BackgroundOptimal breastfeeding has benefits for the mother-infant dyads. This study investigated the prevalence and determinants of cessation of exclusive breastfeeding (EBF) in the early postnatal period in a culturally and linguistically diverse population in Sydney, New South Wales, Australia.MethodsThe study used routinely collected perinatal data on all live births in 2014 (N = 17,564) in public health facilities in two Local Health Districts in Sydney, Australia. The prevalence of mother’s breastfeeding intention, skin-to-skin contact, EBF at birth, discharge and early postnatal period (1–4 weeks postnatal) were estimated. Multivariate logistic regression models that adjusted for confounders were conducted to determine association between cessation of EBF in the early postnatal period and socio-demographic, psychosocial and health service factors.ResultsMost mothers intended to breastfeed (92%), practiced skin-to-skin contact (81%), exclusively breastfed  at delivery (90%) and discharge (89%). However, the prevalence of EBF declined (by 27%) at the early postnatal period (62%). Younger mothers (<20 years) and mothers who smoked cigarettes in pregnancy were more likely to cease EBF in the early postnatal period compared to older mothers (20–39 years) and those who reported not smoking cigarettes, respectively [Adjusted Odds Ratio (AOR) =2.7, 95%CI 1.9–3.8, P <0.001 and AOR = 2.5, 95%CI 2.1–3.0, P <0.001, respectively]. Intimate partner violence, assisted delivery, low socio-economic status, pre-existing maternal health problems and a lack of partner support were also associated with early cessation of EBF in the postnatal period.ConclusionsOur findings suggest that while most mothers intend to breastfeed, and commence EBF at delivery and at discharge, the maintenance of EBF in the early postnatal period is sub-optimal. This highlights the need for efforts to promote breastfeeding in the wider community along with targeted actions for disadvantaged groups and those identified to be at risk of early cessation of EBF to maximise impact.

Palliative sedation is an effective symptom control strategy for patients who suffer from intractable symptoms at the end of life. Evidence suggests that the use of this practice varies considerably. In order to minimize variation in the practice of palliative sedation within our health region, we developed a clinical practice guideline (CPG) for the use of palliative sedation. Using available evidence from the literature, a five step process was employed to develop the CPG: (1) a working group was charged with the mandate to develop a draft guideline; (2) a working definition for palliative sedation was developed; (3) criteria for use of sedation were determined; (4) critical steps to be taken prior to initiation of sedation were defined; and (5) the CPG was reviewed by local stakeholders. Feedback from the wider group of stakeholders was used to arrive at the final CPG, which subsequently received approval from the local Medical Advisory Board. The process used to develop the CPG served to develop consensus within the local community of palliative care clinicians regarding the practice of palliative sedation. Subsequently, the CPG was used as a tool for educating other health care providers.

The Treatment Escalation Plan (TEP) was introduced into our trust in an attempt to improve patient involvement and experience of their treatment in hospital and to embrace and clarify a wider remit of treatment options than the Do Not Resuscitate (DNR) order currently offers. Our experience suggests that the patient and family are rarely engaged in DNR discussions. This is acutely relevant considering that the Mental Capacity Act (MCA) now obliges these discussions to take place. The TEP is a form that the doctor completes, ideally with the competent patient or close relative, documenting what treatment options would be appropriate if that patient were to become acutely unwell. Ventilation of the lungs, cardiac resuscitation, renal replacement therapy, intravenous fluids and antibiotics are all discussed. The study evaluated patient and relative experiences with the TEP. 55 patients or their relatives were interviewed regarding their experience of the TEP and thoughts regarding the process. 96% of patients and relatives evaluated thought that the TEP was a good idea. Free text comments were all positive and only 34% of patients claimed to feel anxious when completing the form. Following this study, the TEP has been expanded hospital wide and into the community within our trust. Discussions are currently taking place in hospitals within our region to introduce the TEP form into other local trusts.

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