Breastfeeding rates are low in the UK, where approximately one quarter of infants receive a breastmilk substitute (BMS) in the first week of life. We investigated the reasons for early BMS use in two large maternity units in the UK, in order to understand the reasons for the high rate of early BMS use in this setting. Data were collected through infant feeding records, as well as maternal and midwife surveys in 2016. During 2016, 28% of infants received a BMS supplement prior to discharge from the hospital maternity units with only 10% supplementation being clinically indicated. There was wide variation in BMS initiation rates between different midwives, which was associated with ward environment and midwife educational level. Specific management factors associated with non-clinically indicated initiation of BMS were the absence of skin-to-skin contact within an hour of delivery (p = 0.01), and no attendance at an antenatal breastfeeding discussion (p = 0.01). These findings suggest that risk of initiating a BMS during postnatal hospital stay is largely modifiable. Concordance with UNICEF Baby Friendly 10 steps, attention to specific features of the postnatal ward working environment, and the targeting of midwives and mothers with poor educational status may all lead to improved exclusive breastfeeding rates at hospital discharge.

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Ann RC ollS urg Engl 2009; 91:5 13-525 522 DISCUSSIONWe haveused this techniqueinfive sequentialpatientstoremove cemented acetabular components, fouro fw hich were well fixed. The average time taken was8m in (range, 3-13 min). In each case,t he component came out with mosto ft he cement mantle attached. There wasl ittle bone loss. In all cases, an uncemented revisions ocket was implanted, witha dditionalb one grafti no ne patient. Postoperativer adiographs were all satisfactory.T his is now the senior author'sf avoured method for extracting aw ellfixed cemented acetabular component. Figure2The medialcompartmentwith pressure from the assistant to the mediala spect of thep opliteal fossa. Note that pathology is easilys een, thus facilitatingr esection. Figure1Illustrating the use of aF oley catheter.We describe as imple technique to aid visualisationo ft he medial meniscus during arthroscopy.T he patient's legi sf lexedo ver the side of theoperating table,with the surgeon exerting aslight valgus strain.T oensure no occult pathology is missed,werecommendthat the assistant performs the simple manoeuvre of pressing the fingertips, exerting only moderate pressure into the medial aspect of the popliteal fossa. This pushes the posterior horn of the meniscus anteriorly and aids the surgeon'sv iew,t hereby easing the procedure shouldresection be required. Thismanoeuvrecan be complimentedby the assistant using their contralateral handt op ush downi na n anteroposteriordirectiononthe patient'sdistal thigh to stabilise the knee. This is illustrated in Figures 1a nd 2. The recommended technique for preventing pin-site infection includess pecially manufacturedI lizarov spongesa nd clips, retailing at £2.24 combined (Iliz sponge and disclip; Smith and Nephew Healthcare,H ull, UK). An alternativef or them ore scrupulouss urgeon cant ake thef orm of ac ut-up urinary