review to be published in conjunction with this document will provide the evidence base in relation to psychosocial issues, neonatal care and appropriate measuring tools. The review will also address breastfeeding mothers' views and experiences of the support and care they have received. These reviews will be invaluable in identifying specific areas for further action.

Ensuring integrated, multi-sectoral support

5.20 All of the above aims require vital action to ensure that maternal nutrition and nutrition in early infancy continue to improve. However, this can only happen through sustained effort across a range of bodies.

5.21 Traditionally NHS Boards have taken the lead in promoting breastfeeding and in developing local plans to improve breastfeeding rates. However, the Infant Feeding Strategy needs to fully encompass the role of other agencies, professions and individuals in helping achieve this aim. We are particularly keen to enhance the role of local authorities and the voluntary sector, in addition to exploring how we can engage some of the less obvious health professions. Examples of the types of individuals we are targeting include:

5.22 The Scottish Executive is committed to working in an integrated manner across internal divisions and departments to deliver on a range of policies. Traditionally we have not focused on infant feeding, and instead have put our efforts into breastfeeding and the health service effort to improve patient satisfaction and support to breastfeed, and to drive up rates. But, infant feeding is not all about breastfeeding and is not the sole responsibility of NHS Scotland.

5.23 There are a wide range of policies which can or could impact on infant feeding and external to the Executive are a wide range of bodies who can help put these policies into practice. In the next section we make our key recommendations for the type of national and local infrastructures that are required to move forward this work and ask the questions that will help us shape the Infant Feeding Strategy - for the future of Scotland's children.

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