Breastfeeding Lecture 14dec2011 DR Espos

Breastfeeding
Getting Started
Roberto A. Espos Jr., MD,

FPPS, MHSA
Challenges
National Breastfeeding
Awareness Campaign
Results
Babies Were Born To Be Breastfed!
Suzanne G. Haynes, PhD

Senior Science Advisor
Office on Womens Health (OWH)
US Department of Health and Human
Services
Conclusions
Respondents generally understand the importance of

and recommendations about breastfeeding, and
awareness and attitudes are improving over time.
Awareness of messages about breastfeeding rose from
28% to 38%
Those who either correctly identified 6 months as the
recommended length to exclusively breastfeed a baby or
said the recommended duration was longer than 6 months
rose from 52% to 63%
The number agreeing that babies should be exclusively
breastfed in the first 6 months increased from pre-wave
(53%) to post-wave (62%)
Significantly more women surveyed had breastfed a child
in the 04/05 study (73%) than in the 04/04 study (63%)
To breastfeed or not to
breastfeed?
Women who are unable or choose
not to breastfeed can still be

wonderful mothers. Breastfeeding
advocates must be careful not to
alienate or judge such women.
Artist: Mary Cassatt
That said, breastfeeding is a

broadly beneficial practice. It
should be encouraged whenever
possible and safe, and made a
more practical and desirable
practice for women everywhere.
Advocacy must be supplemented

with empowerment.
Understanding and addressing
challenges for breastfeeding
women at home, work, and in
society can increase the numbers
of women comfortably
breastfeeding.
Benefits of Breastfeeding
NUTRITION: containing ideal proportions of fats,

vitamins, sugar and water for infant development,
human breast milk is the most complete source
of nutrition for babies. It is easier to digest than
formula and causes less unnecessary
weight gain.
IMMUNITY: immunoglobulins found in breast milk help protect

against infectious diseases caused by viruses, bacteria, and
parasites until the babys immune system has more fully
developed.
REDUCE DISEASE RISK: may decrease risk of chronic

childhood diseases such as types 1 and 2 diabetes, celiac
disease, inflammatory bowel disease, childhood cancer, allergies
and asthma.
BRAIN DEVELOPMENT AND GROWTH: long-chain

polyunsaturated fatty acids important for brain development
and found in breast milk may lead to early visual acuity and
Benefits
of Breastfeeding
MOTHERS HEALTH: breastfeeding increases oxytocin
levels minimizing postpartum blood loss and inducing

more rapid uterine involution. It also can facilitate motherchild bonding.
ECONOMIC: hundreds of dollars cheaper per baby than
formula. Breastfed babies typically require fewer sick
medical appointments, hospitalizations, and prescriptions
than non-breastfed babies. Breastfeeding mothers must
stay home with a sick baby less often and thus miss less
work.
Kerri Lawnby
Paula Modersohn-Becker
Advantages for the Baby
Less illnesses, diseases & disorders

Antibodies in breast milk
Always the right temperature
Nurturing benefits from skin to skin
contact
Aids in development of babys brain
and nervous system
Advantages for Mother

Decreased postpartum bleeding
Earlier return to pre-pregnancy
weight
Delayed resumption of ovulation
Reduced risk of ovarian cancer
Reduced premenopausal breast
cancer
Anatomy & Physiology

During Pregnancy
Breast, areola, & nipple increase in
size
Veins may be more noticeable
Milk glands & ducts increase
Colostrum is produced in the second
trimester
Montgomery glands become
numerous and prominent
How Does a Breast

Produce Milk?
Milk is made in grapelike
structures deep in the breast
When milk lets down it
travels out of the grapes
down the stems ducts and
collects in the pools (sinuses)
under the dark area (areola)
behind the nipple
Babys gums press areola to
release milk
The Mechanics of
Breastfeeding
Gustav
Klimt
The mother should be comfortable and support the babys

neck and shoulders with her arms or a pillow.
Move nipple gently back and forth across the babys

mouth until the mouth opens wide. Move the baby toward
the mothers breast so the baby can close mouth around
nipple.
Make sure the babys chin (not nose) is in contact with the
mothers breast to allow the baby to breath.
The mother may need to hold or support her breast while

nursing.
The babys mouth will usually detach automatically when

baby is finished.
If the mother or baby are not comfortable or relaxed, its

okay to start over.
Reassure the mother that it is ok to ask for help!
What is MBFHI?
MOTHER-BABY FRIENDLY HOSPITAL

INITIATIONS (MBFHI)
1. What is MBFHI?
It is a program transforming
hospitals with maternity and
newborn services and facilities which
fully protect, promote and support
breastfeeding and rooming-in
practices.

INITIATIONS (MBFHI)
What is a Mother-Baby Friendly Hospital?
A hospital that:
C Promotes, protects and supports breastfeeding and
rooming-in practices.
C Empowers the mother to successfully breastfeed.
C Upholds the right of the infant for breastmilk.
C Does not accept free supply of infant formula.
C Does not maintain a nursery for newborn normal
cases.
C Follows the principle of breastmilk first and
foremost.
C Follows the principle of absolutely no milk formula
for the newborn.
C Follows the WHO-UNICEF, 10 steps to successful
breast feeding.

INITIATIONS (MBFHI)
A. What are the goals of MBFHI?

1. Program Goal
All hospitals rendering maternity and newborn
services that are mother and baby friendly will
adopt the MBFHI program.
2. Mid-Decade Goal
All hospitals rendering maternity with newborn
services and having at least 10 deliveries will
be a mother-baby friendly by the year 1995.
REPUBLIC ACT 7600
Republic Act No. 7600
An act providing incentives to all

government and private health
institutions with rooming-in and
breastfeeding practices and for
other purposes. This act shall be
known as the ROOMING-IN AND
BREASTFEEDING ACT OF 1992

Rooming-in and breastfeeding of infants:
1. Normal spontaneous deliveries- The

following newborn infants shall be put to the
breast of the mother immediately after birth
and forthwith roomed-in within thirty (30)
minutes:
a.) well infants regardless of age of
gestation.
b.) infants with low birth weights but who
can suck.

2. Deliveries by caesarian- Infants delivered
by caesarian
sectionofshall
be roomed-in and
Rooming-in
and breastfeeding
infants:
breastfed within three (3) to four (4) hours
after birth.
3. Deliveries outside health institutionsNewborns delivered outside health institutions
whose mothers have been admitted to the
obstetrics department/unit and who both meet
the general conditions stated in Section 5 of
this Act, shall be roomed-in and breastfed
immediately.

4. ExemptionsInfants
whose
Rooming-in
and breastfeeding
of infants:
conditions do not
permit rooming-in and breastfeeding as
determined by the attending physician, and
infants whose mothers are either:
a.) seriously ill;
b.) taking medications contraindicated to
breastfeeding,
c.) violent psychotics; or
d.) whose conditions do not permit
breastfeeding and rooming-in as determined
by the attending physician. Provided, that
these infants shall be fed expressed breastmilk
or wet-nursed as may be determined by the
attending physician.

2.2 The following acts shall be considered as
violations under this rule:
2.2.1 Prescription of infant formula to
neonates without valid acceptable
medical indication.
2.2.2 Acceptance of gifts, samples,
donation of milk and other
supplies from milk companies.

2.2.3. Display of posters related
to infant formula and milk
substitutes by milk companies
anywhere in the health facility.
2.2.4. Conduct
of
continuing
education activities sponsored
by companies manufacturing
milk or related products as
covered by E.O.51 w/o prior
approval.

2.2.5Giving of samples of milk
formula, other than milk
substitutes and related products
like feeding bottles and teats in
the facility.
2.2.6Selling infant formula and
breastmilk substitutes and
related products in the hospital
pharmacy.
EXECUTIVE ORDER NO. 51
Executive Order No. 51

Milk Code
C Protection and promotion of
breastfeeding to ensure the safe,
adequate nutrition of
infants
thru regulation of marketing of infant
foods, related products (e.g. Breastmilk
substitutes, infant formula, feeding
bottles, teats etc.)

Milk Code
C Imposition of restrictive upon

health workers, health care
system, manufacturers and
distributors of regulated products
and the general public. These
details are examined by assessors
when they assess the hospital for
mother and baby friendliness.

Milk Code
Adopting a national code of
marketing of breast milk
substitutes, breas tmilk
supplements and related
products, penalizing violations
thereof and for other purposes.

Milk Code
This Code shall be known and
cited as the National Code of
Marketing of Breastmilk
Substitutes, Breastmilk
Supplement and Other Related
Products.

Milk Code
The aim of the Code is to contribute to
the provision of safe and adequate
nutrition for infants by the protection
and promotion of breastfeeding and by
ensuring the proper use of breastmilk
substitutes and breastmilk supplements
when these are necessary, on the basis
of adequate information and through
appropriate marketing and distribution.
Ten steps to successful

breastfeeding
Step 1. Have a written

breastfeeding policy
that is routinely
communicated to all
health care staff.
A JOINT WHO/UNICEF STATEMENT (1989)
Slide 4.1.32
Breastfeeding policy
Why have a policy?
Requires a course of action and
provides guidance
Helps establish consistent care for
mothers and babies
Provides a standard that can be
evaluated
Slide 4.1.33
Slide 4a
What should it cover?
At a minimum, it should include:
The 10 steps to successful breastfeeding
An institutional ban on acceptance of free or
low cost supplies of breast-milk substitutes,
bottles, and teats and its distribution to
mothers
A framework for assisting HIV positive mothers
to make informed infant feeding decisions that
meet their individual circumstances and then
support for this decision
Other points can be added

Slide 4.1.3
How should it be presented?
It should be:
Written in the most common
languages understood by patients
and staff
Available to all staff caring for
mothers and babies
Posted or displayed in areas where
mothers and babies are cared for
Slide 4.1.4
Slide 4b
Step 1: Improved exclusive breast-milk feeds while

in the birth hospital after implementing
the Baby-friendly Hospital Initiative
Percentage
Exclusive Breastfeeding Infants

40%
35%
30%
25%
20%
15%
10%
5%
0%
33.50%
5.50%
1995 Hospital with minimal 1999 Hospital designated as

lactation support
Baby friendly
Adapted from: Philipp BL, Merewood A, Miller LW et al. Baby-friendly Hospital
Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics,
2001, 108:677-681.
Slide 4.1.5

breastfeeding
Step 2.Train all health-care

staff in skills
necessary to
implement this policy.
Slide 4.2.1
Slide 4c
Photo: Maryanne Stone Jimenez
Slide 4d
Areas of knowledge
Advantages of
breastfeeding
Risks of artificial
feeding
Mechanisms of
lactation and
suckling
How to help
mothers initiate
and sustain
breastfeeding
How to assess a
breastfeed
How to resolve
breastfeeding
difficulties
Hospital
breastfeeding
policies and
practices
Focus on changing
negative attitudes
which set up
barriers
Slide 4.2.2
Additional topics for BFHI training in

the context of HIV
Train all staff in:
Basic facts on HIV and on Prevention of Motherto-Child Transmission (PMTCT)
Voluntary testing and counselling (VCT) for HIV
Locally appropriate replacement feeding
options
How to counsel HIV + women on risks and
benefits of various feeding options and how to
make informed choices
How to teach mothers to prepare and give
feeds
How to maintain privacy and confidentiality
How to minimize the spill over effect (leading
mothers who are HIV - or of unknown status to
Slide 4.2.3
Step 2: Effect of breastfeeding training

for hospital staff on exclusive breastfeeding rates at
hospital discharge
Percentage
Exclusive Breastfeeding Rates at Hospital Discharge

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
77%
41%
Pre-training, 1996
Post-training, 1998
Adapted from: Cattaneo A, Buzzetti R. Effect on rates of breast feeding of training

for the Baby Friendly Hospital Initiative. BMJ, 2001, 323:1358-1362.
Slide 4.2.4
Step 2: Breastfeeding counselling

increases exclusive breastfeeding
Exclusive breastfeeding (%)
Age:
100
3 months
4 months
80
2 weeks after
diarrhoea
treatment
75
72
56.8
60
58.7
Control
Counselled
40
20
12.7
0
Brazil '98
Sri Lanka '99
Bangladesh '96
(Albernaz)
(Jayathilaka
)
(Haider)
All differences between intervention and control groups are significant at p<0.001.
From: CAH/WHO based on studies by Albernaz, Jayathilaka and Haider.
Slide 4.2.5
Which health professionals

other than perinatal staff
influence breastfeeding success?
Slide 4.2.6

breastfeeding
Step 3.Inform all pregnant

women about the
benefits of
breastfeeding.
Slide 4.3.1
Antenatal education should include:

Benefits of breastfeeding
Early initiation
Importance of roomingin (if new concept)
Importance of feeding on
demand
Importance of exclusive
breastfeeding
How to assure enough
breastmilk
Risks of artificial feeding
and use of bottles and
pacifiers (soothers,
teats, nipples, etc.)
Basic facts on HIV

Prevention of motherto-child transmission
of HIV (PMTCT)
Voluntary testing and
counselling (VCT) for
HIV and infant feeding
counselling for HIV+
women
Antenatal education
should not include
group education on
formula preparation
Slide 4.3.2
Slide 4e
Slide 4f
Step 3: The influence of antenatal care

on infant feeding behaviour
No prenatal BF information
70
58
60
Percentage
50
Prenatal BF information
43
40
27
30
18
20
10
0
Colostrum
BF < 2 h
Adapted from: Nielsen B, Hedegaard M, Thilsted S, Joseph A, Liljestrand J. Does antenatal

care influence postpartum health behaviour? Evidence from a community based crosssectional study in rural Tamil Nadu, South India. British Journal of Obstetrics and
Gynaecology, 1998, 105:697-703.
Slide 4.3.3
Step 3: Meta-analysis of studies

of antenatal education
and its effects on breastfeeding
50%
39%
Percentage
40%
30%
Initiation
(8 studies)
Short-term BF
(10 studies)
Long-term BF
(7 studies)
23%
20%
10%
4%
0%
Increase in selected behaviours
Adapted from: Guise et al. The effectiveness of primary care-based
interventions to promote breastfeeding: Systematic evidence review and
meta-analysis Annals of Family Medicine, 2003, 1(2):70-78.
Slide 4.3.4

breastfeeding
Step 4.Help mothers initiate

breastfeeding within a
half-hour of birth.

Slide 4.4.1
New interpretation of Step 4 in the

revised BFHI Global Criteria (2006):
Place babies in skin-to-skin contact with

their mothers immediately following
birth for at least an hour and encourage
mothers to recognize when their babies
are ready to breastfeed, offering help if
needed.
Slide 4.4.2
Early initiation of breastfeeding

for the normal newborn
Why?
Increases duration of breastfeeding
Allows skin-to-skin contact for warmth
and colonization of baby with maternal
organisms
Provides colostrum as the babys first
immunization
Takes advantage of the first hour of
alertness
Babies learn to suckle more effectively
Improved developmental outcomesSlide 4.4.3
Early initiation of breastfeeding

for the normal newborn
How?
Keep mother and baby together

Place baby on mothers chest
Let baby start suckling when ready
Do not hurry or interrupt the
process
Delay non-urgent medical routines
for at least one hour
Slide 4.4.4
Slide 4g
Slide 4h
Slide 4i
Slide 4j
Impact on breastfeeding duration

of early infant-mother contact
Percent still breastfeeding at 3 months
70%
60%
Early contact: 15-20 min suckling

and skin-to-skin
contact within first
hour after delivery
58%
50%
Control:
40%
No contact within first

hour
26%
30%
20%
10%
0%
Early contact (n=21)
Control (n=19)
Adapted from: DeChateau P, Wiberg B. Long term effect on mother-infant behavior

of extra contact during the first hour postpartum. Acta Peadiatr, 1977, 66:145-151.
Slide 4.4.5
Temperatures after birth in infants

kept either skin-to-skin with mother or in
cot
Adapted from: Christensson K et al. Temperature, metabolic adaptation and crying

in healthy full-term newborns cared for skin-to-skin or in a cot. Acta Paediatr,
1992, 81:490.
Slide 4.4.6
Protein composition of human colostrum

and mature breast milk (per litre)
Constituent
Measure
Colostrum
(1-5 days)
Mature Milk
(>30 days)
Total protein
23
9-10.5
Casein
mg
1400
1870
-Lactalbumin
mg
2180
1610
Lactoferrin
mg
3300
1670
IgA
mg
3640
1420
From: Worthington-Roberts B, Williams SR. Nutrition in Pregnancy and Lactation, 5th ed.
St. Louis, MO, Times Mirror/Mosby College Publishing, p. 350, 1993.
Slide 4.4.7
Effect of delivery room practices

on early breastfeeding
Percentage
Successful sucking pattern

70%
60%
50%
40%
30%
20%
10%
0%
63%
P<0.001
21%
P<0.001
Continuous contact
n=38
Separation for procedures

n=34
Adapted from: Righard L, Alade O. Effect of delivery room routines on success of

first breastfeed .Lancet, 1990, 336:1105-1107.
Slide 4.4.8

breastfeeding
Step 5. Show mothers how to

breastfeed and how to
maintain lactation,
even if they should be
separated from their
infants.
Slide 4.5.1
Contrary to popular belief,

attaching the baby on the breast
is not an ability with which a
mother is [born]; rather it is a
learned skill which she must
acquire by observation and
experience.
From: Woolridge M. The anatomy of infant sucking. Midwifery, 1986, 2:164-171.
Slide 4.5.2
Slide 4k
Slide 4l
Effect of proper attachment

on duration of breastfeeding
Correct sucking technique at discharge
Incorrect sucking technique at discharge
Percentage
100%
50%
P<0.001
P<0.01
P<0.01
P<0.01
0%
5 days
1 month
2 months
3 months
4 months
exclusive
breastfeedin
Any breastfeeding
g
Adapted from: Righard L, Alade O. (1992) Sucking technique and its effect on
success of breastfeeding. Birth 19(4):185-189.
Slide 4.5.3
Step 5: Effect of health provider encouragement of

breastfeeding in the hospital
on breastfeeding initiation rates
Percentage
Breastfeeding initiation rates p<0.001

80%
70%
60%
50%
40%
30%
20%
10%
0%
74.6%
43.2%
Encouraged to breastfeed
Not encouraged to
breastfeed
Adapted from: Lu M, Lange L, Slusser W et al. Provider encouragement of breast-feeding:

Evidence from a national survey. Obstetrics and Gynecology, 2001, 97:290-295.
Slide 4.5.4
Effect of the maternity ward system

on the lactation success
of low-income urban Mexican women
NUR, nursery, n17

RI, rooming-in,
n=15
RIBFG, roomingin with
breastfeeding
guidance, n=22
NUR significantly
different from
RI (p<0.05) and
RIBFG (p<0.05)
From: Perez-Escamilla R, Segura-Millan S, Pollitt E, Dewey KG. Effect of the maternity
ward system on the lactation success of low-income urban Mexican women. Early
Hum Dev., 1992, 31 (1): 25-40.
Slide 4.5.5
Supply and demand

Milk removal stimulates milk
production.
The amount of breast milk removed at
each
feed determines the rate of milk
production in the next few hours.
Milk removal must be continued during
separation to maintain supply.
Slide 4.5.6
Slide 4m

breastfeeding
Step 6.Give newborn infants

no food or drink other
than breast milk
unless medically
indicated.
Slide 4.6.1
Slide 4n
Slide 4o
Long-term effects of a change

in maternity ward feeding routines
% exclusively breastfed
100%
80%
Intervention group = early,

frequent, and unsupplemented
breastfeeding in maternity ward.
60%
Control group = sucrose water

and formula supplements given.
P<0.001
40%
20%
P<0.01
0%
1.5
Months after birth

Adapted from: Nylander G et al. Unsupplemented breastfeeding in the maternity
ward: positive long-term effects. Acta Obstet Gynecol Scand, 1991, 70:208.
Slide 4.6.2
The perfect match:

quantity of colostrum per feed
and the newborn stomach capacity
Adapted from: Pipes PL. Nutrition in Infancy and Childhood, Fourth Edition. St.
Louis, Times Mirror/Mosby College Publishing, 1989.
Slide 4.6.3
Impact of routine formula

supplementation
Decreased frequency or effectiveness of
suckling
Decreased amount of milk removed from
breasts
Delayed milk production or reduced milk
supply
Some infants have difficulty attaching to
breast if formula given by bottle
Slide 4.6.4
Determinants of lactation performance

across time in an urban population from
Mexico
Milk came in earlier in the hospital with
rooming-in where formula was not allowed
Milk came in later in the hospital with
nursery (p<0.05)
Breastfeeding was positively associated
with early milk arrival and inversely
associated with early introduction of
supplementary bottles, maternal
employment, maternal body mass index,
and infant age.
Adapted from: Perez-Escamilla et al. Determinants of lactation performance
across time in an urban population from Mexico. Soc Sci Med, 1993,
(8):1069-78.
Slide 4.6.5
Summary of studies on the water

requirements of exclusively breastfed
infants
Country
Temperature
Relative
C
Humidity %
Urine
osmolarity
(mOsm/l)
Argentina
20-39
60-80
105-199
India
27-42
10-60
66-1234
Jamaica
24-28
62-90
103-468
Peru
24-30
45-96
30-544
Note: Normal range for urine osmolarity is from 50 to 1400

mOsm/kg.
From: Breastfeeding and the use of water and teas. Division of Child Health and
Development Update No. 9, Geneva, World Health Organization, reissued, Nov. 1997.
Slide 4.6.6
Medically indicated
There are rare exceptions during
which the infant may require
other fluids or food in addition to,
or in place of, breast milk. The
feeding programme of these
babies should be determined by
qualified health professionals on
an individual basis.
Slide 4.6.7
Acceptable medical reasons for supplementation or replacement
Infant conditions:
Infants who cannot be BF but can receive BM
include those who are very weak, have sucking
difficulties or oral abnormalities or are separated
from their mothers.
Infants who may need other nutrition in addition
to BM include very low birth weight or preterm
infants, infants at risk of hypoglycaemia, or
those who are dehydrated or malnourished,
when BM alone is not enough.
Infants with galactosemia should not receive BM
or the usual BMS. They will need a galactose
free formula.
UNICEF,
Infants
with
phenylketonuria
may
be BF and
revised
BFHI
course and assessment
tools,
Slide 4.6.8
Maternal conditions:
BF should stop during therapy if a mother is
taking anti-metabolites, radioactive iodine, or
some anti-thyroid medications.
Some medications may cause drowsiness or
other side effects in infants and should be
substituted during BF.
BF remains the feeding choice for the majority of
infants even with tobacco, alcohol and drug use.
If the mother is an intravenous drug user BF is
not indicated.
Avoidance of all BF by HIV+ mothers is
recommended when replacement feeding is
acceptable, feasible, affordable, sustainable and
safe. Otherwise EBF is recommended during the
first months, with BF discontinued when
conditions are met. Mixed feeding is not Slide 4.6.9
Maternal conditions (continued):

If a mother is weak, she may be assisted to
position her baby so she can BF.
BF is not recommended when a mother has a
breast abscess, but BM should be expressed and
BF resumed once the breast is drained and
antibiotics have commenced. BF can continue on
the unaffected breast.
Mothers with herpes lesions on their breasts
should refrain from BF until active lesions have
been resolved.
BF is not encouraged for mothers with Human Tcell leukaemia virus, if safe and feasible options
are available.
BF can be continued when mothers have
hepatitis B, TB and mastitis, with appropriate
Slide 4.6.10
treatments undertaken.

breastfeeding
Step 7.Practice rooming-in

allow mothers and
infants to remain
together
24 hours a day.
Slide 4.7.1
Rooming-in
A hospital arrangement where a
mother/baby pair stay in the same
room day and night, allowing
unlimited contact between mother
and infant
Slide 4.7.2
Slide 4p
Slide 4q
Rooming-in
Why?
Reduces costs
Requires minimal equipment
Requires no additional personnel
Reduces infection
Helps establish and maintain
breastfeeding
Facilitates the bonding process
Slide 4.7.3
Morbidity of newborn babies at Sanglah

Hospital before and after rooming-in
% of newborn babies
12%
6 months before rooming-in
n=205
6 months after rooming-in
10%
8%
6%
n=77
4%
2%
n=17
n=61
n=11
n=17
n=25
n=4
0%
Acute otitis
media
Diarrhoea
Neonatal sepsis
Meningitis
Adapted from: Soetjiningsih, Suraatmaja S. The advantages of rooming-in.

Pediatrica Indonesia, 1986, 26:231.
Slide 4.7.4
Effect of rooming-in on frequency

of breastfeeding per 24 hours
Adapted from: Yamauchi Y, Yamanouchi I . The relationship between rooming-in/not

rooming-in and breastfeeding variables. Acta Paediatr Scand, 1990, 79:1019.
Slide 4.7.5

breastfeeding
Step 8.Encourage
breastfeeding on
demand.

Slide 4.8.1
Breastfeeding on
demand:
Breastfeeding whenever the
baby or mother wants, with no
restrictions on the length or
frequency of feeds.
Slide 4.8.2
On demand, unrestricted breastfeeding
Why?
Earlier passage of meconium
Lower maximal weight loss
Breast-milk flow established
sooner
Larger volume of milk intake on
day 3
Less
of jaundice
From:
Yamauchi incidence
Y, Yamanouchi I. Breast-feeding
frequency during the first 24 hours after
birth in full-term neonates. Pediatrics, 1990, 86(2):171-175.
Slide 4.8.3
Slide 4r
Slide 4s
Breastfeeding frequency during the first 24 hours

after birth and incidence of hyperbilirubinaemia
(jaundice) on day 6
30%
28.1%
Incidence
24.5%
20%
15.2%
11.8%
10%
9
32
12
49
5
33
2
17
0
9
0.0%
0%
0-2
3-4
5-6
7-8
9-11
Frequency of breastfeeding/24 hours

From: Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24
hours after birth in full-term neonates. Pediatrics, 1990, 86(2):171-175.
Slide 4.8.4
Serum Bilirubin, mg/dl
Mean feeding frequency during the

first 3 days of life and serum bilirubin
12
10.7
10
7.5
6.7
4.8
4
2
0
5 to 6
7 to 8
9 to 10
11+
Feeding frequency/24 hr
From: DeCarvalho et al. Am J Dis Child, 1982;

136:737-738.
Slide 4.8.5

breastfeeding
Step 9.Give no artificial teats

or pacifiers (also
called dummies and
soothers) to
breastfeeding infants.
Slide 4.9.1
Slide 4t
Slide 4u
Alternatives to artificial
teats
cup
spoon
dropper
Syringe
Slide 4.9.2
Cup-feeding a
baby
Slide 4.9.3
Slide 4v
Proportion of infants who were breastfed up to 6

months of age according to frequency of pacifier
use at 1 month
Non-users vs
part-time users:
P<<0.001
Non-users vs.
full-time users:
P<0.001
From: Victora CG et al. Pacifier use and short breastfeeding duration: cause,
consequence or coincidence? Pediatrics, 1997, 99:445-453.
Slide 4.9.4

breastfeeding
Step 10. Foster the

establishment of
breastfeeding support
groups and refer
mothers to them on
discharge from the
A JOINT
WHO/UNICEF STATEMENT
(1989)
hospital
or clinic.
Slide 4.10.1
The key to best breastfeeding

practices is continued day-today support for the
breastfeeding mother within
her home and community.
From: Saadeh RJ, editor. Breast-feeding: the Technical Basis and
Recommendations for Action. Geneva, World Health Organization, pp.:62-74,
1993.
Slide 4.10.2
Support can include:

Early postnatal or
clinic checkup
Home visits
Telephone calls
Community
services
Outpatient
breastfeeding
clinics
Peer counselling
programmes
Mother support
groups
Help set up new
groups
Establish working
relationships with
those already in
existence
Family support
system
Slide 4.10.3
Types of breastfeeding mothers support

groups
Traditional
Modern, non-traditional
Self-initiated
extended family
culturally defined doulas
village women
by mothers
by concerned health professionals
Government planned
through:
networks of national development groups,
clubs, etc.
health services -- especially primary health care

(PHC)
and trained traditional birth attendants (TBAs)
From: Jelliffe DB, Jelliffe EFP. The role of the support group in promoting breastfeeding in
developing countries. J Trop Pediatr, 1983, 29:244.
Slide 4.10.4
Slide 4w
Slide 4x
Photo: Joan Schubert
Slide 4y
Slide 4z
Step 10: Effect of trained peer counsellors

on the duration of exclusive breastfeeding
80%
70%
70%
Percentage
60%
50%
Exclusively
breastfeeding 5
month old infants
40%
30%
20%
6%
10%
0%
Project Area
Control
Adapted from: Haider R, Kabir I, Huttly S, Ashworth A. Training peer counselors to

promote and support exclusive breastfeeding in Bangladesh. J Hum Lact,
2002;18(1):7-12.
Slide 4.10.5
Home visits improve

exclusive breastfeeding
Exclusive reastfeeding
(%)
90%
80%
70%
60%
80%
Six-visit group
Three-visit group
Control group
67%
62%
50%
50%
40%
24%
30%
20%
12%
10%
0%
2 weeks
3 months
Infant's age
From: Morrow A, Guerrereo ML, Shultis J, et al. Efficacy of home-based peer
counselling to promote exclusive breastfeeding: a randomised controlled trial.
Lancet, 1999, 353:1226-31
Slide 4.10.6
Combined Steps: The impact of baby-friendly practices:

The Promotion of Breastfeeding Intervention Trial (PROBIT)
In a randomized trial in Belarus 17,000

mother-infant pairs, with mothers intending
to breastfeed, were followed for 12 months.
In 16 control hospitals & associated
polyclinics that provide care following
discharge, staff were asked to continue their
usual practices.
In 15 experimental hospitals & associated
polyclinics staff received baby-friendly
Adapted from: Kramer MS, Chalmers B, Hodnett E, et al. Promotion of breastfeeding
training
& support.
intervention
trial (PROBIT)
A randomized trial in the Republic of Belarus. JAMA, 2001,
285:413-420.
Slide 4.11.1
Differences following the intervention
Communication from Chalmers and Kramer (2003)

Slide 4.11.2
Effect of baby-friendly changes

on breastfeeding at 3 & 6 months
50%
Experimental Group n = 8865
43.3%
Control Group n = 8181
Percentage
40%
30%
20%
10%
6.4%
7.9%
0.6%
0%
Exclusive BF 3 months
Exclusive BF 6 months
Adapted from: Kramer et al. (2001)

Slide 4.11.3
Impact of baby-friendly changes

on selected health conditions
25%
Experimental Group n=8865

Control Group n=8181
Percentage
20%
15%
10%
13.2%
9.1%
6.3%
5%
3.3%
0%
Gastro-intestinal tract infections
Atopic eczema
Note: Differences between experimental and control groups for

various respiratory tract infections were small and statistically
non-significant.
Adapted from: Kramer et al. (2001)
Slide 4.11.4
Combined Steps:
The influence of Baby-friendly hospitals on breastfeeding duration in Switzerland
Data was analyzed for 2861 infants aged 0 to11

months in 145 health facilities.
Breastfeeding data was compared with both the
progress towards Baby-friendly status of each
hospital and the degree to which designated
hospitals were successfully maintaining the Babyfriendly standards.
Adapted from: Merten S et al. Do Baby-Friendly Hospitals Influence Breastfeeding

Duration on a National Level? Pediatrics, 2005, 116: e702 e708.
Slide 4.11.5
Proportion of babies exclusively breastfed for

the first five months of life -- Switzerland
.Adapted from: Merten S et al. Do Baby-Friendly Hospitals Influence Breastfeeding

Slide 4.11.6
Median duration of exclusive breastfeeding

for babies born in Baby-friendly hospitals -Switzerland
.Adapted from: Merten S et al. Do Baby-Friendly Hospitals Influence Breastfeeding

Slide 4.11.7
BREASTFEEDING AND CHILD SURVIVAL

POLICY
1. The institution shall incorporate the breastfeeding
policy with the orientation, continuing medical
education programs, on-going staff development
activities, as well as the evaluation and promotion
criteria.
2. The institution shall continue to attract and give
priority to health personnel who shall encourage,
promote, protect, and sustain breastfeeding.
3. Breastfeeding, the breastfeeding policy, as well as
the other five survival programs, shall be
integrated into the medical, nursing, midwifery, and
other paramedical curricula of the De La Salle
University Health Sciences Campus.

POLICY
4. The appointments of all health personnel shall only be
awarded after the applicant/s has/have undergone
training in lactation management and after having
demonstrated satisfactory knowledge, attitude and skills
in the promotion, protection and support of breastfeeding.
5. The waiting room of the Pre-natal Clinic of the Out-Patient
Department shall be provided with all the necessary
audio-visual equipments, reading materials and the like to
ensure that all pregnant mothers are properly informed of
the advantages and management of breastfeeding.
6. All OB-Gyne and Pediatrics Consultants shall provide their
patients with ample and appropriate reading materials
and leaflets which promote, protect and sustain
breastfeeding.

POLICY
7. A Mothers Class shall be held daily by either the
residents, interns, clinical clerks, or the nurse at
the OPD.
8. The husband and any other person/s who are in
close contact with the pregnant mother and who
play/s a significant role in the promotion,
protection and support of breastfeeding are
encouraged to actively interact during the prenatal visit.
9. All clinics and other strategic places in this
institution shall display at least one poster that
promotes breastfeeding.

POLICY
10.All posters and other similar materials
which promote the contrary shall
therefore be removed.
11.The security guard shall perform routine
and thorough inspection of all persons
entering the hospital. The following are
being banned from being taken into the
hospital:
a. Artificial milk formula
b. Milk substitutes
c. Teats, soothers and pacifiers

POLICY
12. Patients visiting time for the OB Ward shall be
limited to 9:00 am-11:00 am and 3:30 pm-6:30
pm.
13. All newborns shall be put to their mothers
breast immediately after delivery. All healthcare
personnel shall assist the mothers in order to
ensure a successful latching-on process.

POLICY
14. The hospital shall strictly implement the
rooming-in practice.
a. The Nursery shall be converted into Neonatal

Intensive Care Unit only.
b. Obstetricians shall inform all their patients about
this policy and rooming-in practice at all times
during the pre-natal consultation.
c. The OB-Gynecological ward shall be improved.
d. All pregnant women admitted to the hospital are
routinely and adequately informed of the
breastfeeding and rooming-in policies.
15. A breastfeeding room shall be provided at the

NICU.

POLICY
16. The NICU staff shall always ensure that the
mothers are constantly reminded of the
advantages, properly taught and professionally
supported about breastfeeding.
17. A properly equipped and functioning breast milk
bank shall be available at the NICU.
18. The hospital pharmacy shall no longer display,
dispense or sell artificial formula, milk
substitutes, teats and soothers and other similar
or related materials.
BREASTFEEDING AND CHILD

SURVIVAL POLICY
19. All health personnel shall see to it that the
babies are fed on demand.
20. A linkage shall be established with GOs and
NGOs who promote and protect breastfeeding.
21. Obstetricians and Pediatricians are encouraged
to routinely check and follow-up the status of
breastfeeding during the post-partum period for
at least 4-6 months.
22. The institution shall establish its own
breastfeeding support group in the near future.
BREASTFEEDING AND CHILD

SURVIVAL POLICY
23. The hospital shall provide a breastfeeding
room for the personnel/employees, where
they can breastfeed even during working
hours.
24. Obstetricians and Pediatricians, and
members of the health staff shall
encourage their patients to ask questions
about breastfeeding and make
themselves available at any time for
similar queries.
25. Mothers who have stopped breastfeeding
shall be motivated to relactate.

POLICY
26. Problems relevant to the policy shall be
discussed during the monthly medical staff
meeting.
27. Mothers shall be encouraged to give their
opinions and suggestions on how the hospital
can improve the practice of breastfeeding and
rooming-in.
28. Non-compliance of any member of the staff of
this policy shall make them subject to
appropriate disciplinary action.
Tips and Troubleshooting!
EPIDURALS rather than general anesthetics allow mothers to be

more alert immediately after giving birth. Typically the pain
medications and antibiotics given after undergoing a CESAREAN
SECTION are compatible with breastfeeding.
PARTNERS, MIDWIVES OR DOULAS can help POSITION mother to

breastfeed after birth. (Note: doula: person experienced in childbirth
who provides advice, information, and emotional support to a mother
before, during, and just after childbirth; midwife: person skilled in
assisting women during childbirth and skilled delivering babies.)
COLOSTRUM: thick, yellowish milk produced initially during

breastfeedinglow in fat and high in carbohydrates, proteins, and
antibodies. It is easy to digest and helps flush out babys stool,
preventing jaundice. Most mothers should save colostrum and feed it
indirectly to infants if direct breastfeeding not successful. Thin, pale,
normal breast milk seen after a few days.
SCHEDULES: mother should watch for signs of hunger in baby, such

as crying or the rooting reflex (sucking on hands/fingers), rather than
watching the clock. Healthy babies should feed every 2-3 hours.
FREQUENT FEEDINGS keep baby healthy and breasts stimulated to
produce an adequate milk supply. As baby ages and babys stomach
grows, feedings naturally become less frequent.
LEAKING: Sometimes milk leaks from one breast while a baby feeds
from the other. A nursing pad or towel can be used to clean up.
Leaking can be minimized by not missing a feeding. If a mother feels a
leak but cannot nurse at the moment, apply slight pressure (i.e., by
crossing arms), to help stop milk ejection.
FULLNESS: When mothers milk supply adjusts to babys needs, the

feeling of fullness may decrease (but does NOT indicate inadequate
production).
It is normal to have one breast that produces more milk than the
other; it is also normal for the baby to prefer one breast over the
other.
Some women never feel or cease to feel a LET-DOWN (milk-ejection)

reflex. They can tell when their milk is ejected by watching to see
when the baby sucks and swallows.
Mothers with INVERTED or FLAT NIPPLES can still breastfeed.
A CROSS-BODY SLING is recommended to carry the baby.

It provides constant tactile contact, promotes healthy
child
development, helps baby transition from
calm womb to outside
environment, encourages nonverbal communication and bonding,
often calms babies,
Mastitis.
Natl Library of Medicine,
NIH.
Breastfeeding SHOULD NOT HURT if done safely and

correctly. SORENESS is usually caused by improper
positioning, blocked milk flow, stress or infection.
Changing
position, applying hot water bottle for
warmth, getting rest,
and frequent feedings
can reduce pain.
MASTITIS: breast infection with tender breast(s), in which

mother may feel achy, tired and feverish; may or may
require antibiotic treatment. See above for initial
care.
CONTINUE TO BREASTFEED BABYthe
antibacterial properties of human milk protect baby from infection and
speed recovery of mother. If symptoms persist after 24 hours, mother
should contact physician. Prescribed medication should be compatible
with breastfeeding. Encourage mothers to take entire antibiotic
course to help avoid infection recurrence.
http://www.lalecheleague.org/FAQ/mastitis.html
THRUSH: yeast infection of the nipples that may cause

sudden, persistent breast or nursing pain, itching, redness,
burning, cracked or flaky nipples. Thrush CAN be
transmitted
from mother to infant.
Mothers with nipple thrush should
consult
Thrush transmitted
doctor for treatment immediately and wash all bras,
from breastfeeding
pads, shirts, blankets, nightgowns, and other items that
mother to baby.
contact their breasts.
Tips and Troubleshooting
Use of lotion/soap or towel to rough up of nipples as

preparation for a feeding is no longer recommended. The breasts
produce protective substances that may be removed by these
synthetic materials. Patients with skin conditions should consult a
doctor.
Thinning milk, less frequent feeding, decreasing stool, and slowing

of baby growth after first few weeks are normal changes and
typically DO NOT INDICATE INADEQUATE MILK SUPPLY.
BITING: often occurs when babies are teething and does NOT
necessarily mean that they want/need to be weaned. Protect
nipple from biting by sliding finger into babys mouth. If a baby
bites while nursing, lightly latch on to your nipple and positioning
baby closer to the breast.
Sudden changes in babys feeding behavior may indicate illness or

reaction to something the mother ate. Mothers should pay
attention to THEIR DIETS while breastfeeding.
REFLUX: return of stomach contents into the esophagus.

Breastfed babies have less severe reflux at night. Continue to
breastfeed babies with reflux. See the La Leche League article for
more info: http://www.lalecheleague.org/FAQ/ger.html
Before Delivery:
Preparing for Breastfeeding
Massage breasts and rub nipples
gently
Avoid using soap on nipples
Expose nipples to air and briefly to
sunlight
Let nipples rub against clothing
Flat or Inverted Nipples

Begin treatment
late in pregnancy
Stop if causes
uterine contractions
Breast shells
Wear 1 hour a day
and gradually
increase to several
hours
Dry area under
nipple often
Breastfeeding:
Getting Started
Is Your Baby Hungry?

Infant Feeding Cues
Bringing hands to mouth or cheek and

trying to suck on them
Rooting
Lip smacking, mouthing, tongue
protrusion
Crying is a late feeding cue
Breastfeeding Your Infant

Wash your hands
Position yourself comfortably and
correctly
Use pillows or towels for support
Uncover the breast you wish to offer
first
The Side-lying Position

Lie on your side
Use pillows
Tummy-to-tummy
Babys mouth in line
with nipple
Illustration by Joyce Kopatch, USACHPPM
The Football Position
Babys legs are under your arm

Use pillows
Helpful for babys who are having
trouble latching on
The Cradle Position

Tummy-to-tummy
Babys head in
crook of your elbow
Shoulders, hips, in
straight line
Level with breast
Pillow in lap will
help
Milk Ejection Reflex

Let Down
Tingling sensation in breast
Relaxed feeling occurs
Let down can occur between
feedings
Offering Your Breast to Baby
Fingers underneath, thumb on top of breast
Fingers well behind areola
Rooting Reflex and Latch-On

Position baby correctly at breast with
mouth directly in front of nipple
Use nipple to tickle babys lips until
mouth opens wide
Support babys head
Babys mouth is open wide enough to
take in nipple and most of areola
Open wide
Quickly center your
nipple in his mouth
and pull him toward
you
Babys lower jaw far
back from the nipple
Babys chin on breast
Nose may be on
breast
Coming off the breast

Watch baby for cues that he is finished
May spontaneously come off the breast
May fall asleep
Allow baby to determine when he is

done
Foremilk and hindmilk
If you need to stop the feeding early,

break suction by inserting finger into
corner of babys mouth
Is baby getting enough to

eat?
Baby feeds frequently
10-15 on each breast per feeding
Adequate wet diapers
Adequate stools
Baby is gaining weight
Nursing Mothers:
Stay Well Nourished
Follow same healthy diet you ate while
pregnant
Breast feeding burns 300-400
additional calories per day
If you are not well nourished, your
supply of breast milk may decrease
Breast Care
Sore or cracked nipples
Engorgement
Plugged Ducts
Mastitis
Preventing Sore or Cracked

Nipples
Properly position infant
Use pillows
Check for good latch on
Do not use ointments or creams

Express a few drops of milk onto
nipple after feeding (antibacterial
properties)
Allow nipples to air dry
Engorgement
May occur between 2nd and 6th day
when your milk comes in
Occurs more frequently in first-time
mothers
Hang in there! This will go away
after a day or so.
Plugged Ducts
Tender spot, redness, or sore lump in
breast
Milk is unable to flow through duct
leads to inflammation
Change feeding positions from time
to time
Mastitis
Occurs when plugged duct is not
treated
Flu-like symptoms (tired, aches,
fever)
Start treatment immediately
Contact physician for antibiotics
Apply heat
Breastfeed frequently
Rest
REMEMBER
Getting breastfeeding correct
from the start is crucial to
long-term breastfeeding
success!
Reasons to Suspend or Avoid

Breastfeeding
Treatment with a medication that
transfers into the breast milk
Level of risk to environmental
exposures at duty station or in the field
Solvents
Chemicals
Fuels
Weaning
Wean gradually
Substitute a bottle or serve drinks in
a sippy cup
Ensure adequate nutrition for baby
Be firm in your decision
DONATING EXCESS BREAST MILK: Mothers unable

to breastfeed may rely on banked milk,
which is also
easier for premature
infants to digest. There are
currently six milk banks in the U.S. For info, contact
the Human Milk
Banking Association.
TRAVEL: Breastfed babies do not require sterilized

bottles and nipples, keeping travel more
simple.
Nursing during
airplane takeoff and landing can
help ease pressure in the babys ears. For general
travel, mothers should be advised to
wear loose garments for comfort, use a light blanket for
privacy, and drink plenty of water/juice to stay hydrated. It
is unsafe (and usually illegal) to hold a baby in a moving
car, so mothers should stop to nurse on long car trips.
OTHER CONCERNS addressed by La Leche League, an

organization with local chapters dedicated to providing
support and information for breastfeeding women. Contact a
local leader, attend a meeting, or visit the website! Great info
Issues for Baby
WEANINGThe American Academy of Pediatrics recommends that

a woman and her baby should as long as they wish to, at least 12
months. Solid foods can be introduced at 6 months as well. In
many societies, children continue to breastfeed up to 3 or 4 years.
Weaning should ideally happen gradually.
Contrary to popular opinion, COSLEEPING (sleeping with baby in

parents bed or room) promotes babys
independence and bonding, regulates
parent and child sleep patterns, and
facilitates continued breastfeeding on
demand.
FREQUENT NURSING will NOT spoil
baby. Research indicates that
breastfeeding provides nutrition,
protection, and security that aid in child
development. See article for more:
http://www.lalecheleague.org/FAQ/spoil.h
tml
A mother can breastfeed an ADOPTED
BABY! The more stimulation the
Artist: Pablo
Picasso
Family Concerns
ROLE OF THE MOTHERS PARTNER: important

for child and
partner. Partner can become attuned to
childs needs and personality.
The partner can hold
the baby, support the mother during times of
stress
and fatigue,
encourage healthy parental lifestyle, and
help deflect negative
comments or criticism from others
about childrearing methods. In addition,
the partner
can
provide mother with desired affection and
intimacy.
Breastfeeding reduces, BUT DOES NOT

ELIMINATE, the probability of BECOMING
PREGNANT. If a baby is less than six months
old, mother is amenorrheic, and baby
breastfeeds around the clock, a womans
chances of becoming pregnant are less than 2%.
Breastfeeding MULTIPLE BIRTHS (twins, etc.)

and MULTIPLE CHILDREN (tandem
Jennifer Loomis
Social
Concerns
DISCRETION is
possible with loose
clothes, specialized or
easy-to-adjust bras,
and small light
blankets. Even when
the nursing mother
does not feel a
personal need for
modesty, such
consideration may
make others more
comfortable,
especially in public
places.
Artist: Tricia Klein
Thank You!!!

Breastfeeding Lecture 14dec2011 DR Espos

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Breastfeeding

Roberto A. Espos Jr., MD,

Suzanne G. Haynes, PhD

Respondents generally understand the importance of

not to breastfeed can still be

Artist: Mary Cassatt

That said, breastfeeding is a

Advocacy must be supplemented

NUTRITION: containing ideal proportions of fats,

IMMUNITY: immunoglobulins found in breast milk help protect

REDUCE DISEASE RISK: may decrease risk of chronic

BRAIN DEVELOPMENT AND GROWTH: long-chain

levels minimizing postpartum blood loss and inducing

Advantages for the Baby

Less illnesses, diseases & disorders

Advantages for Mother

Anatomy & Physiology

How Does a Breast

The mother should be comfortable and support the babys

Move nipple gently back and forth across the babys

The mother may need to hold or support her breast while

The babys mouth will usually detach automatically when

If the mother or baby are not comfortable or relaxed, its

Reassure the mother that it is ok to ask for help!

MOTHER-BABY FRIENDLY HOSPITAL

MOTHER-BABY FRIENDLY HOSPITAL

MOTHER-BABY FRIENDLY HOSPITAL

A. What are the goals of MBFHI?

REPUBLIC ACT 7600

Republic Act No. 7600

An act providing incentives to all

Republic Act No. 7600

1. Normal spontaneous deliveries- The

Republic Act No. 7600

Republic Act No. 7600

Republic Act No. 7600

Republic Act No. 7600

Republic Act No. 7600

EXECUTIVE ORDER NO. 51

Executive Order No. 51

Executive Order No. 51

C Imposition of restrictive upon

Executive Order No. 51

Executive Order No. 51

Executive Order No. 51

Ten steps to successful

Step 1. Have a written

Other points can be added

Step 1: Improved exclusive breast-milk feeds while

Exclusive Breastfeeding Infants

1995 Hospital with minimal 1999 Hospital designated as

Ten steps to successful

Step 2.Train all health-care

Photo: Maryanne Stone Jimenez

Additional topics for BFHI training in

Step 2: Effect of breastfeeding training

Exclusive Breastfeeding Rates at Hospital Discharge

Adapted from: Cattaneo A, Buzzetti R. Effect on rates of breast feeding of training

Step 2: Breastfeeding counselling

Exclusive breastfeeding (%)

Sri Lanka '99

Which health professionals

Ten steps to successful