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A study was conducted to explore the beliefs and practices of 49 New South Wales (NSW) primary school teachers regarding their beliefs and practices concerning the use of concrete materials in the learning and teaching of Number and Algebra. This paper reports on elements of the study regarding why and how teachers use concrete materials. Not only do teacher beliefs influence their classroom practice, Buehl and Beck (2014) propose that teacher practices may impact teacher beliefs suggesting they are interrelated. This paper sought to situate teacher beliefs and practices upon a conceptualisation of this interrelationship based on aspects of classroom practice involving concrete materials. The study employed survey methodology utilising a questionnaire and semi-structured interviews to gather data that were analysed to identify key themes regarding teachers' prevailing beliefs about the use of concrete materials. These themes included a belief in a social constructivist approach to learning and teaching mathematics, a cognitive dimension and engagement. On the basis of these findings an overview is suggested that positions teacher beliefs and practices relating to the use of concrete materials and how it might be used to shift inservice and preservice teachers' beliefs towards a more constructivist teaching approach.

Background Tongue-tie can be diagnosed in 3–11% of babies, with some studies reporting almost universal breastfeeding difficulties, and others reporting very few feeding difficulties that relate to the tongue-tie itself, instead noting that incorrect positioning and attachment are the primary reasons behind the observed breastfeeding difficulties and not the tongue-tie itself. The only existing trials of frenotomy are small and underpowered and/or include only very short-term or subjective outcomes. Objective To investigate whether frenotomy is clinically and cost-effective to promote continuation of breastfeeding at 3 months in infants with breastfeeding difficulties diagnosed with tongue-tie. Design A multicentre, unblinded, randomised, parallel group controlled trial. Setting Twelve infant feeding services in the UK. Participants Infants aged up to 10 weeks referred to an infant feeding service (by a parent, midwife or other breastfeeding support service) with breastfeeding difficulties and judged to have tongue-tie. Interventions Infants were randomly allocated to frenotomy with standard breastfeeding support or standard breastfeeding support without frenotomy. Main outcome measures Primary outcome was any breastmilk feeding at 3 months according to maternal self-report. Secondary outcomes included mother’s pain, exclusive breastmilk feeding, exclusive direct breastfeeding, frenotomy, adverse events, maternal anxiety and depression, maternal and infant NHS health-care resource use, cost-effectiveness, and any breastmilk feeding at 6 months of age. Results Between March 2019 and November 2020, 169 infants were randomised, 80 to the frenotomy with breastfeeding support arm and 89 to the breastfeeding support arm from a planned sample size of 870 infants. The trial was stopped in the context of the COVID-19 pandemic due to withdrawal of breastfeeding support services, slow recruitment and crossover between arms. In the frenotomy with breastfeeding support arm 74/80 infants (93%) received their allocated intervention, compared to 23/89 (26%) in the breastfeeding support arm. Primary outcome data were available for 163/169 infants (96%). There was no evidence of a difference between the arms in the rate of breastmilk feeding at 3 months, which was high in both groups (67/76, 88% vs. 75/87, 86%; adjusted risk ratio 1.02, 95% confidence interval 0.90 to 1.16). Adverse events were reported for three infants after surgery [bleeding (n = 1), salivary duct damage (n = 1), accidental cut to the tongue and salivary duct damage (n = 1)]. Cost-effectiveness could not be determined with the information available. Limitations The statistical power of the analysis was extremely limited due to not achieving the target sample size and the high proportion of infants in the breastfeeding support arm who underwent frenotomy. Conclusions This trial does not provide sufficient information to assess whether frenotomy in addition to breastfeeding support improves breastfeeding rates in infants diagnosed with tongue-tie. Future work There is a clear lack of equipoise in the UK concerning the use of frenotomy, however, the effectiveness and cost-effectiveness of the procedure still need to be established. Other study designs will need to be considered to address this objective. Trial registration This trial is registered as ISRCTN 10268851. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme (project number 16/143/01) and will be published in full in Health Technology Assessment; Vol. 27, No. 11. See the NIHR Journals Library website for further project information. The funder had no role in study design or data collection, analysis and interpretation. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Plain language summary Many mothers and babies experience difficulties in establishing breastfeeding. In some babies it is thought that their difficulties may be linked to a condition called tongue-tie, in which a piece of skin tightly joins the middle part of the underside of the tongue to the base of the baby’s mouth. This can be treated by an operation to divide the tight part/skin in the middle of the underneath of the tongue. We planned to carry out a trial of 870 babies to find out whether an operation together with breastfeeding support helps more mothers and babies with tongue-tie to continue breastfeeding until the baby is 3 months old compared to breastfeeding support on its own and whether the costs were different between the two groups of mothers and babies. We were only able to recruit 169 babies as the trial was stopped because of slow recruitment, changes to services in the COVID-19 pandemic and a high proportion of the babies in the breastfeeding support group going on to have an operation. There were no differences in the rate of breastfeeding at 3 months between the babies in the group who had an operation straightaway and those in the group that had breastfeeding support alone, or had an operation later. More than four in every five babies in both groups were still breastmilk feeding at 3 months. Three babies who had an operation, around 1 in 50 babies, had a complication of the operation (bleeding, scarring or a cut to the tube that makes saliva). Because of the small size of the study, we cannot say whether an operation to divide a tongue-tie along with breastfeeding support helps babies with tongue-tie and breastfeeding difficulties or has different costs. We will need to try different types of research to answer the question. Scientific summary Background Breastfeeding difficulties have been associated with many factors, from a societal to an individual level. Tongue-tie can be diagnosed in 3–11% of babies, with the variation in reported prevalence thought to relate to the use of different diagnostic or severity criteria. Up to half of babies with tongue-tie are reported to have breastfeeding difficulties, but the reported proportion is highly variable. Some studies report almost universal difficulties, and others report very few feeding difficulties that relate to the tongue-tie itself, instead noting that incorrect positioning and attachment are the primary reasons behind the observed breastfeeding difficulties and not the tongue-tie itself. In a UK survey, it was noted that management of tongue-tie in infants with breastfeeding difficulties was therefore highly variable across the country. This is coupled with highly variable provision of breastfeeding support, which can range from minimal to expert and intensive, and using a variety of different models including peer supporter, midwife and health visitor. A Cochrane review identified five prior randomised controlled trials (RCTs) of frenotomy including a total of only 302 infants. The trials are small and underpowered and/or include only very short-term or subjective outcomes, suggesting further robust evidence is needed. Hence there is considerable controversy regarding, not only the diagnosis and clinical significance, but also the management of tongue-tie. Current National Institute for Health and Care Excellence (NICE) guidance allows for the procedure, based on lack of safety concerns, but notes very limited evidence of efficacy. There is therefore a clear need for an assessment of the clinical- and cost-effectiveness of frenotomy for babies diagnosed with tongue-tie in the form of an adequately powered, pragmatic RCT, taking into account the diagnostic controversy and variation in practice. Objective To investigate whether frenotomy is clinically- and cost-effective to promote continuation of breastfeeding at 3 months in infants with breastfeeding difficulties diagnosed with tongue-tie. Methods Study design The FROSTTIE trial was a multicentre, RCT conducted in 12 infant feeding services in England. Participants Inclusion criteria Any infant aged

When infants cannot directly breastfeed after birth, mothers are advised to initiate lactation through mechanical expression. Families are recommended to target an expression volume of at least 500–750 mL by Day 14 after birth, as this is considered a 'critical window' to establish milk supply. This is challenging for many mothers after a very preterm birth. This article explores the relationship of early milk quantity and later full breastmilk feeding as a 'gold standard' outcome, using statistical techniques designed for diagnostic tests. A cohort of 132 mothers of infants born at 23 + 0 to 31 + 6 weeks' gestational age submitted expressing logs on Day 4, 14 and 21 after birth and provided later feeding outcome. Using receiver operating characteristic (ROC) analysis, the following 24‐h milk quantities were identified as associated with high probability of full breastmilk at 36 weeks' post‐menstrual age (PMA): on Day 4, ≥250 g (specificity 88%; positive predictive value 88%) and on Day 21 ≥650 g (specificity 88%; positive predictive value 91%). The following values were identified as associated with low probability of full breastmilk at 36 weeks' PMA: on Day 4 <50 g (sensitivity 92%; negative predictive value 72%) and on Day 21 <250 g (sensitivity 90%; negative predictive value 70%). Participants exceeding the high thresholds had 3–4 times increased likelihood of full breastmilk, whereas those below the low thresholds had 3–5 times lower likelihood. These thresholds have potential as targets for families, to provide individualised prognostic information and to help clinicians target more intensive lactation support. Key messages: Mothers of very preterm infants who expressed at least 250 g at day four after birth had a high probability of providing later full breastmilk: 88% (95% CI: 72%–97%). This was similar for those who expressed at least 650 g at Day 21: 91% (95% CI: 77%–98%).Mothers of very preterm infants who expressed less than 50 g at day four after birth had a low probability of providing later full breastmilk: 28% (95% CI: 10%–53%). This was similar for those who expressed less than 250 g at Day 21: 30% (95% CI: 12%–54%).These thresholds may be useful for families to understand their lactation trajectories and for clinicians to target support. [ABSTRACT FROM AUTHOR]

Background: Inequities in the coverage of 6–8-week maternal checks, health visitor reviews, and infant vaccinations have been reported in England. Ethnic inequities in 6–8-week baby checks have not been studied nationally. Aim: To examine the effect of maternal ethnicity on 6–8 week baby check coverage in England 2006–2021. Design and setting: This cohort study used electronic health records from primary care in England. Method: Baby check coverage was calculated in 16 ethnic groups, by year and region. Risk ratios were estimated using modified Poisson regression. Coverage and timing of baby checks in relation to maternal checks and infant vaccinations by ethnic group were calculated. Results: Ethnic inequities in 6–8 week baby check coverage in England varied by year and region. Coverage increased 2006–2007 to 2015–2016, then stabilised to 80–90% for most groups. Coverage was lowest for Bangladeshi and Pakistani groups 2006–2007 to 2011–2012. In the West Midlands, coverage was lowest at approximately 60% for four groups: Bangladeshi, Caribbean, African, and Any other Black, African or Caribbean background. In the North West, coverage was lowest for Bangladeshi (65.3%) and Pakistani (69.2%) groups. These patterns remained after adjusting for other factors and persisted over time. Coverage was highest in those whose mothers received a maternal check and those who received at least one dose of 8-week infant vaccinations. Conclusion: Coordinated action at the level of integrated commissioning boards, primary care networks, and GP practices is required to better understand the reasons behind these inequities and redress the persistent disparities in 6–8 week baby check coverage. [ABSTRACT FROM AUTHOR]

Introduction: Mothers of very premature infants often have difficulties expressing breastmilk, which can cause distress and potential negative impact on infant health. Clinical recommendations on breastmilk expression are extrapolated from term infants' breastfeeding patterns. This study's objective was to analyse the association of expressing pattern with lactation outcomes after very premature birth. Methods: 132 participants were recruited after birth between 23+0 and 31+6 weeks' gestation. Participants recorded the milk expressed in several 24-hour periods in the three weeks after birth. Results: Expressing frequency was positively associated with 24-hour milk yield, with an adjusted 30.5g increase per expressing session on day four (95% CI 15.7 to 45.3) and 94.4g on day 21 (95% CI 62.7 to 126.2). Expressing ≥8 times per day was associated with higher adjusted milk yield than expressing <6 times (on day four, 146.8g, 95% CI 47.4 to 246.1), but not in comparison to expressing 6–7 times (on day four, 82.1g, 95% CI –25.9 to 190.1). Participants with six months or more prior breastmilk feeding experience had a higher adjusted milk yield than others (on day four, 204.3g, 95% CI 125.2 to 283.3). Night-time (2300–0700 hours) expressing sessions were not associated with increased milk yield after adjustment for time since the prior session. On average, participants who had a longest gap between expressions of less than six hours achieved the UK target of 750g breastmilk, whereas those with a longer gap did not. Conclusion: Expressing frequency was an important determinant of milk yield. Clinical recommendations to express ≥8 times per day were supported but for some, 6–7 times was sufficient. This was particularly likely for those with six months or more of prior breastmilk feeding experience. A need to express during the night-time hours appeared to be related to minimising the gap between expressions rather than an inherent value of night-time expression. [ABSTRACT FROM AUTHOR]