Infant Feeding in Leicester City - East Midlands Public Health ...

5Notes.The data used cover the time period 2005/06 to December 2009 (initiation) and 2004/05 to 2009/10(prevalence).Patients with an „unknown‟ breastfeeding status are assumed to be not feeding.This report looks at the following demographics:‣ Ethnicity.‣ Maternal Age.‣ Deprivation.This report looks at the following health outcomes:‣ Gastroenteritis.‣ Respiratory Tract Infections.‣ Obesity.When looking at the impact of infant feeding on health outcomes, only initiation rates were used, asthese generally have better historical coverage. Initiation rates and prevalence rates are known tohave a strong correlation, so in general areas with high initiation rates will also have high prevalencerates.Data on obesity are from the National Child Measurement Programme (NCMP), 2008/09. Data forall other health outcomes are from the Hospital Episodes Statistics (HES) database. The timeperiodof the HES data matches the time-period of the breastfeeding data used.

6IntroductionThe UK Infant Feeding Survey 2005(1) showed that 78% of women in England breastfed their babies afterbirth. However, by week six only 50% of all new mothers were breastfeeding and 26% by six months. In2009/2010, figures from the Department of Health(56)showed that 73% of mothers were initiatingbreastfeeding within the first 48 hours of life nationally and 45% of mothers reported that they were stillbreastfeeding at 6-8 weeks. In the East Midlands, 73% of mothers initiated breastfeeding in this same timeperiod with 43% were still breastfeeding at 6-8 weeks.Much research has been focused on the benefits of breastfeeding in developing countries, where it is wellrecognised that breastfeeding is associated with reduced mortality and morbidity. There is now a growingbody of evidence showing that even in developed countries breastfed babies are less likely to suffer fromconditions such as gastroenteritis, respiratory illness, atopic dermatitis, and childhood obesity. Theprotective effect is strengthened by exclusivity and longer duration. Mothers who breastfeed are reported tobenefit from a greater weight loss postpartum compared with mothers who bottle-fed their infants, adecreased incidence of premenopausal breast cancer and decreased incidence of ovarian cancer.The WHO currently recommends “exclusive breastfeeding up to six months of age, with continuedbreastfeeding along with appropriate complementary foods up to two years of age and beyond”(2). The UKhas adopted the same recommendation since 2003(3). Its continuing importance as a determinant ofpreventative ill health has been recognised more recently as it has been included in the Healthy Lives,Healthy People: Public Health Outcomes Framework(4). Rates of breastfeeding initiation and prevalence at6-8 weeks have been proposed as indicators in Domain 4 - Prevention of Ill health: reducing the number ofpeople living with preventable ill health. Its inclusion is based on the evidence that breastfeeding haspositive health benefits for both mother and baby in the short and longer term. The proposed framework iscurrently under consultation and it is hoped to be in operation from April 2012.Based on this evidence, it is clear that increasing levels of breastfeeding can significantly improve maternaland infant health in local areas. As specific groups in society are less likely to breastfeed than others it isalso an important issue in addressing health inequalities. Investments in services to support breastfeedingshould be a key part of local child health strategies to improve the health of the local population and reduceinequalities.

7More support is needed for mothers to improve breastfeeding levels. Currently, data are available at PCTlevel but more detailed information is required to ensure adequate planning and appropriate targeting ofservices and initiatives to support breastfeeding in local areas. This report aims to provide such information.It examines levels of breastfeeding for different population groups to identify those groups where furthersupport may be needed. By providing analysis at a lower level, it is hoped that it can be used for moretargeted planning. We have also examined the associations between breastfeeding and specific healthoutcomes (where there is established evidence that an association exists), to provide some indication onthe impact of infant feeding on health outcomes and the use of health services in local areas.

Percent of eligible maternitiesPercent of eligible maternities8Trends over time.Fig.170%60%Breastfeeding rates in Leicester City; trends over time50%40%30%20%10%0%QuarterF. YearInitiation Six week prevalenceQ1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q40405 0506 0607 0708 0809 0910Fig.2100%Breastfeeding coverage in Leicester City; trends over time80%60%40%20%0%QuarterF. YearSix week prevalenceInitiationQ1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q40405 0506 0607 0708 0809 0910

10Local Variation.Fig.3Breastfeeding in Leicestershire City PCT by WardHumberstone and HamiltonAylestoneBeaumont LeysThurncourtAbbeyFreemenEyres MonsellBraunstone Park and Rowley FieldsPercent ofeligible maternities:Spinney HillsStoneygateEvingtonKnightonBelgraveColemanCastleWestern ParkLatimerRushey MeadWestcotesCharnwoodFosseNew ParksSix Week PrevalenceInitiation0% 10% 20% 30% 40% 50% 60% 70% 80% 90%As shown in fig.3 there is variation in both measures; initiation varies from 37% in New Parks to 83% inSpinney Hills. Prevalence varies from 19% in both New Parks and Eyres Monsell to 57% in Spinney Hills.There is a general tendency for wards with higher initiation rates to have a higher prevalence ofbreastfeeding at six-weeks, although there is a lot of variation in drop-off within the PCT, as shown overpage.An Excel book with full details of initiation, prevalence, drop-off, levels of deprivation, and the percent ofmothers who exclusively breast feed at six to eight weeks, is available at www.empho.org.uk.The reasons for variation between wards will include differences in the underlying risk factors forbreastfeeding (including demographic differences), as well as differences in performance.

11Fig.4Breastfeeding in Leicestershire City PCT by WardFosseEyres MonsellWestern ParkWestcotesAbbeyBraunstone Park and Rowley FieldsThurncourtNew ParksFreemenHumberstone and HamiltonAylestoneBeaumont LeysEvingtonCastleKnightonBelgraveRushey MeadStoneygateColemanCharnwoodLatimerSpinney HillsDrop-Off After Six Weeks (%)0% 10% 20% 30% 40% 50% 60% 70%Percent of eligible maternitiesSpinney Hills has both the highest initiation rates and the lowest drop-off rates (31%). Drop-off rates inFosse are almost twice those in Spinney Hills at 58%. Whilst areas with higher initiation rates generallyhave lower drop-off rates; Latimer, Charnwood and Coleman have very low drop-off rates relative to theirinitiation rates. A summary of drop-off rates by ward is shown in fig.4.

14Table 1Initiation6-8 week prevalenceEthnic Group Maternities % BF Children % BF % Drop-offAsian 7,869 84% 2,562 62% 27%Unknown 2,514 83% 1,874 26% 69%Black 2,072 82% 219 40% 52%Other 112 79% 125 58% 27%Not Stated 187 71% 20,892 35% 51%Mixed 466 58% 702 49% 15%White 10,468 43% 3,719 29% 33%The pattern found in the Leicester City is similar to results reported elsewhere for the UK. In the UK it isgenerally seen that White mothers have the lowest rates of breastfeeding, both for initiation and forcontinuation of breastfeeding compared to all other ethnic groups. The 2005 Infant Feeding Survey(1)reported that only 74% of White mothers initiated breastfeeding compared to 94% of Asian/Asian Britishmothers and 96% of Black/Black British mothers. The pattern is similar to that reported above, althoughoverall levels of breastfeeding appear to be lower for all ethnic groups in Leicester City than reported in thissurvey. It also appears that levels of breastfeeding are higher in Asian mothers than Black mothers inLeicester City which is a contrast to national findings. Kelly et al(5) also found that mothers from the BlackAfrican ethnic group were 10 times more likely to initiate breastfeeding than White mothers.This pattern appears to persist when looking at the time that a mother continues to breastfeed her child,which again is consistent with findings from Leicester City. In the 2005 Infant Feeding Survey(1) 87% ofBlack mothers were still breastfeeding at six weeks compared to 46% of White mothers at the same timeperiod. There were also significantly higher levels of breastfeeding in Asian mothers (66%) and Chinese(65%) mothers compared to White mothers. Our findings show a similar pattern of breastfeeding levels at6-8 weeks to that reported in the national survey, although the actual rates presented are lower than thosefound nationally Agboado et al(6) found that White mothers were 69% more likely to stop breastfeedingcompared to non-White mothers at all time periods measured in their study, even after taking other socialfactors into account such as deprivation, mode of delivery and marital status.In the 2005 Infant Feeding Survey(1), the rates of exclusive breastfeeding were also higher in all ethnicminorities compared with those from a White background at birth. However, in contrast to the pattern seenin total breastfeeding, levels of exclusive breastfeeding was lowest in Black mothers than in all other ethnicgroups (including White mothers) at all subsequent time periods measured.

15The literature shows that there are a number of other factors that affect the depth of these ethnicdifferences. For example, the level of integration into UK society is important. Mothers from ethnic minoritygroups were more likely to breastfeed if they were recently migrated or lived a more “traditionally cultural”life e.g. spoke their native language at home(8)(5). It appears that the closer the mother is to the traditionsof their ethnic group they are more likely to breastfeed. While those that have become more integrated intoWestern society are least likely to breastfeed compared to their ethnic counterparts.This study also found some interesting interactions with maternal education. In White mothers, a higherlevel of education is associated with increased rates of breastfeeding. However, the opposite is true formothers from ethnic minorities. Griffiths et al(7) found that higher education levels were associated withshorter breastfeeding duration and earlier introduction of solids in mothers from ethnic minorities. Also,mothers from ethnic minorities that were in managerial or professional work roles were more likely to stopbreastfeeding earlier than those in routine or manual roles. Again, this is the opposite of what is usuallyseen in mothers from a White background.It is clear from our findings that there is variation in breastfeeding levels between ethnic groups in the EastMidlands. Overall, the pattern appears to be similar to those reported in national surveys and the publishedliterature, although a number of slight differences have been noted. Even after considering other influences,such as maternal age and deprivation status, the ethnic group to which the mother belongs will have animpact on their likelihood to breastfeed their baby. In addition, the literature also shows that a number ofother factors can influence the likelihood to breastfeed, e.g. education and integration to society. Thisclearly shows that there is a need to plan breastfeeding initiatives specific to the ethnic groups beingtargeted, taking these considerations into account as the influences on health behaviours can differ.

16Demographics; Age of Mother.Fig.7Breastfeeding in Leicester City PCT by Maternal Age35+30-3425-2920-24Under 20Six Week PrevalenceInitiationFig.80% 10% 20% 30% 40% 50% 60% 70% 80%Percent of eligible maternitiesBreastfeeding in Leicester City PCT by Maternal Age35+ Drop-Off After Six Weeks (%)30-3425-2920-24Under 200% 5% 10% 15% 20% 25% 30% 35% 40%Percent of eligible maternitiesAs shown in fig.7 there is a clear relationship between maternal age and breastfeeding initiation rates.These increase as the mother‟s age increases, until the age of about 30, after which feeding rates remainconstant.

17The relationship is similar for the prevalence of breastfeeding, with rates increasing with every increase inmaternal age. For both initiation and prevalence there is a statistically significant difference betweenfeeding rates in the youngest and oldest age-groups. This difference takes into account any differencesbetween the ethnic-composition of the age-groups, as well as differences in levels of deprivation.Those in the oldest age-group are almost twice as likely as those in the youngest age-group toinitiate breastfeeding, and are two-and-a-half times more likely to be feeding at six-to-eight weeks.Drop-off rates also show an association with maternal age as shown in fig.8, with rates amongst theyoungest mothers (34%) being almost three times those amongst the oldest age-groups (12%). Thissuggests that younger mothers are less likely to initiate breastfeeding, and even if they do feed then theyare more likely to discontinue feeding within the first six-to-eight weeks.In general drop-off rates in Leicester City are much lower than those observed in the rest of the region; forexample the regional drop-off rate for mothers under the age of 20 is 62%, whilst for mothers aged 35 orover it is 26%. Drop-off rates amongst those aged 20-24 are also noticeably low (19%), both relative to theregional average (47%) and also relative to the other age-groups in Leicester City.Table 2Initiation6-8 week prevalenceAge Band Maternities % BF Children % BF % Drop-offUnder 20 1,833 37% 700 24% 34%20 - 24 5,820 57% 2,360 47% 19%25 - 29 7,321 70% 2,919 55% 22%20 - 24 5,414 73% 2,240 60% 18%35+ 3,300 71% 1,332 62% 12%It is clear that maternal age is an important determinant of breastfeeding initiation and duration in LeicesterCity and this is backed up by findings from a national survey and the published literature. A similar patternto that found in Leicester City is seen for the UK in the 2005 Infant Feeding Survey(1). This survey reportsthat the rate of breastfeeding initiation in mothers under 20 was 51% compared to 84% of mothers agedover 35. As with our findings from Leicester City, there was also found to be a significantly higher fall outrate among younger mothers in the national survey. At six weeks, only 14% of mothers under 20 were stillbreastfeeding compared to 62% of mothers aged over 35. This pattern persists at all time points measured.At six months only 7% of mothers aged under 20 were still breastfeeding compared to 36% of those aged

18over 35. It can be seen that the pattern found in our analysis is not unusual and agrees with nationalresults. It is interesting to note that overall breastfeeding initiation levels are lower Leicester City for all agegroups than those reported in the national Infant Feeding Survey.Similar findings to those from Leicester City are reported throughout the literature. Tarrant et al(9)conducted a survey of women attending antenatal clinics in Dublin. They found that mothers aged 35 orover were approximately five times more likely than younger women to both initiate breastfeeding and tostill be breastfeeding at 6 weeks. Bick et.al(10) found similar results in a study based in Birmingham. Theyfound that mothers who were aged 25 or under were significantly less likely to have ever breastfed theirbabies than all older age groups. This study did not report any a significant difference in the age at whichbreastfeeding was stopped between the different age groups. These results are also echoed by Barneset.al(11) who investigated breastfeeding intentions among pregnant women. They found that older mothers(aged 35 and over) were nearly three times more likely to intend to breastfeed than their youngercounterparts (aged 19 and under).A study by Savage et.al(12) examined weaning practices in Glasgow and also found significant differencesby the age of the mother. They found that 60% of mothers aged 16-20 had introduced solid foods whentheir babies were less than 10 weeks old compared to 32% of mothers aged 21-25 and 25% of those aged36-40. Whilst this study does not focus specifically on breastfeeding practices, it is interesting to examinedifferences in mother‟s approaches to infant feeding.Dyson et al(13) investigated why differences in breastfeeding intention and practice vary between teenagemothers and older mothers. In an initial questionnaire they found that moral norms were the most predictivefactors reported by teenage mothers (19 and under) in their intentions related to infant feeding. They weresignificantly more likely to feel that bottle feeding was the morally correct behaviour (described as feelingsof responsibility to perform or refuse to perform certain behaviours) compared to mothers aged 20 andover. This finding was also a major theme which emerged from the subsequent focus groups conductedwith young pregnant women. Teenagers who intended to breastfeed felt the need to justify their decisionand were concerned about being labelled as „lazy‟. Other factors affecting intention to breastfeed identifiedin these focus groups included the sexuality of the breast and concerns about breastfeeding in public whichwere linked to young women‟s confidence and self esteem.Ineichen et.al(14) also conducted a study into the attitudes of teenage mothers towards breastfeeding. Theresponses of young mothers (aged 20 and under) were extracted from a national survey, meaning that

19comparisons could be drawn with an all age sample. Similar to the previous study they found that the mostcommonly reported reason for not breastfeeding was „not liking the idea‟ (40%). This study also found thatsome young women who were breastfeeding saw it as being good for the mother‟s figure (19%) which wasa factor which did not feature in the whole sample of the national survey.Gaining an understanding of what the barriers are for young women in making the decision to breastfeed iscentral to informing interventions to increase breastfeeding rates among this group. It is important thatinterventions consider the cultural pressures felt by young women when promoting breastfeeding andattempt to approach the issue from a wider perspective.

Breast Feednig RatesBreast Feednig Rates20Demographics; Deprivation.Fig.9Breastfeeding in Leicester City PCT by Deprivation QuintileInitiationSix Week Prevalence90%80%70%60%50%40%30%20%10%Fig.100%Most Deprived ← Deprivation → Most AffluentBreastfeeding in Leicester City PCT by Deprivation QuintileDrop-Off After Six Weeks (%)60%50%40%30%20%10%0%Most Deprived ← Deprivation → Most AffluentN.B. Within Leicester City no wards fall within the „most affluent‟ national quintile.Breastfeeding initiation rates show a general increase as levels of deprivation decrease; from 63% in themost deprived quintile to 80% in the second most affluent quintile, as shown in fig.9. There is no clear

21association with six-to-eight week prevalence; whilst rates are highest in the second most affluent quintile(46%), they are also lowest in the middle quintile (36%). After taking into account differences in ethniccomposition and maternal age, only the differences in initiation rates are significant.Initiation rates in the second most affluent quintile (80%) are almost 20% greater than the initiationrates in the most deprived quintile (63%).Drop-off rates show a general increase as levels of deprivation decrease, suggesting that whilst mothersfrom more affluent areas are more likely to initiate breastfeeding, they are also more likely to discontinuefeeding within the first six-to-eight weeks as shown in fig.10. This contrasts with other areas such asNottingham City PCT and Derby City PCT, where drop-off rates show a general decrease as levels ofdeprivation decrease.Table 3DeprivationInitiation6-8 week prevalenceQuintile Maternities % BF Children % BF % Drop-offMost Affluent: - - - - -Above Average: 838 80% 1,083 46% 42%Average: 580 76% 683 36% 53%Below Average: 5,893 69% 6,967 37% 47%Most Deprived: 16,377 63% 19,588 37% 41%Our analysis also showed that for the Leicester City there is an association between levels of deprivationand maternal age. Generally, there are a higher proportion of older mothers in more affluent areas, asshown in the table below. As older mothers are more likely to breastfeed, this may be a reason why thereare higher breastfeeding levels in more affluent areas. However, it may also be that older mothers are morelikely to breastfeed because they live in more affluent areas. It is not certain which is true.Table 4National DeprivationQuintiles:Average Age ofMother (years):Most Affluent: -Above Average: 31.3Average: 30.4Below Average: 28.2Most Deprived: 27.2

22When calculating deprivation quintiles, the income domain of the 2007 „Indices of Multiple Deprivation‟(IMD) was used. National quintiles were used, so for example wards in the „most deprived‟ quintile will beamongst the 20% most deprived wards nationally.N.B. Within Leicester City no wards fall within the „most affluent‟ national quintile.Acheson‟s independent inquiry(15) stated that breastfeeding is a strong indicator of social inequalities suchthat those women that are most disadvantaged are least likely to breastfeed. This association is quiteevident in our findings from Leicester City, where those who are most deprived are least likely to initiatebreastfeeding even after taking ethnicity and age into account.Our findings for the Leicester City are similar to those reported for the UK in the 2005 Infant FeedingSurvey(1). This survey found a clear relationship between socio-economic status, defined as maternalprofession, and initiation of breastfeeding. It was reported that mothers in professional or managerial roleswere more likely to initiate breastfeeding than those in routine/manual roles or those who never worked. Asimilar pattern is seen if education level is used as a marker of socio-economic status. 91% of mothers wholeft full-time education after 18 initiated breastfeeding compared to 59% of those whole left full-timeeducation before 16. The differences reported in the Infant Feeding Survey are greater than we havereported for Leicester City, but this may be due to the different indicators used to measure deprivation.A study undertaken in Australia(16) reported a significant relationship between socio-economic status(using a deprivation measure similar to IMD in the UK) and breastfeeding initiation. They reported that 91%of mothers in the most affluent quintile initiated breastfeeding compared to 81% of mothers in the mostdeprived quintile. These inequalities were also prevalent when looking at levels of exclusive breastfeeding.The Infant Feeding Survey 2005(1) found that at birth, 77% of those in professional/managerial roles wereexclusively breastfed compared to 54% of those in routine/manual roles and 48% of those who neverworked.Our analysis did not find an association between deprivation and breastfeeding levels at 6-8 weeks. This isof interest as it is different to findings from the 2005 Infant Feeding Survey(1). This found that at six weeksafter birth, 65% of those in managerial/professional roles are still breastfeeding compared to 32% ofmothers in the routine/manual category and 38% of mothers who have never worked. Interestingly, after sixweeks a gap appears between the proportion of mothers still breastfeeding in routine/manual group andthose who never worked. By six months, 25% of those who never worked are still breastfeeding comparedto 16% of those in routine/manual roles. One of the most likely reasons for these differences is that theformer group do not have the added pressure of having to go back to work. Mothers from routine/manualroles were also more likely to introduce formula milk or solid foods at an earlier age than those in

23professional/managerial roles. This pattern is also reported in other studies. In the 2004/05 Australiannational health survey, Amir and Donrath(16) found that those in the most affluent quintile were 26% morelikely to be still breastfeeding at six months than those in the lowest quintile. A similar gradient was seen atthree months.However, a study carried out in the Netherlands(17) found that differences by socio-economic group (usingmaternal education as a marker) only remained until two months after birth. This may be due to a numberof reasons. It is likely that cultural differences between the UK and Netherlands lead to different patterns inbreastfeeding levels. It was also shown that differences in lifestyle-related and birth characteristics,between the different groups, partly explained the inequalities. It is possible that after two months factorsother than maternal education are important determinants of continuation.There were a number of reasons as to why more deprived mothers are less likely to breastfeed. Theseinclude a lack of family support; less ability to seek help; less flexibility with working arrangements andconcerns about breastfeeding in public(16). Goldade et al(18) found that more deprived mothers felt thattheir lives were very „public‟ and this limited their ability to breastfeed regularly. These mothers said thatthey spent a significant amount of their time on public transport or in waiting rooms (e.g. social services)and that they did not feel comfortable breastfeeding in such situations. Regular life challenges were also ofconcern for these mothers, as they often had to deal with problems at short notice such as house evictionsor changes in jobs. Combined with a lack of family and community support to breastfeed, it often meant thatthese mothers did not initiate breastfeeding or stopped feeding at an earlier age.Deprivation is a complex issue and determined by a number of different factors. It is difficult to assessthose elements of socio-economic status that affect breastfeeding – is it the level of education a motherhas; the flexibility of her professional role; or the social support she receives from her family and localcommunity? It is most likely that it is a combination of these factors. From our findings and the results ofnational surveys and published literature, it is clear that deprivation is an important factor in determining thelikelihood to breastfeed. It is also clear that more research is needed to identify the role that each elementof deprivation plays to adequately address such issues.

24Health Outcomes; Gastroenteritis.Fig.11Within Leicestershire City PCT there is a significant association between breastfeeding rates and rates ofemergency admissions for gastroenteritis for children under the age of one as shown in fig.11. There is noassociation for children under the age of five.For those under the age of one, a 5% increase in breastfeeding is associated with a 4% reduction inthe risk of gastroenteritis, although the true reduction may lie between 0.2% and 7%.The above association takes into account the effects of maternal age and or deprivation. There is evidencethat the association is the same when ethnicity is taken into account, but there is too much variation withinthe data to verify this association statistically.It is well established that breastfeeding has a protective effect against incidence of GI in infants. The 2005Infant Feeding Survey(1) found that babies who were breastfed for a minimum of six months weresignificantly less likely to experience diarrhoea (26%) than those who were never breastfed (48%). The

25duration of breastfeeding also had an important effect, and the longer an infant had been breastfed the lesslikely they were to experience GI (once they had been breastfed for longer than two weeks).This relationship is clear in other studies. Quigley et al(19) found that infants that were formula fed weremore than four times as likely to experience diarrhoeal disease as those who were exclusively breastfed,although they needed to be breastfed for at least six months. In a later study, Quigley et al(20) found thatinfants who had been exclusively breastfed had significantly lower admissions for GI (65% less likely to beadmitted to hospital) than those who had never been breastfed. They suggested that 53% of all GIadmissions could be prevented by exclusive breastfeeding and 31% by partial breastfeeding. A study in theNetherlands(21), found that infants who had breastfed for greater than six months were 55% less likely toexperience GI than those who had never been breastfed. There were no protective effects for infants thathad been breastfed for a shorter time period.While it is clear that breastfeeding has a protective effect against incidence of GI, there is debate on thetime period required to confer health benefits. In the 2005 Infant Feeding Survey(1), a significant drop inprevalence of GI was seen in those babies that had been breastfed for at least four months, and this dropwas even greater if they had been breastfed for at least six months. Some studies have shown that infantswere less likely to have diarrhoeal disease if they had been breastfed for at least three months(22)(23)(24).However, others have found that infants have to be breastfed for at least six months for significant effectsto be seen(21)(20)(19).The duration that such health benefits remains after cessation of breastfeeding also differs betweenstudies. In general, the longer an infant has been breastfed the longer the protective effect will exist; but thetime since cessation of breastfeeding is also an important factor. Howie et al(24) found that infants who hadbeen breastfed for at least 13 weeks had less incidence of diarrhoeal disease than those who had beenformula fed, and this protective effect was maintained until 52 weeks. Other studies have reported that theprotective effect only lasts an additional one or two months if they have been breastfed for at least sixmonths(19)(20). While Duijts et al(21) found that the protective effect was only maintained as long asbreastfeeding continued.Another factor which seems to have an impact on the protective effect of breastfeeding was whetherbreastfeeding was exclusive or partial. Quigley et al(20) found that infants who had been exclusivelybreastfed had significantly lower admissions for GI than those who had never been breastfed; this was nottrue for those who had been partially breastfed. A similar finding was reported in Quigley et al in 2006(19)for infants aged less than six months. However if breastfeeding was continued beyond six months partialbreastfeeding was associated with lower risk of GI. Howie et al(24) also reported that partial breastfeeding

26was associated with a reduced risk of GI. Raisler et al(25) reported that a reduced risk of diarrhoea wasonly associated with exclusive breastfeeding or where breastfeeding was a significant part of the infant‟sdiet. It is possible that there is a threshold level for the passive immunity conferred by maternal breast milkand that breast milk must make up the majority of the diet to achieve such health benefits and protectagainst GI.Breastfeeding clearly has a protective effect against GI but the precise strength of this effect is not fullyunderstood. In addition, the exact duration of breastfeeding needed for health benefits to be seen and thelength of time protection remains after breastfeeding stops are also areas where further work is needed.

27Health Outcomes; Respiratory Tract Infections.Fig.12Within Leicester City PCT there is a significant association between breastfeeding rates and rates ofemergency admissions for respiratory tract infections as shown in fig.12. This significant association occursfor both age-groups.For those under the age of one, a 5% increase in breastfeeding is associated with a 5% reduction inthe risk of respiratory tract infections, although the true reduction may lie between 2.5% and 8%.For those under the age of five, a 5% increase in breastfeeding is associated with a 3% reduction inthe risk of respiratory tract infections, although the true reduction may lie between 0.8% and 6%.The above associations take into account the effects of maternal age and deprivation. For both age-groupsthere is evidence that the associations are the same when ethnicity is taken into account, but there is toomuch variation within the data to verify these associations statistically.

28A number of studies have shown that breastfeeding has a protective effect against RTI inchildhood(26)(21)(27). In the most recent Infant Feeding Survey(1), the highest rates of chest infectionswere reported in those infants that had been formula-fed from birth (31%) but only 24% of those that hadbeen breastfed experienced chest infections. The duration of breastfeeding was also important. After twoweeks of breastfeeding, the longer an infant had been breastfed the less likely they were to experienceillness. It was reported that 29% of infants that had been breastfed for two weeks experienced chestinfections compared to 24% of those that had been breastfed for four-six months and 20% of thosebreastfed for longer than six months.Bacharach et al(27) analysed the results of nine studies to examine the link between lower respiratory tractdisease in infancy and breastfeeding (both exclusivity and duration). They reported a consistent protectiveeffect of breastfeeding against lower respiratory tract disease. Exclusive breastfeeding for longer than fourmonths was seen to significantly reduce the risk of respiratory hospitalisation in infancy by 72% comparedwith formula-fed infants. This still remained even after accounting for differences in parental smoking statusand socioeconomic status. They found that formula-fed infants were more than 3 ½ times more likely to beadmitted to hospital for respiratory illness than those that had been exclusively breastfed for over fourmonths. The authors also reported that 26 more infants would need to be breastfed exclusively for longerthan four months to prevent one lower respiratory tract disease admission.Quigley et al(20) also found breastfeeding to have a protective effect on hospitalisation for respiratory tractillness. Infants who were exclusively breastfed were 34% less likely to be admitted to hospital for lowerrespiratory tract infection than those who were never breastfed. A similar pattern was seen for partialbreastfeeding but the relationship was not significant. The authors suggest that 27% of hospitalisations forlower respiratory tract infections could be prevented by exclusive breastfeeding and 25% by partialbreastfeeding. The time since breastfeeding cessation was also important and the protective effect seemedto weaken almost immediately once breastfeeding was stopped.A study undertaken in Rotterdam, Netherlands(21) also examined the effect of breastfeeding (exclusivityand duration) on respiratory illness in infants. This study also reported that breastfeeding had a protectiveeffect against both upper and lower respiratory tract infections in infants. Infants that had been breastfedexclusively for four months and partially thereafter were less likely to experience either lower respiratorytract illness (50% less likely) or upper respiratory tract illness (35% less likely) until the age of six months,compared to those infants that had never been breastfed. This group were also less likely to experiencelower respiratory tract illness between seven and twelve months. A similar pattern was reported for those

29exclusively breastfed for longer than six months. Partial breastfeeding, even for six months, was notassociated with a reduced risk of respiratory illness in infants.While a longer duration of breastfeeding is associated with reduced risk of respiratory illness, Sinha etal(28) examined the effect of breastfeeding on admissions for respiratory tract infections in neonates. Theyfound that infants who were exclusively breastfed were 30% less likely to be admitted to hospital forrespiratory illness in the first 30 days of life compared to infants that had been formula-fed. This relationshipwas only found to be significant for girls and not for boys. It is unclear why the health benefits were limitedto girls and further work is needed to identify if such sex differences are true in other groups. It does showthat exclusive breastfeeding does have health benefits even in early life.As severe infantile respiratory illness has been linked to subsequent development of childhood asthma, it isimportant to identify factors which can reduce the incidence of respiratory illness. It is clear thatbreastfeeding confers protection against respiratory illness in infancy, but what is less clear is the strengthof that protection and the duration which it lasts after breastfeeding cessation.

30Health Outcomes; Obesity in Reception.Fig.13Within Leicestershire City PCT there is a significant association between breastfeeding rates and levels ofoverweight children as shown in fig.13. There is no association with levels of obesity.A 5% increase in breastfeeding is associated with a 6% reduction in the risk of being overweightduring reception year, although the true reduction may lie between 3.5% and 8%.The association for levels of overweight children takes into account the effects of maternal age anddeprivation. There is too much variation within the data to take into account the effects of ethnicity.Rapid early weight gain before two years of age is associated with an increased risk of overweight in laterchildhood(29)(30)(31) and most excess weight gained before puberty is gained by the age of five(32).Some studies have shown that breastfeeding can lead to a slower weight gain in early life(33)(34) thushaving a protective effect against overweight and obesity in childhood and later life.

31Owen et al (2005)(35) analysed the results from 61 studies to evaluate the extent to which infant feedinginfluences overweight. This found that there was consistent evidence of a relationship betweenbreastfeeding and reduced risk of obesity. Overall, infants were 13% less likely to be defined as obese ifthey had been breastfed compared to those that had been formula-fed. As differences in obesityprevalence may be due to a number of social and lifestyle factors it is necessary to take these into accountduring analysis. Such factors include socio-economic status, parental BMI and maternal smoking status.This adjustment was seen to reduce the protective effect of breastfeeding such that infants were now only7% less likely to be obese if breastfed, but the association was still reported to be significant. Duration ofbreastfeeding was also an important factor. Infants who were breastfed for over two months were nearly20% less likely to be obese than those formula fed.Harder et al(36) analysed the results from 17 studies and reported that infants who were breastfed for atleast four to six months were 24% less likely to be overweight than those breastfed for less than onemonth. After one month, the risk of becoming overweight in childhood continuously decreased and eachadditional month of breastfeeding was associated with a 4% decrease in the prevalence of overweight at alater age. This effect was prevalent up to nine months of breastfeeding. This relationship was reported tobe true regardless of the age at which the infant was followed up in childhood, some of which were notfollowed up until age 14. Koletzko et al(33) also showed that breastfeeding had a protective effect againstoverweight and obesity. Children that had been breastfed were 21% and 25% less likely to be overweightand obese, respectively, at age five to six compared to those that had not been breastfed.Using subjects from the Millennium Cohort Study (MCS), Hawkins et al(8) examined various individual,family and community-level factors and the risk of overweight at three years of age. Breastfeeding wasseen to have a protective effect against overweight, and infants who were breastfed for greater than fourmonths were 25% less likely to be overweight at age three than those who were never breastfed. Thisprotective effect still remained, albeit reduced, even when all other factors were taken into account,including birth weight, ethnicity, maternal smoking, and parental weight. This study found that individual andfamily-level factors, which include breastfeeding duration, were more important in predicting overweight inearly childhood than community level factors, such as access to play areas/garden/food shops andsatisfaction with local area. They hypothesised that different factors may be more important at specific lifestages. It is likely that breastfeeding is more important in early childhood than wider social factors, andthese may become more important later in childhood.A number of studies have challenged this association between breastfeeding and overweight. They arguethat it is other lifestyle factors associated with the likelihood to breastfed that are responsible for thedifferences reported in obesity prevalence rather than breastfeeding having a direct effect on weight.

32Mangrio et al(37) found no significant association with ever having been breastfed and overweight at fouryears. The same study did report a significant association with obesity at four years but this was removedwhen parental BMI was taken into account. A similar pattern was seen in a study from the US(38). Ashorter duration of breastfeeding was associated with an increased likelihood to be overweight in childhoodbut once other lifestyle factors were taken into account, such as gestational age and weight gain in firstyear, this relationship was removed. This suggests that such factors need to be considered and also playan important role in childhood.Lamb et al(38) also found no association between exclusive breastfeeding and childhood BMI. Theyreported that it is likely there are inter-relationships between different predictors of childhood BMI. Weightgain in the first year of life was seen to be a significant predictor of overweight in childhood. Theysuggested that breastfeeding may lead to slower infant weight gain in the first year and this is how it isassociated with later childhood weight.Kramer et al(39) reported that prolonged, exclusive breastfeeding was not protective against increased BMIor other measures of adiposity in six-year old children. They found that differences in BMI between childrencould be explained by social or lifestyle factors, rather than incidence of breastfeeding. This study justlooked at duration of breastfeeding rather than comparing breastfeeding to formula feeding, and so justrefutes that longer duration is beneficial to a shorter breastfeeding time.Burdette et al(40) argue that BMI should not be used as a marker of overweight as it overestimates theeffect of breastfeeding. They argue that other measures of adiposity should be used, e.g. percentage fatmass, as these are more important predictors of poor health outcomes related to obesity than weight alone.This study found that there was no significant difference in the percentage fat mass at three years betweenchildren who had been breastfed and those who were not. When using BMI as an indicator, breastfeedingwas seen to have a protective effect against overweight but this disappeared after taking other factors intoaccount, such as ethnicity, birth weight, income and education.Based on the information available, breastfeeding does have a protective effect against overweight andobesity in childhood but the strength of this association is unclear. Consideration of additional lifestyle andsocial factors is seen to reduce or remove the benefits of breastfeeding on childhood weight. This makes itdifficult to determine the true nature of the relationship. Numerous factors influence overweight and obesitydevelopment. It is likely that breastfeeding does play a role but in conjunction with other lifestylebehaviours. It is possible that each is important at different stages of growth/development withbreastfeeding being an important factor in early life.

33Cost effectiveness of breastfeeding interventionsThere is a significant body of evidence to suggest that breastfeeding has a significant effect on healthoutcomes for both children and mothers. Breast milk has been shown to have a protective effect from anumber of conditions in infants such as acute otitis media(41), gastrointestinal infections(55) andasthma(42) and has also been linked to lowering the incidence of sudden infant death syndrome(43) .There is also evidence to suggest that breastfeeding may have beneficial effects for mothers such asreducing the risk of breast cancer(44). This evidence is consistent with the results regarding breastfeedingin the East Midlands.In order to gain some idea of what the potential cost savings may be in actual terms an estimate has beencalculated based on the cost of hospital admissions for gastroenteritis and respiratory tract infections in2009/10 in the East Midlands and the predicted reduction in hospital admissions which could be achievedby increasing breastfeeding as discussed earlier in this report. This analysis has not been carried out atPCT level due to small numbers and so refers to the East Midlands Region as a whole. The results of thisanalysis are shown below.Table 5GastroenteritisAgeTotal Actual CostPercentage Reduction inAdmissionsPotential savingAll 0-4 £4,438,605.00 21% £932,107.05Under 1 only £3,295,918.00 19% £626,224.42Respiratory Tract InfectionsAgeTotal Actual CostPercentage Reduction inAdmissionsPotential savingAll 0-4 £2,816,773.00 9% £253,509.57Under 1 only £1,179,510.00 10% £117,951.00This shows that across both of these conditions and all children under 5 that approximately £1 million couldbe saved in the East Midlands by increasing breastfeeding rates by 5%. It is important to note that thesecalculations are approximate; however this does show that increasing breastfeeding rates could have asignificant impact on NHS expenditure.The National Institute for Clinical Excellence (NICE) (45) have produced a cost effectiveness model for bothpaid and voluntary peer support interventions to increase breastfeeding initiation and duration. Although the

34model has been applied specifically to peer support interventions it is noted that it could usefully be appliedto other interventions designed to increase breastfeeding initiation and prevalence. The model uses a“what if” approach where by the potential cost savings are calculated based on the relationship betweenbreastfeeding and health outcomes reported in the academic literature. Health outcomes are used wherebreastfeeding has been shown to provide significant benefits. As a result NICE have adopted a threshold of£20,000 to £30,000 per QALY (Quality Adjusted Life Year) gained for breastfeeding interventions to beconsidered cost effective. This measure takes into account both the actual cost savings to the NHS andplaces a value upon the improvement in individual quality of life gained through avoiding illness. This figureis estimated to represent achieving an increase of 15 percentage points in breastfeeding initiation rates.Battersby et.al(46) reviewed the cost effectiveness of a breastfeeding peer support intervention in Sheffield(UK) where women who have successfully breastfed are trained to offer support and encouragement tonew mothers. This intervention resulted in a significant increase in breastfeeding initiation as comparedwith previous rates in the same area from 22% to 49%. An assessment of the cost-effectiveness wasperformed and showed that the potential savings to the NHS by reducing the incidence of admission tohospital, gastroenteritis, respiratory infections and otitis media per year alone were enough to roughly equalthe cost of the intervention. When other potential savings are taken in to account, the authors contend thatthe implementation of peer support initiatives is financially valuable.A review and analysis of the economic benefits of breastfeeding in the USA(47) also discusses the impactof increasing breastfeeding in terms of potential cost savings from reducing the incidence of otitis media,gastroenteritis and necrotizing enterocolitis. The potential cost savings were estimated based on publisheddata and included prevention of premature death, medical costs and indirect costs such as parental loss ofearnings. The review concludes that an estimated saving of $3.6 billion per year could be made ifbreastfeeding was increased from current levels (64% initiation and 29% at 6 months) to the ratesrecommended by the U.S. Surgeon General (75% and 50% respectively).A systematic review by the Cochrane Collaboration(48) looking at support for breastfeeding mothersexamined 34 studies from 14 countries and found that both professional and lay or peer support wereeffective for increasing both breastfeeding initiation rates and duration of exclusive or any breastfeeding.The effect of support on overall breastfeeding was found to be greatest in areas where initial rates ofbreastfeeding were between 40% and 80% and a greater effect was found in increasing exclusivebreastfeeding than any breastfeeding up to five months. Although no assessment was made in this reviewof cost-effectiveness it may be concluded in view of the NICE guidance that interventions which increasebreastfeeding are likely to reduce poor outcomes and therefore reduce costs. This is also true for a second

35review by the Cochrane Collaboration(49) assessing interventions to promote breastfeeding initiation. Thereview included data from eleven studies which all focused on low income women in the USA and reportsthat health education and peer support interventions were successful in increasing breastfeeding initiationin these groups. The authors also conclude that needs-based, informal interventions appeared to be moresuccessful than generic formal antenatal sessions. There were no specific references to cost effectivenessin this review; it did however report that there were statistically significant differences between control andintervention groups.A systematic review of studies examining the effect of antenatal peer support on breastfeeding initiationwas conducted by Ingram et.al in Canada(50). Their findings showed no significant effect of universalantenatal peer support but that support may be advantageous when it is targeted to individuals. Theseresults complement those of the previous study and suggest that targeted peer support may be asuccessful method of increasing breastfeeding prevalence.Further evidence of the effectiveness of targeted breastfeeding peer support comes from an Americanrandomised controlled trial of low-income women by Pugh et.al(51). The intervention group received extrasupport from a community health nurse and peer counselling team. They found that women in theintervention group breastfed for longer and their babies had fewer sick visits than the control group whoreceived usual care.Morrell et al(52) conducted a randomised controlled trial to investigate the effectiveness of providingcommunity postnatal support workers to assist women in the first month after birth, in addition to routinemidwife visits in the UK. Support workers were available to women for up to ten home visits during the trialperiod with each visit lasting up to three hours. The results of the study showed that there was nosignificant difference in health status or breastfeeding rates between women who had access to communitypostnatal support workers and those who only received routine care from community midwives.In another randomised controlled trial Hoddinott et al(53) looked at the effectiveness of providingbreastfeeding support groups for pregnant and breastfeeding women in Scotland. Additional breastfeedingsupport groups were set up in intervention localities and compared with similar localities receiving usualcare. The results showed that there was no significant difference in breastfeeding rates at 6-8 weeksbetween localities and that the cost was similar to providing breastfeeding support in the home.Stevens et al (54) examined the economics of home vs. hospital breastfeeding support for new mothers inCanada. They found that there was no significant difference in direct costs or outcome between groups

36given the same support in different locations, suggesting that home support may be a more beneficialoption in order to reduce other hospital related costs.It is fair to say that the evaluation of the cost-effectiveness of breastfeeding interventions does not providedefinitive conclusions, largely due to a lack of research evidence. However, it is clear that increasingbreastfeeding prevalence will reduce costs for the NHS and achieve better health outcomes. The strongestavailable evidence appears to advocate targeted peer support interventions as a successful way toincrease breastfeeding initiation and prevalence with relatively low costs. It is also important to consider thepotential emotional costs of ill health especially to the families of young infants, a factor which is to someextent addressed by the use of QALYs in calculating cost-effectiveness. However, more research isneeded in to the direct cost-effectiveness of breastfeeding interventions in order that more efficientstrategies for increasing prevalence can be developed and therefore the health and well being of mothersand their babies may be improved.

37ConclusionOur evidence clearly demonstrates that there is a significant and substantial link between breastfeedingand health outcomes in infants and young children in the East Midlands. We have shown that increasingthe levels of breastfeeding in the East Midlands should reduce the number of infant deaths and hospitaladmissions for certain conditions. Thus, an increase in breastfeeding levels should be associated with areduced financial cost for the local health service and improved health outcomes in the local population. Wehave also shown that the levels of breastfeeding vary by age, ethnicity and deprivation status. Thisacknowledges the importance of understanding the make-up of your local population to allow for accurateand appropriate targeting of local services and public health initiatives. This should allow for better supportto be provided to mothers in the East Midlands and a subsequent improvement in breastfeeding levels andinfant health outcomes.

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