E - NEWSLETTER

BREAST FEEDING

PROMOTION

B R E A S T C O M M I T T E E O F F O G S I

e - Newsletter onBreast Feeding

March 2021

Editors

Dr. Laxmi ShrikhandeICOG Chair Designate

Dr. Archana VermaVP Elect FOGSI 2021

Coordinators

Dr. Mangala WaniPresident- Breast feeding Promotion network of

India,Maharashtra.(BPNI, Mah)

Dr. Shashibala BhonsaleSecretary Gwalior Obstetrics and Gynaecology

Society 20-21West Zone coordinator Breast Committee FOGSI 19 -21

Dear FOGSIANs

Breastfeeding is a mother’s gift to herself, her baby, and

the earth.” Pamela Wiggins.

Breast milk has always been the first food a baby

receives, and for many centuries, it was the only food

available to an infant. No one ever questioned its amount,

its nutritional content, or its availability. But with the

advent of milk formulas and other such replacement

products, the importance of breastfeeding was diluted for

many decades. Now however, it is slowly but surely taking

center stage again. Doctors as well as patients alike have

understood the importance of exclusive breastfeeding. We

all know how it helps the babies: there is a reduced risk of

infections and allergies, reduced chances of constipation

and colic, helps in development of healthy gut bacteria,

strengthens the immune system.

Breastfeeding provides health benefits for mothers:

emotional satisfaction and bonding, faster recovery from

childbirth, natural contraception, reduced rates of breast

and ovarian cancer in later life. Some studies have found

that breastfeeding may reduce the risk of developing type

2 diabetes, rheumatoid arthritis, and cardiovascular

disease, including high blood pressure and high

cholesterol.

Understanding these benefits, and, the commitment of our

obstetricians towards breastfeeding is clearly visible

today, with lactation consultants available on demand,

baby-friendly hospitals and promotion and encouragement

of exclusive breastfeeding.

Communicating these benefits and measures to the

doctors as well as patient community is the need of the

hour.

I applaud the Breast committee, FOGSI and it’s

chairperson Dr. Sneha Bhuyar for taking up this important

cause, and wish you success in promoting this vital

message across the country.

Dr. Alpesh GandhiPresident FOGSI 2020

Dear Dr. Sneha S Bhuyar

It is my proud privilege to be in charge of breast

committee and to be associated with you, a

dynamic, dedicated person with out of the box

thinking.

Your present endeavors are really needed and

with you at helm of affairs, I know they will be of

great help to all readers.

I wish you very best.

I am with you at each step.

Many many congratulations for this launch.

Thanks

Dr. Ragini AgrawalVice President FOGSI 2020 &

Incharge Breast Committee

My Dear Fellow FOGSIAN’S, It is a pleasure and

privilege to write this message.

It is sometimes surprising that what is considered

to be an instinctive or “natural” act could have so

many questions, barriers and myths surrounding

it.

Breastfeeding promotion was the first ever annual

theme adopted by FOGSI more than two decades

ago under the Presidentship of the Late Dr D K

Tank.

Great progress has been made since then, but

much more needs to be done. An element of

nuance and realism also is the need of the hour.

I am delighted that the Breast Committee led by

Dr Sneha Bhuyar, Editors- Dr Laxmi Shrikhande, Dr

Archana Varma and Coordinators- Dr Mangala

Wani, Dr Shashibala Bhonsle and the authors have

produced this informative and timely newsletter.

It will act as both a resource and an advocacy

tool for physicians and other stakeholders at

large.

Congratulations are due to all those who have

worked hard for the newsletter.

Warm regards,

Dr. Jaydeep TankSecretary General FOGSI(2018 - 2021).

Breastfeeding is one of the most effectiveways to ensure child health and survival.However, nearly 2 out of 3 infants are notexclusively breastfed for the recommended6 months—a rate that has not improved in 2decades.

It gives us immense pleasure to present thisdedicated newsletter towards achieving thisgoal. The entire gamut of breast feeding,right from physiology to pathology, hasbeen presented in a crisp, concise manner.

All the authors have taken great efforts toprovide you with up-to-date and clinicallyrelevant information.

Our sincere thanks to FOGSI President DrAlpesh Gandhi for his Dedication towardspromoting Breast feeding. Thanks to DrJaydeep Tank (Secretary General FOGSI) forhis guidance from time to time. Specialthanks to Dr Sneha Bhuyar for her vision ofhaving this newsletter in the capacity ofChairperson Breast Feeding CommitteeFOGSI and also for entrusting us with thisresponsibility.

Our endeavour will be worthwhile ifeveryone incorporates these changes intheir daily practice as-

“Change is the end result of all truelearning.” ―Leo Buscaglia

Editor's desk

Dr. Laxmi ShrikhandeICOG Chair Designate

Warm Greetings from our enthusiasticteam of Breast Committee FOGSI!!

We have come out with a e newsletterfor a novel and noble cause.

Breast feeding every woman’s dream andevery child’s right.

Dr. Sneha Bhuyar’s dream turning intoreality!!

Breast feeding is a miracle of God butproper breast feeding needsdeliberations.

This issue tells you all .

From basics to roadblocks every thing iscovered.

All topics help you to understand thenuances.

A good and great guide for new Momsand its at your fingertips.

Learning never goes waste and this willmould you to be a great Mom

Happy Being Mommy Days!! !

Dr. Archana VermaVP Elect FOGSI 2021

Editor's desk

FOGSI Breast FeedingWeek Celebrations

August 2019 - August 2020

LACTACON 2019 Pune

Nagpur Society August 2019

Yavatmal Society August 2019

ICOG – FOGSI – BreastCommittee Certificate Coursefor Breast Feeding - 31st May

to 2nd June 2020

ICOG – FOGSI – BreastCommittee Certificate Coursefor Breast Feeding - 31st May

to 2nd June 2020

ICOG – FOGSI – Breast CommitteeCertificate Course for Breast Feeding -

1800 viewers

FOGSI Breast Weekcelebrations

1st August - 7thAugust 2020

Webinar By Pune Obstetric &Gynaecological Society (POGS)

1st August 2020

Mega Scientific Session – PAN INDIA

2nd August 2020

Mega Scientific Session – PAN INDIA

2nd August 2020

Interactive Webinar ByPerinthalmanna Ob/Gyn

Society (POGS)4th August 2020

Webinar On Breast Feeding By Breast Committee – FOGSI

4th August 2020

Webinar ByGwalior Obstetrics And

Gynaecology Society5th August 2020

Webinar ByGwalior Obstetrics And

Gynaecology Society5th August 2020

6th August 2020

FOGSI Breast Committee with iMumz App Public Awareness

Session7th August 2020

FOGSI Breast Committee with iMumz App Public Awareness

Session7th August 2020

7th August 2020 Session was a bigsuccess with 58,200 viewers

FOGSI Breast Committee with iMumz App Public Awareness

Session7th August 2020

TAB

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TEN

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EARLY INITIATION OF BREASTFEEDING “WELL

BEGUN IS HALF DONE”

Dr. Neerja Puranik

BREAST FEEDING PROMOTION

Dr. Veena Pradhan & Dr. Sushma Sinha

NUTRITION OF BREAST-FEEDING MOTHER

Dr. Manisha Ghate & Dr. Anita Rajorhia

DIFFICULTIES IN BREAST FEEDING

Dr. T. Ramani Devi & Dr. S. Divya

BREAST FEEDING FRIENDLY HOSPITAL INITIATIVE

Dr. Mangala Wani

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6

10

13

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TAB

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HUMAN MILK BANKING

Dr. Sandhya Satish Khadse & Dr. A. Agila

MARKETING OF BREAST MILK SUBSTITUTES: IMS

ACT

Dr. Alka Kuthe

BREAST ABSCESS

Dr. Milind Shah

CARE OF BREASTS DURING BREAST

FEEDING:GYNECOLOGIST’S PERSPECTIVE

Dr. Shraddha Agrawal & Dr. Shashibala Bhonsale

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28

32

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Dr. Neerja Pauranik, MS, DGOSenior Consultant, Department of OBGYNMotherhood Hospital, Indore

The physiological aspects of the initiation ofbreastfeeding related to hypothalamus, pituitaryand overall hormonal control are not beingdiscussed herein. I will restrict myself to clinicalaspects only which will be covered in two parts.

1. Why early initiation of Breastfeeding isimportant

2. How to ensure early initiation.

Who does not support immediate initiation ofbreastfeeding? Including WHO, I think no one.Everybody agrees, believes and support thisconcept. Yet unfortunately actions betrayhypocrisy. Baring a few, it is most of the timemearly a lip service.

The benefits of immediate initiation ofbreastfeeding are tremendous and innumerable,and need to be remembered and hammeredrepeatedly.

1. Utilization of strong sucking reflex which lastsfor first 40 to 60 minutes only and re-appear after24 hours

2. Release of oxytocin, which in turns contractsuterus and reduces the risk of PPH(Postpartumhaemorrhage) and expels the placenta

3. Intensity of Jaundice is found to be less inearly fed babies.

4. Weight loss of newborns occurs withinphysiological limits

5. Skin to skin contact is important for bondingbetween mother baby duo.

6. It stabilizes the temperature of baby & preventshypothermia

Early Initiation ofbreastfeeding“Well begun

is half done”

Introduction

Immediate initiation of breastfeeding iscomparable to a miracle vaccine, which canprevent millions of infant deaths per year. Avaccine which is freely available, can beadministered orally, does not need cold chain,has no side effects and is very safe. The vaccineimparts many benefits other than immunity like,Nutrition, Brain development, Bonding,Antimicrobial protection and is availableeverywhere, every time at right temperature.

Why Early Initiation of Breastfeeding is Important

Advantages of immediate breastfeeding

This vaccine does not need a cold chain butneeds a warm chain of support. The above-mentioned analogy was given in an editorial ofLancet (1994), The statement still holds true evenafter 25 years.[1]

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The greatest reason for emphasis on earlyinitiation of breastfeeding is to ensure thatbabies do not miss out benefits of colostrum.Initial few drops of colostrum paints the sterile,permeable new born gut mucosa and preventsentry of infections in to the gut of infant. Babypasses meconium because of the laxative actionof colostrum. Colostrum is higher in Protein,Sodium, Chloride & Potassium, Vitamins such asA & E and three times higher than mature milk.

Carotenoids & secretory Iga are 10 times higher.Colostrum is low in sugar, fat & lactose. It is richin antioxidant, antibodies, immunoglobulins richin Interforone having strong antiviral activity.

Colostrum contains PSTI (Pancreatic secretorytrypsin inhibitor) 7 times higher than mature milk,which protects & repair delecate intestine of newborn.

Leucocytes are maximum on day 1 and 2 (10,000per cumm) and drops down to minimum 1000 percumm later on.

Benefits of Colostrum

Lack of knowledge and motivation is the mainobstacle, which is seen not only in obstetrician,pediatrician, but also in mothers family members,primary health care workers, labour room andoperation theatre staff. Many of them lack thetrue knowledge harbour a variety of myths andare not passionate enough, towards the goal ofearly & optimum breast feeding.

The most difficult time in breastfeeding journeyis first week; of the baby and mother, and motherdyad which can be over come to a great extent bysupporting mothers, preparing them mentallyduring antenatal period, educating husband andfamily members (specially mother-in-law), aboutmyths and misconceptions related tobreastfeeding.

How to Ensure Early Initiation

Adequacy of colostrum is many times questionedand mother get false advises.

To ensure early initiation ofbreast feeding it is essential todispel many myths.

Initiation of breastfeeding should be as early aspossible. According to WHO recommendation itshould be within first one hour. We should notwait till 59th minute. Obstacle which come in theway of early initiation are bathing and cleaningthe baby, giving injections of Vitamin K, orvaccinating for Hepatitis B, putting honey intobaby's mouth, weighing the baby and many otherunnecessary rituals.

Best time to figure out mother and baby duo tolearn latching, co-ordinated sucking swallowingand breathing is immediately after birth and firstthree days .

The above picture depicts that the requirement ofa new born baby is very small in first week. Gradually increases day by day. Colostrumcomes in right quantity, drops by drops Peopleshould not expect free flow right from the dayone.

Capacity of the newborn stomach on 1st day isonly 5 to 7 ml. which is exactly the amount ofcolostrum secreted by the mother. For the initial36 hours, a full term baby needs only colostrumwhich is coming drop by drop. Newborn carriescontents extra 20% calories in stores at the timeof birth gifted by nature which is used as bufferfor baby and mother to figure things out.

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Educating mother as well as relatives aboutnormal physiology, correct techniques can boosther confidence and can prevent use of formulafeeds.

Clinical situations where evaluation is necessarybut supplementation is not indicated.

1. The healthy term, appropriate for gestationalage infant with bilirubin level less than 18 mg%after 72 hours of age when baby is feeding welland stooling adequately and weight loss is lessthan 7%.

2. The infant who is fussy at night or constantlyfeeding for several hours.

3. The sleepy infant with fewer then 8 to 12feedings in first 24 to 48 hours with less than 7%weight loss and no signs of illness. Newborns arenormally sleepy after 2 hours alert period afterbirth.

It is not a rocket science; Babies may feed veryirregularly at first, they may feed only a few timesin first day or two, then they may feed very oftenfor several days. Rhythm settles down after aweek or two.[2]

Frequent unrestricted suckling from soon afterbirth stimulates production of Prolactin whichhelps the breast milk to establish earlier andhelps to prevent breast engorgement.

As soon as the baby is born, let the mother holdhim close, against her bare chest so that theymay have skin to skin contact.[3]

Breast feeding technique

Many obstetricians recommended Breast crawl.The neonate has instinctive reflexes to crawl andsearch for areola when placed prone on the chestof the mother

Baby Crawl

Dry the baby and cover them on mother to keepwarm. There is no need to force the baby tosuckle immediately. But most babies are ready totry within about an hour

Unfortunately breastfeeding is commonly notstarted till two days. Immediate breastfeedingshould be the norm in cesarean delivery also.Mother can feed their babies in laid back or lyingdown position

Cesarean Delivery

A general rule in the first week is that an awakebaby is a hungry baby.

Increased skin to skin time can encourage morefrequent feeding.

Some Recommendations

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Healthy infants should be put skin to skin withmother immediately after birth to facilitatebreastfeeding. [4-6]

Antenatal education and in hospital support cansignificantly improve rate of exclusivebreastfeeding.

Healthy newborns do not need supplementalfeeding for poor feeding.

Delay in time between birth and initiation of thefirst breastfeed is a strong predictor of formulause.[7,8]

Apart from weight loss hypoglycemia is newbornis unnecessarily feared of by pediatricians.Definition of hypoglycemia, its clinicalsignificance & management remain controversial.Blood glucose level in the first hours of life aretypically lower than normal values of olderchildren or adults in healthy infants bloodglucose level can often be maintained in theappropriate range by initiating feeding soon afterbirth. Most cases of hypoglycemia are transient.

As soon as the umbilical cord is cut there isabrupt interruption of supply of glucose andhence the peptic stones are utilized andglycogenisis, gluconeo genesis occurs plus

Fear of neonatal Hypoglycemia :How Common? How serious?

Healthy term infant have sufficient body water tomeet their needs even in hot climates.[9-15],Insensible loss of fluid is managed by breast milkalone. Newborns lose weight because ofphysiologic diuresis of extracellular fluid[16].Between 48 to 72 hours after birth there is weightloss ranging maximally between 5 to 6.6 %, whichis regained in 6-8 days. Weight loss needs closemonitoring, majority of breastfeed infants will notrequire supplementation.

The concerns about weight loss :How grave?

All the above mentioned facts stronglyrecommend initiation of breastfeeding as early aspossible. Healthy infants should be put skin toskin to facilitate this because the delay in time(Golden Hours) is a strong predictor of formulause.

Antenatal education and in hospital support cansignificantly improve rates of exclusivebreastfeeding.[17]

Hospitals should strongly consider instituting a‘policy’ regarding supplemental feedings torequire a physician's order and formula consentof mother when supplement are not medicallyindicated.

Conclusion

Before labeling, diagnosing and treating,hypoglycemia in a newborn baby it is necessaryto know exact gestational age, large for date orsmall for date, infants of diabetic mother, historyof birth asphyxias and many more.

nutrients from feeding maintain adequate glucoselevel. During this normal transition newbornglucose levels fall to a low point (nadir) in first 1to 2 hour of life as low as 30 mg% then increasedto 45 mg %.

1. Lancet Editorial, Nov 1994, Pages 1700-1702John Dobbing

2. Helping Mothers to Breastfeed, Page 37, 2001

3. How breastfeeding should begin, HelpingMothers to Breastfeed, Page 35, 2001

4. American Academy of Pediatrics Committee onDrugs : Transfer of drugs and other chemical intohuman milk, Pediatrics 108:776-789, 2001.

5. Division of Child Health and Development,World Health Organization. Evidence for the

References

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6. Saadeh R, Akre J: Ten Steps to successfulbreastfeeding : summary of the rationale and scientific evidence, birth 23:154-160, 1996.

7. Kurinij N, Shiono P : Early formulasupplementation of breastfeeding. Pediatrics88:745-750, 1991

8. Smale M: Working with breastfeeding mothers :the psychosocial context. In clement S, editor:Psychological perspectives on pregnancy andchildbirth, Edinburgh, 1998, Churchill Livingstone,pp 183-204.

9. Cohen RJ, Brown K., Rivera L, et al: Exclusivelybreastfed, low birth weight term infants do notneed supplemental water, Acta Paediatr 89:550-552, 2000

10. Goldberg N, Adams E: Supplementary waterfor breast-fed babies in a hot and dry climate-notreally a necessity, Arch Dis Child 58:73-74, 1983

11. Marchini G, Stock S. Thirst and vasopressinsecretion counteract dehydration in newborninfants, J Pediatr 130:736-739, 1997

12. Rodriquez G, Ventura P.l Samper M et al :Changes in body composition during the initialhours of life in breast-fed healthy term newborns,Biol Neonate 77:12-16, 2000

13. Sachdev H, Krishna J. Puri R, et al: Watersupplementation in exclusively bresatfed infantsduring summer in the topics, Lancet 337:929-933,1991.

14. Sachdev H, Krishna J, Puri R: Do exclusivelybreastfed infants need fluid supplementation?Indian Pediatr 29:535-540, 1992

Ten Steps to successful Breastfeeding. 15. Shrago L: Glucose water supplementation ofthe breastfed infants during the first three daysof life, Arch Pediatr Adolesc Med 151:830-832,1997

16. Zangen S, DiLorenzo C, Zangen T, et al: Rapidmaturation of gastric relaxation in newborninfants, Pediatr Res 50:629-632, 2001

17. Su LL, Chong YS, Chan YH et al: Antenataleducation and postnatal support strategies forimproving rates of exclusive breastfeeding :randomized controlled trial, BMJ 335:596, 2007

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Dr. Veena Pradhan. MBBS DGORetd I/C Medical officerWorking as a social worker-school health programme,National immunization programme, awareness forseasonal diseasesGOGS(past vice president 2017 -2020)

Breast FeedingPromotion

Breastfeeding promotion refers to coordinatedactivities and policies to promote health amongwomen, newborns and infants throughbreastfeeding. The World Health Organization(WHO) recommends infants should be exclusivelybreastfed for the first six months of life toachieve optimal health and development,followed by complementary foods whilecontinuing breastfeeding for up to two years orbeyond.However, currently fewer than 40% ofinfants under six months of age are exclusivelybreastfed worldwide.

Public health awareness events such as WorldBreastfeeding Week, as well as training of healthprofessionals and planning, aim to increase thisnumber. World Breastfeeding Week is aninternational initiative of the World Alliance forBreastfeeding Action that seeks to promoteexclusive breastfeeding. Since 1992, it has beenheld each year from August 1 through August 7.

Effective support techniques for breastfeedinginclude support given by nurses, physicians, andmidwives during and after pregnancy, regularscheduled visits, and support that is directedtowards specific groups of people. Support hasbeen shown to be effective when offered by bothprofessional ,peers, or a combination. Providing

face-to-face support has been shown to be morelikely to be successful for women who arebreastfeeding exclusively.It is essential thathealthcare providers receive high quality trainingin clinical lactation to provide skilled and timelysupport to breastfeeding families.

Dr. Sushma Sinha, M.D. FMAS,FICOG,FICMCH FIMSA

HOD & Senior Specialist (Govt Of NCT ofDELHI)

Lactation consultantsLactation consultants are health careprofessionals whose primary goal is to promotebreastfeeding and assist mothers withbreastfeeding on an individualized or groupbasis. The majority of lactation consultants holda certification

Social marketing and mediaSocial marketing has been shown to influencewomen's decision to breastfeed their children.

The growth of the Internet's influence has alsoinfluenced women's choices in infant feeding.The Internet has served as both a vector forformula advertisement and a means by which

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One social medium used to promotebreastfeeding is video. These videos are oftenindependently filmed and produced by lactationconsultants who seek a new way to reach clients.While the efficacy of these videos has not beenformally studied, they are a relatively newmedium of conveying messages aboutbreastfeeding.

women can connect with other mothers to gainsupport and share experiences frombreastfeeding. In addition, social media is acategory of advertising that did not exist whenthe International Code of Marketing of Breast-milk Substitutes was published; thus, while someadvertising practices undertaken by formulacompanies on the Internet violated the Code, theydid so in ways that could not have beenanticipated.

On a global scale, recommendations have beenmade to educate school age children usingcurriculum that promotes healthy nutrition whichincludes breastfeeding. The World HealthOrganization's Global Strategy for Infant andYoung Child Feeding recommend educationauthorities help form positive attitudes throughthe promotion of evidence-based scienceregarding the benefits of breastfeeding and othernutrition programmer in Women.

On a global scale, recommendations have beenmade to educate school age children usingcurriculum that promotes healthy nutrition whichincludes breastfeeding. The World HealthOrganization's Global Strategy for Infant andYoung Child Feeding recommend educationauthorities help form positive attitudes throughthe promotion of evidence-based scienceregarding the benefits of breastfeeding and othernutrition programmer in Women.

The Baby Friendly Hospital Initiative (BFHI) is aninitiative of the World Health Organization andUNICEF that seeks to encourage initiation ofbreastfeeding among mothers who give birth totheir children in hospitals. Facilities that achieveits "Ten Steps to Successful Breastfeeding" andimplement the International code of MarketingBreast-milk Substitutes can be recognised as aBaby-Friendly facility by the BFHI. In the UnitedStates, accreditation by the BFHI allows facilitiesto approach the Healthy People 2020breastfeeding initiation goals. Worldwide,facilities that fulfill the requirements of the BFHIhave been able to greatly increase theirbreastfeeding initiation rates among patients.

The Government of India initiated the nation-widebreastfeeding programme: MAA- Mother’sAbsolute Affection, in August 2016. Initiation ofbreastfeeding within the first hour of birth andexclusive breastfeeding for at least six monthsare the two main goals of the MAA programme

requires public schools to provide similar facilityto the lactating students.

.

It is desirable for the employer to provide breaktime to accommodate employees to expressbreast milk for the employee's infant child,breast-feed an infant child or address other needsrelated to breast-feeding. This amendment also

Supporting breastfeeding amongworking mothers

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Counselling of lady starts fromAntenatal period BY all strata ofHEALTH CARE PROVIDER withthe help of Banner, Poster andRole Play

Health promotion messages rarely work whenthey simply tell people what to do. We all knowwhat a healthy diet looks like, yet that knowledgedoesn’t prevent us from ordering anothertakeaway. The same is true for breastfeeding.

Rather than focusing on telling women tobreastfeed, all the stakeholders must recognizetheir wider public health responsibility, and workto create an environment that actually supportsbreastfeeding. It shouldn’t be left to charities andvolunteers alone. Support should be part andparcel of society – and implementing a newstrategy is not as difficult as it appears

Good quality education, rather than simply a listof reasons why women should breastfeed, is keyto success here. Before the birth, mothers shouldbe offered information on how breastfeedingworks, challenges that might arise and who theycan get support from. Peer supporter schemesare a highly valued source of practical andemotional help for new mothers, but in manyplaces are absent or have had their funding cut.

1. Education and support

But this is not just about teaching mothers,ongoing breastfeeding education is crucial for allwho support them, including GPs and childcarestaff, so that women get consistent, high qualityadvice. However, this education is not much useunless staff are also given the time to work withmothers after birth.

Breastfeeding promotion should not just targetmothers, but the wider population. A mother maywant to breastfeed but if those close to her donot understand why, or how to help, herexperience will be more challenging.

Counselling for the parents and other activefamily member (Grand Mother) // SAAS:BAHUSAMMELAN: Involving them in decision makingand explaining about the benefits of mother’smilk. Involving the family has a positive impacton the women’s mental status which is helpful inadequate secretion of breast milk.

The public need to know why it is important tosupport breastfeeding, and that it has legalprotection too. Breastfeeding Welcome schemes– participating organisations display signs sayingthey are supportive of breastfeeding – can playan important role here to reassure mothers, andalso send a strong signal to potential critics.Public acceptance is not just an issue for adults:children should also learn about the breast, andits role in nutrition, health and reproduction, justas they would any other body part. Doing thiswould mean that the next generation would noteven think to question breastfeeding.

2. Public acceptance

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3. Maternal legal rightsCountries, like Sweden, that have longer, well-paid maternity leave and flexible working rightsalso have the highest breastfeeding rates.However, in the UK for example, statutorymaternity pay drops to just £140 (R2368.36) aweek after six weeks, and in the US it is non-existent – meaning many mothers return to workweeks after the birth. When they return, manystruggle to continue breastfeeding due to poorfacilities – despite research showing that whenwomen have private, paid breaks to express, thisleads to continued breastfeeding and happierstaff. Some simple changes here would not onlyenable women to breastfeed for longer, but showthat society values mothering.

5. Formula controlFormula milk is lifesaving for babies who cannotbe breastfed but advertising these products issimply not necessary. Many of the claims madehave already been challenged by health bodies asmisleading or unnecessary.

In countries that have implemented these fiveelements, there have been clear increases inbreastfeeding rates. In Norway, for example, bothmothers and fathers have extended, well-paidleave after the birth, while laws are upheld, andadverts for infant formula are regulated. Brazilhas had success too, following similar changesand investing in over 200 BREAST MILK BANKS.This concept is being gradually incorporated inIndian context as well

In the absence of a village, professional supportis again vital. Research has shown that enablinghealth visitors to spend more time with newmothers, even just to simply talk about they arefeeling, can help mothers’ mental healthimmensely. Community support networks are alsovital, to reduce feelings of isolation.

not down to one mother, but a whole village.However, in the West, new mothers are oftenisolated, lonely and exhausted, which can makebreastfeeding feel insurmountable.

4. Mental healthCaring for a baby invariably leaves new mothersfeeling exhausted. In many cultures, childcare is

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Dr. Manisha Ghate, MBBS,DGO,DFPConsultent,Ghate surgical and maternityhospital,Chandrapur,Maharashtra.

Nutrition of breast-feeding mother

The Food and Nutrition Board has suggested anextra 500 Kilo-calories per day for first sixmonths. Around 400 additional Kilo-calories arerequired for the next 6 months.

Dr. Anita Rajorhia MBBS,MD,FICOGSenior Consultant and Head of the

Department(O & G), Sardar Vallabh Bhai PatelHospital, Government of NCT of Delhi

Constituents of additionalnutrition

The additional nutrition requirement should be inthe form of

1) Proteins2) Fats3) Minerals4) Omega-3 Fatty acids5) Water and other nutrients

1) ProteinsProteins are the principle and the most importantconstituent in food for the breast-feedingmothers. As the milk contains 1.15 gm ofproteins / 100 ml, the requirement should be 75gm of proteins/ day for first six months oflactation and 68 grams/ day for the subsequent 6months. The mother should take locally availableand affordable Protein rich foods like:

1) Milk and milk products like paneer and cheese 2) Legumes, beans and lentils3) Whole grain and pulses4) Soya products5) Nuts and seeds 6) Eggs and meat7) Fruits and vegetables.

IntroductionBreast milk is the Gold standard for infantnutrition and is rightly called ‘Liquid Gold’. For theproduction of this liquid Gold, the lactatingmother needs special nutrition. Nutrition can bedefined as the food required for properfunctioning of the body. Scientifically, it is theenergy or nourishment that is obtained from thefood consumed. When it comes to nutrition of abreastfeeding mother, importance of propernutrition increases several folds. Thebreastfeeding mother has to share the dualresponsibility of nourishing herself & her baby.The breastfeeding mother should follow properguidelines & recommendations made for theirproper nutrition. These mothers need extranutrition to nourish their babies through theirbreast milk. Any inadequacy in mother’s diet caninfluence both the quality and quantity of herbreast milk. If her diet is inadequate, the bodyreserves would be depleted affecting her ownhealth and well-being.

Calorie requirement duringbreastfeeding

It has been documented that about 85 Kilo-calories (Kcal) are required to produce 100 ml ofbreast milk. During first six months of lactation,mothers require an additional 640 Kilo-caloriesper day, considering that average daily milkproduction is around 750 ml.

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The amount of fat in the breast milk is areflection of her dietary fat intake, but it does notaffect the quantity of milk produced. A calorie-rich diet should have fat sufficient to meet thedemand.

Approximately 200 mg of Calcium is transferredper day to baby through breast-milk. ICMR hasrecommended an additional intake of 600 to 1200mg of Calcium per day. Sources are Milk and milkproducts, green leafy vegetables, juices, cereals,soya- milk, soya- yoghurt and fish etc.

Calcium, Iron and Vitamin D supplements areencouraged.

2) Fats

3) Minerals

Mother’s milk is ‘not’ a good source of iron.Therefore, to compensate for a very smalltransfer of 0.5.- 0.7mg/day, an additional 15-25mg Iron per day is recommended. The sourcesof Iron include lentils, enriched and fortifiedcereals, green leafy vegetables, peas and dry-fruits. Vitamin C intake in form of citrus fruits ishighly recommended for better Iron absorption.

Vitamins in breast milk depend on dietary intakeby mother. Breast milk contains both watersoluble Vitamins C, B1,B6, B12 and Folate and fatsoluble vitamins A,D and K. The prenatal vitaminsupplementation must continue in lactation asmaternal vitamin deficiency is reflected in breastmilk. Essential vitamins required are discussedbelowa) Calcium

b) Iron

It is present in minimal amount in breast milk,therefore the mother should take a sufficientamount of Vitamin D.

C) Vitamin D

Docosahexaenoic Acid (DHA) is an essential longchain Omega -3 Fatty acid which is important forthe development of brain, skin and eyes of thebaby. Low intake of DHA by mother is reflected inbreast milk. DHA intake reduces behavioral and

4) Omega-3 fatty acids

cognitive issues in baby. Sources are oats, nuts,rice, carrots, garlic, ginger, fennel, yoghurt,spinach, sesame, flax seeds, butter, papaya andoil.

5) Vitamins

Eating a variety of food while Breastfeedingchanges the flavor of breast milk. This willexpose the babies to different tastes, which helpsthem to accept solid food while weaning

The sources of vitamins

WaterWater intake should be adequate and at least 8-10 glasses per day are recommended asbreastfeeding mothers feel thirsty due to

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increased oxytocin levels. It should beremembered that Prolactin is responsible for milkproduction and oxytocin is involved in milkejection from breast.

These should be avoided during breast-feeding asthey are secreted in breast milk. Excessive intakeof caffeine such as coffee, tea, soda, energydrinks and chocolates can make the infantsirritable and may interfere with their sleep. Thebiggest concern is addiction of the mother andthe baby, hence should be avoided.

Alcohol and Caffeine

A good nutrition during pregnancy and lactationis required for healthy mother and baby. We mustraise awareness regarding a ‘healthy balancednutritional diet’ in all pregnant and lactatingmothers.

Key MessagesMothers should have 3 regular meals with 2 to 3light snacks in a day as part of their lactationdietary allowance. Dieting should be avoidedduring breastfeeding as it may reduce thequantity and quality of milk. If the gainedpregnancy weight needs to be lost, limit theintake of foods that are high in fat and sugar.Moderate exercises must be advised. Specialdietary allowances are made for lactatingmothers who are obese, breast-feeding twins ortriplets, have undergone bariatric surgery, arefollowing vegan or ovo-lactovegetarian diet.Undernourished and anemic mothers need specialdietary counselling. Avoid smoking or use of anydrug without doctor’s prescription.

Counselling needs to be done for stress, anxietyand eating disorders. Help of nutritionists anddieticians may be required.

Conclusion

An individualized approach in the form ofnutritional counselling is required depending onher age, body-mass Index, socio-demographicprofile, access to food, prevalent food fads, foodpreferences etc.

1.MichelleA.Kominiarek.Nutritionrecommendations in pregnancy and lactation.Med Clin North Am.2016 Nov;100(6):1199-1215

2.https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-andmicronutrients/Maternal-diet.html

3.https://healthengine.com.au/findapractitioner.php/Nutrition during breastfeeding

References

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Difficulties in breastfeeding

Factors associated with infantsThis includes low birth weight, temporary illness,over-distension of the stomach with swallowedair and congenital malformation of palate and themouth.

Dr. T. Ramani Devi, MD; DGO; FICS;FICOG;National Vice President FOGSI 2020Consultant Obstetrician and Gynecologist DirectorRamakrishnaMedical Centre LLP Director Janani FertilityCentre Trichy.

Dr. S. Divya, MD (OG).,Consultant Obstetrician and Gynecologist

Ramakrishna Medical Centre LLPTrichy

IntroductionBreast feeding is the best gift any mother cangive to her new born. After all, a new born has gotonly three demands, i.e., warmth in the arms ofthe mother, food from her breast and security bythe way of her presence. All the three can beachieved by simple breastfeeding as said by,Grantly Dick Read[1].

This write-up throws light on various aspects ofdifficulties in breast feeding like difficulty ininitiation, insufficient milk secretion, difficulty inlatching, problems in the breast, problemsassociated with the nipple, breast infections suchas mastitis and breast abscess and leaking ofmilk or slow flow of milk.

Factors associated with themother

25% do not initiate breast feeding within 1 hour ofbirth, 50% discard colostrum and 75% give prelacteal feeds like sugar syrup or formula feeds asthey feel that they do not have milk. Some havereluctance or dislike for breast feeding. Anxietyand stress following operative delivery could alsobe a vital reason. Breast ailments occasionallygive problems to the mother.

Breast Feeding InitiationThe alert, healthy newborn can latch on to thebreast within the first hour of life. If the infant isplaced skin-to-skin immediately after the birth,the baby can often reach the breast and latch onwith little or no assistance [2]. If the mother hasreceived medications that sedate the baby, thenhe or she may need more assistance. Thenewborn baby may be dried, have Apgar scoresassigned, and be assessed while on the mother’sabdomen or chest. Thus, the mother helps to aidin newborn thermoregulation. Delaying weights,measures, bathing, vitamin K injection, and eyeprophylaxis will encourage effective latch andmaternal and newborn attachment. Unless thereare unusual circumstances, the infant shouldremain with the mother throughout the recoveryperiod.

Labor and delivery personnel should be trainedand knowledgeable in breastfeeding support. Lactation specialists, such as nurses or and

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Generally mature milk begins within 72 hours.Mother feels that the breast is heavier and fuller.Occasionally, some mothers experience delayedonset of milk production. Causes could be overhydration with fluids and retained placentalfragments.

In case of delayed onset of milk production, it isnecessary to review the hydration status of thebaby, weight, neo natal jaundice and suggestsolutions to the mother[3].

Frequent nursing once in 2 hours or moredepending on the baby’s need may be advised.Massaging of the breast while nursing may besuggested. Pumping should be done after nursingto stimulate the breast. Herbal secretagogues(fenugreek), medications (Domperidone 10mgTDS) administered orally may also help to combatdelayed onset of milk production.

Milk Production

Causes for inadequate milk secretion areincorrect methods of breastfeeding, engorgementof breast, associated illness, painful conditionsof the breast, maternal stress, insufficient sleepand lack of prolactin and oxytocin secretion. Wecan advise the mother to take sufficient rest,ensure adequate fluid intake, feed baby ondemand and create the confidence of themother[3].

expertise or International Board-CertifiedLactation Consultants (IBCLCs), should beavailable for consultation for specialcircumstances.

Retracted and inverted nipples bring aboutdifficulty in latching. Improper suckling may inturn lead to sore and excoriated nipple.Treatment with manual eversion or with plasticsyringe may be beneficial in such cases.

Eating a variety of food while Breastfeedingchanges the flavor of breast milk. This willexpose the babies to different tastes, which helpsthem to accept solid food while weaning

Management of a baby who doesnot suckle

When a baby does not suckle avoidance ofartificial food or water, provision of expressedbreast milk only, placement of nipple slightlyupwards towards the roof of the baby’s mouth

Sore nipple may be caused by improper latching,frequent washing with soap and water or pullingof baby while still suckling. It can be a source ofinfection. Treatment includes proper positioningand latching, maintenance of local hygiene,exposure to air, application of breast milk orlanolin and use of nipple shield and breast shells.

Inadequate milk secretion

Problems with Breast

and keeping the baby’s nose free during breastfeeding may be of help.

Breast Engorgement

Breast engorgement is usually caused by delayedor infrequent feeding, improper latching andpositioning. Engorged breasts are swollen, hard,warm and painful. Prevention can be throughearly and frequent feeds and correct attachment.Treatment includes warm water packs, breastmassage, analgesics, milk expression to softenbreast and fomentation with ice bags.

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One of the most serious complications of breastfeeding includes a breast infection, otherwiseknown as mastitis. Mastitis can be caused by astaphylococcus. Baby is the source of infectionand through cracked nipples it ascends. Therapyincludes administration of antibiotics,continuation of breast feeding, provision ofadequate breast support and expression of milkfrom the infected side.

Breast abscess is yet another complication thatis found to arise in breast feeding mothers. Chiefcauses are engorged breast, cracked nipple andmastitis. It clinically manifests as high-gradefever with raised blood count. Treatment includesadministration of analgesics and antibiotics,incision and drainage or aspiration of the pus.Continuation of breast feeding and expression ofbreast milk from the infected side should also bedone.

There can be difficulty in letting down, probablystimulus by suckling will improve that. Mothershould be encouraged to be relaxed andconcentrate fully on breast feeding andsometimes the problem of latching and sucklingmay reduce the milk supply. Some of the mothersdo have excess milk which leaks and they need tobe advised to use a breast pad[3].

Mastitis

Latching of the baby -difficultiesfaced

Latching the baby can be done by cradle, football,clutch and by lying down position.

Difficulties in latching may be because of womenwho do not have a previous experience in breastfeeding, infants with micrognathia, tongue tie,protruding tongue, tongue suckling and also be

Other reasons for difficult latching are nippleissues such as flat nipple, dimpled nipple andinverted nipple. Poor latching may inadvertentlylead to nipple soreness.

Solutions include nursing within 2 hours of birthas baby tend to latch better, getting help toposition the baby for nursing, avoiding artificialteats in the first few days and pumping for ashort while before nursing as it can help to pullnipple out for better nursing.

Help of the family members is essential in theearly hours of post-natal period.

due to preference to bottle teat because of thebreasts that are filled.[4,5]. This can be managedby expressing milk before feeding or by applyingice to the breast before feeding or by goodpositioning.

Breast Abscess

Flow of Milk

Recommended BreastfeedingPractices

The American Academy of Pediatrics (AAP) policystatement recommends certain breast-feedingpractices. Routine use of supplementary feedingshould be avoided in exceptional medicalindications where the physician has to order.Pacifiers should be avoided till the breast feedingis established very well [6].

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AAP recommends the following feeding pattern.Encourage atleast 8 to 12 feeds per dayalternating the breast, the infant should benursed in one breast till it is totally empty thenfeeding could be pursued in the next breast.

The formal evaluation of breastfeeding techniqueand practices throughout the hospital stay,including documentation in the mother’s andinfant’s charts, and again at 3–5 days of age areessential to promote successful breastfeeding.Close follow-up helps to provide a safety net toguard against the breastfeeding newborndeveloping significant dehydration or breast milkjaundice. The infant should be observed at thebreast and assessed for weight pattern, jaundice,hydration status, patterns of breastfeeding andinfant elimination pattern.

Water, juice, formula feeds and solids are notnecessary in the first 6 months for breastfedinfants.

All breastfed infants and children should receive400 IU of Vitamin D daily as human milk does notcontain sufficient Vitamin D to prevent ricketsand supplementation of iron by 6 months.

AAP does not recommend introduction of wholecow’s milk prior to the first birthday. Mothers whoare not breastfeeding exclusively or who chooseto wean their infants from the breast prior to thefirst birthday should feed iron-fortified infantformula.

Feeding Pattern

Breastfeeding should be initiated within 1 hourafter birth. Supplementation is rarely indicatedand interferes with successful lactation. Goodbreastfeeding practice helps to preventbreastfeeding problems. One of the mostfrequent reasons for mothers to stopbreastfeeding or start supplementation is theirperception that they do not have “enough milk.” Close follow-up and good education should helpto minimize concerns about lack of milk. Allbreastfed infants need an office visit by 3-5 daysof life, or about 48-72 hours after hospitaldischarge.

Conclusion

Milk Expression

If a mother is separated from her infant becauseof premature birth, maternal or infant illness, orher return to work or school, she should be taughtto express her milk so that she can maintain milksupply and continue to provide milk for her infant.Hand expression or a manual pump is effectivefor expression of milk.

1) Dick-Read G. Childbirth without fear: theprinciples and practice of natural childbirth.Pinter & Martin Ltd; 2013 Jun 13.

2) Dennis CL. Breastfeeding initiation andduration: A 1990‐2000 literature review. Journalof Obstetric, Gynecologic, & Neonatal Nursing.2002 Jan;31(1):12-32.

3) Amir LH. Breastfeeding: Managing supplydifficulties. Australian family physician. 2006Sep;35(9):686.

4) Gianni ML, Bettinelli ME, Manfra P, SorrentinoG, Bezze E, Plevani L, Cavallaro G, Raffaeli G,Crippa BL, Colombo L, Morniroli D. Breastfeedingdifficulties and risk for early breastfeedingcessation. Nutrients. 2019 Oct;11(10):2266.

5) Hauck Y, Langton D, Coyle K. The path ofdetermination: exploring the lived experience of

References

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6) Eidelman AI. Breastfeeding and the use ofhuman milk: an analysis of the AmericanAcademy of Pediatrics 2012 Breastfeeding PolicyStatement. Breastfeeding medicine. 2012 Oct ;7(5):323-4.

breastfeeding difficulties. Breastfeeding Review.2002 Jul;10(2):5.

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Substantial evidence has accumulated that theBFHI has the potential to significantly influencesuccess with breastfeeding. In Belarus, a group-randomized trial undertaken at the end of the1990s increased the rate of exclusivebreastfeeding at 3 months to 43% in hospitalsthat implemented the Ten Steps, compared toonly 6% in the hospitals that did not receive theintervention.[1] A systematic review of 58 studiespublished in 2016 demonstrated clearly thatadherence to the Ten Steps impacts rates ofbreastfeeding.[2] One study found that adherenceto six of the specific maternity- care practicescould reduce the odds of early termination ofbreastfeeding 13-fold [see Fig.1].[3]

friendly if they adopt the “Ten Steps” and followthese practices. BFHI is progressing in thecountry and about 1300 hospitals have beendeclared as Baby Friendly.

Although breastfeeding is associated with manyhealth benefits in children and mothers, andWorld Health Organization (WHO) recommendsexclusive breastfeeding until 6 months of age andcontinued breastfeeding until 2 years of age,overall breastfeeding rates remain low.

Recent analyses have documented that increasingrates of breastfeeding could add US$ 300 billionto the global economy annually.

Dr. Mangala Wani. M.D.,F.R.C.O.G.,I.B.C.L.C.Obstetrician,Gynaecologist & Lactation Consultant.Director- Hirkani Gynaecology & Breastfeeding medicine Clinic, PunePresident- Breast feeding Promotion network of India,Maharashtra.(BPNI, Mah)

Breast feeding FriendlyHospital Initiative

WHO and UNICEF launched the Baby-friendlyHospital Initiative (BFHI) to help motivatefacilities providing maternity and newbornservices worldwide to implement the Ten Steps toSuccessful Breastfeeding. The Ten Stepssummarize a package of policies and proceduresthat facilities providing maternity and newbornservices should implement to supportbreastfeeding. WHO has called upon all facilitiesproviding maternity and newborn servicesworldwide to implement the Ten Steps.

BFHI was started in India in 1993. Thesehospitals are assessed and certified as baby

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Ten steps for successfulbreastfeeding

The core purpose of the BFHI is to ensure thatmothers and newborns receive timely andappropriate care before and during their stay in afacility providing maternity and newborn services.

Revision of the Ten Steps to SuccessfulBreastfeeding is done by WHO in 2018.[4]

Step 1a: Comply fully with the International Codeof Marketing of Breast-milk Substitutes andrelevant World Health Assembly resolutions.

The facility should have a policy that describeshow it abides by the Code, including procurementof breast-milk substitutes, not accepting supportor gifts from producers or distributors ofproducts covered by the Code and not givingsamples of breast-milk substitutes, feedingbottles or teats to mothers.

Step 1b: Have a written infant feeding policy thatis routinely communicated to staff and parents.

Written policies are the vehicle for ensuringpatients receive consistent, evidence-based care,and are an essential tool for staff accountability.Policies help to sustain practices over time andcommunicate a standard set of expectations for

Observations in the facility confirm that asummary of the policy is visible to pregnantwomen, mothers and their families.

Step 1c: Establish ongoing monitoring and data-management systems.

Two of the indicators, early initiation ofbreastfeeding and exclusive breastfeeding, areconsidered “sentinel indicators”. Recording ofinformation on these sentinel indicators shouldbe incorporated into the medical charts andcollated into relevant registers. The group orcommittee that coordinates the BFHI- relatedactivities within a facility needs to reviewprogress monthly to start with and then every 6months. If the targets are not met, implementcorrective actions.

all health workers. The health facility should havea written infant feeding policy that addresses theimplementation of all eight key clinical practicesof the Ten Steps, Code implementation, andregular competency assessment.

Step 1: Facility policiesStep 2: Ensure that staff have sufficientknowledge, competence and skills to supportbreastfeeding.

Timely and appropriate care for breastfeedingmothers can only be accomplished if staffs havethe knowledge, competence and skills to carry itout. Training of health staff enables them todevelop effective skills, give consistentmessages, and implement policy standards. Staffcannot be expected to implement a practice oreducate a patient on a topic for which they havereceived no training. It is important to focus noton a specific curriculum but on the knowledgeand skills obtained.To increase skills of healthworkers in breastfeeding management, currentexperience seems to confirm that 18 hours (3days) training is an appropriate minimum lengthof training, while longer courses (e.g. 5-6 fulltime days) with daily clinical sessions are more

Step 2: Staff competency

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Step 3: Discuss the importance and managementof breastfeeding with pregnant women and theirfamilies.

All pregnant women must have basic informationabout breastfeeding, in order to make informeddecisions. A review of 18 qualitative studiesindicated that mothers generally feel that infantfeeding is not discussed enough in the antenatalperiod and that there is not enough discussion ofwhat to expect with breastfeeding.[2] Motherswant more practical information aboutbreastfeeding. Pregnancy is a key time to informwomen about the importance of breastfeeding,support their decision- making and pave the wayfor their understanding of the maternity carepractices that facilitate its success.

Breastfeeding education should includeinformation on the importance of breastfeedingand the risks of giving formula or other breast-milk substitutes, along with nationalrecommendations for infant feeding. Practicalskills such as positioning and attachment, on-demand feeding, early feeding cues, and possiblechallenges are a necessary component ofantenatal counselling.

desirable. Training must be compulsory for allstaff including seniors. There is also a need tochange attitudes, which create barriers tobreastfeeding promotion.

Step 3: Antenatal information Step 5: Support with breastfeeding

Step 5: Support mothers to initiate and maintainbreastfeeding and manage common difficulties.

Mothers should receive practical support toenable them to initiate and maintainbreastfeeding and manage commonbreastfeeding difficulties . It is essential todemonstrate good positioning and attachment atthe breast, which are crucial for stimulating theproduction of breast milk and ensuring that theinfant receives enough milk. Mothers should becoached on how to express breast milk as ameans of maintaining lactation in the event oftheir being separated temporarily from theirinfants.

Step 4: Facilitate immediate and uninterruptedskin-to-skin contact and support mothers toinitiate breastfeeding as soon as possible afterbirth.

Early contact positively influences the mother asregards breastfeeding and increased its duration,as it establishes an increase in oxytocine levels and determines increased sucking competencyby

Step 4: Immediate postnatal care

the baby during the first breastfeeding. Thispractice represented one of the factors positivelyassociated with exclusive breastfeeding.[5]

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Step 6: Supplementation

The correct latch- Max possible areola in baby’smouth

Mouth wide openLower lip turned outwardChin touches the breast

Step 6: Do not provide breastfed newborns anyfood or fluids other than breastmilk, unlessmedically indicated.

Giving newborns any foods or fluids other thanbreast milk in the first few days after birthinterferes with the establishment of breast-milkproduction. Mothers should be discouraged fromgiving any food or fluids other than breast milk,unless medically indicated .Infants should beassessed for signs of inadequate milk intake andsupplemented when indicated, but routinesupplementation is rarely necessary in the firstfew days of life.

Step 7: Rooming-inStep 7: Enable mothers and their infants toremain together and to practice rooming-in 24hours a day.

Rooming-in involves keeping mothers and infantstogether in the same room. Babies should only beseparated from their mothers for justifiablemedical and safety reasons.

Step 8: Support mothers to recognize andrespond to their infants’ cues for feeding.

Breastfeeding involves recognizing andresponding to the infant’s display of hunger andfeeding cues and readiness to feed. Mothers areadvised to breastfeed whenever the infant ishungry or as often as the infant wants. Scheduleof feeds is not recommended.

Step 8: Responsive feeding

Step 9: Counsel mothers on the use and risks offeeding bottles, teats and pacifiers.

If expressed milk or other feeds are medicallyindicated for term infants, feeding methods suchas cups, spoons or feeding bottles and teats canbe used during their stay at the facility. However,it is important that staff do not become reliant onteats as an easy response to suckling difficultiesinstead of counseling mothers and enablingthem to attach babies properly and suckleeffectively.

Step 9: Feeding bottles, teats andpacifiers

Step 10: Coordinate discharge so that parentsand their infants have timely access to ongoingsupport and care.

Breastfeeding support is especially critical in thesucceeding days and weeks after discharge, toidentify and address early breastfeedingchallenges that occur. Community resourcesinclude primary health-care centres, communityhealth workers, home visitors, breastfeedingclinics, lactation consultants, peer counselorsand mother-to- mother support groups, Thefacility should maintain contact with the groupsand individuals providing the support as much aspossible. In Pune, Hirkani clinic is the first

Step 10: Care at discharge

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Coordination in IndiaBreastfeeding Promotion network ofIndia,Maharashtra (BPNI Maharashtra) isdesignated to serve as the BFHI coordinatingorganization in collaboration with Unicef inMaharashtra. We do training of the hospital staff,external assessment, correction of inappropriatepractices and certification. In other states of theIndia , BPNI,Mah. does training of the hospitalstaff and correction of inappropriate practices,and for certification, the hospital has to contactthe local government and Unicef.

breastfeeding clinic by IBCLC in India.Mother tomother support group classes are being heldregularly over there. Breast feeding club India hasa whatsapp group where mothers discuss theirbreastfeeding problems with other moms underthe guidance of lactation consultant.

Obstetricians and Gynaecologists are primaryhealthcare providers for mothers before, duringand after delivery. They can play an active role inbreastfeeding support and enable mothers toachieve their infant feeding goals

References1) Protecting, promoting and supporting breast-feeding: the special role of maternity services. Ajoint WHO/UNICEF statement. Geneva: WorldHealth Organization; 1989.

2) Hospital Initiative on breastfeeding and childhealth outcomes: a systematic review. MaternChild Nutr. 2016;12(3):402–17.

3) DiGirolamo AM, Grummer-Strawn LM, Fein SB.Effectof maternity-care practices onbreastfeeding. Pediatrics. 2008;122(Suppl.2):S43–9.

4) Protecting, promoting, and supportingbreastfeeding in facilities providing maternity andnewborn services: the revised Baby-friendlyHospital Initiative 2018 , Implementationguidance:World Health Organization, UNICEF

5)Newton KN, Chaudhuri J, Grossman X,Merewood A. Factors associated with exclusivebreastfeeding among Latina women giving birthat an inner-city baby friendly hospital. J HumLact. 2009;25(1):28-33

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Human MilkBanking

Ma, at whose breast humanity isnourished and civilization iscultured

It is universally accepted that breast milk is theoptimum exclusive source of nutrition for the firstsix months and continues to be the significantpart of the healthy infant diet for two years andbeyond. Human breast milk provides a bioactivematrix of benefits that cannot be replicated byany other source of infant nutrition. According toa joint statement made by the WHO andUNICEF,”where it is not possible for the biologicalmother to breastfeed, the first alternative, ifavailable, should be the use of human milk fromanother healthy mother. Human milk banksshould be made available in appropriatesituations.” The cost to benefit of establishinghuman milk banks has been well proven, and thusthis intervention is seen in a continuum of effortstowards achieving exclusive breastfeeding up tosix months of age and continuing breastfeedingbeyond.

According to the medical journal of Lancet,suboptimal breastfeeding results in more than800000 child deaths annually. Suboptimalbreastfeeding was estimated to be responsiblefor 1.4 million child deaths and 44 million DALYs.

Dr. Sandhya Satish KhadseEx- Dean, Rajiv Gandhi Medical College &Chhatrapati Shivaji Maharaj HospitalChief Child Health Monitoring Officer, Governmentof Maharashtra.Advisory Board Member IAP ICANCLE GroupTechnical Expert for Human Milk Banking in India& abroad

Dr. A. AgilaAssistant Professor, Sri Lakshmi Narayana

Institute of Medical Sciences, Puducherry

It is estimated that 13% of the under-five deathscan be prevented by breastfeeding which means 1in 8 of the young lives lost each year could beprevented through breastfeeding alone, making itone of the most effective ways to preventdiseases and malnutrition that results in childdeath. When mother’s own milk is unavailable forthe sick, hospitalized newborn, pasteurizedhuman donor breast milk should be madeavailable as an alternative feeding choice.

History of Human milk bankingWet nursing began as early as 2000BC andextended until the 20th century. As theavailability of wet nurses dwindled, breast milkbanks were introduced early in the 20th century.The first official milk bank was opened in Viennaat the outset of 20th century. In 1911, anothermilk bank was started in Boston. The first milkbank in U.K was started at Queen Charlotte’shospital in London in 1937. In the U.S., mother’smilk bank of Wilmington Delaware, was started in1947. With the emergence of infant formula,extensive advertising of formula products, therewere only 3 functional milk banks existing in theearly 70’s. However, extensive researchsupporting the nutritional and immunologicalsuperiority of the breast milk, re-established theundeniable importance of breast milk over

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Lactation management centres are intended toemphasize the importance of breastfeeding. Theprimary function of such centres is to make surethat every child receives breast milk. In case ofinsufficiency or unavailability of mother’s ownmilk, Donor Human Milk (DHM) is the next bestalternative to bridge the gap, thereby improvingexclusive breastfeeding rates. The Governmenthas set a target of ensuring 70 percent infants tohave access to breast milk by the year 2025.Target will be subsequently increased to 100percent.

There is currently a limited supply of donor breastmilk in India and it should be prioritized to sick,hospitalized neonates who are the mostvulnerable and most likely to benefit fromexclusive human milk feeding.

Comprehensive Lactation Management Centre(CLMC) is an elaborate set up established for thepurpose of collecting, screening, processing,storing and distributing donor human milk(DHM).CLMCs are established at Government MedicalColleges or District Hospitals with high deliveryload and availability of newborn treatment unitssuch as NICU/SNCUs. It serves as ancillarysupport to the baby friendly hospital practices ofpromoting and supporting breastfeeding. It is anon-profit set up.

Lactation Management Unit (LMU) would beestablished in District hospitals/ Sub districthospitals. This unit should be established in thevicinity of SNCU. No screening of mother isrequired as babies are fed by milk expressed bytheir own mothers. The expressed breast milkusing electric/manual pumps are carefullylabelled and dispensed. There is no requirementfor pasteurization or culture tests on theexpressed breast milk.

formula. This increased the demand for donatedhuman milk and human milk bank regained itspopularity. The American Academy of Pediatricswas the first to publish guidelines for milk bankoperations in 1943. To address the growingpractice of milk banking, the Human Milk BankingAssociation of Northern America (HMBANA) wasestablished in 1985. Asia’s first human milk bankwas established at SION hospital, Mumbai on the27th November 1989 under the eminent guidanceof Dr.Armida Fernandez, the pioneer of milkbanking in India. Currently there are over 550milk banks approximately all over the worldincluding approximately 80 milk banks only inIndia. In 2019, the Human Milk Bank Associationof India was formed. It is a network of medicalpractitioners who work in the field of human milkbanking and related areas including childnutrition, infant feeding, and maternal health inIndia in order to develop scientific and evidence-based practices and recommendations in thefield of human milk banking.

Milk banking in IndiaAs per the “National Guidelines on Establishmentof Lactation Management Centres in PublicHealth Facilities”, Breast milk banks in India areknown as Comprehensive Lactation ManagementCentres(CLMC) and Lactation ManagementUnit(LMU) depending on the level of healthfacilities where these units are established. Theforemost endeavor of the health care providers ina health centre is to promote and conserve thenatural act of breastfeeding.

Human milk banks around theworld

Definition of CLMC and LMU

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1. Milk collection room

The processes in CLMC have sixbasic steps

Who can donate?Any healthy lactating mother can volunteer(noincentives) to donate milk to CLMC after signingan informed consent form and going through amedical check fulfilling the eligibility criteria andserological tests( HIV, HBsAg, VDRL).

Donor milk is given to babies only on prescriptionon priority basis. The highest priority is the mostvulnerable group of neonates who are admitted inthe NICU due to complications at birth such asprematurity, low birth weight, sepsis.

Who is to receive DHM

The milk bank at B.J.Govt.Medical College, NICU

2. Electric breast pump

3. Deep Freezer

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4. Refrigerator and hot air oven

5. Pasteurizer

Mobile Milk Collection UnitA state of art Human Milk Collection Unit, thefirst in the country was inaugurated atB.J.Govt.Medical College and Sassoon GeneralHospital, Pune in collaboration with Rotary Clubof Poona, on August 1, 2016 which is the first dayof the World Breastfeeding Week. The idea ofhaving a milk van for human milk collection was aunique innovation, conceptualized by Dr.Sandhya Khadse and the total implementationincluding designing was done by her teamcomprising of Dr. Chhaya Valvi, Dr. RajeshKulkarni and Dr.Uday Rajput. It is the one andonly of its kind in the country. This unique idea

received BMJ award in 2018 for the bestinnovation for strengthening maternal and childcare practices. The milk collection van includes arefrigerator, an air conditioner, specially designedchairs, baby cradle and an inverter. The van willnow go to the residences of the voluntary donormothers and collect the excess milk which will bedelivered at the human milk bank. Afterpasteurization, it is utilized for the preterm, sickbabies in the NICU. This concept of human milkcollection should be widely adapted and it willhelp in improving donation rates and will ensurethe successful running of milk banks in anyplace.

The donation of milk is a non-incentivizedprocess and remains a completely voluntaryactivity. Quality assurance of the entire processare extensively detailed in the guidelines andadhered to in the milk banking process

The Indian guidelines for the current COVID-19pandemic regarding breastfeeding is to

Impact of the COVID19 pandemicon milk banking

26

continue breastfeeding with precautions andexpressed breast milk if isolation of the mother ispossible. The ongoing pandemic warrants forextra precautions to ensure safe and securefunctioning of human milks. This includes

1. Screening of mothers for symptoms of flu-likeillness, history of travel, history of contact withCOVID-19 positive

2. Adherence to social distancing ,hand hygieneand wearing face masks by the mothers andhealth care professionals

3. Limiting the number of mothers and healthcare professionals in the expression room at anygiven time.

4. PPEs to be provided for lactation counsellorsfor assisting a COVID-19 suspect or positivemother during pumping.

5. Autoclaved closed containers are supplied tothe milk bank from the NICU and mothers carrytheir expressed milk in those closed containers tothe NICU.

Every newborn brings with it a hope that God isnot yet disappointed with man!

Breast milk gives a very beautiful healthy life tothe baby!

1. Jones G, Steketee RW, Black RE, Bhutta ZA,Morris SS. How many child deaths can we preventthis year? Lancet.2003;362(9377):65-71

Impact of the COVID19 pandemicon milk banking:

2. Black RE, Allen LH, Bhutta ZA, Caulfield LE, DeOnis M, Ezzati M et al. Maternal and childundernutrition: global and regional exposures andheath consequences.

3. UNICEF. Wbw2013-los-unicef.pdf.2003, Letterof Support.

4. World Health Organisation; UNICEF,Breastfeeding Advocacy Initiative For the beststart in life.2015;9

5. Khadse S, HIremath A. Human Milk BankUpdate. Med J Western India. 2013;41:45-7

6. National Guidelines on lactation managementcentres in public health setups, Ministry of healthand family Welfare, Government Of India.

7. Bhasin M. Nangia S, Goel S, Role of HumanMilk Banks amid COVID-19:perspective from amilk bank in India. International BreastfeedingJournal.2020;15:104

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In 1939’S whole world noticed horrific results ofArtificial Food. There was Global concern for thisin between 1950-1970. In 1970, there was 1stglobal meeting in which there was lot of concernregarding commercial marketing of breast-milksubstitute, infant food and feeding bottles.UNICEF and WHO recognized need of controllingthis commercial marketing as they underminebreastfeeding. In 1981 World Health Assemblyadopted International Code of marketing breast-milk substitutes. To protect infant health, Indiabecame one of the few countries in Asia to fullyimplement the International Code of Marketing ofBreast-milk Substitutes with the enactment of theInfant Milk Substitutes, Feeding Bottles andInfant Foods (Regulation of Production, Supplyand Distribution) Act, 1992 (41 of 1992)(hereinafter referred to as "the IMS Act) whichwas amended in 2003 to strengthen certainprovisions and close any loopholes infant formulacompanies had found.

The statement of objectives presented inParliament during the enactment of the IMS Actclearly stated: "Inappropriate feeding practiceslead to infant malnutrition, morbidity andmortality in our children. Promotion of infantmilk substitutes and related products likefeeding bottles and teats do constitute a healthhazard. Promotion of infant milk substitutes andrelated products has been more extensive andpervasive than the dissemination of informationconcerning the advantages of mother’s milk and

Dr. Alka Kuthe Consultant Gynecologist & Lactation Specialist Past president BPNI Maharashtra State LLM Criminology & PG Dip InHuman Rights Education

Breastfeeding is best feeding. It is natural,instinctive, physiological & Species Specific.

“If breastfeeding did not already exist, someonewho invented it today, would deserve a dualNobel Prize in medicine and economics” - Keith Hansen, World Bank

The lines are so precious and meaningful and ifthey were followed in true sense, there would not have been need of any enactment.

In fact breastfeeding is our culture. But we,Indians blindly followed western culture.Aggressive marketing & promotion bymanufacturers of breast - milk substitutes, infantfoods and feeding bottles, made them easilyavailable for public, in show-cases, in shops &markets. Free samples and gifts were given tomothers/ parents along with discount coupons.Retailers received inducement. Informationbrochures were totally biased, incomplete &unscientific. Health Workers received attractiveposters, calendars , information materials alongwith free gifts, pens, growth charts with companylogo. Companies gave Advertisements in medicaljournals, sponsored medicos meetings,conferences trips etc. donated funds, grants forresearch activities. It resulted in to rampant risein use of bottles, breast- milk substitute andinfant food/formula.

Marketing of breast milksubstitutes: IMS Act

Introduction

28

Objectives of IMS Act

Thus, the IMS Act had a clear intent; the saving ofmillions of children’s lives and improving theirnutritional status by preventing the baby foodindustry from enticing mothers and the healthsystem to give infants breast-milk substitutes.The IMS Act comprehensively bans all forms ofpromotion of foods marketed to children up totwo years of age and sponsorship to health careprofessionals and health organizations by infantformula companies

breast feeding and contributes to decline inbreastfeeding. In the absence of stronginterventions designed to protect, promote andsupport breastfeeding, this decline can assumedangerous proportions subjecting millions ofinfants to greater risks of infections,malnutrition and death…………"

Protection and promotion of breastfeeding andensuring the proper use of infant foods and formatters connected therewith or incidentalthereto. (It extends to the whole of India.)

Ensures proper breastfeeding education ofpregnant and lactating mothers through accurateinformation.

Defines role of government, health care system tosupport mothers and remain clear of baby food.

Controls marketing & ensures proper labeling ofbaby food.

Main ComponentsThe IMS Act extends to all of India and stipulatesthat no person shall:

Advertise for the distribution, sale or supply ofinfant milk substitutes feeding bottles or infantfoods.

Give an impression or create a belief in any

manner that feeding of infantmilk substitutes andinfant foods are equivalent to, or better than, mother's milk

Promote infant milk substitutes, feeding bottlesor infant foods to health staff.

Supply or distribute free samples of infant milksubstitutes or feeding bottles or infant foods gifts of utensils or other articles except toorphanages.

Contact any pregnant woman or the mother of aninfant to offer inducement of any of the above.

In addition, infant milk substitute or infant foodcontainers must indicate in a clear, conspicuous and in an easily readable and understandablemanner, the words “important notice” in capitalletters with the following “MOTHER’S MILK ISTHE BEST FOR YOUR BABY”, a warning thatformula is not the sole source of nourishment forinfants, instructions for safe and cleanpreparation, and the composition, among otherparticulars. In addition to this

Printed Information should be unbiased,scientific.

No Information like “humanized milk”

No linking of remuneration with sale

No Any inducement to retailer/health workers Conferences, meetings sponsorship should beavoided.

The containers and labels are not allowed to havepictures of women and infants.

Likewise, advertisements and promotional material for formula must include the benefitsand superiority of breastfeeding, the healthhazards of improper preparation and use offormula, among other stipulations .

29

Section 2 of the Act gives somedefinitions like

Thus the IMS Act strictly bans promotion ordistribution of formula materials in any healthcare system. Finally, the IMS Act reiterates strictstandards of the formula nutritional compositionestablished by previous laws, establishes theright to confiscation of inappropriate formula,establishes monitoring rights of government-approved NGOs, food safety officials, and othergovernment officials.

Section 20 mentions aboutpunishment in case one breaksthe law as follows

Any person who contravenes the provisions ofSection 3,4,5,7,8,9,10 or sub-section (2) ofsection 11 and the rules made under section 26of the Act shall be punishable with imprisonmentfor a term which may extend to three years, orwith fine which may extend to five thousandrupees, or with both.

In June 2003, following increasing informationon the benefits of exclusive breastfeeding andthe subtle promotional techniques adopted by

(c) “feeding bottle” means ant bottle orreceptacle used for the purpose of feeding infantmilk substitutes, and includes a teat and a valveattached or capable of being attached to suchbottle or receptacle;

(f) “Infant food” means any food (by whatevername called) being marketed or otherwiserepresented as a complement to mother's milk tomeet the growing nutritional needs of the infantafter the age of six months and up to the age oftwo years;

(g) “infant milk substitute” means any foodbeing marketed or otherwise represented as apartial or total replacement for mother's milk, forinfant up to the age of two years

Key Provisions of the IMS Act, 1992 as Amendedin 2003 to control marketing,

Bans advertising: By print media, electronicmedia or any other method

No Gifts and Free Samples can be distributed toparents /health workers

Donation of Products, Educational Materials orEquipments Not Allowed

Picture of Mother, Baby, Cartoons on Labelsand Tins not allowed

Use of Educational Materials or Advertisementsfor Giving Incorrect or Incomplete InformationProhibited

Display of Posters, Calendars or OtherPromotional Materials in Hospital, Chemist ShopBanned

No Sponsoring and giving payments toHealthcare Workers and Their Associations

Prohibits All forms of Promotion of Baby Foodsfor Babies Under the Age of Two Years

Prohibits Providing Commission to CompanyStaff to Increase Sales

some manufacturers to circumvent the IMS Act,the Act was amended to include complementaryfoods and banned all forms of promotion of babyfoods.

Limitations of the ActGeneral Stores not included

Orphanages exempted

Production of artificial food/formula continues

No control over acceptance of sponsorships/gifts

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It was also suggested to include PromotionSupport and Protect Breastfeeding in the titleof the Act

The united efforts saved the IMS Act as amendedin 2003 from being repealed through the modern"Food Safety and Standards Bill 2005".

In spite of the specific legislation, Companiescontinue to break the law. Therefore is law theonly answer? Of-course no as there are manyLoop-holes in the law.

Therefore its our duty to

PROMOTE BREASTFEEDING BY POSITIVE RE-ENFORCEMENT

Breastfeeding is NOT A MATTER OF TRIAL &ERROR but it’s INVESTMENT FOR LIFE.

Health providers definitely have important roleas it’s Battle against Bottle/Formula. Lot ofhealth education, awareness programs andcounseling is required

What obstetrician can do?1.Educate people about the IMS Act2.Reach grass-root level3.Hold public meetings, seminars, radio show, TVshow4.Establish links & spread the word5 .Monitor marketing & report violations 6.Resist commercial promotion7.Remove ads with brand names, logos8.Refuse growth charts, literature ---,,----9.Refuse free gifts & samples 10.Resist sponsorship from IMS/IMF companies11. Resist any other way of promotion12.Resist use of formula for orphanages etc.

Where to report violations?1. Breast feeding promotion network of India(BPNI)

2. Association of Consumer Action on Safety andHealth (ACASH)

3.Indian Council for Child Welfare (ICCW)

4. Central Social Welfare Board (CSWB)

5. Civil Surgeon 6.Health Officer MunicipalCorporation

.

The IMS act was passed after a lot of thinking.We are not only legally bound by it, but it is alsoour moral responsibility to see that the act works.Most of our colleagues are unaware of theprovisions and importance of this act. Don’t letthe formula companies to use loopholes of theLaw to allow breaking the law in spirit if not inletter. If we don't act now then there is everypossibility that this act may become one of thehistorical legal documents. Hence it is time for allof us to become an activist or counselor forBREASTFEEDING.

BREASTFEEDING WAS THE BEST, IS THE BEST & WILL REMAIN THE BEST FOR INFANT FEEDING WE PLEDGE TO PROMOTE, SUPPORT & PROTECTBREASTFEEDING

Conclusion

31

Dr. Milind ShahPresident of ISOPARB (2016-18)Deputy Secretary General, FAOPS (Asia Oceania Federation ofPerinatology Societies)Vice President of FOGSI (2011)

Predisposing Factors for MastitisDamaged Nipples

Primiparity

Breast Abscess 32

The Breast has always been symbol ofwomanhood and ultimate fertility. Therefore, anydisease or surgery evokes fear in mind of womenof losing its beauty, shape or feminity. Many ofthem feel it as like mutilation. Breast abscess isone of the condition that occurs at younger agewhen this feeling is at its intense. Many of thesewomen approach their obstetrician whenever theyget mastitis or breast abscess.

Previous history of mastitis

Maternal or neonatal illness

Maternal Stress

Work outside home

Trauma

Genetic

ClassificationInfectious

Non Infectious

Milk Stasis

Abscess Formation

Breast infection can occur in non-lactatingwomen as well due to tuberculous or fungalinfection. It could be periductal infection with orwithout perialevolar infection.

Lactational breast abscesses are most oftencaused by Staphylococcus aureus andStreptococcal species, Methicillin-resistant S.aureus is becoming increasingly common.Typically, non-lactational breast abscesses are aresult of a mixed flora with S. aureus,Streptococcus, and anaerobic bacteria.

PathophysiologyThe breast contains breast lobules, each of whichdrains to a lactiferous duct, which in turn emptiesto the surface of the nipple. There are lactiferoussinuses which are reservoirs for milk duringlactation. The lactiferous ducts undergoepidermalization where keratin production maycause the duct to become obstructed, and in turn,can result in abscess formation. Abscessesassociated with lactation usually begin with anabrasion or tissue at the nipple, providing anentry point for bacteria.

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Abscess Formation

It is seen in 5-11% cases of mastitis.

Most common in first six weeks. It can affectfuture lactation in 10% of cases. It is found thatthere is no difference between groups by age,parity localization of infection, cracked nipples orrelated to milk culture. There is no specific

Effective milk removal in early stages is again achallenge for obstetrician or nurse. Properbreastfeeding techniques, Frequent feeding andexpressing excessive milk by hand towards nipplecan control further progression of infection.

As in most cases its Staphylococcus Aureusinfection, suitable antibiotics need to beadministered with anti-inflammatory agents andanalgesics. Choice of antibiotics are,

1. Dicloxacillin 250 mg BD

2. Amoxycillin Clavulanic acid 875 mg BD

3. Cephalexin 500 mg QID

4. In MRSA infection that is methicillin resistantcases Trimethoprim-Sulphamethoxazole 180/800mg BD

5. Clindamycin or Tetracycline depending onsituation if no breastfeeding is advised.

In advanced cases, injectable antibiotics areneeded with need of further investigation andsurgical intervention.

Complete blood count, CRP and Ultrasound withhigher frequency probes helps for management.Pus C/S either by needle aspiration or while doingincision and drainage is important. Rarely blood

duration between appearance of symptoms anddevelopment of abscess. In cellulitis stage breastas a whole becomes red and is extremely painful.Whereas when the abscess develops, rednessbecomes limited to area of abscess formation. Inbreastfeeding women with light mastitis,massage and application of heat prior to feedingcan help as this may aid unblocking the ducts.However in more severe cases of mastitis heat ormassage make the symptoms worse and coldcompresses are better suited to control theinflammation. Its clinical acumen of OBGYN toadvice accordingly to very commonly askedquestion by mothers whether they should applyheat or cold when they get mastitis.

Surgical TechniquesIt depends on abscess size. In smaller abscess ofless than 5 cm, daily aspiration with 18-19 gaugeneedle may help to avoid scar on breast. It can beoptimized under USG guidance. However, in largerabscesses or in cases where aspiration fails,incision and drainage is required. It is veryessential to give cosmetic scar as breast is oneof the beautiful organ and women are verycautious about it. Hiding scar in perialevolarcircle where black and white areas meet givesgood cosmetic appearance. However manysurgeons differ on it and insist on radial incisionto avoid injury to ducts. In partially treated cases,chances of developing mammary duct fistula arevery high.

Preventive MethodsKeep the breasts clean by washing them dailywith mild soap and water.

Wipe of dried secretions and gently dry the breastwith clean towel.

Wipe the nipples and areolae with sterilizedcotton dipped in boiled and cooled water.

Apply lanolin cream daily to the nipples andareolae to prevent them from cracking.

Apply warm and moist compresses to theaffected area several times a day.

34C/S is required. On USG, abscess presents as ahypoechoic fluid collection in the tissue with theabsence of vascular signals.

Breast-feeding can be continued in early mastitis.However, it is avoided in in infected breast ifabscess present.

Potential Complication of BreastAbscess

Chronic Infection leading to sinus formation

Chronic Pain

Disfigurement and scarring

Lactation failure

Sepsis leading to life threatening bacterial bloodinfection

It is very important to address this problem ofmastitis and breast abscess by every obstetricianwith utmost care and humanity taking intoconsideration cosmetic outcome.

35

ABCs of BreastfeedingA = Awareness. Watch for baby's signs of hunger,and breastfeed whenever baby is hungry. This iscalled "on demand" feeding. The first few weeks,nursing is required eight to 12 times every 24hours. Hungry infants move their hands towardtheir mouths, make sucking noises or mouthmovements, or move toward breast. Don't waitfor baby to cry.

B = Be patient. Breastfeed as long as baby wantsto nurse each time. Don't hurry the infant throughfeedings. Infants typically breastfeed for 10 to 20minutes on each breast.

C = Comfort. This is key. Relax whilebreastfeeding, and milk from breast is more likelyto "let down" and flow. Positions should becomfortable with pillows as needed to supportarms, head, and neck, and a footrest to supportfeet and legs before one begin to breastfeed.

Cradle position: The mother rest the side ofbaby's head in the crook of elbow with his wholebody facing her. her other, "free" arm can wrapsaround to support baby's head and neck.

Football position: The mother Lines baby's backalong forearm to hold baby like a football,supporting baby's head and neck in her palm. Itis also a good position when recovering from acesarean birth .

Side-lying position: This position is good for night feedings in bed. Side-lying also works wellwhile the mother is recovering from anepisiotomy, the mother uses her free hand to lift breast and nipple into the baby's mouth.

Best Positions for BreastfeedingThe best position is where mother and baby areboth comfortable and relaxed, and don't have tostrain to hold the position or keep nursing. Hereare some common positions for breastfeedingbaby:

Dr.Shraddha AgarwalDirector K.C.Hospital , palwal haryanaFounder and past president POGS Member Breast committee FOGSI 2019-2021

Care of breasts during breastfeeding: gynecologist’s

perspective

Dr. Shashibala Bhonsale, MS OB/Gynae Working as Specialist in Public Health and Family

Welfare Department Gwalior Secretary Gwalior Obstetrics and Gynaecology Society

20-21 West Zone coordinator Breast Committee FOGSI 19 - 21

Common Challenges WithBreastfeeding

Cracked/Sore/ damaged nipples. You can expectsome soreness in the first weeks of

36

ManagementGood latching techniqueProper breast feeding positionRoutine once a day cleaning of breast with waterTreat fungal infection in mother as well as inbabySurgical correction of tongue tieUse one finger to break the suction of babiesmouth after each feeding to prevent sore nipples.Keep nipples dry between feedings.Cold compressionUsing cotton bra pads.

Improper latch onFungal infectionTight frenulum Improper positionFrequent washing of nipple and areola with soapand water

breastfeeding.Causes are :

Retracted and Inverted nipples.The pulling back of the nipple may be harmless (majority) or malignant (breast cancer).The retracted nipple appears flat and broad andcannot be pulled outwards. An inverted nipple canbe pulled out and mother should be taught during antenatal care visits about inverted nipple.Syringe method can be tried in few mothers.

Breast engorgement.Breast engorgement means the blood vessels in breast have become congested. This trapsfluid in your breasts and makes them feel hard,painful, and swollen. Alternate heat and cold, forinstance using ice packs and hot showers, torelieve mild symptoms. It can also help to release milk by hand or use a breast pump.

Blocked ductsA single sore spot on breast, which may be redand hot, can signal a plugged milk duct. This can often be relieved by warm compresses and gentlemassage over the area to release the blockage.More frequent nursing can also help.

Breast infection (mastitis). It is preventable butcommon problem and occurs due to :

Milk stasis Hyperlactation Cracked nipple Insufficient milk removal. Maternal stress Use of nipple creams

Breast feeding information and education,adequate rest, good nutrition, psychologicalsupport, proper hand washing, warm moist packsor cold. Cabbage compresses between feeds.Proper antibiotic therapy.

37

Breast abscess: if mastitis is not treated, it mayprogress to breast abscess. The baby should beallowed to continue breast feed and abscess canbe treated with aspiration technique.

Galactocele: a benign cyst which should not interrupt feeding breast.

Duct ectasia also called as granulomatousmastitis. Can be aggrevated by lactation.

Dermatitis involving breast nipple and areola.Herpes simplex with active oozing nipple andareola are contraindication for the breast feedingtill the lesions heal.

How to Care for Breasts whileBreastfeeding

Here are some tips to help care for nursingmothers and prevent some of the commonproblems of breastfeeding.

1.Practice good hygiene. Wash hands beforetouching breasts. Keepr breasts and nipplesclean by washing them each day with warm waterin the shower or bath. Avoid using soap on breasts since it can cause dry, cracked, and

Insufficient milk supply: mother should be taughtabout normal physiological breast feeding about8-12 or more times in 24 hours, feeding at nightand not to decrease the frequency of breastfeeding to let the breast fill. One breast should befully drained before offering the second one.Mother should constantly be supported andencouraged by teaching different positions ofbreast feeding.

2. Wear a supportive bra. Nursing mothers should Choose a nursing bra or a regular brathat fits well, but is not too tight. Cotton is anexcellent choice of fabric since it allows skin tobreathe.

Good latching technique, and nursing very often— at least every 2 to 3 hours — can help preventthe development of painful breast problems suchas sore nipples, breast engorgement, pluggedmilk ducts, and mastitis.

Proper position of breast feeding as shownabove.

3. Changing breast pads often. If mother isusing breast pads or cotton squares inside bra tosoak up the breast milk from leaking breasts, sheshould change them when they become wet.Clean, dry nursing pads can help to prevent sorenipples, thrush, or mastitis from occurring.

1.Moisturize nipples with breast milk. Afternursing baby, rub some of breast milk on nipplesand areola then let them air dry.

2.Remove child from breast correctly. Whenmother is ready to take baby off of the breast,avoid pulling the baby. Instead, place one fingerin the corner of her mouth to break the suctionbetween baby's mouth and breast.

3.Discuss sore nipples with doctor. If mother has sore nipples, she should talk to a lactationconsultant about using purified lanolin orhydrogel pads to help soothe breasts.

4.Treat breast engorgement. If then breastsbecome painfully overfull, hard, and swollen, coldcabbage leaves or cold compresses to reduceinflammation and relieve pain can be used.

irritated skin. It can also remove the natural oils produced by the Montgomery glands locatedon the dark area surrounding nipples. These oilshelp to keep the nipples and areola clean andmoisturized.

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Caring for Breasts to SuppressLactation

It could take a few weeks or months to dry up thebreast milk in breasts. Here are some tips forcaring for breasts if in case breast feeding hasto be stopped. The following has to be taught tomothers,

Wear a bra that is supportive but not tight.

Use breast pads or a cotton cloth to soak upleaks.

Place a cold compress or cold cabbage leaves onyour breasts to help relieve swelling anddiscomfort.

If breasts are painfully full, pump or hand expressa little bit of breast milk to relieve some of thepressure. Pumps are better avoided.

Try not to touch nipples or breasts. Regularstimulation of the breasts and nipples tells bodyto keep producing milk.

Medicines for pain relief can be given.

5. Feeding the baby before it becomes too hungry.

Continue to perform monthly breast self-examination. In nursing mothers also, it'simportant to check breasts each month. Whileit's normal for breasts to feel lumpy when they'refull of milk, the lumps should go away withbreastfeeding, pumping, or massaging thebreasts.

Hydrogel pads can be placed on sore nipples tooffer instant breastfeeding pain relief, as well ascreating ideal conditions for healing.

Breast shells fit inside bra. They’re good forstopping clothing rubbing against sore nipples,and have holes in so air can still get to nipples tohelp them heal.

Nursing bras made from either a breathablematerial like cotton, or a fabric that dries quickly and wicks excess moisture away fromdamaged nipples.

Nipple shields are silicone covers that fit overnipples, with small holes for breast milk to flowthrough as you breastfeed. They protect the skinunderneath and can give a baby with a poor latchsomething firmer to attach to. In general nippleshields should be considered a short-termsolution. If problems or pain occur, consultlactation consultant or breastfeeding specialist.

Useful nipple care productsNipple cream made from ultra-pure lanolin – anatural product obtained from sheep’s wool. This moisturises and supports healing. It’sharmless for baby, so there’s no need to washoff lanolin before breastfeeding.

Safe & Dry™ Ultra thin nursingpads

Purelan™ 100 lanolin cream

39

ConclusionThe breastfeeding is important for both motherand child and it needs proper counseling,guidance, education and support at all levels toovercome troubles which occur during pregnancy,lactation till weaning. As gynecologists it is ourfirst and foremost duty to teach all the mothersabout proper techniques of breast feeding anddevelop self confidence in them.Every childshould get the benefit of mothers milk so as toreduce the complications during infancy. so letthe every mother enjoy her motherhood and everychild blossom with pure love in the form ofmothers milk.

Contact™ nipple shields

Safe & Dry™ Washable bra padsSafe & Dry™ Disposable nursing padsMilk collection shells

Hydrogel pads

If you’re breastfeeding and have sore or crackednipples, Medela hydrogel pads support ...

Breast shells

40

Breastfeeding is a natural instinct & is theDream of every Mother.

That's the very reason, I believe, providingadequate & appropriate information onBreastfeeding will definitely improve the

percentage of Breastfeeding in the womenacross India.

We as Health care Providers definitely have a

major role to play as far as the support isconcerned.

At the same time we can council & Train theFamily members especially the Husband to

support & actively enjoy Parenting.

We should try to help them if at all anyproblems in Breastfeeding. Breastfeeding

should be a pleasure & not a PainfulExperience.

Let's all pledge to Promote & Support

Breastfeeding.

Thanks to President FOGSI Dr. Alpesh Gandhi,VP Incharge Dr. Ragini Agrawal, Secretary

General Dr. Jaydeep Tank, Editors Dr. LaxmiShrikhande, Dr. Archana Varma, Contributors &

All my Committee Advisors , Coordinators &Members.

Dr. Sneha S BhuyarChairperson Breast Committee FOGSI 2019 - 2021

Chairperson's Message

Thank youDesigned by S. Kalpana