EARLY INISIATION

BREASTFEEDING

1
 Prolactin - Endocrine

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 OXYTOCIN
• In response to baby suckling, the posterior pituitary
releases oxytocin triggering the Milk Ejection Reflex
(MER) or letdown
• Released in pulse like waves
• Women may feel areolar pressure, tingling, and/or a warm
sensation during a milk ejection
• May experience several let downs during a feed

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 LET DOWN REFLEX

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Summary of milk production

• Endocrine ( Hormonal driven): drives cell

proliferation during pregnancy and early
postpartum
• Autocrine (Baby Driven): retained milk in alveoli
closely regulates the rate of synthesis hour by
hour at the lobular level
• Physical pressure from retained milk affects
secretory function

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 Breast Structure
• Overlies ribs & pectoral muscles
• Skin, Cooper’s ligaments support
• Duct Framework
• Nipple-areola complex
• Blood and lymph supply
• Nerve pathways
• Fat and glandular tissue

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 BREAST STRUCTURE

OLD CONCEPT

Lactiferous Duct
NEW CONCEPT
(USG) 7
 Ramsay D et al. Anatomy of the lactating human breast
redefined with ultrasound imaging. J. Anatomy 2005; 206:
525–534

• 9 lobes & openings (range 4-16)

• Ducts 2 mm; dilate with MER
• Easily compressed
• Near the skin surface
• Begin branching under areola
• 2/3 glandular tissue under areola & nipple
• No “sinuses”
• Fat interspersed throughout breast

The Breast – mammary gland

- a conglomeration
of independent glands

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The first 24hrs
• Mothers produce 30-100 ml of colostrum in
the first 24 hours, with only 2-10 ml per
feeding on day 1

• So how will that fill the infant?

International Lactation Consultant Association, 2005

Infant Stomachs are
Very Small!
Day 1
Size of marble
Capacity 5-7ml Day 3
Size of ping pong ball
Capacity 22-27ml

Day 10
Size of extra large chicken egg
Capacity 22-27ml

http://www.ameda.com/breastfeeding/started/stomach.aspx
 Benefits of Breastfeeding
• Disease prevention- reduces risk of asthma, Hodgkin’s
disease, hypercholesterolemia, leukemia, obesity, types 1&2
diabetes, reduces hospitalizations for lower respiratory
illnesses and SIDS
• Immunological- decreases bacterial meningitis, bacteremia,
diarrhea, late-onset sepsis, necrotizing enterocolitis, otitis
media, respiratory tract infections, urinary tract infections
• Developmental- improved developmental outcomes in
premature infants, increased IQ 6-7points

Keister et al, 2008

Benefits of Breastfeeding
• Maternal Health- decreased risk of breast and ovarian cancers,
decreased post-partum bleeding, earlier return to prepregnancy
weight, lactation amenorrhea

• Psychological- analgesic effects during painful procedures

• Nutritional- species specific, superior to substitutes

Keister et al, 2008

Breastfeeding is the physiologic norm for mammalian
mothers and babies
Benefits of Breastfeeding

• Environmental- Decreased disposal of formula

cans and bottles
• Economical- decreases annual health care
costs by $3.6billion, decreases cost for public
supplementation programs (WIC), decreases
sick care visits, decreases maternal work
absenteeism
• And best of all, it is entirely…

Keister et al, 2008

FREE!
 Beginning Breastfeeding within ONE hour :
Beginning life with “life”

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 OBJECTIVE

• To draw the world’s attention to save ONE million

babies with just ONE action, just ONE hour
support and just ONE message….
• To encourage establishing breastfeeding within
ONE hour as key indicator of health progress by all
communities locally and globally.

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Background
• 36% of all child deaths are ‘neonatal’
• Lancet Neonatal series recognised 16 interventions and
exclusive breastfeeding is one
• Early initiation of breastfeeding within one hour was not
on the list
• New study presents increased risk of neonatal deaths in
addition to earlier data on exclusive breastfeeding
• Poor coverage of Initiation of breastfeeding within one
hour of birth , only 1 in 3.
• Nov 2005 Lancet did an article on tracking of child survival
interventions; Initiation of breastfeeding within one hour of birth was
added in the newborn health section

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BFHI 1992
• Step 4 was, “Help mothers initiate breastfeeding
within a half-hour of birth”

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World Summit for Children Commitments

• Millennium Development Goals (MDG) 4 calls for U-5 child

mortality to go down to HALF by 2015.
• UNICEF priority is in 60 countries ( U5MR>90/100live
births, or No. of U5 deaths >50,000
• These 60 countries account for 91% of all neonatal deaths
• Almost all neonatal deaths occur in developing countries

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 Risk of neonatal mortality according to
time of initiation of breastfeeding within
ONE hour

4.5 4.2
4
3.5
3 2.6
2.3
2.5
2
1.5 1.2
1 0.7
0.5
0
With in 1 From 1 hour Day 2 Day 3 After day 3
hour to end of day
1

Pediatrics 2006;117:380-386
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Potential Mechanisms
• Suckling shortly after birth have a greater chance of
successfully establishing and sustaining breastfeeding
throughout infancy.
• However, the effect of early initiation persisted after
controlling for established neonatal breastfeeding
patterns.
• Early feeding with non human milk proteins may severely
disrupt normal gut function
• Rich immune and non-immune components that are
important for early gut growth and resistance to infection.
• Promotion of warmth and protection may reduce the risk
of death from hypothermia.

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Key findings of the study
• 30% of the study population initiated breastfeeding
after day 1 (late initiation)
• 30% were not exclusively breastfed in the neonatal
period
• Exclusive breastfeeding was associated with a 4 fold
reduction in risk of death when compared to infants
who were fed solids or other milk. This confirms
previous findings.

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Key findings
• Translating these benefits to the whole population of
neonates (breastfed and not breastfed) means that 16% of
neonatal lives can be saved if all babies were breastfed
from day 1, and 22% if breastfeeding were started within
the first hour.
• Neonatal mortality was also shown to increase markedly
as delay in initiation increased.

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 Global impact of increases in coverage and
promotion of early initiation of breastfeeding in less
developed settings.

• Projected absolute numbers of lives saved and the

proportion of neonatal deaths avoided if 99% of infants
initiated breastfeeding during the first hour or during the
first day of life. [1]
• Only 38 of the 60 countries had data available on initiation
of breastfeeding within 1 hour and 1 day of birth.
• The neonatal mortality rate for these 38 countries ranged
from 15-70/1,000 live births.

[1] Karen M Edmond, Ellie C Bard, Betty R Kirkwood, Meeting the millennium development goals
for child survival: global impact of early initiation of breastfeeding on neonatal mortality. (Un
published)

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Contd
• An additional 2.5 fold reduction in risk of death
was demonstrated in babies who survived to day 2
who initiated breastfeeding on the first day of life
(early initiation) compared to infants who
initiated after the first day of life (late initiation).

• This type of effect of early initiation has never

been reported.

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Contd…
• Neonatal mortality could be reduced by 24% if
99% of infants initiated breastfeeding on day 1 of
life and by 31% if 99% of initiation was within the
first hour.
• Numbers of lives saved were estimated to be
867,000 and 1,117,000 in these two cases."

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 1st ONE hour initiation cuts 22% of all neonatal
deaths( 0-28 days): Pediatrics 2006;117:380-386

INITIATION OF BREASTFEEDING within ONE hour

If ALL Women start BF

within ONE hour
15.8%(INDIA)
100%

NEONATAL DEATHS SAVED

India: 1.1 M 1 million

World : 4 M

250,000 babies can be saved in India and

ONE MILLION in the world
WBW 2007 28
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Other benefits of ONE hour !!!
• Skin to skin
• Warmth
• Development
• Less bleeding postpartum

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Oxytocin factor
• Role of oxytocin which is best during first 45
minutes
• Suckling is at it best and babies are active during
first hour

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Benefits to both women and babies
• Nourishment and its first immunisation
• Production of milk enough for the next feed
• It makes use of the baby’s sucking reflex (which is
strongest during the 1st hour) to establish proper latching.
• Prevent blood loss in the women.
• Provides the skin-to-skin contact and warmth that babies need
most, particularly premature and LBW babies.
• It is more beneficial for low weight babies because they are more
likely to die, and they need more support at birth to be able to
suck well.

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 How to help women to begin
breastfeeding within the 1st hour?
• Women need minimum essential support to succeed tin
exclusive breastfeeding including early breastfeeding e.g.

• assistance at time of birth to initiate the process of

breastfeeding
• help and a policy to keep the baby and mother together after
delivery
• avoidance of giving pre-lacteal feeds and artificial
nipple/teats
• Accurate information
• Breastfeeding education and counseling during pregnancy
• Maternity benefits like leave and cash benefits for poor
women and Crèches

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Where we stand ?
Initiation of breastfeeding within ONE hour

• In 38 countries : 26-52( 36 median)

• South Asia worst hit , but needed most

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Why World Breastfeeding Week(WBW):2007 for
ONE hour support

• Should not allow to get it old

• Too important to ignore
• Currently this is not a key indicator in reports like
UNICEF SOWC .

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 What can we do if we’re not in a Baby-
Friendly facility?

• Physicians can write orders specifying immediate skin-skin

contact, initiation of breastfeeding in 1st hr of life, no
formula supplementation or pacifier use.*

• Twice daily evaluations of breastfeeding by skilled health

professionals also improves breastfeeding initiation.**

*Keister et al, 2008; **Phillipp, Merewood, 2004.

What next

• Advocacy for support to mothers during 4th stage of

labour
• Policy : Coverage, promotion and reporting should
improve along with exclusive breastfeeding
• Services: BFHI should make at least this as doable
intervention and as a “standard of good hospital
practice”
• Family level: All women should be supported at birth at
home/ family level and increased awareness of family
members is required to create suitable environment

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