BABY FRIENDLY HOSPITAL INITIATIVE AND EXCLUSIVE

BREAST FEEDING

BABY FRIENDLY HOSPITAL INITIATIVE

Definition:• The Baby Friendly Hospital Initiative was

introduced in 1991 by the World Health Organization/United Nations Children's Fund (WHO/UNICEF) to promote, protect and support breastfeeding in the hospital or birth setting. A key element in this promotion and support is outlined in their Ten Steps to Successful Breastfeeding. To date, approximately 19,000 hospitals and birth centers in about 125 countries have received the "Baby Friendly" designation.

CRITERIATen steps to successful breastfeeding recommended by code of

practice of WHO/ UNICEF :-

• Have a written breastfeeding policy that is routinely communicated to all health care staff.

• Train all health care staff in skills necessary to implement this policy.

• Inform all pregnant women about the benefits and management of breastfeeding.

• Help mothers initiate breastfeeding within one half-hour of birth.

• Show mothers how to breastfeed and maintain lactation,even if they should be separated from their infants.

• Give newborn infants no food or drink other than breastmilk, unless medically indicated.

• Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day.

• Encourage breastfeeding on demand.• Give no artificial teats or pacifiers (also called

dummies or soothers) to breastfeeding infants.• Foster the establishment of breastfeeding

support groups and refer mothers to them on discharge from the hospital or clinic.

Step 1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

Breastfeeding policyWhy 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

Breastfeeding policyWhat 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

Breastfeeding policyHow 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

Step 2. Train all health-care staff in skills necessary to implement this policy.

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 resolve breastfeeding difficulties• How to assess a breastfeed• Hospital breastfeeding policies and

practices• Focus on changing negative attitudes

which set up barriers

Step 3. Inform all pregnant women about the benefits of breastfeeding.

Antenatal education should include:

• Benefits of breastfeeding• Early initiation• Importance of rooming-in (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 mother-to-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

Step 4. Help mothers initiate breastfeeding within a half-hour of birth.

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.”

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 baby’s first

immunization• Takes advantage of the first hour of alertness• Babies learn to suckle more effectively• Improved developmental outcomes

Early initiation of breastfeeding for the normal newborn

How?• Keep mother and baby together• Place baby on mother’s chest• Let baby start suckling when ready• Do not hurry or interrupt the process• Delay non-urgent medical routines for at

least one hour

Protein composition of human colostrum

and mature breast milk (per litre)Constituent Measure Colostrum

(1-5 days)Mature Milk(>30 days)

Total protein G 23 9-10.5

Casein mg 1400 1870-Lactalbumin mg 2180 1610

Lactoferrin mg 3300 1670

IgA mg 3640 1420

• Step 5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants

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.

Supply and demandMilk removal stimulates milk production.

The amount of breast milk removed at eachfeed determines the rate of milk production in the next few hours.

Milk removal must be continued during separation to maintain supply.

• Step 6. Give newborn infants no food or drink other than breast milk unless medically indicated

• 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

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.

• Infants with phenylketonuria may be BF and receive some phenylalanine free formula.

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 recommended.

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 T-cell leukaemia virus, if safe and feasible options are available.

• BF can be continued when mothers have hepatitis B, TB and mastitis, with appropriate treatments undertaken.

Step 7. Practice rooming-in — allow mothers and infants to remain together — 24 hours a day.

• 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

Rooming-inWhy?

• Reduces costs• Requires minimal equipment• Requires no additional personnel• Reduces infection• Helps establish and maintain

breastfeeding• Facilitates the bonding process

Step 8. Encourage breastfeeding on demand.

• Breastfeeding on demand:• Breastfeeding whenever the baby or

mother wants, with no restrictions on the length or frequency of feeds

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 incidence of jaundice

Step 9. Give no artificial teats or pacifiers (also called dummies and soothers) to breastfeeding infants.

Alternatives to artificial teats

• cup• spoon• dropper• Syringe

• Cup-feeding a baby

Step 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The key to best breastfeeding practices is continued day-to-day support for the breastfeeding mother within her home and community.

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

EXCLUSIVE BREAST FEEDING

Definition: The feeding of an

infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container.

Benefits to the Baby

Perfect nutrition Perfect nutrition Higher IQHigher IQComplete food for the first Complete food for the first six monthssix monthsEmotional bondingEmotional bondingPrevents infectionsPrevents infectionsPrevents chronic diseasesPrevents chronic diseasesEasily digestedEasily digested

Benefits to the Mother

Reduces post delivery Reduces post delivery bleeding and anemiableeding and anemiaHelps delay next Helps delay next pregnancypregnancyProtective effect against Protective effect against breast and ovarian cancerbreast and ovarian cancerHelps to loose weightHelps to loose weightEmotional bondingEmotional bondingNeeds no preparationNeeds no preparation

Breastfeeding in the Correct Position

Milk producing glandsLactiferous canaliculiLactiferous sinusesMyoepithelial tissueAdipose tissue

Signs of Correct Attachment

Mouth wide open Mouth wide open Lower lip is turned outsideLower lip is turned outsideChin touching the breast Chin touching the breast Black part of the breast not Black part of the breast not visible below the lower lipvisible below the lower lipLarge black portion of breast Large black portion of breast and nipple including milk and nipple including milk collecting ducts are inside collecting ducts are inside baby’s mouthbaby’s mouthTongue under the teatTongue under the teat

Incorrect Sucking Position

Mouth is not wide openMouth is not wide openChin is away from the breastChin is away from the breastBaby is sucking only nippleBaby is sucking only nippleMost black portion of the Most black portion of the breast is outside the baby’s breast is outside the baby’s mouthmouthTongue away from the teatTongue away from the teat

Causes of Incorrect Attachment

• Use of feeding bottles. Leads to nipple confusion

• Inexperienced mother• Functional difficulty with the mother or the

baby• Lack of skilled support

Breastmilk ProductionThe Prolactin reflexThe Prolactin reflex

Sensory Impulses from nipple

More prolactin secreted at More prolactin secreted at nightnight Secreted after feed to Secreted after feed to produce next feedproduce next feed Suppresses ovulationSuppresses ovulation

Baby sucking

Prolactin in blood

The Feeling of “Not Enough Milk”

Not True. Just a perception

Reinforce mothers:Self confidence is mustEnsure frequent sucklingEnsure effective suckling

ConclusionExclusive Breastfeeding for First Six

MonthsBeing Successful-• Initiate breastfeeding as early as possible within one hour of birth.• Do not give the baby any prelacteal feeds• No bottles, artificial teats or pacifier • Breastfeeding on demand at least 8-10 times in a day and at night a• Breastfeed in a correct position• Build mother’s confidence to sustain good milk supply and alleviate

feeling of not enough milk.

• Newborn deserves the best Nutrition, Improved Survival, Optimum Development and Healthy Life

• Breastfeeding can do

this miracle !!!

INDICATORS OF ADEQUACY :-

Adequacy of breast feeding is indicated and established by the following:-

• Audible feeding sound while swallowing• Let down sensation in mother’s breast• Breast is full before the feed and soft after feed • Wet nappies 6 or more in 24 hrs• Frequant soft bowel movements 3 to 8 times in 24 hrs• Average weight gain of 18-30 gm/day• Baby sleeps well and doesnot cry frequently• Baby has good muscle tone and healthy skin

IMMUNOLOGIC SPECIFICITY• Protection against

pathogens & allergens• Kills pathogenic

organisms or modifies their growth

• Stimulates epithelial maturation for future defence

• First immunization• Protection against

common respiratory and intestinal diseases

IMMUNOLOGIC SPECIFICITY• Colostrum = Baby’s

first vaccination• Less risk of illness

such as: Ear infections,

pneumonia, crohn’s disease and other bowel illnesses, stomach flu and other intestinal illnesses, ear infections, childhood cancers, diabetes, arthritis, allergies, asthma and eczema

PERFECT FOOD FOR BABIES

• Just the right amount of nutrients in the right proportions

• Over 200 components in human milk• Composition of breast milk: -Live cells, fat, carbohydrates, proteins,

vitamins, minerals -Less fat than most other mammals -More lactose than other mammals

BREAST MILK COMPOSITION• Fat (4% concentration

provides up to 50% of caloric needs, cholesterol levels constant, lipolytic enzymes aid in fat digestion)

• Carbohydrates (lactose = milk sugar predominantly in human milk, 7% concentration provides up to 40% caloric needs, essential for development of CNS, enhances calcium & iron absorption)

BREAST MILK COMPOSITION• Carbohydrates (Bifidus

factor = growth factor present only in human milk required for establishing an acidic environment in the gut to inhibit growth of bacteria, fungi and parasites)

• Protein -Lactoferin => Isolates

external iron -Secretory IGA => Most

important immunoglobulin, breast milk = only source for first 6 weeks

BENEFITS OF BREASTFEEDING

• Ecological: -Saves resources -Less waste -No refrigeration -No manufacturing -No bottles, cans -No trucking -No handling

BENEFITS OF BREASTFEEDING

• For Society -Smarter -Healthier -Less cost to

healthcare system

-Stronger families

BENEFITS OF BREASTFEEDING

• To Families -Less trips to

doctors, hospitals -Less prescriptions -Less stress -Less illness -More bonding -Inexpensive

BENEFITS OF BREASTFEEDING

• Benefits to baby: -Better dental health -Increased visual

acuity -Decreased duration

and intensity of illnesses

-Less allergies -Better health & less

risk of illnesses

BENEFITS OF BREASTFEEDING• Benefits to mother: -Psychological (Attachment,

bonding, security, skin to skin, fulfillment of basic needs, relationship)

-Easier weight loss -Decreased risk of illness

(breast cancer, osteoperosis, hemmorhage, ovarian cancer)

-Birth control -Pride, empowerment,

fulfillment

HARMFUL EFFECTS OF FORMULA MILK

Why some mothers choose formula vs. breast milk

• Distressed by physical discomfort of early breastfeeding problems.

• Convenience issues

• Pressures of employment/school

• Worries that breast shape will change

• Formula manufacturers manipulate people through their ads

• Doctors and nurses need more lactation training

Why some mothers choose formula vs. breast milk

• Moms given very little time to adjust to changes of postpartum

• Family demands

• Non-supportive family/health professionals

• Embarrassment

• Lack of confidence in self

• Feeling that one cannot produce enough milk

Mother’s milk vs. formula milk• Human milk is designed

to support the development of large brains, capable of processing and storing lots of information.

• Cows milk is designed to support functions, like constant grazing.

Illness Relative risk• Allergies, eczema 2 to 7

times• Urinary tract infections 2.6

to 5.5 times• Inflammatory bowel disease

1.5 to 1.9 times• Diabetes, type 1 2.4 times• Gastroenteritis 3 times• Hodgkin's lymphoma 1.8 to

6.7 times• Otitis media 2.4 times• Haemophilus influenzae

meningitis 3.8 times• Necrotizing enterocolitis 6 to

10 times

Illness Relative risk

• Pneumonia/lower respiratory tract infection 1.7 to 5 times

• Respiratory syncytial virus infection 3.9 times

• Sepsis 2.1 times• Sudden infant death

syndrome 2.0 times• Industrialized-world

hospitalization 3 times