Breast Care

Breastfeeding

Introduction:

“The more we know about human breast milk the more we discover about its value in human
nutrition and development”

Definition of Terms

Breastfeeding is the feeding of an infant or young child with breast milk directly from
female human breasts (i.e., via lactation) not from a baby bottle or other container
Breastfeeding helps defend against infections, prevent allergies, and protect against a
number of chronic conditions.
Breastfeeding for the first 6 months of life is the ideal start for babies.
Initiative by WHO and UNICEF to give every baby a best start in life by creating
BREASTFEEDING as a norm.
According to the WHO & AAP Breastfeeding is the normal way of providing young
infants with the nutrients they need for healthy growth and development.

10 Steps to Successful BREASTFEEDING

1. Have a written breast feeding 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 within 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 no food or drink other than breast milk unless medically indicated.
7. Practice rooming in. Allow mother-infant to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of BF support groups and refer mothers to them on discharge
from hospital or clinic.

ANATOMY AND PHYSIOLOGY

• The breast consists of glandular tissue and supporting tissue and fat.
• Milk is secreted by the glands and travels through tubules which drain into lactiferous
sinuses.
• The sinuses which store small quantities of milk, lie below the areola.
• They open out on to the nipple through lactiferous ducts.
• The thin layer of muscle (myo-epithelium) surrounds each gland.
• The contraction of these muscles causes ejection of milk from the glands.
OUTSIDE of the breast

• Areola- a darkened area around the nipple.

• Glands of Montgomery- Provides an oily fluid to keep the skin healthy. The glands are
the source of the mother’s smell, which helps the baby to find the breast and recognize
her.
INSIDE of the breast

• Fat and supporting tissue- gives the breast its size and shape
• Nerves- transmits messages to the brain to trigger the release of lactation hormone
• Alveoli- the little sacs of milk producing cells that produce milk (one gland is called
alveolus, and multiple glands are alveoli)
• Milk ducts- carry milk to the nipple.
• Little muscles- contact to squeeze the milk out into the ducts. There is also network of
blood vessel around the alveolus that brings the nutrients to the cells to make milk.

• It is important to reassure mothers that there are many variations the size and
shape of women’s breast. The amount of milk produced does not depend on the
breast size. Small breast maybe not able to store as much milk between feeds as
large breasts. Babies and mother with small breasts may need to feed more
often, but the amount of milk produced in a day is as much as from large
breasts.
• Be sure to tell mothers that her breasts are good for breastfeeding, and avoid
frightening words like “problem”

During Pregnancy – hormones help breasts

• To develop and grow
• To start to make colostrum
After Delivery, hormones of pregnancy decreases

Breast milk production

Prolactin and Oxytocin – are important to help in the production and flow of milk
Prolactin
• Makes alveoli produce milk
• Works after a baby has taken a feed to make milk for the next food
 • Can male mother feel sleepy and relax
• Level is HIGH 2 hours after birth and at night
Oxytocin
• Causes muscles cells to contract and makes milk flow down the ducts
• Oxytocin reflex
• Milk ejection reflex
• Let down
Signs of oxytocin reflex
• Painful uterine contraction, with rush of blood(sometimes)
• A sudden thirst
• Milk spray from the breast/leaking breast which is NOT being suckled
• Feels a squeezing sensation in the breast

HELP the oxytocin to work by:

 Feeling pleased about her baby and confident that her milk is best
 Relaxing and getting comfortable for feeds.
 Expressing a little milk and gently stimulating the nipple
 Keeping baby near to see, smell, touch, and respond to her baby Back massage along
 the sides of the backbone.

Inhibited oxytocin release temporarily by:

 Extreme pain from fissured nipple/stitches from CS/episiotomy
 Stress from any cause, doubts,
 anxiety, embarrassment
 Nicotine and alcohol

Ways to keep milk production Plentiful

• Increase BF soon after birth
• Make sure baby is well attached
• Do not give artificial teats or pacifiers
• Breastfeed exclusively
• Feed on demand basis
• Feed at night when the prolactin release in response to suckling is high

Milk Transfer and Milk Production

Milk transfer and milk production are linked

If the milk is not being removed from the breast, the milk production will decrease
If you help the baby to remove milk more efficiently then, sufficient milk production will
usually follow.

Breastfeeding on demand
“demand feeding” - “baby-led feeding”
This means that the frequency and length of feeding is determined by the baby’s needs and
signs

Importance of baby-led feeding

 1. Baby gets more immune rich colostrum
2. Faster development of milk supply
3. Faster weight gain,
4. Less neonatal jaundice,
5. Less breast engorgement.
6. Mothers learn to respond to her baby.
7. Breastfeeding established faster,
8. Less crying, less temptation to supplement
9. Longer breastfeeding duration

Human Milk
1. Provides ideal nutrition to meet the infants needs for growth and development
2. Protects against many infection, may prevent some infant deaths.
3. Mother’s milk is unique (special)
4. Human milk is a living fluid that actively protects against infection. Artificial formula
provides no protection from infections.
5. Reduces risk of allergies and of conditions such as juvenile onset diabetes in families
with positive history.
6. Program’s body systems that may assist in blood pressure regulation and reduction of
obesity risk in later life
7. A mother’s milk is especially suited for her own baby and changes from day to day,
month to month, and feed to meet the baby’s needs. The baby learns the tastes of the
family food through the flavor of breast milk.

“Dose responsive”- LONGER AND EXCLUSIVE BREASTFEEDING SHOW A GREATER BENEFIT

Types of milk
Preterm milk
• Birth at 37th week of gestation
• More protein an immune properties suitable for premature infants

Mature Milk
• Contain all major nutrients

Colostrum
Produces by 7th month to 1st days after birth
Paint” to protect gut
First immunization
Laxative- helps pass stool
Small amounts – suits baby’s small stomach

Hind milk
Actively squeezed out a few minutes after the foremilk
The high fat content in hid milk makes it look whiter than foremilk
Provides much of the energy of a breast feed
This is why it is important to allow the baby to continue breastfeeding until he has had
all that he wants do that he has plenty of fat rich hind milk

Foremilk
The bluish milk is passively secreted at initial suckling
Produced in larger amounts
Foremilk quenches the baby’s thirst. If they satisfy their thirst on water supplements,
babies may take less breast milk
It provides plenty of protein, lactose and other nutrients.
Because a baby gets large amounts of foremilk, he gets all the water that he needs from
it.
Babies do not need other drinks or water before they are 4-6 months old, even in a hot
climate.
Human Milk Nutrients
 Protein- growth and brain development
 Fat and Fatty Acids- source of energy
 Carbohydrate- (lactose) calcium absorption, fuel for brain growth
 Water
 Vitamins- required for good nutrition and health (Vitamin A, D, E, K, Water Soluble
Vitamins, B Complex, Vitamin C)
 Flavor- affected by what mother eats, get used to the taste the family eats

Support and Breastfeeding

Good supportive practices in the health facilities would build the confidence of the pregnant
woman. She would be then in control of her situation while the doula staff is supporting her.
Doula will prepare her so she would be ready to interact with her newborn. Naked Baby will be
placed over her naked chest upon delivery for an early skin to skin contact. Allow the pair to be
together, give the baby time to seek the breast in own pace.
  DOULA- any person who assists a mother in labor or delivery
 STS- Skin to Skin Contact

Skin to Skin Contact

 BABY IS NOT WRAPPED but BOTH MOTHER AND BABY should be COVERED
 Continue for at least one hour after birth
 Babies should be dried off as they placed on the mother’s skin.
 Babies who are not stable at birth can receive STS contact later when they are stable.

IMPORTANCE:
1. Calms the mother and baby and helps to stabilize the baby/s heart beat and breathing
2. Keeps the baby warm with heat from mother’s baby
3. Assist with metabolic adaption and blood glucose stabilization in the baby
4. Reduces infant crying, thus reducing stress and energy used.
5. Initiate early breastfeeding
Attachment

Signs of GOOD attachment

1. Chin touching breast (or nearly so)
2. Mouth wide open
3. Lower lip turned outwards
4. Areola: more visible above than below the mouth

Signs of POOR attachment

1. Chin away from breast
2. Mouth not wide open
3. Lower lip pointing forward, or turned in
4. Areola: more visible below than above, or equal amounts.

A. Positioning for the breastfeeding

1. Position for the baby
i. Baby’s body in line
ii. Baby’s body close to the mother’s body bring the baby to breast
2. Position for the mother
i. Comfortable with back, feet, and breast supported as needed
3. Position for the helper
i. Comfortable and relaxed, not bending over
B. Assessing a breastfeed
1. Observe:
i. The mother and the baby in general
ii. The mother’s breasts
iii. The position of the baby
iv. Attachment during the feed
v. The baby’s suckling
2. Help a mother to learn to position and attach her baby
3. Remember this point when helping a mother.
i. Always observe a mother breastfeeding before you help her
ii. Give a mother help only if there is a difficulty
iii. Let the mother do as much as possible herself.
iv. Make sure that she understands so that she can do it herself.

C. Baby who has difficulty attaching to the breast

1. Observe the baby going to the breast and if suckling.
2. Management
i. Remove or treat the cause if possible
ii. Encourage skin to skin contact between mother and baby in calm environment
iii. Do not force the baby to the breast
iv. Express and feed breast milk by cup if necessary
3. Prevention
i. Ensure early skin to skin contact to help the baby learn that the breast is safe place
ii. Help the mother to learn the skill of positioning and attachment in calm unhurried
environment
 iii. Be patient while the baby learns to breastfeed,
iv. Care for the baby in a gentle confident manner

Cradle Hold
• This is the most common position used by mothers.
• Infant’s head is supported in the elbow, the back and buttock is supported by the arm and
lifted to the breast.

Side Lying Position

• The mother lies on her side propping up her head and shoulder with pillows.
• The infant is also lying down facing the mother.
• Good position after Caesarean section.
• Allows the new mother some rest.
• Most mothers are scared of crushing the baby.
Underarm position
• Useful for twins or to help drain all areas of the breast.
• Gives the mother a good view of attachment.
• Take care that the baby is not bending his neck forcing the chin down to the chest.

Cross Cradle Hold Position

• Ideal for early breastfeeding.
• Mother holds the baby crosswise in the crook of the arm opposite the breast the infant is to
be fed.
• The baby's trunk and head are supported with the forearm and palm.
• The other hand is placed beneath the breast in a U-shaped to guide the baby's mouth to your
breast.

Football Hold Position

• The infant’s is placed under the arm, like holding a football
• Baby’s body is supported with the forearm and the head is supported with the hand.
• Many mothers are not comfortable with this position
• Good position after operative procedures Breastfeeding

Position for Twins

Positioning a preterm infant
• One way to hold a small baby is with the baby’s head supported – but not gripped – by
the mother’s hand. The mother’s arm can support the baby’s body.
• The mother can support her breast with her other hand to help the baby keep the
breast in his or her mouth.
• To increase milk flow, massage and compress the breast each time the baby pauses
between suckling bursts.

SIGNS

PRE FEEDING BEHAVIORS OR CUES:

 Taking a short rest in an alert state
 Bringing hands to his mouth
 Focusing on areola
 Moving towards breast
 Finding the nipple
The typical feeding pattern for a full term healthy newborn:
 Every 1-3 hours in the first 2-7 days.
 Night feeds are important.
 Once lactation is established – 8-12 times / 24 hrs.
 During periods of rapid growth, a baby may be hungrier.
 Let babies feed whenever they want.

SIGNS THAT A BABY IS SUCKLING EFFECTIVELY

• Slow deep sucks sometimes with short pause
• May hear or see the baby swallowing
• Baby’s cheeks are full during a feed
• Baby finishes the feed and release the breast by himself
• Looks contented
SIGNS OF NOT SUCKLING EFFECTIVELY
• Makes rapid swallow sucks
• Makes smacking or clicking sounds
• Has cheeks drawn in
• Fusses or appears unsettled at the breast and comes on and off the breast
• Feeds for a long time (unless low birth weight)
• Not contented at the end of the feed

Signs of hunger

• Increase eye movement under closed eye lids or open eyes.

• Open his or her mouth, stretches out the tongue and turns the head to look for the
breast.
• Makes soft whimper sounds
• Sucks or chews on hand, fingers, blanket or sheet, or other object that comes in mouth
contact
• If the baby is crying loudly, arches his or her back, and has difficult attaching to the
breast, these are late hunger signs.
• Some babies are very calm and wait to be fed or go sleep if not noticed. This can result
in underfeeding. Other babies wake quickly and become very annoyed if not fed
immediately.
 • Help the mother to recognize her baby’s temperament and learn how to best meet her
baby’s needs.

Sign of satiety

• At the start of a feed, most babies have a tense body. As they get full, their body relaxes.
• Most babies let go of the breast when they have had enough, though some continue to
take small gentle sucks until they are asleep.
• Explain to the mother that she should let her baby finish one breast before she offers
the other breast in order to feed the rich hind milk and to increase milk supply.
Reliable signs of sufficient milk intake are:

1. Output- milk must be going in, if urine and stools are coming out.
2. Alert, good muscle tone, healthy skin and is growing too big for his or her clothes.
3. A consistent weight gain, with an average 34 of 150 grams per week.

NORMAL GROWTH PATTERNS OF A BABY

 The ranges may be 100-200 grams
 (3.5-7 ounces) per week.

Benefits of Rooming-in
1. Babies sleep and cries less
2. Before birth, the mother and infant have developed a sleep/awake rhythm that would
be disturbed if separated
3. Breastfeeding is well established and continues longer and the baby gains weight quickly
4. Feeding in response to a baby’s cues is easier when the baby is near. Thus helping
develop a good milk supply.
5. Mothers become confident in caring for the bay.
6. Mother’s can see that their baby is well and they are not worried that a baby crying in
the nursery is their baby.
7. Baby is exposed to fewer infections when next to his mother rather than in a nursery.
8. It promotes bonding between mother and baby even if mother is not breastfeeding.
DANCER’S HOLD

How to support breast:

• Resting the fingers on the chest wall under the breast, so the first finger forms a support
at the base of the breast.
• Using the thumb to press the top of the breast slightly. This can improve the shape of
the breast so that it is easier for the baby to attach well, however, the pressure should
be light, and not always on the same spot. Make sure that the fingers are not near the
nipple so that they do not block the baby from getting a big mouthful of breast.

BREASTFEEDING INFANTS WITH SPECIAL NEEDS

Breast milk is very important for babies who are preterm, low birth weight or have special
needs as it protects, provide food, and aids in growth and development

Categories based on the baby's ability to suckle:

 Baby not able to take oral feeds
 Baby able to suckle but not for full feeds
 Baby can suckle well
 Baby is not able to receive breast milk
Manual expression

Encourage the milk to flow

• Warming her breast and gently massaging or stroking it.
• Gently rolling her nipple between her finger and thumb.
• Being comfortable and relaxed,
• Thinking about her baby, looking at the baby (or even at photograph)

Find the milk ducts

• Ask the mother to gently feel the breast near and outer edge of the areola or about the
length for her first thumb joint back from the nipple (about one and a half inches or
4cms) until she finds a place where the breast feels different

Compares the breast over the ducts

• Ask the mother to gently press her thumb and finger slightly back towards the chest
wall.
• Colostrum may come out in drops, as it thick and small amount.
Repeat in all parts of the breast
• When the milk flow slows, the mother moves her thumb and finger around the edge of
her areola to another section and repeats the press and release movement.
Breast pumps
• Breast pumps are not always practical, affordable or available, so it is preferable for
mothers to learn how to express milk by hand
• If the mother is getting little or no milk from pumping, check that the pump is working
and check her pumping technique (including stimulating the oxytocin reflex). Do not
conclude that she has no milk.
• Ensure that the mother is able to sterilize the pump if she intends to feed milk to her
baby.
• Avoid the rubber bulb type hand pumps. These damage mother’s nipple, are difficult to
clean and the milk cannot be used for feeding a baby.

Expressed breast milk (EBM)

When to express

• If the baby is not able to suckle, begin expressing as soon after delivery as possible, by 6
hours long preferably.

How long to express

 Colostrum 5-10min=a tsp

To increase production 20 min/6hrs

To soften areola Compress3-4 times
To clear blocked duct Compress until cleared
For storage 15-30 min

Breast milk storage

Fresh milk =25-37°C 4 hours

=15-25°C 8 hours
=Below 15°C 24 hours

refrigerated =2-4°C 8 days

freezer =1 door ref 2 weeks
=2 door ref 3 months
(separate)
=Deep freezer 6 Months

BREASTMILK STORAGE

Healthy baby at home

1. Fresh Milk
 At 25-37°C for 4 hours,
  At 15-25°C for hours,
 Below 15°C for 24 hours.
 Milk should not be stored above 37°C.

2. Refrigerated (2-40C: up to 8 days

 Place the container of milk in the coldest part of refrigerator or freezer.
 Many refrigerators do not keep a constant temperature. Thus, a mother may prefer to
use milk within 3-5days or freeze milk that will not be used within 5 days, if she has a
freezer.

3. Frozen milk
 In a freezer compartment inside refrigerator:3 months
 In a freezer part of refrigerator – freezer: 3 months
 Thawed in a refrigerator: 24 hours (do not re-freeze), or place the container in warm
water to thaw quickly.

BREASTMILK STORAGE

III Baby in hospital

1. fresh milk
• At room temperature (up to 250C):4 hours
• Refrigerated (2-40C):8 hours
2. Frozen milk
• In a freezer compartment inside refrigerator:2 weeks
• In a freezer part of a refrigerator-freezer or a separate deep freeze(-200C): 3 months
• Thawed in a refrigerator: 12 hours (do not re-freeze)
HAND EXPRESSION VS PUMP
o Hands are always with you
o Very effective and quick once experienced
o Mothers preference-STS stimulation
o Gender than pump
o Less cross- infection

Alternative feeding methods

1. A syringe or dropper
can be used for very small amounts of milk
Example: colostrum
2. Spoon- feeding
is similar to syringe feeding in that very small amount are given.
3. Tube feeding
is needed for babies who cannot suckle and swallow.
4. Cup feeding
can be used for babies who are able to swallow but cannot(yet) suckle well enough to
feed themselves fully from the breast.

HOW TO FEED A BABY BY CUP

 Sit the baby upright or semi-upright on your lap; support the baby’s back, head and neck
 Hold a small cup of milk to the baby’s lips.
 DO NOT POUR the milk into the baby’s mouth. Just hold the cup to the baby’s lips and
let him or her take it himself or herself.
Advantages of cup feeding
• Pleasant for the baby- no tubes
• Allows use of tongue, taste
• Stimulates digestion
• Coordinate breathing/swallow
• Baby held close with eye to eye contact
• Baby in control
• Cup easier to clean
• Must be considered a traditional method

Disadvantages of cup feeding

• Milk can be wasted if the baby dribbles
• Term babies can come to prefer the cup if they do not go to breast regularly,
• Cup feeding may be used instead of direct breastfeeding because it is easy to do.
• For example, a special care baby nurse may prefer to give a cup fed rather than bring
the mother from the post-natal ward and help her to breastfeed her small baby.
 • Nipple can change shape during pregnancy and become more protractile or “stretchy”

Nipples
1. long or big nipples
• May also cause difficulties because the baby does not take the breast far enough back in
his or her mouth.
• Babies grow quickly and their mouths soon become bigger
2. Inverted nipples do not always present a problem.
• Babies attach to the breast, not to the nipples.

Syringe method for inverted nipples

Breast changes

Normal breast fullness

• When the milk is “coming in”, there is more blood supply to the breast as well as more
milk. The breasts may feel warm, full and heavy. To relieve fullness, feed the baby
frequently and use cool compress between feed. In a few days, the breast will adjust
milk production to the baby’s needs.

Abnormal: engorgement:
• The nipple may be stretched tight, shiny and flat, which makes it difficult for the baby to
attach and which can result in sore nipples.
Causes
• Infrequent feeding, not feeding at night or short duration of feeds.
• Delay in starting to breastfeed soon after baby’s birth;
• Poor attachment, so that milk is not removed effectively;

HOW TO RELIEVE
 Check attachment
  Encourage frequent feeds ; express between feeds
 Apply warm compress(milk flow); Massage; Cold compress (pain relief)
 Help mother to be comfortable; provide supportive atmosphere

Blocked Duct or Mastitis

• Milk remains in a part of a breast-
Causes:
 infrequent feedings
 Inadequate removal
 Local pressure

Signs and symptoms:

• fever, chills
• Tiredness or nausea, headache and general aches and pains.
• A woman with a blocked duct may tell you that she can feel a lump, and the skin over it
may be red. The lump may be tender. The mother usually has no fever and feels well.

TREATMENT
 Frequent emptying of breast; offer affected breast first
 Check attachment; check clothing
 Help milk to flow; gentle massage, warm compress
 Rest with baby

Sore Nipples
DO NOT stop breastfeeding
DO NOT limit breastfeeding
DO NOT apply any substance
NO Artificial teats and pacifiers
 Cause difficulties because it has a different mouth action
 May come to prefer the artificial teats
 May reduce the suckling time at the breast- less stimulation-less production

Breast Engorgement Blocked Ducts or Mastitis

Sore Nipple

Breast care
It is essential that midwives offer support and advice on common breast and breastfeeding
problems. With a woman’s permission a midwife needs to check for any physical problems such
as engorgement, cracked or bleeding nipples, mastitis, or signs of thrush. Engorgement on
postnatal day 3 and 4 is a common problem for most mothers regardless of whether they have
chosen to breast or formula-feed. It is important that mothers are aware of this and this needs
to be discussed antenatally so it does not come as a complete surprise. If breastfeeding and
engorged, advise the mother to feed on demand, perform breast massage from under her axilla
and towards the nipple, to hand express, take analgesia if necessary, and to wear a well-fitting
bra. For further content on complications see Chapters 24 and 34. (Myles Textbook)
Care of the breasts

 Daily washing is all that is necessary for breast hygiene. Brassieres may be worn in order
to provide comfortable support and are useful if the breasts leak and breast pads (or
breast shells) are used.

PRELACTEAL FEEDS

PRELACTEAL feeds are any fluid or feed given starting to breastfeed.

 Healthy full term babies rarely have a medical need for supplements or prelacteal feeds.
They do not require water to prevent dehydration. The needs of babies who are
premature or ill and medical indications for supplements are discussed in a later session.
 Healthy full term babies rarely have a medical need for supplements or prelacteal feeds
they do not require water to prevent dehydration.

Danger of supplements
Exclusive breastfeeding is recommended for the first six months.
Supplement can:
• Overfill a baby’s stomach
• Reduce milk supply
• Can cause insufficient weight gains
• Reduce protective effect of breastfeeding
• Reduce the mother’s confidence
• Be an unnecessary expense
• May indicate that mother is having difficulties feeding and caring or her baby
 • May indicate an overall stressful atmosphere

Communication skills
• Good communication means you respect the women's own thoughts, beliefs, and
culture.
• Look for cause of difficulties and suggest action to fix problem.

Counseling
• Is a way of working with people in which you try to understand how they feel and help
them to decide that they think is best to do in their situation.
Informed decision
In order to make an informed decision about feeding her baby a woman needs:

Information
• In order to make an informed decision about feeding her baby, a woman needs:
• Information that is accurate and factual.
• It should NOT be the personal opinion of health worker (HW) nor marketing information
from a formula company.

Understanding of the information

  In words that are suitable for the woman
 In the context of her situation

Confidence
 Building the woman’s confidence in her ability to exclusively breastfeed.
 If she is not breastfeeding, she needs to be confident that she can find a replacement
feeding method that is as safe as possible in her situation.

Support
 To carry out her feeding decision. This includes support to successfully feed her baby
and overcome any difficulties

Skills to listen and learn

1. Use verbal and non-verbal communication

• Non-verbal communication means showing your attitude through your posture, your
expression, everything except through speaking

P-posture -sit/sit, stand/stand

E –eye contact -look at him

B- barriers - remove table/ chairs/ folders

T- taking time -don’t hurry

T- touch appropriately -ask permission before touching baby

 • Verbal communication- tone of your voice is important. Always try to sound gentle and
king when taking to mothers. Try to find out how people feel. We need to be interested
and to prove beneath if we wish to learn their worries and their concerns.

2. ASK OPEN QUESTION

• Open questions usually start with
I. how
II. What
III. Why
IV. Who
V. When
VI. Where
• Closed questions are usually less helpful. They tell a mother the answer that you
expect, and she can answer them with a
“Yes or No”
• Closed questioned usually start with words like
“Are you?’” or ‘Did He?’ or Has He? Or Does He?

3. USE RESPONSES AND GESTURES WHICH SHOW INTEREST

• Important ways to show that you are listening and interested are;
With gestures, for example.
look at her, nod and smile.
With simple responses, you say
‘mmm’, ‘oh dear!’ aha’,

4. REFLECT BACK WHAT THE MOTHER SAYS

 • It is more useful to repeat back or reflect what a mother says.
• This is another way to show you are listening and encourages the mother or caregiver to
continue talking and to say what is important to her.
• It is best to say it in a slightly different way, so that it does not sound as through you are
copying her.

5.EMPHATIZE- SHOW THAT YOU UNDERSTAND HOW SHWE FEELS

• When a mother says something which shows how she feels, it is useful to respond in a
way which shows that you heard what she said, and that you understand her feelings
from her point of view.
Example, if a mother says:
“My baby wants to feed very often and it makes me feels so tired!”
You respond to what she feels, perhaps like this:
“You are feeling very tired all the time then?”

6. Avoid words which sound judging

• Judging words are words like:
Right, wrong, well, badly, good, Enough, properly
BUILD CONFIDENT AND GIVE SUPPORT

1. Accept what a mother thinks and feels

 Without agreeing
 Without disagreeing
2. Recognize and acknowledge what is right
3.Give practical help
4.Provide relevant information using suitable language
 Find out what she needs to know at this time
 Use suitable words that the mother understands
 Do not overwhelm her with information
5. Make suggestion rather than commands
 provide choices and let her decide what will work for her.
 Do not tell her what she should do or must not do.
 Limit your suggestion to one or two suggestion that are relevant to her situation.

6. Make suggestions rather than commands

 Provide choices and let her decide what will work for her.
 Do not tell her what she should do or must not do.
 Limit your suggestions to one or two suggestions that are relevant to her situation

Republic ACT NO. 10028

March 16, 2010

REPUBLIC OF THE PHILIPPINES

Congress of the Philippines

 Metro Manila

Fourteenth Congress

Third Regular Session

Begun and held in Metro Manila, on Monday, the twenty-seventh day of July, two thousand
nine.

REPUBLIC ACT No. 10028

AN ACT EXPANDING THE PROMOTION OF BREASTFEEDING, AMENDING FOR THE PURPOSE

REPUBLIC ACT NO. 7600, OTHERWISE KNOWN AS “AN ACT PROVIDING INCENTIVES TO ALL
GOVERNMENT AND PRIVATE HEALTH INSTITUTIONS WITH ROOMING-IN AND
BREASTFEEDING PRACTICES AND FOR OTHER PURPOSES”

Be it enacted by the Senate and House of Representatives of the Philippines in Congress

assembled:

Section 1. Short Title. – This Act shall be known as the “Expanded Breastfeeding Promotion Act
of 2009”.

Section 2. Section 2 of Republic Act No. 7600 is hereby amended to read as follows:

Sec. 2. Declaration of Policy. – The State adopts rooming-in as a national policy to encourage,
protect and support the practice of breastfeeding. It shall create an environment where basic
physical, emotional, and psychological needs of mothers and infants are fulfilled through the
practice of rooming-in and breastfeeding.

“The State shall likewise protect working women by providing safe and healthful working
conditions, taking into account their maternal functions, and such facilities and opportunities
that will enhance their welfare and enable them to realize their full potential in the service of
the nation. This is consistent with international treaties and conventions to which the
Philippines is a signatory such as the Convention on the Elimination of Discrimination Against
Women (CEDAW), which emphasizes provision of necessary supporting social services to enable
parents to combine family obligations with work responsibilities; the Beijing Platform for Action
and Strategic Objective, which promotes harmonization of work and family responsibilities for
women and men; and the Convention on the Rights of the Child, which recognizes a child’s
inherent right to life and the State’s obligations to ensure the child’s survival and development.

“Breastfeeding has distinct advantages which benefit the infant and the mother, including the
hospital and the country that adopt its practice. It is the first preventive health measure that
can be given to the child at birth. It also enhances mother-infant relationship. Furthermore, the
practice of breastfeeding could save the country valuable foreign exchange that may otherwise
be used for milk importation.

“Breastmilk is the best food since it contains essential nutrients completely suitable for the
infant’s needs. It is also nature’s first immunization, enabling the infant to fight potential
serious infection. It contains growth factors that enhance the maturation of an infant’s organ
systems.

“Towards this end, the State shall promote and encourage breastfeeding and provide the
specific measures that would present opportunities for mothers to continue expressing their
milk and/or breastfeeding their infant or young child.

Section 3. Section 3 of Republic Act No. 7600 is hereby amended to read as follows:

“Sec. 3. Definition of Terms. – For purposes of this Act, the following definitions are adopted:

“a) Age of gestation – the length of time the fetus is inside the mother’s womb.

“b) Bottlefeeding – the method of feeding an infant using a bottle with artificial nipples, the
contents of which can be any type of fluid.

“c) Breastfeeding – the method of feeding an infant directly from the human breast.
“d) Breastmilk – the human milk from a mother.

“e) Breastmilk substitute – any food being marketed or otherwise represented as partial or total
replacement of breastmilk whether or not suitable for that purpose.

“f) Donor milk – the human milk from a non-biological mother.

“g) Expressed breastmilk – the human milk which has been extracted from the breast by hand
or by breast pump. It can be fed to an infant using a dropper, a nasogastric tube, a cup and
spoon, or a bottle.

“h) Expressing milk – the act of extracting human milk from the breast by hand or by pump into
a container.

“i) Formula feeding – the feeding of a newborn with infant formula usually by bottle feeding. It
is also called artificial feeding.

“j) Health institutions – are hospitals, health infirmaries, health centers, lying-in centers, or
puericulture centers with obstetrical and pediatric services.

“k) Health personnel – are professionals and workers who manage and/or administer the entire
operations of health institutions and/or who are involved in providing maternal and child health
services.

“l) Health workers – all persons who are engaged in health and health-related work, and all
persons employed in all hospitals, sanitaria, health infirmaries, health centers, rural health
units, barangay health stations, clinics and other health-related establishments, whether
government or private, and shall include medical, allied health professional, administrative and
support personnel employed regardless of their employment status.

“m) Infant – a child within zero (0) to twelve (12) months of age.

“n) Infant formula – the breastmilk substitute formulated industrially in accordance with
applicable Codex Alimentarius standards, to satisfy the normal nutritional requirements of
infants up to six (6) months of age, and adopted to their physiological characteristics.

“o) Lactation management – the general care of a mother-infant nursing couple during the
mother’s prenatal, immediate postpartum and postnatal periods. It deals with educating and
providing knowledge and information to pregnant and lactating mothers on the advantages of
breastfeeding, the risks associated with breastmilk substitutes and milk products not suitable as
breastmilk substitutes such as, but not limited to, condensed milk and evaporated milk, the
monitoring of breastfeeding mothers by health workers and breastfeeding peer counselors for
service patients to ensure compliance with the Department of Health, World Health
Organization (WHO) and the United Nations Children’s Fund (UNICEF) on the implementation of
breastfeeding policies, the physiology of lactation, the establishment and maintenance of
lactation, the proper care of the breasts and nipples, and such other matters that would
contribute to successful breastfeeding.

“p) Lactation stations – private, clean, sanitary, and well-ventilated rooms or areas in the
workplace or public places where nursing mothers can wash up, breastfeed or express their
milk comfortably and store this afterward.

“q) Low birth weight infant – a newborn weighing less than two thousand five hundred (2,500)
grams at birth.

“r) Nursing employee – any female worker, regardless of employment status, who is

breastfeeding her infant and/or young child.

“s) Mother’s milk – the breastmilk from the newborn’s own mother.

“t) Non-health facilities, establishment or institution – public places and working places, as

defined in subparagraphs (u) and (y), respectively.
“u) Public place – enclosed or confined areas such as schools, public transportation terminals,
shopping malls, and the like.

“v) Rooming-in – the practice of placing the newborn in the same room as the mother right
after delivery up to discharge to facilitate mother-infant bonding and to initiate breastfeeding.
The infant may either share the mother’s bed or be placed in a crib beside the mother.

“w) Seriously ill mothers – are those who are: with severe infections; in shock, in severe cardiac
or respiratory distress; or dying; or those with other conditions that may be determined by the
attending physician as serious.

“x) Wet-nursing – the feeding of a newborn from another mother’s breast when his/her own
mother cannot breastfeed.

“y) Workplace – work premises, whether private enterprises or government agencies, including

their subdivisions, instrumentalities and government-owned and -controlled corporations.

“z) Young child – a child from the age of twelve (12) months and one (1) day up to thirty-six (36)
moths.

Section 4. Section 4 of Republic Act No. 7600 is hereby amended to read as follows:

Sec. 4. Applicability. – The provisions in this Chapter shall apply to all private enterprises as well
as government agencies, including their subdivisions and instrumentalities, and government-
owned and -controlled corporations.

Upon application to, and determination by, the Secretary of the Department of Labor and
Employment for the private sector, and the Chairperson of the Civil Service Commission for the
public sector, all health and non-health facilities, establishments and institutions may be
exempted for a renewable period of two (2) years from Section 6 of this Act where the
establishment of lactation stations is not feasible or necessary due to the peculiar
circumstances of the workplace or public place taking into consideration, among others,
number of women employees, physical size of the establishment, and the average number of
women who visit.

All health and non-health facilities, establishments or institutions which are exempted in
complying with the provisions of this Act but nevertheless opted to comply are entitled to the
benefits herein stated: Provided, That they give their employees the privilege of using the same.

Section 5. Section 10 of Republic Act No. 7600 is hereby amended to read as follows:

Sec. 10. Provision of Facilities for Breastmilk Collection and Storage for Health Institutions. – The
health institution adopting rooming-in and breastfeeding shall provide equipment, facilities,
and supplies for breastmilk collection, storage and utilization, the standards of which shall be
defined by the Department of Health. Health institutions are likewise encouraged to set up milk
banks for storage of breastmilk donated by mothers and which have undergone pasteurization.
The stored breastmilk will primarily be given to children in the neonatal intensive care unit
whose own mothers are seriously ill.

Section 6. A new Section 11, under a new Chapter, is added to read as follows:

CHAPTER III
Lactation Stations

Sec. 11. Establishment of Lactation Stations. – It is hereby mandated that all health and non-
health facilities, establishments or institutions shall establish lactation stations. The lactation
stations shall be adequately provided with the necessary equipment and facilities, such as:
lavatory for hand-washing, unless there is an easily-accessible lavatory nearby; refrigeration or
appropriate cooling facilities for storing expressed breastmilk; electrical outlets for breast
pumps; a small table; comfortable seats; and other items, the standards of which shall be
defined by the Department of Health. The lactation station shall not be located in the toilet.

In addition, all health and non-health facilities, establishments or institutions shall take strict
measures to prevent any direct or indirect form of promotion, marketing, and/or sales of infant
formula and/or breastmilk substitutes within the lactation stations, or in any event or
circumstances which may be conducive to the same.

Apart from the said minimum requirements, all health and non-health facilities, establishments
or institutions may provide other suitable facilities or services within the lactation station, all of
which, upon due substantiation, shall be considered eligible for purposes of Section 14 of this
Act.

Section 7. A new Section 12 is hereby added to read as follows:

Sec. 12. Lactation Periods. – Nursing employees shall granted break intervals in addition to the
regular time-off for meals to breastfeed or express milk. These intervals, which shall include the
time it takes an employee to get to and from the workplace lactation station, shall be counted
as compensable hours worked. The Department of Labor and Employment (DOLE) may adjust
the same: Provided, That such intervals shall not be less than a total of forty (40) minutes for
every eight (8)-hour working period.

Section 8. Section 11, which shall be under the renumbered Chapter IV of Republic Act No.
7600, is hereby amended to read as follows:

“CHAPTER IV”
“INFORMATION, EDUCATION AND RE-EDUCATION DRIVE”

“SEC. 13. Continuing Education, Re-education and Training of Health Workers and Health
Institutions. – The Department of Health with the assistance of other government agencies,
professional and nongovernmental organizations shall conduct continuing information,
education, re-education, and training programs for physicians, nurses, midwives, nutritionist-
dietitians, community health workers and traditional birth attendants (TBAs) and other health
worker on current and updated lactation management.

Information materials shall be given to all health workers involved in maternal and infant care
health institutions.”
Section 9. Section 12 Information Dissemination and Educational Programs of Pregnant Women
and Women of Reproductive Age. – During the prenatal, perinatal and postnatal consultations
and/or confinements of the mothers or pregnant women in a health institution and the health
worker to immediately and continuously teach, train and support the women on current and
updated lactation management and infant care, through participatory strategies such as
organization of mothers’ clubs and breastfeeding support groups and to distribute written
information materials on such matters free of charge.

“The Department of Health is hereby mandated to develop and provide breastfeeding programs
for working mothers whose employees are encouraged to avail of it as part of their human
resource development programs.

“To equip women of reproductive age with accurate information on maternal nutrition and
proper nourishment in preparation for successful and sustainable breastfeeding, the
Department of Health is likewise mandated to produce and make available relevant
information and programs which should be disseminated to all city, municipal and barangay
health centers.

“Employers are also highly encouraged to develop breastfeeding or lactation support programs
which main functions are to assess the needs of lactating employees with adequate information
regarding lactation management in the form of brochures, pamphlets and other educational
materials.”

Section 10. A new Section 15 is hereby added to read as follows:

“SEC. 15. Integration of Breastfeeding Education in the Curricula. – To encourage and promote

breastfeeding, the Department of Education, the Commission on higher Education. And the
Technical Education, and the Technical Education and Skills Development Authority shall
integrate in the relevant subjects in the elementary, high school and college levels, especially in
the medical and education, the importance, benefits, methods or techniques of breastfeeding,
and change of societal attitudes towards breastfeeding.”
Section 11. A new Section 16 is hereby added to read as follows:

“SEC. 16. Breastfeeding Awareness Month. – To raise awareness on the importance of and to
further promote breastfeeding, the month of August in each and every year throughout the
Philippines shall be known as “Breastfeeding Awareness Month.”

Section 12. A new Section 17. Is hereby added to read as follows:

“SEC. 17. Public Education and Awareness Program. – To ensure the meaningful observance of
breastfeeding month as herein declared, a comprehensive national public education and
awareness program shall be undertaken in order to achieve the following objectives:

“a) To protect, promote and support breastfeeding in the Philippines as the normal, natural and
preferred method of feeding infants and young children;

“b) To guarantee the rightful place of breastfeeding in society as a time honored tradition and
nurturing value as well as a national health policy that must be enforced;

“c) To provide information about the benefits and superiority of breastfeeding and the high
risks and costs of bottlefeeding;

“d) To generate awareness on, and full enforcement of, national and international laws, codes,
policies and programs on the promotion and protection of safe and adequate nutrition for
infants and young children by promoting and protecting breastfeeding and regulating the
marketing of certain foods and feeding bottles, teats and pacifiers; and

“e) To instill recognition and support and ensure access to comprehensive, current and
culturally appropriate lactation care and services for all women, children and families, including
support for breastfeeding mothers in the work force.

“The Department of Health shall lead in the implementation of the comprehensive national
public education and awareness program on breastfeeding through a collaborative interagency
and multi-sectoral effort at all levels.”
Section 13. A new Section 18, which shall be under the renumbered Chapter V of Republic Act
No. 7600, is hereby added to read as follows:

CHAPTER V
Miscellaneous Provisions

“Sec. 18. Department of Health Certification. – Any health and non-health facility,

establishment or institution satisfying the requirements of Sections 6 and 7 herein relative to a
proper lactation station may apply with the local Department of Health office for a ‘working
mother-baby friendly’ certification. The Department of Health shall promulgate guidelines to
determine eligibility for such certification, which shall include an annual Department of Health
inspection to confirm the continued compliance with its standards.

“The Department of Health shall maintain a list of ‘mother-baby-friendly’ establishments, which

it shall make available to the public.”

Section 14. Section 13 of Republic Act No. 7600 is hereby renumbered and amended to read as
follows:

“Sec. 19. Incentives. – The expenses incurred by a private health and non-health facility,
establishment or institution, in complying with the provisions of this Act, shall be deductible
expenses for income tax purposes up to twice the actual amount incurred: Provided, That the
deduction shall apply for the taxable period when the expenses were incurred: Provided,
further, That all health and non-health facilities, establishments and institutions shall comply
with the provisions of this Act within six (6) months after its approval: Provided, finally, That
such facilities, establishments or institutions shall secure a “Working Mother-Baby-Friendly
Certificate” from the Department of Health to be filed with the Bureau of Internal Revenue,
before they can avail of the incentive.

“Government facilities, establishments or institutions shall receive an additional appropriation

equivalent to the savings they may derive as a result of complying with the provisions of this
Act. The additional appropriation shall be included in their budget for the next fiscal year.”
Section 15. A new Section 20 shall be added to read as follows:

“Sec. 20. Implementing Agency. – The Department of Health shall be principally responsible for
the implementation and enforcement of the provisions of this Act.”

Section 16. Section 14 of Republic Act No. 7600 is hereby renumbered and amended to read as
follows:

“Sec. 21. Sanctions. – Any private non-health facility, establishment and institution which
unjustifiably refuses or fails to comply with Sections 6 and 7 of this Act shall be imposed a fine
of not less than Fifty thousand pesos (Php50,000.00) but not more than Two hundred thousand
pesos (Php200,000.00) on the first offense.

“On the second offense, a fine of not less than Two hundred thousand pesos (Php200,000.00)
but not more than Five hundred thousand pesos (Php500,000.00).

“On the third offense, a fine of not less than Five hundred thousand pesos (Php500,000.00) but
not more than One million pesos (Php1,000,000.00) and the cancellation or revocation of the
business permits or licenses to operate.

“In all cases, the fine imposed should take into consideration, among others, number of women
employees, physical size of the establishment, and the average number of women who visit.

“In addition, the Secretary of Health is hereby empowered to impose sanctions on health
institution for the violation of this Act and the rules issued thereunder. Such sanctions may be
in the form of reprimand or censure and in case of repeated willful violations, suspension of the
permit to operate of the erring health institution.

 “Heads, officials and employees of government health and non-health facilities, establishments
and institutions who violate this Act shall further be subject to the following administrative
penalties:

“First offense – Reprimand;

“Second offense – Suspension for one (1) to thirty (30) days; and

“Third offense – Dismissal.

“This shall be without prejudice to other liabilities applicable under civil service law and rules.”

Section 17. Funding. – Government agencies, including their subdivisions and instrumentalities,

shall use their respective budget for gender and development or their budgets for repairs,
maintenance and materials acquisition to comply with Section 6 hereof.

Section 18. Rules and Regulations. – The Department of Health, as the lead agency, in
coordination with the Department of Labor and Employment, the Department of Trade and
Industry, the Department of Justice, the Department of Social Welfare and Development, the
Department of Education, the Department of the Interior and Local Government, the Civil
Service Commission, the Commission on Higher Education, the technical Education and Skills
Development Authority and professional and nongovernmental organizations concerned, shall
issue within one hundred and twenty (120) days upon its effectivity the rules and regulations
necessary to carry out the provisions of this Act.

Section 19. Separability Clause. – If any clause, sentence, paragraph or part of this Act shall be
declared to be invalid, the remainder of this Act or any provision not affected thereby shall
remain in force and effect.

Section 20. Repealing Clause. – All laws, presidential decrees, executive orders, rules and
regulations or parts thereof which are not consistent with this Act are hereby repealed,
amended or modified accordingly.

Section 21. Effectivity Clause. – This Act shall take effect fifteen (15) days after its publication in
the Official Gazette or in at least two (2) newspapers of general circulation, whichever comes
earlier.

Approved,
 (Sgd.) PROSPERO C. NOGRALES (Sgd.) JUAN PONCE ENRILE
Speaker of the House of Representatives President of the Senate

This Act which is a consolidation of Senate Bill No. 1698 and House Bill No. 879, 4012 and 6076
was finally passed by the Senate and the House of Representatives on December 16, 2009.

(Sgd.) MARILYN B. BARUA-YAP (Sgd.) EMMA LIRIO-REYES

Secretary General Secretary of Senate
House of Represenatives

Approved: March 16, 2010

(SGD.) GLORIA MACAPAGAL-ARROYO
PRESIDENT OF THE PHILIPPINES

(SGD.) GLORIA MACAPAGAL-ARROYO

PRESIDENT OF THE PHILIPPINES

Group 3
Leader: Anamae Banquil

Members:
Miraflor Bustamante
Maybeline Dinque
Ruchelle Cahilig

References:

Hand Outs provided by Ms. Mary Sharon Abonado

(Baby- Friendly Hospital Initiative)
https://www.slideshare.net/azadhaleem/breast-feeding-64546851
Myles Textbook for Midwives 16th Edition