BREAST-FEEDING : CURRENT KNOWLEDGE , ATTITUDES AND PRACTICES OF PAEDIATRICIANS AND OBSTETRICIANS

O bjective-To assess the current knowledge, attitudes and practices of Paediatricians and Obstetricians in the greater Johannesburg area, using WHO/UNICEF 10 Steps to Successful Breastfeeding as a guideline.

During 1989, WHO and UNICEF published a jo in t sta te m e n t, e n title d " P ro te c tin g , Promoting and Supporting Breastfeeding: The special role of maternity services" in which the "Ten Steps to Successfol Breastfeeding" were introduced.The benefits of breast-feeding in the third world are undisputed.Cunningham et al (1991) refer to the many advantages of breast-feeding at all socioeconomic levels.Benefits tend to increase with increased d u ra tio n and in c re ase d ex c lu siv ity of breast-feeding.Research has shown that breastfed infants have a lower incidence of acute diarrhoeal disease (Morrow et al 1992, Blake et al 1993) urinary tract infections (Pisacane et al 1992) otitis media lower respiratory tract infections, meningitis and bacteraemia (Cunningham 1991) as well as a d e c re a s e d in c id e n c e an d se v e rity o f necrotising enterocolitis in pre-term infants.(Caplan & MacKendrick 1993).
Long term health benefits for breastfed infants include a lower incidence of insulin dependant diabetes mellitus (Metcalf & Baum 1992, Drash et al 1994) and other auto-immune diseases including C rohns disease and ulcerative colitis (Rigas et al 1993).The in c id en c e o f ch ild h o o d ly m phom as is decreased (Schwartzbaum 1991) and certain forms of chronic liver disease have been prevented or modified by breast-feeding (Curringham et al 1991).Recent research by Wong et al (1993) indicates that breast-fed infants have a lower rate of endogenous cholesterol production as a result of the higher cholesterol levels found in breastmilk.
The second follow -up report of the US surgeon general's workshop on breast-feeding and human lactation (U.S. Dept, of Health) cites inadequate professional education as an important barrier to initiation and continuation of breast-feeding.
T h e stu d y sh o w s la c k o f s u p p o rt or encouragement from physicians, nurses, and o th e r h o s p ita l s ta f f , in a c c u ra te or in a p p ro p ria te ad vice from h ealth care personnel, and lack o f access to health professionals adequately trained in lactation management, as important factors in failure to achieve successful lactation (Spisak & Gross 1991).

O B JE C T IV E :
The objective of the study was to determine the current knowledge, attitudes and practices o f paediatricians and obstetricians in the greater Johaimesburg area.South Africa, by means of a survey.

M E T H O D S :
Postal q u estio n n aires were sent to 259 paediatricians and obstetricians.The list of participants was generated from the South African Medical and Dental Council register (1992).All registered paediatricians and o b ste trician s p ractisin g in the g reater Johannesburg area were included in the study.This includes doctors working in academic hospitals as well as those in private practice.

R E SU LT S:
O f the 259 doctors surveyed, 188 (73%) responded, 112 initially and a further 76 on follow up.Twenty (7%) of the respondents refused to participate or were self-excluded on the basis that their current work does not involve breastfeeding (Table 1).
The questionnaire related to some of the 'T en Steps to Successful Breastfeeding" as set out below; Step 3: Inform all pregnant women about the benefits and m anagem ent of breastfeeding.
The majority of obstetricians(O) (90%) and paediatricians(P) (89%) believe that most pregnant women attending their service are informed about the benefits of breastfeeding.About two thirds of the obstetricians (68%) and half the paediatricians (50%) routinely advise pregnant women to attend childbirth education classes.There are many doctors who provide incorrect advice concerning breastfeeding management (Table 2).
Step 4: Help m others initiate breastfeeding within half an hour of birth.
About half of the obstetricians (44%) and paediatricians (50%) advise mothers who have had a vaginal delivery to breastfeed their babies within half an hour of the birth.
Slightly more, (O -60%, and P -55%) advise mothers who have caesarean sections to breastfeed within four hours of the birth.
Step 6: Give new born infants no w ater o r milk feeds other than breastm ilk, unless indicated for a medical reason.
Thirty five percent of obstetricians and 15% of paediatricians advise water or dextrose feeds.Fifty eight percent of obstetricians and 90% of paediatricians feel that colostrum alone can satisfy adequately the baby's nutritional needs.One third of obstetricians (37%) feel that it is routinely necessary to su p p lem ent b rea stfeed in g infants with formula feeds during the first few days after birth.Only a few paediatricians (4%) share this view.Similar percentages of obstetricians and paediatricians (O 12%, P 12%) feel that routine heel-prick blood glucose estimations Step 8: E ncourage n atu ral breastfeeding frequently and on dem and.A p p ro x im a te ly tw o th ird s o f d o cto rs encourage frequent breastfeeding as needed.Less than half (O-39%; and P-48%) feel that mothers should limit the duration of feeds.
F ew er obstetrician s than paediatricians recommend exclusive breastfeeding for at least four months (O-66% ; P-88%) and advise the continuation of breastfeeding for at least nine months (O 71% ; P-84%).Twenty percent of obstetricians routinely advise the introduction of solids before three months.
Most doctors (O -62%; P -70%) believe that the infant should have regained birthweight before two weeks of age, and would start w o rry in g w ith in th is tim e p erio d .An alarmingly high percentage of doctors would then start supplementing with breastmilk substitutes (O -78%, P -63%) or would recommend test-weighing (O -79%, P -80%).Some encourage the mothers to breastfeed m ore o ften (O -57% , P -67% ) or to supplement with solids (O -5%, P -2%).
Step 9: Do not give, or encourage, the use of artificial teats o r dum m ies to breastfed infants.Do not encourage the use of nipple shields either.
Very few doctors advise mothers against the u se o f p a c if ie r s ( o b s te tr ic ia n s 29% ;paediatricians 20%) or the use of bottles (obstetricians 29% ; paediatricians 51%).
Step 10: Prom ote the establishm ent of breastfeeding su p p o rt groups and refer m others to these on discharge from the hospital or clinic.
The most common reason given by mothers presenting with breastfeeding problems is insufficient milk production (O -66%, P -50%).Obstetricians prefer to send women with lactation problems to paediatricians, while a number of paediatricians refer to lactation consultants (Table 4).Sim ilar percentages of doctors (obstetricians 74% ; paediatricians 72%) would like to work in association with a specialized lactation consultant.
The following steps were not directly assessed in the questionnaire: Step 1: Have a w ritten breastfeeding policy th at is routinely communicated to all health care staff.
Step 2: T rain all health care staff in skills necessary to implement this policy.Step 5: Show m others how to breastfeed, and how to m aintain lactation even if they should be separated from their infants.
Step 7: Allow m others and infants to rem ain together 24 hours a day from birth.

D ISC U SSIO N :
M any w om en w ant to b rea st-fe ed , but experience problems.A common reason given for discontinuation of breast-feeding is "insufficient or inadequate" milk supply.This could be due to a lack of confidence by the mother in her ability to produce enough milk rath er than a ph y sio lo g ical deficiency.
E ncouragem ent, support and consistent advice from the medical profession may ultimately improve the breast-feeding success rate.
Few studies have investigated the role of doctors, as part of the overall healthcare team, in breast-fe«ding management.There is often u n d e rly in g c o n flic t b e tw e e n d o c to rs, midwives and lactation consultants.This may r e s u lt fro m c a re g iv e rs n o t u p d a tin g themselves adequately with current research and progress on breastfeeding.Incorrect attimdes towards holistic health care and team w ork m ay ex acerb ate the problem and disagreem ent among health professionals about roles in management of breast-feeding also has been identified by some researchers (Lowe 1990).
T he m ajority o f w om en who decide to breast-feed make their decision very early in pregnancy or even before conception (Sarett et al 1983).Few studies have investigated how the medical profession and specifically paediatricians and/or obstetricians are able to influence this decision and more information from trials assessing health professionals who follow the recommended guidehnes is needed.
This study has shown that many doctors provide antenatal management guidelines that perpetuate breast-feeding myths.A woman who wishes to breast-feed her baby need not prepare her breasts/nipples in any way and the use of all ointments, alcohols, abrasives and u-v light is unnecessary.
A randomised controlled trial of breast shells and Hoffman's exercises reported that "there was no good evidence that recommending breast shells conveys any benefit in terms of a n a to m ic a l c h a n g e o r s u c c e ssfu l breast-feeding.Women allocated shells were significantly less likely to be breast-feeding six weeks post-natally."(Alexander et al 1992) Correct positioning of the baby at the breast and frequent feeding on demand are important for the prevention of nipple problems (Freed & Landers 1991), and a successful first feed augurs well for successful short and long term breast-feeding.
Breast-feeding is a learned skill requiring specific techniques in order to succeed and it is important for mothers to receive consistent advice during all phases of this learning period.In circumstances in which the mother and baby have to be separated, they require additional help and support.A new mother with an infant who is ill or compromised in any way, may be influenced by her attending doctors and a doctor's own attitudes and practices may influence the mother and baby, as well as the health-care team in the ultimate c h o ic e o f in fa n t fe e d in g u n d er th ese circumstances.
Evidence from randomised trials, although inconclusive (Steer et al 1992) 1993).However, a recent study by Van De Perre et al (1993) suggests that HIV-1 IgM in breastm ilk could be pro tectiv e against postnatal transmission of the vims.
Significant numbers of medical personnel co n tin u e to ad v ise m others to give a p r e -la c te a l w ate r o r d e x tro s e feed .Supplementary and complementary feeds of either water, glucose/dextrose or formula have not been shown to be of any benefit to healthy, term breast-fed infants.
Observations show that supplementary fluids ultimately may reduce the length of time for which a mother breast-feeds her baby, either by underm ining her co nfidence, or by impairing her ability to establish effective lactation (Gray-Donald 1985).Colostmm is unique in composition and supplies the infant with all caloric requirements in the first few days of life, provided that the baby has unrestricted access to the breast (Salariya et al 1978).
When a mother experiences breast-feeding problem s there are many d octors who incorrectly advise supplementary formula feeds, and then resort to test weighing to try to solve the problem on a more scientific basis.
In the present survey, 80% of doctors felt that they would use test weighing as a means of intervention if the infant was not gaining weight adequately.Test weighing may be harmful to a mother's confidence in her ability to breast-feed (de Chateau 1977) and the m easurem en t o f one feed may not be representative of feeds taken throughout the day.
O ne sh o u ld alw ays check and co rrec t breast-feeding position and latching to ensure that the baby is able to feed well.It is important for doctors to persist and remain patient, encouraging and supportive during a difficult stage of breast-feeding rather than suggesting the abandonment of breast-feeding in favour of artificial feeds.Samples of breastmilk substitutes are provided to many patients despite notification from the Department of H edth to stop all free samples.Bergevin et al (1983) suggest that the use o f an infant formula sample shortens the duration of breast-feeding and hastens the age at which solids are introduced.Giving a breast-feeding mother a sample of formula milk is an active step in discouraging her from breast-feeding, e sp e c ia lly if she is e x p e rie n c in g any difficulties.
Normal, full term neonates should be fed on demand from birth with no recommended schedule during both day and night.Feeding the baby at frequent intervals will minimize or prevent breast engorgement (Inch & Renfrew 1989).For many years there has been a widespread behef that it is necessary to limit sucking time, particularly in the early stages, in order to prevent sore or cracked nipples but studies have shown that nipple soreness is not affected by the duration of a feed (Slaven & Harvey 1981).The composition and rate of flow of milk from the breast changes as the feed progresses (Hytten 1954).At the start of the feed the baby takes a large volume of low calorie foremilk, changing to a small volume of high calorie hindmilk at the end of the feed.
Limiting the baby's time at the breast thus may lead to a simation in which the infant fails to gain weight despite frequent feeds and an apparently good supply of milk.Research suggests that infants who are allowed to regulate the frequency and duration of their feeds gain weight more quickly and remain breast-fed for longer (de Carvallho et al 1982).B reast-feeding sup p o rt groups play an important role in providing encouragement and advice to a mother with a newborn baby who may not have traditional family support systems and many of the doctors surveyed p a r tic ip a te in a r e fe rra l n e tw o rk .
Breast-feeding support groups play a vital role in offering updated information and ongoing referral service to all health care professionals working in the field of maternal and child health.

CO N C L U SIO N :
Results from this study indicate that current W HO/UNICEF guidelines are not being followed adequately at present.Paediatricians and obstetricians advocate breastfeeding, but are not "baby friendly" enough.

R E C O M M E N D A T IO N S
This research shows that there is a need for ongoing education of health professionals to update their knowledge about breast-feeding.
TTiere is a need, too ensure that undergraduate and p o stg rad u ate m edical and nursing teaching is in keeping with current knowledge about breastfeeding.There is evidence that intervention programmes can result in positive changes in breast-feeding behaviour (Newton 1992).
As a global goal for optimal maternal and child health and nutrition, all women should be enabled to practice exclusive breast-feeding and all infants should be fed exclusively on breastmilk from birth to 4 -6 months of age.
Thereafter, children should continue to be breast-fed, while receiving appropriate and adequate complementary foods Gnnocenti Declaration 1989).
Medical professionals who care for women d u rin g p re g n a n c y , c h ild b irth and the post-natal period have a crucial role to play in enabling mothers to initiate successfully and maintain breast-feeding.In o rd er to conform to W H O /U N ICEF guidelines, the results of this survey show that doctors should attempt to: • r e je c t th e m y th s su rro u n d in g breast-feeding practice.
• reject the premise that hygienic bottle feeding is just as good as breast-feeding.
• not impose restrictions on the duration or frequency o f feeds.
• not encourage the use of bottles or pacifiers in breast-fed infants • terminate the practice of giving free milk powder samples to mothers • actively encourage women to breast-feed their babies.
• know how to help a mother to position her baby correctly at the breast.
• be able to id e n tify and tre a t early breast-feeding problems.
• provide continuity and personal support b a s e d on sou n d k n o w le d g e o f breast-feeding.
• form pan of a larger network incorporating breast-feeding support groups, clinics and any person/organisation involved with the promotion and support of breast-feeding.
• continually update their knowledge about benefits of breast-feeding and advances in breast-feeding management and practices.
Doctors, as part of the healthcare team, can have a significant impact on a m other's decision to breast-feed and on the successful initiation and maintenance of breast-feeding.
The questionnaires were self-administered and returned by post.The questionnaire consisted o f 24 questions and required approximately 15 minutes to complete.The questions covered various aspects of b re a s tfe e d in g m a n a g e m e n t in c lu d in g assessment of knowledge, practical skills, d e c is io n m a k in g and a ttitu d e s .N o n -re sp o n d e rs w ere fo llo w ed up by telephone and questionnaires were sent out again where relevant.A postal reminder was sent to non-responders.All data were analysed using Statgraphics 5.0.

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g re a te r com m itm en t on th e p art of paed iatricians and o b stetrician s to use re c o m m e n d e d g u id e lin e s to p ro m o te breastfeeding could accelerate the current tre n d b ac k to b r e a s tf e e d in g at all socio-cconomic levels.

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E F E R E N C E S Alexander JM , A drian M G, Campbell M J. (1992): Randomised controlled trial of breast shells and Hoffman's excercises for inverted and non-protractile nipples.BMJ 1992;2:125-27.Bergevin Y, D ougherty C, K ram er MS (1983).Do infant formula samples shorten the duration of breastfeeding?Lancet 1148.Blake P, Ramos S, M acdonald KL, Rassi V, Tardelli Gomes TA, Ivey C et al (1993): P a th o g e n sp e c ific risk fac to rs and protective factors for acute diarrheal disease in urban Brazilian infants.J Infec Dis 167:627-32.C a p la n M , M a cK en d ric k W . (1993): N ecrotising enterocolitis: a review of pathogenetic mechanisms and implications for prevention.Pediatr Pathol, 13:357-69.