INTRODUCTION:

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of
infants; it is also an integral part of the reproductive process with important implications for the health of
mothers. Review of evidence has shown that, on a population basis, exclusive breastfeeding for 6 months
is the optimal way of feeding infants. Thereafter infants should receive complementary foods with
continued breastfeeding upto 2 years of age or beyond.

DEFINITION:
Excessive breastfeeding is defined as an infant being fed only breast milk, with the possible
exception of vitamin D in certain populations and iron in infants of relatively low birth weight.

PHYSIOLOGY OF MILK PRODUCTION:

Milk is produced as a result of interaction between hormones and reflexes. Two hormones come
into play during lactation.

Prolactin reflex (milk secretion reflex):

Prolactin produced by the anterior pituitary gland is responsible for milk secretion by the alveolar
epithelial cells. When the baby sucks, the nerve ending of the nipple carry message to the anterior
pituitary which in turn release prolactin and that acts on the alveolar glands in the breast to stimulate
milk secretion. Since prolactin is produced during night time, breastfeeding during night is important for
the maintenance of this reflex.

Oxytoxin reflex (milk ejection reflex):

Oxytoxin is a hormone produced by the posterior pituitary. It is responsible for the contraction of the
milk from the glands into the lactiferous sinuses and the lactiferous ducts. This hormone is produced in
response to stimulation to the nerve ending s in the nipple by suckling as well as by the thought, sight or
sound of the baby. Since this reflex is affected by the mother s ‘emotions, a relaxed, confident attitude
helps the milk ejection reflex. On the other hand, tension and lack of confidence hinder the milk flow.

FACTORS WHICH LESSEN MILK PRODUCTION:

1. Dummies, pacifiers, bottles. Even two or more supplemental feed would hinder successful
breastfeeding.
2. Giving things like sugar water, grip water, honey, breast milk substitutes or formula, either as
prelacteal feeds or supplemental feeds.
3. Painful breast conditions like sore or cracked nipples and congested breast.
4. Lack of night feeding, as it interferes with the prolactin reflex.
5. Inadequate emptying of the breast such as when sick or small baby is unable to suck on the mother’s
breast and the mother does not manually express breast milk.
 WHO AND UNICEF RECOMMENDATION TO ESTABLISH AND SUSTAIN EXCLUSIVE
BREASTFEEDING FOR 6 MONTHS:

 Initiation of breastfeeding within the first hour of life.

 Exclusive breastfeeding – that is the infant only receives breast milk without any additional food
or drink, not even water.

 Breastfeeding on demand – that is as often as the child wants, day and night.

 No use of bottles, teats or pacifiers.

ADVANTAGES OF BREASTFEEDING :
A)Nutritive value :
 It contains all the nutrients in the right proportions which are needed for optimal growth and
development of the body upto 4-6 months.

 Essential for growth of the infant because it has high percentage of lactose and galactose which
are important components of galactogerebroside.

 Facilitate absorption of calcium which helps in bony growth.

 Contains amino acids like tauirne and cysteine which are important as neurotransmitters.

 Breast milk fats are polysaturated fatty acids which are necessary for myelination of the nervous
system.

 It has vitamins, minerals, electrolytes and water in right proportion for the infant which are
necessary for the maturation of intestinal tract.

 It provides 66 calories per 100ml and contains 1.2 kg protein,3.8 g fat,7g lactose and vitamin A 170 to
670 IU,Vitamin C 2 to 6 mg ,vitamin D 22IU,calcium 35 mg,phosphorous 15 mg in 100 ml .The total
amount of milk secretion per day about 600-700 ml for the baby.
 It provides specific nutrients for preterm baby in preterm delivery.
B) Digestively :
 Breast milk is easily digestable.

 The proteins are mostly lactoalbumin and lactoglobulin which forms soft curds that is curdy to
digest.

 The enzyme lipase in the breast milk helps in the digestion of fats and provides free fatty acids.
C )Protective value :
 Breast milk contains IgA, IgM, macrophages, lymphocytes, bifidus factors, unsaturated
lactoferrin, lysoxyme, and interferon.
  So, breastfed bodies are less likely to develop infections esp. gastrointestinal and respiratory
tract infections, viral infections like skin infection.

 BF protects the infant from allergy and bronchial asthma. It protects against neonatal
hypocalcaemia, tettany, necrotizing entercolitis, deficiencies of Vit E and zinc, neonatal
convulsions and SID syndrome.

 Exclusive breast feeding has less chances of developing malnutrition,herpertension,diabetes

mellitus, CAD , arthrosclerosis , ulcerative colitis,appendicitis,childhood lymphoma, liver
disease; celiac disease and dental caries.
D)Psychological benefits :
 Promotes close physical and emotional bondage with the mother by frequent skin to skin
contact, attention and interaction.

 It stimulates psychomotor and social attention.

 It leads to better parent child adjustment, fewer behavioral disorders in children and less risk of
child abuse and neglect.

 It develops higher development of intelligence and feeling of security in child.

E)Maternal benefits :
 Reduces the chances of post partum hemorrhage and help in better uterine involution.

 Lactation amenorrhea promotes in recovery of iron stores and also protects from pregnancy for
the first 6 months if exclusive breastfeeding is given.

 Improves metabolic efficiency and satisfaction with sense of fulfillment of the mother.

 Reduces the risk of ovarian and breast cancer of the mother.

 Improves slimming of the mother by consuming extra fat which is accumulated during
pregnancy. It takes approximately 20 calories to produce an ounce of milk.

 More convenient and time saving for the mother. She can provide fresh, pure, readymade, clean
uncontaminated milk to her baby at the right temperature without any preparation.

 Mother feels comfortable to feed the baby especially at night time.

F) Family and community benefits:
Breastfeeding is economical in terms of saving of money, time and energy. The cost of formula
for 12 months is approximately $1000 - $1200.
 Family has to spend less on milk, health care and illness.

 Community expenditure on health care and contraception are reduced. It is economical for the
 families, hospitals, communities and for countries.

PREPARATION FOR BREAST FEEDING :

Preparation for breast feeding should begin in the antenatal period. The idea of breast feeding should be
introduced in childhood and school education about its importance.Mothercraft training should be
provided and includes benefits of breast feeding which should be given in the prepragnant state.

In the antenatal period, examination of the breast and identification of problems like
retracted nipples should be done with necessary advice for interventions. Adequate diet in prenatal
period should be consumed in terms of energy and nutrients. Prevention of micronutrient deficiencies,
rest, and regular exercise, hygiene measures should be advised for better health in antenatal period.
Antenatal counseling, family support and mother support group should also be emphasized as the
preparation of mothers for breasstfeeeding. Mothers should also be prepared psychologically to feed her
baby immediately after birth.

INITIATION OF BREAST FEEDING :

Breastfeeding should be initiated within first half hour to one hour of birth or as soon as possible and
within 4-6 hours after cesarean birth delivery. Early suckling provides warmth, security and colostrums
the baby’s first immunization. It contains a high concentration of proteins and other nutrients the body
needs.

Mothers should be demonstrated about the techniques of breastfeeding. Rooming- in or bedding-

in should be done with the mother and the infant as soon as possible to prevent separation. The mothers
should also be advised for exclusive breastfeeding upto 4-6 months and as demand feeding. No food or
drink other than breast milk should be given to neonates. No water, no glucose water, animal milk,
gripe water,indegineous medicines, vitamins and mineral drops or syrup should be given .No bottles or
pacifier are allowed

In case of preterm babies or sick babies, being in care unit, they should be fed with expressed
breast milk (EBM).

INDICATIONS OF ADEQUACY OF BREAST FEEDING :

1. Audible swallowing sound during the feed.
2. Let down sensation in the mother’s breast.
3. Breast is full before feed and softer afterward.
4. Wet nappies 6 or more in 24 hours.
5. Frequent soft bowel movements, 3 to 8 times in 24 hours.
6. Average weight gain of 18 to 30 gms per day.
7. Baby sleep well and does not cry frequently.
8. Baby has good muscle tone and healthy skin.

DIFFERENT COMPONENTS OF BREAST MILK :

1)COLOSTRUM : It is secreted during the first three days after delivery. It is thick, yellow and small in
quantities. It contains more antibodies and cells in higher amount of proteins and fat soluble vitamins
(A, D, E, and K) .It is sufficient and protective for the baby and should not be discarded.
2 ) TRANSITIONAL MILK : Follows the colostrums and secretes during first two weeks of postnatal
period. Transitional milk is thin and white, and contains high quantities of fat, calories, protein, lactose
and vitamins. Many mothers notice the quantity and consistency of their milk changing about two to
three days after their baby’s birth.
3.MATURE MILK : Approximately 10 to 15 days following baby’s birth, the production of mature
milk begins. Mature milk primarily consists of water but contains all the nutrients for optimal growth of
the baby.
4.PRETERM MILK : It is the breast milk secreted by the mother who delivered preterm baby is
different from the milk of a mother who has delivered a full term baby. This milk contains more
proteins, sodium, iron, immunoglobulin and calories appropriate for the requirements of the preterm
neonates.
5)FORE MILK : Secreted at the starting of the regular breastfeeding and it often appears bluish in color.
It is more watery to satisfy the baby’s thirst and contains more proteins, sugar, vitamins and minerals.
6)HIND MILK : Secreted towards the end of regular breastfeeding and contains more fat and energy
.The mother should feed the baby allowing one breast to empty to provide both fore milk and hind milk,
before offering the other breast. For optimal growth and to fulfill adequate fluid and nutritional
requirements, both fore milk and the hind milk are needed for the baby.

CARE OF THE BREAST :

Daily washing of the breast with clean water are essentials .The modern practice of breast feeding aims
at minimizing breast irritation and so breast should be washed once daily .Brassieres should be wear fro
support and comfort.

TECHNIQUES OF BREAST FEEEDING :

Mother should be comfortable and relaxed physically and mentally before giving breast feeding. She
should wash her hand and can have a glass of milk or water. Mother should not have due work in her
hand. Baby should be dried and cleaned before feeding, otherwise baby may feel discomfort or may
non- cooperate during feeding.
POSITIONING:
Correct positioning of mother and baby is an important aspect of successful breast feeding.
1.For the mothers:
Mother can be sitting or side lying position. Her back should be well supported and should not be
leaning on her baby. Mothers can even lay flat with the baby on the top of the mother especially
following the cesarean section.
2.For the babies:
Make sure the baby is wrapped properly in a cloth.
1. Baby should be supported by the mother’s forearm in slight head elevated position and the head, neck
and back in a straight line.
2. Baby should be hold close to mother with trunk to trunk; or abdomen to abdomen in touch and facing
towards the breast.
3. Baby’s nose is at the level of the nipple.

The different feeding positions are :

1. Cradle hold.

The cradle hold position is the most common nursing position of them all. This position is best for the
older baby who already has control over head and neck movement, and can latch on easily. If you want
to try this position with a newborn, you will need baby’s head resting on your forearm; you will need to
keep baby close with skin on skin contact.

Step By Step Cradle Hold for Newborn

* Make sure that mother’s back is supported.

* Put the base of baby’s head in the crook of mother’s arm.

* Tuck baby’s lower arm under her body.

* Baby’s tummy should be against her tummy. His face and knees should be facing mother’s body.

* Use a U hold to hold the breast; when positioning your breasts, make sure that mother’s fingers are
not touching areola; this is so that they do not get in the way when baby is trying to latch on.

* Tickle baby’s lips and wait until he/she opens their mouth wide; then bring the baby to mother’s
breast.

* Baby should have whole nipple and a large part of areola in their mouth.
 2. Cross cradle hold.

The cross cradle hold for breastfeeding allows a Mom complete control during breastfeeding. This
position is used for the newborn and only until baby has learned to latch on correctly.

Step By Step Cross Cradle Breastfeeding Hold

* Use a breastfeeding pillow for support. Mother’s arm should be supporting the length of baby’s back.

* Baby’s head should be supported with mother’s thumb and forefinger just behind baby’s ears.

* Baby should be held tummy to tummy.

* With mother’s free hand she must hold her breast in a U shape

* Tickle baby’s lips with nipple until he/she opens their mouth wide, then quickly push his body
towards mother and latch on.

* Baby should have all of the nipple and most of the lower areola in their mouth. Nipple should be quite
far back in baby's mouth. If the latch feels uncomfortable or painful, mother can break the seal by
placing her fingers in the corner of baby’s mouth and try again.

* If baby’s bottom lip is curled in, it sometimes helps to try pull it out, for a better latch.

* Do not try to make an air pocket on the top of the breast for baby to breathe. Doing this can cause
nipple pain. Babies’ noses are made especially for breastfeeding, and if baby is struggling to breathe,
he/she will pull off on their own.

* If your baby is drinking well with the cross breastfeeding hold, and mother’s arm becomes tired, she
can transition into the normal cradle hold shown above.

This is a really great breast feeding position for mothers who:

* Have small babies.

* Have large breasts.

* Have inverted nipples.

* Have babies with latching on problems.

3. Football hold.

The football breastfeeding hold also called the underarm hold or clutch hold. With this nursing position
mother will be holding baby on either one of her sides. This is a great position for Mothers who have
just had a Cesarean section. The breastfeeding football hold is also great for Mothers with large
breasts. Moms with heavy let down reflexes and Moms with premature babies. This position is usually
used only until baby is latching on well.

Step by Step Breastfeeding Football Hold

* Mother will need a pillow to support baby. Baby should be at breast height.

* Tuck baby in, under the same arm as the breast that is being fed to baby.

* Mom's forearm should be positioned up the length of baby’s back.

* Baby’s head supported by Moms thumb and forefinger, behind baby’s ears just like when she hold
baby in the cross cradle position.

* Again hold the breast with other hand...in a U shape with fingers away from the areola.

* Baby should be resting on mother’s forearm, tucked under her arm.

* Latch baby the same way as the cross cradle hold.

* Make sure mother’s shoulders and back are relaxed.

4.Lying down

The lying breastfeeding position is the easiest position breastfeeding for many Moms. Breastfeeding
lying down is nice for Moms that sleep with their babies.

How it is done:

* She should lie on side and support her head and her back with pillows.

* Lie baby next to her so that their tummies are touching. If baby is still very young, she can place
something behind his/her back to prevent baby from rolling backwards.

* Baby will be drinking from the breast that is against the mattress.

* After baby has securely latched on, she can use her lower arm to support her own head.

* When she wish to keep baby other side, she only need to cuddle him/her over her chest, and gently
roll herself over.

* This position is great for Moms who have had a C-section delivery.

Saddle Hold (Australian hold):

The Saddle Hold is a fun way to easily nurse babies who are sitting up. It also works well if baby has a
runny nose or a sore ear. This is a great position for breastfeeding toddlers!

LATCHING OR ATTACHMENT :
After positioning, when baby’s chin touches the breast, cheek touches the nipple, baby will open the
mouth in “rooting reflex”. Then the baby will quickly move on to the breast with the lower lip below
the nipple so that the nipple and most of the areola go into the baby’s mouth. It is important that the
baby is brought to the mother rather than mother leaning to the baby. The nipple should be slightly
tilted downward using a “C – hold”
Signs of good attachment :
 1. The baby’s mouth is wide open.

2. Most of the areola and nipple in the mouth, only upper areola visible and not the lower one.

3. The baby’s chin touches the breast.

4. The baby’s lower lip is everted.

Effective suckling :
1. Baby suckling slowly and pauses in between to swallow.
2. One may be able to see the movement of the throat bones and muscles and hear the gulping sound
that baby is swallowing milk.
3. Baby’s cheeks are full and not hollow or retracting during suckling.

BREAKING THE WIND :

All babies swallow varied amount of air during sucking. To break up the wind the baby should be held
upright against the chest and the back is patted gently till the baby belches the air out .It is better to
break the wind during sucking so as to make the stomach empty, enabling the baby to take more food
and at the end to prevent hiccough and abdominal colic. Burping is not necessary if the baby is having
good latching and attachment during feeding which prevent air entry into the baby’s mouth. The baby
should be placed on right side after the feeding. Usually the baby falls asleep. Mother should make the
baby dry and comfortable

FREQUENCY OF FEEDING :
1.Time schedule:
Initially breast feeding can be given 1-2 hours interval and the regularity becomes established at 3-4
hours by the end of the first week. Baby should be feed on self demand by the baby. A baby usually
cries when feels hungry and then must be put into the breast.
2.Duration of feeding :
Duration of feeding should be continued till the baby is satisfied. The duration of feeding depends on
the vigour of the baby and on the ‘let down reflex’. One breast should be emptied completely before
starting with the opposite breast. Next feeding should be started with the opposite breast i.e. which was
last fed in the previous feeding. Initial feeding should last for 5-10 mins at each breast.
3.Night feed :
In initial period, a night feed is required to avoid long interval between feeds of over 5 hours. It not only
eliminates excessive filling and hardening of the breasts but also quietens and ensures sound sleep of
the baby.
4.Amount of food :
The average requirement of milk is about 60 ml/kg /24 hours on the first day, 100ml/kg/24 hours on the
third day and is increased to 150ml/kg/24 hours on the tenth day. However the baby can take as much as
he wants.
Breastfeeding should be continued exclusively for 4 months of age or preferably may be upto 6
months if adequate breast milk is available. The baby should be given only breast milk and nothing else,
not even water for the first 4 months of life; even in summer month .Frequent suckling help to have
adequate amount of milk for the baby.
Complementary foods can be started between 4-6 months, exact age may vary, but the
breast feeding should be continued upto 2 years of age or beyond and especially at night. Mothers
should maintain hygienic measures; take bath and wash her breast during bath and wear clean blouse
during this period to prevent contamination of breast milk.

CONTRAINDICATION OF BREAST FEEDING:

1.Absolute contraindications :
 Use of addictive drugs e.g. cocaine or excess alcohol consumption.

 HIV infection in developed countries.

 Certain drugs: bromocriptine, doxorubicin, lithium, phenidione.

 Breast cancer.

 Human T cell virus type infection.

 Herpes simplex infection of the breast.

.
 Phenylketonuria.

2.Relative contraindications :
Maternal conditions like—
 Radiotherapy.

 Ergot therapy.

 Antimetabolic therapy.

 Lithium therapy.
3.Neonatal factors :
 Very low birth weight.

 Asphyxia and intracranial stress.

 Acute illness.

 Severe degree of cleft palate.

 Galactosemia.

DISADVANTAGES :
Breast problems –
 Breastfeeding isn’t necessarily problem-free; you may have trouble with sore or cracked nipples,
engorged and painful breasts and mastitis. All of these are uncomfortable for the mother and
mastitis will require treatment, but it’s quite common and can be treated effectively.
Dietary restrictions –
 As you are continuing as your baby’s source of nutrition you have to be careful about your own
nutrition and continue to avoid certain food and limit your intake of others, e.g. alcohol and
caffeine.
Hormonal instability –
 Breastfeeding releases hormones that make you feel good, but the continuing fluctuation in
hormones after pregnancy can also play havoc with your emotions.
Inconvenience –
 While in some ways breastfeeding is incredibly convenient in that you can in large part dispense
with hauling around bottles and sterilizing equipment everywhere you go, it’s less convenient
when you’re not at home and trying to find a suitable quiet place to feed. Breastfeeding may also
make you feel a little trapped as your breasts are in frequent demand.
Dads –
 Breastfeeding is obviously something that dad can’t take part in and he may feel left out (though
probably not at 3.30 in the morning when baby’s demanding a feed), to compensate for this you
can express milk with a breast pump so dad can bottle feed your baby while you get chance to
be somewhere else for a change.

Sex –
 Some mothers find that they have lower libido when breastfeeding and it may interfere with
your sex life in other ways, for instance by changing the way you view your breasts.
PROBLEMS OF BREAST FEEDING :
A)INVERTED NIPPLES :
 Treatment should start after the birth of the baby.

 Nipple is manually stretched and rolled out several times a day.

 A pump or a plastic syringe is used to draw out the nipple and the baby is then put to the breast.
B)SORE NIPPLE :
 Correct positioning and latching of the baby to the breast.

 Frequent washing with the soap and water should be avoided.

 Baby should not pull off the breast while still sucking.

 Hind milk should be applied to the nipple after a feeding.

 Nipples should be aired and allowed to heal in between feeds.

c)BREAST ENGORGEMENT :
 Occurs on 4-5 th postpartum. Breasts are swollen and hard.
 Frequent feeding and correct attachment of the baby to the breast during feeding to be done to
prevent engorgement.

 Treatment should be done with local warm packs and analgesics to the mothers to relieve the
pain.

 Milk should be expressed gently to soften the breast and then baby should be put to the breast
with good latching.
D)BREAST ABSCESS :
 Treatment should be done with analgesics and antibiotics.

 Abscess may need incision and drainage.

 Breast feeding must be continued.

E)NOT ENOUGH MILK :
Many mothers complain that they don’t have enough milk. Reassurance is needed if the child is gaining
weight adequately and passing urine 6-8 times/ day and sleeping for 2 – 3 hrs after feed. Common
causes of not enough milk include –not breastfeeding enough, too short or hurried breastfeeds, poor
suckling position, poor oxytoxin reflex, breast engorgement or mastitis. Back massages are sufficiently
useful for stimulating lactation.
F)LONG NIPPLES :
It causes poor feeding due to improper latch on to the nipple without the areola. Mothers have to help
the baby to draw the areola.

Measures to be taken to overcome the problems of breast feeding are as follows :

1.The baby who does not suck :
 No undeed drugs to be given to breastfeeding mothers.

 No artificial food or water to be given to the baby.

 Breast feeding to be given when the baby is alert and ready.

 Milk to be expressed into the nipple just prior to feed the baby.

 Nipples should be placed slightly upwards towards the roof of the baby’s mouth.

 Keeping the baby’s nose free during the breast feeding.

2.The baby who refused to breastfeed :

The baby should be held in comfortable position with good attachment to the breast and should be kept
dry and warm.

 Avoiding pressure on painful areas during feeding.

 Express breast milk to maintain lactation in both breast

 Allowing one baby to feed only one breast.

BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)

It was launched in India in 1992, as a part of “INNOCENT DECLARATION’’ on breastfeeding. The
historical Innocent declaration on the promotion, protection and support of breastfeeding was produced
and adopted by participants at the WHO/UNICEF policy makers ‘meeting on breast feeding in the
1990’s,held at the Spedate degli Innocenti.Florence,Italy on July 30 to August 1st 1990.

TEN STEPS TO SUCCESSFUL BREASTFEEDING:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding within one half-hour of birth.

5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their
infants.

6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
from the hospital or clinic.

OTHER PURPOSES OF BABY FRIENDLY HOSPITAL INITIATIVE:

1. Mother friendly delivery services.
2. Standardized institutional support of immunization.
3. Diarrheal management.
4. Promotion of healthy growth and development.
5. Widespread availability and adoption of family planning.

The government of India has also enacted a law “ THE INFANT MILK SUBSTITUTES,
FEEDING BOTTLES AND INFANT FOOD ACT, 1998” which prohibits the advertising of infant
milk substitutes and feeding bottles to the public, free sampling, hospital promotion and gifts of sample
of infant milk substitute to health workers. Violation of this law can lead to fine or imprisonment.

CONCLUSION:
Breast feeding is the “GOLD STANDARD “for infant feeding. All babies irrespective of the type of
delivery should get exclusive breast feeding upto 6 months of age. The nurses should encourage the
mothers to breastfeed the baby so as to prevent the baby from many complications in the later life and
also implements the ten successful steps of successful breastfeeding.
GENERAL OBJECTIVES:
1. Identify the different components of exclusive breast feeding and Baby Friendly Hospital Initiative.
2. To list out what a nurse can do in helping mothers to maintain lactation.
3. To apply the knowledge gained related to exclusive breast feeding and Ba w2by Friendly Hospital
Initiative in helping mothers both in clinical and community areas.
BIBLIOGRAPHY
1. Dutta Parul; “Pediatric Nursing’’; Jaypee Publication, 2nd edition;
Page no.51-56
2. Ghai OP; “Essential Pediatrics’’; CBS publications; 7th edition;2009
Page no.122-128.

3.Marlow R. Dorothy; “Textbook Of Pediatric Nursing”; Elsevier publications;6 th edition; 2010: Page
no. 372-373.

4 Wong’s; “Essential Of Pediatrics Nursing’’; Elsevier Publication; 7th edition;2005;Page no 205-207.

5.Dutta D. C.; “Textbook of Obstetrics’’; New Central Book Agency (P) Ltd publications;6 th edition;
page no. 449-453.