BREAST FEEDING, BREAST FEEDING WEEK &

BABY FRIENDLY HOSPITAL INITIATIVE

• Breastfeeding is the feeding of an infant or young child with breast milk directly from a
woman's breasts, not from a baby bottle or other container.
According to a 2001 World Health Organization (WHO) report alternatives to breastfeeding
include:

• expressed breast milk from an infant’s own mother

• breast milk from a healthy wet-nurse or a human-milk bank
• A breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and
teat.

 In most situations human breast milk is the best source of nourishment for human infants,
preventing disease, promoting health and reducing health care costs (exceptions include
situations where the mother is taking certain drugs or is infected with tuberculosis or HIV).

 In both developing and developed countries, artificial feeding is associated with more
deaths from diarrhoea in infants.

 The WHO recommends a minimum of two years of breastfeeding and exclusive

breastfeeding for the first six months of life. Exclusive breastfeeding for the first six
months of life "provides continuing protection against diarrhea and respiratory tract
infection" that is more common in babies fed formula.

Lactation

The production, secretion and ejection of milk is called lactation.

Breast milk

 Breast milk is made from the nutrients in the mother's bloodstream and bodily stores. Some
studies estimate that a woman who breastfeeds her infant exclusively uses 400 - 600 extra
calories a day in producing milk. The composition of breast milk changes depending on
how long the baby nurses at each session, as well as on the age of the child.

"Research shows that the milk and energy content of breast milk actually decreases after the first
year. Breast milk adapts to a toddler's developing system, providing exactly the right amount of
nutrition at exactly the right time. In fact, research shows that between the ages of 12 and 24
months, 448 milliliters of a mother's milk provide these percentages of the following minimum
daily requirements:

Energy 29% Folate 76% Protein 43% Vitamin B12 94% Calcium 36% Vitamin C 60% Vitamin A
75% "

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Benefits for the infant
Superior nutrition

Breast milk contains the ideal ratio of the amino acids cystine, methionine, and taurine to support
development of the central and peripheral nervous system. Children aged seven and eight years old
who were of low birthweight who were breastfed for more than eight months demonstrated
significantly higher intelligence quotient scores than comparable children breastfed for less time.

Less Diarrhea

Breastfeeding protects infants against diarrhea as compared to formula-fed peers and also
compared to formula-fed peers, death rates due to diarrhea in breastfed infants are lower
irrespective of the development level of the country.

Greater immune health

Breast milk include several anti-infective factors such as bile salt stimulated lipase (protecting
against amoebic infections), lactoferrin (which binds to iron and inhibits the growth of intestinal
bacteria) and immunoglobulin A protecting factor against microorganisms.

High levels of certain polyunsaturated fatty acids in breast milk (including eicosadienoic,
arachidonic and gamma-Linolenic acids) are associated with a reduced risk of child infection when
even nursed by HIV-positive mothers. Arachidonic acid and gamma-linolenic acid may also
reduce viral shedding of the HIV virus in Breast milk.

Higher Intelligence

Babies with a specific variant of the FADS2 gene (approximately 90% of all babies) demonstrate
an IQ an average of 7 points higher if breastfed

Long Term Health Effects

Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers
with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.
Breastfeeding also appears to protect against diabetes mellitus type 2, at least in part due to its
effects on the child's weight.

Breastfeeding appears to reduce the risk of extreme obesity in children aged 39 to 42 months.
The protective effect of breastfeeding against obesity is consistent, and appears to increase with the
duration of breastfeeding.

A review of the association between breastfeeding and celiac disease (CD) concluded that breast
feeding while introducing gluten to the diet reduced the risk of CD.

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 Fewer Infections
Breastfeeding reduced the risk of acquiring urinary tract infections in infants up to seven months
post-partum. Breastfeeding appears to reduce symptoms of upper respiratory tract infections in
premature infants up to seven months after release from hospital. Increased duration of certain
types of middle ear infections (otitis media with effusion, OME) in the first two years of life is
associated with a shorter period of breastfeeding. A reduced proportion and duration of any otitis
media infection was associated with breastfeeding rather than formula feeding for the first twelve
months of life.

Less Atopy
In children who are at risk for atopy (defined as at least one parent or sibling having atopy), atopic
syndrome can be prevented or delayed through exclusive breastfeeding for four months.
Atopic dermatitis, the most common form of eczema, can be reduced through exclusive
breastfeeding beyond 12 weeks in individuals with a family history of atopy.

Less necrotizing enterocolitis

Necrotizing enterocolitis (NC), found mainly in premature births, is six to ten times more common
in infants fed formula exclusively, and three times more common in infants fed a mixture of breast
milk and formula, as compared to exclusive breastfeeding.

Possible protection from sudden infant death syndrome

Breastfed babies have improved arousal from sleep, which may reduce the risk of sudden infant
death syndrome

Benefits for mothers

Breastfeeding is a cost effective way of feeding an infant, and provides the best nourishment for a
child at a small nutrient cost to the mother. Frequent and exclusive breastfeeding can delay the
return of fertility through lactational amenorrhea.

Cancer
Breastfeeding mothers have less risk of endometrial, and ovarian cancer, and osteoporosis.Women
who were breast fed in infancy may have a lower risk of developing breast cancer than those who
were not breast fed.

Other health benefits

Mothers who breastfeed longer than eight months also benefit from bone re-mineralization and
breastfeeding diabetic mothers require less insulin. Breastfeeding helps stabilize maternal
endometriosis, reduces the risk of post-partum bleeding and benefits the insulin levels for mothers
with polycystic ovary syndrome.

Arthritis

Women who breast feed for longer have a smaller chance of getting rheumatoid arthritis.

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Bonding

The hormones released during breastfeeding strengthen the maternal bond.

Hormone release

Breastfeeding releases the hormones oxytocin and prolactin which relax the mother and make her
feel more nurturing toward her baby. Breastfeeding soon after giving birth increases the
mother's oxytocin levels, making her uterus contract more quickly and reducing bleeding.

Weight loss

As fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6
months—can help mothers lose weight.

Methods and considerations

Early breastfeeding

In the half hour after birth, the baby's suckling reflex is strongest, and the baby is more alert, so it
is the ideal time to start breastfeeding.

Time and place for breastfeeding

Breastfeeding at least every two to three hours helps to maintain milk production. For most
women, eight breastfeeding or pumping sessions every 24 hours keeps their milk production high.
Newborn babies may feed more often than this: 10 to 12 breastfeeding sessions every 24 hours is
common, and some may even feed 18 times a day. Feeding a baby "on demand" (sometimes
referred to as "on cue"), means feeding when the baby shows signs of hunger; feeding this
way rather than by the clock helps to maintain milk production and ensure the baby's needs for
milk and comfort are being met.

The sucking patterns and needs of babies vary. Babies may also nurse when they are lonely,
frightened or in pain.

The "rooting reflex" is the baby's natural tendency to turn towards the breast with the mouth
open wide; mothers sometimes make use of this by gently stroking the baby's cheek or
lips with their nipple in order to induce the baby to move into position for a breastfeeding
session, then quickly moving baby onto the breast while baby's mouth is wide open.

Exclusive breastfeeding
Exclusive breastfeeding is when an infant receives no other food or drink besides breast
milk. National and international guidelines recommend that all infants be breastfed
exclusively for the first six months of life. Breastfeeding may continue with the addition of
appropriate foods, for two years or more. Exclusive breastfeeding has dramatically reduced infant
deaths in developing countries by reducing diarrhea and infectious diseases.

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Exclusively breastfed infants feed anywhere from 6 to 14 times a day. Newborns consume from
30 to 90 ml .After the age of four weeks, babies consume about 120ml per feed. Each baby is
different, but as it grows the amount will increase.

It is important to recognize the baby's hunger signs. It is assumed that the baby knows how much
milk it needs and it is therefore advised that the baby should dictate the number, frequency, and
length of each feed. The supply of milk from the breast is determined by the number and length of
these feeds or the amount of milk expressed.

Babies that fail to eat enough may exhibit symptoms of failure to thrive. If necessary, it is
possible to estimate feeding from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet
disposable, and 2–5 soiled per 24 hours suggests an acceptable amount of input for newborns
older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of
adequate input as some normal infants may go up to 10 days between stools. Babies can also be
weighed before and after feeds.

Assessment of Breast feeding

ASK, CHECK RECORD
Ask the mother,
 How is the breast feeding going?

 Has your baby fed on the previous hour?

 Is there any difficulty?

 Is your baby satisfied with the feed?

 Have you fed your baby any other foods or drinks?

 How do your breasts feel?

 Do you have any concerns?

If baby more than one day old:

 How many times has your baby fed in 24 hours?

LOOK, LISTEN, FEEL

 Observe a breastfeed

If the baby has not fed in previous hour, ask mother to put the baby on her breasts &
observe for about 5 minutes.

 LOOK

 Is the baby able to attach correctly?

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 Is the baby well positioned?

 Is the baby sucking effectively?

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 If mother has fed in last one hour, ask her to tell you when her baby is wiling to feed again.

SIGNS CLASSIFY TREAT & ADVISE

 Sucking effectively FEEDING  Encourage the mother to continue
 Breast feeding 8 WELL feeding on demand
times in 24 hours on
demand
 Not yet breastfed(first  Support exclusive B.F.
hour of life)  Help the mother to initiate B.F.
 Not well attached  Teach correct positioning &
 Not sucking effectively FEEDING attachment
 B.F. less than 8 times DIFFICULTY  Advise to feed more frequently, day
per 24 hour & night
 Receiving other foods or  Advise mother to stop other foods &
drinks drinks
 Several days old &  Reassess at next feed or follow-up
inadequate wt.gain visit in 2 days.
 Not sucking(after 6 NOT ABLE TO  Refer baby urgently to hospital
hours of age) FEED
 Stopped feeding

Support exclusive breast feeding

 Keep the mother & baby together, Do not separate them

 Encourage B.F. on demand, day & night, As long as the baby wants.

 A baby needs to feed day & night, 8 or more times in 24 hours from birth.

 A small baby should be encouraged to feed, day & night, at least 8 times in 24 hours from
birth.

 DO NOT FORCE THE BABY TO TAKE BREAST.

 DO NOT INTERRUPT BABY BEFORE BABY WANTS.

 DO NOT GIVE ANY OTHER FEEDS OR WATER.

 DO NOT USE ARTIFICIAL TEATS OR PACIFIERS.

Teach correct positioning & attachment

 Show the mother how to hold her baby, she should;

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  Make sure baby’s head & body are in a straight line

 Make sure baby is facing the breast; the nose is opposite to nipple

 Hold baby’s body close to her body

 Support baby’s whole body, not just head & shoulder

 Show the mother how to help baby to attach, she should;

 Touch her baby’s lips with her nipple

 Wait until baby’s mouth is opened wide

 Move baby quickly on to breast, aiming infant’s lower lip well below nipple.

 Look for signs of good attachment;

 More of areola visible above baby’s mouth

 Mouth wide open

 Lower lip turned outwards

 Baby’s chin touching breast

 Look for signs of effective sucking(i.e. slow, deep sucks)

 If the attachment or sucking is not good, try again. Then reassess.

 If breast engorgement, express a small amount of breast milk before starting to soften
nipple area so that to make attachment easier.

Expressing breast milk

Manual breast pump

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When direct breastfeeding is not possible, a mother can express (artificially remove and store) her
milk. With manual massage or using a breast pump, a woman can express her milk and keep it in
freezer storage bags, a supplemental nursing system, or a bottle ready for use.

"Exclusively Expressing", "Exclusively pumping" and "EPing" are terms for a mother who
feeds her baby exclusively on her breastmilk while not physically breastfeeding.

It is generally advised to delay using a bottle to feed expressed breast milk until the baby is 4-6
weeks old and is good at sucking directly from the breast. Because it takes less effort to suck from
a bottle, a baby might lose its desire to suck from the breast. This is called nursing strike or
nipple confusion. To avoid this when feeding expressed breast milk (EBM) before 4-6 weeks of
age, it is recommended that breast milk be given by other means such as feeding spoons or
feeding cups.

Express breast milk

Need clean container to collect & store milk, with a well fitting lid to cover.

INDICATION: - To provide milk when she is away.

-To feed if baby is small & weak to suckle.

-To relieve engorgement.

-To drain when severe mastitis or abscess.

How to express;

• Wash hands thoroughly.

• Sit comfortably & hold a clean container underneath breast.

• Put first finger & thumb on either side of areola, behind the nipple.

• Press slightly inwards toward breast between finger & thumb.

• Express one side until milk flow slows. Then express other side.

• Continue alternate side for at least 20-30 min.

If milk does not flow well:

• Apply warm compresses.

• Do massage on back & neck before next expression.

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 • Teach mother breast & nipple massage.

• Feed baby by cup immediately. If not store properly.

Hand express breast milk directly in to baby’s mouth.

• Teach mother how to express.

• Hold baby in skin to skin contact, mouth close to nipple.

• Wait until baby is alert & opens mouth or stimulate baby lightly to awaken.

• Let the baby smell, lick the nipple & attempt to suck.

• Let some milk fall in to baby’s mouth.

• Wait until baby swallows before expressing more milk.

• When baby has had enough milk he will close mouth & take no more.

• Repeat this process every 1-2 hour if baby is very small.

ASSESS REPLACEMENT FEEDING

SIGNS CLASSIFY TREAT & ADVISE
 Sucking & swallowing  Encourage mother to continue feeding by
adequate amount of milk, FEEDING cup on demand.
spilling little WELL
 Feeding 8 times in 24 hours on
demand day & night
 Not yet fed(first 6 hours of life)  Teach mother replacement feeding
 Not fed by cup  Teach mother cup feeding
 Not sucking & swallowing  Advice to feed more frequently, on
effectively, spilling more demand, day & night
 Not feeding adequate amount
FEEDING  Advise to stop feeding other foods or
per day DIFFICULTY drinks
 Feeding < 8 times per day  Reassess at next feed or follow-up visit in
 Receiving other foods & drinks 2 days
 Several days old & inadequate
wt.gain
 Not sucking(after 6 hours of NOT ABLE  Refer baby urgently to hospital
age) TO FEED
 Stopped feeding

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Mixed feeding

Expressed breast milk (EBM) or infant formula can be fed to an infant by bottle

Predominant or mixed breastfeeding means feeding breast milk along with infant formula,
baby food and even water, depending on the age of the child. Babies feed differently with
artificial teats than from a breast. When feeding from the breast, the tongue massages the milk
out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a
bottle, an infant will suck harder and the milk may come in more rapidly. Therefore, mixing
breastfeeding and bottle-feeding (or using a pacifier) before the baby is used to feeding from its
mother can induce the infant to prefer the bottle to the breast

Tandem breastfeeding

Feeding two children at the same time is called tandem breastfeeding. The most common
reason for tandem breastfeeding is the birth of twins, although women with closely spaced
children can and do continue to nurse the older as well as the younger. As the appetite and
feeding habits of each baby may not be the same, this could mean feeding each according to their
own individual needs, and can also include breastfeeding them together, one on each breast.

Give special support to breastfeed twins

• Explain mother, she has enough supply for two.

• Twins may take longer to establish B.F., as they are frequently born preterm with
low birth wt.

• Start feeding one baby at a time until B.F. is well established.

• If one baby is weaker, make sure that weaker gets enough milk.

Shared breastfeeding

It used to be common worldwide, and still is in developing nations such as those in Africa, for
more than one woman to breastfeed a child. Shared breastfeeding is a risk factor for HIV infection
in infants. A woman who is engaged to breastfeed another's baby is known as a wet nurse

Weaning

Weaning is the process of introducing the infant to other food and reducing the supply of
breast milk. The infant is fully weaned once it relies on other food for all its nutrition and it no
longer receives any breast milk. In the past, bromocriptine was sometimes used to reduce the
engorgement experienced by many women during weaning. But this medication posed serious
health risks such as stroke so not used nowadays.

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Sociological factors with breastfeeding
There are several social factors that correlate with differences in initiation, frequency, and duration
of breastfeeding practices of mothers. Race, ethnic differences and socioeconomic status and
other factors have been shown to affect a mother’s choice whether or not to breastfeed and how
long she breastfeeds her child.
Race and culture; African American women are less likely than white women of similar
socioeconomic status to breastfeed and Hispanic women are more likely to breastfeed. This may
be evidence that breastfeeding acceptability is based on cultural acceptance, and that acceptance
is related to socioeconomic status in the mother’s culture.

Income; income level can also contribute to women discontinuing breastfeeding early. More
highly educated women are more likely to have access to information regarding difficulties with
breastfeeding, allowing them to continue breastfeeding through difficulty rather than weaning
early. Women in higher status jobs are more likely to have access to a lactation room and suffer
less social stigma from having to breastfeed or express breastmilk at work. In addition, women
who are unable to take an extended leave from work following the birth of their child are less likely
to continue breastfeeding when they return to work.

Other factors found to have an effect on breastfeeding are “household composition,

metropolitan/non-metropolitan residence, parental education, household income or poverty status,
neighborhood safety, familial support, maternal physical activity, and household smoking status.”

Economic factors of breastfeeding

Women who are less likely to breastfeed, their babies lack the protection that breast milk
provides. In the case of poor mothers this combined with the extra cost of artificial feeding could
result in more debt, and even worse poverty.

The birth of a child puts an economic strain on parents, but this is exacerbated if the baby is not
breastfed. This is also linked to Michael Marmot’s theory of status syndrome, in which status
level, determined by education, wealth, occupation, and social prestige, determines how healthy
people are.

Higher breastfeeding rates will not reduce the socioeconomic disparity, but it might help to
increase the health of those who are poor and disadvantaged.

Breastfeeding difficulties
Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained
midwives, doctors and hospital staff, and lactation consultants. There are some situations in which
breastfeeding may be harmful to the infant, including infection with tuberculosis or HIV, some
medications and some drugs.

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 Breastfeeding Difficulties – Mother

ASSESS THE MOTHER’S BREAST IF COMPLAINING OF NIPPLE OR BREAST PAIN

SIGNS CLASSIFY TREAT & ADVISE

 No
swelling,redness,tenderness
 Normal body temp.
 Nipple not sore & no fissure
seen
 Baby well attached
 Nipple sore or fissured
 Babe not well attached
 Both breast are swollen,
shiny & patchy red
 Temp.<38 C
 Baby not well attached
 Not yet breast feeding
 Part of breast is painful,
swollen & red
 Temp.>38 C
 Feels ill
 Reassure the mother
BREAST
HEALTHY
 Encourage mother to continue B.F.
NIPPLE  Teach correct position & attachment
SORENESS  Reassess after 2 feed(or 1 day).If not
OR better, teach mother how to express
FISSURE milk from affected breast &feed by
cup, continue B.F. on healthy side
 Encourage to continue B.F.
 Teach correct position & attachment
BREAST  Advice to feed more frequently
ENGORGEMENT  Reassess after 2 feed(1 day).If not
better, teach mother how to express
enough milk before feed to relieve
discomfort
 Encourage mother to continue B.F.
 Teach correct position & attachment
MASTITIS  Give cloxacillin for 10 days
 Reassess in 2 days, if worse or no
improvement refer to hospital
 If severe pain, give paracetemol

Sore Nipples

Probably it is the most common difficulty, Caused by different factors.

If nipples feel painfully sore or the nipples or areola feel bruised, it is mainly due to an improper
latch-on process or ineffective sucking. Suspect a difficulty with baby's latch or sucking if nipples
become very red, raw, blistered, or cracked. A latch or sucking difficulty or a structural variation in
the baby's mouth might result in nipples that look creased or blanched (turn white) at the end of
feedings. Certain creams or dressings may promote healing, but others can actually cause more
damage. Also, avoid any treatment that might result in drying the nipple tissue, which may lead to
cracking of the skin.

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When nipples become red and burn, or feel extremely sore after weeks or months of pain-free
breastfeeding, it may be due to a yeast infection such as thrush, appear as white patches in the
baby's mouth or it may show up as a bright red diaper rash. Specific medications are needed to
treat yeast infections.

Insufficient or Delayed Milk Production

A delay in the time when milk "comes in" sometimes occurs in mothers dealing with certain health
conditions.

Infrequent or insufficient breastfeeding (milk removal) is the most common reason for a delay in
the time when the milk "comes in," for insufficient milk production, or for any drop in production.

First thing to do is a review of the number and length of breast feedings.

Occasionally, a mother has a health condition that may temporarily delay the large increase in
milk production usually seen between three to five days following birth (postpartum). These
mothers do not begin to obtain large amounts of milk until seven to 14 days after giving birth. The
cause for a delay in increased milk production may be due to:

• severe stress
• cesarean (surgical) delivery
• postpartum hemorrhage
• retained placenta fragments
• infection or illness with fever
• diabetes - juvenile, adult-onset and gestational
• thyroid conditions
• strict or prolonged bed rest during pregnancy

Low Milk Production

Sometimes, a delay in the time when milk "comes in" turns into an ongoing problem with low milk
production. Sometimes, a mother has been producing sufficient amounts of milk, and then milk
production slowly, or quite suddenly, decreases. Some of the conditions associated with a delay
may also have an ongoing effect on milk production, including the following:

• severe postpartum hemorrhage (excessive bleeding)

• retained placental fragments
• thyroid conditions

Mothers with previous breast surgery that cut some of the nerves, milk-making tissue, or milk
ducts, may have difficulty producing enough milk to fully feed a baby.

Other factors can also lead to insufficient milk production. Maternal smoking has been shown to
result in less milk. Some medications and herbal preparations have a negative effect on the
amount of milk produced. Hormonal forms of birth control, especially any containing estrogen,
have been found to have a big impact on milk production. However, some mothers report a drop
in milk production after receiving/taking a progestin-only contraceptive during the first four to eight
weeks after delivery (postpartum). Milk production may also decrease if mother become
pregnant again.

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If insufficient milk production seems to be a problem, yet the baby seems to be sucking
effectively, physician may recommend the following:

(1) Increase the number of breastfeeding to 10 to 12 in 24 hours.

(2) Increase the period of skin-to-skin contact with baby.
(3) A review of health history of mother to discover if there may be a health condition,
treatment, or medication interfering with milk production.
(4) Pump breasts for several minutes after breastfeeding, using a hospital-grade electric
breast pump.
(5)Consider a galactogogue, which is a medication or an herbal preparation found to have a
positive effect on milk production.

Flat or Inverted Nipples

Techniques for flat or inverted nipples:

Usually there is little trouble in breastfeeding even if mother's nipples appear to be flatter. The
benefit of using hard plastic breast shells is not conclusive. Breast shells exert a small amount of
traction to help draw the nipple outward. Using a breast pump to draw the nipple out just prior to
breastfeeding may also help.

If nipples invert, or "dent" inward, with stimulation, Nipple eversion devices are available.
Occasionally, a mother has one or more severely inverted nipples. If one breast is less affected,
babies can breastfeed on only one breast.

The management of flat nipples (much engorgement contributes to the problem)–:

 Try to manipulate the nipple a little, to make it more erect and easy to grasp.

 It is often helpful to remove some of the milk so that the breast becomes a little softer –
either express by hand, or use a breast pump.

 Gently and patiently, put the infant to the breast for another try. One drop of milk left at the
tip of the nipple may act as an ‘appetizer’.

 Remember that the nipple and the areola must both be put well into the baby’s mouth.
Sometime to do these press the baby rather firmly on to the breast. Don’t be afraid to do
this – if you think the breast is going to block the baby’s nose, use a finger to hold the
breast clear of the nose – don’t pull the baby’s head away!

If the baby still does not succeed, let it suck through a nipple shield for a few days, until
engorgement subsides and the nipple has stretched.

Plugged Milk Ducts

A plugged duct feels like a tender lump in the breast. Usually they occur when a mother goes too
long without emptying her breasts, or if insufficient milk is removed during feedings. Review
baby's feeding routine and see if the time between one or more feedings has recently changed for
any reason. Ineffective sucking may contribute to plugged ducts.

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Management; be sure to breastfeed/remove milk often and alternate different feeding positions. It
often helps to apply warm compresses to the area or soak the breast with warm water. Massage
above and then over the affected area when breastfeeding and after application of warm
compresses.

Mastitis

Mastitis is often due to breast infection or due to an inflammation. Often a reddened area is noted
on the breast. Reasons are similar to those for plugged duct development, and the same
interventions usually are helpful.

Management; It is especially important to keep the affected breast "empty" through frequent
breastfeeding. If there are flu-like symptoms or the temperature increases to 100.4° F or higher,
patient should be prescribed an antibiotic probably for 10 to 14 days.

Breastfeeding Difficulties – Baby

Ineffective Latch-On or Sucking

A baby must be able to effectively remove milk from the breast to gain weight .Therefore;
ineffective milk removal can result in poor weight gain which is then followed by a drop in the
amount of milk being produced for the baby.

A baby's ability to suck and remove milk may be affected by Prematurity, labour and delivery
medication, and conditions such as Down syndrome, may initially make it difficult for a baby's
central nervous system to remain alert or coordinate suck-swallow-breathe actions.

Acute health conditions (jaundice or infections) and chronic conditions, such as cardiac
defects may also influence a baby's level of alertness or the ability to suck.

A "mechanical" issue, such as tongue-tie or a cleft lip or palate might directly interfere with a
baby's ability to use the structures in the mouth for effective sucking.

Signs of ineffective sucking may include the following:

The baby who consistently:

1. Does not wake on his/her own to cue for feedings eight or more times in 24 hours.
2. Cues to feed 14 or more times in 24 hours.
3. Latches on and then let’s go of the breast repeatedly.
4. Pushes away or resists latch-on.
5. falls asleep within five minutes of latch-on or after sucking for only two or three minutes.
6. Does not suck almost continuously for the first seven to 10 minutes of a feeding.
7. Continues to feed without self-detaching at the first breast after 30 to 40 minutes.
8. Feeds for more than 45 minutes without acting satisfied or full after a meal.
9. Produces less than 3 stools in 24 hours by the end of the first week (for the first 4 to 8 weeks).
10. seems "gassy" and produces green, frothy stools after the first week.
11. Produces fewer than six soaking wet diapers in 24 hours by the end of the first week.
12. Has difficulty taking milk by other alternative feeding methods.

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The mother who:

1. Have persistent sore or bruised nipples or areola.

2. Develops red, scraped or cracked nipples.
3. Frequently observes misshapen nipples after feedings (i.e., creasing or flattening).
4. Rarely or never notices fullness prior to, and a softening of the breasts after, a feeding,
especially if there are several hours between feedings.
5. Experiences more than one episode of plugged ducts or mastitis.

How you can help with the breastfeeding process:

1. Wake the baby to breastfeed every two to three hours if he/she is "sleepy" and still has not
mastered feeding cues.

2. Your baby probably will do better for some feedings. Do not be discouraged if he/she is too
sleepy or seems to "forget" from feeding to feeding.

3. Some feedings will last longer than others, and your baby may need time to "get going" at
the breast for some feeds.

4. Massage your breast with downward and inward strokes to deliver milk into the baby's
mouth when he/she begins to fall asleep at the breast too soon after starting to feed.

5. Chart the number, amount, and color of urine and stools for wet and dirty diapers on a daily
record.

6. Use a hospital-grade, electric breast pump to ensure milk removal. Express milk for several
minutes after breastfeeding. How long you will need to continue to pump depends on how
quickly your baby learns to breastfeed effectively.

7. Weigh the baby regularly or record a test-weight before and after one or more daily
feedings.

8. Offer additional calories by giving baby any expressed breast milk available first or a
prescribed infant formula based on his/her progress at breast. The amount used and the
alternative feeding method used should change as your baby's sucking ability improves.

 Certain breastfeeding devices or alternative feeding methods may encourage effective

sucking during the "learning to breastfeed" process. Devices that may be helpful in certain
situations include the following:

o Nipple shield
A thin silicone or latex nipple shield, which is centered over the nipple and areola, has been
shown to encourage a better latch, more effective sucking pattern, and better milk intake
during breastfeeding for certain babies.

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 o Feeding tube system
a feeding-tube system may be taped to the breast or your finger so that a baby receives
additional milk through the tube when the baby sucks. When a thin feeding tube is attached
to a syringe and taped it to the breast or your finger (finger-feeding), you or a helper can
gently press the plunger to deliver a few drops of milk in the baby's mouth if the baby
"forgets" to suck. Commercial feeding-tube systems are also available.

o Alternative feeding methods

In addition to a feeding-tube system, there are other alternative feeding methods that will
ensure that your baby gets enough food, yet are less likely to interfere with long-term
breastfeeding. These include cup-feeding, syringe-feeding, spoon-feeding, or (eye) dropper-
feeding. If using a bottle, bottle nipples (teats) with a slower rate of flow usually are
preferred.

• If any structural variation in the baby's mouth is found, work with the proper healthcare
professionals to correct or treat it.

Slow or Poor Infant Weight Gain

Determining slow or poor infant weight gain:

Weight gain is one of many signs of good health in the breastfeeding baby. Sometimes, a
perfectly healthy baby simply gains weight slowly because it is just his/her own unique growth
pattern. If a baby is not gaining weight according to certain patterns, the baby and the mother
should be checked.

Distinguishing the "natural" slow gainer from a slow-weight-gain problem:

A baby that is a "natural" slow-gainer still gains weight steadily, albeit slowly:

• Maintains a particular growth curve.

• Increases in length and head circumference increase according to typical rates of growth.

• Wakes on his/her own and are alert and cues to breastfeed about 8 to 12 times in 24
hours.

• Produces wet and dirty diaper counts similar to a faster-growing baby.

• Does not gain at least one-half an ounce (15 g) a day by the fourth or fifth day after birth.

• Does not regain birth weight by two to three weeks after birth.

• Does not gain at least one pound (454 g) a month for the first four months (from lowest
weight after birth versus birth weight).

• Exhibits a dramatic drop in rate of growth (weight, length, or head circumference) from
her/his previous curve.

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 Mismanaged Breastfeeding

Managing mismanaged breastfeeding:

Perhaps the most common cause of slow weight gain is related to mismanaged breastfeeding.
The following are some ways to help your baby gain weight if breastfeeding management is the
reason for the slow weight-gain pattern.

• Watch for signs from baby that he/she wants to feed. baby should wake and "cue" to
breastfeed about eight to 12 times in 24 hours by rooting, making licking or sucking
motions, bobbing his/her head against the mattress, mother’s neck or a shoulder, or
bringing his/her hand to the face or mouth. Put him/her to breast right then.
• Crying is a late feeding cue. Usually a baby latches and breastfeeds better if he/she does
not have to wait until he/she is crying, frustrated, or too tired to feed. Putting a baby off to
try to get the baby to go longer between feedings and frequently offering a pacifier instead
of the breast when a baby demonstrates feeding cues are often linked to poor weight gain.

• If your baby is a "sleepy" baby who does not cue to feed at least eight times in 24 hours,
you will have to wake the baby to feed frequently - about every two hours during the
daytime and evening hours and at least every three to four hours at night until weight gain
improves.

• Be sure baby is mainly uncovered during breastfeeding. A baby that is bundled papoose-
style seems to get much too warm and comfy, and he/she is more likely to doze off too
quickly during feedings. If there is a chill in the air, drape a sheet or light blanket over you
and the baby, as needed.

• If the baby falls asleep within minutes of latching on, massage the breast as you
breastfeed to re-trigger sucking by stroking downward and inward on the breast.

• Make sure the baby is latching on correctly and sucking effectively.

• In general, avoid "switch nursing." That is, breastfeeding at one breast for a few minutes,
then the other, and then back again. This may interfere with your baby getting enough of
the calorie-rich hindmilk, which your baby gets more of as a feeding continues on one
breast. However, the "switch" strategy sometimes stimulates the "sleepy" baby so he/she
wakes up and begins sucking again.

• Offer a supplement during, or after, breastfeeding (when prescribed) to provide additional

calories. Use mother’s own expressed milk first for any alternative feedings if any
supplementary feedings are recommended.

• Use an alternative feeding method recommended , Alternative feeding methods include:

o cup feeding
o a tube system with a special feeding tube taped to the breast or a finger
o syringe feeding
o an eyedropper

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 o spoon feeding
o bottle-feeding

• Baby should be weighed on a frequent and regular basis until he/she is gaining weight at
a satisfactory rate. Digital scales are available to get precise pre- and post-feeding weights
in order to measure how much milk a baby takes in during a particular breastfeeding.
Although this can be helpful, babies take in different amounts at different feedings
throughout a 24-hour period. They also may suggest recording only a daily or weekly
weight, depending on the situation.

If breastfeeding is properly managed, yet the baby still is not gaining adequate weight, it is likely
that some other factor is affecting milk production or the baby's ability to breastfeed effectively.
Always consult your physician in this case.

Over-Active Let-Down
Although most babies with breastfeeding difficulties have problems related to getting enough milk,
a few have the opposite problem - handling too much milk. Some mothers have such a strong let-
down that the baby cannot handle the volume of milk.

If your baby chokes, gags, pushes off of the breast a minute or two after beginning to feed, an
over-active let-down may be the cause.

Most babies do learn to handle let-down as they mature, but until then you might take the baby off
the breast until the milk flow slows. Try using only one breast each feeding. Some mothers find it
helps to position the baby so that the back of her throat is higher than the nipple, so that the milk
has to "travel" uphill during a let-down, which slows the flow. Another option is to try pumping
through the let-down immediately before a feeding.

Contraception while breast-feeding

During breastfeeding, many types of contraceptives are safe. Suitable methods for breastfeeding
women are:
Abstinence
Condoms
Diaphragm
Cervical cap
Mini-Pill
Depo Provera
Implanon
IUD: copper and Mirena
Mirena

Breastfeeding your premature baby

When a baby arrives prematurely, there are many good reasons for supplying baby with
breastmilk. The breastmilk of mothers who deliver prematurely is ideally suited to the special
needs of the premature baby.
• Help a premature baby to resist infection.
• Improve the neurological development of premature infants.

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.Give special support to small baby (preterm and/or LBW)
 Reassurance

 Explain she can breast feed & she has enough milk

 Explain How the appearance of milk changes

 A small baby will not feed as well as normal baby in first days;

 May tire easily & suck weakly at first

 May Suckle for shorter periods

 Long pause between sucking

 Does not always wake up for feeds.

 Encourage skin to skin contact since it makes B.F. easier.

HELP THE MOTHER

 Initiate B.F. within 1 hour.

 Feed baby every 2-3 hours, wake baby for feeding,2 hours after last feed.

 Always start with B.F. before offering a cup.

 Keep the baby long at breast. Allow long pause or slow feed. Do not interrupt feed if baby
is still trying.

 If baby is not yet sucking well and long enough,

 Let the mother express breast milk in baby’s mouth.

 Let the mother express breast milk and feed by cup.

 Teach mother to observe swallowing if giving expressed milk.

 Weight baby daily, record & assess weight gain.

Infant weight gain Pattern

Breastfed infants generally gain weight according to the following guidelines:

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 0–4 months: 170 grams per week†
4–6 months: 113–142 grams per week
6–12 months: 57–113 grams per week
†
It is acceptable for some babies to gain 113–142 grams (4–5 ounces) per week. This
average is taken from the lowest weight, not the birth weight.

The average breastfed baby doubles birth weight in 5–6 months. By one year, the typical
breastfed baby will weigh about 2½ times birth weight. At one year, breastfed babies tend to be
leaner than bottle fed babies. By two years, differences in weight gain and growth between
breastfed and formula-fed babies are no longer evident.

What is the best way to store and freeze/thaw milk?

General guidelines;

Containers used for collection or storage of breastmilk should be clean and sterile. Small plastic
bags or disposable bottle liners (double bag) can be used to freeze milk which are commercially
available.
Label each collection with name and date, as the oldest milk will be used first. It is safest to
refrigerate or freeze milk promptly after pumping. Fresh milk can be refrigerated and transported
on ice to the NICU

Storage times: Recommendations provided by WHO

Fresh milk(6 hours at room temperature),

refrigerator (3-4 days, at the back of the fridge where it is coldest),
freezer compartment of your refrigerator (2 weeks),
if the refrigerator has a separate door (3 months),
deep freezer (6-12 months).
Frozen milk: if thawed in the fridge but not warmed (4 hours or less at room
temperature),
thawed in the fridge (24 hours but don't refreeze),
thawed in warm water (only for the duration of the feed, or back in
the fridge for a maximum of 4 hours).

To defrost: Thaw under warm running water or in a tepid water bath. Do not use hot
water, as this can destroy some of the milk's benefits. Do not thaw by leaving on the
counter for a long period of time (the refrigerator is O.K. though). Do not microwave
breast milk to heat it or thaw it. Breast milk also separates, so gently swirl to remix
2007: Breastfeeding: The 1st Hour - Save ONE million babies!
2006: Code Watch: 25 Years of Protecting Breastfeeding
2005: Breastfeeding and Family Foods: LOVING & What is the WBW?
HEALTHY
2004: Exclusive Breastfeeding: the Gold Standard Safe, Sound, The World Breastfeeding Week (WBW)
Sustainable is the greatest outreach vehicle for the
2003: Breastfeeding in a Globalised World for Peace and breastfeeding movement, being
Justice celebrated in over 120 countries.
2002: Breastfeeding: Healthy Mothers and Healthy Babies
2001: Breastfeeding in the Information Age 22
2000: Breastfeeding It's Your Right!
1999: Breastfeeding - Education for Life
1998: Breastfeeding - The Best Investment
1997: Breastfeeding - Nature's Way
Officially it is celebrated from 1–7 August. However, groups may choose other dates to make it a more
successful event in their countries.

WBW themes over the years

The World Alliance for Breastfeeding Action (WABA) was formed in 1991 to act on the Innocenti
Declaration (1990) to protect, promote and support breastfeeding. As part of its action plan to
facilitate and strengthen social mobilisation for breastfeeding, WABA envision a global unifying
breastfeeding promotion strategy. A day dedicated to breastfeeding was suggested to be marked in
the calendar of international events. The idea of a day's celebration was later turned into a week.

This has become to be known as World Breastfeeding Week (WBW) celebrated every 1-7 August
to commemorate the Innocenti Declaration. World Breastfeeding Week was first celebrated in
1992. Now it involves over 120 countries and is endorsed by UNICEF, WHO and FAO.

Overall coordination of World Breastfeeding Week is done at the WABA Secretariat in Penang,
Malaysia, which includes the selection of the theme and slogan, identifying resource persons for a
specific theme and the preparation and dissemination of World Breastfeeding Week materials such
as the calendar announcement, posters, action folders and banners. These advocacy materials serve
to stimulate action among local groups, governments, UN and other agencies and other issue
organisations for their own World Breastfeeding Week activities in their area/country.

World Breastfeeding Week 2008

Mother Support: Going for the Gold

Breastfeeding results from a reproductive health continuum for the mother to the child with no beginning
or end, from generation to generation. When a practice is disrupted, it must be restored. However,
restoration of the breastfeeding culture demands more resources and mobilization.

In conjunction with the Olympics next August, WBW 2008 calls for greater support for mothers in
achieving the gold standard of infant feeding: breastfeeding exclusively for six months, and
providing appropriate complementary foods with continued breastfeeding for up to two years or
beyond.

As every country sends its best athletes to compete at these global games, it is important to remind
ourselves that, in a similar fashion, a healthy young athlete can only emerge from a healthy start on
life. There is no question that optimal infant and young child feeding is essential for optimal
growth and development.

Supporting Mother = Supporting Her to Provide the Golden Start For Every Child!

Baby-friendly hospital
Baby-friendly hospital is a designation awarded by the World Health Organization and the
United Nations Children's Fund to hospitals worldwide that foster evidence based strategies
concerning infant feeding. These strategies have as an outcome an increased likelihood of

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informed decision making regarding infant feeding and greater skills for mothers to initiate and
sustain breastfeeding. It is termed baby friendly because it is a global strategy inclusive of and
beneficial to all mothers regardless of how they decide to feed their infants. The designation is
awarded according to stringent criteria. The award recognizes facilities that offer mothers the
information, confidence and skills needed to successfully initiate and continue breastfeeding their
babies.

The initiative was launched in 1991 as part of an effort to promote nursing over formula feeding.
In developing countries, formula feeding is associated with higher infant mortality and higher
social and economic costs. Even in developed countries, breastfeeding offers nutritional,
developmental, immunologic, and psychological advantages.

The criteria for designation as Baby-Friendly include:

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, not even sips of water, 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

The program also restricts use by the hospital of free formula or other infant care aids provided by
formula companies.

Between 1991 and 2005, approximately 15,000 facilities worldwide have been inspected and
accredited as "Baby-Friendly."

The concept of "rooming in" is rapidly being converted to the concept of bedding in, where the
neonate is transferred to the mother within 30 minutes after a normal vaginal delivery and
maximum of 4 hours following a caesarean section.

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