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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (138 page)

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Children are brought up with their own family, and local authorities have a duty to support and facilitate this, wherever possible.
Wherever possible, professionals should work in partnership with parents, involving them in the care and decisions made about their children.
The race, religion, culture, and language of the child are to be taken into account in the provision of services.
Intervention by the statutory services should occur when it is in the child’s best interest, and legal measures are only used as a last resort.
The wishes and feelings of the child should be sought (depending on his age and level of understanding) and taken into account when decisions are made about his/her future.
The midwife’s role
Current guidance on implementation of the legislation that midwives should be familiar with are
Working Together to Safeguard Children
,
¹the
Framework for the Assessment of Children in Need and Their Families
,
²and the
National Service Framework for Children and Young People
.
³This guidance requires all relevant agencies to work together with children and families. Midwives have a central role in this process, ensuring
that the parents and families are involved in discussions and in the preparations for the care of the newborn baby.
⁴
The midwife has an accepted role within society with pregnant
mothers, their families and their newborn babies, and will frequently
undertake an advocacy role to support the parent(s) and baby, giving
additional parenting education support, as necessary. In the case of teenage mothers, both the mother and her baby, and possibly the baby’s father, may be regarded as children in need and require services in their own rights.
Within the multi-professional context, the midwife contributes significantly to the assessment, planning, and intervention required, particularly in pre-birth assessments and post-birth care, in terms of the child’s development needs, parenting capacity and family and
environmental factors. The close contact with the mother, including home visiting, places the midwife in the ideal situation to be aware of the care of the newborn and other children in the family, conditions in the home, parenting, lifestyle, and injuries to the mother or children.
A midwife working in an independent capacity should know how to seek advice, support, and training and should consult her supervisor of midwives for guidance.
Pre-birth assessment
Examples of issues that may trigger a pre-birth assessment or a referral to social services are:
Young and vulnerable mothers, who have no support mechanism—a girl herself ‘in need’, looked after by the local authority, recently left local authority care, or subject to a Care Order
CHAPTER 23
Care of the newborn
652
- Extreme poverty or inadequate housing
- Social exclusion
- A mother with physical or learning disability, making it difficult for her to care for her baby
- Concern about the mental health of the mother or adult likely to have care of the child
- Substance abuse: persistent use of illegal drugs or alcohol by the mother or within her environment
- The mother lives with, or has frequent social contact with, someone who has been convicted of an offence against children
- Families where a child has previously been placed on the child protection register
- Pregnancy as a result of rape.
  Making a referral
  You should identify vulnerable children and decide whether to refer them to social services for assessment, consulting the supervisor of midwives and named midwife (safeguarding children) before taking any action.
  Assessment of risk and significant harm
- Significant harm is defined in the Children Act (1989) as ‘ill treatment or impairment of health or development’. Abuse and neglect are considered under the following categories:
  - Physical abuse
  - Emotional abuse
  - Sexual abuse
  - Neglect.
    •
    The local authority has a duty to make enquiries, to decide whether or
    not any action to promote or safeguard the child’s welfare is required. Each case is assessed individually. The decision as to whether or not the harm is significant is judged against what is reasonably expected for a child. A range of factors is considered and legal advice will normally be sought when the assessment determines that there is significant risk.
- Assessment under the
  Framework for the Assessment of Children in Need and Their Families
  ²is child centred, so that the impact of parenting capacity, family, and environment on the child can be clearly identified. A quarter of the reasons identified refer to the child, whereas more than half relate to factors in respect of the parents.
  Emergency Protection Order (EPO)
  Section 44 of the Children Act (1989) allows emergency action if there is reasonable cause to believe that a child is likely to suffer harm unless the child is removed to other accommodation.
  In respect of young babies, an EPO may be applied for at birth if there are concerns that the parent will remove the child. This usually applies when the baby is subject to
  Safeguarding Children
  proceedings and the parent(s) are threatening to remove the child.
  Other powers allow the perpetrator to be removed from the home/ baby’s environment through an Exclusion Order attached to an EPO, or Interim Care Order.
  SAFEGUARDING CHILDREN
  653
  Female genital mutilation
  FGM has been illegal in the UK since 1985. The possibility of FGM is a legitimate reason for safeguarding children investigation and proceedings, as it constitutes physical injury and abuse and can take place any time from 1 week after birth to 12 years of age.
  It can provide evidence for an EPO or a Care Order.
  Practice points
The safety and welfare of the child is paramount.
The Children Act protects the rights of children within society and provides the protection of children at risk.
2 You must be aware of the context of working with vulnerable families and the impact on practice.
You have a crucial and integral role in the interprofessional team, notably in pre-birth and post-birth assessments.
2 Always seek guidance and support from the named professional nurse and midwife for child protection whenever dealing with actual or possible cases.
Further reading
Department of Health (2003).
Every Child Matters
. London: DH.
1. Department of Health (2006).
  Working Together to Safeguard Children.
  London: DH
2. Department of Health (2000).
  Framework for the Assessment of Children in Need and Their Families.
  London: DH.
3. Department of Health (2004).
  National Service Framework for Children, Young People and Maternity Services
  . London: DH.
4. Nursing and Midwifery Council (2008).
  Child Protection and the Role of the Midwife
  . Advice Sheet. London: NMC. Available at:
  www.nmc-uk.org (accessed 12.4.10).
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  Part 7
  ‌
  Feeding
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  Breastfeeding
  ‌‌
  Chapter 24
  657
  Constituents of breast milk
  658
  Advantages of breastfeeding
  660
  Contraindications to breastfeeding
  661
  Management of breastfeeding
  662
  The 10 steps to successful breastfeeding
  670
  Support for breastfeeding
  672
  Practices shown to be detrimental to successful breastfeeding
  676
  Expression of breast milk
  680
  Breastfeeding and returning to work
  686
  Discontinuation of breastfeeding
  688
  Breastfeeding problems
  690
  Breastfeeding in special situations
  698
  Lactation and nutrition
  704
  CHAPTER 24
  Breastfeeding
  658‌‌
  Constituents of breast milk
  Colostrum
  - Provides complete nutrition for the healthy term baby until lactation is established, provided frequent feeds are offered and supplements are not considered medically necessary.
  - Produced in the first 3 days after delivery.
  - Volume: 2–10mL daily.
  - Transparent and yellow, due to high B-carotene content.
  - Easily digested and absorbed.
  - Energy content: 58kcal/100mL.
  - Rich in immunoglobulins responsible for passive immunity.
  - Contains higher levels of protein and vitamins A and K than mature milk.
  - Contains lower levels of sugar and fat than mature milk.
  - The presence of lacto bifidus factor provides favourable (acidic) conditions, which encourage colonization of the infant’s gut with the beneficial microbe,
    Lactobacillus bifidus
    .
  - Stimulates the passage of meconium.
    Breast milk
    Breast milk is a complex fluid that contains above 200 known constitutents,
    ¹and changes to meet the needs of the infant, from:
  - Colostrums to transitional then mature milk
  - The beginning to the end of the feed
  - Morning to evening.
    ²
    Nutritional composition
  - Carbohydrate
    : the main type being lactose, a disaccharide.
  - Fat
    : the most variable constituent. Provides 50% of the energy supplied by breast milk. Linoleic and linolenic acids are converted into long- chain polyunsaturated fatty acids, which are essential for development of the nervous system.
  - Protein
    : in the form of whey protein, required for growth and energy. Consists of anti-infective factors, including lactalbumin,
    immunoglobulins, lactoferrin, lysozyme and other enzymes, hormones and growth factors.
    ³
  - Non-protein nitrogens
    : the three most important are taurine, nucleotides and carnitine. Taurine is important for bile acid conjugation, brain, and retinal development.
    ²Nucleotides are important for the function of cell membranes and for normal development of the brain.
    ²Carnitine plays an important part in lipid metabolism and is thought to be important in thermogenesis and nitrogen metabolism.
    ⁴
  - Minerals and trace elements
    : the major ones are sodium, calcium, phosphorus, magnesium, zinc, copper, and iron. The quantities and ratios of these elements are species specific; human and cow’s milk differ significantly.
  - Vitamins
    : human milk contains all the vitamins required for a term neonate, with the possible exception of vitamins D and K.
CONSTITUENTS OF BREAST MILK
659