Improved breastfeeding rates

Description:
Improved breastfeeding rates
 
Indicator:
Following publication of our recommendations, breastfeeding initiation rates improved from 66.2 to 73.7% 2005/6 to 2010/11, but have plateaued since.
Citing our work on the association between the dose of fentanyl and breastfeeding, 7 guidelines recommend restrictions on epidural fentanyl doses. Our 2005 recommendations against high doses and the need for further research were adopted by NICE: the NICE Evidence statement reports the association between the dose of fentanyl and the success of breastfeeding, and indicates “a need for studies:(...): to assess the impact of low-dose epidurals with opioids (fentanyl) on neonatal outcomes, including resuscitation and breastfeeding.” (NCC 2007 p.123). Recommendations (p.14) include informing women that “opioids may interfere with breastfeeding”.
The US Academy of Breastfeeding Medicine Protocol (2008 p.129), citing our 2005 work, states: “consideration should be given to the type and dose of analgesia. Higher doses of intrapartum fentanyl may impede establishment of breastfeeding.” Taking our work with a small trial, Reynolds recommends: “When prolonged epidural analgesia using local anaesthetic-opioid combination is extended for emergency section, it is unwise, for the baby’s sake, to give further opioid epidurally or systemically until after delivery” (Reynolds 2010 p.298). Our work is also cited to encourage women to persevere with breastfeeding while the effects of opioids abate: West & Marasco (2009 p.59) advise: “epidurals (...) can temporarily diminish infants’ nursing behaviours (...); it may take a little more work to get breastfeeding started”.
Practice changes Following adoption of our work by NICE (NCC 2007) and other guidelines, lower doses of fentanyl have been administered during labour. The first trial of epidural fentanyl in labour initiated analgesia with a bolus dose of 80 mcg (Justins et al 1982); further trials used 100mcg (D’Athis et al 1988, Connelly et al2000). In 2003 a 50mcg bolus was considered ‘ultra-low-dose’ (Radzyminski 2003). Bolus doses of 10-30mcg fentanyl are now recommended for initiation of epidural analgesia (NCC 2007, p.137). Before this change in the guidelines some 4-6% parturients and their infants were exposed to higher doses. For example, in our hospital in 2000, 4% primiparae received above the current maximum dose of epidural fentanyl, 40-240 mcgs. Similarly, in 2000 155/757, 20.5% UK parturients received >200mcgs and 41/757, 5.4% received >300mcgs (Wilson et al 2010).
Changes in Breastfeeding Rates Our paper (2005) and guidelines citing it (2007) were followed by improved breastfeeding initiation in England 2005-2011. Breastfeeding initiation rates improved from 66.2 to 73.7% 2005/6-2010/11, but have plateaued since (DH 2013) (Table 1, Figure 3).
Table 1. Changes in Breastfeeding Rates in England (DH 2013)
Breastfeeding Initiation % (95% CI) OR increase Breastfeeding 6-8 weeks %(95% CI)
2005/06 66.2(66.1-66.3)
2008/09 Q1 48.7(48.4-49.0)
2010/11 73.7(73.6-73.8) 1.076(1.074-1.077) pa since 2005 2009/10 Q1 50.3 (50.0-50.5)
2011/12 74.0(73.9-74.1) 1.016 (1.008-1.023) from 2010/11 2011/12 Q1 49.1(48.9-49.4)
2012/13 73.9(73.8-74.0) 1.007 (0.999-1.015) from 2011/12 2012/13 Q1 47.1(46.9-47.2)
The deceleration in improvement from >1% to <0.5% pa after 2010 intimates that the impetus for improvement was discrete and sustainable. Similarly, 6-8 week data (only available from 2008/9) indicate improvement to 2009/10, but not thereafter. The quinquennial Infant Feeding Surveys from 1980 indicate that breastfeeding rates deteriorated when epidural fentanyl and routine uterotonics were introduced in the 1980s, and recovery was co-temporaneous with our work.
Alternative explanations, and commonly held beliefs regarding strategies to improve breastfeeding rates, are not supported by evidence from industrialised countries (Lumbiganon et al 2016, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006425.pub4/full, Balogun et al 2016 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001688.pub3/full) .