BREASTFEEDING

The two vital considerations for the infants in tropical

countries are breastfeeding and avoidance of infection.
Artificial feeding may be required in a very rare situation, but
where the mothers have an inadequate knowledge of the
technical details of artificial feeding, gastroenteritis and
malnutrition of the neonates are inevitable consequences. All
the babies, regardless of the type of delivery, should be given
early and exclusive breastfeeding up to 6 months of age.
Exclusive breastfeeding means giving nothing orally other
than colostrum and breast milk. Medicines and vitamins are
allowed.
Breastfeeding is the “Gold standard” for infant feeding.
There are several areas of biological superiority of
breastfeeding and breast milk over artificial (formula) milk.
Obstetricians and midwives should educate the mother during
prenatal and postnatal care for the usefulness of breastfeeding.

BABY FRIENDLY HOSPITAL INITIATIVE: Baby Friendly

Hospital Initiative with ten steps to successful breastfeeding
(WHO/UNICEF 1992: Protecting, Promoting and Supporting
breastfeeding). These are:
(i) There must be a written breastfeeding policy.
(ii) All health care staff must be trained to implement
this policy.
(iii) All pregnant women must be informed about the
benefits of breastfeeding.
(iv) Mothers should be helped to initiate breastfeeding
within half an hour of birth.
(v) Mothers are shown the best way to breastfeed.
(vi) Unless medically indicated, the newborn should be
given no food or drink other than breast milk.
 (vii) To practice ‘rooming-in’ by allowing mothers and
babies to remain together 24 hours a day.
(viii) To encourage demand breastfeeding.
(ix) No artificial teats to babies should be given.
(ix) Breastfeeding support groups are established and
mothers are referred to them on discharge.

A baby friendly hospital should also provide other preventive

health cares, e.g. infant immunization, rehydration salts
against diarrheal dehydration and child’s growth and
development surveillance.

ADVANTAGES OF BREASTFEEDING:
A. Composition: Breast milk is an ideal food with easy
digestion and low osmotic load.
Carbohydrate: Mainly lactose, stimulates growth of
intestinal flora, produces organic acids needed for synthesis of
vitamin B
Fat: Smaller fat globules, better emulsified and digested
Protein: Rich in lactalbumin and lactoglobulin, less in casein
tMinerals: Low osmotic load (K+, Ca2+, Na+, Cl–), less
burden on the kidney.

B. Protection against infection and deficiency states:

1. Vitamin D promotes bone growth, protects the baby
against rickets.
2. Leukocytes, lactoperoxidase prevents growth of infective
agents.
3. Lysozyme, lactoferrin, interferon protect against
infection.
4. Long-chain omega-3 fatty acids essential for neurological
development.
5. Immunoglobulins IgA (secretory), IgM, IgG protect
against infection.
6. Supply of nutrients and vitamins.

C. Breast milk is a readily available food to the newborn at

body temperature and without any cost.

D. Breastfeeding acts as a natural contraception to the

mother.

E. Additional advantages are: (i) It has laxative action; (ii)

No risk of allergy; (iii) Psychological benefit of mother-child
bonding; (iv) Helps involution of the uterus; and (v) Lessens
the incidence of sore buttocks, gastrointestinal infection and
atopic eczema. The incidence of scurvy and rickets is
significantly reduced.

Long-term risks of exclusive artificial (bottle) feeding: (a)

Type I diabetes; (b) Sudden infant death;
(c) Adult type 2 diabetes; (d) Childhood obesity; (e) Adult
obesity; (f ) Crohn’s disease; (g) Ulcerative
colitis; (h) Atopic dermatitis; and (i) Reduced Intelligence
Quotient (IQ).

PREPARATIONS FOR BREASTFEEDING: The

preparations for breastfeeding should actually be started
from the middle of pregnancy. Any abnormality in the nipple,
like cracked or depressed nipple should be adequately treated.
Massaging the breasts, expression of the colostrum and
maintenance of cleanliness should be carried out during the
last four weeks of pregnancy.
MANAGEMENT OF BREASTFEEDING: The modern
practice is to reduce nipple cleansing to a minimum and to
wash the breasts once daily. A clean, soft supporting brassiere
should be worn. The mother should wash her hands prior to
feeding. Mother and the baby should be in a comfortable
position during feeding. Frequent feedings, 8–12 feeds/24
hours are encouraged.

First feed—In the absence of anatomical or medical

complications, a healthy baby is put to the breast immediately
or at most 1/2–1 hour following normal delivery. Following
cesarean delivery a period of 4–6 hours may be sufficient for
the mother to feed her baby.

Milk transfer—Milk transfer to infant is a physiological

process. It starts with good latch on. The nipple is tilted
slightly downward using a “C-hold”. The milk is extracted by
the infant not by negative pressure but by a peristaltic action
from the tip of the tongue to the base. The latent period
between latch on to milk ejection is about 2 minutes. Nearly
90% of the milk is obtained in the first 5 minutes. The calorie
rich hind milk is obtained at the end part of suckling. The
inflexible artificial nipple resists the undulating motion of
infant’s tongue and mouth.

Frequency of feeding:
Time schedule—During the first 24 hours, the mother
should feed the baby at an interval of 2–3 hours. Gradually,
the regularity becomes established at 3–4 hours pattern by the
end of first week. Baby should be fed more on demand.
Demand feeding—The baby is put to the breast as soon as
the baby becomes hungry. There is no restriction of the
number of feeds and duration of suckling time.
Duration of feed—The initial feeding should last for 5–10
minutes at each breast. This helps to condition the letdown
reflex. Thereafter, the time spent is gradually increased. Baby
is fed from one breast completely so that baby gets both the
foremilk and the hind milk. Then the baby is put to the other
breast if required. Hind milk is richer in fat and supplies more
calories and satiety to the infant. The next feed should start
with the other breast.
Night feed—In the initial period, a night feed is required to
avoid long interval between feeds of over 5 hours. It not only
eliminates excessive filling and hardening of the breasts but
also quietens and ensures sound sleep for the baby. However,
as the days progress, the baby becomes satisfied with the
rhythmic 3–4 hourly feeding.
Amount of food—The average requirement of milk is about
60 mL/kg/24 hours on the first day, 100 mL/kg/24 hours on
the third day and is increased to 150 mL/kg/24 hours on the
10th day. However, the baby can take as much as he wants.

Technique—The mother and the baby should be in a

comfortable position. Feeding in the sitting position, the
mother holds the baby in an inclined upright position on her
lap; the baby’s head on her forearm on the same side close to
her breasts, the neck is slightly extended. Good attachment
means the infant’s mouth is wide open and chin touches the
breast. The mother should guide the nipple and areola into
the baby’s mouth for effective milk transfer. The milk
transfer to the infant begins with good latch on and by a
peristaltic action of the tip of the tongue to the base. The
proper position for milk transfer is chest to chest contact of
the infant and mother. The infant’s ear, shoulder and hip are
in one line. Baby sucks the areola (lactiferous sinuses) and the
nipple holding between the tongue and the palate. Feeding in
lateral position following cesarean delivery or with painful
perineum is carried out by placing the baby along her side
between the trunk and the arm. The failure to develop good
milk transfer is the major cause of lactation failure and breast
pain. Inhibition of let down reflex and failure to empty breasts
leads to ductal distortion, parenchymal swelling and breast
engorgement. Normally breast is washed with clean water and
allowed to air dry.

Nipple confusion: If the baby is fed with an artificial nipple

of a bottle, he cannot suck the mother’s nipple effectively due
to nipple confusion. In case of artificial nipple, he has to press
the nipple only. But in case of mother’s nipple, he has to press
the areola and suck the nipple. The baby is confused
between these two procedures and lactation failure
develops. So artificial nipple is strictly discouraged. If at all
needed, the artificial feed is given by spoon or jhinuk.

Breaking the wind (Burping)—All babies swallow varied

amount of air during sucking. To breakup the wind, the baby
should be held upright against the chest and the back is gently
patted till the baby belches out the air. It is better to breakup
the wind in the middle of sucking so as to make the stomach
empty, enabling the baby to take more food and at the end of
sucking to prevent hiccough and abdominal colic.

FACTORS FOR SUCCESSFUL LACTATION:

(i) Positioning, (ii) Attachment to breast, (iii) Nursing
technique (to avoid breast pain, nipple trauma, incomplete
emptying), and (iv) A rotation of positions is helpful to reduce
focal pressure on the nipple and to ensure complete emptying.
To break the suction, a finger is inserted between the baby’s
lips and the breast. Otherwise it can injure nipple by forceful
disengagement.

DIFFICULTIES IN Breastfeeding AND THE

MANAGEMENT: At times, breastfeeding poses some
problems and if it is not promptly detected and rectified, it
may lead to adverse consequences.
The causes may be classified as those: 1) Due to mother
2) Due to infant
1)Due to mother:
— Reluctance or dislike to breastfeeding—careful listening
to mother and intelligent counseling can solve the problem.
— Infant’s attachment to breast—when poor, it leads to
quick shallow sucks instead of slow and deep. Areola remains
outside the lips. This causes nipple pain. Skilled support from
health care provider can improve the technique of
breastfeeding. Prelacteal feeds (e.g. honey, milk) inhibit
lactation process and should be avoided.
— Anxiety and Stress, previous history of failed lactation or
elderly primipara—the mother fails to relax during feeding
and as such, the baby refuses to suck. Reassurance and
practical support is helpful.
— Following operative delivery such as cesarean section or
following prolonged and exhaustive labor often there is a
delay. So mother should be helped to feed the baby in a
comfortable position as early as possible.
— Milk secretion is inadequate—unrestricted feeding, well
positioned infant, practical and emotional support to
mother—all are important. Dopamine antagonist
(metoclopramide) may be useful.
— Breast ailments such as engorgement of breast, cracked
nipple, depressed nipple and mastitis need treatment. Previous
breast surgery, circumareolar incision have unsuccessful
breastfeeding. Loss of breast sensation may be the cause.

2)Due to infant:
— Low birth weight baby—The baby is too small or feeble
to suck.
— Temporary illness such as respiratory tract infection,
nasal obstruction due to congestion, lethargy due
to jaundice and oral thrush. All these conditions lead to
imperfect suckling and is managed appropriately.
— Overdistension of the stomach with swallowed air—The
problem can be overcome by breaking the wind of the baby
several times during feeding.
— Congenital malformation such as cleft palate needs
surgical correction.

CONTRAINDICATIONS OF BREASTFEEDING
In cases of temporary contraindications, the baby should
be put to the breasts as soon as the condition permits. HIV
positive mothers are counseled as regard the risks and
benefits. She is helped to make an informed choice.
DRUGS AND BREASTFEEDING: Most drugs taken by the
mother appear in the breast milk. Fortunately drug level in the
breastfed infant ranges from 0.001% to 5% of the therapeutic
doses. The infant tolerates the drug without any toxicity. Very
few drugs are absolutely contraindicated. These are:
anticancer drugs, chloramphenicol, radioactive materials,
phenylbutazone and atropine.

MATERNAL NUTRITION DURING LACTATION: A

healthy mother while breastfeeding will produce about 500–
900 mL breast milk per day. This will give her baby about 75
kcal/dL. This requires additional 750 kcal/day for the
mother. This amount is either to be supplemented through her
diet or is made up from her body stores. A store of 5 kg of fat
throughout pregnancy is adequate to make up the nutritional
deficit. There is additional need (increased by 50%) of folic
acid, iron, calcium and protein during pregnancy. Mother
should drink at least 1 extra liter of fluid per day to make up
the fluid loss through milk. Bone mineral density decreases in
the breastfed women and it returns to normal after 12 months
of stoppage of breastfeeding.

ASSESSMENT OF WELL-BEING OF THE INFANT:

Whether the baby with the feeding schedule is progressing
normally is evidenced by: (1) General condition—The baby
is happy, sleeps between feeds and at night, does not vomit
and passes urine at least six times in 24 hours; (2) Good vigor
which is manifested by movements of the limbs and cry; (3)
Infant has stopped losing weight; (4) Has yellow seedy stools
and no more meconium stools; and (5) Expected level of
weight curve.

UNDERFEEDING: It is commonly seen in artificially–fed

babies. The features are: (1) Failure of the infant to gain
weight as per schedule, evidenced from the weight curve; (2)
The infant appears dissatisfied with the feeds evidenced by
cry in between feeds and at night disturbing the sleep; (3) The
baby has constipation; (4) The urinary output (normally> 6
times) becomes scanty and high colored; and (5) Test feeding
is the only reliable method of diagnosis (vide infra).
Management—The deficient amount of milk should be
substituted by artificial milk. The required deficit of 24 hours
as calculated from test feeding is to be divided by the number
of feeds to be given in 24 hours. The amount of deficit for
each feed, so calculated, should be given after each feed. As
soon as sufficient milk comes to the breast, the supplementary
feed is withdrawn.

CARE OF THE BREASTS: Daily washing of the breasts with

clean water is essential. The nipple should be cleaned with
clean water before and after each feed. Brassieres are to be
worn for support and comfort.

FEEDING DIFFICULTIES DUE TO NIPPLE

ABNORMALITIES
Breast engorgement usually occurs on day 3–5 postpartum.
There is copious milk production. Breasts are swollen and
hard. There is difficulty to latch on for the infant.
Treatment options are:
Gentle hand expression of milk to make the breasts soft so
that the infant can latch on; (ii) Applicationof moist heat and
cold compress to relieve edema; (iii) Gentle breast massage
during feeding or milk expression; and (iv) Pain relief and to
reduce inflammation (Ibuprofen).
Long nipples may cause poor feeding due to improper latch
on to the nipple without the areola. Mother has to help the
baby to draw the areola also.
Short nipples usually cause no problem. Mother is reassured.
Inverted and flat nipples attachment to the breasts is
possible and babies are able to feed adequately. In difficult
cases, lactation is initiated by expression. Baby is then
attached to breast as breast tissue become soft and protractile
gradually. It can be corrected by suction with a syringe or
breast pump.
Expression of breast milk or artificial removal of breast milk
is not generally needed where breastfeeding is normal.
The indications of expressing breast milk are: (i) Where
the baby is separated from the mother due to prematurity or
illness; (ii) Where there are difficulties in breastfeeding as in
attaching the baby to the breast, e.g. cleft palate; (iii) When
the mother is separated from the baby because of work; and
(iv) Colostrum should always be expressed and given to the
babies if they cannot suck properly.
Methods of milk expression: (a) Manual expression is
advantageous over the mechanical pumping.
It increases the level of prolactin that helps to maintain
lactation for longer period. It can be practiced anywhere and
costs nothing. (b) Breast pumps may be electrical or manually
controlled.
Donor Breast Milk: Historically, it has been used for
centuries. Currently its use is limited. Transmission of
infection (HIV, CMV, Hepatitis B, TB) is the concern for its
safety. If the donor breast milk or milk banks are used, donor
screening, pasteurization of milk and parental counseling are
recommended. Breast milk can be stored frozen at – 20°C for
up to 6 months, refrigerated at 4°C for 24 hours and at room
temperature for 4 hours. Fresh, unrefrigerated milk can be
used within 4 hours of expression.
METHODS OF ESTABLISHMENT OF LACTATION: The
following methods may be employed with varying success to
establish lactation after it has been temporarily withheld.
For the baby: (1) To discontinue bottle feedings; (2) To put
the baby to the breast at frequent intervals; (3) Baby should
suck in a well-attached manner.
For the mothers: (1) To encourage plenty of fluid (1 L extra)
and milk intake; (2) Drugs like metoclopramide or oxytocin
(nasal spray) are of help.
Government programs on breastfeeding-
1) India launches MAA (mothers’ absolute
affection)- A National Breastfeeding Promotion
Programme
. MAA – Mothers’ Absolute Affection, a nation-wide
programme for promoting breastfeeding was launched by the
Hon’ble Union Minister of Health and Family Welfare on 5th
August 2016 in New Delhi. Ministers of State Ms Anupriya
Patel, Sh. Faggan Singh Kulaste along with UNICEF
Celebrity Advocate Ms Madhuri Dixit graced the occasion.

2. MAA is an intensified programme of the Ministry of Health

and Family Welfare, Government of India, for creating an
enabling environment to ensure that others, husbands and
families receive adequate information and support for
promotion of breastfeeding.

3. The goal of the MAA Programme is to enhance optimal

breastfeeding practices, which includes early initiation of
breastfeeding within one hour of birth, exclusive
breastfeeding for the first six months, and continued
breastfeeding for at least two years, along with feeding of safe
and appropriate nutritious food on completion of six months.

The goal of the Programme that will continue for a year, is to

enhance optimal breastfeeding practices, which includes
initiation of breastfeeding within an hour of birth, exclusive
breastfeeding for the first six months, and continued
breastfeeding for at least two years. The government will
train nurses in government hospitals, Accredited Social
Health Activists (ASHA), Auxiliary Nurse Mid-wives (ANM) to
provide relevant information and counselling support to
mothers for breastfeeding. Monitoring and impact
assessment is also an integral part of MAA programme.
Progress will be measured against key indicators, such as
availability of skilled persons at ground for counselling,
improvement in breastfeeding practices and number of
accredited health facilities.
WHO and UNICEF launched the Baby-friendly Hospital
Initiative in 1992, to strengthen maternity practices to support
breastfeeding. The foundation for the BFHI are the Ten Steps to
Successful Breastfeeding described in Protecting, Promoting
and Supporting Breastfeeding.

NGO working in breastfeeding promotion-

Breastfeeding Promotion Network of India (BPNI)

was founded on 3rd December,1991 atWardha,

Maharashtra.BPNI is a registered,

independent,nonprofit,national organization;working towards

protecting, promoting and supporting breastfeeding and

appropriate complementary feeding of infants & young

children.BPNI acts on the targets of Innocenti Declarations,

Convention on the Rights of the Child (CRC),International

Code of Marketing of Breastmilk Substitutes,and the Global

Strategy for Infant and Young Child Feeding (WHO 2002).

 WHO Guidelines for breastfeeding-
Guideline1 : protecting, promoting and supporting
breastfeeding in facilities providing maternity and
newborn services

Purpose of the guideline

This guideline provides global, evidence-informed

recommendations on protection, promotion and support for

breastfeeding in facilities that provide maternity and

newborn services, as a public health intervention, to

protect, promote and support optimal breastfeeding

practices, and improve nutrition, health and development

outcomes.

Recommendations

Immediate support to initiate and establish breastfeeding

1. Early and uninterrupted skin-to-skin contact between
mothers and infants should be facilitated and encouraged as
soon as possible after birth (recommended, moderate-quality
evidence).
 2. All mothers should be supported to initiate breastfeeding
as soon as possible after birth, within the first hour after
delivery (recommended, high-quality evidence).
3. Mothers should receive practical support to enable them
to initiate and establish breastfeeding and manage common
breastfeeding difficulties (recommended, moderate-quality
evidence).
4. Mothers should be coached on how to express breast milk
as a means of maintaining lactation in the event of their
being separated temporarily from their infants
(recommended, very low-quality evidence).
5. Facilities providing maternity and newborn services should
enable mothers and their infants to remain together and to
practise rooming-in throughout the day and night. This may
not apply in circumstances when infants need to be moved
for specialized medical care (recommended, moderate-
quality evidence).
6. Mothers should be supported to practise responsive
feeding as part of nurturing care (recommended, very low-
quality evidence).

Feeding practices and additional needs of infants

7. Mothers should be discouraged from giving any
food or fluids other than breast milk, unless medically
indicated (recommended, moderate-quality evidence).
8. Mothers should be supported to recognize their
infants’ cues for feeding, closeness and comfort, and
enabled to respond accordingly to these cues with a
variety of options, during their stay at the facility
providing maternity and newborn services
(recommended, high-quality evidence).
9. For preterm infants who are unable to breastfeed
directly, non-nutritive sucking and oral stimulation may
be beneficial until breastfeeding is established
(recommended, low-quality evidence).
10. If expressed breast milk or other feeds are
medically indicated for term infants, feeding methods
such as cups, spoons or feeding bottles and teats may
be used during their stay at the facility (recommended,
moderate-quality evidence).
11. If expressed breast milk or other feeds are
medically indicated for preterm infants, feeding
methods such as cups or spoons are preferable to
feeding bottles and teats (recommended, moderate-
quality evidence).
Creating an enabling environment
12. Facilities providing maternity and newborn services
should have a clearly written breastfeeding policy that
is routinely communicated to staff and parents
(recommended, very low-quality evidence).
13. Health-facility staff who provide infant feeding
services, including breastfeeding support, should have
sufficient knowledge, competence and skills to support
women to breastfeed (recommended, very low-quality
evidence).
14. Where facilities provide antenatal care, pregnant
women and their families should be counselled about
the benefits and management of breastfeeding
(recommended, moderate-quality evidence).
15. As part of protecting, promoting and supporting
breastfeeding, discharge from facilities providing
maternity and newborn services should be planned for
and coordinated, so that parents and their infants have
access to ongoing support and receive appropriate care
(recommended, low-quality evidence).