Written by Brooke MacKenzie
During my undergraduate education I have been exposed to many clinical experiences including one in a neonatal unit in a tertiary hospital in New Zealand. During my time there I was made aware of the lack of education mother’s had around breast and formula feeding. This increased my interest into this area of nursing where I then researched the literature around this topic. It is known that ‘breast is best’ however there are times when formula is needed due to factors affecting the mother’s ability to breastfeed her infant and the nutritional needs of a particular infant.
After searching the literature into this particular topic, I have discovered the global effort currently being made to achieve an increase in the number of infants being breastfed as opposed to formula fed. Further searching of the literature demonstrated that there were some mothers who were unable to breastfeed for a short period of time, usually for a short period after the child is born. However the majority of children, who were formula fed, were fed this way for the first six months of their life. Having discovered this, I have noticed the increased effort to encourage breastfeeding world-wide but on the other hand I noticed that there is still a high percentage of families using formula as an exclusive form of nutrition for their babies.
To breast or formula feed, is one of the biggest questions expectant parents will have to ask when preparing for their new-born (Adler & DiMaggio, 2015). The World Health Organisation identify breastfeeding as a necessity for the growth and development of infants and recommend mothers breastfeed until their infant is six months of age (World Health Organisation, 2001). Plunket New Zealand’s statistics state that in 2014, 55% of six week old babies, 43% of three month olds and 17% of six month olds were exclusively breastfed without the addition of formula, water or other liquid or solid foods. These statistics show a gradual incline in the use of breast milk since 2008. However these same statistics also show that 14% of infants aged six weeks old, 24% of three month old infants and 34% of six month old infants were fed exclusively artificial feeds in the past 48 hours without any breast milk. These results have also shown a gradual increase in the number of infants being breastfed but are also evident of a large amount of children being formula fed (2014).
Increasing the statistics for babies being breastfed is currently a global goal, in 2002 the World Health Organisation (WHO) released the ‘Global strategy on infant and young child feeding’ (World Health Organisation, 2003). This process has been developing since 1998, when the Executive Board identified the need for global commitment in regards to the appropriate infant and young child’s nutrition, with a focus applied to breastfeeding. In collaboration with UNICEF and the WHO, a strategy was released in 2002. The strategy aimed to use optimal feeding and to improve the nutrition status, growth, development and general health of infants and children and from here three main objectives were developed:
1. To raise awareness of the main problems affecting infant and young child feeding, identify approaches to their solution, and provide a framework of essential interventions;
2. To increase the commitment of governments, international organizations and other concerned parties for optimal feeding practices for infants and young children;
3. To create an environment that will enable mothers, families and other caregivers in all circumstances to make - and implement - informed choices about optimal feeding practices for infants and young children (World Health Organisation, 2003).
In New Zealand, the Public Health Organisation states the breast feeding rates have remained static for a few years. They also assert that there has been a decline in the rates of breast feeding from the time the infant is discharged from the maternity ward to six months of age. They also publicise that population groups with higher needs than others, such as Maori, have lower duration rates to the general population (Public Health Association of New Zealand, 2002). New Zealand Health Strategies such as improving nutrition; reducing obesity; reducing the incidence and impact of cancer; reducing the incidence and impact of cardiovascular disease; reducing the impact and incidence of diabetes; and improving oral health can all be contributed to by increasing the rates of breast feeding, there for the health of New Zealand’s can be greatly improved by the initial nutritional decisions made by parents (Public Health Organisation, 2002).
The American Pregnancy Association identify that there are advantages and disadvantages to both breast feeding and formula feeding. Breast milk is free, it has no cost towards the family, it is always the perfect temperature, no preparation is required and milk is available anywhere and anytime (with consideration to some mothers with supply issues). This compared to formula which has one main benefit, allowing anyone to feed the baby, while breast feeding requires the mother to be readily available to feed or to have expressed milk. Additionally breast fed babies can experience certain medications – affecting the supply and amount of nutrients the baby is obtaining. Formula has disadvantages associated with preparation such as warming the formula and carrying equipment for preparation. Babies can also have difficulty tolerating formula and do not gain as much nutrients depending on the type of formula and the degree of preparation (American Pregnancy Association, 2015).
The issue is raised that although it is fully recommended by the Ministry of Health in accordance with the World Health Organisation, there are babies and infants still being formula fed. So, what is the impact developmentally on these children that are not fed with breast milk? What are the reasons for them being formula fed as opposed to being fed breast milk? Do these mothers wish they were able to breast feed or was formula feeding a choice for them? Evidence proves there are 14% of six week old babies nationwide who are exclusively formula fed and a higher rate as age increases. This identifies the search problem and the aim of the literature review is to explore the developmental benefits of those babies and infants that are breastfed and those that are not.
Through inclusion and exclusion the search question was made more specific. I chose to include the time frame of six months of age as this is the World Health Organisations recommended time frame of breastfeeding. It was also appropriate to include a comparison so I am able to compare the benefits of breast and formula feeding. This literature review excludes any non-peer-reviewed articles and include ones that have been peer reviewed.
Through using the PECOT model a definite, refined question was produced, ‘In babies and infants that have been breastfed by their mothers, what are the developmental benefits compared to those babies and infants that have been formula fed with formula?’(Whitehead, 2013).
This review contains a variety of literature; allowing me to gather a broad range of evidence and information to relate to each part of the review question. As stated in the critical issue section, climate change is one of the 21 centuries’ largest health threats (Costello et al., 2009). The adverse health effects of climate change will effect populations in many ways. The most prominent and severe effects climate change will have on the worlds health are; patterns of disease and mortality, food/water availability and sanitation, shelter and human settlements, extreme weather events, and population and migration (Allen, 2015). In 2030 and 2050 it is estimated that climate change is expected to cause up to 250,000 additional deaths per year due to these health implications. (World Health Organization, 2016) with rising temperatures, the rate of disease and mortality will increase.
A study completed by Shepard, Power and Carter (2008) continues to acknowledge the fact that breastfeeding has been proven to reduce the risk of mortality in infants, reduce the morbidity of infections, enhance the immune system of infants and reduce the chance of infant atopic diseases. Their study also identified the differences in breast and formula feeding. Mothers who breastfed were shown to be more likely to be married, own their own home, smoked less, had decided on the feeding method of their infant before conception, were from a higher social class and had a longer duration of higher education (Shepard et al., 2008). The point identified in this study around the developmental benefits being higher in breast milk than formula is supported by another study. Zhang, Himes, Guo, Jiang, Lu, Ruan and Shi (2013) focussed a study around birth weight, growth and feeding patterns in infancy and the obesity status at two years of age. Their study identified 13% of infants were formula feed in their first month and 87% were formula fed at two years of age (954/1098 infants). With additional results of the infants BMI, the study showed 16.08% of boys and 15.74% of girls were normal weight, 17.76% of boys and 17.48% of girls were overweight and 19.07% of boys and 19.01% of girls were obese, at two years of age (Zhang et al., 2013). The results of the studies reflect each other in regards to the increase in the use of formula and the increase in obesity.
In contrast to this, a study comparing breast versus formula in low birth weight babies, identified formula feeding as more efficient over breast. In regards to the infant’s current health and development at the time of feeding, breast and formula feeding have proven to have different advantages and disadvantages. Infants who are breastfed take longer to feed but do have better respiratory function resulting in less hypoxic episodes (Furman & Minich, 2004). They also identified that those infants that were formula fed had more sucking bursts, a more complete seal on the nipple, less sucking bursts and spend more time burping than infants breast fed (Furman & Minich, 2004).
There are also situations where the mother must result to formula feeding either due to her own health or the health of the infant; they may require an increase in nutrients specifically available in formula feeding. A study aimed at understanding the effect on formula and cup feeding on breast feeding, argues that formula feeding is mainly used to provide supplements to infants that are breastfeed. This is most commonly seen in infants who have a low weight for their gestation (Howard, Howard, Lanphear, Eberly, deBlieck, Oakes & Lawrence, 2003). However this study was established in the United States of America and according to the World Health Organisation statistics in the year 2003, only 71.4% of infants had ever been breastfeed (World Health Organisation, 2010).
Although the National Library of Medicine (2015) states that breast milk is an excellent form of nutrition that provides the baby with natural nutrients, antibodies and the decreased likely hood of hospitalisation due to respiratory infections, it also reduces chances of obesity which is an increasing health issue for New Zealand children (Michels, Willet, Graubard, Vaidya, Cantwell, Sansbury, & Forman, 2007). This is because infants who are breast fed, gain weight at a slower rate over their first year than those who were formula fed; this may be due to the increased amount of protein in formula as well as the limitations of natural energy supply from breast milk (Michels et al, 2007). The World Health Organisation’s 10 Steps to Successful Breast Feeding Policy has a clear theme of ensuring mother and her baby are able to spend a large amount of time together(Perinat, 2007). Breast feeding is a natural way for mother to create a bond with her baby and often when babies are born in hospital setting and require special attention after birth; they can be taken away from their mother for long periods of time. This can affect breastfeeding as well as the relationship, also known as ‘bonding’ between mother and child (World Health Organisation, 1998). Initiating breast feeding as early on as possible in the relationship allows the bond to be made between mother and child (Perinat, 2007). The implications of not breastfeeding can affect the mother as well, for them, not breast feeding has been associated with an increased incidence of both ovarian and breast cancer as well as Type 2 diabetes, myocardial infarction and weight gain (Stuebe, 2009).
From the literature search completed, it is recommended that in order for women to be willing to continue breastfeeding they have to have the confidence knowing they are doing it correctly.
With all the above studies identifying and backing up the importance of the use of breast milk, the following study strengthens the importance of an increase in education provided for undergraduate students. Jones (2004) calls for added training as part of undergraduate midwifery courses in order to achieve the World Health Organisations goal of reducing formula feeding and increasing breast feeding in infants. An increase in skills around supporting breastfeeding mothers as part of the core course curriculum not only for midwives but also for undergraduate nurses will ensure that adequate and strengthened knowledge and skills will be passed on to the mothers. Jones (2004) also states that 85% of mothers in high occupations start out breastfeeding, compared to only 59% of those mothers in a lower occupation. With this knowledge, it is evident that an there needs to be an increase in the availability of breast feeding classes and support from public health professionals for the lower socio-economic groups. Therefore by making classes and advice available from health professionals subsidised or provided through government funding, this will make them more accessible to those requiring it most.
Another recommendation to increase the amount of mothers breast feeding is to increase the amount of breastfeeding friendly spaces for mothers to feed their babies, for example shopping malls and employment areas. Breastfeeding Ultimate Refuel Place (BURP) was an app released last year (2015) providing mothers with a map of breast feeding friendly venues throughout Otago and Southland. An increase in both venues and apps of this form will allow mothers to feel more comfortable breastfeeding, especially if their daily routine involves a lot of time in public or away from home and work. Increasing mother’s confidence in breastfeeding is the key to increasing breast feeding as a whole (Breastfeeding Ultimate Refuel Place, 2015).
Developing an increase in the amount of education both for health professionals and families, increasing the programmes available to educate and support breastfeeding mothers as well increasing breastfeeding friendly environments throughout New Zealand and also globally, all align with the five principles of the Ottawa charter (Patterson, 2007).
‘Build healthy public policy’ can be focussed on through the increase in the use of community programmes such as BURP as well as providing funded support for lower socio-economic families who may feel excluded from other programmes due to their financial position.
‘Create supportive environments’ will be achieved through the use of an increase in breast feeding classes, this will allow mothers to bond with other mothers and gain knowledge through them. Creating spaces where mothers feel comfortable and are encouraged to breastfeed through a supportive environment will allow them to increase their confidence and their ability to breastfeed.
‘Strengthen community action’ will be made possible through encouraging communities to become breastfeeding friendly. As well as this is would mean breast feeding courses, programmes and apps around breastfeeding friendly areas will be readily available, easily accessible and easy to sign up for.
‘Develop personal skills’, according to Patterson (2007), has a focus on enabling individuals (mothers) to gain control of their health through making informed choices through education from a health professional. This is a key to increasing breastfeeding and can be achieved through the increased in training both nurses and midwives and the mothers themselves.
‘Reorient health services’ is aimed around the recommendation of increasing the training for breastfeeding in undergraduate midwives and nurses.
The Public Health Association of New Zealand (2002) has proven there are a significant number of babies and infants still feeding from formula feeds rather than breast milk. They have also proven that a large percentage of the mothers who do formula feed, are a part of a lower socio-economic group. Increasing the amount of free support then makes the education and support readily available, accessible, affordable, appropriate and accountable for those mothers. The education provided to the mothers by health professionals may also be the first she receives, there for it should be highly educated information and increasing the education provided to undergraduate nurses and midwives can assist in this education being provided to an adequate standard (Public Health Association of New Zealand, 2002).
Ultimately the literature discussed in the literature review has shown that increasing breastfeeding is a global effort; there are still infants who are fed formula which can be due to various reasons, usually due to the socio-economic placing of the family or choice. Literature has also shown that breast milk has increased benefits compared to formula, not just associated with the nutrients and benefits of what is in the breast milk but also developmentally due to it decreasing the infant’s chances of particular diseases as well as obesity. In order to meet the World Health Organisation’s goal of decreasing the rates of infants being formula fed, community actions must take place to provide these mothers with the education, confidence and support to breastfeed their child.
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Furman, L., & Minich, N. (2004). Efficiency of breastfeeding as compared to bottle-feeding in very low birth weight (<1.5kg) infants. Journal of Periontology, 24, 706-713
Howard, C., Howard, F., Lanphear, B., Eberly, S., DeBlieck, E., Oakes, D., & Lawrence, R. (2003). Randomised clinical trial of pacifier use and bottle-feeding or cup feeding and their effect on breastfeeding. Journal of Pediatrics, 11, 511-518
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