Mastitis and Mammary Abscess Management Audit (MAMMA) in the UK and Ireland.

BACKGROUND: The aim of this multicentre prospective audit was to describe the current practice in the management of mastitis and breast abscesses in the UK and Ireland, with a specific focus on rates of surgical intervention. METHODS: This audit was conducted in two phases from August 2020 to August 2021; a phase 1 practice survey and a phase 2 prospective audit. Primary outcome measurements for phase 2 included patient management pathway characteristics and treatment type (medical/radiological/surgical). RESULTS: A total of 69 hospitals participated in phase 2 (1312 patients). The key findings were a high overall rate of incision and drainage (21.0 per cent) and a lower than anticipated proportion of ultrasound-guided aspiration of breast abscesses (61.0 per cent). Significant variations were observed regarding the rate of incision and drainage (range 0-100 per cent; P < 0.001) and the rate of needle aspiration (range 12.5-100 per cent; P < 0.001) between individual units. Overall, 22.5 per cent of patients were admitted for inpatient treatment, out of whom which 72.9 per cent were commenced on intravenous antibiotics. The odds of undergoing incision and drainage for a breast abscess or being admitted for inpatient treatment were significantly higher if patients presented at the weekend compared with a weekday (P ≤ 0.023). Breast specialists reviewed 40.9 per cent of all patients directly, despite the majority of patients (74.2 per cent) presenting within working hours on weekdays. CONCLUSIONS: Variation in practice exists in the management of mastitis and breast abscesses, with high rates of incision and drainage in certain regions of the UK. There is an urgent need for a national best-practice toolbox to minimize practice variation and standardize patient care.

Mastitis and breast abscess is a painful infection of the breast. It is an extremely common breast problem. One in three women can get this condition at some stage in their life. To treat a breast abscess, the pus inside should be drained out of the body. This can be done either by cutting into the breast using surgery or by inserting a fine needle using an ultrasonography scan (which uses ultrasound). Fine-needle drainage has the benefit that it does not require admission to hospital. Surgery can cause the breast to look misshapen. It is unknown which method is used more often in the UK and Ireland. The aim of this study was to describe how mastitis and breast abscesses are treated in the UK and Ireland. This study involved a survey of practice (phase 1) and collection of data, which are routinely recorded for these patients (phase 2). This study involved 69 hospitals and 1312 patient records. One in five women had an operation for a breast abscess. This was higher than expected. Six in 10 women had a pus drainage using a fine needle. The chance of having an operation depended on the hospital. Women that came to hospital at the weekend were almost twice as likely to have an operation. One in five women were admitted to hospital. The chances of that more than doubled if a woman came to hospital at the weekend. There are differences in treatment of mastitis and breast abscesses across the UK and Ireland. Changes need to be put in place to make access to treatment more equal.

Barriers to optimal breastfeeding of medically complex children in the UK paediatric setting: a mixed methods survey of healthcare professionals.

BACKGROUND: Breastfeeding is indisputably significant for infants and children, as well as their mothers. However, when breastfed children are admitted to the paediatric ward, they may experience breastfeeding modification due to clinical challenges, lack of staff training and institutional barriers. Although previous research has identified multiple barriers to optimal feeding within the maternity, neonatal and community settings, we know less about the barriers that exist in paediatrics. Paediatric healthcare staff attitudes, training and awareness as well as ward culture are likely to have an impact on the experiences of families but are relatively unresearched in the paediatric setting, especially with regard to the multidisciplinary nature of clinical paediatric care. The aim of this study was to explore the attitudes, awareness and perceived barriers to effective breastfeeding support provision, as well as healthcare professional perception of barriers for families. METHODS: This was a mixed methods study utilising a questionnaire which was completed by 409 healthcare professionals who identified as working within the paediatric setting. It included responses from paediatricians of all training grades, nurses, healthcare assistants and allied health professionals. Qualitative data from professionals were analysed to develop themes around professional and perceived parent barriers to optimal breastfeeding. RESULTS: This study explored the barriers experienced by staff, as well as professionals' perception of parent barriers. These included lack of knowledge of how to help, a default formula culture, the pressure of maintaining strict fluid balance and breastfeeding being a low priority in the face of critical illness. Of the paediatric departments represented by this sample of healthcare professionals, most had a relatively poor culture of supporting breastfeeding, with multiple institutional barriers identified. Most professionals felt that there was not enough support for breastfeeding families on an average shift, and a large proportion identified as being one of just a few breastfeeding advocates on their ward. CONCLUSION: In this relatively motivated and experienced sample of healthcare professionals, there were many identified barriers to optimal breastfeeding which could potentially be addressed by training that is carefully nuanced for the paediatric population. Ensuring that paediatric multidisciplinary healthcare professionals have sufficient skills and knowledge would address the identified challenge of poor awareness of breastfeeding and of how to overcome clinical lactation obstacles. Further improvements at policy level need to address the systemic lack of resourcing in paediatrics, as well as the lack of embedded breastfeeding-friendly organisational structures.

The lactation skill gaps of multidisciplinary paediatric healthcare professionals in the United Kingdom.

BACKGROUND: Breastfeeding is an important public health priority and may be particularly beneficial for medically complex infants and children. However, childhood illness and disability are associated with increased challenges and lower breastfeeding rates. The Baby Friendly Initiative has been shown to increase initiation of breastfeeding and improve health professional skills although as yet the standards have not been adopted in paediatrics. Previous studies have found breastfeeding knowledge gaps among paediatric nurses, and a recent systematic review highlighted insufficient lactation support, discouragement by healthcare professionals and lack of resources. The aim of this survey of UK paediatric professionals was to establish their self-defined confidence and skills supporting breastfeeding. METHODS: An online survey was developed to explore associations between level of training and staff confidence and perceived skill, to establish whether there is evidence that more training and/or higher breastfeeding training credentials improve skill. In total, 409 professionals, including paediatric doctors at all grades, paediatric nurses and allied health professionals, were included in the analysis. RESULTS: This study identified specific skill gaps among professionals. Many healthcare professionals felt that different skills and specific training are required to support medically complex children. Several professionals noted that existing breastfeeding training focuses on establishing breastfeeding in healthy newborns rather than sick children in paediatrics. Participants were asked about 13 clinical competencies, and an aggregate skill score was calculated. Multiple univariate analysis of variance found that more extensive training and higher credentials are correlated with higher skill scores (p ≤ 0.001), whereas type of professional was not. CONCLUSIONS: Despite this being a relatively motivated sample of healthcare professionals, the findings of this study suggest that breastfeeding skills are patchy and inconsistent, and particularly lacking when it comes to more complex clinical scenarios. This is significant, because it may mean that children who have more significant illness or medical complexity are disproportionately affected by gaps in knowledge and skill. Medically complex children encounter many barriers to optimal feeding - including absence of designated paediatric lactation staff, resources and support - and may have challenges such as low tone, higher calorie need and transitioning to the breast after ventilation or enteral feeding. Current skill gaps indicate that existing training would be insufficient, and bespoke paediatric breastfeeding training based on identified clinical challenges is thus justified.

Breastfeeding sick children in hospital: Exploring the experiences of mothers in UK paediatric wards.

There is a paucity of literature exploring the challenges of breastfeeding sick children in hospital. Previous research has focused on single conditions and hospitals which limits understanding of the challenges in this population. Although evidence suggests that current lactation training in paediatrics is often inadequate, it is unclear where the specific training gaps are. This qualitative interview study of UK mothers aimed to explore the challenges of breastfeeding sick infants and children on a paediatric ward or paediatric intensive care unit. From 504 eligible respondents, a sample of 30 mothers of children aged 2-36 months with various conditions and demographic backgrounds was purposively chosen, and a reflexive thematic analysis undertaken. The study identified previously unreported impacts such as complex fluid needs, iatrogenic withdrawal, neurological irritability and changes to breastfeeding behaviour. Mothers described breastfeeding as emotionally and immunologically meaningful. There were many complex psychological challenges such as guilt, disempowerment, and trauma. Wider struggles such as staff resistance to bedsharing, inaccurate breastfeeding information, lack of food and inadequate breast pump provision made breastfeeding more challenging. There are numerous challenges related to breastfeeding and responsively parenting sick children in paediatrics, and these also impacted maternal mental health. Staff skill and knowledge gaps were widespread, and the clinical environment was not always conducive to supporting breastfeeding. This study highlights strengths in clinical care and provides insight into what measures are perceived as supportive by mothers. It also highlights areas for improvement, which may inform more nuanced paediatric breastfeeding standards and training.

The challenges of medically complex breastfed children and their families: A systematic review.

Exclusive breastfeeding for the first 6 months and then alongside solid food for the first 2 years and beyond is the gold standard in young child nutrition. There is an abundance of literature relating to the preventative nature of breastmilk and breastfeeding against many infectious diseases and chronic conditions. However, despite medically complex infants and children being a group that could benefit most from continued breastfeeding, breastfeeding duration and exclusivity are lower among more complex paediatric populations. The reasons for this are not well known, and there is a paucity of data relating to supporting infants who have acute or chronic illness, disability or congenital anomaly to breastfeed. This systematic review aimed to understand the challenges of breast/chestfeeding the medically complex child and to establish the gaps in healthcare provision that act as barriers to optimal infant and young child feeding. The search was limited to studies published in English, focused on breastfed sick infants in hospital, with no date limits as there is no previous systematic review. Of 786 papers retrieved, 11 studies were included for review, and seven themes identified. Themes included practical and psychological challenges of continuing to breastfeed in a hospital setting, complications of the condition making breastfeeding difficult, lack of specialist breastfeeding support from hospital staff and a lack of availability of specialist equipment to support complex breastfeeding. The findings affirm the lack of consistent high-quality care for lactation support in paediatric settings and reinforce the need for further focused research in this area.

Support for families after prolonged admission to a neonatal intensive care unit.

Many parents whose baby has been a patient on the neonatal unit experience a range of complex emotional and practical problems following discharge home. Health visiting teams play a significant role in helping these families rehabilitate in the community. After discharge from the neonatal unit, parents frequently need support in a number of specific areas that health visiting teams are well placed to provide. Families may need additional support with feeding, child development and accessing local services, as well as knowing where to meet other parents with babies. Health visiting teams are a key component in mitigating some of the potential negative outcomes for families with babies who have experienced illness or premature birth.

Using art to raise awareness of breastfed children with medical complexity.

BACKGROUND: Current infant feeding support is often targeted at establishing breastfeeding in healthy term infants, or supporting lactation for preterm infants in the neonatal setting. Breastfeeding presents different challenges for children beyond the neonatal period who have a medical complexity. The tendency to focus on breastfeeding as a preventative public health intervention overlooks the fact that mothers and children with medical complexity often require additional and targeted support to continue to breastfeed. Despite this identified need, there is very little research, policy or clinically specific teaching within paediatrics that is nuanced enough to support this vulnerable population. RAISING AWARENESS OF BREASTFED CHILDREN WITH MEDICAL COMPLEXITY IN PAEDIATRICS: While research, policy and embedded Baby Friendly Health Initiative (BFHI) standards in both the maternity and neonatal directorates exists, paediatrics is a separate discipline and contrastingly, has very little lactation support infrastructure. To this end, a doctoral study was commenced aiming to identify the differences for this vulnerable and largely overlooked group. One of the related outputs of the ongoing research is the use of creative methods to raise awareness. This commentary highlights a project with an artist to develop a series of portraits alongside a book and health professional education to increase awareness of these children's needs. CONCLUSIONS: The breastfeeding needs and challenges of children in the paediatric setting are unique and require additional awareness, creativity and skills to support optimal infant and young child breastfeeding. Using art can connect professionals to the lived experiences of families trying to persevere through medical complexity.