Debbie G F Johnson

THE TRANSITION TO PARENTHOOD: WHAT DOES IT MEAN FOR FATHERS?

AIM This paper is a report of a study to explore the needs of first-time fathers in relation to the care, support and education provided by healthcare professionals during the antenatal period, particularly in relation to preparing them for the transition to fatherhood. BACKGROUND Pregnancy and transition to parenthood are major developmental periods within families throughout the world. Previous research suggests that fathers in many different countries feel unprepared for parenthood. METHODS Purposive sampling was used to recruit 20 partners of primiparous women from two healthcare provider organizations in South-West England between December 2005 and July 2006. Recruitment took place at about 28 weeks gestation. Semi-structured interviews were undertaken at home in the last trimester of pregnancy and 3-4 months postpartum. Content analysis of the interview data was undertaken. FINDINGS Several common themes emerged from both the ante- and postnatal data, including lack of support mechanisms, involvement in antenatal provision and the need for more information given in the antenatal period on parenting, baby care and relationships. CONCLUSIONS Adequately preparing new fathers for parenthood in advance of the birth of their baby is important, and healthcare professionals can contribute to this by involving and supporting new fathers. Further study is needed to explore the role of fathers in antenatal education and the types of interventions that are effective in improving their early experiences of parenthood. The study needs to be repeated with fathers from black and ethnic minority groups.

Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie

Trial design A randomised, parallel group, pragmatic trial. Setting A large UK maternity hospital. Participants Term infants <2 weeks old with a mild or moderate degree of tongue-tie, and their mothers who were having difficulties breastfeeding. Objectives To determine if immediate frenotomy was better than standard breastfeeding support. Interventions Participants were randomised to an early frenotomy intervention group or a ‘standard care’ comparison group. Outcomes Primary outcome was breastfeeding at 5 days, with secondary outcomes of breastfeeding self-efficacy and pain on feeding. Final assessment was at 8 weeks; 20 also had qualitative interviews. Researchers assessing outcomes, but not participants, were blinded to group assignment. Results 107 infants were randomised, 55 to the intervention group and 52 to the comparison group. Five-day outcome measures were available for 53 (96%) of the intervention group and 52 (100%) of the comparison group, and intention-to-treat analysis showed no difference in the primary outcome—Latch, Audible swallowing, nipple Type, Comfort, Hold score. Frenotomy did improve the tongue-tie and increased maternal breastfeeding self-efficacy. At 5 days, there was a 15.5% increase in bottle feeding in the comparison group compared with a 7.5% increase in the intervention group. After the 5-day clinic, 44 of the comparison group had requested a frenotomy; by 8 weeks only 6 (12%) were breastfeeding without a frenotomy. At 8 weeks, there were no differences between groups in the breastfeeding measures or in the infant weight. No adverse events were observed. Conclusions Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.

The effects of Baby Friendly Initiative training on breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health-care staff

AIM To evaluate the effects of Baby Friendly Initiative (BFI) community training on breastfeeding rates, staff and mothers in a large Primary Care Trust (PCT). BACKGROUND UK Government policy promotes the adoption and implementation of the World Health Organization/United Nations Childrens Fund BFI as the best evidence to raise breastfeeding initiation and prevalence. METHODS A total of 141 health visitors and nursery nurses were trained on mandatory three-day BFI courses during 2008; 137 staff (100 health visitors, 37 nursery nurses) took part in the evaluation. Breastfeeding attitudes, knowledge and staff confidence in helping mothers to breastfeed were measured using a validated Breastfeeding Questionnaire and a self-efficacy tool at three time points before and after training. FINDINGS Breastfeeding rates at eight weeks increased significantly, and a baby born in 2009 was 1.57 times more likely to be breastfed than one born in 2006. Statistically significant improvements in staff breastfeeding attitudes, knowledge and self-efficacy were seen after attending the course, in addition to increases in the appropriate management of breastfeeding problems.Process evaluation interviews with 43 health visitors, nursery nurses and managers explored views of the training and changes in practice. The response to the course was overwhelmingly positive and felt to be extremely worthwhile. It has led to renewed enthusiasm, improved the consistency of advice among team members and raised confidence levels of all staff who help mothers with breastfeeding. Health visitors felt confident about enabling nursery nurses to take a greater role in breastfeeding support. A small survey of mothers reported increases in exclusive breastfeeding and signs of increased breastfeeding self-efficacy. Making the training mandatory across the whole PCT has improved the consistency of breastfeeding advice and confidence of all health-care staff who help breastfeeding mothers.

The development of a new breast feeding assessment tool and the relationship with breast feeding self-efficacy

Objective to develop a breast feeding assessment tool to facilitate improved targeting of optimum positioning and attachment advice and to describe the changes seen following the release of a tongue-tie. Design development and validation of the Bristol Breastfeeding Assessment Tool (BBAT) and correlation with breast feeding self-efficacy. Setting maternity hospital in South West England. Participants 218 breast feeds (160 mother–infant dyads); seven midwife assessors. Findings the tool has more explanation than other tools to remind those supporting breast-feeding women about the components of an efficient breast feed. There was good internal reliability for the final 4-item BBAT (Cronbach׳s alpha=0.668) and the midwives who used it showed a high correlation in the consistency of its use (ICC=0.782). Midwives were able to score a breast feed consistently using the BBAT and felt that it helped them with advice to mothers about improving positioning and attachment to make breast feeding less painful, particularly with a tongue-tied infant. The tool showed strong correlation with breast feeding self-efficacy, indicating that more efficient breast feeding technique is associated with increased confidence in breast feeding an infant. Conclusions the BBAT is a concise breast feeding assessment tool facilitating accurate, rapid breast feeding appraisal, and targeting breast feeding advice to mothers acquiring early breast feeding skills or for those experiencing problems with an older infant. Accurate assessment is essential to ensure enhanced breast feeding efficiency and increased maternal self-confidence. Implications for practice the BBAT could be used both clinically and in research to target advice to improve breast feeding efficacy. Further research is needed to establish its wider usefulness.

Does family-centred neonatal discharge planning reduce healthcare usage? A before and after study in South West England

Objective To implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care. Design Before and after study, investigating the effects of the intervention during two 11-month periods before and after implementation. Setting Four local neonatal units (LNUs) in South West England. Participants Infants without major anomalies born at 27–33 weeks’ gestation admitted to participating units, and their parents. Train-to-Home intervention A family-centred discharge package to increase parents’ involvement and understanding of their babys needs, comprising a train graphic and supporting care pathways to facilitate parents’ understanding of their babys progress and physiological maturation, combined with improved estimation of the likely discharge date. Main outcome measures Perceived Maternal Parenting Self-Efficacy (PMP S-E) scores, infant length of stay (LOS) and healthcare utilisation for 8 weeks following discharge. Results Parents reported that the Train-to-Home improved understanding of their babys progress and their preparedness for discharge. Despite a lack of change in PMP S-E scores with the intervention, the number of post-discharge visits to emergency departments (EDs) fell from 31 to 20 (p<0.05), with a significant reduction in associated healthcare costs (£3400 to £2200; p<0.05) after discharge. In both study phases, over 50% of infants went home more than 3 weeks before their estimated date of delivery (EDD), though no reduction in LOS occurred. Conclusions Despite the lack of measurable effect on the parental self-efficacy scores, the reduction in ED attendances and associated costs supports the potential value of this approach.

The development of a tongue assessment tool to assist with tongue-tie identification

Aim To produce a simple tool with good transferability to provide a consistent assessment of tongue appearance and function in infants with tongue-tie. Methods The Bristol Tongue Assessment Tool (BTAT) was developed based on clinical practice and with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF). This paper documents 224 tongue assessments using the BTAT. There were 126 tongue assessments recorded using the BTAT and ATLFF tools to facilitate comparisons between them. Paired BTAT assessments were obtained from eight midwives who were using the new assessment tool. Results There was acceptable internal reliability for the four-item BTAT (Cronbachs α=0.708) and the eight midwives who used it showed good correlation in the consistency of its use (ICC=0.760). The BTAT showed a strong and significant correlation (0.89) with the ATLFF, indicating that the simpler BTAT could be used in place of the more detailed assessment tool to score the extent of a tongue-tie. Midwives found it quick and easy to use and felt that it would be easy to teach to others. Conclusions The BTAT provides an objective, clear and simple measure of the severity of a tongue-tie, to inform selection of infants for frenotomy and to monitor the effect of the procedure.

What matters to children with CFS/ME? A conceptual model as the first stage in developing a PROM

Background Paediatric chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME) is relatively common and disabling. Research is hampered because current patient-reported outcome measures (PROMs) do not capture outcomes that are important to children with CFS/ME. Aim The aim of this study was to explore the aspects of life and health outcomes that matter to children with CFS/ME. Methods Twenty-five children with CFS/ME were interviewed (11 males, 14 females; mean age 12.9 years (SD 2.2), range 8–17). Twelve were trial participants interviewed during the trial and 13 were recruited as part of a follow-up qualitative study. Parents were present in 19 interviews with their children. Three mothers participated in a focus group. All the interviews and the focus group were audio-recorded and transcribed. Data were analysed thematically using techniques of constant comparison. NVivo was used to structure and categorise data in a systematic way. Results Children identified four key themes (health outcome domains): ‘symptoms’ that fluctuated, which caused an unpredictable reduction in both ‘physical activity’ and ‘social participation’ all of which impacted on ‘emotional well-being’. These domains were influenced by both ‘management’ and ‘contextual factors’, which could be positive and negative. The relationship between healthcare and school was considered pivotal. Conclusions Childrens descriptions helped to inform a conceptual model that is necessary to develop a new paediatric CFS/ME PROM. Doctors need to be aware of how children conceptualise CFS/ME; the relationship between healthcare and school is fundamental to ameliorate the impact of CFS/ME. Trial registration number ISRCTN81456207.

Estimating discharge dates using routinely collected data: improving the preparedness of parents of preterm infants for discharge home

The length of stay for moderately preterm infants has progressively become shorter in the UK in recent years but staff still commonly inform parents that their baby will go home around their estimated date of delivery (EDD). Parents need as much notice as possible to prepare for the discharge of their baby, and to gain the necessary skills and knowledge to care for their infant safely. We report the use of routinely collected neonatal data to develop and implement a simple centile chart for date of discharge from hospital, which allows staff and parents to predict the likely discharge date more accurately for preterm infants, most of whom now go home more than 3 weeks before their EDD. This information allows better and timelier planning for discharge of such infants, by parents and staff.

Protocol for a feasibility trial for improving breast feeding initiation and continuation: assets-based infant feeding help before and after birth (ABA)

Introduction Breast feeding improves the health of mothers and infants; the UK has low rates, with marked socioeconomic inequalities. While trials of peer support services have been effective in some settings, UK trials have not improved breast feeding rates. Qualitative research suggests that many women are alienated by the focus on breast feeding. We propose a change from breast feeding-focused interactions to respecting a woman’s feeding choices, inclusion of behaviour change theory and an increased intensity of contacts in the 2 weeks after birth when many women cease to breast feed. This will take place alongside an assets-based approach that focuses on the positive capability of individuals, their social networks and communities. We propose a feasibility study for a multicentre randomised controlled trial of the Assets feeding help Before and After birth (ABA) infant feeding service versus usual care. Methods and analysis A two-arm, non-blinded randomised feasibility study will be conducted in two UK localities. Women expecting their first baby will be eligible, regardless of feeding intention. The ABA infant feeding intervention will apply a proactive, assets-based, woman-centred, non-judgemental approach, delivered antenatally and postnatally tailored through face-to-face contacts, telephone and SMS texts. Outcomes will test the feasibility of delivering the intervention with recommended intensity and duration to disadvantaged women; acceptability to women, feeding helpers and professionals; and feasibility of a future randomised controlled trial (RCT), detailing recruitment rates, willingness to be randomised, follow-up rates at 3 days, 8 weeks and 6 months, and level of outcome completion. Outcomes of the proposed full trial will also be collected. Mixed methods will include qualitative interviews with women/partners, feeding helpers and health service staff; feeding helper logs; and review of audio-recorded helper–women interactions to assess intervention fidelity. Ethics and dissemination Study results will inform the design of a larger multicentre RCT. The National Research Ethics Service Committee approved the study protocol. Trial registration number ISRCTN14760978; Pre-results.

“Giving us hope”: Parent and neonatal staff views and expectations of a planned family‐centred discharge process (Train‐to‐Home)

Preparing families and preterm infants for discharge is relatively unstructured in many UK neonatal units (NNUs). Family‐centred neonatal care and discharge planning are recommended but variable.