BREASTFEEDING (WHO)

Key facts
 Every infant and child has the right to good nutrition according to the "Convention
on the Rights of the Child".
 Undernutrition is associated with 45% of child deaths.
 Globally in 2020, 149 million children under 5 were estimated to be stunted (too
short for age), 45 million were estimated to be wasted (too thin for height), and 38.9
million were overweight or obese.
 About 44% of infants 0–6 months old are exclusively breastfed.
 Few children receive nutritionally adequate and safe complementary foods; in
many countries less than a fourth of infants 6–23 months of age meet the criteria of
dietary diversity and feeding frequency that are appropriate for their age.
 Over 820 000 children's lives could be saved every year among children under 5
years, if all children 0–23 months were optimally breastfed. Breastfeeding improves
IQ, school attendance, and is associated with higher income in adult life. (1)
 Improving child development and reducing health costs through breastfeeding
results in economic gains for individual families as well as at the national level.
Undernutrition is estimated to be associated with 2.7 million child deaths annually or 45% of all child deaths.
Infant and young child feeding is a key area to improve child survival and promote healthy growth and
development. The first 2 years of a child’s life are particularly important, as optimal nutrition during this period
lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall.

Optimal breastfeeding is so critical that it could save the lives of over 820 000 children under
the age of 5 years each year.

WHO and UNICEF recommend:

 early initiation of breastfeeding within 1 hour of birth;

 exclusive breastfeeding for the first 6 months of life; and
 introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with
continued breastfeeding up to 2 years of age or beyond.

However, many infants and children do not receive optimal feeding. For example, only about
44% of infants aged 0–6 months worldwide were exclusively breastfed over the period of 2015-
2020.

Recommendations have been refined to also address the needs for infants born to HIV-infected
mothers. Antiretroviral drugs now allow these children to exclusively breastfeed until they are 6
months old and continue breastfeeding until at least 12 months of age with a significantly
reduced risk of HIV transmission.
Breastfeeding
Exclusive breastfeeding for 6 months has many benefits for the infant and mother. Chief
among these is protection against gastrointestinal infections which is observed not only in
developing but also industrialized countries. Early initiation of breastfeeding, within 1 hour of
birth, protects the newborn from acquiring infections and reduces newborn mortality. The risk
of mortality due to diarrhoea and other infections can increase in infants who are either
partially breastfed or not breastfed at all.

Breast-milk is also an important source of energy and nutrients in children aged 6–23 months.
It can provide half or more of a child’s energy needs between the ages of 6 and 12 months, and
one third of energy needs between 12 and 24 months. Breast milk is also a critical source of
energy and nutrients during illness, and reduces mortality among children who are
malnourished.

Children and adolescents who were breastfed as babies are less likely to be overweight or
obese. Additionally, they perform better on intelligence tests and have higher school
attendance. Breastfeeding is associated with higher income in adult life. Improving child
development and reducing health costs results in economic gains for individual families as well
as at the national level.(1)

Longer durations of breastfeeding also contribute to the health and well-being of mothers: it
reduces the risk of ovarian and breast cancer and helps space pregnancies–exclusive
breastfeeding of babies under 6 months has a hormonal effect which often induces a lack of
menstruation. This is a natural (though not fail-safe) method of birth control known as the
Lactation Amenorrhoea Method.

Mothers and families need to be supported for their children to be optimally breastfed. Actions
that help protect, promote and support breastfeeding include:

 adoption of policies such as the International Labour Organization’s "Maternity Protection Convention
183" and "Recommendation No. 191", which complements "Convention No. 183" by suggesting a longer
duration of leave and higher benefits;
 adoption of the "International Code of Marketing of Breast-milk Substitutes" and subsequent relevant
World Health Assembly resolutions;
 implementation of the "Ten Steps to Successful Breastfeeding" specified in the Baby-Friendly Hospital
Initiative, including:
o skin-to-skin contact between mother and baby immediately after birth and initiation of
breastfeeding within the first hour of life;
o breastfeeding on demand (that is, as often as the child wants, day and night);
o rooming-in (allowing mothers and infants to remain together 24 hours a day);
o not giving babies additional food or drink, even water, unless medically necessary;
 provision of supportive health services with infant and young child feeding counselling during all
contacts with caregivers and young children, such as during antenatal and postnatal care, well-child and
sick child visits, and immunization; and
  community support, including mother support groups and community-based health promotion and
education activities.

Breastfeeding practices are highly responsive to supportive interventions, and the prevalence
of exclusive and continued breastfeeding can be improved over the course of a few years.

Complementary feeding
Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is
provided by breast milk, and complementary foods are necessary to meet those needs. An
infant of this age is also developmentally ready for other foods. If complementary foods are not
introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth
may falter. Guiding principles for appropriate complementary feeding are:

 continue frequent, on-demand breastfeeding until 2 years of age or beyond;

 practise responsive feeding (for example, feed infants directly and assist older children. Feed slowly and
patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);
 practise good hygiene and proper food handling;
 start at 6 months with small amounts of food and increase gradually as the child gets older;
 gradually increase food consistency and variety;
 increase the number of times that the child is fed: 2–3 meals per day for infants 6–8 months of age and
3–4 meals per day for infants 9–23 months of age, with 1–2 additional snacks as required;
 use fortified complementary foods or vitamin-mineral supplements as needed; and
 during illness, increase fluid intake including more breastfeeding, and offer soft, favourite foods.

Feeding in exceptionally difficult circumstances

Families and children in difficult circumstances require special attention and practical support.
Wherever possible, mothers and babies should remain together and get the support they need
to exercise the most appropriate feeding option available. Breastfeeding remains the preferred
mode of infant feeding in almost all difficult situations, for instance:

 low-birth-weight or premature infants;

 mothers living with HIV in settings where mortality due to diarrhoea, pneumonia and malnutrition
remain prevalent;
 adolescent mothers;
 infants and young children who are malnourished; and
 families suffering the consequences of complex emergencies.

HIV and infant feeding

Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant
ways to improve infant survival rates. While HIV can pass from a mother to her child during
pregnancy, labour or delivery, and also through breast-milk, the evidence on HIV and infant
feeding shows that giving antiretroviral treatment (ART) to mothers living with HIV significantly
reduces the risk of transmission through breastfeeding and also improves her health.
WHO now recommends that all people living with HIV, including pregnant women and lactating
mothers living with HIV, take ART for life from when they first learn their infection status.

Mothers living in settings where morbidity and mortality due to diarrhoea, pneumonia and
malnutrition are prevalent and national health authorities endorse breastfeeding should
exclusively breastfeed their babies for 6 months, then introduce appropriate complementary
foods and continue breastfeeding up to at least the child’s first birthday.

 Questions and answers on HIV and infant feeding

WHO response
WHO is committed to supporting countries with implementation and monitoring of
the "Comprehensive implementation plan on maternal, infant and young child nutrition", endorsed
by Member States in May 2012. The plan includes 6 targets, one of which is to increase, by
2025, the rate of exclusive breastfeeding for the first 6 months up to at least 50%. Activities that
will help to achieve this include those outlined in the "Global strategy for infant and young child
feeding", which aims to protect, promote and support appropriate infant and young child
feeding.

UNICEF and WHO created the Global Breastfeeding Collective to rally political, legal, financial,
and public support for breastfeeding. The Collective brings together implementers and donors
from governments, philanthropies, international organizations, and civil society. The
Collective’s vision is a world in which all mothers have the technical, financial, emotional, and
public support they need to breastfeed.

WHO has formed the Network for Global Monitoring and Support for Implementation of the
International Code of Marketing of Breast-milk Substitutes and Subsequent Relevant World
Health Assembly Resolutions, also known as NetCode. The goal of NetCode is to protect and
promote breastfeeding by ensuring that breastmilk substitutes are not marketed
inappropriately. Specifically, NetCode is building the capacity of Member States and civil society
to strengthen national Code legislation, continuously monitor adherence to the Code, and take
action to stop all violations.

In addition, WHO and UNICEF have developed courses for training health workers to provide
skilled support to breastfeeding mothers, help them overcome problems, and monitor the
growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

WHO provides simple, coherent and feasible guidance to countries for promoting and
supporting improved infant feeding by HIV-infected mothers to prevent mother-to-child
transmission, good nutrition of the baby, and protect the health of the mother.
The World Health Organization (WHO) and UNICEF today issued new ten-step guidance to
increase support for breastfeeding in health facilities that provide maternity and newborn
services. Breastfeeding all babies for the first two years would save the lives of more than
820,000 children under age 5 annually.

The Ten Steps to Successful Breastfeeding underpin the Baby-friendly Hospital Initiative,
which both organizations launched in 1991. The practical guidance encourages new mothers
to breastfeed and informs health workers how best to support breastfeeding.

Breastfeeding is vital to a child’s lifelong health, and reduces costs for health facilities,
families, and governments. Breastfeeding within the first hour of birth protects newborn
babies from infections and saves lives. Infants are at greater risk of death due to diarrhoea
and other infections when they are only partially breastfed or not breastfed at all.
Breastfeeding also improves IQ, school readiness and attendance, and is associated with
higher income in adult life. It also reduces the risk of breast cancer in the mother.
“Breastfeeding saves lives. Its benefits help keep babies healthy in their first days and last
well into adulthood,” says UNICEF Executive Director Henrietta H. Fore. “But
breastfeeding requires support, encouragement and guidance. With these basic steps,
implemented properly, we can significantly improve breastfeeding rates around the world
and give children the best possible start in life.”

WHO Director-General Dr. Tedros Adhanom Ghebreyesus says that in many hospitals and
communities around the world, whether a child can be breastfed or not can make the
difference between life and death, and whether a child will develop to reach his or her full
potential.

“Hospitals are not there just to cure the ill. They are there to promote life and ensure people
can thrive and live their lives to their full potential,” says Dr Tedros. “As part of every
country’s drive to achieve universal health coverage, there is no better or more crucial place
to start than by ensuring the Ten Steps to Successful Breastfeeding are the standard for care
of mothers and their babies.”

The new guidance describes practical steps countries should take to protect, promote and
support breastfeeding in facilities providing maternity and newborn services. They provide
the immediate health system platform to help mothers initiate breastfeeding within the first
hour and breastfeed exclusively for six months.

It describes how hospitals should have a written breastfeeding policy in place, staff
competencies, and antenatal and post-birth care, including breastfeeding support for
mothers. It also recommends limited use of breastmilk substitutes, rooming-in, responsive
feeding, educating parents on the use of bottles and pacifiers, and support when mothers and
babies are discharged from hospital.
The physiological basis of breastfeeding
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2.1. Breast-milk composition

Breast milk contains all the nutrients that an infant needs in the first 6 months of life, including fat,
carbohydrates, proteins, vitamins, minerals and water (1,2,3,4). It is easily digested and efficiently used. Breast
milk also contains bioactive factors that augment the infant's immature immune system, providing protection
against infection, and other factors that help digestion and absorption of nutrients.

Fats
Breast milk contains about 3.5 g of fat per 100 ml of milk, which provides about one half of the energy content
of the milk. The fat is secreted in small droplets, and the amount increases as the feed progresses. As a result,
the hindmilk secreted towards the end of a feed is rich in fat and looks creamy white, while the foremilk at the
beginning of a feed contains less fat and looks somewhat bluish-grey in colour. Breast-milk fat contains long
chain polyunsaturated fatty acids (docosahexaenoic acid or DHA, and arachidonic acid or ARA) that are not
available in other milks. These fatty acids are important for the neurological development of a child. DHA and
ARA are added to some varieties of infant formula, but this does not confer any advantage over breast milk, and
may not be as effective as those in breast milk.

Carbohydrates
The main carbohydrate is the special milk sugar lactose, a disaccharide. Breast milk contains about 7 g lactose
per 100 ml, which is more than in most other milks, and is another important source of energy. Another kind of
carbohydrate present in breast milk is oligosaccharides, or sugar chains, which provide important protection
against infection (4).

Protein
Breast milk protein differs in both quantity and quality from animal milks, and it contains a balance of amino
acids which makes it much more suitable for a baby. The concentration of protein in breast milk (0.9 g per 100
ml) is lower than in animal milks. The much higher protein in animal milks can overload the infant's immature
kidneys with waste nitrogen products. Breast milk contains less of the protein casein, and this casein in breast
milk has a different molecular structure. It forms much softer, more easily-digested curds than that in other
milks. Among the whey, or soluble proteins, human milk contains more alpha-lactalbumin; cow milk contains
beta-lactoglobulin, which is absent from human milk and to which infants can become intolerant (4).

Vitamins and minerals

Breast milk normally contains sufficient vitamins for an infant, unless the mother herself is deficient (5). The
exception is vitamin D. The infant needs exposure to sunlight to generate endogenous vitamin D – or, if this is
not possible, a supplement. The minerals iron and zinc are present in relatively low concentration, but their
bioavailability and absorption is high. Provided that maternal iron status is adequate, term infants are born with
a store of iron to supply their needs; only infants born with low birth weight may need supplements before 6
months. Delaying clamping of the cord until pulsations have stopped (approximately 3 minutes) has been shown
to improve infants' iron status during the first 6 months of life (6,7).
Anti-infective factors
Breast milk contains many factors that help to protect an infant against infection (8) including:
 immunoglobulin, principally secretory immunoglobulin A (sIgA), which coats the intestinal mucosa and
prevents bacteria from entering the cells;
 white blood cells which can kill micro-organisms;
 whey proteins (lysozyme and lactoferrin) which can kill bacteria, viruses and fungi;
 oligosacccharides which prevent bacteria from attaching to mucosal surfaces.
The protection provided by these factors is uniquely valuable for an infant. First, they protect without causing
the effects of inflammation, such as fever, which can be dangerous for a young infant. Second, sIgA contains
antibodies formed in the mother's body against the bacteria in her gut, and against infections that she has
encountered, so they protect against bacteria that are particularly likely to be in the baby's environment.

Other bioactive factors

Bile-salt stimulated lipase facilitates the complete digestion of fat once the milk has reached the small intestine
(9). Fat in artificial milks is less completely digested (4).
Epidermal growth factor (10) stimulates maturation of the lining of the infant's intestine, so that it is better able
to digest and absorb nutrients, and is less easily infected or sensitised to foreign proteins. It has been suggested
that other growth factors present in human milk target the development and maturation of nerves and retina
(11).
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2.2. Colostrum and mature milk

Colostrum is the special milk that is secreted in the first 2–3 days after delivery. It is produced in small
amounts, about 40–50 ml on the first day (12), but is all that an infant normally needs at this time. Colostrum is
rich in white cells and antibodies, especially sIgA, and it contains a larger percentage of protein, minerals and
fat-soluble vitamins (A, E and K) than later milk (2). Vitamin A is important for protection of the eye and for
the integrity of epithelial surfaces, and often makes the colostrum yellowish in colour. Colostrum provides
important immune protection to an infant when he or she is first exposed to the micro-organisms in the
environment, and epidermal growth factor helps to prepare the lining of the gut to receive the nutrients in milk.
It is important that infants receive colostrum, and not other feeds, at this time. Other feeds given before
breastfeeding is established are called prelacteal feeds.
Milk starts to be produced in larger amounts between 2 and 4 days after delivery, making the breasts feel full;
the milk is then said to have “come in”. On the third day, an infant is normally taking about 300–400 ml per 24
hours, and on the fifth day 500–800 ml (12). From day 7 to 14, the milk is called transitional, and after 2 weeks
it is called mature milk.
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2.3. Animal milks and infant formula

Animal milks are very different from breast milk in both the quantities of the various nutrients, and in their
quality. For infants under 6 months of age, animal milks can be home-modified by the addition of water, sugar
and micronutrients to make them usable as short-term replacements for breast milk in exceptionally difficult
situations, but they can never be equivalent or have the same anti-infective properties as breast milk (13). After
6 months, infants can receive boiled full cream milk (14).
Infant formula is usually made from industrially-modified cow milk or soy products. During the manufacturing
process the quantities of nutrients are adjusted to make them more comparable to breast milk. However, the
qualitative differences in the fat and protein cannot be altered, and the absence of anti-infective and bio-active
factors remain. Powdered infant formula is not a sterile product, and may be unsafe in other ways. Life
threatening infections in newborns have been traced to contamination with pathogenic bacteria, such
as Enterobacter sakazakii, found in powdered formula (15). Soy formula contains phyto-oestrogens, with
activity similar to the human hormone oestrogen, which could potentially reduce fertility in boys and bring
early puberty in girls (16).
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2.4. Anatomy of the breast

The breast structure (Figure 3) includes the nipple and areola, mammary tissue, supporting connective tissue
and fat, blood and lymphatic vessels, and nerves (17,18).

FIGURE 3
Anatomy of the breast.
The mammary tissue – This tissue includes the alveoli, which are small sacs made of milk-secreting cells, and
the ducts that carry the milk to the outside. Between feeds, milk collects in the lumen of the alveoli and ducts.
The alveoli are surrounded by a basket of myoepithelial, or muscle cells, which contract and make the milk flow
along the ducts.
Nipple and areola – The nipple has an average of nine milk ducts passing to the outside, and also muscle fibres
and nerves. The nipple is surrounded by the circular pigmented areola, in which are located Montgomery's
glands. These glands secrete an oily fluid that protects the skin of the nipple and areola during lactation, and
produce the mother's individual scent that attracts her baby to the breast. The ducts beneath the areola fill with
milk and become wider during a feed, when the oxytocin reflex is active.
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2.5. Hormonal control of milk production

There are two hormones that directly affect breastfeeding: prolactin and oxytocin. A number of other hormones,
such as oestrogen, are involved indirectly in lactation (2). When a baby suckles at the breast, sensory impulses
pass from the nipple to the brain. In response, the anterior lobe of the pituitary gland secretes prolactin and the
posterior lobe secretes oxytocin.

Prolactin
Prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood
increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in
preparation for the production of milk (19). However, milk is not secreted then, because progesterone and
oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and
oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.
When a baby suckles, the level of prolactin in the blood increases, and stimulates production of milk by the
alveoli (Figure 4). The prolactin level is highest about 30 minutes after the beginning of the feed, so its most
important effect is to make milk for the next feed (20). During the first few weeks, the more a baby suckles and
stimulates the nipple, the more prolactin is produced, and the more milk is produced. This effect is particularly
important at the time when lactation is becoming established. Although prolactin is still necessary for milk
production, after a few weeks there is not a close relationship between the amount of prolactin and the amount
of milk produced. However, if the mother stops breastfeeding, milk secretion may stop too – then the milk will
dry up.

FIGURE 4
Prolactin.
More prolactin is produced at night, so breastfeeding at night is especially helpful for keeping up the milk
supply. Prolactin seems to make a mother feel relaxed and sleepy, so she usually rests well even if she
breastfeeds at night.
Suckling affects the release of other pituitary hormones, including gonadotrophin releasing hormone (GnRH),
follicle stimulating hormone, and luteinising hormone, which results in suppression of ovulation and
menstruation. Therefore, frequent breastfeeding can help to delay a new pregnancy (see Session 8 on Mother's
Health). Breastfeeding at night is important to ensure this effect.

Oxytocin
Oxytocin makes the myoepithelial cells around the alveoli contract. This makes the milk, which has collected in
the alveoli, flow along and fill the ducts (21) (see Figure 5). Sometimes the milk is ejected in fine streams.

FIGURE 5
Oxytocin.
The oxytocin reflex is also sometimes called the “letdown reflex” or the “milk ejection reflex”. Oxytocin is
produced more quickly than prolactin. It makes the milk that is already in the breast flow for the current feed,
and helps the baby to get the milk easily.
Oxytocin starts working when a mother expects a feed as well as when the baby is suckling. The reflex becomes
conditioned to the mother's sensations and feelings, such as touching, smelling or seeing her baby, or hearing
her baby cry, or thinking lovingly about him or her. If a mother is in severe pain or emotionally upset, the
oxytocin reflex may become inhibited, and her milk may suddenly stop flowing well. If she receives support, is
helped to feel comfortable and lets the baby continue to breastfeed, the milk will flow again.
It is important to understand the oxytocin reflex, because it explains why the mother and baby should be kept
together and why they should have skin-to-skin contact.
Oxytocin makes a mother's uterus contract after delivery and helps to reduce bleeding. The contractions can
cause severe uterine pain when a baby suckles during the first few days.

Signs of an active oxytocin reflex

Mothers may notice signs that show that the oxytocin reflex is active:
  a tingling sensation in the breast before or during a feed;
 milk flowing from her breasts when she thinks of the baby or hears him crying;
 milk flowing from the other breast when the baby is suckling;
 milk flowing from the breast in streams if suckling is interrupted;
 slow deep sucks and swallowing by the baby, which show that milk is flowing into his mouth;
 uterine pain or a flow of blood from the uterus;
 thirst during a feed.
If one or more of these signs are present, the reflex is working. However, if they are not present, it does not
mean that the reflex is not active. The signs may not be obvious, and the mother may not be aware of them.

Psychological effects of oxytocin

Oxytocin also has important psychological effects, and is known to affect mothering behaviour in animals. In
humans, oxytocin induces a state of calm, and reduces stress (22). It may enhance feelings of affection between
mother and child, and promote bonding. Pleasant forms of touch stimulate the secretion of oxytocin, and also
prolactin, and skin-to-skin contact between mother and baby after delivery helps both breastfeeding and
emotional bonding (23,24).
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2.6. Feedback inhibitor of lactation

Milk production is also controlled in the breast by a substance called the feedback inhibitor of lactation, or FIL
(a polypeptide), which is present in breast milk (25). Sometimes one breast stops making milk while the other
breast continues, for example if a baby suckles only on one side. This is because of the local control of milk
production independently within each breast. If milk is not removed, the inhibitor collects and stops the cells
from secreting any more, helping to protect the breast from the harmful effects of being too full. If breast milk is
removed the inhibitor is also removed, and secretion resumes. If the baby cannot suckle, then milk must be
removed by expression.
FIL enables the amount of milk produced to be determined by how much the baby takes, and therefore by how
much the baby needs. This mechanism is particularly important for ongoing close regulation after lactation is
established. At this stage, prolactin is needed to enable milk secretion to take place, but it does not control the
amount of milk produced.
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2.7. Reflexes in the baby

The baby's reflexes are important for appropriate breastfeeding. The main reflexes are rooting,
suckling and swallowing. When something touches a baby's lips or cheek, the baby turns to find the stimulus,
and opens his or her mouth, putting his or her tongue down and forward. This is the rooting reflex and is present
from about the 32nd week of pregnancy. When something touches a baby's palate, he or she starts to suck it.
This is the sucking reflex. When the baby's mouth fills with milk, he or she swallows. This is the swallowing
reflex. Preterm infants can grasp the nipple from about 28 weeks gestational age, and they can suckle and
remove some milk from about 31 weeks. Coordination of suckling, swallowing and breathing appears between
32 and 35 weeks of pregnancy. Infants can only suckle for a short time at that age, but they can take
supplementary feeds by cup. A majority of infants can breastfeed fully at a gestational age of 36 weeks (26).
When supporting a mother and baby to initiate and establish exclusive breastfeeding, it is important to know
about these reflexes, as their level of maturation will guide whether an infant can breastfeed directly or
temporarily requires another feeding method.
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2.8. How a baby attaches and suckles at the breast
To stimulate the nipple and remove milk from the breast, and to ensure an adequate supply and a good flow of
milk, a baby needs to be well attached so that he or she can suckle effectively (27). Difficulties often occur
because a baby does not take the breast into his or her mouth properly, and so cannot suckle effectively.

Good attachment
Figure 6 shows how a baby takes the breast into his or her mouth to suckle effectively. This baby is well
attached to the breast.

FIGURE 6
Good attachment – inside the infant's mouth.
The points to notice are:
 much of the areola and the tissues underneath it, including the larger ducts, are in the baby's mouth;
 the breast is stretched out to form a long ‘teat’, but the nipple only forms about one third of the ‘teat’;
 the baby's tongue is forward over the lower gums, beneath the milk ducts (the baby's tongue is in fact
cupped around the sides of the ‘teat’, but a drawing cannot show this);
 the baby is suckling from the breast, not from the nipple.
As the baby suckles, a wave passes along the tongue from front to back, pressing the teat against the hard
palate, and pressing milk out of the sinuses into the baby's mouth from where he or she swallows it. The baby
uses suction mainly to stretch out the breast tissue and to hold it in his or her mouth. The oxytocin reflex makes
the breast milk flow along the ducts, and the action of the baby's tongue presses the milk from the ducts into the
baby's mouth. When a baby is well attached his mouth and tongue do not rub or traumatise the skin of the
nipple and areola. Suckling is comfortable and often pleasurable for the mother. She does not feel pain.

Poor attachment
Figure 7 shows what happens in the mouth when a baby is not well attached at the breast.

FIGURE 7
Poor attachment – inside the infant's mouth.
The points to notice are:
 only the nipple is in the baby's mouth, not the underlying breast tissue or ducts;
 the baby's tongue is back inside his or her mouth, and cannot reach the ducts to press on them.
Suckling with poor attachment may be uncomfortable or painful for the mother, and may damage the skin of the
nipple and areola, causing sore nipples and fissures (or “cracks”). Poor attachment is the commonest and most
important cause of sore nipples (see Session 7.6), and may result in inefficient removal of milk and apparent
low supply.

Signs of good and poor attachment

Figure 8 shows the four most important signs of good and poor attachment from the outside. These signs can be
used to decide if a mother and baby need help.

FIGURE 8
Good and poor attachment – external signs.
The four signs of good attachment are:
 more of the areola is visible above the baby's top lip than below the lower lip;
 the baby's mouth is wide open;
 the baby's lower lip is curled outwards;
 the baby's chin is touching or almost touching the breast.
These signs show that the baby is close to the breast, and opening his or her mouth to take in plenty of breast.
The areola sign shows that the baby is taking the breast and nipple from below, enabling the nipple to touch the
baby's palate, and his or her tongue to reach well underneath the breast tissue, and to press on the ducts. All four
signs need to be present to show that a baby is well attached. In addition, suckling should be comfortable for the
mother.
The signs of poor attachment are:
 more of the areola is visible below the baby's bottom lip than above the top lip – or the amounts above
and below are equal;
 the baby's mouth is not wide open;
 the baby's lower lip points forward or is turned inwards;
 the baby's chin is away from the breast.
If any one of these signs is present, or if suckling is painful or uncomfortable, attachment needs to be improved.
However, when a baby is very close to the breast, it can be difficult to see what is happening to the lower lip.
Sometimes much of the areola is outside the baby's mouth, but by itself this is not a reliable sign of poor
attachment. Some women have very big areolas, which cannot all be taken into the baby's mouth. If the amount
of areola above and below the baby's mouth is equal, or if there is more below the lower lip, these are more
reliable signs of poor attachment than the total amount outside.
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2.9. Effective suckling

If a baby is well attached at the breast, then he or she can suckle effectively. Signs of effective suckling indicate
that milk is flowing into the baby's mouth. The baby takes slow, deep suckles followed by a visible or audible
swallow about once per second. Sometimes the baby pauses for a few seconds, allowing the ducts to fill up with
milk again. When the baby starts suckling again, he or she may suckle quickly a few times, stimulating milk
flow, and then the slow deep suckles begin. The baby's cheeks remain rounded during the feed.
Towards the end of a feed, suckling usually slows down, with fewer deep suckles and longer pauses between
them. This is the time when the volume of milk is less, but as it is fat-rich hindmilk, it is important for the feed
to continue. When the baby is satisfied, he or she usually releases the breast spontaneously. The nipple may
look stretched out for a second or two, but it quickly returns to its resting form.

Signs of ineffective suckling

A baby who is poorly attached is likely to suckle ineffectively. He or she may suckle quickly all the time,
without swallowing, and the cheeks may be drawn in as he or she suckles showing that milk is not flowing well
into the baby's mouth. When the baby stops feeding, the nipple may stay stretched out, and look squashed from
side to side, with a pressure line across the tip, showing that the nipple is being damaged by incorrect suction.

Consequences of ineffective suckling

When a baby suckles ineffectively, transfer of milk from mother to baby is inefficient. As a result:
 the breast may become engorged, or may develop a blocked duct or mastitis because not enough milk is
removed;
 the baby's intake of breast milk may be insufficient, resulting in poor weight gain;
 the baby may pull away from the breast out of frustration and refuse to feed;
 the baby may be very hungry and continue suckling for a long time, or feed very often;
 the breasts may be over-stimulated by too much suckling, resulting in oversupply of milk.
These difficulties are discussed further in Session 7.
Go to:

2.10. Causes of poor attachment

Use of a feeding bottle before breastfeeding is well established can cause poor attachment, because the
mechanism of suckling with a bottle is different. Functional difficulties such as flat and inverted nipples, or a
very small or weak infant, are also causes of poor attachment. However, the most important causes are
inexperience of the mother and lack of skilled help from the health workers who attend her. Many mothers need
skilled help in the early days to ensure that the baby attaches well and can suckle effectively. Health workers
need to have the necessary skills to give this help.
Go to:

2.11. Positioning the mother and baby for good attachment

To be well attached at the breast, a baby and his or her mother need to be appropriately positioned. There are
several different positions for them both, but some key points need to be followed in any position.

Position of the mother

The mother can be sitting or lying down (see Figure 9), or standing, if she wishes. However, she needs to be
relaxed and comfortable, and without strain, particularly of her back. If she is sitting, her back needs to be
supported, and she should be able to hold the baby at her breast without leaning forward.
FIGURE 9
Baby well positioned at the breast.

Position of the baby

The baby can breastfeed in several different positions in relation to the mother: across her chest and abdomen,
under her arm (See Figure 16 in Session 6), or alongside her body.
Whatever the position of the mother, and the baby's general position in relation to her, there are four key points
about the position of the baby's body that are important to observe.
 The baby's body should be straight, not bent or twisted. The baby's head can be slightly extended at the
neck, which helps his or her chin to be close in to the breast.
 He or she should be facing the breast. The nipples usually point slightly downwards, so the baby should
not be flat against the mother's chest or abdomen, but turned slightly on his or her back able to see the
mother's face.
 The baby's body should be close to the mother which enables the baby to be close to the breast, and to
take a large mouthful.
 His or her whole body should be supported. The baby may be supported on the bed or a pillow, or the
mother's lap or arm. She should not support only the baby's head and neck. She should not grasp the
baby's bottom, as this can pull him or her too far out to the side, and make it difficult for the baby to get
his or her chin and tongue under the areola.
These points about positioning are especially important for young infants during the first two months of life.
(See also Feeding History Job Aid, 0–6 months, in Session 5.)
Go to:

2.12. Breastfeeding pattern

To ensure adequate milk production and flow for 6 months of exclusive breastfeeding, a baby needs to feed as
often and for as long as he or she wants, both day and night (28). This is called demand feeding, unrestricted
feeding, or baby-led feeding.
Babies feed with different frequencies, and take different amounts of milk at each feed. The 24-hour intake of
milk varies between mother-infant pairs from 440–1220 ml, averaging about 800 ml per day throughout the first
6 months (29). Infants who are feeding on demand according to their appetite obtain what they need for
satisfactory growth. They do not empty the breast, but remove only 63–72% of available milk. More milk can
always be removed, showing that the infant stops feeding because of satiety, not because the breast is empty.
However, breasts seem to vary in their capacity for storing milk. Infants of women with low storage capacity
may need to feed more often to remove the milk and ensure adequate daily intake and production (30).
It is thus important not to restrict the duration or the frequency of feeds – provided the baby is well attached to
the breast. Nipple damage is caused by poor attachment and not by prolonged feeds. The mother learns to
respond to her baby's cues of hunger and readiness to feed, such as restlessness, rooting (searching) with his
mouth, or sucking hands, before the baby starts to cry. The baby should be allowed to continue suckling on the
breast until he or she spontaneously releases the nipple. After a short rest, the baby can be offered the other side,
which he or she may or may not want.
If a baby stays on the breast for a very long time (more than one half hour for every feed) or if he or she wants
to feed very often (more often than every 1–1½ hours each time) then the baby's attachment needs to be checked
and improved. Prolonged, frequent feeds can be a sign of ineffective suckling and inefficient transfer of milk to
the baby. This is usually due to poor attachment, which may also lead to sore nipples. If the attachment is
improved, transfer of milk becomes more efficient, and the feeds may become shorter or less frequent. At the
same time, the risk of nipple damage is reduced.

Breast milk and infection

Robert M Lawrence 1, Ruth A Lawrence

Affiliations expand

 PMID: 15325535

 PMCID: PMC7133241

 DOI: 10.1016/j.clp.2004.03.019

Free PMC article

Abstract
Reasonable guidelines have been pro-posed for when and how to avoid breast milk in the case of
maternal infection. For other viruses, prophylactic immune therapy to protect the infant against all
modes of transmission are indicated (VZV, varicella-zoster immunoglobulin, HAV and
immunoglobulin, HBV, and HBIg + HBV vaccine). In most maternal viral infections, breast milk is not
an important mode of transmission, and continuation of breastfeeding is in the best interest of the
infant and mother (see Tables 2 and 3). Maternal bacterial infections rarely are complicated by
transmission of infection to their infants through breast milk. In a few situations, temporary cessation
of breastfeeding or the avoidance of breast milk is appropriate for a limited time (24 hours for N
gonorrheae, H infiuenzae, Group B streptococci, and staphylococci and longer for others including B
burgdorferi, T pallidum, and M tuberculosis). In certain situations, prophylactic or empiric therapy may
be advised for the infant (eg, T pallidum, M tuberculosis, H influenzae) (see Table 1). Antimicrobial use
by the mother should not be a reason not to breastfeed. Alternative regimens that are compatible
with breastfeeding can be chosen to treat the mother effectively. In most cases of suspected infection
in the breastfeeding mother, the delay in seeking medical care and making the diagnosis means the
infant has been ex-posed already. Stopping breastfeeding at this time only deprives the infant of the
nutritional and potential immunologic benefits. Breastfeeding or the use of expressed breast milk,
even if temporarily suspended, should be encouraged and supported. Decisions about breast milk
and infection should balance the potential risk compared with the innumerable benefits of breast
milk.

5 August 2020 – In observance of Breastfeeding Awareness Month, the Department of

Health (DOH), World Health Organization (WHO), and United Nations Children’s Fund
(UNICEF) jointly appeal to the public to protect, promote, and support the practice of
exclusive breastfeeding of infants from birth up to six months, and continued with
complementary feeding onwards with breastfeeding being the most healthy, efficient, and
environmentally-sustainable action of mothers for their children.

This year’s theme, “I-BIDA ang Pagpapasuso Tungo sa Wais at Malusog na Pamayanan!”,
reinforces the importance of breastfeeding now, more than ever, because of the COVID-19
pandemic which poses a challenge to infant feeding. We enjoin everyone to ensure that
Filipino infants will have proper and adequate nutrition to improve their resilience against
the disease and minimize the long-term effects of malnutrition, ultimately meeting the
country’s commitment to sustainable development.

The COVID-19 pandemic has taken a toll in many Filipino families’ health. Because of this,
we cannot stress enough the importance of ensuring that the correct information on health
and nutrition —which includes breastfeeding—reach our people. The child and the
environment greatly benefit from the efficient, climate-smart practice of breastfeeding that
contributes to food security and reduces our carbon and ecological footprints.

“Breastfeeding is the most complete and sustainable nutrition for the first 6 months of life,
with continued benefits when done with complementary feeding for older infants and
children. In this pandemic, mothers should not be worried about breastfeeding, as long as
proper infection prevention and control (IPC) measures are observed,” Health Secretary
Francisco T. Duque, III said.
Duque added that mothers with suspected and/or confirmed COVID-19 should continue
breastfeeding, following proper wearing of masks, and frequent, proper handwashing before
and after contact with the child. Among the few cases of confirmed COVID-19 infection in
children, most have experienced only mild or asymptomatic illness—and this must be
supported with the immunological benefits of breastfeeding in infants and young children.

To date, COVID-19 has not been detected in the breastmilk of any mother with confirmed or
suspected COVID-19. While researchers continue to conduct tests, it appears unlikely that
COVID-19 would be transmitted through breastfeeding or by giving breastmilk that has
been expressed by a mother who is confirmed or suspected to have COVID-19. Babies who
receive their mothers’ breastmilk receive antibodies that protect them from potentially
deadly infections like pneumonia, diarrhea, and sepsis. This is a call for mothers to
breastfeed without any additional food or fluids, not even water, for the first six months—
and continue breastfeeding with safe, nourishing, and diverse complementary food.
Appropriate complementary feeding should be introduced at six months with continuous
breastfeeding up to 2 years and beyond.

Following delivery, medical practitioners and midwives are also advised to facilitate
immediate and continued skin-to-skin care, including Kangaroo Mother Care, to improve
thermal regulation of newborns and several other physiological outcomes. Aside from the
association with reduced neonatal mortality, placing the newborn close to the mother also
enables early initiation of breastfeeding which also reduces neonatal mortality.

“Exclusive breastfeeding protects against childhood diseases and death in infancy and
childhood, while improving the nutritional status of babies. The protective effect of
breastmilk is particularly strong against infectious diseases that are prevented through both
direct transfer of antibodies and other anti-infective factors.” said Dr. Rabi Abeyasinghe,
WHO Representative in the Philippines “Therefore, it is important to ensure all babies enjoy
exclusive breastfeeding during the first six months of their life even during the COVID-19
pandemic, following standard infant feeding guidelines but with appropriate precautions for
infection prevention and control, such as wearing a mask, practicing hand hygiene and
cough etiquette.
In all socio-economic settings, breastfeeding improves survival and provides lifelong health
and development advantages to newborns and infants. Breastfeeding also improves the
health of mothers. According to the 2018 Expanded National Nutrition Survey, however, the
percentage of 0-5 months old children who are exclusively breastfed remains to be low at
29.0 percent.

“Exclusive breastfeeding is the first step towards achieving optimum nutrition for children.
Aside from improving lifelong health and development, it paves the way for addressing
nutrition gaps that prevent children from achieving their full potential,” said Oyunsaikhan
Dendevnorov, UNICEF Philippines Representative. “We call on mothers to take this
necessary first step as we remain committed in working towards sustainable health and
nutrition services for every child and mother in the country.”

Several legislations have been enacted by the Philippine Congress to support better nutrition,
especially during the first 1000 days of a child’s life, including Republic Act (RA) 11148 or
the Kalusugan at Nutrisyon ng Mag-Nanay Act, RA 11210 or the Expanded Maternity Leave
Act, RA 10028 or the Expanded Breastfeeding Promotion Act, RA10821 or the Children’s
Emergency Relief and Protection Act, and the Executive Order 51 or the Philippine Milk
Code.

DOH, WHO, and UNICEF call for the firm and continuous enforcement of these
legislations, particularly the Philippine Milk Code, the strict regulation of milk donation, and
the implementation of Essential Infant and Newborn Care (EINC) or “Unang Yakap” during
the time of COVID-19.

1. Myth: Breastfeeding is easy.

Babies are born with the reflex to look for their mother’s breast. However, many mothers
need practical support with positioning their baby for breastfeeding and making sure their
baby is correctly attached to the breast. Breastfeeding takes time and practice for both
mothers and babies. Breastfeeding is also time intensive, so mothers need space and support
at home and work.

2. Myth: It’s usual for breastfeeding to hurt – sore nipples are

inevitable.
Many mothers experience discomfort in the first few days after birth when they are learning
to breastfeed. But with the right support with positioning their baby for breastfeeding and
making sure their baby is correctly attached to the breast, sore nipples can be avoided. If a
mother faces breastfeeding challenges like sore nipples, support from a lactation consultant
or other skilled professional can help them overcome the issue.

3. Myth: You should wash your nipples before breastfeeding.

Washing your nipples before breastfeeding isn’t necessary. When babies are born, they are
already very familiar with their own mother’s smells and sounds. The nipples produce a
substance that the baby smells and has ‘good bacteria’ that helps to build babies’ own
healthy immune system for life.
UNICEF/UN0140320/Ayene

Did you know? Breastfeeding protects your baby from ear

infections, diarrhoea, pneumonia and other childhood diseases.
4. Myth: You should separate a newborn and mother to let the mother
rest.
Doctors, nurses and midwives often encourage the practice of ‘skin-to-skin’ – also known as
kangaroo mother care – immediately after birth. Bringing your baby in direct contact, so
their skin is against yours, is a very important practice that helps them to find and attach to
the breast. If you can practice this within one hour after birth and then frequently after, it
helps to establish breastfeeding. If the mother cannot do this, then the partner or another
family member can step in.
5. Myth: You should only eat plain food while breastfeeding.
Like everybody else, breastfeeding mothers need to eat a balanced diet. In general, there is
no need to change food habits. Babies are exposed to their mothers’ food preferences from
the time they are in the womb. If a mother perceives that her baby reacts to a specific food
she eats, it is best to consult a specialist.

6. Myth: Exercise will affect the taste of your milk.

Exercise is healthy, also for breastfeeding mothers. There is no evidence that it affects the
taste of your milk.

7. Myth: You won’t be able to breastfeed unless you do it straight away.

It is easier to get breastfeeding started if you begin in the first hour after birth because a
baby’s reflexes are very strong at that time. They are ready to learn to feed at the breast. If
you do not latch your baby on right after birth, do it as soon as possible in your situation. If
you need help putting your baby to the breast, ask for support from a qualified lactation
consultant or other skilled professional. Frequent skin-to-skin contact and putting your baby
to the breast will help to get breastfeeding going.
UNICEF/UN040621

Did you know? Breastfeeding protects the mother from

diabetes, breast and ovarian cancers, heart disease and
postpartum depression.
8. Myth: You can never use formula if you want to breastfeed.
Mothers may decide they need to use formula on some occasions, while continuing to
breastfeed. It is important to seek unbiased information on formula and other products that
replace breastmilk. To keep breastmilk production going, continue offering the breast to
your baby as often as possible. It can be useful for mothers to consult a lactation specialist or
skilled professional to help with a plan that works best for them to continue breastfeeding.

9. Myth: Many mothers can’t produce enough milk.

Almost all mothers produce the right amount of milk for their babies. Breastmilk production
is determined by how well the baby is latched on to the breast, the frequency of
breastfeeding and how well the baby is removing milk with each feeding. Breastfeeding isn’t
a ‘one woman’ job and mothers need support. Support like ongoing breastfeeding guidance
from health care providers, help at home, and staying healthy by eating and drinking well.

10. Myth: You shouldn't breastfeed if you’re sick.

Depending on the kind of illness, mothers can usually continue breastfeeding when they’re
sick. You need to make sure you get the right treatment, and to rest, eat and drink well. In
many cases, the antibodies your body makes to treat your disease or illness will pass on to
your baby, building his or her own defences.

11. Myth: You can’t take any medication if you’re breastfeeding.

It’s important to inform your doctor that you are breastfeeding and to read the instructions
with any medications you buy over the counter. It might be necessary to take medications at
a specific time or in a specific dosage, or to take an alternative formulation. You should also
tell the baby’s doctor about any medications that you’re taking.
UNICEF/UN0160505/Soares

Did you know? The ‘first milk’ – or colostrum – is rich in

antibodies and gives newborns an immunity boost while their
own immune systems are still developing.
12. Myth: Babies who have been breastfed are clingy.
All babies are different. Some are clingy and some are not, no matter how they are fed.
Breastfeeding provides not only the best nutrition for infants, but is also important for their
developing brain. Breastfed babies are held a lot and because of this, breastfeeding has been
shown to enhance bonding with their mother.

13. Myth: It’s hard to wean a baby if you breastfeed for more than a
year.
There’s no evidence that it is more difficult to stop breastfeeding after one year, but there is
evidence that breastfeeding up to two years is beneficial for both mothers and children. All
mothers and babies are different and need to determine together how long they want to
breastfeed.

14. Myth: If you go back to work, you’ll have to wean your baby.
Many mothers continue breastfeeding after going back to work. First, check the policies in
your country and your own workplace. If you have the right to time and a place to breastfeed
during working hours, you may be able to go home and breastfeed, ask a family member or
friend to bring your baby to you, or to express your milk and take it home. If you don’t have
the option to breastfeed during working hours, look for moments during the day to express
your milk and then feed your baby directly when you are at home. If you decide to give your
baby a breastmilk substitute for some feeds, it still very good to continue breastfeeding
whenever you are with your baby.

an breastfeeding reduce hospitalisation from common

infectious diseases in childhood?: 2021 Annual
Conference guest speaker Dr Claire Neill discusses
the impact of breastfeeding
Dr Claire Neill is a Specialty Registrar in Public Health Medicine, currently in her final year of training. She trained as a
General Practitioner and completed a research Masters with the Department of General Practice and Centre for Public
Health at Queen’s University Belfast before going on to complete a Masters in Public Health in 2018.

As a doctor and clinician, I have had a strong interest in infectious disease prevention and have been aware of the impact of
breastfeeding on hospitalisation from common infectious diseases in childhood. In 2017 I had my son, and I grew to appreciate
the topic even more. Whilst I encountered challenges along the way in my breastfeeding journey, my awareness of its lifelong
benefits is what made me persist, and in the end my son really thrived from it.

Although breastfeeding rates have been increasing across Northern Ireland, there is significant variability across the country and
rates are still lower than in other parts of the world. There are also limited longitudinal studies on the subject of breastfeeding as
it relates to infectious disease prevention, particularly in the western world.

In the UK, respiratory-tract infections are the most common cause of hospitalisation in children, followed closely by
gastrointestinal infection. I set out to investigate whether breastfeeding is associated with reduced odds of hospitalisation from
respiratory tract or gastrointestinal illness in children up to the age of two years in Northern Ireland and to identify the risk
factors associated with not initiating breastfeeding and childhood hospitalisation from infectious disease.

Our study analysed 100,000 babies from 2012-2015, followed up over their first two years of life. We looked at a range of
different influence factors, but the main interest was breastfeeding rates at different time points and the differences between
partially and fully breastfed babies. These were assessed against outcomes of hospitalisation, and multivariable logistic
regression was used to assess and quantify the independent association of both breastfeeding exposure and additional variables
with each outcome.

Overall, we found that infants fully breastfed at six months had a 41% reduction in odds of hospitalisation for gastrointestinal
infection and a 32% reduction in odds for respiratory-tract infections. Even at two years after cessation of breastfeeding, this is
still reduced by 25%.
It was very encouraging that, even when adjusting for other factors, breastfeeding was significantly associated with
reduced hospitalisation and mortality from common childhood infections, with reductions proportional to both the
duration and exclusivity of breastfeeding. Longer-term protection also remained post-breastfeeding cessation until at
least two years of age.
Following the research, I worked with the Breastfeeding Strategy Implementation Group to incorporate our findings into
education and training materials, and then presented these to infant feeding groups and health trusts around Northern Ireland so
that they could relay the valuable information to the mothers and families they work with and support.

Having this information is powerful – I know this from my own experience. It can make all the difference to be fully informed
and have the data on just how impactful breastfeeding is. These findings can be particularly helpful for mothers who are ‘on the
fence’ about breastfeeding and are able to seek out the help and care they may need.
 RELATED STUDIES – From NATIONAL INSTITUES OF
HEALTH
While breastfeeding mothers are generally aware of the benefits of breastfeeding, they
experience barriers at individual, interpersonal, and organizational levels. It is important to
acknowledge that breastfeeding is associated with challenges and provide adequate supports for
mothers so that their experiences can be improved, and breastfeeding rates can reach those
identified by the World Health Organization. Public health efforts to educate parents about the
importance of breastfeeding can be dated back to the early twentieth century. The World Health
Organization is aiming to have at least half of all the mothers worldwide exclusively breastfeeding
their infants in the first 6 months of life by the year 2025, but it is unlikely that this goal will be
achieved. Only 38% of the global infant population is exclusively breastfed between 0 and 6 months
of life, even though breastfeeding initiation rates have shown steady growth globally. The literature
suggests that while many mothers intend to breastfeed and even make an attempt at initiation, they
do not always maintain exclusive breastfeeding for the first 6 months of life. The literature identifies
various barriers, including return to paid employment, lack of support from health care providers and
significant others, and physical challenges as potential factors that can explain premature cessation
of breastfeeding.
From a public health perspective, the health benefits of breastfeeding are paramount for both
mother and infant. Globally, new mothers following breastfeeding recommendations could prevent
974,956 cases of childhood obesity, 27,069 cases of mortality from breast cancer, and 13,644 deaths
from ovarian cancer per year. Global economic loss due to cognitive deficiencies resulting from
cessation of breastfeeding has been calculated to be approximately USD $285.39 billion dollars
annually. Evidently, increasing exclusive breastfeeding rates is an important task for improving
population health outcomes. While public health campaigns targeting pregnant women and new
mothers have been successful in promoting breastfeeding, they also have been perceived as too
(UNICEF, 2020)ability to breastfeed. In some cases, public health messaging itself has been
identified as a barrier due to its rigid nature and its lack of flexibility in guidelines. Hence, while the
literature on women’s perceptions regarding breastfeeding and their experiences with breastfeeding
has been growing, it offers various, and sometimes contradictory, explanations on how and why
women initiate and maintain breastfeeding and what role public health messaging plays in women’s
decision to breastfeed.
(World Health Organization, 2009) (National Health Institute, 2021)

(World Health Organization, 2015)

Bibliography
National Health Institute. (2021). Women's Perceptions and Experiences of Breastfeeding: a scoping review of the
literature. National Library of Medicine.

UNICEF. (2020). Breastfeeding must continue amidst COVID-19. UNICEF.

World Health Organization. (2009). Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students
and Allied Health Professionals.

World Health Organization. (2015). Breastfeeding.