Self-StudyModulesFourthEditionandRuth A. Wester, BA, RN, PNP - PDF document

Self-StudyModulesFourthEditionandRuth A. Wester, BA, RN, PNP 2014 Cite as:Wellstart International(2013) Lactation Management Self-Study Moduleselburne, Vermont: Wellstart 2013Wellstart InternationalThe First andSecond Editions ofthis documentweredeveloped with supportofThe Maternaland ChildHealthBureau,HealthResources and Services Administration,U.S.DepartmentofHealthand HumanServices.Under noconditions mayanypartofthese First or SecondEditions be sold byanyone otherthan WellstartInternationalor the DepartmentofHealth and Human Services oftheUnitedStates. Permissionfrom Wellstartis required to reproduceortranslatethese First andSecond Editionsdocument in partor infull.TheThird Edition(Revised)and theFourth Editionofthedocumentwas developed entirelybyWellstart International.Permissionfrom Wellstartis required to reproduce these editions in partor in full.Wellstart intends thesedocuments to be availableatlow (productionand shippingcosts only) or nocost. Permissionisalso requiredfromWellstartInternational to charge for these documentsor anypartthereof byanyone other thanWellstartInternational.WellstartInternational alsowelcomes requests totranslatethis FourthEdition inpartor infullbut permission mustbegranted byWellstartbeforesuchtranslationis undertakenas wellas before any translated version is published or distributed.Informationregardingorderingcopiesandpermissiontoreproduceortranslatemaybeobtainedfrom:Wellstart International E-mail: info@wellstart.orgFourthEditionof the Wellstart InternationalSelf-Study Modules,LevelImay bedownloaded withoutcharge fromthe WellstartWebsite: www.wellstart.orgWellstartInternational is nonprofitorganization (501)(C)(3) and iscompliantwiththeInternational Code of MarketingofBreastmilk Substitutes. DedicationThisEditionofWellstartInternational’sLactationManagementSelf-StudyModules,Level1isdedicatedtoallofthemothers,fathersandfamilieswhoareraisingthenextgenerationoftheworld’scitizens.Whethertheyliveinurbanorruralsettings,developedordevelopingnations,arerichorpoor,theydeserveourrespectandwellpreparedservicesandsupportatalltimes. We areguiltyof many but ourworst crime isabandoning the children, neglecting the foundation of life. Many of thethings we need can wait.The child cannot.Right now is thetime his bones are being formed, his blood is beingmadeand his senses are being developed.Tohim wecannot answer ‘tomorrow’.His name is Today. SectionI Contents Section I About Wellstart About the authorsSection II: Pre-test Without answers Breastfeeding: A Basic Health Promotion Strategy in Primary Introduction: Case ExerciseCurrent Recommendations for BreastfeedingReferences Module Two Introduction: Case ExerciseLength (Duration) and Frequency of a FeedingInternational Code of Marketing of Breastmilk Substitutes References Case #7 : Jaundice in the Breastfed Baby Breastfeeding the Infant with Special Medical ProblemsMaternal Medical ProblemsBreastfeeding During Emergency SituationsReferences Without answersWith answersSection V: Annexes A.HighlightsB.Acceptable Medical Reasons for Use of Breast-milk SubstitutesC.Infant Feeding in Emergency SituationsD.Ten Major Provisions of the International Code of Marketing E.ABM Protocol #8: Storage of Human Milk F.Guidelines for Hand ExpressionG.Web Sites of InterestH.Alphabetic Listing of References I.Additional References Suggested byReviewers for the 4Edition WELLSTARTINTERNATIONALAbout Wellstart International…WellstartInternationalisanonprofitorganizationwith(501)(C)(3)taxdeductiblestatus.ItwaslaunchedoriginallyastheSanDiegoLactationProgram(SDLP)in1979-1980.InitiallytheSDLPwaswithintheDepartmentofCommunityandFamilyMedicineoftheUniversityofCaliforniaSanDiegoMedicalSchoolandwasacomponentoftheperinatalservicesandteachingoftheUniversityofCaliforniaSanDiegoMedicalCenter. In1983withfundingfromtheUnitedStatesAgencyforInternationalDevelopment(USAID)SDLPaddedaninternationalfacultyeducationanddevelopmentprogram,TheLactationManagementEducationProgram(LMEP).Theprogramdesignincludedbringingmultidisciplinary,leadershiplevelteamsofhealthcareproviders(OB,Pediatricians,FamilyPractitioners,Nurses,NurseMidwivesandNutritionists)fromteachinghospitalsfromseveralcountriestogetherfor3weeksoflactationmanagementeducationandskilldevelopmentand1weekofplanningaprogramthattheywouldundertakeuponreturninghome.Afollow-upvisitwasprovidedtotheirhomesiteattheinvitationoftheteamsometimeaftertheirprogramwasunderway.TheconversionoftheSDLPtoanindependentnonprofitorganization,WellstartInternational,andamovetoanearbybutseparatelocationoccurredin1985.AprimaryobjectiveofLMEPwastocreatea“cascade”ofskilledandknowledgeableleadersinmedical,nursingandnutritioneducationthatcouldmakeneededchangesintheircurriculumaswellastheservicesprovidedtomothersandbabiesthatwouldpromotesuccessfulbreastfeeding.Theprogramwasconsideredquitesuccessfulandinthe15yearsofcontinuation,655healthcareprovidersfrom55countries(includingtheUnitedStates)becameWellstartAssociates.Afollow-upstudyof40oftheseAssociatesundertakenattherequestofUNICEFin2003suggestedthattheprogramthroughthecascadeoftrainingapproach,hadchangedthecaregiventomother-babypairsinhundredsofhospitals,modifiedcurriculuminasignificantnumberofprofessionaltrainingprograms,contributedtohundredsofthousandsofsecondarytrainingeventsandcontributedtotheglobalexpertiseregardinglactationmanagement.Since1985,Wellstart,asanorganizationorthroughstaffparticipationhasalsobeenveryactiveandinfluentialinmanyglobaleventsrelatedtotheprotection,promotionandsupportofoptimalinfantandyoungchildfeeding.Theseincludethedevelopmentofthe“TenSteps”,InnocentiDeclarationof1990and2005,WABAandWorldBreastfeedingWeek,TheBabyFriendlyHospitalInitiative,TheUnitedStatesBreastfeedingCommitteeandthedevelopmentoftheAcademyofBreastfeedingMedicine.Aswillbefurtherdescribedintheforeword,Wellstartalsohasconsiderableexperienceindevelopinganumberofusefulteachingtechniquesandtools.AlsosincetheconversionoftheSDLPtoWellstartInternationalin1985,theorganizationhasmaintainedanofficeinCaliforniabuthashadadditionalofficesinWashingtonDC,andCairo,Egypt.AtthepresenttimeadministrativetasksarecarriedoutinCaliforniaandprogrammaticactivitiesareplannedandcoordinatedinVermont. WELLSTARTINTERNATIONALAbout theEditors….AudreyNaylorAudreyNaylor,PresidentandCEOofWellstartInternationalisaboardcertifiedpediatricianwithadditionaltrainingininfantdevelopment,maternalandchildhealthandepidemiology.InadditiontoreceivingadegreeinMedicinefromtheUniversityofCaliforniaLosAngelesSchoolofMedicine,shealsoholdsaDrPHinEpidemiology(withamajorfocusonperinatalcare)fromUCLASchoolofPublicHealth.Shehasalifetimeprofessionalinterestinmaternal,infant,andfamilyhealthpromotion,preferringtopreventratherthantreatdisease.In1985,withRuthWester,sheco-founded,WellstartInternational,anonprofitorganizationestablishedtoeducatehealthcareproviders(medicalandnursingstudentsaswellasperinatalspecialtyresidents),inthe“whyandhows”ofoptimalinfantandyoungchildfeeding.ShehasbeeninstrumentalinbothinternationaleffortsaswellasthosefocusedprimarilyintheUnitedStatestopromotebreastfeedingasthenormalwaytofeedinfantsandyoungchildren.SheisafoundingmemberoftheAcademyofBreastfeedingMedicine,theWorldAllianceofBreastfeedingAction,theUnitedStatesBreastfeedingCommitteeandtheSectiononBreastfeedingoftheAmericanAcademyofPediatrics.SheisalsoanexperiencedmedicalschooleducatorandhasbeenamemberofseveralmedicalschoolfacultiesincludingOhioStateUniversityCollegeofMedicine,TheUniversityofSouthernCaliforniaSchoolofMedicine,TheUniversityofCaliforniaSanDiegoSchoolofMedicineandTheUniversityofVermontCollegeofMedicinewheresheiscurrentlyaClinicalProfessorofPediatrics(Voluntary,part-RuthWesterRuthWester,Vice-PresidentofWellstartInternationalisaregisterednursewithextensiveexperienceinbothinpatientandoutpatientpediatricnursing.ShealsowastheHeadNurseoftheMarionDaviesPediatricClinic,ahighlyregardedteachingandserviceclinicatUCLA.WhileservingUCLA,sheacceptedanopportunitytotrainasapediatricnursepractitioner(PNP)andsubsequentlyservedtheclinicasboththeHeadNurseaswellasaPNP.In1978,sheacceptedapositionasthenormalnewborndischargenurseandAssistantProfessorofPediatricsatUCSDMedicalCenterinSanDiegoandbegantoinstructmedicalstudentsandresidentsaboutbreastfeedingandlactationmanagement.WithDr.Naylor,sheco-foundedWellstartInternationalandhasprovidedservicetomanythousandsofbreastfeedingfamiliesandtaughtlactationmanagementtomedicalandnursingstudentsaswellasresidentsandfacultyallovertheworld.Sheisanexpertinthefieldoflactationmanagementeducation. WELLSTARTINTERNATIONALAcknowledgementsAcknowledgementsFirstEdition,2000AFirstEdition is always the inspirationofall future editions. Thecreation and developmentoftheFirst Edition oftheWellstartInternational Lactation ManagementSelf-StudyModules, Level Iin2000 wouldnothave been possible without the inputandeffortofa number oftalentedpeople.We would like toexpressourcontinuing gratitude tothefollowing individuals whoassisted withthatdocument:Eyla Boies, MD, ClinicalAssociateProfessor of Pediatrics, Universityof California, San DiegoElizabethCreer, RN, FNP, MPH, Wellstart InternationalfacultyPamela Deak,MD, Division ofObstetrics and Gynecology,Universityof California, San Diego DonataEggers, BS, RD, Instructor, Department of Pediatrics, SouthernIllinois UniversityStephanie Gabela, MPH, RD, Wellstart InternationalfacultyHelen Moose, MS, CNM, Instructor, Department of Family and CommunityMedicine, SouthernIllinois UniversityVictoriaNichols-Johnson, MD, Associate Professor, Division of General Obstetrics andGynecology,Southern Illinois UniversityJanineSchooley, MPH, Wellstart International, Project ManagerKirstenSearfus, MD, Assistant Professor, Divisionof FamilyMedicine, Universityof California, SanDiego Kim Solis, Wellstart International Assistant Project ManagerYvonne Vaucher, MD, MPH,ClinicalProfessor of Pediatrics, Division of Neonatal/PerinatalMedicineInaddition,themedicalstudents from SouthernIllinois Universityand UniversityofCalifornia,San Diegoandnursing students atSt.John’s College inSpringfield,Illinois deservethanks for their useful feedback.SecondEdition,2005As is usuallythecase,theSecondEdition was developedonthebasis ofthecontentoftheFirst Edition.Several membersoftheoriginalteam oftalented people participated increating therevisions for the second edition.WegratefullythankYvonne Vaucher, MD, MPH,ClinicalProfessor ofPediatrics, Division ofNeonatal/PerinatalMedicine,UniversityofCalifornia,SanDiegowhoencouragedand gave manyhours tothis effortas wellas Kirsten Searfus, MD,AssistantProfessor, Division ofFamily Medicine,UniversityofCalifornia,SanDiego for theirsupport.Aspecial thanks also goestoMaria Elena Sandoval,WellstartInternational Administrative Manager,for her skill,patience and extraeffortin helping to preparethe second editionFinally,we would likethank DeniseSofka, RD, MPH ofthe USDepartmentofHealthandHumanServices, HealthResources andServices Administration,Maternaland Child HealthBureau, for hercontinuing encouragementofWellstart International and ofthe preparation ofboththefirstandsecond editions ofthis teaching tool.ThirdEdition,2009Inplanningfor aThirdEditionofWellstart’s Self-StudyModules, LevelI,it was importanttoassure that theinformation was both currentanduseful internationally.Thus toprepare this edition thesecondeditionwascarefullyreviewed forsuggestions, corrections and international relevance byanoutstanding team of30volunteerreviewers andcontributors from all over the world.The following list includes these colleagueswho havesignificantteaching experiencein medical,nursing andpharmacy schools andresidency training programsand/or provide service tobreastfeedingmothers andbabies aroundtheworld.ManyareWellstartAssociates (*)or facultymembers who taught inWellstart International’sLactation ManagementEducation FacultyDevelopmentProgram(**) WELLSTARTINTERNATIONALAcknowledgementsPhillipAnderson, D.Phar **Health Sciences ClinicalProfessor UCSD SkaggsSchool ofPharmacyand PharmaceuticalScience, San Diego, California, USANadia Badwar,MD*Professor of Pediatrics, Cairo University, President of ArabNetwork for QualityAssurance inHigher Education, Cairo,Egypt Eyla Boies,MD**ClinicalProfessor of Pediatrics, UCSDSchool of MedicineMedicalDirector of Premature Infant Nutrition Clinic,San Diego, California,CarmenCasanovas,MD, MPH* TechnicalOfficer NHD/NPL WorldHealthOrganization Geneva,Switzerland JudyCanahuati, MPh,*Nutrition andHIV Advisor, Office of Food for Peace, UnitedStates Agencyfor International DevelopmentWashington, D.C. USAWirapongChatranon, MD*ProfessorEmeritus (Pediatrics), Facultyof Medicine, SirirajHospital, Mahidol UniversityFormer Senior Consultant for Implementing BFHI, UNICEFfor Asia, andPacific Region, BangkokThailandSarahCoulter-Danner, RN,CNM, CPNP Adjunct Faculty, DepartmentofNursing, Salish Kootenai College,Pablo MT,Former Chairperson, Department of Nursing, Oglala LakotaCollege, Pine Ridge, SD, Patrice DeMarco, RNLactation ConsultantFletcher Allen Health Center, Burlington, VermontLawrence Gartner, MD**,Professor Emeritus, Departments of Pediatrics and OB/GYN, UniversityofChicago, President of MedWordValleyCenter,California, USAAngelaGatzke-Plaman, MDResident inFamilyPractice, Universityof Vermont Collegeof Medicine, Burlington,Vermont,VeronicaGomez, MA,*Breastfeeding Program Manager, GhanaHealth Service, Accra,GhanaTom Hale, RPh, PhDProfessor, Department of Pediatrics, Texas TechUniversityHealth SciencesCenter, School of MedicineAmarillo, Texas USAZeinab Heada,MD,*Component Manager, RH/HIV,Care International, Cairo,EgyptElisabet Helsing, PhD**Former RegionalAdviser, WHO Regional Office for Europe, Copenhagenand SeniorAdviser, Norwegian Board of Health, Oslo,Norway Elizabeth Hunt, MDClinicalAssociate Professor andNewborn HospitalistDepartment of Pediatrics Universityof VermontBurlington, Vermont USARose Kast, RN,President Momma’s PumpsCarlsbad, California,Ruth A. Lawrence, MD**Professor of Pediatrics, Obstetrics andGynecology, Department of Pediatrics, Universityof Rochester Schoolof Medicine and DentistryRochester, NewYork, USA WELLSTARTINTERNATIONALAcknowledgementsCecila Muxi, MBA,*NutritionistNational Program of Infant Health Ministryof Health of Uruguay Montevideo,UruguayRoxanaSaunero Nava, MD*Pediatrician, Docente Instructor depre y post grad HospitalMaterno Infantil, CajaNacional deSaludDirectora EjecutivadeCOTALMA, Secretaria Permanentede Comité Nacional deLactancia, LaPaz, BoliviaKetevan Nemsadze, MD,* Professor,Tbilisi StateMedicalUniversity, Pediatric DepartmentDirector of M.Lashvili Children's CentralHospital,Tblisi, GeorgiaVictoriaNichols-Johnson, MD, MS,*Associate Professor of OB/Gyn, Chief of theSection of Maternal NutritionandMetabolism, Southern IllinoisUniversity School of Medicine, Springfield, Illinois,Sallie Page-Goertz, MN ARNP* ClinicalAssociateProfessorDepartment of PediatricsKansas UniversitySchool of Medicine, Kansas City, Kansas, USAMarinaRea,MD, PhD*Consultant, Instituto deSaude, SaudedoEstadodeSao Paulo Sao Paulo,BrazilClavel Sanchez,MD,MPH*Coordinadora dela Comision Nacional de LactanciaMaterna,Santo DomingoDominican RepublicFelicitySavage-King, BM, Bch Oxon, FRCPCH, FABM**HonorarySenior Lecturer, Institute of Child Health London, Leeds,United Kingdom Wendelin Slusser, MD**Assistant ClinicalProfessor, UCLA School of Medicine, Director of theUCLABreastfeedingResource Program, Co-Director of theCommunityHealthand Advocacy, UCLA Residency ProgramLos Angeles, California, USALisa Stellwagen, MDAssociate Professor of Clinical Pediatrics, UCSanDiego Schoolof Medicine, Director of NewbornService,Lactation Director of theSPIN Program, San Diego, California,TeresaToma, MD,*Pediatrician Researcher , Instituto de Saude, Secretaria de Saude doEstado deSao Paulo,BrazilVeronicaValdes, MD,*Pediatrician, Former Adjunct Associate Professor of FamilyMedicine at theCatholic UniversityandConsultant for UNICEF Chile, Argentina and Uruguay,Santiago, ChileYvonne Vaucher,MD, MPHProfessor of Pediatrics and Attending Neonatologist, Director,InfantSpecialCare Follow-Up Program, UCSD School ofMedicine, San Diego, California, USAThesecolleagues have done an outstanding job ofhelping to assurethatthis tool is currentandinternational in scope.Theyhave our mostsincere and heartfeltthanks.We also wanttothankAlisonBlenkinsop,DipHE(midwiferystudies),Aldershot,United Kingdom and Andrea Herron,RN,MN,CPNP,San Louis Obispo,California,United States fortheir additional correctionsand suggestions.Their helpis greatlyappreciated.Finally,onceagain,thanksgoes to MariaElena Sandovalfor helpingto preparethis Third Editionof Wellstart’s Lactation Management Self-StudyModules, Level I.Withouther dedicatedassistance,this toolwould probablynothavebeenfinished. WELLSTARTINTERNATIONALAcknowledgementsFourthEdition,2013Inplanningfor aFourth EditionofWellstart’s Self-StudyModules, Level I,itwas importantto assurethatthe informationwas upto dateandusefulinternationally.Thustoprepare this edition thethird edition wascarefullyreviewed forsuggestions, corrections and international relevancebyanoutstanding team of16volunteerreviewers andcontributors from all over the world.The following listof4Edition reviewers includes thesecolleagueswhohave significantteachingexperience inmedicalandnursing programs and/or provideservicetobreastfeeding mothers and babies aroundtheworld.NadiaBadwar,MD*Professor ofPediatrics,Cairo University,PresidentofArab Network for QualityAssurance inHigher Education,Cairo,Egypt Eyla Boies,MD**Clinical Professor ofPediatrics,UCSDSchool ofMedicineMedicalDirector ofPremature Infant NutritionClinic,SanDiego,California, USAWirapong Chatranon,MD*Professor Emeritus(Pediatrics), FacultyofMedicine,SirirajHospital, MahidolUniversityFormer Senior ConsultantforImplementingBFHI,UNICEFfor Asia, and Pacific Region,Bangkok ThailandLawrence Gartner,MD **,Professor Emeritus,Departments of Pediatricsand OB/GYN, Universityof Chicago,PresidentofMedWord ValleyCenter,California,Rose Kast,RN,President Momma’s PumpsCarlsbad,California, USARuthA.Lawrence,MD**Professor ofPediatrics,Obstetrics and Gynecology,Departmentof Pediatrics,UniversityofRochester School ofMedicine andDentistry Rochester,New York,RoxanaSaunero Nava,MD*Pediatrician,Docente Instructor de pre ypostgradHospitalMaterno Infantil, CajaNacionaldeDirectora Ejecutiva deSecretaria Permanente deComité Nacional de Lactancia,LaPaz, BoliviaKetevan Nemsadze,MD,* Professor, Tbilisi StateMedicalUniversity, Pediatric DepartmentDirector ofM.LashviliChildren'sCentral Hospital,Tblisi, GeorgiaVictoriaNichols-Johnson,MD,MS,* AssociateProfessor ofOB/Gyn,ChiefoftheSectionofMaternalNutritionand Metabolism, SouthernIllinois UniversitySchoolofMedicine, Springfield,Illinois,SalliePage-Goertz, MN ARNP* Clinical AssociateProfessor DepartmentofPediatrics Kansas UniversitySchool ofMedicine,Kansas City,Kansas, USAMarinaRea,MD,PhD*Consultant,InstitutodeSaude, Saude do Estado deSaoPaulo SaoPaulo,FelicitySavage-King,BM,Bch Oxon,FRCPCH,FABM**HonorarySenior Lecturer, InstituteofChild HealthLondon,Leeds,UnitedKingdom WELLSTARTINTERNATIONALAcknowledgements Wendelin Slusser,MD**Assistant Clinical Professor, UCLASchool ofMedicine, Director oftheUCLABreastfeeding ResourceProgram,Co-Director ofthe CommunityHealth and Advocacy, UCLAResidencyProgramLos Angeles, California, USALisa Stellwagen,MDAssociateProfessor ofClinical Pediatrics,UC SanDiegoSchool ofMedicine,DirectorofNewborn Service,Lactation DirectoroftheSPIN Program,San Diego,California, Veronica Valdes,MD,*Pediatrician,Former Adjunct AssociateProfessor ofFamily Medicine attheCatholicUniversityandConsultantfor UNICEF Chile,Argentina and Uruguay,Santiago, Finally,onceagain,a heartfeltthanks goes to MariaElena Sandovalfor assistinginthe preparationof this Fourth Edition.Withouther skilled and dedicated assistance,this tool wouldnever have beenfinished andputup on Wellstart International website.Audrey J.Naylor,MD,DrPH,FAAP,FABMRuthA.Wester,BA,RN,PNPPresident and CEOVice-PresidentWellstartInternationalWellstartInternational ClinicalProfessor ofPediatrics (vol.part-time)UniversityofVermontCollege ofMedicineShelburne,Vermont June2013 WELLSTARTINTERNATIONALForwardOtitis Media 50 Exclusive BF for � 3 or 6 mo 0 .50 Recurrent OM 77 Exclusive BF for � 6 mo 1.95 Upper Respiratory trct infect. 63 Exclusive BF for � 6 mo 0.30 Lower Respiratory trct infect 77 Exclusive BF for � 6 mo 4.27 NEC (NICU stay) 77 Preterm infants, exclusive HM 0 .23 Gastroenteritis 64 Any 0.36 Obesity 24 Any 0.76 Type 1 diabetes 30 Exclusive BF for � 3 mo 0.71 Type 2 diabetes 40 Any 0.61 Leukemia (ALL) 20 � 6 mo 0.80 Leukemia (AML 15 � 6 mo 0.85 SIDS�Any 1moInaseriesofarticlespublishedinLancetin2003itisnotedthatsome13%ofthe9.5millionannualdeathsintheworldamongchildrenunder5yearscanbepreventedorsignificantlydecreasedinseveritybybreastfeedingexclusivelyforsixmonthsandthenaddingappropriatenutritiouscomplimentaryfoods.Themajorityofthesedeathsoccurredinthelesseconomicallydevelopednationsoftheworld.Inaddition,breastfeedingisnowwellacceptedasaveryeffectiveevidencedbasedprimaryhealthcarestrategyindevelopednationsforimprovingboththeimmediatehealthandwellbeingofmothers,infantsandchildrenaswellasloweringtheriskofasignificantnumberofchronicdiseasesofolderchildrenandadults.(Figure1)BenefitsofBreastfeedingAdapted from Breastfeeding and the Use of Human Milk, Pediatrics, March 2012Condition % Lower Risk Breastfeeding Odds Ratio Thuswhenbreastfeeding,abiologicallynormalreproductiveprocessandwaytofeedhumaninfantsandyoungchildren,issupportedasabasiccomponentofoptimalinfantandyoungchildfeeding(OIYCF,Figure2)individual,familyandcommunityhealthcanbesignificantlyimproved WELLSTARTINTERNATIONALForward C = conceptionB = birthThereare,ofcourse,manyinfluencesonachievingOIYCF.Amongthesearehealthcareproviderswithknowledgeandskilloflactationmanagementandbreastfeedingsupport.Unfortunatelymanyhealthcareprovidershaveonlyalimitedknowledgeofthistopic.Animportantreasonforthislackofknowledgeisthatmanyschoolsofmedicineandnursingaswellasnutritionprogramshavenotincludedlactationmanagementeducationintheircurricula.LactationManagement Curriculum: A Faculty GuideIn1985,toassistinmeetingthisneedforcurriculumcontentinlactationmanagement,WellstartInternationalbeganprovidingeducationandtraininginlactationmanagementbreastfeedingpromotionforbothstudentsandfacultyofthehealthprofessions.In1999,withfundingfromTheUnitedStatesMaternalChildHealthBureauoftheHealthResourcesandServicesAdministrationandincollaborationwiththeUniversityofCaliforniaSanDiegoMedicalSchool,WellstartdevelopedLactationManagementCurriculum:AFacultyGuideforSchoolsofMedicine,NursingandNutrition(LMCG),nowinitsfourthedition.TheLMCGwasdevelopedtofacilitatetheintegrationoflactationmanagementknowledgeandskillsintothecurriculumofmedicine,nursingandnutritionprograms.Itisacompetencybasedtoolandprovidesguidanceincurriculumassessment,contentsuggestionsandresourcesforthreelevelsofprofessionalresponsibility.LevelIprovidesbasicknowledgeneededbyallhealthcareproviderstobesupportiveofnormalmothersandtheirhealthyfullterminfants.LevelIIincludesmoreclinicaldetailforcomplexsituationsandistargetedatthosewhopracticeoneoftheperinatalspecialties(pediatrics,obstetrics,familymedicine,neonatology,etc). WELLSTARTINTERNATIONALForwardisdesignedforthosewhowillspecializeinbreastfeedingmedicineand willserveaskeyfacultyinleadershippositions.(Figure3) ContentFocus of Modules LevelI BasicKnowledge NeededbyAllHealth Care Providers Level II PerinatalCareProviders Level III BreastfeedingMedicine SpecialistsandFaculty Module 1 ScientificBasis Module 2 ClinicalManagement Module 3 ProfessionalPractice Figure3.LactationManagementCurriculum-SchematicDiagramLevel I AllhealthprofessionalsregardlessofwhetherornottheyspecificallyprovidecareforbreastfeedingmothersandinfantsshouldattainLevelIknowledgeandskillsduringtheirinitialpreparatory(preservice)program.Beforeenteringthepracticeoftheirprofession,theyshouldhaveanunderstandingaboutthescientificbasisforencouragingandsupportingbreastfeeding,thephysiologyandbasicsofclinicalmanagementoflactationfornormalmothersandnewbornsandthesocietalinfluencesonlactationandbreastfeedingpromotion.Theyshouldbeabletoprovidehealthcarethatsupportsbreastfeedinginitiationandmaintenance,andavoidscreatingbarriers.Whiletheyneedtobeawareoftheprinciplesoflactationmanagement,theydonotnecessarilyneedtoattainclinicalexpertiseinthearea. WELLSTARTINTERNATIONALForwardLactationManagement Self-StudyModules, Level IThoughtheLMCGachievedconsiderablesuccess,limitationsofavailabletimeinapreservicehealthprovidercurriculumledtoarecommendationbyearlyusersthatalevelItoolbedevelopedthatcouldbecompletedinafewhoursandatatimeandplaceofthestudent’schoosing.WithfurthersupportfromTheMaternalChildHealthBureauoftheHealthResourcesandServicesAdministration,asetofthreeclinicallyoriented,competencybasedself-studymoduleswasdevelopedtohelpstudentsachieveLevelIknowledge.Initiallypublishedin2000,LactationManagementSelf-StudyModules,LevelIhavebeenrevisedandupdatedtwice(2005and2009)toincorporateimportantnewevidencedbasedknowledgeandskills.Thesemodulesareparticularlyfocusedonthebreastfeedingcomponentofoptimalinfantandyoungchildfeeding.Scientificevidenceregardingtheimportanceofbreastfeeding,areviewofthephysiologyandbasicmanagementstrategiestosupportlactationandbreastfeedingandsolutionstocommonproblemsareincluded.Theyprovideaself-containedunitofbasicknowledgethatcanbeutilizedbyfaculty,students,andotherhealthcareprofessionalsinavarietyofsettings.Theycanbeassignedduringclinicalrotationsinpediatrics,familymedicine,nutrition,obstetrics,andcommunityhealthorasanelectivecourse.Eachinstitutioncandecidewherethemoduleswouldhavethemostimpactintheircurriculum.Theycanalsobeusedbythosealreadyinpracticewhoseprofessionaltrainingdidnotincludethesetopicsorwishtohaveareviewofthebasics.Asadditionallearningtools,pre-testsandpost-testshavealsobeenincluded.Usersareurgedtotakethepretestbeforebeginningareviewofthemodulesandcomparetheirscoreswiththeposttesttakenaftercompletionofallthreemodules.Answersheetshavealsobeenprovidedforbothpre-testandpost-tests.Theanswersheetforthepost-testincludesabriefexplanationoftheanswer.ForthisEditionanannexhasbeenaddedwhichprovidesanumberofusefulreferencedocuments.TheseincludeanupdatedsummaryofkeyclinicalpointsfromtheModulescalledHighlights,TheTenStepstoSuccessfulBreastfeeding,WHO’s2009AcceptableMedicalReasonsforUseofBreastmilkSubstitutes,InfantfeedinginEmergencies,TenkeypointsofTheInternationalCodeofMarketingofBreastmilkSubstitutesandRelevantWorldAssemblyResolutions,HowtoStoreHumanMilk(Protocol#8fromTheAcademyofBreastfeedingMedicine),GuidelinesforHandExpression,WebsitesofInterest,anAlphabeticListingofReferencesusedinthistooland resources suggested by the reveiwersof the 4edition.AswassaidintheopeningparagraphofthisForewordtothisEditionoftheSelf-StudyModules,establishingbreastfeedingasabiologicallynormalreproductiveprocessandwaytofeedhumaninfantsandyoungchildrenwillhaveamajorimpactonimprovingindividualandcommunityhealthglobally.Knowledgeablehealthcareprovidersarefundamentaltoachievingthisgoalandpreserviceeducationisthefoundationtothisknowledge.Inordertoencouragethis“revolution”inpreserviceeducation,WellstartInternationalhasmadeadecisiontoprovidethisEditiononitswebsiteasadownloadableteaching/learningtoolwithoutcharge. WELLSTARTINTERNATIONALForwardWeonlyaskthatuserstakethisopportunityseriously:readthematerialcarefullyandassumeresponsibilityforprovidingtheevidencebasedcarethatisexplainedandrecommended.Becomepartofthesolutionthatwillhelpofchildrenandtheirfamiliessurviveandlivelifetothe 1.AAP. Policy Statement: Breastfeeding and the Use 2.Black,RE,Morris,SS,Bryce,J.Whereandwhyare10millionchildrendyingeveryyear?(2003)TheLancet;316;2226-22343.Horta,BL.Bahl,R,Martines,J,Victora,CG.(2007)Evidenceonthelong-termeffectsofbreastfeeding:SystematicReviewsandMeta-analyses.WHO,Geneva4.Ip.S,Chung,M,etal.(2007)BreastfeedingandMaternalandInfantHealthOutcomesinDevelopedCountries.EvidenceReport/TechnologyAssessmentNo153.AHRQPublicationNo07-E007.AgencyforHealthcareResearchandQuality.5.WellstartInternationalandtheUniversityofCaliforniaSanDiego(1999).LactationManagementCurriculum:AFacultyGuideforSchoolsofMedicine,NursingandNutrition,FourthEdition.SanDiego,California;WellstartInternational6.WorldCancerResearchFund/AmericanInstituteforCancerResearch(2007).Food,Nutrition,PhysicalActivity,andthePreventionofCancer:AGlobalPerspective.Washington,DC:AICR,2007 WELLSTARTINTERNATIONALFacultyGuide Modules are designed to be used duringthe beginning of clinical assignmentsof students of the health professions (i.e.medical, nursing, nutrition)or by those who havenot hadprevious exposuretocontent. They have also been usefulas a reviewof the basics.They can be usedas the entire content of a courseor as a part of a course. For example, this materialmay be assigned as part ofrequired clinical experiences in newborn and/or maternalcare or as part of anelective or independent study. Themanner inwhich these tools are usedisup to the responsible faculty.Faculty are encouragedto incorporate localor regional experience of theparticipants. For example, in someareas of theworld, HIV andAIDS are a major concern and may warrant moredetailed special attention. Or perhaps the most commonly used human milk substitute isnot commercialformula butcowor goat milk requiring appropriate information andcomparisons.Regardlessof whetherthey are used as a course or arepart of acourse, theModulescan be studied by the users at atime and place most convenient for the user.Though faculty involvementis not required, experience with the first andsecondeditions suggests that users are likely to gain grfaculty member. Experiencehas also indicated that medical students andresidents are most responsivewhen the responsiblefaculty member and role model is a physician. For nursing students, a faculty member fromthe schoolof nursing is most effective.While the modules can be completed independent of oneanother, they are best reviewed in sequence. Thus a student may have time tocomplete Module 1 and later undertake Module2 and evenlater, Module3.A pre-test ofknowledge is includedbefore beginning Module1as wellas a pre-test withanswers andwhere an explanation of the answers can befound in the modules. to havestudents take both a pre-test anda post testforcomparison with the pre test scores,apost-test aswell as a post-test with the answers brieflyexplained included following Module3. In addition, each modulehas a set ofreferencesthat can be utilized for selecting assignedreadings if so desired by responsible faculty.Theformat of the modules provides application of the materialby means of short case exercises. Theinformationin the modules and the case exercises will be enhanced by a structured clinical experiencesuch as bedside rounds where students can apply their newknowledge to a realistic setting. A clinical instructor, experienced inlactation management, should help the student carry out the breastfeedproblem solving steps.If time is available, additional assignments in prenatalclinics, delivery rooms, follow-up clinics, home viuseful.Experience with previous editionshas indicated that thethree modules can be completedwithina 6 to 7 hour timeframe including reviews of two or three short DVDsor videos. Additionaltime will be required for theclinical experiences,essential to enhance application of theknowledgeto real mother/infant situations. Welltart does notgiveCME's. However manyhospitlals throulgh their educational officehave arrangedforCMEs tobe givenfor completion of the Self-Study Modules. FacultyPreparationFaculty memberswho will direct or coordinate thisself-study learning experience need to work throughthe modules to become familiar with the content, exercises, and accompanying materials. Ideally responsible facultywho plan to use this tool shouldbe prepared at Level IIorIII.Iffaculty do not feeladequately prepared, enrollment is recommended inoneof the workshops frequentlyprovided by several organizations includingthe Academy of Breastfeeding Medicine(ABM), AmericanAcademy of Pediatrics(AAP), or other faculty development workshops. Forthose whowill be working with studentswho intend to pursuecertification by the International Board of LactationConsultant Examiners, out byInternational Lactation Consultant Association (ILCA) workshops would behelpful.Theseworkshop opportunities are announced by the sponsors on their organizationalwebsites provided inannexG.Recently the AAPmade their Residency Curriculum available on their web site(www.AAP.org/breastfeeding thoughsome recommendeditems such as training videos/DVDs mustbe obtainedfor a fee from non AAPsources. This would also helpprepare faculty at LevelII.ThoughtheAAP Residency Curriculum material is not intended to beaself-study course, it offersinformationand tools that can be helpful to someone who isalready reasonably knowledgeable.TeachingResources1.TextbooksIt is also recommended that faculty assigned to direct or coordinate an experience using the Wellstart Self-Study Modules, havethe following references availableThefirst three texts are particularly intended for physicians. Thereferenceby Jan Riordan is alsovery often used in physician training butespeciallyusefulin programs focusedon nursingstudents.a.American Academy of Pediatrics and the American College of Obstetricians and Gynecologists(2006)Breastfeeding Physicians. AAP, Elk Grove Village,IL andACOG, WDC.b.Hale, TW. Hartman, PE. (2007)Textbook of Human Lactation, FirstEdition, Amarillo, TX. Hale Publishing, L.P.c.LawrenceRAand LawrenceRM (2011)Breastfeeding, A Guide for theMedical Profession, SeventhEdition, St. Louis, MO:Mosby, Inc.d.Riordan J and Wambach K (2010)Breastfeeding and HumanLactation, rtlett Publishers, Ince.Walker,M (2014) the Clinician: Using the Evidence. 3 2.ReferencesAt the endof each of the three modules a list ofrelevant referencesfor the content of the particular moduleis provided. These havealso been put together as an alphabetized list inthe annexincluded at theendof thistool.The World Health Organization has developed andmadeavailablea “ModelChapter on Infant andYoungChild Feeding” for textbooks for medicalstudents andallied health professionals. This materialis inThechapter can be reviewed and downloaded without charge at thefollowing www.who.int/nutrition/pub9789241597494/en/index.html 3.DVDSHaving an opportunityto visualize some of the techniques andskills described in Modules 2 and 3 ofthis LevelISelf-Study tool can be particularly helpful to user of this tool. Several short DVDs regarding immediate breastfeeding at birthand howto assist a newmother-baby couplewith achieving an effective, comfortableattachmentor latch-on are available. Medicaland nursing schools frequently maintain a library ofteaching tools and mething appropriateintheir collections. If thatis not the case, faculty responsiblefor directing a program inwhich the Self Study Moduleswill be utilizedare urgedto consider reviewing and possiblyobtaining one or two oftheseveral relevant DVDs that are currentlyavailable. Titles and web sites where further informationmay be obtainedinclude:a.Initiation of Breastfeeding by Breast Crawl http://breastcrawl.org/video.htm DeliverySelfAttachmentwithDr.LennartRighard www.geddesproduction.com/breast-feeding-delivery- selfattachment.php c. Baby-LedBreastfeeding:TheMotherBabyDancewithChristinaM.Smiley,MD geddesproduction.com/breast-feeding-baby-led.php MakingEnoughMilk,theKeytoSuccessfulBreastfeeding:PlanningforDay with JaneMorton, MD www.breastmilksolutions.com/making_enough.html e.Latch 1,2,3: Troubleshooting Breastfeeding in theEarlyweeks www.healthychildren.cc (note:tofindinformationregarding this DVD,select“BreastfeedingInformationLinks” fromlefthand column) f.Re: Basic Breast Massage and Hand Expression http://www.bfmedneo.com/BreastMassageVideo.aspx g.Re: Milk banking in Brazil www.youtube.com/watch?v=X8KHJvE6AtU SectionII WELLSTARTINTERNATIONALPre-TestPleasecircletheappropriateresponse:Identifythecomponentofhumanmilkthatbindsironlocallytoinhibitbacterialgrowth:secretoryIgAoligosaccharidesIdentifythecomponentofhumanmilkthatprovidesspecificimmunityagainstmanysecretoryIgAThemost importantcriterionforassessingthemilktransferduringafeedingatthebreastvisibleareolacompressionaudibleswallowproperalignmentproperattachmentComparedtoformula,humanmilkcontainshigherlevelsof:vitaminDvitaminAnoneoftheaboveThehormoneconsideredresponsibleformilkejectionis:oxytocin WELLSTARTINTERNATIONALPre-TestAmotherwithathree-dayoldbabypresentswithsorenipples.Theproblembeganwiththefirstfeedingandhaspersistedwitheveryfeeding.Themostlikelysourceoftheproblemis:feedingtoolongpoorattachmentbaby’ssuckistoostronglackofnipplepreparationduringpregnancyThehormoneconsideredresponsibleformilksynthesisis:oxytocinWhichofthefollowingwouldyousuggestthatawomanwithinvertednipplesdoduringthethird trimester?UsebreastshellswithguidancefromherhealthcareproviderCutholesinthebratoallowthenipplestoprotrude;wearitdayandnightEncourage everting the fourtimesadaytopermanentlyeverthernipplesDonothingbecausethenaturalchangesinthebreastduringpregnancyandtheinfant’ssucklingpostpartummayevertthenipplesWhichofthefollowingismostlikelytohavethegreatesteffectonthevolumeofmilkawomanproduces?maternalweightforheightmaternalfluidintakesupplementationoftheinfantwithformulamaternalcaloricintakebothaandcInfantsexclusivelybreastfedforaboutsixmonthswillhave:Fewerepisodesoflowerrespiratoryinfectionfewerepisodesofdiarrheanoneoftheabovebotha and b aboveTheadditionofcomplementaryfoodstobreastfedinfantsisrecommendedatabout:2months4months6months8months10months WELLSTARTINTERNATIONALPre-TestSignsofadequatebreastmilkintakeintheearly(first4-6)weeksincludeallEXCEPT:babygainsweightatleast3-4stoolsin24hourssoundsofswallowingbabysleepsthroughthenightatleast6diaperswetwithurinein24hoursItisespeciallyimportantthataninfantwithastrongfamilyhistoryofallergyshouldbe breastfedfor:2months4months6months8months10monthsSevereengorgementismostoftendueto:highoxytocinlevelinfrequentfeedingshighprolactinlevelpostpartumdepressionThemostcommoncauseofpoorweightgainamongbreastfedinfantsduringthefirstfourweeksafterbirthis:maternalendocrineproblemsmaternalnutritionaldeficienciesinfantmetabolicdisordersinfrequentorineffectivefeedingslowfatcontentofbreastmilkAbreastfeedingmotherwitha3-montholdinfanthasaredtenderwedge-shapedareaontheouterquadrantofonebreast.Shehasflu-likesymptomsandatemperatureof39YourmanagementincludesallofthefollowingEXCEPT:extrarestinterruptbreastfeedingfor48hoursmoistheattotheinvolvedregionantibioticsfor10to14daysdaysStudieshaveindicatedthattheLactationalAmenorrheaMethod(LAM)ofcontraceptionislessreliableunderwhichofthefollowingcircumstances:feeds8ormoretimesin24hoursisgivennoregularsupplementsislessthan8monthsoldcontinueswithnightfeedings WELLSTARTINTERNATIONALPre-TestWhichofthefollowingstatementsisnottrueofTheInternationalCodeofMarketingofBreastmilkSubstitutesapprovedasaresolutionintheWorldHealthAssembly(WHA)inisupdatedeverytwoyearsbytheWHAprovidesguidelinesfortheethicalmarketingofinfantformulaisincorporatedintotheBabyFriendlyHospitalassessmentwasapprovedbyallWHAmembercountriesincludesbottles,nipples,andbreastmilksubstitutesNipplecandidiasiscanbeassociatedwithallofthefollowingEXCEPT:oralthrushintheinfantburningpaininthebreastfeverandmalaisepinkandshinyappearanceofthenipplesandareolaJaundiceinanormalfulltermbreastfeedinginfantisimprovedby:givingglucosewaterafterbreastfeedinggivingwaterafterbreastfeedingbreastfeedingfrequently(atleast8ormoretimesin24hours)bothaandcBreastfeedingiscontraindicatedinwhichofthefollowingconditions:infantwithgalactosemiamotherwithmastitismotherwithhepatitisBmotherwithinvertednipplesbothaandcReasonsforincludingbreastfeedingsupportformotherinfantinplanningfororrespondingtomajoremergencieswherecleanwater,sanitationandpoweraredisrupteddonotinclude:ItislessexpensivethanprovidingforinfantformulaWithsupportevenmotherswhohavealreadyweanedcanbeassistedtoBreastmilkprovidesimmunoglobulinsthatactivelypreventinfection.InastressfulemergencysituationbreastfeedingprovidesasecureenvironmentforinfantsandyoungchildrenHospitalpoliciesthatpromotebreastfeedinginclude:useofadropperforroutinewatersupplementationuninterruptedsleepthefirstnighttoallowmother’smilksupplytobuildupunlimitedaccessofmothertobabyuseofpacifierstopreventsorenipples WELLSTARTINTERNATIONALPre-Test through28.Labelthestructuresofthebreastbyinsertingnexttotheappropriatepointerthenumberofthestructurelistedbelow:Montgomery’sglandsSupportingfatandothertissues WELLSTARTINTERNATIONALPre-TestModule identified where answer is discussed Identifythecomponentofhumanmilkthatbindsironlocallytoinhibitbacterialgrowth:secretoryIgA oligosaccharidesIdentifythecomponentofhumanmilkthatprovidesspecificimmunityagainstmanysecretoryIgA Themost importantcriterionforassessingthemilktransferduringafeedingatthebreastvisibleareolacompressionaudibleswallow properalignmentproperattachmentComparedtoformula,humanmilkcontainshigherlevelsof:vitaminD vitaminAnoneoftheaboveThehormoneconsideredresponsibleformilkejectionis:oxytocin (Module 2) WELLSTARTINTERNATIONALPre-TestAmotherwithathree-dayoldbabypresentswithsorenipples.Theproblembeganwiththefirstfeedingandhaspersistedwitheveryfeeding.Themostlikelysourceoftheproblemis:feedingtoolongpoorattachment baby’ssuckistoostronglackofnipplepreparationduringpregnancyThehormoneconsideredresponsibleformilksynthesisis: oxytocinWhichofthefollowingwouldyousuggestthatawomanwithinvertednipplesdoduringthethird trimester?UsebreastshellswithguidancefromherhealthcareproviderCutholesinthebratoallowthenipplestoprotrude;wearitdayandnightEncourageeverting the nipplesfourtimesadaytopermanentlyeverthernipplesDonothingbecausethenaturalchangesinthebreastduringpregnancy andtheinfant’ssucklingpostpartummayevertthenipples Whichofthefollowingismostlikelytohavethegreatesteffectonthevolumeofmilkawomanproduces?maternalweightforheightmaternalfluidintakesupplementationoftheinfantwithformula maternalcaloricintakebothaandcInfantsexclusivelybreastfedforaboutsixmonthswillhave:Fewerepisodesoflowerrespiratoryinfectionfewerepisodesofdiarrheanoneoftheabovebotha and b (Module1)Theadditionofcomplementaryfoodstobreastfedinfantsisrecommendedatabout:2months4months6months 8months10months WELLSTARTINTERNATIONALPre-TestSignsofadequatebreastmilkintakeintheearly(first4-6)weeksincludeallEXCEPT:babygainsweightatleast3-4stoolsin24hourssoundsofswallowingbabysleepsthroughthenight atleast6diaperswetwithurinein24hoursItisespeciallyimportantthataninfantwithastrongfamilyhistoryofallergyshouldbe breastfedfor:2months4months6months 8months10monthsSevereengorgementismostoftendueto:highoxytocinlevelinfrequentfeedings highprolactinlevelpostpartumdepressionThemostcommoncauseofpoorweightgainamongbreastfedinfantsduringthefirstfourweeksafterbirthis:maternalendocrineproblemsmaternalnutritionaldeficienciesinfantmetabolicdisordersinfrequentorineffectivefeedings lowfatcontentofbreastmilkAbreastfeedingmotherwitha3-montholdinfanthasaredtenderwedge-shapedareaontheouterquadrantofonebreast.Shehasflu-likesymptomsandatemperatureof39YourmanagementincludesallofthefollowingEXCEPT:extrarestinterruptbreastfeedingfor48hours moistheattotheinvolvedregionantibioticsfor10to14daysdaysStudieshaveindicatedthattheLactationalAmenorrheaMethod(LAM)ofcontraceptionislessreliableunderwhichofthefollowingcircumstances:feeds8ormoretimesin24hoursisgivennoregularsupplementsislessthan8monthsold continueswithnightfeedings WELLSTARTINTERNATIONALPre-TestWhichofthefollowingstatementsisnottrueofTheInternationalCodeofMarketingofBreastmilkSubstitutesapprovedasaresolutionintheWorldHealthAssembly(WHA)inisupdatedeverytwoyearsbytheWHAprovidesguidelinesfortheethicalmarketingofinfantformulaisincorporatedintotheBabyFriendlyHospitalassessmentwasapprovedbyallWHAmembercountries includesbottles,nipples,andbreastmilksubstitutesNipplecandidiasiscanbeassociatedwithallofthefollowingEXCEPT:oralthrushintheinfantburningpaininthebreastfeverandmalaise pinkandshinyappearanceofthenipplesandareolaJaundiceinanormalfulltermbreastfeedinginfantisimprovedby:givingglucosewaterafterbreastfeedinggivingwaterafterbreastfeedingbreastfeedingfrequently(atleast8ormoretimesin24hours) bothaandcBreastfeedingiscontraindicatedinwhichofthefollowingconditions:infantwithgalactosemia motherwithmastitismotherwithhepatitisBmotherwithinvertednipplesbothaandcReasonsforincludingbreastfeedingsupportformotherinfantinplanningfororrespondingtomajoremergencieswherecleanwater,sanitationandpoweraredisrupteddonotinclude:Itislessexpensivethanprovidingforinfantformula WithsupportevenmotherswhohavealreadyweanedcanbeassistedtoBreastmilkprovidesimmunoglobulinsthatactivelypreventinfection.InastressfulemergencysituationbreastfeedingprovidesasecureenvironmentforinfantsandyoungchildrenHospitalpoliciesthatpromotebreastfeedinginclude:useofadropperforroutinewatersupplementationuninterruptedsleepthefirstnighttoallowmother’smilksupplytobuildupunlimitedaccessofmothertobaby useofpacifierstopreventsorenipples WELLSTARTINTERNATIONALPre-Test through28.Labelthestructuresofthebreastbyinsertingnexttotheappropriatepointerthenumberofthestructurelistedbelow:Montgomery’sglandsSupportingfatandothertissuesPre-testScoreCard PossibleScore:28Pre-testscore: SectionIIISelf-StudyModules WELLSTARTINTERNATIONALModule1-Importance ModuleOneBreastfeeding:ABasicHealthPromotionStrategyinPrimaryCareAfter completingthis module, you will be ableto:1.Describe the reasons why breastfeeding isimportant as wellas evidencebased risks of notbreastfeeding for the infant, mother, family and community at large.2.Identify factors that contribute to the breastfeeding decision.3.Counsel a woman about breastfeeding.IntroductionAll mothers want toprovide what’s best for their babies and often turn to their health care provider foradvice. This module will help prepare you for thisdiscussion by reviewing human milk composition and some of themajor benefitsof breastfeeding for infant, mother, familyandthe community. Some of the factors that influence how ng choicewill alsobe described.CaseExerciseVeronica, a 26-year-oldwoman, has come for a prenatal visit.You join herintheconsultationroomandbegintoreviewthehistoryformshefilledoutin preparationforhervisitwithyou. Younotethatshehasnotansweredthequestion regardinghowsheplanstofeedhernewbaby. Whenyouinquireaboutthis,she respondsthatshehasn’tthoughtaboutitasyetandwouldliketotalkaboutwhat wouldbebest. Manyofherfriendshavetoldherthatitreallydoesn’tmatterhow What do you needto know to advise this mother? WELLSTARTINTERNATIONALModule1-Importance Aren’tbaby formul asnearly thesame as m other’s mil k? Theanswer is of course “no”. Human milk is specific to the human species, a dynamic and complexbiological fluid containing over 200 bio-active constituents including immuno-protectiveagents, enzymes, hormones, vitamins andother factors as well as essential nutrients in perfect balancefor the growth and development of human infants. It changes in composition during a feed, fromfeed to feed during the day andover time asthe growingHumanMilkCompositionWELLSTART INTERNATIONALBreast milk changes inappearance over time.Colostrum Colostrum is a thick, yellowish fluid present inthebreast during pregnancy and for about the first 2to 4 days after birth. It differs from mature milk in many respects (1-1) andisa blend of prepartum breast secretions, which begin to accumulate inthe breast fromabout thetwelfth week of secretions resulting from the effects on thebreasts of hormonalchanges surrounding labor and delivery. Thoughsmall inquantity (40-50 cc duringthe first 24 hours),colostrum provides an idealnutrient andimmunological substance to help assure the newborn’s successfultransitionfrom the protected sterile intra-uterine environment to the non-sterile extra-uterine environment. Colostrum contains much more proteinandre milk and is particularly richin beta-carotene, a precursor of vitaminA, which gives colostrum its yellow color. Vitamin A is important for protection against infection andfor earlyretinaldevelopment. It also contains white cells whichalso helppreventinfection in the newborn.TABLE1-1ComparisonofColostrum(day1)andMatureHumanMilk* perliter )Colostrum Mature Milk Energy (kcal/deciliter)57.0Protein(g)9.029.0*DataadaptedfromLawrenceandLawrence(2011),pp105andtables4-5and4-8,pp105 WELLSTARTINTERNATIONALModule1-Importance Theprotein content of colostrum is largely a concentration of immunoglobulins, especially secretory immunoglobulin A (sIgA). As noted inTable1-2, during the firsttwenty-fourhours after delivery, colostrum in80 mg of IgG, 120 mg of IgM and 11,000mg of sIgA, and can provide the breastfed infantwith a powerful passive immunization against ns. Although theconcentrationof immunoglobulinsdecreases in transitional and mature milk, a significantquantity of immunologicalprotection continues to be transmittedtothe infant throughout the TABLE1-2ImmunoglobulinsinHumanMilkOutput-mg/24 hoursDayPostpartum IgG IgM IgA 8012011,000 50402,000 25101,000 8–5010101,000 Adaptedfrom:RemingtonJSandKleinJO(2001)InfectiousDiseasesoftheFetusandNewborn,FifthEdition.Philadelphia,WBSaundersCo.UNICEF Chile Breastfeeding immediatelyafterbirth andreceiving theprotectionof colostrum.Colostrum alsoprovides lactose which prevents hypoglycemia and facilitates the passage of meconium, which in turn aids in the excretion of bilirubin. Even if a mother decides not to breastfeed, it is desirable to encourage her to provide colostrum to assure thather infant receives the transitional protectiononly availablein this maternal substance. Colostrum is often considered the “first immunization”. WELLSTARTINTERNATIONALModule1-Importance MatureHumanMilk Thedevelopment of the breast tissue andsecretion colostrum andmilk actuallybeginsaboutthe 12week of pregnancy andextends until shortly after delivery. This first stage isknown as lactogenesis I. Lactogenesis II begins to occurbetween the 2and4milk “comingin” ingreater quantity. The mother notes that her breasts feel full, andthe baby’s swallowing pattern becomes more distinct.Approximately 7 to 10days after delivery, milk is defined as ”transitional”. By 14 days milk is considered “mature”. A volume of 600-900ml can eventually produced every 24 hours andhas a biochemicalcomposition assummarizedin. Importantaspects include the following:-Asis true of most mammal milks, water is the major constituent of human milk.Even in hot climates, human milk, whichis 87% water, prwater for the exclusively breasy hydrated. Only if theinfant is unableto nurse effectively as needed or has an unusualhealth problemdiabetes insipidus) would add-About 50% of the calories in human milk come from lipids. The primary fats e phospholipidsand triacylglycerols. Some 167fatty acidshavebeen identified inhuman milk, many of whichare long chain,polyunsaturated fatty acids unique to human milk. Human milk contains omega-3fattyacids, includingdocosahexaenoic acid (DHA), important forbrain and retinal development and function.Cholesterol, important tothe development of membranes, is also present insignificant quantities.While the content of milk fat in mature3.8%, it is importantto recognize that thesefigures represent an average fat content. In reality, thefat content is variableand influenced by a numberparticular clinical importanceis the significant increase whichoccurs during a feeding from the lowfat content of the milkof about 1.5 to 2.0 %whichhas accumulated in the breasts since“foremilk”)to the higher fat levelspresent inmilk secreted during a feeding. Fat content in milkavailable near the end of a feeding (“hindmilk”) canbe as Allowing an infant to nurse until there is an indicationof satiationis important iffull~1.7%~5.5%~0.7%fat (andthereby caloric andfat-solublevitamin) intake is to be achieved.ForemilkHindmilkWellstart International WELLSTARTINTERNATIONALModule1-Importance-Thetotal protein content of human milk, 0.9%, is the lowest amount mammalmilks whichhave been studiedto date. Thislow protein content is well matched with the still developing renal function of theneonate and younginfant. Thelowrenal solute load of human milk places less excretory burden on the immaturesystem while providing optimalgrowth and Milk protein can be dividedinto twomajor components, whey andcasein. Milk curd, whichforms from the casein when the milk pH(normally ranging from 6.7to 7.4) drops below 5.0, is an insolublecalcium caseinate-calcium phosphate complex. The liquidthat remains after the curds are formed is whey. Whey contains water, electrolytes and important proteins that contribute to disease resistance includingrrin, lysozyme and the immunoglobulins. Human milkprotein is predominantly whey. Whenacidified (such as occurs inthe stomach),human milk results in a flocculent suspension allowing for easy digestion and absorptionof nutrientsas wellas rapidtransit throughthe intestinal tract of the humaninfant. This results in the normal pattern of frequent feeding and stooling characteristic of breastfed infants.In commercial substitutes for human milk the ratioof casein to whey has been adjusted from the predominant casein of cow’s milk. Even with this adjustment, the feeding frequency,stools and stool patterns of formula-fed infants are not thesame as breastfed infants. In addition, stools of formulafed infants are firmer thanthose of breastfed infants.It is important to notethat there area number of nitrogen containing compounds in human milk with bioactive roles important to the newborn and young infant.These epidermalgrowth factor -contributes tothe development andfunction of the intestinal mucosa -a free amino acid associated with bile acidconjugation and neurotransmissionnucleotides -metabolic andimmunefunctions -neededin the lipolysis of long-chain fatty acidsCarbohydrates -Lactose, synthesized inthe breast, isa disaccharide consisting of galactose and glucose. At concentration levels of 7.2g/dl, it is the major carbohydrate inhuman milk and is essentialas a source of glucose. Lactoseis alsothe source of galactose neededto produce galactolipids for infantbrain development.Othercarbohydrates found in human milk includemonosaccharides, oligosaccharides and glycoproteins.Oligosaccharides,oneof themajor components of humanmilk are short non-digestable sugars. Although the mechanisms by whichhuman milk oligosaccharidsare produceandexert their e believedto promote the establishment of normal intestinalgut flora by acting as a prebiotic or food for probiotic bacteria. Theyalsoplay arole inbacterial attachment tomay modulate gut immune responseandmay play a rolein the prevention of invasive enteric infecti WELLSTARTINTERNATIONALModule1-Importance Sodium (mg)15 Potassium (mg)57 Calcium (mg)35 Phosphorus (mg)15 Iron(microgram)100 Zinc (microgram)120 Theoligosaccharidesandglycoproteins, known collectively as the “bifidus factor”, are important instimulatingthe growth and colonization of t, a non-pathogenic bacteria which protects against invasive es alsoprevent the adherenmucosal intestinal mucosa.-Whilethe profile of minerals found inmammal milks is similar, theconcentrations, ratios,andbioavailability are highly speciesspecific. Ingeneral, all minerals neededfor newbort in, and well absorbed from human milk. (Table1-).Thelower quantities of minerals inhuman milk result ina substantially lower solute load to the infant’s immature renal system.TABLE1MineralsinMatureHumanMilkMineral (per deciliter)Adaptedfromtable4-19,pp127anddescriptionofzincinhumanmilk,pp130-131,LawrenceandLawrence(2011)Is theiron content ofhuman milksufficient tomeet theneeds of the growing infant? Although the quantity of iron inhuman milk is not large(100 µg/liter), studies have demonstratedthat theabsorptionfrom human milk is superiorcompared to cow milk andiron fortified formula(). Lactoferrincontributes to iron bioavailability in human milk.It is a complexproteinfound in whey where it binds iron and makes it available for digestion andabsorption by the infant. (This binding of iron also inhibits bacterialgrowth by makingthe iron unavailableto iron dependent organisms.) Normal full-term infants can be “exclusively breastfed” (no other foods or fluids) for sixmonths without becoming iron deficient. After six months, with the continuation of breastfeedingandthete iron-containing complementary foods, term infants continue to havenormaliron stores and hemoglobin. Preterm infants or term infants with perinatal blood loss may needadditional Fe while still exclusively breastfed.Zinc is another essentialmineral for humans and is importantto enzyme activity. Likeiron,it is wellabsorbed from humanmilk (Zinc deficiency, demonstrated inthe form of intractable diaper andperioral rash, is veryrare inbreastfed infants whose mothers have important to normal braindevelopment and TABLE1-4IronandZincAbsorptionIron Zinc Human milk49%41%Ironfortifiedformula4%31%Cowmilk10%28Data abstractedfromLawrence andLawrence (2011), table4-22,pp WELLSTARTINTERNATIONALModule1-Importance 1.9 15 5.9 -Human milk, particularly colostrum andearly transitional milk, is a major vitaminAvitamin E(Table1-5). As previously vitaminAis importantfor protection against infection and for earlyretinalVitamin E protectsthered cell against hemolysis. Thequantity of vitaminDin human milk, whichoccurs inboth fat-soluble and water-solubleforms,is sufficient when maternaldiet fficient maternaland infant exposure to sunlight. Maternaldeficiency duringpregnancy can result in newborns with reduced stores ofVitaminD. In recent years, cases of ricketshave beenreported inbreastfed infants with limited exposure to sunlight. Infants with darker skinpigment seem tobe at greater risk.Inorder to assure that no infants developrickets, theAmerican Academy of Pediatrics currently recommends thatallbreastfed infants shouldreceive400IU/day beginning in the first fewdays of life and gesting or exposed to sufficient VitaminD from other Vitamin K the placenta to thefetus and is alsolimited in human milk. Newborns whether breastfed or not areat riskfor hemorrhagic disease, a life threatening disease. Thus it is recommended that allnewborns receive an intramuscular injection of 0.5to 1.0 mg ofvitaminKoral form isavailablethe first dose (2.0 mg)is givenat birth and repeated at 1 to2weeks and againat 4 weeks of age.TheUnited States has no approved formoforal Table1-5SelectedVitaminsinColostromandMatureHumanMilkMicrogramsperliter MatureMilk Beta carotene112231.5Water SolubleFoodandNutritionBoardNationalResearchCouncil,NationalAcademyofSciences,RecommendedDietaryAllowances,10ed.Washington,DC1989Enzymes -Over 20 bioactiveenzymes havebeen identified inhuman milk. Some milk,some compensate for digestiveenzymes neededbutnot yetproduced inadequate quantity by the newborn,some helptransport minerals, and others areanti-infective. For example, lipase inbreast milk WELLSTARTINTERNATIONALModule1-Importance works synergistically with lingual lipase andgastric lipase to forman efficient system for complete digestion of humanmilk fat. This is particularly important during the months after birth whenpancreatic enOther Important Components -Human milk containsnumerouspeptide and non-peptide bioactive hormones: thyroxine, prolactin, erythropoetin, epidermal growth Prostaglandins,alsopresent, influencegastrointestinalmotility.Cellular Components-Humanmilk is a living tissue. It contains about 4000 cellsper cubic mm including neutrophils, macrophages, and lymphocytes. Thesecellsare most concentrated incolostrum but continueto be present intransitional andmature milk.Neutrophils helpprevent infection of the breast tissue while macrophages (2000 to 3000 per cubic mm) and lymphocytes (400per cubic mm) are actively involved inproviding immuno-protection for the newborn and young infant. Macrophagessecrete lysozyme, kill bacteria, andare activein phagocytosis.EnteromammaryPathway-Maternal lymphocytes, both T and Bcells, synthesize immunoglobulins and are thought to originatmaternalgut andbronchialsystem. The developing lymphoblasts are sensitized bythe antigenic material(bacteria, viruses) ingested by the mother and cominginto contact with the particular mucosalsurface.As the lymphoblasts mature theymigrate into the lymphatic system andare ultimately distributed throughout the body includingbreast tissue.Duringlactation thesecells and the immunoglobulins theyMaternalMaternal gutAntigensInfant gutOthermucosalMesenteric nodeBlood Thoracic ductEnteromammaryPathwayare transferred to the nursing infant. continuous passiveimmunization to protectagainst whatever organisms arepresent in theenvironment shared by the mother andinfant. While the concentration of cells andimmunoglobins isgreatest in colostrum, significant bioactive amounts arepresent throughout lactation. WELLSTARTINTERNATIONALModule1-Importance Table1-6SummaryofMajorDifferencesBetweenHumanMilkandCommercialSubstitutesMarketedforNormalTerminfantsHumanmilkSubstitutes Appropriate (species specific) quality/quantity, easier to digestquality ( not species specific) Appropriate quality/quantity of essential fatty acids, lipase presentLipase absent Adequate except for vitaminsD andK in some situations (see text)Vitaminsadded Correct amountPartly corrected Anti-infective Growth enzymes Hormones Present Absent AdaptedfromWHO/CDR/93.6.andfurthermodified,2009 WELLSTARTINTERNATIONALModule1-Importance GrowthPatternsofBreastfedInfants Obviously the bio-active factors inhuman milk not only provideessentialnutrients but help to assure the newborn’s successful transition from intra to extra-uterine life. In th. Unfortunatelythe growth charts used to evaluate infant growthall over the worldwere developedsome years ago on a samplereflected the growth parameters ofsuch infants. Whennormal breastfed infants arecharted on such charts they do not follow the formulafeeding curves butgainmore rapidly during the first 3to4 months and slow down in the latter halfof thefirst year (Figure 1.3). Breastfed infantsare healthy but become leaner. Becauseof thisnormal growth patternthey are often judged as faltering intheirgrowth and parents advisedto supplement. The pediatric growth charts Center for DiseaseControl (CDC) are an improvement but represent an average growth pattern of breast-fed and formula-fed e a picture of the growth of healthy WeightQuartilesofinfantsbreastfedatleast12Months(N=226)Figure1.3WHOWorkingGroupBecauseofthe clear biologic differences in growth patterns, theWorld Health Organization sponsored an nto develop appropriate. Theresults of this collaborationwere completed in2006 and indicate how healthybreastfed infantsshould resultingWHO and CDC growth charts (for boys) is given inAs isevident in the figure, the WHO charts (healthy breastfed infants) are quite different from theCDC charts.In the UnitedStates theCDC now recommends the use of theWHO growth grids for the first two year of life. A fullset ofthe newWHO growthstandards for boys andgirls may be obtained from the WHO web site:www.who.int/childgrowth/en . WELLSTARTINTERNATIONALModule1-Importance %daysill-diarrhea(mean)%daysill-otitis(mean)ComparisonofWHOandCDCWeightforAgeZ-scorecurvesforboysFrom: de Onis et al, jn.nutrition, 2007;137;144-148 ImportanceofBreastfeedingandtheRisksof NotBreastfeedingforInfants Supplementation or replacement of breastmilk whilesometimes medically necessary shouldnever be a casualdecision. There is strong evidencethat substitute feeding, in both industrialized and developing countries, increases the risk of anumber of illnesses among infants andyoung children such as such as diarrheaand otitis media PrevalenceofDiarrhealIllnessamongBreastfedPrevalenceofOtitisMediaamongBreastfedandFormulaFedInfants3.52.51.50.50-6m6-12m12-18m18-24minfantage(months)0-6m6-12m12-18m18-24minfantage(months)BreastfedFormulaFedBreastfedFormulaFedAdaptedfrom:Deweyetal(1995):699-700 WELLSTARTINTERNATIONALModule1-ImportanceA recent review of the relevant literature byIp et al also indicated that non-breastfed infants also havean increased risk of non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, and necrotizing enterocolitis as well as suddeninfant death syndrome (SIDS). In addition, rebreastfeeding is associated with a higher risk of dental caries and severalchronic, serious conditions including type I diabetes, obesity, Crohn’s andceliac disease, ulcerative colitis, lymphoma and leukemia.There is also a correlation between exclusive breastfeeding for 6 months and a loweredrisk of allergic disease includingatopic dermatitis, rhinitis, reactiveairwaydisease, and food allergies. This appears to be related to the sIgA, whichbinds foreign food macromolecules and prevents their absorption during the first several monthsafter delivery when the infant’s own production of IgA is not yet fully activated.Therelationship betweenbreastfeeding and psychosocial development has received a great deal of attention.Recent animal, as well as human, studies suggest the hormones of lactation, particularly oxytocin, play an importantrole inbonding between infant andmother.With every feeding, maternal oxytocinlevels rise. This not only results in the let-down of milk,satisfying the hungry infant, butalso provides the mother with pleasant, enjoyablefeelings. Thusocess is strengthened. Additionally evidence is beginningto accumulate that the risk of maternally perpetrated childabuse may be lower among breastfed infants.Studies have alsosuggested that breased with a smallbut consistent increase in I.Q. scoresand improved schoolperformance. This maybe the result of specific nutrients found only in human milk, of the closesbetween mother andinfant, of the increased opportunities for interaction between the lowered risk of a variety of illnesses which temporarily interfere with learning capacity. Itis likely that allof these are important toan infant’s cognitivedevelopment.OtherInfantRisksofUsingBreastMilkSubstitutes Besides the loss of specific benefits tfeeding andalready described, additional risks to infanthealth are associated with the use of human milk substitutes (e.g. cowmilk, goat milk, formula). These includemamixing mistakes, contamination duringpreparation and overfeeding. In addition, even though powdered formula is made from pasteurized milk, contaminationcan occur during the later stagesof manufacturing. Thus powdered formulais not actually sterile. Reports havebeen published regardingillness and deaths amongpreterm infants due to Enterobactersakazakii(Chronobacter)found to be present in the powdered formula used inneonatal intensivecare units.. Thereare alsoreports of powderedformula contamination with various strains of Salmonella. WELLSTARTINTERNATIONALModule1-ImportanceImportanceofBreastfeedingandtheRisksofNotBreastfeedingforMothers In addition to the many risks toinfant health associatedwith not being breastfed there erns for motherswho do not breastfeed.Oxytocin secreted during breastfeeding not only brings about milk let-down but also:decreases postpartumblood lossenhancesbonding, attachment and maternalparenting behaviorsreduced vulnerability to stressMothers who do not breastfeed are likely to losetheir prenatally acquired weight more slowly than mothers who do breastfeed.Recent studies suggest an increased risk ofcancers among women who have not breastfed.The explanation for theseriskrelationships is not yetclear.Breastfeeding plays a role inchildspaciovulate by 6 weeks postpartum,women who exclusively or predominantly breastfeedusually do not ovulate until at least 6 months afterdelivery. Full nursingduring the first 6 months with no signs of menstruation reduces the likelihood of pregnancyto less than2%. Exclusive breastfeeding with thoseconditions reduces the likelihood evenfurther to 0.5%.Breastfeeding has also been reported to decreasethe risk of serious postpartumdepression andmaternally caused child abuse and neglect.ImportanceofBreastfeedingandRisksofNotBreastfeedingforFamilies Theuse of breastmilk substitutes is more costly tofamiliesmothers need to eat a little more than thosewho do not nursetheirinfants, thecost of foods to provide the extra calories need not be great and is far exceeded by the savings achieved by not buying substitutes and bottles. There is no need to use costly energy sources toheat substitutes and cleancontainers. Moreimportantly, there willbe a greater expenditure inmoney and in family time formedical care for a sick child. Babieswho are exclusively breastfeedduring the first sixmonths of theirlives rarelybecome sick duringthat time.In addition the higherincidence of illness in the non-breastfed from work and lost income.ImportanceofBreastfeedingandRisksofNotBreastfeedingforCommunities Thoughmost ofthe benefits andrisksreviewed inthis module weredescribed in terms of individual infants andmothers,these issues assume community-wide importance.There is increasing evidencethat not breastfeeding increases the risk of childhood obesity, both types I andII diabetes as well as hypertensionand subsequent cardiovascular diseaseBreastfeeding reduces the waste and pollutioncreated by discarding the by-products of formula feeding, is renewable resource andanenvironmentally friendly “green” activity. WELLSTARTINTERNATIONALModule1-Importance Economically, breastfeeding canbe a majorsourceof saving community funds. In the USalone, it has been estimated that if the US breastfeeding goals for 2010 can be realized, it has been estimated that 3.6 billion dollars will besaved.child-spacing than allother familyplanning efforts combined. Becauseof thenatural infertility that accompanies optimal breastfeeding, it is uniqueamong the manyprograms undertakento decrease morbidity andmortality. It simultaneously and naturally limits population growth.CurrentRecommendationsforBreastfeedingBecauseofthe importance of human milkdevelopment of infants and their mothers and the significant risks of using a substitute for humanmilk, the World HealthOrganization (WHO),UNICEF, the United States Centers for DiseaseControl and Prevention(CDC) as well as theAmerican Academy of FamilyPractice(AAFP), American Academy of Pediatrics (AAP), The American College of Obstetrics and Gynecology (ACOG),Academy of Breastfeeding Medicine andsimilar professional organizations aroundthe worldrecommend:Infantsshouldbeexclusively*breastfedforsixmonthsandcontinuebreastfeeding,withtheintroductionofappropriatecomplementaryfoods,throughthesecondyearoflifeandbeyond**Exclusivebreastfeeding=only humanmilk . Exceptionsincludedrops or syrups of vitamins, minerals, or medicines orrehydration solution.Thedefinition allows for aninfant to bebreastfedby his or her mother or awet nurse orfedexpressed milk.**Note:norecommendationregarding the a breastfeeding is provided in this statement. It is conseptablefor mothersto breastfeedtheir children through the second year of lifeand beyond for the many logic anddevelopmental benefits.This recommendation shouldbe the goalfor all health providers who care formothers, infants andtheir families. Our professional task is to help mothers and families make an informed decision and then provide appropriate evidence-based care that will help them achieve their decision. WELLSTARTINTERNATIONALModule1-Importance TheBreastfeedingDecisionIfbreastf eeding is sogreat, w Some women do not choose to breastfeed.Very often they lack information.Itcan be an emotional decision,and only one of the many decisions a parent needs tomake. Some women may beembarrassed by the idea of breastfeeding or may lacktheconfidence that they can be “successful”. There may alsobe cultural factors that play a role. Friends and family membersmay not be supportive. In manycases, simply providing informationwill helpawoman make her decision. Other influences on the decision to breastfeedinclude;Formula Marketing –It is acommonly held belief that formulais equivalent to human milk. Formula advertising is intended to support that conclusion and convince families that bottle-feeding is normal. If mothers heard the facts abouthuman milk fromtheir health care providers they would be better prepared to makean informed decision about feeding their infants.Work andSchool–After their babies are born, many women enter or re-enterthe work force or school. Ideally, women should be able to delay returning to workor school until at least6months when they are no longer exclusivelthis is not possible, there are several strategies motherscan use tocontinue to breastfeedor providetheir milk. These strategies include:makingarrangementstotakethebabytowork/schoolandcontinuebreastfeeding,findingachild-caresettingnearworkwheretheycangoduringbreaksandcontinuebreastfeeding,arrangingpart-time,flex-timeorjobsharing,arrangeforworkathomeexpressingtheirmilkbyhandormechanicalmeansandstoringthemilkfordailyorfutureusebytheirbaby.Ideally,suchexpressionisbestbegunafteramonthpostpartumandbreastfeedingisestablished.(GuidelinesforhandexpressioncanbefoundinAnnexF)In the United States the Affordable Care Act requires some breastfeeding services to be covered by insurers under “preventive services”..Many countries have legislation requiring employers to provide time fornursing breaks and/or timeand space for milk expression. Several states in the U.S. haverecently passed similar legislation.Restriction on Activity-Mothers thesedays are involved in many activities, andin some cultures women feelbreastfeeding will “tie them down”.They fear a loss of freedom ifthey are the only ones who can feed their child. In fact,infants areveryportableand can be easily taken along on most outings. It is possibleto feed discretely with a light blanket or shawldrapy if necessary. In some countries, laws specificallyprotect theright of mothers to breastfeedin public WELLSTARTINTERNATIONALModule1-Importance Concerns,ControversiesandContraindicationsAren’t t heresome situations when a mother shouldn’t breastfeed? While there are somecontroversies surrounding breastfeeding, there are very few true contraindications.Illness and other health conditions-Thereare no nutritionalreasons to deny infants breast milk unless they havespecial health problems such asgalactosemia. Infants with other inbornerrors of metabolismlikephenylketonuria (PKU) and maple syrupurine disease,very rare metabolic conditionscan receive breastmilkwith very close monitoring.Mothers may be advised to discontinue brtemporarily, in a few circumstances:se Control and Prevention(CDC)recommends that mothers infected withnot breastfeedbecause of therisk of transmission of HIV to the infant throughhuman milkThe World Health Organization recognizes the impact that anti-retroviral medications (ARVs) have madeduring the breastfeeding period. It recommends that national authorities in eachcountry decide which infant feeding practice, (i.e.with ARV intervention) toreduce transmission or avoidance of allbreastfeeding, shouldbe promoted and supported by theirMaternaland Child Health services. Regardless,breastfeeding should be exclusive for sixmonths.Thereader is encouragedto follow the international research and watch for updated WHO information andguidelines at: www.who.int/entity/nutrition/publications/hivaids In the caseofthe mother and infant shouldbe separated only untilthe mother isconsidered noninfectious. Theinfant should be placed on preventive therapyimmediately. Theinfant can continue to receive expressed breast milk while separated. Medications used to treattuberculosis, including INH, are compatiblewith breastfeeding.Hepatitis often bringsup questions about beginning orcontinuingeptablewith allthree major types ().In thecase ofHepatitis B, the infant can begin breastfeeding before receiving HBIG andthe first doseof theHepatitis B vaccineseries which canbe given up to 7 daysafter birthpreferably within12hours.Medications-Most medications taken bybreassafe for the normal full term infant.Therisk of affecting the infant is highest duringthe first2 months of life (especially the firstmonth) and decreases markedlyafterthat time. Drugs of low molecularweight or low protein bindingmore readily pass into breast milk. This does not necessarily result inharm tothe infant but suggests careful monitoring is warranted. New medications that have not been tested for theireffects onthe infant or on the milk supply should be closely monitored or alternatives WELLSTARTINTERNATIONALModule1-Importanceshouldbe selected if possible.Sometimes one drug can be substituted for another.Drugs of abuse are contraindicated. Mothers maintained on the proper dose of methadone or a long actingopioid can usually breastfeed. Infant withdrawalsymptomsare usuallyless severe if breastfeedingis allowed. Both mother and baby shouldbemonitored closely. Most radioactive compounds used for diagnostic purposes often require a temporary cessation of breastfeeding, while thoseused for therapeutic purposes may preclude breastfeeding.Becauseoffrequentadditions to available drugs as well as changes in recommendations, readers shouldconsult the following sources regardingspecific (1)HaleT (2012)Medications and Mothers’Milk,Fifteenth Edition, Amarillo: Hale Publishing. LP.(2)LactMed, National Library of Medicine data base. A freefrequently updated internet serviceaccessed at:www.toxnet.nlm.nih.gov/cgi-bin/sis/html.gen?LACT Alcohol–Occasional andlimited use of alcohol is not a contraindication to breastfeeding.Alcohol passes quickly intodstream andintoher milk equilibrating with maternalblood level. General adviceis to avoidbreastfeedingfor atleast 2hours after oneor two alcoholiclevels to fallin both maternal plasma and milk. There is no needto expressanddiscard milk that hasaccumulated during the waiting time. Thealcohol present in the milk will have been reabsorbedinto the plasma and metabolized by the mother’s liver. Because of thedifferences in interpretation of the terms“occasional” and “limited”, amother shouldbe individually counseled regarding her alcohol intake.Caffeine –Caffeine is excreted into breast milk. The amount contained in breast milk after one cup of coffee is insignificant. However, caffeine is not wellmetabolized by the younginfant andmay accumulate ininfants ofmothers whoconsume large amounts of caffeinated beverages (such as severalcups of coffee or cola drinks daily); the use of caffeine-free beverages is suggested for thesemothers.For generalhealth reasons in both motherand baby, womenandtheirhouseholdmembersare encouraged to cut downor quit smokandlactation and to avoid exposing the baby to smoke.For thosewho cannotstop,cigarette smoking is not a contraindication to breastfeeding. Infact the benefits of human milk to a babywho lives in asmokingenvironment are important toprotect n and reactive airway disease. Women who cannotstop smokingshould be counseled tosmoke only afternursing (but notaroundthe baby) to providetheleast amount of nicotineto thebaby viathe milk. Some doctors recommendchanging clothes before breastfeeding. Maternal smokingdiminishes the milk supply, and the growth of their infants shouldbe carefully monitored because the rate of growth can be decreased. Infantexposure to cigarette smoke has also been reported to be related to Sudden Infant Death Syndrome (SIDS).BodyImage -There may be other concerns, such lose elasticity as a result of pregnancy and years passing, irrespectiveof whethera WELLSTARTINTERNATIONALModule1-Importance woman breastfeeds. Concerns about body image shouldbe identified.Fitness–There are usually no contraindications to exercise inmoderation during lactation.Breastfeeding prior toexercise and wearinga supportivebra is recommended.There have been reportsthat increased lactic acid inthe milk forabout 30 –90 minutes following strenuous exercise has led to a temporary rejection of the milkby some babies. This has been attributed toa change in the tasteof the milk.If itoccurs, mothers could postponefeeding or offer previously expressed milk.Diet-Some women feel that inorder to breastfeed they must eat a “perfect” diet.Breastfeeding motherslikeeveryone else need to eat anutritious diet and consumeenoughadditional calories (approximately 300 to 500calothe size and activity levelof themother) to provide energy and make milk. Itis also ontinued during lactation. There are nolists of foods toavoid.Poor maternalnutrition is not a contraindication to Mothers makenourishing milk for their infants from all kinds of food.There are no foods that mustbeavoided, unless mother or babydevelops an allergic reaction.Breastfeeding mothershave an increased thirst that usually maintains an adequate fluidintake; no data support the assumption that increasing fluid intake will increase milk volume.Mothers donot need todrink milk to makemilk; thirst can be satisfied from a variety of nourishing beverages, including water.Calcium is available not only in milk and milk products but inmanyother foodssuch as broccoli, spinach, kale, bok choy, andcollard, mustard and turnipgreen, almonds, andcanned fish.ReturningtoVeronicaatherfirstprenatalvisit…Yourecallsheleftblankthequestionabouthowsheplanstofeedherbaby.Thisisyourchance. Areyouconvincedabouttheimportanceofbreastfeedingasaprimaryhealthcarestrategy? Foreachofustherearedifferentfeaturesofhumanmilkandbreastfeedingthatcaptureourinterest.Whatarethethreemostimportantthingsyou wouldlikeVeronicatoknowaboutbreastfeeding? 2. 3. WELLSTARTINTERNATIONALModule1-Importance ct that breast milk and formulaare not the same, that breastfeeding provides many benefits to both motherand baby, and that there are very few contraindicationsYou may have mentioned detailswithin each of these categories.How would you provide a mother with breastfeeding information? address any misconceptions. Studies have shown it is not the length of the“lecture” on breastfeeding, but thenumber of times the topic is introduced andthe support for breastfeeding. Since prenatalcare usually spans several months, there are many opportunities to discussthe topic. Concerns can be elicited andindividualsuggestions made to help the mother adapt the informationto her ownneeds. It is also importantto consider if andwhat cultural influences are likely to affect her decision and to engage the father of the babyor another significant family member or support person inthe counseling sessions.PrenatalCounselingQuestionsTheanswers tothe following questHaveyou thought about howyouwill feed your baby?What haveyou heard Open-ended questions provide the opportunity tocontinue the discussion. If the patient has previousHowlongdidyou breastfeeda previouschild?Whydidyou stop at that time?Didyou have anyproblems?Oftenmothers stoppedbreastfeeding earlier than theyplanned becauseof a problem or perceived problem. This wouldbe a good time to reassure the mother thatthere is a lot of newinformation, and help isavailable to prevent theproblem or solveit if it recurs.What is your breastfeeding plan for this child?Do you plan to return towork/school?Many mothers wouldlike to knowthe currentrecommendations for the duration of breastfeeding so they can think about howto fitit intotheir lives. Ifmotherswillbe returning to work or school they can be advisedin generalterms thatit is possibleto continue breastfeeding and thatmore detailed information will be available whenthey are ready toconsider it. Many countries (and states in the WELLSTARTINTERNATIONALModule1-Importance US) nowhave maternity protection laws that providetime for milk expression at work. The localsituation should be investigated.Are your family(your mother, the baby’s father andthe father’smother) andfriends supportive of breastfeeding?Wereyou breastfed?Was the baby’s father breastfed?It is helpful for themother to identifysupportive people in her family. Grandmothers who breastfed may be a good source of support. Peopleclose to the mother who are not supportive couldbe invited to learn more about the advantages breastfeeding confers on both mother andbaby. It isalsoimportant to exploreany cultural andreligious attitudes thatmay influence a mother’s decision about how she plans to feed her baby.Mother’shistory:Haveyou hadprevious breast surgery?Haveyou hadprevious breast problems?Are you taking regularmedications?Mothers may be concernedthere is something wrong with their breasts thatwillt. If the mother hashad problems with her breasts,she may need some help with breastfeeding. Alerting mothers toask for assistanceas soon as possible postpartum willbe helpful. Mostmedications arecompatiblewith breastfeeding and the mother can be reassured; thefew medications that arenot compatible could be reviewedandan alternative rgery are notalways revealed in prenatal history. tfeeding. Implants are rarelya problem. Reduction surgery may result inincreasing the risk of low milk production. In both ss and indicators of adequate milk intake need close Do you have a familyhistoryof allergies,breast cancer or diabetes?Breastfeeding seems toprovide protection from allof these conditions. A mother with a family history of such conditions may bemotivated to breastfeedin order to lower the risks forherself and her children.Wouldyou likeinformation about a breastfeedingclass?It is veryhelpful to give the patient either a brochure with informationabout available classes (date, time,location) or towrite out this information for sharingwith the father of the baby or other family members. WELLSTARTINTERNATIONALModule1-Importance Whatresourcesforbreastfeedinginformationareusuallyavailableincommunities? CommunityResourcesMany hospitals provide childbirth educationclasses and printed informationas part of their maternity services; often breastfeeding is discussed as part ofthe childbirth preparation class or there may bea separate breastfeeding class availaorganizations with local offices, such as Red Cross, YWCAand local NGOs offer classes. Inthe United States many communiBreastfeedingCoalitionwhichgives classes and other support services.It is important forhealth careproviders literature offered by the hospital and other organizations in order to ensure that consistent, up-to-date information is being offered to families.Note:Althougheducational resources offered byformula companies on the topic of breastfeeding do notalways includeclear advertisements forthe company, it is important to remember thata formula company’s goal istosell formula.They are skilledat implying that substitutes are as good as breastmilk.It isbest to seek other materialsthat do not havethisconflict ofinterest.In the United States the Special Supplementfor Women, Infants andChildren (WIC) forlower income families encourages breastfeeding by counseling ation managementadvice to WIC clients. Breastfeeding clients alsoreceive La LecheLeague Internationalhas longbeen a source of information and support for breastfeeding mothers.Theirmother-to-mother approach provides individual problem solving, classes, written information, videotapes, and equipment.Several international professional organizations with a specialized interest in lactation andbreastfeeding promotion can alsobe helpful such as the Academy of BreastfeedingMedicine (ABM) and theInternational Lactation Consultant Association (ILCA). These organizations can be contacted for informationfor localspecialists and consultants. (see Annex G for website contact information.)There are numerous web sites that address thetopicof breastfeeding available to families on-line.Prior torecommending one, be sure to review it for accuracy. Not everything on the Internet is up-to-date and accurate.Bookstores may carry a selection of breastfeeding books in their Parenting Section. You may wishto reviewthe choices and have oneor two recommendations in mind for WELLSTARTINTERNATIONALModule1-Importance Whatresourcesforbreastfeedinginformationandsupportareavailableinyourcommunity? 2. 3. eeding education opportunities withinyour hospital, used the Yellow Pages to find or inquiredabout classes offered by community organizations.Each woman brings her own frame of reference to the pregnancy and motherhood experience.Asking, “Have you thought about breastfeeding?” during the prenatal phase of care provides the opportunity to present information, elicit concerns, solve potentialproblems and refer themother toresources in the community. Askingabout breastfeeding duringprenatal visits provides the opportunity to giveanticipatory guidance, recognize problems early and assist themother to initiate and continue breastfeeding for as long as she wishes. If she indicates that she is not interested, it may be best topostpone this discussion and bring it up againat a later visit.Getting mother andnewborn off toa good start inthe postpartum periodis covered in Module Two: Basics of Breastfeeding.References1.American Academy of Pediatrics (2008) Prevention of Rickets and vitamin D Deficiency in Infants, Children and Adolescents. Pediatrics 122(5) 1142-2.American Academy of Pediatrics (human milk. Pediatrics. Vol129: e827-e841.3.AmericanAcademy of Pediatrics (2009) Red Book: TheReport of the Committee onInfectious Diseases, 284.Anderson, P (1998) Drugs inPregnancy and Lactation, Fifth Edition,Baltimore, MD: Williams & Wilkins.5.Bachrach, V, Schwartz, E, Backrach, L (2003) Breastfeeding and the risk of hospitalization for respiratory disease ininfancy,Arch Pediatr Adolesc WELLSTARTINTERNATIONALModule1-Importance 6.Black, RE, Morris, SS,Bryce, J.(2003). Where and why are 10 million children dying every year? The Lancet; 316; 2226-2234.7.Briggs, GG, Freeman, RK, Yafee SJ (2005). Drugs inPregnancy and Lactation Edition . Baltimore Lippincott Williams andWilkins.8.Chen, A and Rogan, W.J.(2004) Breastfeeding and the risks of postneonatal death inthe United States. Pediatrics, 113:e435-e439.9.CDC (2000) CDC Growth Charts:United States, AdvanceData #314, May 30http://www.hhs.gov/news/pr10.de Onis,M, Garza,C, Onyango,AW, Martorell, R. (2006) WHOChild Growth Standards. Acta PaediatricaSupplement 450, April 2006, 95:7-101.11.de Onis, M, Garza,C,Onyango, AW, Borghi (2007) Comparison of theWHO childgrowth standards and the CDC 2000 growth charts. J.Nutr. 137:144-148.12.deOnis, M et al . Comparisonof theWHO child growthstandards and the National Center forHealth Statistics/WHO international growth reference: Implications for childhealth programs. Public Health Nutrition: 9(7), 942-947.13.Dewey K, Heinig J, Nommsen-Rivers L (1995) Differences inmorbidity between breast-fedandformula-fed infants,J Pediatr 126(5), Part 1: 696-702.14.Food and Nutrition Board, National Research CounciSciences: RecommendedDietaryAllowances, 10ed.Washington, DC,U.S. Government Printing Office,1989.15.Hale, TW. Hartman, PE. (2007) Textbook of Human Lactation, FirstEditionAmarillo, TX. Hale Publishing, L.P.16.HaleT(2012)Medications andMothers’MilkPublishing. LP.17.Hamosh M (2001) BioactiveFactors in Human Milk,America 48(1): 69-86.18.Himelright, I etal (2002)infections associated with the use of powdered infant formula ---Tennessee, 2001. CDC MMWR Weekly April19.Horta, BL.Bahl, R, Martines, J, Victora, CG. Evidence on the long-term effects of 20.Ip. S,Chung, M, etal. (2007) Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.EvidenceReport/Technology Assessment No153. AHRQ PublicationNo 07-E007. Agency for Healthcare Research and Quality.21.Kramer, MS et al Breastfeeding and child cognitive development: newevidence from alarge randomizedtrial (2008) Arch Gen Psychiatry 65(5):578-584.22.LawrenceRAand LawrenceRM (2011)Breastfeeding, a guide for the medical profession, Seventh Edition, St. Louis, MO:Mosby, Inc.23.Perez, A, etal.(1992) Clinical study of the lactationalamenoarrheamethod forfamily planning.Lancet 1992; 339: 968-970. WELLSTARTINTERNATIONALModule1-Importance24.Remington JS andKlein JO (2001)Infectious Diseasesof the Fetus and Philadelphia: WB Saunders Co.25.Riordan J and Wambach K (2010)Breastfeeding and human lactation,Fourth rtlett Publishers, Inc.26.Strathearn,L, Mamun,AA, Najman, MJ, O’Callaghan (2009) Doprotect against childabuseand neglect? A 15-Year cohort study.Pediatrics (2), 27.World Cancer Research Fund/American Food, Nutrition, Physical Activity, andthe Prevention of Cancer: AGlobalPerspective. Washington, DC: AICR, 200728.WHO (2009) Infantand Young Child Feeding: ModelChapter for Textbooks for MedicalStudents and Allied Health Professionals. WHO Geneva. www.who.int/nutrition/publications/i1597494/en/index.html 29.WHO Working Group on Infant Growth (1994)AnEvaluation of Infant GrowthGeneva: World Health Organization. WHO/NUT/94.8.Guidelines on HIV and infant feeding 2010:Principles and recommendations for infant feeding inthe context of HIV and a summary of evidence.Banta-Wright SA, Shelton,KCet al.(2012). Breastfeeding successamong infants with phenylketonuria. J Pediatr Nurs, 2012 (4): 319-327.Huner,G,Baykal,T, et al (2005).JInherit Metab Dis 28(4):457-465. WELLSTARTINTERNATIONALModule2-Basics ModuleTwoBasicsofBreastfeeding:GettingStartedAftercompletingthis module,youwill be ableto:1.Describethe processofmilkproduction and removal.2.Recognizecorrectattachmentand effectivesucklingatthe breast.3.Identifycomponentsofanticipatoryguidance forall women.4.Recognizethe impactofperinatalhospital practiceson breastfeeding.IntroductionAlthoughthe mother’sbodyproducesmilkasa normalpartof thereproductivecycle, the technique ofbreastfeeding isalearnedskill enhanced by practiceandsupport.While parentsneed helpfulinformation prenatally toknowwhat to expect, the opportunitypostpartum to practiceattaching thebabyto the breastand assessing thebaby’sbreastfeedingeffectivenesscan provide thefamily with confidence as they embarkonthisparticularexperience ofparenthood.Thekeyto helping newbreastfeedingfamilies is an understanding ofthe basic anatomyofthe breastandphysiologyofthe milkproductionandremovalprocess.Thismodule will focuson thescience oflactationandpractical clinical skillstohelp mothersget started.The moduleisapplicable to both theobstetricandpediatricsidesofthe equation,asthe managementof the peripartum courseandnewborn care can profoundly affectthe earlybreastfeedingexperienceand laterinfantfeedingoutcomes. Asfarasbreastfeeding isconcerned,the motherandbabyare a biologicunit; whatever influencesoneaffectsthe other.CaseExerciseAsaresultofthe prenatal discussionsofthebenefitsofbreastfeeding, Veronica,our26year-old first-timemother,haschosento breastfeed her baby.Sheexperienced a normal spontaneousvaginal delivery(NSVD) about24hoursago,producing ahealthy terminfantmale weighing 3.5kg. She will begoinghomewithin thenext24 hours.You encounterherin thepostpartumunitonyourregularmorningrounds.She hasattemptedtobreastfeed three times.Herbabyfell asleep eachtimeshetried tonurse.She saysshe doesn’thaveanymilkand she is afraid herbabyisn’tgetting enoughto eat.She isaskingforformulatogiveherbaby. WELLSTARTINTERNATIONALModule2-Basics Basic knowledgeneeded to advise thismother Majorstructures ofthe breastincludethenipple and areola,subcutaneous tissue, alveoli(dividedinto lobules),ducts, myoepithelial cells,bloodand lymphaticvessels, Cooper’sligamentsandfat.Fat givesthebreastsize andshapeas well as supplyingthe metabolicfuel formilkfatproduction.Recentstudies indicate thatinfantsof mothers withsmallerbreaststendto feed more oftenthanthosewithmotherswho have largerbreasts.Thesensoryinnervation originatingprimarilyfrom the3intercostal nervesisalso essential tothe milkproducing function ofthe breast.Earlyin pregnancy,the mothernotes changes inherbreasts,includingfullness, tenderness,and a more prominentvenous pattern.As the pregnancyprogresses,shesees the areola enlargeanddarken in color.Montgomery’stubercles,small noduleswithin theareola,become more prominentand prepare tosecretealubricating substance thatprotectsandconditionsthe nipple and areola (Figure 2.1).The nipple is locatedinthecenterof the areola and contains about5-9 milkductopenings.Figure2.1Montgomery’s Eachductextendsbeneaththeareolaandinto a mammarylobule where milk is produced inthealveoli.Thenipplecontainssmooth musclefiberand sensorynerve endings.The sizeandshape ofnipplesvaryfrom womantowoman.Theareola alsovaries insize from woman towoman. WELLSTARTINTERNATIONALModule2-Basics Figure2.2Adapted fromUNICEF/WHO:Promotion andSupportin a Baby-Friendly Hospital,20 hour Course 2006Themammarylobulesare composed ofalveoli,the grape-likeclusters where milk is produced inresponse to prolactin.Thealveoli are surrounded bymyoepithelial cells, string-likestructures thatrespond to oxytocin by contracting andsqueezing themilkout ofthe alveoli into theductstowardthenipple (Figure 2.2).ThePhysiologyofMilkSecretion How does it work? While manyhormonesare involved inpregnancy,estrogen,progesterone and prolactin are thethree majorhormonesofthisreproductive phase.Theelevatedlevels of estrogen and progesteroneduring pregnancypreventprolactinfrom stimulating milk secretion.With theremovalofthe placenta,estrogenand progesteronelevelsfall dramatically, while theprolactin level remainselevated.Thisisthesignal tothe breast to begin milkproduction.Prolactin receptorsin the breasthave anincreasedaffinityfor prolactin immediatelyafter birth.Immediatelypostpartum,colostrum,which hasbeenpresentin the breastsinceabout the twentieth weekofpregnancy,()isavailabletothenewborn for the firstfewdaysoflifeuntilthe milk“comesin”in greaterquantity.Normal term infants are born with a numberof reflexesandbehaviorsto help assure thatthe newborn survivesthe transitionfrom intrato extra uterine life.Thesereflexesenable himto begin feeding immediatelyafter birth. WELLSTARTINTERNATIONALModule2-Basics Thetotalamountofcolostrum available thefirstdayissmall (40-50 ml).Itis well matchedtothe newborn’ssmall stomachcapacityofabout20 ml (about4teaspoons) or5 ml/kg (Figure 2.3)Figure2.3FulltermNewborn Stomachabout4TeaspoonsMilk will begin toappearafewdays postpartum (lactogenesis stageII)whetherthe womanbreastfeedsornot,butthe stimulus ofthe infantsucklingatthe breastbuilds and maintainsmilkproduction.Breastmilkproduction is“babydriven”,thatis,the normal fullterm babyindicates whenhe ishungryandwhen hehashad enough.Breast milkiseasilydigested,so theinfantsignalshis need toeatabouteverytwo to three hours(sometimesmore often),or atleasteighttimesevery24hours,in theearly weeks.Some normalbabies cluster theirfeedingsinto one particularpartofthe24 hoursandfeedlessfrequentlyduringtheremaining24.Breastfeeding involvesa setof reflexesand hormonesthatalso drive themilksupply. Milkproduction is influenced positively byearlyfrequentandeffective milkremoval andnegativelybylate infrequentfeedsorbythe feeding thebabyotherliquidsorfoodsbefore sixmonths ofage.Asillustrated inFigure 2.4 eachtimethebabysucklesatthe breasthestimulatesthe release ofprolactin (milkproduction hormone)from theanteriorpituitaryandoxytocin (milkejectionhormone)from theposteriorpituitary.It is the oxytocin thatstimulates themyoepithelial cells tocontractaround thealveoli, makingthemilkflow,sendingthemilk downthrough theducts.Themilkejectionreflex,or let-downreflex, maybenoticeable to the motherasaphysical sensation suchas“pinsandneedles”ora flush ofheat. Somewomen donotdescribefeeling anything,buttheymaysee the milkdripping from the nipples.Whenmilkstarts to flowthe babychangesthewayhe moveshis mouth, WELLSTARTINTERNATIONALModule2-Basics going into a pattern of wide excursionsofhisjawanddownward motion ofthe posterior tongueresultingin a lowering ofpressure inthe infant’soral cavityandincrease in milk flow. The flowof milkcausesthebabyto swallowin a slower rhythmic,audible manner thatsoundslikeaquiet“cuh”.Swallowing isa good indicationthemilkisbeingeffectively removedbythe baby.Thebabymaystimulate severalejectionreflexesduring thefeeding.Each timethe milk isejected itcontains a little more fat.Asnoted in module 1,the milkthatispresentin the breastatthe beginning ofthe feed(“foremilk”)contains about1.5 to 2% fat while the milkpresentat the endofthe feedcontains about5-6% fat.Allowing thebabyto feedwithouttimelimitsenableshim togetmore ofthe higher fat “hindmilk”, providing fat-solublevitamins,caloriesto gain weight,andthe abilityto wait2-3 hoursfrom thestart ofonefeeding tothestartofthe next.AnteriorPituitaryProlactin PosteriorPituitaryOxytocinFigure2.4SucklingHormoneReflexArcHypothalamicsupraoptic(SON)andparaventricular(PVN)nucleiwhereoxytocinisformedandthentransportedtoandstoredintheposteriorpituitaryuntilreleasedduringsucklingMilk ProductionAlveoliMyoepithelialCellOxytocin Milk EjectionSuckling(Contractions)Efferent ArcAdaptedfromdiagramcreatedbyHelenMoose WELLSTARTINTERNATIONALModule2-Basics Thefrequency offeedingregulatesmilksupply. The more often a babyremovesthe milkthe greaterthe milksupply.Conversely,a baby whosleepsmanyhoursatatime in theearlyweeksor feedsless thananaverage ofeighttimesin 24 hoursdoes not have theopportunitytostimulate the breast, causingthemilksupply to drop.Thisis referredto as the“lawofdemand andsupply”.Because each breastrespondsto theamountof milk demandedbythe infant,itis possible to exclusively breastfeed more than onebabyatatimeorto useonlyonebreast.Initially,ifthe milkisnotremoved thebreastbecomesfull andeventuallyengorged.Atthatpoint,a localfactorknown as the feedbackinhibitoroflactation (FIL)begins todecreasemilksecretion.The exact mechanismofFIL is still understudy.TheresomeevidencethatFILS isSerotonin.TheImportance of Skin to SkinContact Evidence hasbeenaccumulating indicatingthatmother-babypairswho havean opportunityfor the unclothednewborn infantto beplaced ontheskin ofthe mother beginning immediatelyafterbirth, skintoskin(“),experiencefewer breastfeeding problems(Figure 2.5).Milkproductionisenhancedand infantsare morecontented. Unmedicatednewborns exhibitcrawlingbehaviorthathelps them reach theirmother’s breastandsome,though notall willfeedwithin thefirst hour.Studies also suggestthat extending S2S beyond theimmediatenewborn periodcontinuesto supportsuccessful breastfeeding.Even babies born bycesarean sectioncanbe allowed S2S experience onthe chestareaas soonasthe motherisalert.Babies who areplacedS2S after deliveryalso havelessdifficulty with subsequentattachment.PhotofromUNICEFChileSkin toskin immediatelyafter birthContinuing S2S contactin hospitaland afterdischarge improves milkoutput.Hospitals can help encourage S2Sbysupporting continuousrooming-in.Prenatal and discharge WELLSTARTINTERNATIONALModule2-Basics counseling should includethis topic.Fathersand otheradultfamilymemberscan alsoparticipate inholding the infantS2S,allowing themothertimetosleep,batheor take care ofotherneeds.GettingTogether:PositionandAttachment Overthe pastfewyearsa numberof reports haveappearedinthe breastfeedingliterature describingnewapproaches to help a mother-infantdyadachievecomfortable andeffective breastfeeding.Thesehavebeen called “babyled”breastfeedingandbiological positioning.Thewaya motherholds herbabyto breastfeedmayalso be influencedbycultural orfamilytraditions.Whateverposition the motherandherbaby chooseshould becomfortable for themother andsafe for theinfant as well as effective forboth.The following guidelinesdescribe several approachesto helping the dyadbecomecomfortableand effective.Infantshouldbe inlightsleep orin a quietalertstate butnotcrying.Acryingbaby will need calmedbefore encouragingthebabyto beginbreastfeeding.Asleepy babymaynotrespond with a rootingreflexand maynottake the breast.Unwrappingandundressing ababymay help awaken a sleepy baby.Agentle massage oftheinfant’sbackor thesoles ofthe feetmayalso help.Mothershould sitorliedown comfortably, withherbackwell supported,and bringbabyin close to her.She offersherbreastto thebabyinaway thatpromotesgoodattachmentofthe baby’smouth tothe breast.She maysupportherbreastwithallfourfingersbelowandthumbresting lightlyatopthe breast.Thisisoften called a“C hold”.Thebabyshouldapproachthe breastwith his/hernosetowards the nipple,so thathehastotip hisheadbackand reachuptothenipple with hischin going closeintothe breastandwell underthe areola.Herthumbandfingersshould beawayfrom the areolaso thatbabycan graspthenippleand areolaareawithout interference.Oftenwesee mothersofferingthe breasttothe babyusing a “scissors”hold,with the nipple between the forefingerand middle finger.If herfingersblock theareola,the babycannotattach properly.(Figure 2.6)With themotherseatedinthisposition,the infantshouldbeheld on thesamelevelas mother'sbreast,turned sothebaby’sabdomenfacesthe mother’sabdomen(“tummytotummy”),held closeandwell supportedwith pillows.WELLSTARTINTERNATIONAFor“babyled”orbiological positioningmothersare encouragedtolie back rather be ina moresitting position.Thebabyisplaced on the mother’schestandallowedto useinfantreflexesandnaturalbehaviorsto find eitherbreastandself-attach. WELLSTARTINTERNATIONALModule2-Basics CommonPositionsforBreastfeedingMother-InfantDyads Figure 2.7Cradle(cross-chest):Thebabyliesacrossmother’slap; baby’shead lies on herforearmor inherhandonthesidefrom which she is feeding.Hishead should not be in thecrookofherarmbecause thattakeshimtoo farouttothe side andhehasto bend hisheadforward andcannotgethischinandtongueunderneaththe nipple.E.HelsingModifiedcradle:Thebabyliesacrossthemother’slap;mother’sopposite armandneck.Thisposition isveryusefulfornewborns andvery smallbabies,givingthe mother bettercontrolofthe baby’sheadandneckthanthecradle hold.©WellstartInternational WELLSTARTINTERNATIONALModule2-Basics Side-sitting(“football”):In the Side-sitting position:babyand mothersitting up;babysitsfacing mother withhislegsundermother’sarm; mother’shandsupportsbaby’sbackand neck. Thisposition iscomfortableafter a cesarean deliverybecause thebaby’s weightisawayfrom the incision.Sleepy babies maystayawakeandfeed better inthis moreuprightposition.WELLSTARTINTERNATIONAL©WellstartInternationalSide-LyingThemotherandbabylie sideby sidewithmother’slowerarm extended as showninthepicture.v.valdesAttachment Thewaythe babygraspsthe nipple/areola area andpulls itintohis mouth forfeeding is referredto as "attachment”or “latch”. Attachment is consider to be the MOSTimportant factor forpreventing earlyproblems thatlead to prematureweaning.Asnotedearlier,normal terminfantsare born with a numberofreflexesandbehaviors. Thesereflexesincludea “rooting reflex”that promptshimto open hismouthandturn toward the breastwhen hungry.A lighttouchtothe middle ofthe infant’supperlipwill help elicitthisreflex.Themothershould aimthe nippletowards theroofofthe baby’s mouth.The infantopens his mouth wide and bringshistongue downandforward over the lowergum topull the nipple into hismouth.Acryingbaby will needtobecalmed, sincethetongue isusually elevated duringcrying andthe baby’stongueneedsto be down in orderto breastfeed.When properlyattached thebaby’slipsare flanged WELLSTARTINTERNATIONALModule2-Basics outward over the areola as illustrated in Figure 2.11 below.UNICEFChileWith effectivepositioning,the infant’stonguepressesthenipple/areola againstthehard palate and thenlowers the posteriorareaofthe tongueandsoftpalate,creating a vacuum.Thislower intra oral pressure resultsin milkflowing into thebaby’smouth from the areolastimulatingswallowing andfurthersucklingactions ina rhythmicalpattern.Assisting a motherto learn howto help herbabyattach orlatch-on effectivelyisvery importanttopreventing problemsand achieving breastfeeding success.(Note:Always observebreastfeedingbefore intervening.Mothersand babies maybedoingfine andneedonly encouragement.)Step 1:Elicitthe rootingreflexby touchingthe baby’supperlip with mother’snipple.©WellstartInternational Step 2:Bringbabyintothebreastso thatbaby getsa large mouthfulofnippleandareola.©WellstartInternationalOnce thebaby is attachedcorrectly,the infant'slips are flangedout,the mouth is wide open,isagainstthe breast.Ifthe motherhasalarge areola,moreoftheareola isvisible abovethe upperlipthan belowthe lowerlip.Thisisknown asan“asymmetrical latch”. WellstartInternationalGood Attachment(Lipswidelyflangedout, Poor Attachment(Lowerlipcurled in, nose WELLSTARTINTERNATIONALModule2-Basics SummaryofPoorAttachmentandIneffectiveSucklingAdaptedfromWHO/UNICEF20hourBFHICoursePoorattachmentreflected by:tightpursed lipsspacebetweenchin and breastspacebetweenbreastandnoseinfant'slowerlip pulled inmothermay feel painnipple maybeflattenedafterafeedingnipple abrasionsand/orcrackingIneffectivesuckling technique reflectedby:no soundsofswallowingshort, quick(flutter)sucking movementsonlymothermay feel painIfsomeoneisassistingthemother with getting thebabyattached,the helper’shandshould supportthe headneckand shouldersbelowthe infant’socciput.Forward pressure tothe backoftheheadcausesthebabyto arch making itdifficultfor the baby to attach effectively. WELLSTARTINTERNATIONALModule2-Basics What’s thedifference betweenbreastf eeding and bottle-feeding? There are significantdifferencesbetweenwhatisnecessaryfora babyto removemilk from a bottle with anartificialnippleincontrastto effectivelybreastfeed (Figure2.8). Breastfeedingrequiresthecoordination ofsuckle,swallow, breatheandtongue action. Theartificialnipple feelsandfunctionsdifferentlyandmilkflows from a bottle by simple suction,compressionandgravity.Until thebabyisan effective breastfeederandmother’smilksupplyisestablished itisbetterto avoidartificialnipples,includingpacifiers,sothe oralstimulus is consistent.Once a newborn hasmasteredbreastfeeding(usually by three tofour weeks ofage)manybabieswillverylikelybeable totransition betweenboth methods withoutdifficulty.Ifbreastfeeding istemporarilynotpossible,or there is an acceptable medical reason tosupplement, a babycan be fed bycup ifnecessary.This helpsto avoid theproblem of becoming adaptedtobottle feedingtechnique andrefusing toreturn to breastfeeding.WELLSTARTINTERNATIONALBreastfeedingWELLSTARTINTERNATIONALBottle FeedingEvaluationofaBreastfeed…Howdo we know ifthe baby issuckling effectively…? Mothersbreastfeed successfullywithoutknowingall ofthe followingdetails,butthese details maybehelpful ifthe motherisexperiencing problemsorifthe babyisnot WELLSTARTINTERNATIONALModule2-Basics gaining orfeedingveryfrequently.A common explanation isineffective sucklingwhich can oftenbeeasily modified.Thefollowing are signsofsucklingeffectiveness.Signsofeffective suckling include:afewrapidsucksatthe beginning ofafeedwith noactive swallowsofmilk stimulatingthe oxytocin reflexand milkflow(“call-up”suckling),nutritive suckling:deeper,slower sucks(1:1 suckperswallow)witha briefpausewhenthemilkstarts flowingaudible swallowing (aquiet“cuh”sound)shows thatmilkisbeing transferred3 or4 good sizedbowel movements/24 hours.25–30 grams weightgain perdayafter the milk“comesin”.Be sure toobservebreastfeedingbefore suggestinginterventions.Interventionsshould besuggestedonlyifa problemexists.Length(Duration)andFrequencyofFeeding… Howlong should a breastfeed last? … Breastfeeding is“babyled”.Thebabyasksto feedwhenhungryandstops when itis satisfied.Feeding “ondemand”allowsthe infantto indicatewhenhe orshe is hungry.Crying isalatesignofhunger.Breastfeedingshould beinitiated inresponse toearly hungercuesratherthan waitinguntil thebabyiscrying.Early cues include:wakingupbringinghands to hisorhermouthrootingmouthingmovementsBreastfeedingshould alsoreflectthe needs ofthe motherandshe may try togetthe babyto feed ifherbreastsare becominguncomfortablyfull.Feeding patterns varygreatlyamongbabies;somefeedquickly,othersslowly.The importantthing isto feed long enoughtoobtain the hindmilk.Milkhasslightlymore fat with each let-downejection.Infantsusually “signal”byspontaneouslyreleasing thebreast,falling asleep with the nipple in itsmouth,or discontinuingsuck/swallowpatternswhentheyare either finished orreadyto changesides.If necessaryburp babyto seeifdisplacingairmakesbabyinterested in takingmore,then offerthe secondside.Sometimesonebreastissufficient.Switch startingsidesateach feeding.Mothershavevariable amountsofmilkfatandtotal milkvolumethroughoutthe day, WELLSTARTINTERNATIONALModule2-Basicsso thebabymay feedfor differentlengths oftimefrom onefeeding tothenext.Everymother/infantpairisdifferent.Thebaby’s style offeedingandtheflowof themother’smilkvaryfrom pairto pair.Verylong orveryshortfeedsmay indicate a problemand should be evaluated.Thebestway to evaluate thebaby’seffectivenessisto observe a feeding.Lookathowthebabyisattached,listenfor swallows,and assesswhetherthe motheriscomfortable throughoutandbabyis contentafterthe feed.Ifa motherneedsto releaseherbabyfrom the breastduring a feeding,she canbreakthe suctioncreated by feeding usingafingerto pressonherbreastatthejunction ofthe baby’slips orbyputting a clean fingerinto thecornerof the baby’sThisgentle mannerofhelping thebabyoffthebreastcanhelp preventsore nipples.The nipplesshould appearastheydid before thefeeding;i.e., round,not reshaped orflattened.What is atypical breastfeeding pattern for a newborn? Thehealthynewborn should be given theopportunityto breastfeed immediately afterbirth–atimewhennormal non-medicatedtermbabies are mostalert.Skin-to skinhasbeen shown toveryimportantto breastfeedingsuccess.Theinitial alertperiod is usually followed by a period ofsleep.Though many newbornsinitiatebreastfeedingwithin the first60minutesofbirth, noteverynormal babydoesthis. Somesimply nuzzle anddonotattach until abitlater.Asnotedearlier,studies suggestthatthe opportunityforS2S contactisimportantto breastfeeding success.Anewborn usuallysignalstheneedtofeedevery1-3hours(timedfrom the startof onefeeding tothestartof thenext).Newborns oftenfeed mostfrequentlyduring first 2-7days,when theonsetofa more abundantmilksupply(lactogenesisII) begins.Adaily frequency of8 to 12feedsisideal,especiallyin theearly weeksoflifenormal babiesseem to breastfeedmore atnightespeciallyduringthefirst weekor Duringthefirst 2-7 days,manyhealth care providersbelieve thatintervals ofgreater than 3 hoursare notappropriate.The mothershould gentlyawaken theinfantandofferthe breastifhesleepslongerthan 3 hours,orif motherfeelstoo full.If the babydoesnot wantto feed,heshouldnotbeforced orgiven a supplement.Once lactation isestablished,apattern ofatleast8feedings/24 hours(dayandnight)iscommon.Sleeping longerstretchesatnightmaybe apattern seenafter aboutsixweeksofage.Ababywhosleepsallnightin thebeginning isprobablynotgetting enoughcalories.Since prolactinlevels are highestatnight,nightfeedsare importanttoensure adequate stimulation formilkproductionandforsuppression of WELLSTARTINTERNATIONALModule2-Basics ovulation.Somebabies will “cluster feed”thatisfeedveryfrequentlyattimesandextendthe timebetween otherfeedings.If the babyisgaining well thisisanormalvariation.… Howdo we knowif the babyis gettingenough? … Atrained observer(healthcare provider/lactation specialistorconsultant)should watchafeeding toevaluate the baby’sposition and attachmentandthenewborn’s effectiveness ofsuckling.Themain concern ofmostparentsis whetherthe babyis getting enoughmilk.If the motheristaughttowatchfor signsofadequate intake,she can feel more relaxed whenthebabyshowsthe followingsigns;conversely,iftheinfantdoesnotshowthesesigns,he mayneedanevaluation:Frequent,softbowel movements(3-4 ormore/24hours by daythree,yellow stools bydayfour)during theearly weeks.After 5 or6weekssomenormal breastfed babies do notstool forseveraldays.Wetdiapers:6 ormore/24hours by daythree.Diapercountmaynotbe accurate ifnewer absorbentdiapersare usedbuta normalinfantwill urinateatleast6timesin 24 hours.Soundsofswallowing during a feedContentedbetween feedsAverage weightgain of20–30gm.(¾ -1 ounce)perdayor100–200 gm (5-7oz).per week.Recentstudies indicatethatvelocityof weightgainvaries withbirthweight,smaller babiesgaining more slowlythan largerbabies.Full term infantsshould startto gain weightbythe third tofifth dayoflife;mostinfants regain birthweightbyaboutseventotendaysafterbirth.Infantswho lose7-8% ormore oftheirbirthweightneedcarefulevaluation and follow-up to be sure there isn’treally a problem.Babies who breastfeed earlyregain theirbirthweight Additional signsforthe mother:Mother’sbreastsfeel full before afeed andsofterafterwardEjection (Let-down)sensationin mother'sbreasts(not all mothersexperiencethissensation)Uterine cramping maybefeltforthe firstfewdays with everybreastfeeding.This isasignof oxytocin releaseandlet-down. WELLSTARTINTERNATIONALModule2-Basics AnticipatoryGuidanceItishelpful totalkto mothersabouttheirknowledge ofbreastfeeding andabouttheir individual situation in orderto knowbest howto provideinformationandsupport.Open ended questionsallowamotherto express herconcernsandworries.Whatinformationaboutbreastfeedingdoyoualreadyhave?Itishelpfulto knowherbaseline breastfeedingknowledge andifshe is aware ofthe risks ofnot breastfeeding.Aprenatal breastfeeding classprovidesthe foundationfor themotherandbabygetting offtoa successfulbreastfeeding experience.Thentheshorttime from deliveryto dischargecanbe utilized forskilled staffto help with breastfeedingandwith newborn care.Also amothermay havewatched breastfeedingvideos,read books,andtalked tofamilyandfriends.Somewomendonotavail themselvesofprenatal breastfeeding informationbecause theythink“it’sanatural process”so whatisthereto learn?Health careproviders can beinstrumental inthissituation.Arefamilymembersandfriendssupportiveofyourinterestinbreastfeeding?Unsupportivefamilymembersandfriendseasilyundermineanewmother’s confidence.Willsomeonebeathometohelpyouintheearlyweeks?Allnewmotherscanusehelpathomeintheearlydays. Shewillneedtimetoeat,sleepandfeedthebabyfrequently. Itismosthelpfulifsomeoneelsecanhelpwithhouseworkand/orerrands. Withnohelp,anewmotherisathighriskforearlyweaningsincethe firstcouple of weekscan beoverwhelming.Doyouhaveanyspecialmedicalproblemsthatrequiremedications?Thoughthere areafewdrugsthatare contraindicatedduring breastfeeding (seemodule I) mostmedicationsare compatible with breastfeeding.The mother’sregular medicationsshould bereviewedand alternative selectionsmadeifnecessary.Whatisyourbreastfeedingplan?Somemothershavepreconceivedideasaboutthe length oftimebreastmilkshouldbe provided,andtheseideasmaybebased on amisunderstanding ofthe currentrecommendations.A familycanbe encouraged to breastfeed foraslongaspossible.Potential barriersandwaystoovercomethem can be discussed,such as thereturn toworkor school. Current recommendationsbymanyagenciesand organizationssuggest6 monthsof exclusivebreastfeeding.Solid foodsshould be introduced at6 monthsalongwith continued breastfeedingfor twoyearsoflife and beyond foraslong asmutually WELLSTARTINTERNATIONALModule2-Basicsdesired bymotherandchild.Areyouplanningtoreturntowork/school?Mothersmaybelievebreastfeedingandwork/schoolarenotcompatible. Theycanbeadvisedthatbreastfeedingcancontinue,perhapsinamodifiedform,andthatthiscanbediscussedin moredetail atalatertime.Ifa motherdecidesto expresshermilkand leaveitfor thecaregiverto feedthebaby,sheneedsto have the informationpriorto returning towork/school soshecan learn tohand expresshermilkorobtain a pump andstore some milkahead oftime.(Ideally thisdiscussion isstarted prenatally.)Haveyouhadanybreastproblemsorsurgeryinthepast(toincreaseordecreasebreastsize,biopsiesetcPrevioussurgerydoesnotnecessarilyindicatethat there willbeany difficulties with breastfeeding but morecarefulfollow-up may bewarranted.In additionto thequestions listedabove,amultipara who hassome breastfeedingexperienceshould beaskedthefollowing:Howlongdidyoubreastfeedbefore?Whydidyoustopatthattime?Amothermayhavebegunbreastfeedingapreviousinfantbutstoppedbecausesheexperiencedproblems. Thisisagoodtimetoletherknowthatmostproblemsarepreventable andthereare resourcesin thehospitalandcommunityto help.She should be praised forchoosingto breastfeed this newbaby.Thismothershould be givenextraattentionto make surethingsaregoingwell inthehospital andbeyond.Aconsult with alactationspecialistmaybeindicated.Ofcourse,asapartof thorough prenatalcare,acarefulexamination ofbreastsshould bedone.In additiontothe usualevaluationforpossiblemasses,observationsshould includevariationsin breastornipple shape andbreastchanges consistent with pregnancy.The examination offersa good opportunitytodiscussanyconcernsthatthe reassurance.EarlyHospitalRoutinesHospitalpoliciesandpracticesinfluence breastfeedingoutcomesbyencouraging or discouragingoptimalbreastfeeding behaviors.Motherswhochooseto breastfeed their newborns should be helped to assure a goodstart.In 1989,adocumenttitled“Protecting, Promoting and Supporting Breastfeeding: TheSpecial Role of Maternity Services” was issued as a jointstatementbythe WorldHealth Organization(WHO) andUnited NationsChildren’sFund(UNICEF)toprovideguidelinesforhospitals and maternitycenters.ThisdocumentdescribedTheevidence-basedTenStepsnowcomprise WELLSTARTINTERNATIONALModule2-Basicsthe basisfor theinternational Baby-FriendlyHospital Initiative (BFHI), a UNICEF/WHO sponsoredhospital centeredvoluntaryprogram oftrainingandpolicy developmenttosupportthe breastfeeding motherandnewborn.At thetimeofthepreparationofthe3Edition ofthe Self-StudyModules,nearly20,000hospitalsaroundtheworld hadbeendesignatedasBabyFriendly.Inaddition,manyhospitals,though notasyetdesignated,are nowworking on policiesthatincludethe“TenSteps”.Thefirsttwo oftheTenSteps” providethefoundationbyrequiring a hospitalpolicy thatsupportsbreastfeedingand trainedstaffwhocanassistthe mother.Specific clinical practicesare thendelineated:Step1:Haveawrittenbreastfeedingpolicythatisroutinelycommunicatedtoallhealthcarestaff.TheAcademy ofBreastfeedingMedicine offersa modelhospitalpolicy(Protocol #7) which canbedownloadedwithoutchargeandadapted as needed by hospitals and maternityservices.(See AnnexG,Web Sites of Step2:Trainallhealthcarestaffinskillsnecessarytoimplementthispolicy.Acourse to provide basictrainingforhealth care staffhasbeen designed byWHOandisavailable fordownloading withoutchargefromthe WHOwebsite (seeAnnexG: Web SitesofInterest)Step3:Informallpregnantwomenaboutthebenefitsandmanagementofbreastfeeding.Women needtoknowearlyinpregnancytheimportance ofbreastfeeding inorderto make aninformed choice aboutinfantfeeding.Themother’spreviousexperiencewith breastfeedingshould beelicited in orderto correctmisconceptions orto prevent problemsshe experiencedAll pregnant womenshould knowwhat to expectin thefirst fewdays postpartumandthebasics ofcontinued breastfeeding.Step4:Helpmothersinitiatebreastfeedingwithinanhourofbirth.Thebabyshould be given skin-to-skin contactimmediatelyafterbirthsothat hecanfindhis way to the breastandstarttobreastfeedimmediately afteranormal delivery.Thesuckling reflexesare presentatbirth,andcolostrum inthe mother’sbreastsisfull ofimmunoglobulinandvitamin A.Colostrum is consideredbymanytobethebaby’s“firstimmunization”.Asnotedearlierthis first breastfeedshouldbe“skin toskin”.Amother whohashadacesareanbirthshould startto breastfeed within one WELLSTARTINTERNATIONALModule2-Basicshourofbeingable to respond tohernewborn.Step5:Showmothershowtobreastfeedandhowtomaintainlactationeveniftheyshouldbeseparatedfromtheirinfants.Themothershould beshown howto positionandattach herbabyand a breastfeed should beobserved andevaluated by a knowledgeable observer.Everymothershould beshown howto hand express hermilk.Ifshe is separated from herbabyshe can maintain hermilksupplyandin many casesthe milkcan be savedandgivento thebaby.Step6:Givenewborninfantsnofoodordrinkotherthanbreastmilk,medicallySupplementation with breastmilksubstitutes should be givenonlyifmedically indicated*.Ifsupplementsare necessary,human milkisbesteitherfrom thebaby’sownmotherordonormilk.Ifsubstitutes for human milare introduced,there is a riskofallergies.Soy-based formula is probablynobetter thancow’smilk-basedformula.Ifa non-human milksupplementisrequired,hydrolyzed cow’s milk is bestto decreasethe riskof allergy.Even inhot,dry climates,humanmilkcontains sufficient water for a younginfant’sneeds.Additional water,sweetdrinks,or teasare notneeded.Ifthe babyissupplemented,there is a missedopportunityto practice breastfeedingskills andbaby ingestslessbreastmilk.With lesshuman milkintake thereislessimmunological protectiveeffect.*Note:In early 2009WHO and UNICEF completed an updatedstatement ofAcceptableMedicalReasons for Useof Breast-milk Substitutes. A copyisincluded in the annexes of this Self-Studytoolas annexB”. It mayalsobeobtained from WHO, theDepartments of Childand Adolescent Health and Nutrition for Healthand Development.www.who.int/child_adolescent_health andwww.who.int/nutrition Step7:Practicerooming-inandallowmothersandinfantstoremaintogether24hoursaday.Minimizesseparation.Providespracticefor the motherin theskillofbreastfeeding.Mothercanrespond to herbaby’sneedsrightaway and startto buildhermilkItisa prerequisite for a baby-driven feedingpattern.Step8:Encouragebreastfeedingondemand.Frequentsuckling isthestimulusto produceenoughbreastmilkforthebaby’s WELLSTARTINTERNATIONALModule2-BasicsFrequenteffective feedingsstimulate passage ofmeconium and help minimizephysiologicjaundice.Step9:Givenoartificialnipplesorpacifierstobreastfeedinginfants.*Useofthese devicesintroducesthepossibilityof reinforcing poorsucklingtechnique andmaybe thesource ofinfection.Thebreastboth pacifiesandnourishesthe infant.*Note:TheSectiononPerinatalPediatricsoftheAmericanAcademyofPediatricsbelievesthatthereareevidenced-basedmedicalindicationsforpacifieruseincludingpainreductionandcalmingeffectinadrugexposedinfant.Step10:Fostertheestablishmentofbreastfeedingsupportgroupsandrefermotherstothemondischargefromthehospitalorclinic.Supportgroupsprovide information andsocialization.Help motheridentifythe supportive people in herenvironment(e.g., family,friendsandcommunitysupportgroups).Encourage mothersto gethelpfrom familyandfriendsduringtheearly postpartumperiod.Restandrelaxationare helpful both torecoverfrom birthandforsuccessful lactationand breastfeeding.Furtherinformation regarding BFHIcan beobtained fromUNICEF orWHOvia their websites provided in AnnexG.International Codeof Marketing of Breastmilk Substitutes Duringthe1960sintense marketing ofsubstitutes forhuman milkandbreastfeeding begantobeobservedin partsof Africa and otherregionsin theearlystagesof economicdevelopment. Health care providers working inthese areasnotedthatthe useofthese substitutes wasassociatedwith increasesin infantmalnutrition,diarrhea and mortalityinthe targetregions.Muchconcernwasexpressedbyinternational agencies, governmentsandthegeneralpublic.In 1981,aftera numberofinternational meetings andlegal actions,the membercountriesofthe WorldHealth Assembly(WHA) with theexceptionoftheUnitedStates,approvedaresolutionknown asof Marketing of Breastmilk SubstitutesThis document,updatedeverytwo years through resolutionsofthe WHA,providesguidelinesforthe companies thatmakeandmarketsubstitutes andbottlesand nipples(teats),the healthprofessionals who may advisetheuse ofsubstitutes for theirpatients and governmentswho are responsible for the health oftheircitizens. WELLSTARTINTERNATIONALModule2-Basics In 1992UNICEF andWHOdevelopedaninternationalvoluntaryprogram to assess anddesignate hospitalsthatputthe “TenSteps”into place as thecore ofthe Baby Friendly Hospital Initiative.Evidence ofbeing“CodeCompliant”wasincorporated into the assessmentcriteria.AsaresulttheInternational Code of Marketingof Breastmilk Substitutesisconsidered by manyto bean Eleventh Step.Among criteria ofbeing“CodeCompliant”isthatthe hospital cannolongerreceive freesupplies offormula butmustpurchaseformula foruse inthe hospital.In addition,the marketingmethodof givingfreeformula company “gift”packsto newmothersas theyare being dischargedfrom the hospital isnotallowed.Asummaryoften majorprovisionsofthe CodeofMarketingcanbefound in AnnexD. A moredetailedguideregarding specificresponsibilitiesofhealth professionalsunder the Codehasrecentlybeenrevisedandpublishedbythe International Code Documentation Center(ICDC).Copies ofthisdocumentmay be ordered from theIBFAN Office in Penang,Malaysia.Additional detailedinformationregardingtheCodeofMarketingcanbeobtained from the following websites:International BabyFood ActionNetwork: www.ibfan.orgWorld AllianceforBreastfeedingAction (WABA):www.waba.org.myBabyFriendlyCommunities Because ofthe successofthe “Ten Steps”andtheBabyFriendly Hospital Initiative insupporting mothersandfamilieswhowish to beable to achieveoptimalfeedingfor their infantsandchildren,there hasbeenanincreasing interestin expanding these conceptsbeyond hospitals.Communities thathavebegun to explore this idea are adaptingthe“Ten Steps”to othernon-hospitalhealthcare facilities. Theyare also workingonlegislationandregulationsthataccommodate working breastfeeding motherssuch as bringingbabies towork,daycarefacilitiesthatare preparedtosupporttheir breastfeeding mother-babypairsandtimeandanappropriate place to expressorpumpmilk whileat work.DischargePlanningObserve abreastfeed foreffectivenessbefore discharge.Make any suggestionsthatseem to be needed.Arrange follow-upfor motherandinfantatthree tofive daysofage (andwithin 48-72 hoursof hospital discharge);checkinfant’sweight,voidingand stooling patterns,performa physicalexam andobserve a feeding.Atthisandfuture routinevisits,askaboutbreastfeedingtoreinforce successful feeding orto identifyproblemsearly. WELLSTARTINTERNATIONALModule2-Basics Ifa problem developsbefore thefollow-upvisit,mothersshould beinstructed whom tocontactandurged to doso.…………..Veronicaisstillwaitingforyouonthepostpartumunit.Shedelivered24hoursago. Sheisworriedabouthersleepybabyandwhatshebelievestobelackofmilk. Thenursetellsyoushehasaskedforformulatogivethebaby. Asyouenterherroom,youseethebaby,wrappedsnuglyinhisblanket,beginningtostir. Whatarethreethingsyouwilldotohelpthismotherandbaby? 2. 3. You mayhaveanswered in following ways:1.Findouthowbreastfeedinghasgonesofarbytalking to themother,to thestaff,andreviewingthemedical records(checkurineandstooloutput,weight).2.Examine the baby.The babyshould bebeyondthenormal postpartum sleepy period now.Thefactthathe isstirring mayindicate a readinesstofeed.Your exam will also stimulatehim.3.When theinfantisawake,requestthatthe motherfeed herbaby.Observe a feeding,noting position,attachment,andwhetherthe babyiseffectivelyfeeding (listenforswallows).Makeadjustmentsto improveposition/attachmentas 4.Reviewwiththemotherthe landmarksforgoodattachmentandpointoutthe quiet soundsofswallowing.5.Reviewwiththemotherthe signsofadequate milk intake(contentedbaby,weight gain,stoolingandurination).6.Reviewwiththemotherthe basicsofbuildingandmaintaininga milksupply (frequentbreastfeeding,milkremoval stimulatesmilkproduction,leavebabyon WELLSTARTINTERNATIONALModule2-Basicsfirst sideuntilhesignals he isfull thenoffersecondside).Withoutaclearmedical indication,formula usecan interferewith building a milksupply.7.Referral to a lactationspecialist/consultantorto a hospital staffmember with formal lactationtraining ifmom andbabyare havingbreastfeeding problems.Motherandbabyshould notbedischargeduntil feeding is going well.8.Dischargeinstructionsshould includethefollowing:Ifdischargedearly,less than48 hoursof age,babymust beseenwithin 48hoursofdischargeIfdischargedafter 48hours,thebaby shouldbeseen2-3daysafter dischargeA24hourhelplinephonenumberInformation formothers onwhentocallfor helpfromprimarycareprovider orlactationspecialist/consultantAbreastfeedingdailydiary formforrecording thenumber of breastfeeds, andchangesof wet orsoileddiapers(“nappys”).Printedinformationon breastfeedingsupport groupsinthecommunityandencouragementto attend suchagroup.Anunderstandingofthe anatomyandphysiologyinvolvedin thenatural processof breastfeeding isessential in orderto providecare thatsupportsoptimalbreastfeedingpractices.Thebasicbreastfeedingroutinesare basedonevidence-basedphysiologic principles,andadheringtothem preventsproblemsfrom developing.Helping a mother andinfantoffto agood startisone ofthe bestinvestmentsin time and effort.References1.AmericanAcademyofPediatricsandtheAmerican CollegeofObstetriciansandGynecologists (2006)BreastfeedingHandbook for Physicians.AAP,ElkGrove Village,IL and ACOG,WDC.2.AmericanAcademyofPediatrics. (2012).Breastfeedingandtheuse ofhumanmilk.Pediatrics 129 (3)e827-8413.Balkam,JAJ,Cadwell,K,Fein,SB.(2011)The effectofcomponentsoftheJlactation program onbreastfeeding durationamong employeesofapublic-sector employer.Matern Child Health J(15):677-683.4.Colson,SD,Meek,JH,Hawdon,JM.(2008).Optimal positions forthe release of primitiveneonatal reflexesstimulating breastfeeding.Early Hum Dev(2008), WELLSTARTINTERNATIONALModule2-Basicsdoi:10.1016/j.earlhumdev.2007.12.0035.Declercq,E etal (2009).Hospitalpracticesandwomen’slikelihoodoffulfilling theirintentionto exclusivelybreastfeed.AJPH 99(5)929-935.6.Geddes,DT,Kent,JC,Mitoulas,LR,Hartmann,PE.Tongue movementandintra-oralvacuum in breastfeedinginfants.(2008)EarlyHum Dev.2008:84:471-477.7.Hale,TW.Hartman,PE.(2007) Textbook of Human Lactation, FirstEditionAmarillo,TX.Hale Publishing,L.P.8.Kean,YJ,Allian,A.(2009) Code Essentials 3: Responsibilities of Health Workers under the InternationalCode of Marketing of Breastmilk Substitutes and subsequent WHAresolutions.ICDC Penang,Malaysia.9.Lawrence RA and Lawrence RM(2011),Breastfeeding—A Guide for the Medical Profession, Seventh Edition,St.Louis,MO: Mosby,Inc10.Naylor,AJ. (2001)Baby-FriendlyHospitalInitiative:Protecting,Promoting,and Supporting Breastfeeding in theTwenty-FirstCentury.PediatricClinicsofNorthAmerica48(2)475-483.11.RamsayDT,KentJC,HartmannRA,HartmannPE.Anatomyofthe lactating human breastredefined with ultrasound imaging.(2005)J.Anat206,pp525-534,12.Riordan Jand Wambach K (2010)Breastfeeding and Human Lactation, Fourth :Jonesand BartlettPublishers,Inc.Boston13.Walker,M.(2014)ment for the Clinician: Using the EvidenceThird EditionJonesandBartlettPublishers,Inc.Boston14.WHO(2009).InfantandYoungChildFeeding:ModelChapterforTextbooksforMedicalStudentsandAlliedHealthProfessionals.WHOGeneva.www.who.int/nutrition/publications/infantfeeding/9789241597494/en/index.htm 15.WHO/UNICEF (2006)Promotionand Supportin a Baby-FriendlyHospital,20hourCourse WHOGeneva16.WHO/UNICEF (1989),Protecting,Promoting and Supporting Breastfeeding:TheSpecial Role ofMaternityServices.AJointStatement.WHO Geneva WELLSTARTINTERNATIONALModule3-Problems After completingthis module, you will be able to:1.Discuss causes and prevention of commonbreastfeeding problems.2.Recognizethat infantsand mothers with specialhealth care needs can breastfeed.3.Recommendtreatment options compatible with breastfeeding4.Recognizewhen and howlactation can be sustained duringmother/infant IntroductionFrom time to time, mothers encounter problems with breastfeeding. Mostpreventable withgood breastfeeding practicescorrectpositioning and attachment, frequent unlimited feeds, and attentionto the effectiveness of theinfant’s suckling. When problems do occur, early recognition andtreatment enableamother tobeginor continue toenjoy breastfeeding and help reach the recommended goals of exclusive breastfeeding for sixmonths and continued breastfeeding for a year and beyond.MaternalProblemsCase#1:InvertedNipplest.Shehasread about the advantages of breastfeedingandwishesto nurse her child, but her mother andsister both have inverted nipples and were not successful at breastfeeding their babies. Today, at her prenatalappointment she would liketo find out if she hasinverted nipplesandwants your opinion on whether she shouldtry to breastfeedor not. WELLSTARTINTERNATIONALModule3-Problems Whatare “inverted nipples”? Inverted nipples are often afamily trait, present from birth, and causedby failure of the mammarypit to elevate during fetal development. Oneor both nipples may be affected. This condition may hinder the newborn’s ability to grasp enough nipple/areolato suckle effectively.WELLSTARTINTERNATIONALInverted NippleCan a woman withinverted nipplesbreastfeed? Yes, so long as the areola is soft and pliablebabies caneffectively breastfeedon a variety of shapes of nipples. Howevermothers andbabies sometimems need a little extra help.Thenatural hormonal changes duringpregnancy that affectthe breast oftencausethe nippleto protrudeto some degree.Some babies are ableto pull out the inverted nipple andfeedwell andwith every breastfeedtheybring the nipple out a littlemore.When only one side is involved, the mother may elect to continuebreastfeedingprimarily or exclusively from the unaffected side.e they will begin suckling. In this case, themother can use apump to gently draw the nipple out before each feeding.She mayneed help with position and attachment from aknowledgeableperson in the early postpartum period. The helper shouldteachthe mother toevaluate the feedby providing her with indicators of adequate breast milk intake andgive her resources for additional assistance afterdischarge from the hospital. WELLSTARTINTERNATIONALModule3-Problems As a last resort, an ultra-thin silicone nipple shield can be temporarily used. It is best to avoid bottles andpacifiers in the case of inverted nipples because the baby can get usedto the feel andflow of the longer artificial nippleandmay refuse the breast.Can Anndo anything during pregnancyto everther nipples? Until recently women with inverted nipples were toldtouse a variety ofexercisesanddevices to tryto evert the nipple. Thelatest clinical trials demonstratedthat these Women who did nothing to prepare their nipples prepartumhadthebest results. Currentadvice, then, is toalertthe mother that she should requestassistancewith breastfeeding at thetime of delivery and postpartum untilthe baby isAtAnn’svisittoday,what3pointswouldyouliketobesuretocovertoanswerherquestions? 2. 3. You may have selected from the following:1.Women with inverted nipples can breastfeedbuttheymay needmore help 2.She should request assistance with breastfeeding as soon as possible after herbaby is born..3.After delivery a breast pump might be usefulto help evert the nipples.If a pumpis not available, a 20 ml syringe with the adaptor endcut off and plunger insertedbackwards is usedto help draw out a nipple.4.Avoidbottleand pacifier use sothebaby does not become accustomed to thelongerartificial nipple which feels andflows differently.5.When allelse fails, an ultra-thinsiliconenipple shield can be triedtemporarily.Note thatnipplepreparation during pregnancy in no longer recommended. WELLSTARTINTERNATIONALModule3-Problems Case#2:SoreNipplesJaneis 7 days postpartum. Shehas been breastfeeding every twoor three hours. Her nipples have beengetting progressively more tender with each breastfeeding session. Today she notices scabs on both nipples. She had heard thatbreastfeeding hurts inthefirstfew days andshe expected to have to “toughen” her nipples, butthis is too much! She hascome to you for advice.What are the most common causes of painful nipples? Among many mythsaboutbreastfeeding, the most commonis that “breastfeeding hurts”. Althoughpainful nipples is a major reason given for early cessation of breastfeeding, today there arean increasingnumber of healthcare providers and lactationconsultantswith the skills and knowledge to assistmothersinavoiding nipple problems.WELLSTARTINTERNATIONALNippleTrauma Nipple tenderness and sensitivity willusually subsidewithin a fewdays ifpositioningandattachment arecorrected. Usuallyrelatedtophysicaltrauma(mechanical)InfectionA mother with intense prolonged pain needs an evaluation and management by an experienced lactation expert.Causes of physical trauma to nipples Improperposition and attachmentEngorgement makingit difficult for the baby to effectively attachNot breaking suction when removing baby fromthe breast.Ankyloglossia(short lingualMandibular asymmetry or torticollis resulting from intra-uterine positioningDelivery related issues which may cause alterations inthe baby’soral motor WELLSTARTINTERNATIONALModule3-Problems traumatic deliveryintra-partum drugs transferred from motherto infant before delivery.What canbe doneto alleviate painful nipples duetophysical trauma? Examine the breasts before and after afeeding. Thefirst step in abreastfeedingassessment is todiagnose the reason for thetrauma.Observe abreastfeeding to evaluate andcorrectposition andattachment. Withcorrect position pain willoften decreaseandmother cancontinue to breastfeed whilenipples heal.Check baby’s mouth for ankyloglossia. Clipping of a short lingual frenulum(frenotomy)by an experienced health care givermay benecessary to allow appropriate tongue movementsand avoid chronic nipple trauma.Ensure frequent feeding to avoid engorgement.Changing position of the baby at eachfeeding may helpto avoid friction on theUse of emollient such as purified lanolinmay improve rates of healing. Avoid the development of crusts (scabs) on nipplelesions. Theuse of hydrogelpads may increase comfortfor some women withnipplewounds. Breastmilk to themay helpsome mothers.Candidiasis as a cause of nipple pain hatcauses thrush)thrives in moist environments like thevagina, nipples, areola of breastfeeding mothers, andinfant’s mouth anddiaper areas. Infants are exposedto candida during birth and often develop oralan overgrowth of either mother andor baby receiving antibiotics. Infants with recurrentthrush shouldbe tested for HIV.Mother andbaby need to be treatedsimultaneously evenif symptomsare present inonly one of the dyad.Mother: Nipple and Areola Candidiasis:Findings Nipplemay appear red and dry.Areola may be shiny, pink, depigmented, andflaky or there maybe no visible signs.Breasts may feelitchy or feelburning throughout andafter afeed.Painmay radiate into the breastandto the WellstartInternational WELLSTARTINTERNATIONALModule3-ProblemsTreatmentfor Maternal Candidiasis Evaluate attachmentand make changes if needed.Good hand washingIbuprofen can be used for painUsedisposable orclean, dry nursing pads dilute bleach or sun dryAir dry breasts as much as possible.All pump parts touching milk orbreastshouldbe washedand boiled daily.Eliminate alcohol and minimize sugarinthe diet.Add acidophilus in the formofyogurt, pills or acidophilusmilk to diet to assist normal colonizing of bacterial flora.Specific Antifungal medicationMycostatin(Nystatin)Though mycostatinhas beencommonly used for firstline treatment of Candidasis,increasing resistance and poor absorptionoften favorsother medications. Theseinclude:Miconazole(Monistat)not wellabsorbedKetaconazole(Nizoral)Although this drug is not approved by the US Federal Drug Administration(FDA) foused if othertreatmentsare unsuccessful or if candida reappears.is a purpledye which when applied to affected area works quickly to kill candida. Even though the baby does not have findings of oral thrush,gentianvioletshouldbe used for both the mother’s nipples andbaby’s mouth.It mustbe dilutedto an aqueous solutionof 0.25%for the infant’s mouth and 0.5% for themother’s nipples inorder to avoid chemicalburn of theskinor oral mucosa.Note: If anantifungal medication is prescribed, it is importantto complete the course of treatment.Baby: OralThrush: Findings White cheesy patches on tongue, palate, buccaland gingivalsurfaces which a may think is milk.Yeast is difficult to remove fromthemucosalsurfacewithout causing bleeding.Milk is easily removed.Baby may be irritableand not feedwell.BabyTreatmentfororal thrush WELLSTARTINTERNATIONALModule3-Problems After breastfeeding apply an tongue and allareas of Wash, boil or discardall objects touchinginfant’s mouth; i.e., pacifier, bottles, Baby: Candida Diaper Rash: Findings Therash maybefiery red, wet appearing with sharp demarcated edges and satellite lesions.Baby is irritable andfussy and may not feedwell.Does notrespond to usual diaper rashtreatmentsIt is important to examine the infant forsigns of acandida diaperrash and trush. If the treatment of candidiasis of themother’s nipple andareola is to be successful, the baby’sdiaper rashandthrush must be simultaneously treatedBabyTreatmentforCandida Diaper RashChangediapersoftenRinsediaperareawithwarmwaterandairdryApplyalocalantifungaltreatmenttotheareaasdirected.IfrashpersiststheinfantasystemicmedicationbeneededGoodhandwashing…Jane and her baby await your assistance. The infant’s weight is a few ounces below his birth weight. Heis alert.Jane tells you he has many wet are no riskfactors for candidiasis and no signs of the infection in either themother or infant. You ask Jane to feed thebaby.You noticescabs in the center of eachnipple.She tellsyou the painbegan the first day postpartum and has become worse, not better. She holds the infant acrossher lap. Theinfant is lyingpartially onhis back with his face turned up toward the mother.There is quite a lot of areolavisiblearound thebaby’s mouth. Jane winces as the infant begins to suckle.WELLSTARTINTERNATIONAL WELLSTARTINTERNATIONALModule3-ProblemsUNICEF WhatdoyouthinkiscausingJane’ssorenipples?WhatwillyoudotohelpJane? 2. 3. You may have done the following:1.Helped the mother andher babymake adjustmentsto the position and attachment.Ifthese changes ease Jane’spainask her to practicehelping herbaby attach a few times so she is more comfortable and confident thatshe can do this at home. In the commonlyusedcradle holdthe baby should be lyingonhis side facing the mother(so called “tummyto tummy”)His body shouldbeonll supported in his mother’s arms.You may also haveelected to encourage the mother to lieback and allow“baby led” or biologic positioningto occur.2.Assisted the mother and baby to achieveaneffective andcomfortable attachment by:having the baby in a quiet alert statepositioningthe baby’s nose at about the levelof the mother'snippleUNICEFChile WELLSTARTINTERNATIONALModule3-Problems stimulating the baby’s upper lipwith mother’s nipplewhich will cause the baby to openits mouth widegently encouraging the baby to attach whilethe mouth is 3.Checkedfor effectiveattachment:the baby’s nose touches the breastlips are flangedout,chin is against the breastmore of the areolais visibleabove thebaby’supper lip than below the lower lip(“asymmetricallatch”).Case#3:EngorgementCarmen asks for advice about her 4-day-oldinfant. Hehad attached well during postpartum feedings in the hospital and his first day at home. He is nowrefusing to attach tothe breast and feed. She can feelthat her milk has come in, andher breasts are swollen and tender. She is quite uncomfortable.What is themost common cause of engorgement? The most common causeofengorgement is infrequent or ineffectivemilk removal.At thetime when the “milk comes in” at 3to 5 days postpartum, therapidincrease inmilk volume can cause vascular congestion and result in edema.This can also happen if mother or baby skips a feeding. Thebreasts becomeswollen andhave a shiny appearance.They may be tender,often feelhot and havediffuse redness. Themother may evenhavea slight elevation of temperature.Intravenous fluidsgiven during labor can result inexcessiveinterstitial fluids and alsocontribute topostpartumengorgement and areolar edema.Inaddition to thediscomfort, ifck Inhibitor ofLactation (FIL), described in Module 2,begins todecrease milk production.WELLSTARTINTERNATIONALBreast EngorgementThetreatment is milk removal, and the mostsensiblestrategy isfor the baby toattach and feed! Sometimes engorgementandareolar edemamay be sosevere that the areolar area becomes swollen and hard and the nipple flattened. The infant has a difficult time pulling the nipple into his mouth. WELLSTARTINTERNATIONALModule3-Problems Helpfulstrategiestoreducetheengorgementinclude:A warm showeror warm moist packs to thebreastsmay helpthe mother relaxand enhancemilk flow.Gentle massage,hand expressionor minimaluse of a breast pump (handor electric)areoften usedto soften the areola aroundthe nipple to facilitate attachment. Some lactationspecialistsminimize the edematous areolar swelling around the nipple. This is known as areolar compression or reversepressuresoftening.If thebaby is unable to latch, judicious use of a thinsilicone nippleshield may facilitate latch untilthe areolais softened.More frequent andeffective femorefrequently if the baby Ifbaby will not nursefrequent and effective emptying of breasts by handor breast pump untilengorgement is resolved.If available,coldpacks can be applied afterfeeding tohelp relieve congestion, and pain.Evaporation from themoist cloths adds tothecooling effect.Anti-inflammatory drugs may alsobe useful.There is not sufficient evidence for other complimentary therapies to evaluate theireffectiveness.WhatwillyoudotohelpCarmentoday? 2. 3. You may have done some of thefollowing:1.Explainedto Carmen that engorgement is a temporary problem and the treatment is to getthe milk to flow. WELLSTARTINTERNATIONALModule3-Problems 2.Applied warm, moist compresses, such as washcloths wrung out inwarm water before feedings to help with milk ejection.3.Ask her togently massage anduse finger pressure on the areola as wellashand express milk to softenthe area so the baby can attach.Helped with position and attachmentand observe the baby for signsof effective nursing.4.Applied cool compresses forabout 5 or 6minutes after feeding or pumping.5.Encouraged frequent feeding or pumping(about every 2-3 hours) will prevent reoccurrenceof engorgement.6.Prescribed anti-inflammatory medicationsuch as ibuprofen for pain.If thebaby is not able to suckleeffectively, the mother may needto use handexpressionor a breast pump untilthe engorgement is resolved. (Theexpressed milk can be given to the baby some other way.) If expression is effective the baby shouldbe able to feeddirectly from the breastas soon as the areolais softened.If engorgement persists longer than 24 hours or iftheinfant cannot attach andnurse effectively, referthemother to ahealth care professional withexpertise in lactation Case#4:ObstructedLactiferousDuctMariahas been breastfeeding her sixweek oldson. Yesterday she noticed a tender areain her left breast. Shefelt a lump in thesame area. Shefeels well otherwise.Her baby recentlyat night. Duringthe day she wears a nursing bra with under-wire support.What is anobstructed duct? Anobstructed duct presents as alocalized, red, firm and tender area inthe breast. The obstruction isa result of improper drainage of milk from alactiferous duct.Inspissated (thickened)milk can sometimes actually beseenas a white dot or blebat the duct opening on the nipple. The blebs often causeexcruciating pain.WELLSTARTINTERNATIONAL WELLSTARTINTERNATIONALModule3-Problems What causesa duct todrain improperly? Ineffectivemilk removal(usually caused by poor attachment)Local consistent pressure on thebreast, caused, for example, by tight clothingRarely but important,an obstructed duct may be caused by a tumor (benign ormalignant)What canbedoneto relieve the obstruction? Start feeding from the affected breastfirst.Change the positionof the babyat eachfeeding to encourage morecompleteemptying of the ductsandincrease the chance of removing the obstruction.Cease wearing underwire bras and any other constrictive clothing.Emptythe affectedbreastascompletelyaspossible,eitherbyfeedingormilk expression.Sometimes warm moist compresses to area 3-5 minutes before feeding is helpful.Itmay be helpful for the mother to handexpress or pump following eachfeeding untilthe problem is resolved.WhatcarecanyouprovideforMariatoday? 2. 3. By nowyou get the drift…you will examine the mother’s breasts andwatch a feeding. During the visit you may have made the following suggestions:1.Have the mother gently massagethe breast over the lump. WELLSTARTINTERNATIONALModule3-Problems 2.Apply warm, moist compresses tothe affected area,3.Observe the feeding noting position and attachment; make suggestions as needed.4.Advisethe mother to continue feeding frequently, every twoor three hours, untilthe lump is resolved.In this case, thenewlonger sleeppattern of the baby may have contributed to the development of the obstructed duct. Thebreasts willadjust to minor changes in frequency; inthe meantime Maria could continue with the treatmentyou have discussed.5.Note theappearance of the breasts. Are there markson the skinthat wouldsuggest the bra is too tight? Suggest she remove theunderwire in the bra if it appears to be a mechanical obstruction.6.Ifthe lump does not resolve after a few days of thetreatment describedabove, she shouldreturn for reassessment of the situation because an unresolved blocked duct may lead to mastitis.Additionally if the lump does not resolve or recurs,consider referral torule out other causes such as tumors.Case#5:MastitisAmandaandher5week-oldsonhavecometoseeyoutoday.Amandahasbeenbreastfeedingherbabyandaweekagodevelopedacrackednippleonherrightbreast.Forthelast12hoursshehasnoticedflu-likesymptoms(bodyaches,fatigue,feverto 101F)Shealmostskippedherappointmenttodaybecauseshehasbeenbusycleaning the houseinpreparationforhermother-in-law’svisit,butsheisfeelingquite miserable now.What is mastitis? Mastitis isan inflammation of the breast, manifested by flu-like symptoms and/or localized heat, redness and tenderness. Itis usually restricted to onebreast. Itmay occur in the mother has missed some feedings orhas not been feedingas often asbefore perhaps because the baby has been sleeping throughthe night or because of blockageto the milk flow from tightclothing.It is often caused by a bacterial infection with the ted to bestaphylococcus aureus, E. coli, and (rarely)streptococcus.Currently thepossibilityof methicillin resistant S. aureus( MRSA) must always bekept inmind.WELLSTARTINTERNATIONALMastitisTheportal of entry isoften through a break in thenipple skin. Recurrent mastitis may alsobe associated with anover-abundant milksupply. Themother usually complains of WELLSTARTINTERNATIONALModule3-Problemsbreast pain, fever,andheadache. She mayalsonoticea redwedge-shaped area on the affected breast.Can a mother withmastitis breastfeed? Theinflammationis mammary cellulitis. Even whendue to a bacterial infection,the organismis rarely in the milk andinfants do not become illfrom sporadic mastitis in tfeeding or breast milkremovalwillavoid engorgement, facilitate vascular and lymphatic drainage and is an important partoftreatment. ismay lead to a breast abscess, a complication usually requiring surgicalintervention.There is a saying that “flu-like symptoms inabreastfeeding mother shouldbe considered mastitis until proven otherwise.”To differentiate the diagnosis, ask the mother if she has nasal discharge, cough, or other symptoms of respiratory illness. If she does not,her symptoms aremost likely dueto mastitis.There is some evidence that stress plays a role in the developmentof mastitis,because it seems to occur aroundespecially hectic times in themother’s life when there is an in Amanda’s case, gettingready for avisit from arelative. It may also be because she maymiss a feeding or may breastfeedfor only a short time dueto preparations for the visit.How do you managea case of mastitis? Continue breastfeedingApply warm, moist compresses tothearea3 to 5 minutes before feeding or pumpingFrequentmilk removal (every 2 ½to 3 hours or sooner) by feeding, hand expressionor pumping of theeffective sideis most important.Encourage mother toenlist family and friends to help while she goes to bedfor24hours. This willalsofacilitate feeding.Encourage the mother to rest as much as possible for 24 hours.Encourage the mother to drink extra nourishTreat nipple trauma as described above in Case #2.A mildanalgesic, such as acetaminophenor ibuprofen ishelpfulinrelieving pain ifPrescribeantibiotic therapy as appropriate usually for 10 to 14 days:Dicloxacillin for thosenot penicillin sensitiveor erythromycinfor those who are penicillin sensitive.Clindamycin, trimethoprim or sulfamethoxazole are often used in communitieswhere methacillin resistant S.aureaus (MRSA) is prevalent. WELLSTARTINTERNATIONALModule3-Problems Remind the mother tofinishthe fullcourse of antibiotics. Most antibiotics are safe for the baby but when indoubt, check withoneofthesuggested sources given on page17 of Module1.Many clinicians will send a mother home witha prescriptionbut suggest that she be diligent about going to bed,applying warm moist compressesandfrequentemptying of the breasts.Ifshe is not feeling better after 24 hours, she shouldfill the prescription andtake all of the antibiotic. If she is not better in24 hoursafter starting antibiotics,she should callher health care provider.Instruct themother tocontinue breastfeeding frequently. If her brtoo sore tobreastfeeddirectly, she should handexpress or use apump to ensure effective milk removal andlower therisk of developing anabscess.Ensure proper positioning and attachment of the baby to the breast tobe sure he is effectively removing milk.WhatadvicedoyouhaveforAmanda? 2. 3. Examination of the breasts confirms the diagnosis of mastitis. You may have recommended the following:1.Continue frequentbreastfeeding, or at least milk expression,at least every 2½2.Rest as much as possiblefor 24 hours and havea relativeor friend help with meals andhousehold activities.Emphasize that rest isan important part of the 3.Antibiotics for 10 to 14days and an analgesic as needed.(Recent reports suggest that if milk isremovedeffectively antibiotics may not be needed) WELLSTARTINTERNATIONALModule3-Problems 4.Evaluate position and attachmentas a contributing factor to manage as indicated.5.If hercondition has not improved after48 hours, she shouldcontact her healthcareprovider.Case#6: “NotEnoughMilk”Monica is 6 weeks postpartum. She has been breastfeeding her son, John, since birth.Shebreastfed about 7 times each day because she neededher 8 hours of sleep at night.Her husbandgave a bottleof formula atnight.Lately Johnhas been fussy, especially in the early evenings, and they havebeen providing a second bottle of formulabecause the baby does not seem satisfiedwith her milk. She had planned to breastfeedfor sixmonths and is worried she is losing her milk. . .What factors contribute to thematernal concern of“not enoughm il k”? Infants’ fussy behaviormay cause motherstothink theydon’t have enoughMilk evenwhenthey do. Newborns tend tobe morefussy in the evenings irrespective of howthey are fed.Breastfeeding women tendto interpret infant fussiness as hunger. Fussiness peaks at aboutThemost common causeof lowmilk supply is ineffective sucklinfeeding routines that do not adequately stimulate milk production and milk removal.Early introduction (before three weeks of age) of bottleswhichrequire that the baby use a different type of feeding effortorsuckling technique andmay cause the baby to havedifficulty nursing orrefuseto breastfeed.Introduction of formula supplements, while calmingthe infant,decreases thenumber of times the baby breastfeeds thereby reducing breast stimulation and thus milkConditionsof the baby, such asillness or ankyloglossiamay causeineffective suckling (ineffective suckling reduces the milk supply).Condition of themother such as fatigue, stress, use ofcertain medications (i.e.,estrogen-containing oral contraceptives that inhibit milk production),psychological inhibition, pregnancy, andsmoking.At around 4 weeks postpartum, normal lactatfullbefore a feed; thischangeleads mothers to believe they have“lost theirmilk”.Mother lacks confidence in her ability to produceenough milk because her baby begins to be fussy or crymoreandfeed more frequently for several days. This seems to occur several times during the first 3 months. Mothers oftenthink theyhavelost their milk supply because the baby(“perceived” lowmilk supply). Onexamination the infant is judgedto be normal. These transient periods of time whenthe babydemands to feedmore frequently havebeen called “growth or activity spurts”.As yetthere are no published studies to WELLSTARTINTERNATIONALModule3-ProblemsWELLSTARTINTERNATIONAL confirm that either growth oractivity are responsiblefor this behavior. Because more frequent feeding stimulates a larger milk supply and babies usually returnto less frequentbreastfeeding after afew days, it is assumed that the babies have increased the supply to meet their needs.Fatima andJohn (cont). . .John’sweight is normal for his age and hisphysical exam is normal. Monica is well and is not taking any medications. You ask Monica to breastfeedJohn so you can assess the situation. Hefeeds effectively.WhatisthemostlikelycauseofMonica’slowmilksupply?WhatadvicewillyougiveMonicatoday? 2. 3. WELLSTARTINTERNATIONALModule3-Problems Themost likely cause of Monica’s problembecause of the introduction of formula(without extra milk removalbyhand or a pump). Your advice may have included the following:Reassure Monica that she can build up hermilk supply by breastfeeding more frequently,8 or moretimes in24 hours; review with her the principles of demand and supply that drive breast milk supply.Feed the baby frequently, day and night, tostimulate milk production. Studies show that prolactinlevels are highant tomaintaininga good milk supply.Around sixto eight weeks ofage some babies start to sleeplonger at night andwill feedmoreoften duringthe day to maintain about 8 or more feedings in 24 hours.Review with Monica the possibility ofan “appetite spurt” or “growthspurt” inababyJohn’s age,and reassure her John’s requests for morefrequent feeding are normal, temporary,andwilllikely result inan increased milk supply.Case#7:JaundiceinthebreastfedbabyAliceis5dayspostpartum.Hernewbornson,Kevin,bornattermbyCesarean sectionfor“failuretoprogressinlabor”,hasbeenasleepybaby,wakingtofeed about6timesadayandfallingasleepafterabout5minutesoneachbreast.He hashad2dark-coloredstoolsperdaysincehospitaldischargeonday3.They are here for theirroutine check-up 48 hours after hospital discharge. ..Jaundice in Normal Breastfeeding NewbornsMost normalhealthy newborns have an elevated unconjugated (indirect) serum bilirubinconcentration during the first week of life, peaking on the third or fourth days.About half will be visibly jaundiced at least on the face. This normal situation is known as Physiologic Jaundice of the Newbornandis dueto acombination of increased bilirubin production from the shorter life span bilirubin absorption and decreased hepatic metabolism and clearance of bilirubin.Erythrocytedegradation results in productionof biliverdin (a green pigment) which is then reduced enzymatically to bilirubin(a yellow pigment), iron, whichis reutilized, and carbon monoxide (CO) which is excreted in exhaled breath and can be quantitated as a measure of bilirubin production with very sensitive instruments. Unconjugated bilirubin cells is insoluble inplasma and is bound to albumin for transport to the liver where it is conjugated by the glucuronyltransferase enzyme into solubleconjugated bilirubin(direct-reacting) enabling it to be excreted into bile, subsequently flowing into the duodenum.Most of the conjugated bilirubin will be hydrolyzed back to unconjugated bilirubin in the intestine by the beta glucuronidase WELLSTARTINTERNATIONALModule3-Problemsenzyme, whichis very activein the newborn,resulting in large amounts of bilirubin that is reabsorbedand flows back to the liver viathe portal circulation. Thevery limited capacity of the liver to conjugate bilirubinresults in retentbilirubin in the circulation, whichif it reachesaconcentrationin excess of 5 mg/dl willproducejaundice.Exaggerated hemolysisdueto RH or ABO incompatibility or decreased hepatic conjugating capacity dueto prematurity or inherited abnormalities of the conjugating enzyme willfurther increase serum bilirubinconcentrations and the frequency and intensity of jaundice.In the greatmajorityof breastfednewborns serum bilirubinconcentrations remain elevated abovethe adult normal levelof 1.5 mg/dl for at least three weeks and sometimes as longas three months due to a factor intransitional and mature human milkwhich further increases the intestinal absorptionof unconjugated bilirubin. Thespecific factor(s)in human milk increasing intestinalabsorption has not been identified,but is part of amechanism for efficient retentionof many nutritional andhormonalcomponents that arein the intestines of thenewborn infant. The resulting prolongation Physiologic Jaundice of theNewborninthe breastfed infant,known as , is believed to be part of a protective mechanism. Bilirubin has been shown to be a very effectiveantioxidant, preventing excessive injury during the critical transition of thefetustoindependent existence.During the first five days of life, the optimally breastfed infant andthe artificially-fed infant haveidentical serum bilirubinconcentrations.Theserum bilirubinconcentration of the artificially-fed newborn willdecline to adult normal levels by the tenth or eleventh days of life, reducing antioxidantg or reduced caloric intake inthe artificially-fed newborn willbilirubin concentrations and more intense jaundicedue to afurther increase in intestinal bilirubinabsorptoccurs to amild degree inolder children and adults as well and is known as.When it occurs intheneonate, it is knownasStarvation Jaundice of the , andwas previously known as BreastNon-While mildandmoderate levelsof hyperbilirubinemia are not harmful, serum bilirubinconcentrations that exceedcertainlevels can cause both transient and permanent brain damage, known as . Unconjugatedbilirubin which isnot retained within the circulation can enter the brons in the basalganglia and cerebellum.In the newborn period this type of injuryismanifest initially as lethargy and poor feeding, progressing to movements which look like seizures, extensor stiffeningandarching of the back and neck (opisthotonus). Hearingloss, loss of upward gaze of the eyes, and moderate to severeloss of movement control (choreoathetoidcerebral palsy) are thelater andpermanent consequences of bilirubin damageto thebrain.Prevention of excessive rises in serum bilirubinconcentration and closemonitoring of jaundiceand serum bilirubinconcentrations are essential inthe prevention of kernicterus. Thus,early andeffectiveinitiation of breastfeeding without water or other least tentotwelve feeds per day starting with the first day oflife, andclose monitoringof the nursing mother andinfant to detect andcorrectproblems promptly can assure adequate caloric intake which minimizes WELLSTARTINTERNATIONALModule3-Problemsjaundiceand serum bilirubinconcentrations. Close monitoringof the infant for the appearance of jaundiceis critical. Theappearanceof any jaundice, even juston the face, during the first 24 hours of life is almost always evidence of a pathologicprocess whichmay well progress to more intense hyperbilirubinemia. As serum bilirubin concentrations increase, thejaundiceprogresses downward on the body, and may be gs at levels in excessof 15 to 20mg/dl. Competent observation of jaundicein the newborn requires very strong and wellbalanced light, best achieved at a window indaylight andsome experience. Jaundice in the first 24 hours of life andanywhere below the face afterward requires measurement of aserum bilirubin concentration by laboratory or useof the newer transcutaneous methods. Many hospitals are now routinely performingbilirubin measuremon all newborns usingeither serum drawn during the metabolic screenor a of ageor just prior to discharge.These bilirubin values shouldbe graphed on the age-specific charts whichprovide predictive guidance on future bilirubinconcentrations and risk forkernicterus (see AAPguidelines: 2004;114:297-316).Infants with serum bilirubinconcentrations in excess of 12 mg/dl need to haveadditional laboratorystudies to ruleout pathologic conditions such as RHand ABOerythroblastosis, spherocytosis, glucose-6-Phosphatedehydrogenase(G-6PD) deficiency, hypothyroidism, etc. Carefulmonitoring of jaundice after discharge is also critical. Every newborn should be examined by a licensed health practitioner at 3 to 5 days of agefor jaundice and feeding, as well for many other system problems. Infants with significant risk factorsforexcessivejaundice may be seeneven sooner after discharge or kept inthe hospitalan additional day.Thepresence of any jaundicebelow theface or intense jaundiceon the face at the time of scheduled post-discharge examinationor later requires aserum bilirubinmeasurement. Treatment is determinedby the levelof theserum bilirubin as describedin the guidelines fromthe American Pediatrics 2004;114:297-316ands may includeimprovements in breastfeeding management, additional feeding with expressed or banked human milk, otherapy and/or exchangetransfusion. These may be used incombination.At no time shouldan infant be allowed to continue to haveinadequate caloric intake.Thelethargy induced by moderately elevated serum bilirubin concentrations, usually in excess of15 mg/dl, often leads to reduced frequencyand efficacy of breastfeeding. Theresulting reduction infeeding and caloric intake increases intestinalbilirubinabsorptionandthe concentration of serum bilirubin. This increase inserum bilirubin further depresses feeding. Thisvicious cycle can lead to severe increases in serum bilirubin and to kernicterus. Every effort needs to be made to prevent this progressive increase in serum bilirubin.To minimizejaundice:The infant shouldreceiveadequatefluid and caloric intake. Effective isthe ideal way for the baby to have adequate fluidand caloric intake.If an infant is not suckling well, consider having the mother pump after feeds and givethe baby supplements of this expressed milkwhich providesnutrients and WELLSTARTINTERNATIONALModule3-Problems hydration. Supplemental water orglucose water doesnot lower serum bilirubin andshouldnot be given.Early follow-up should be arranged, particularly in Note that any jaundice on the first day of life is not normal.……AliceandhersonAndrewarereadyfortheirvisitwithyou.Thebabyis11% belowbirthweight.Histemperatureisnormal.Hisskinlooksjaundicedtoaboutthe levelofhislegs.Heissleepybutrootswhenaroused.YouaskAlicetofeedthebaby. Heisdressedandiswrappedinablanket.Heattachestothebreastandnurseswithonly a few audible swallows for about 3 minutes before falling asleep.WELLSTARTINTERNATIONALAndrewat5 days of ageWhatwillyoudointhissituation? 2. 3. WELLSTARTINTERNATIONALModule3-Problems You may have done the following:You will want to checkthe bilirubin leveland evaluate the jaundice; but whatever the cause, this baby needs more oralintake. Increase the frequency of effective Ask motherif her milk has “comein” andhow she is doing. Arrange for mother to Since the baby doesnot appear to be feeding well, Alice must express her milk and giveit to the baby. Alternatives to using an artificial nipplefor giving thebaby breast milk include syringe feeding, cup feeding. Abottlemay be usedif any of these methods are not appropriate for themotbreast milkcannot be expressedor otherwise providedfrom amilk bank, formula Provide Alice with a plan for feeding the baby and recording intake andoutput for the next 24 hours. Thismay include putting the baby to the breast every 3 hours or sooner and offering supplemental expressed breastmilkor formulaafter nursing.Arrange for follow-up in your office or by a home health provider the following dayto check the baby’s weight andassess his ability tofeed effectively.Since jaundicedbabies are oftensleepy, offer Alicesuggestions for stimulatingthe baby such as less bundling, side sitting position for feeding, burping, andchangingConsider referral to an experienced professional knowledgeable inmanagement of These recommendations are focused onbreastfeeding infant. A more detailed discussion of neonataljaundice is beyond the scopeof this Level 1 tool. For the interested readerwho wishes to explore this topic thorough reviews are available inthe suggested textbooks by Lawrence and Lawrence or Haleand Hartmann.BreastfeedingtheInfantwithSpecialMedicalProblemsAs previously mentioned, with rareexceptions, breast milk provides the best nourishment for nearly allinfants (refer toModule1). If there is a question, the risk/benefit of human milk andthe risk/benefit of not receiving the milk in a given medicalcondition must be weighed. In the case of structural defects such ascleft lip/palate, breastfeeding can be accommodated with an adjustmentin the position, or can be assisted with a variety of feeding devices. The anti-infectivebenefits of breast milk to thechildwith a cleft are especially important,as these infants are atincreased risk of otitismedia. WELLSTARTINTERNATIONALModule3-Problems LatePretermInfants_(Previouslycalled“NearTerm” Infants) Thelate preterm infant(34 0/7to 36 6/7 weeks of gestation) frequentlyhas troublegetting started with breastfeeding.They are often considered more capablethanthey are. These babies areoften sleepy, fatigueeasily and have difficulty with attachment andcoordination of suck-swallow-breathing. They areat riskfor hypothermia, weight loss.They are also frequently separated from theirmothers.Mothers oflate preterm infants often havemultiple births and/or a medicalcondition rtension with a subsequent pitocin induced delivery or c-section.Skilled lactationsupportis indicated for bothmother and baby. Such support needs tobe ongoing not only while they are in hospitalbut afterMaternalMedicalProblemsWomen can breastfeedthroughmost medical illnesses and conditions including colds andflu.Babies benefitfrom the immuneprotection breast milk provides. The few exceptions(such as HIV, active tuberculosis prior to treatment, herpes lesion on the breast, substance abuse) are discussed indetailin several referenceslisted at the end of this module.There is a very shortlist ofdrugs contraindicated duringlactation andbreastfeeding. Thedrugs may either pose a risk to the infant ingesting them or affect themother’s milk supply.Again, the risk/benefit is weighedinmakingthe choice. In almost allcases, there is an alternative drug that can be used, or the drug can be given with close observation, so breastfeeding can continue. For more information on drugs and lactation refer back toModule1 orsee thereferenceslisted at theend of thismodule.BreastfeedingDuringEmergencySituationsEmergency situations (earthquakes,tsunamis, hurricanes, forest fires, blizzards,floodsand wars) occur all over the world affecting hundreds and thousandsofmothers and infants, every year. Thoughit isnot possibleto predict exactly whatandwhen these situations willhappen, it is predictablethat a major emergency event will happensome place inthe world severaltimes each year. It is very important tosupport breastfeeding during such emergencies. Breasfood and water fortheinfant, it offers immunoglobulinsandother protectivefactorsthat actively help prevent infection. Breastfeedingalsoprovides warmthand a secure environment for babies during stressful situations. Contrary tofolklore, lactating women ulevents. Even motherswho have elected not to breastfeed or have already weaned can often be assisted with relactationduring such events.A descriptionofInfant Feeding in Emergency SituationsappendixCfor the interested reader. WELLSTARTINTERNATIONALModule3-Problems ContraceptionduringBreastfeedingIUDs, condoms, spermicides, diaphrams and cervicalcaps. Permanent methods includetuballigation,intrauterine fallopian tube occlusion and vasectomy for the male partner. Allof the above methods have no ing. Hormonal methods includeprogestin onlypills, progestinIUDs, injectables, implants andcombined oral contraceptives. Becauseof thepossibledecrease in milk supply seen with hormonal methods it is advised that women not start these methods until breastfeeding is wellestablished, probably not before four to sixweeks postpartum.Extensivestudies of thesuppression of ovulationduring lactation indicate that this contraception (LactationalAmenorrheaMethodor LAM) Ifguidelines* areadhered to during the first sixmonths postpartum, the risk of pregnancy is less than 2%. Thestudies also indicate that iftrueexclusive breastfeeding is done for the first sixmonths the risk of pregnancydrops to 0.5%.*LAM Guidelines Baby less than sixmonths oldNoreturn ofmenstruation (no bleedingafter the56Noregular supplementsFeeding at least 8 times in24 hours Night feedingsSeparationofMotherandInfantA mother who chooses to providebreast milkfor her baby when they are separated needs the help and encouragement of her family, healthcare providers, friends, caregiver, co-workers, andanyoneelse that motherand baby encounter. If at all possible, the mother and baby shouldremaintogether even if themother is returningto school orwork.If oneof the otherof them ishospitalized, many hospitals allow a pair to remaintogether.If separation is necessary the mother will need help with planning for maintaining her milk supply, milk expression,storage and transportationof the milk. The physiology of breastfeeding dictates that morestimulation and emptying of the breast yields more milk.Milkshouldbeexpressed and stGood hand washing is essentialwhile pumpingand handling her milk.Themother can express her milk by hand or with the use of a pump. Breast pumps come in a variety of manualand electric models to suit the particular needsof the individual mother.Themother should expressher milk around the time she wouldordinarily be breastfeeding.Theexact schedule dependson the baby’s age, feeding pattern, andthe mother’s situation at that time. Expressed milk shouldgo into a BPA free or WELLSTARTINTERNATIONALModule3-Problems closablecontainer with an airtight lid. Specific milk storage bags may beusedbut for short periods of time as they may leak, spill or become contaminated or some of thecomponents of the milk may be lost in longtime storage.Milk should be stored in amounts that the baby wouldtake.Thenewly expressed or warm milk needs tobechilled before adding to cold, refrigerated milk. Severalexpressions with-inthe same day can be combinedand used within 24 hours.For details regarding storage see Thaw milk overnight in the refrigerator orplace the milk container ina bowl under warmrunning water.Warm milk toroom temperature. Neveruse a microwave to thaw or warm milk.Offer onlythe amount of milk that baby is likely to takeat a feeding.Once a bottleof milk has beenin the baby’s mouth the remaining milk must be discarded.In the caseof a hospitalized infant, the mother should follow the policies of theinstitutions to label and store themilk. (seeAnnexes EandF for additional information regardingexpressingandstoring of humanmilk)ResourcesWhen mothers encounter problems with breastfeeding they often turn to their physician or other health care provider. The amount of knowledge and experienceamong physicians andnursesis quite variable.Identifyknowledgeable and experienced colleagues inyour community.Your community may havelactation specialists andconsultants available to mothers through organized health systemsor through individuals in private settings. Identify and familiarizeyourself with the lactation sespecialists to whom you wouldrefer your patients. Provide information as part of the referral and request feedback in order to buildyour ownexperience with lactationmanagement. If your medicalcenter provides lactation services, try to arrange a clinical learning experienceinprenatal, postpartum and outpatient health care settings.Most breastfeeding problems can be prevented by providing women with helpful informationduring the prenatal period so they knowwhat to expectandprovidingperinatal care for motherandinfant that follows physiologic principles. In spite of providing informationand goodcare, problems do occur. Information about when and howto seek assistanceif problems develop is essential.Early intervention can helpbreastfeeding families onthe path toward exclusiveand continued breastfeeding. WELLSTARTINTERNATIONALModule3-Problems References1.Academy ofBreastfeeding Medicine (2010).Protocal #8: Human Milk Storage Information forHomeuse for Healthy Full-TermInfantsBreastfeeding Medicine 5(3):127-130.2.Academy of Breastfeeding Medicine (2008).Protocol #4: Mastitis.Breastfeeding Medicine, 3 (3)177-180.3.Academy of Breastfeeding Medicine (2005).Breastfeeding. Breastfeeding Medicine .(being revised)4.Academy of Breastfeeding Medicine (2009).Protocol #20: Engorgement.Breastfeeding Medicine 4(2) 111-1135.American Academy of Pediatrics andthe AmericanCollege of Obstetricians and Breastfeeding Handbook for Physicians. AAP, Elk Grove Village, Il andACOG, WDC.6.American Academy of Pediatrics (2004). Management of Hyperbilirubinemiain the Newborn Infant 35or MoreWeeks of Gestation. Pediatrics July; 114(1): 297-7.Briggs, GG, Freeman, RK, YaffeSJ. (2005) Drugs inPregnancy and Lactationed, BaltimoreLippincott Williams & Wilkins8.Geddes, DT, Langton, DB, Gollow, I Jacobs, LA, Hartmann, PE, Simmer, K (2008) Freunlotomy for breastfeeding Infants with ankyloglossia: effect onmilkremovaland sucking mechanism as imaged by ultrasound. Pediatrics 2008; 9.HaleT (2012)Medications andMothers’Milk Amarillo: Hale Publishing. LP10.Hale, TW. Hartman, PE. (2007)Textbook of Human Lactation, FirstEditionAmarillo, TX. Hale Publishing, L.P.11.Smith,LJ (2010)Impact of Birthing Practices on Breastfeeding.Second EditionJones and BartlettPublishers, Inc. Boston12.Labbok, M. Cooney, K, Coly S (1994) Guidelines: Breastfeeding, family planning, and the LactationalAmenorrheaMethod–LAM. Washington,DC:Institutefor Reproductive Health, GeorgetownUniversity13.Lawrence RAand LawrenceRM (2011),Breastfeeding—A Guide for the Medical Profession,Seventh Edition, St. Louis, MO:Mosby. WELLSTARTINTERNATIONALModule3-Problems 14.LactMed, National Library of Medicine data base. (A free frequently updated internet serviceaccessed at:www.toxnet.nlm.nih.gov/egi-bin/sis/html.gen?LACT 15.McClellan,HL, Hepworth,AR, etal.(2012)Breastfeeding frequency, milk volume, andduration in mother-infant dyads with persistent nipplepain.BreastfeedMed(7) pp 275-281.16.Mohrbacher,N)Breastfeeding Answers Made Simple: A Guide for Helping Mothers. HalePublishing Co. Amarillo, Texas17.Noonan,M. Breastfeeding:enough milk?BJ Midwifery 19(2)pp82-89.18.Riordan J and Wambach K(2010)Breastfeeding and Human Lactation, Fourth : Jones and Bartlett Publishers, Inc.Boston19.Truitt ST, Fraser AB, GrimesDA, Gallo MF,Schulz KF.Cochrane Database Syst Rev. 2003; (2):CD003988. Combined hormonal versus nonhormonalversus progestin-only contraceptionin lactation20.Walker, M (2014)Breastfeeding Management for the Clinician: Using the Evidence. 3ishers Inc. Boston21.WHO (2009) Infantand Young Child Feeding: ModelChapter for Textbooks for MedicalStudents and Allied Health Professionals. WHO Geneva. .who.int/nutrition/publications/inf97494/en/index.html SectionIV WELLSTARTINTERNATIONALPost-TestPleasecircletheappropriateresponse:Identifythecomponentofhumanmilkthatbindsironlocallytoinhibitbacterialgrowth:secretoryIgAoligosaccharidesIdentifythecomponentofhumanmilkthatprovidesspecificimmunityagainstmanysecretoryIgAThemost importantcriterionforassessingthemilktransferduringafeedingatthebreastvisibleareolacompressionaudibleswallowproperalignmentproperattachmentComparedtoformula,humanmilkcontainshigherlevelsof:vitaminDvitaminAnoneoftheaboveThehormoneconsideredresponsibleformilkejectionis:oxytocin WELLSTARTINTERNATIONALPost-TestAmotherwithathree-dayoldbabypresentswithsorenipples.Theproblembeganwiththefirstfeedingandhaspersistedwitheveryfeeding.Themostlikelysourceoftheproblemis:feedingtoolongpoorattachmentbaby’ssuckistoostronglackofnipplepreparationduringpregnancyThehormoneconsideredresponsibleformilksynthesisis:oxytocinWhichofthefollowingwouldyousuggestthatawomanwithinvertednipplesdoduringthethird trimester?UsebreastshellswithguidancefromherhealthcareproviderCutholesinthebratoallowthenipplestoprotrude;wearitdayandnightEncourage everting the nipples fourtimesadaytopermanentlyeverthernipplesDonothingbecausethenaturalchangesinthebreastduringpregnancyandtheinfant’ssucklingpostpartummayevertthenipplesWhichofthefollowingismostlikelytohavethegreatesteffectonthevolumeofmilkawomanproduces?maternalweightforheightmaternalfluidintakesupplementationoftheinfantwithformulamaternalcaloricintakebothaandcInfantsexclusivelybreastfedforaboutsixmonthswillhave:Fewerepisodesoflowerrespiratoryinfectionfewerepisodesofdiarrheanoneoftheabovebotha and baboveTheadditionofcomplementaryfoodstobreastfedinfantsisrecommendedatabout:2months4months6months8months10months WELLSTARTINTERNATIONALPost-TestSignsofadequatebreastmilkintakeintheearly(first4-6)weeksincludeallEXCEPT:babygainsweightatleast3-4stoolsin24hourssoundsofswallowingbabysleepsthroughthenightatleast6diaperswetwithurinein24hoursItisespeciallyimportantthataninfantwithastrongfamilyhistoryofallergyshouldbe breastfedfor:2months4months6months8months10monthsSevereengorgementismostoftendueto:highoxytocinlevelinfrequentfeedingshighprolactinlevelpostpartumdepressionThemostcommoncauseofpoorweightgainamongbreastfedinfantsduringthefirstfourweeksafterbirthis:maternalendocrineproblemsmaternalnutritionaldeficienciesinfantmetabolicdisordersinfrequentorineffectivefeedingslowfatcontentofbreastmilkAbreastfeedingmotherwitha3-montholdinfanthasaredtenderwedge-shapedareaontheouterquadrantofonebreast.Shehasflu-likesymptomsandatemperatureof39YourmanagementincludesallofthefollowingEXCEPT:extrarestinterruptbreastfeedingfor48hoursmoistheattotheinvolvedregionantibioticsfor10to14daysdaysStudieshaveindicatedthattheLactationalAmenorrheaMethod(LAM)ofcontraceptionislessreliableunderwhichofthefollowingcircumstances:feeds8ormoretimesin24hoursisgivennoregularsupplementsislessthan8monthsoldcontinueswithnightfeedings WELLSTARTINTERNATIONALPost-TestWhichofthefollowingstatementsisnottrueofTheInternationalCodeofMarketingofBreastmilkSubstitutesapprovedasaresolutionintheWorldHealthAssembly(WHA)inisupdatedeverytwoyearsbytheWHAprovidesguidelinesfortheethicalmarketingofinfantformulaisincorporatedintotheBabyFriendlyHospitalassessmentwasapprovedbyallWHAmembercountriesincludesbottles,nipples,andbreastmilksubstitutesNipplecandidiasiscanbeassociatedwithallofthefollowingEXCEPT:oralthrushintheinfantburningpaininthebreastfeverandmalaisepinkandshinyappearanceofthenipplesandareolaJaundiceinanormalfulltermbreastfeedinginfantisimprovedby:givingglucosewaterafterbreastfeedinggivingwaterafterbreastfeedingbreastfeedingfrequently(atleast8ormoretimesin24hours)bothaandcBreastfeedingiscontraindicatedinwhichofthefollowingconditions:infantwithgalactosemiamotherwithmastitismotherwithhepatitisBmotherwithinvertednipplesbothaandcReasonsforincludingbreastfeedingsupportformotherinfantinplanningfororrespondingtomajoremergencieswherecleanwater,sanitationandpoweraredisrupteddonotinclude:ItislessexpensivethanprovidingforinfantformulaWithsupportevenmotherswhohavealreadyweanedcanbeassistedtoBreastmilkprovidesimmunoglobulinsthatactivelypreventinfection.InastressfulemergencysituationbreastfeedingprovidesasecureenvironmentforinfantsandyoungchildrenHospitalpoliciesthatpromotebreastfeedinginclude:useofadropperforroutinewatersupplementationuninterruptedsleepthefirstnighttoallowmother’smilksupplytobuildupunlimitedaccessofmothertobabyuseofpacifierstopreventsorenipples WELLSTARTINTERNATIONALPost-Test through28.Labelthestructuresofthebreastbyinsertingnexttotheappropriatepointerthenumberofthestructurelistedbelow:Montgomery’sglandsSupportingfatandothertissues WELLSTARTINTERNATIONALPostTest(note:anexplanationoftheanswerisdiscussedinmoduleidentified)Infantsexclusivelybreastfedforaboutsixmonthswillhave:fewerepisodesofdiarrheafewerepisodesoflowerrespiratoryinfectionc.botha and babove d.noneoftheabove(Module1)Comparedtoformula,humanmilkcontainshigherlevelsof: vitaminAvitaminDnoneoftheabove(Module1)Thehormoneconsideredresponsibleformilksynthesisis:oxytocin (Module2)Thehormoneconsideredresponsibleformilkejectionis:oxytocin (Module2)Identifythecomponentofhumanmilkthatbindsironlocallytoinhibitbacterialgrowth: secretoryIgA(Module1)Identifythecomponentofhumanmilkthatprovidesspecificimmunityagainstmany WELLSTARTINTERNATIONALPostTestsecretoryIgA (Module1)Whichofthefollowingwouldyousuggestthatawomanwithinvertednipplesdoduringthethirdtrimester?cutholesinthebratoallowthenipplestoprotrude;wearitdayandnightdonothingbecausethenaturalchangesinthebreastduringpregnancy andtheinfant’ssucklingpostpartummayevertthenipples usebreastshellswithguidancefromherhealthcareproviderencourage everting the nipples fourtimesadaytopermanentlyeverthernipples(Module3)Themost importantcriterionforassessingthemilktransferduringafeedingatthebreastis:audibleswallow properalignmentproperattachmentvisibleareolacompression(Module2)Amotherwithathree-dayoldbabypresentswithsorenipples.Theproblembeganwiththefirstfeedingandhaspersistedwitheveryfeeding.Themostlikelysourceof theproblemis:baby’ssuckistoostrongfeedingtoolonglackofnipplepreparationduringpregnancypoorattachment (Module3)Signsofadequatebreastmilkintakeintheearly(first4-6)weeksincludeallEXCEPT:atleast3-4stoolsin24hoursatleast6diaperswetwithurinein24hoursbabygainsweightd.babysleepsthroughthenight e.soundsofswallowing(Module2)Severeengorgementismostoftendueto:highoxytocinlevelhighprolactinlevel WELLSTARTINTERNATIONALPostTestinfrequentfeedings postpartumdepression(Module3)NipplecandidiasiscanbeassociatedwithallofthefollowingEXCEPT:burningpaininthebreastfeverandmalaise oralthrushintheinfantpinkandshinyappearanceofthenipplesandareola(Module3)Abreastfeedingmotherwitha3-montholdinfanthasaredtenderwedge-shapedareaontheouterquadrantofonebreast.Shehasflu-likesymptomsandatemperatureofC.YourmanagementincludesallofthefollowingEXCEPT:antibioticsfor10to14daysdaysextrarestinterruptbreastfeedingfor48hours moistheattotheinvolvedregion(Module3)Whichofthefollowingismostlikelytohavethegreatesteffecton thevolumeofmilkawomanproduces?maternalcaloricintakematernalfluidintakematernalweightforheightsupplementationoftheinfantwithformula bothaandc(Module2)Theadditionofcomplementaryfoodstobreastfedinfantsisrecommendedatabout:2months4months6months 8months10months(Module1)Itisespeciallyimportantthataninfantwithastrongfamilyhistoryofallergyshouldbe breastfedfor:2months4months6months 8months10months(Module1) WELLSTARTINTERNATIONALPostTestThemostcommoncauseofpoorweightgainamongbreastfedinfantsduringthefirstfourweeksafterbirthis:infantmetabolicdisordersinfrequentorineffectivefeedings lowfatcontentofbreastmilkmaternalendocrineproblemsmaternalnutritionaldeficiencies(Module3)Jaundiceinanormalfulltermbreastfeedinginfantisimprovedby:breastfeedingfrequently(atleast8ormoretimesin24hours) givingglucosewaterafterbreastfeedinggivingwaterafterbreastfeedingbothaandc(Module3)Breastfeedingiscontraindicatedinwhichofthefollowingconditions:infantwithgalactosemia motherwithhepatitisBmotherwithinvertednipplesmotherwithmastitisbothaandc(Module1and3)Hospitalpoliciesthatpromotebreastfeedinginclude:uninterruptedsleepthefirstnighttoallowmother’smilksupplytobuildupunlimitedaccessofmothertobaby useofadropperforroutinewatersupplementationuseofpacifierstopreventsorenipples(Module2)StudieshaveindicatedthattheLactationalAmenorrheaMethod(LAM)ofcontraceptionislessreliableunderwhichofthefollowingcircumstances:isgivennoregularsupplementscontinueswithnightfeedingsc.islessthan8monthsold d.feeds8ormoretimesin24hours(Module3)ReasonsforincludingBreastfeedingsupportformotherinfantpairsinplanningfororrespondingtomajoremergencieswherecleanwater,sanitationandpoweraredisrupteddonotinclude:Breastmilkprovidesimmunoglobulinsthatactivelypreventinfection.b.Itislessexpensivethanprovidingforinfantformula Inastressfulemergencysituationbreastfeedingprovidesasecureenvironmentforinfantsandyoungchildren WELLSTARTINTERNATIONALPostTest Withsupportevenmotherswhohavealreadyweanedcanbeassistedto(Module3)WhichofthefollowingstatementsisnottrueofTheInternationalCodeofMarketingofBreastmilkSubstitutesapprovedasaresolutionintheWorldHealthAssembly(WHA)inprovidesguidelinesfortheethicalmarketingofinfantformulaisincorporatedintotheBabyFriendlyHospitalassessmentc.wasapprovedbyallWHAmembercountries isupdatedeverytwoyearsbytheWHAincludesbottles,nipples,andbreastmilksubstitutes(Module2)through28.Labelthestructuresofthebreastbyinsertingnexttotheappropriatepointerthenumberofthestructurelistedbelow:Montgomery’sglandsSupportingfatandothertissues(Module2)Post-testScoreCard PossibleScore:28Post-testscore: SectionV Highlights from LactationManagementSelf-Study Modules, LevelIAcceptableMedical Reasons for Use of Breastmilk Substitutes, World Health Organization/UNICEF,Infant Feeding in Emergency SituationsTenMajor Provisionsof the InternationalCode of Marketingof BreastmilkSubstitutesABM Protocol #8: The Human Milk Storage: Informationfor Home Use forHealthy Full-termInfants.Guidelines for HandExpressionWeb Sites of InterestAlphabetic Listing of References ThismaterialprovidesasummaryofsomeoftheimportantclinicalpointscontainedintheSelf-StudyModules.Forthosewholiketohaveclinicalremindersintheirhandheldelectronicdeviceorpocketnotebook,theformatallowsthesesummariestobeeasilytransferredorclippedandinsertedintoasmallnotebookWELLSTARTINTERNATIONAL HumanmilkCommercialSubstitutes Proteinquality/quantity,easiertodigestPartlycorrected quality/quantityofessentialfattyacids,lipasepresentLipaseabsent VitaminsAdequateexceptforDandKVitaminsadded CorrectamountPartlycorrected Anti-infectiveproperties Growth Digestiveenzymes Hormones RecommendationsforAdequateBreastmilkIntake:Breastfeedingatleast8timesin24hoursIndicatorofAdequateIntake(earlyweeks):Bowelmovements:3-4ormoreevery24hrs.Urination:6ormoretimesevery24hrs.BabyiscontentbetweenfeedingsAverageweightgain:5-7ounces/week(100-200gmsperweek)SignsofEffectiveMilkRemoval:SoundsofbabyswallowingduringafeedBreastsfullbeforefeeding,softerafterward(earlyweeks)“Let-downsensation”ormilkdripping©WELLSTARTINTERNATIONAL WhyDoMothersStopBreastfeeding?Timeand Reason Counseling Points First 2weeks:Problems such as sore nipples Attachmentassessment andhelpLack of SupportWhereto go for help Support groupsQuestionsfortheBreastfeedingMotherWhy didyoudecideto breastfeed your baby?Whatinformationaboutbreastfeeding doyoualreadyhave?Are familymembers supportive ofyour interestin breastfeeding?Will someonebeathome to help youintheearly weeks?Do you haveanyspecial medical problems that require treatmentor medications?Haveyoueverhad breast surgery? Ifso for whatproblem?How long doyou plan to breastfeed?Do you planto returnto work/school?(Ifhas breastfed otherchildren before) How long did you breastfeed before?Whydid you stop atthattime? Did you haveanyproblems?SummaryofDifferencesBetweenHumanMilkandCommercialSubstitutesMarketedforNormalTermInfantsAt3-4weeks:Mother’s breasts nolongerThemilk supplyhasfeel firm betweenfeedingsadjusted to baby’s needsAt3-6weeks:“Appetitespurt” or “growthMorefrequent feedingwill spurt”increasethemilk supplyandsatisfythebabyuntilthe next spurtReturn towork or schoolBelief that breastfeedingStrategies to continuebreast andwork/schoolarenotfeeding:compatibleExpress & storebreast milk, feedduring breaks atnearbychildcare facility,takebabytoworkAt5-7monthsEruptionof teethGentlemotion of baby’s tongueover the lower gumareunchangedwhen teeth have erupted6monthsIntroduction of solidsBreast milk continues to providenourishment and protection from infection©WELLSTARTINTERNATIONAL AcceptableMedicalReasonsforSupplementation*Permanent Inborn errorsofmetabolism,i.e.,galactosemia, phenylketonuria, maplesyrup urine disease. (rare).Mothers whoare infectedwith HIVifARV interventionsare notavailable.Verylow birthweight ( 1500 g) and infants born before32 weeks gestational ageInfants atriskfor potentiallysevere hypoglycemia(smallfor gestational age, preterm,intra-partum stress,diabetic mothers)and blood sugar does notrespondtobreastfeedingor breastmilkfeeding.Motherwho istooillpostpartumtocarefor her baby,i.e.,psychosis,eclampsia,unresponsiveor shock.Mothers taking medications contraindicatedwhen breastfeeding(rare).Whensupplementing,mother’s milksupplyshould be maintainedinmostcasesthesemedical reasonsforsupplementationareconsistentwiththe2009 approvedWHOrecommendations.TenStepstoSuccessfulBreastfeedingEveryfacilityprovidingmaternityservices and care for newborninfantsshould:Haveawritten breastfeeding policy thatis routinelycommunicatedto allhealth carestaff.Train allhealth carestaffinskills necessaryto implementthis policy.Informall pregnantwomenaboutthebenefitsand managementofbreastfeeding.Help mothersinitiatebreastfeeding within ahalf-hour ofbirth.Show mothers how tobreastfeed and how to maintainlactation even iftheyshould beseparatedfromtheir infants.Givenewborn infants no food or drinkother thanbreast milk, unless medically Practice rooming-in (allow mothers and infants toremain together) 24 hours aday.Encourage breastfeeding on demand.Giveno artificial nipples orpacifiers tobreastfeedinginfants.Foster theestablishmentofbreastfeedingsupportgroups and refer mothers tothemondischarge fromthehospital or clinic. CommonBreastfeedingProblemsBreastfeedingproblemsareusuallyeasilypreventedandtreated.Fortheproblemslistedhere,thecontinuationofbreastfeedingisnotonlysafe,butcanhelpremedytheproblem.MastitisCommoncause:NippleabrasionsMilk stasisTreatment:Treat nippleabrasions and assureeffectivesuckling.Nurse more frequently(mastitis is aninfection of thebreast,notthemilk).Applymoist heat for severalminutes before each feedingRelieveinflammation, pain andfever.Takeappropriate antibiotics as prescribedfor10to14 days.Rest as much as possibleforat least 24hours.Drink more fluids to meet thirst needs.“Not enoughMilk” Commoncause:Ineffectiveand/orinfrequent sucklingTreatmentCheckforeffectivesucklingpositionIncreasefeedingfrequency,and feed bothdayand nightApplymoist heat beforefeedingGentle stimulationof nippleand areola Massage breasts beforeand duringfeedingReassurance©WELLSTARTINTERNATIONAL CommonBreastfeedingProblemsBreastfeeding problems are usually easilyprevented and treated.For theproblems listedhere, thecontinuation of breastfeeding is not onlysafe, but canhelp remedytheproblem.Engorgement Commoncause:Insufficient frequencyof breastfeedsInsufficient emptyingof thebreastPoor positioning or poor attachment to thebreastTreatment:Express breastmilk byhand, or pump, before feeds to soften the areola.Compression to edematous areola using fingers (reverse pressure softening).Breastfeed more frequentlyand/or for longerperiodsImproveinfant positioningand attachmentUsemoist heat andgentle massage before feeding; coolpacksafter.If available,anti-inflammatorydrugs to reduce inflammation.Cracked/Sore Nipples Common cause:Poor positioning andattachment of infant on thebreastInappropriatesuckling techniqueCandidiasis mother and babyTreatment:Assistwith positioningandattachmentContinue breastfeedingTreat both mother and bab y for Candidiasis B.Acceptable Medical Reasons for Use of Breast-MilkSubstitutes, World Health OrganizationandUNICEF TheteachingmaterialsandassessmentcriteriaoftheWHO/UNICEFTheBabyFriendlyHospitalInitiative,begunin1992,haverecentlybeenupdatedtoincorporatethemostrecentresearch.AmongthedocumentsrelevanttotheconcernsofusersoftheLevelISelf-StudyModulesaretherevisedcriteriafortheappropriateuseofbreastmilksubstitutes.Thefollowingmaterialincludesthe2009approvedWHO/UNICEFstatementregardingthismatter WHO/NMH/NHD/09.01 WHO/FCH/CAH/09.01 Acceptablemedicalreasonsforuse ofbreast-milksubstitutes ©WorldHealthOrganization2009Allrightsreserved.Publicationsofthe WorldHealthOrganizationcan be obtainedfrom WHOPress, WorldHealthOrganization, 20AvenueAppia,1211Geneva27,Switzerland(tel.: +41227913264;fax:+41227914857;e-mail:bookorders@who.int ).Requestsforpermissiontoreproduceortranslate WHOpublications–whetherforsaleorfor noncommercial distribution–should beaddressedto WHOPress,attheabove address(fax: +4122 7914806;e-mail:permissions@who.int) Thedesignationsemployedandthepresentationofthematerial inthispublication donotimplythe expressionof anyopinionwhatsoeveronthe partofthe WorldHealthOrganizationconcerningthelegal statusofanycountry,territory,cityorareaorofitsauthorities,orconcerningthedelimitationofits frontiersorboundaries.Dottedlines onmapsrepresentapproximate borderlinesforwhichtheremay notyetbefull agreement.Thementionofspecificcompaniesorofcertainmanufacturers’products doesnotimplythattheyare endorsedorrecommended bythe World HealthOrganizationinpreferencetoothersof asimilarnature thatarenotmentioned.Errorsandomissionsexcepted,thenamesofproprietaryproductsare distinguishedbyinitialcapital letters.Allreasonable precautionshavebeentakenbythe World HealthOrganizationtoverifytheinformationcontained inthis publication.However,the publishedmaterialisbeingdistributedwithoutwarrantyof any kind,eitherexpressed or implied.Theresponsibilityfortheinterpretationanduseofthemateriallieswiththe reader.Innoeventshallthe World HealthOrganizationbeliablefordamages arisingfrom AlistofacceptablemedicalreasonsforsupplementationwasoriginallydevelopedbyWHOandUNICEFasanannextotheBaby-friendlyHospitalInitiative(BFHI)packageoftoolsin1992.WHOandUNICEFagreedtoupdatethelistofmedicalreasonsgiventhatnewscientificevidencehademergedsince1992,andthattheBFHIpackageoftoolswasalsobeingupdated.TheprocesswasledbythedepartmentsofChildandAdolescentHealthandDevelopment(CAH)andNutritionforHealthandDevelopment(NHD).In2005,anupdateddraftlistwassharedwithreviewersoftheBFHImaterials,andinSeptember2007WHOinvitedagroupofexpertsfromavarietyoffieldsandallWHORegionstoparticipateinavirtualnetworktoreviewthedraftlist.Thedraftlistwassharedwithalltheexpertswhoagreedtoparticipate.Subsequentdraftswerepreparedbasedonthreeinter-relatedprocesses:a)severalroundsofcommentsmadebyexperts;acompilationofcurrentandrelevantWHOtechnicalreviewsandguidelines(seelistofreferences);andc)commentsfromotherWHOdepartments(MakingPregnancySafer,MentalHealthandSubstanceAbuse,andEssentialMedicines)ingeneralandforspecificissuesorqueriesraisedbyexperts.TechnicalreviewsorguidelineswerenotavailablefromWHOforalimitednumberoftopics.Inthosecases,evidencewasidentifiedinconsultationwiththecorrespondingWHOdepartmentortheexternalexpertsinthespecificarea.Inparticular,thefollowingadditionalevidencesourceswereused:TheDrugsandLactationDatabase(LactMed)hostedbytheUnitedStatesNationalLibraryofMedicine,whichisapeer-reviewedandfullyreferenceddatabaseofdrugstowhichbreastfeedingmothersmaybeexposed.TheNationalClinicalGuidelinesforthemanagementofdruguseduringpregnancy,birthandtheearlydevelopmentyearsofthenewborn,reviewdonebytheNewSouthWalesDepartmentofHealth,Australia,2006.Theresultingfinallistwassharedwithexternalandinternalreviewersfortheiragreementandispresentedinthisdocument.Thelistofacceptablemedicalreasonsfortemporaryorlong-termuseofbreast-milksubstitutesismadeavailablebothasanindependenttoolforhealthprofessionalsworkingwithmothersandnewborninfants,andaspartoftheBFHIpackage.Itisexpectedtobeupdatedby2012.ThislistwasdevelopedbytheWHODepartmentsofChildandAdolescentHealthandDevelopmentandNutritionforHealthandDevelopment,inclosecollaborationwithUNICEFandtheWHODepartmentsofMakingPregnancySafer,EssentialMedicinesandMentalHealthandSubstanceAbuse.Thefollowingexpertsprovidedkeycontributionsfortheupdatedlist:PhilipAnderson,ColinBinns,RiccardoDavanzo,RosEscott,CarolKolar,RuthLawrence,LidaLhotska,AudreyNaylor,JairoOsorno,MarinaRea,FelicitySavage,MaríaAsunciónSilvestre,TerezaToma,FernandoVallone,NancyWight,AnthonyWilliamsandElizabetaZisovska.Theycompletedadeclarationofinterestandnoneidentifiedaconflictinginterest. IntroductionAlmostallmotherscanbreastfeedsuccessfully,whichincludesinitiatingbreastfeedingwithinthe firsthouroflife,breastfeedingexclusivelyforthefirst6monthsandcontinuingbreastfeeding (alongwithgivingappropriatecomplementaryfoods)upto2yearsofageorbeyond.ExclusivebreastfeedinginthefirstsixmonthsoflifeisparticularlybeneficialformothersandPositiveeffectsofbreastfeedingonthehealthof infantsandmothersareobservedinallsettings. Breastfeedingreducestheriskofacuteinfectionssuchasdiarrhoea,pneumonia,earinfection, Haemophilusinfluenza,meningitisandurinarytractinfection(1).ItalsoprotectsagainstchronicconditionsinthefuturesuchastypeIdiabetes,ulcerativecolitis,andCrohn’sdisease. Breastfeedingduringinfancyisassociatedwithlowermeanbloodpressureandtotalserum cholesterol,andwithlowerprevalenceoftype-2diabetes,overweightandobesityduring adolescenceandadultlife(2).Breastfeedingdelaysthereturnofawoman'sfertilityandreduces therisksofpost-partumhaemorrhage,pre-menopausalbreastcancer andovariancancer(3).Nevertheless,asmallnumberofhealthconditionsoftheinfantorthemothermayjustify recommendingthatshedoesnotbreastfeedtemporarilyorpermanently(4).Theseconditions, whichconcernveryfewmothersandtheirinfants,arelistedbelowtogetherwithsomehealth conditionsofthemotherthat,althoughserious, arenotmedicalreasonsforusingbreast-milksubstitutes.Wheneverstoppingbreastfeedingisconsidered,thebenefitsofbreastfeedingshouldbeweighedagainsttherisksposedbythepresenceofthespecificconditionslisted.INFANTCONDITIONSInfantswhoshouldnotreceivebreastmilkoranyothermilkexceptspecialized Infantswithclassicgalactosemia:aspecialgalactose-freeformulaisneeded.Infantswithmaplesyrupurinedisease:aspecialformulafreeofleucine,isoleucine andvalineis needed.Infantswithphenylketonuria:aspecialphenylalanine-freeformulaisneeded(somebreastfeedingispossible,undercarefulmonitoring).InfantsforwhombreastmilkremainsthebestfeedingoptionbutwhomayneedotherfoodinadditiontobreastmilkforalimitedperiodInfantsbornweighinglessthan 1500g(verylowbirthweight).Infantsbornatlessthan32weeksofgestation(verypreterm).Newborninfantswhoareatriskofhypoglycaemiabyvirtueofimpairedmetabolicadaptationorincreasedglucosedemand(suchasthosewhoarepreterm,smallforgestationalageorwhohaveexperiencedsignificantintrapartumhypoxic/ischaemicstress,thosewhoareillandthosewhosemothersarediabetic (5)iftheirbloodsugar failstorespondtooptimalbreastfeedingorbreast-milkfeeding. MATERNALCONDITIONSMotherswhoareaffectedbyanyoftheconditionsmentionedbelowshouldreceivetreatment accordingtostandardguidelines.Maternalconditionsthatmayjustifypermanentavoidance ofbreastfeedingHIVinfection:ifreplacementfeedingisacceptable,feasible,affordable,sustainableandsafe(AFASS)(6).Otherwise,exclusivebreastfeedingforthefirstsixmonthsisrecommended.MaternalconditionsthatmayjustifytemporaryavoidanceofbreastfeedingSevereillnessthatpreventsamotherfromcaringforherinfant,forexamplesepsis.Herpes simplexvirustype1(HSV-1):directcontactbetweenlesionsonthemother's breastsandtheinfant'smouthshouldbeavoideduntilallactivelesionshaveresolved.Maternalmedication:sedatingpsychotherapeuticdrugs,anti-epilepticdrugsandopioidsandtheircombinationsmaycausesideeffectssuchas drowsinessandrespiratorydepressionandarebetteravoidedifasaferalternativeisavailable(7)radioactiveiodine-131isbetteravoidedgiventhatsaferalternatives areavailable-amothercanresumebreastfeedingabouttwo months afterreceivingthissubstance;excessiveuseoftopicaliodineoriodophors(e.g.,povidone-iodine),especiallyonopenwounds ormucousmembranes,canresult inthyroidsuppressionorelectrolyte abnormalitiesinthebreastfedinfantandshouldbeavoided;cytotoxicchemotherapyrequiresthatamotherstopsbreastfeedingduringtherapy.Maternalconditionsduringwhichbreastfeedingcanstillcontinue,although healthproblemsmaybeofconcernBreastabscess:breastfeedingshouldcontinueontheunaffectedbreast;feedingfromthe affectedbreastcanresumeoncetreatmenthasstarted(8).HepatitisB:infantsshouldbegivenhepatitisBvaccine,withinthefirst48hoursor assoon aspossiblethereafter(9).HepatitisC.Mastitis:ifbreastfeedingisverypainful,milkmustberemovedbyexpressiontoprevent progressionofthecondition(8).Tuberculosis:motherandbabyshouldbemanagedaccordingtonationaltuberculosisguidelines(10).Substanceusematernaluseofnicotine,alcohol,ecstasy,amphetamines,cocaineandrelatedstimulants hasbeendemonstratedtohaveharmfuleffectsonbreastfedbabies;alcohol,opioids,benzodiazepinesandcannabiscancausesedationinboththemother andthebaby.Mothersshouldbeencouragednottousethesesubstances,andgivenopportunitiesandsupporttoabstain.ThemostappropriateinfantfeedingoptionforanHIV-infectedmotherdependsonher and herinfant’sindividual circumstances,includingherhealth status,butshould takeconsideration ofthehealth servicesavailable andthe counselling andsupportshe islikelyto receive.Exclusivebreastfeedingis recommended for thefirstsixmonthsoflifeunless replacement feedingisAFASS.When replacement feedingisAFASS,avoidanceof allbreastfeeding byHIV-infected women is recommended.Mixed feedinginthe first6monthsoflife(thatis,breastfeeding while alsogiving otherfluids,formulaor foods)shouldalways beavoidedbyHIV-infectedmothers.Motherswhochoosenottoceasetheiruseofthesesubstancesorwhoareunabletodososhouldseekindividualadviceontherisksandbenefitsofbreastfeeding dependingontheirindividual circumstances.Formotherswhousethesesubstancesinshortepisodes,considerationmaybe giventavoiding breastfeeding temporarilyduring thistime. Technical updatesofthe guidelines onIntegratedManagement ofChildhood Illness(IMCI).Evidenceandrecommendationsforfurtheradaptations.Geneva, WorldHealthOrganization,2005.Evidence onthelong-termeffectsofbreastfeeding:systematicreviews andmeta-analyses.Geneva, WorldHealthOrganization, 2007.(3)León-CavaNetal.Quantifyingthe benefitsofbreastfeeding: a summaryoftheevidence. Washington, DC,PanAmericanHealthOrganization, 2002(http://www.paho.org/English/AD/FCH/BOB-Main.htm accessed 26June 2008).(4)ResolutionWHA39.28.InfantandYoungChild Feeding.In:Thirty-ninthWorldHealth Assembly, Geneva, 5–16May1986.Volume1. Resolutionsandrecords. Final.Geneva, WorldHealthOrganization,1986 (WHA39/1986/REC/1),Annex 6:122–135.(5)Hypoglycaemiaofthenewborn:reviewoftheliterature.Geneva, WorldHealthOrganization,1997 (WHO/CHD/97.1;http://whqlibdoc.who.int/hq/1997/WHO_CHD_97.1.pdf ,accessed 24June2008).HIVandinfantfeeding:updatebased on thetechnicalconsultationheld onbehalfoftheInter-agencyTask Team(IATT) onPreventionofHIVInfectioninPregnant Women,Mothersand theirInfants,Geneva, 25–27October2006.Geneva, WorldHealthOrganization, 2007http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf ,accessed23June 2008).Breastfeedingandmaternalmedication:recommendationsfordrugsintheEleventh WHOModel Listof Essential Drugs.Geneva, WorldHealthOrganization,2003.Mastitis:causesandmanagement.Geneva,WorldHealthOrganization,2000(WHO/FCH/CAH/00.13;http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.13.pdf ,accessed 24June 2008).Hepatitis B andbreastfeeding.Geneva, WorldHealthOrganization, 1996.(Update No.22).BreastfeedingandMaternaltuberculosis.Geneva, WorldHealthOrganization,1998(UpdateNo.23).(11)Backgroundpaperstothe national clinicalguidelinesforthemanagementofdrug use duringpregnancy, birthandtheearlydevelopmentyearsofthenewborn.Commissioned bytheMinisterial Council onDrugStrategyunderthe CostShared FundingModel. NSWDepartmentofHealth, NorthSydney, Australia,2006.http://www.health.nsw.gov.au/pubs/2006/bkg_pregnancy.htmlFurtherinformation onmaternalmedicationandbreastfeedingisavailableatthefollowingUnitedStates National LibraryofMedicine(NLM)website:http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT Forfurtherinformation,pleasecontact:DepartmentofNutritionforHealthand Developmentnutrition@who.int Web:www.who.int/nutrition DepartmentofChildandAdolescentHealthandDevelopmentE-mail:cah@who.int www.who.int/child_adolescent_health Address:20AvenueAppia,1211Geneva27,Switzerland C.Infant Feedingin Emergency Situations: Guidelines from Wellstart InternationalSincethefirsteditionoftheseSelf-Studymodules,severaldevastatinginternationalemergencysituationshaveoccurred:theTsunamiinnorthernIndonesia,hurricaneKatrinainLouisianaandfiresinCaliforniaintheUnitedStatesandearthquakesinChina.Formanyreasons,breastfeedingisthebestinfantfeedingmethodundersuchconditions.Breastmilkprovidesessentialnutrientsandfluids,preventsGIandrespiratoryinfectionscommonunderemergencyconditions,providesbabieswithasenseofsecurityandisstressreducingforbothmothersandbabies.Anyone,atanytime,maybeinvolvedinorcalledupontorespondtoemergencysituations.Thusall healthcareprovidersregardlessoftheirareaofprofessionalpractice,needtounderstandtheimportanceofbreastfeedingandassistinsupportingandsustainingthisessentialmodality.ThesebriefWellstartGuidelinesincludesixmostimportantconceptsaswellasatriagetoolfromtheEmergencyNutritionNetworkFurtherdetailsareavailablefromtheirwebsite:http://www.ennonline.net/ife . WELLSTARTINTERNATIONAL InfantandYoungChildFeedinginEmergencySituationsInfants and young children are particularlemergency situations andfeeding must becarefully done. Becauseof the increased risk of diarrhealdiseases .In addition, the security andwarmth providedby breastfeeding is crucial for both mothers and children in chaotic circumstances of an emergency. Therisks associated with bottle and formulafeedingare dramatically incrlimited water and fuel. Theroleof breastfeeding is even more important in the only sustainablsecurity forinfants andyoung children. Exclusiveand prolongedbreastfeeding is often the only form offamily plannisituations. Last but not least, women need validation of their owncompetence, BF is oneof their important traditional roles that can be sustainedduringastressful situation.Misconceptionsaboutbreastfeedinginemergencies1.Women under stress cannot breastfeed2.Malnourished women don’t produce enough milk3.Weaning cannot be reversed4.General promotion of BF is enough5.Human milk substitutes (infant formula and/or milk) areanecessary 1.Women under stress successfullybreastfeedMilk release (letdown) is affectedby stress.Milk production is NOT. Different hormones control these two processes. The treatment for poor milk releaseis increased suckling which increases the releaseof oxytocin, thehormone. Research suggests that lactating women have a lower response tostress, sohelping women to initiate or continue to BF may help them relieve2.MalnourishedwomenIt is extremely important to distinguish between true cases of insufficient milk production(rare) andperceptions. Milk production is relatively unaffected in quantity andquality except in extremely malnourishedwomen (only 1% ofourished it is the mother who suffers, notthe WELLSTARTINTERNATIONALinfant. The solution to helping malnourishedwomen and infants isto feedthe mother not theinfant.Themother will be less harmed by pathogens and she obviously needs morefood. By feeding her, you are helping both the mother and childand harming neither. Remember thatgiving supplements to infants can decrease milk production by decreasing suckling. The treatmentfor truemilkinsufficiencyis increased sucklingfrequencyandduration.3.A mother whohasweaned redevelop her milksupplyremoval, it ispossiblefor women tore-lactate, that is toredevelop a milk supply. The stimulationcan be provided by a willing baby or evenolder child, by hand expressionand stimulationand/or pumping. The process may take severaldays or evena couple of weeks. Mothers need much encouragement, a reasonable supplyof foodand water and protection from stress to the extent possible.Babies, of course, need to be fed in the safestmanner until the milk supply returns.Breastfeedingwomen need; general promotion of breastfeeding isnot enoughLessons learned indevelopment programs showthat most health practitioners havelittle knowledge of breastfeeding anapply equally to emergency programs. Women whosuffer throughviolent situations leading to displacement andemergency situations are at increasedrisk ofbreastfeeding problems. Mothers need help not just motivationalmessages. Relief agencies andfieldworkephysiologyandon how to counselmothers to helpthem optimally breastfeed;howto assess proper positioningandeffectivesuckling andremedy whenng specialists may be useful. Maternalperception of risk of breastmilk insufficiency isan important factor in a women’s decision for early termination of breastfeeding. Theseperceptions may be intensified by the stress of emergency situations. Our firstconcerns shouldbe ensuring optimal breastfeeding behaviors, which may require the selective feeding of lactating women and trauma counseling for women whomay believe they don’t haveenough milk. Policies and services which undermine optimal feeding such as giving food supplements to infants months and using bottles for OralRehydration Solution, shouldcontribute to the restorationor enhancementof woman’s self-esteem, criticalto her ability to carefor herself and her family.5.Humanmilk substitutes (infantformula and/or milk) arealwaysProviding infants andyoung children caught in an emergency situation with substitutes for humanmilk is extremely risky. It should be undertaken only after WELLSTARTINTERNATIONALcareful consideration andfullawareness of theproblems thatmay result. Human milk substitutes must be:limited to the special circumstances of the emergency;guaranteed for the lifetime of emergency;accompanied by additional healthcare resources, clean water, fuel, andmeans to treatdiarrhea;includeplans forthere-establishment of optimal feeding fromthe outsetofthe emergencypublic health authorities.be provided in accordance with the International Code of Marketing of BreastmilkSubstitutesThese guidelines shouldbe disseminated and followed by allagencies working inemergency situations.1.OptimalFeeding Practices inEmergencies:ng within one hour of birthEffective infant positioning (latch-on)Frequent, on-demand feeding untilabout6 months of ageExclusive, breastfeeding until6 months of ageeeding after beginning the addition of appropriate 6 monthsof agell intothe second year of life or beyondand continuedfeeding duringillness.fterillness for catch up growth.Feeding Infants Under Six Months in Emergencies: A Triage Approach to Decision-MakingEmergency situations are usuallyinitially confusing andchaotic. Determiningwho needs what is an essential early step. For protecting and supportingbreastfeeding, the first step is toidentify infants who areor should be breastfedandfurther notingany infants who are temporarily or permanently without theirmother. Ultimately three groups can be established:1.oneneeding only breastfeeding support,2.a secondrequiring more intensive re-lactation help3.a third inwhich substitute feeding is deemed necessary andwill need to be very carefully managed and monitored. WELLSTARTINTERNATIONAL Thefollowing triage diagram maybe helpful. It isfrom:Infant Feeding in Emergencies: Policy, Strategy &PractFeeding inEmergencies, May 1999. This tool is available fromtheEmergency Nutrition Networkon their website: www.ennonline.net/ife .TheEmergency Nutrition Network has a large amount of usefulinformation and andfrequently updates the content ofthe website. The interested reader is encouragedto reviewthis material.DecisionMakinginEmergencies:ATriageApproachforFeedingInfantsUnderSixMonthsofAgeMOTHER ACCOMPANYING CHILDMOTHER NOT ACCOMPANING CHILDchild beforeWet nursing acceptable and availableMother not Wet Nursing not availableLactation OK Lactation Interrupted/reducedLactation possible and acceptableLactation not possible or acceptableBreastfeeding supportRelactation Ensure safe artificial feeding D.Ten Major Provisions of the WHOInternational Code of Marketingof BreastmilkSubstitutesand Subsequent World Health Assembly ResolutionsThefollowinglistsummarizesthemajorprovisionsoftheWHOCodeofMarketingandthesubsequentresolutionspassedbytheWorldHealthAssembly(WHA).TheoriginalCode,passedbyWHAresolutionin1981has11articles.ThroughaprocessofreviewsandresolutionsundertakenbytheWHAeverytwoyears,theCodehascontinuedtoremaincurrentasainternationalguidingdocument.Therearenow14WHAresolutions.Overtheyearsithasbeenmadeclearthatitappliestoanyfoodthatismarketedassuitableforinfants(allformulas,juices,commercialsemisolidweaningfoods)aswellasfeedingbottlesandnipples(teats). D. Ten Major Provisions of the WHO International Code of Marketing of Breastmilk Substitutes and SubsequentResolutions of the World Health Assembly1. No advertising or promotion oftutes and productswithin the scope of the code and relevant WHA resolutions to the General2. No free samples or gif3. Information and labels must advocate breastfeeding and warn againstbottle feeding and contain no pictures or text that idebreastmilk substitutes.4. The health care system must not e use of breastmilk5. No free or low-cost supplies of breastmilk substitutes.Health professionals allowed to receive samples only for research8. No contact between marketing personnel and mothers.9. No gifts or personal samples to health workers.10. All information on artificial feeding, including labels, should explain thebenefits of breastfeeding, the costs and hazards associated with artificialfeeding and the correct use of breastmilk substitutes.Note that the italicized items (2, 4, 6, 7, and 9) are responsibilities of the health professionals.Adapted from: Code Essentials 3: Responsibilities of Health Workers under the of Marketing of Breastmilk Health Assembly Resolutions. 2009. International Baby Food Action Network and theInternational Code Documentation Center, Penang, Malaysiaobtain further details about the Code provided on the IBFAN website: www.ibfan.org E.AcademyofBreastfeedingMedicineProtocol#8:Human milk storage informationfor home use forhealthy full-term infantsTheAcademyofBreastfeedingMedicine(ABM)wasestablishedin1994tobringtogetherphysiciansfromanydisciplinewhohaveacommoninterestinsupportingbreastfeeding.ABMmakesavailable(downloadablewithoutcharge)protocolsregardingsomeofthemostfrequentclinicalmanagementconcerns.ForthisFourthEditionofSelf-StudyModules,LevelI,the Table 1 of the 2010 Protocol#8givescurrentguidelinesonhowtostoreofhumanmilkforhealthyfullterminfants. Students are urged to perature Maximum Storage Duration Room Temperature16–29 C(60 –85 F)3–4 hours optimalRefrigerator 5–8 days under very -17 C (0F)__________________________________________ 1.Wash your hands with soap2.Apply warm moist cloths to your breasts for 3 or 4 minutes before beginning to express.3.With 4 fingers together, gently massage your breasts in a circular pattern followed by light stroking of the breasts toward the nipples. This will help the let-down reflex to stimulate milk flow.4.To express place your thumb on the top of your breast about 1 to 1½ inches (3 to 4 cm) back from the edge of the areola (the more pigmented portion near nipple) and your index finger underneath your breast also about 1 to 1½ inches(3 to 4 cm) from the edge of the 5.Gently press your fingers and thumb back toward your rib cage and then gently compress your thumb and fingers together just behind the areola.6.Rotate the positionof your fingers and thumb around the areola to express all areas.7.Alternate breasts every few minutes or when the flow slows. Repeat the massage and stroking of the breast and express cycle several times on each breast.8.The appearance of the milk will change during t the milk may appear thin and alsmost clear. After the let-down reflex begins the milk appears more creamy white. Some medications, foods and vitamins may slightly alter the color of the milk. Note that the amount of milk obtained may vary at each expression. Don’t worry this is normal. It does not indicate that your milk production is decliningYou can express directly into clean glass or plastic bottles. Remember to not use plastic bottles that contain Bisphenol A. © Wellstart International Areola Thumb hereIndex finger here Gently press thumb and Index finger back toward rib cage and gently G.Web Sitesofinterest in Lactation Management and Breastfeeding PromotionTheinterestinlactationmanagementandbreastfeedingpromotionhasgrownsignificantlysincethefirsteditionoftheseSelf-StudyModuleswaspublishedandmanyusefulwebsiteshaveappeared.Someofthemorefrequentlyusedsitesarelistedonthefollowingpage.FortheinteresteduserofthisLevelItoolthesesiteswillhavefurtherinformationaboutthetopicsincludedaswellasadditionalinformationconcerningtopicsthatarenotconsiderednecessarytocoveratLevelI G.WebSitesofInterestinLactationManagementandBreastfeedingPromotionAcademyofBreastfeedingMedicinewww.bfmed.org AmericanAcademyofFamilyPractice AmericanAcademyofPediatricswww.aap.org/healthtopics/breastfeeding.cfm AmericanCollegeofObstetricsandGynecology Baby-FriendlyUSAwww.babyfriendlyusa.org EmergencyNutritionNetwork InternationalBabyFoodActionNetwork InternationalLactationConsultantsAssociation InternationalSocietyofResearchinHumanMilkandLactationwww.isrhmil.org.umu.se 10.LaLecheLeagueInternational 11.NationalLibraryofMedicineon-lineserviceregardingdrugsduringlactation(LactMed)http://toxnet.nlm.nih.gov/cgi-bin/htmlgen?LACT 12.www.unicef.org 13.U.S.CentersforDiseaseControlwww.cdc.gov/breastfeeding 14.U.S.OfficeofWomen’sHealthwww.womenshealth.gov/breastfeeding 16.WellstartInternationalwww.wellstart.org 17.WorldHealthOrganization(WHO)www.who.int/child_adolescent_health andwww.who.int/nutrition/en 18.WorldAllianceforBreastfeedingAction(WABA)www.waba.org.my WELLSTARTINTERNATIONAL H.Alphabetic Listing of ReferencesReferencesusedinthisSelf-Studytoolarelistedattheendofthespecificpartofthetoolinwhichtheyareused.Tofacilitateasearchforaparticulartext,paperorreportthesereferenceshavealsobeenlistedalphabetically AlphabeticListingofReferencesAcademy of Breastfeeding Medicine (2004). Protocal #8: HumanMilk Storage Information for Homeuse for Healthy Full-TermInfantsBreastfeedingMedicine 5(3):127-130.Academy of Breastfeeding Medicine (2008).Protocol #4:Mastitis.Breastfeeding Medicine, 3 (3)177-180.Academy of Breastfeeding Medicine (2005).during Breastfeeding.Breastfeeding Medicine .(being revised)Academy of Breastfeeding Medicine (2009). Protocol #20: Engorgement.Breastfeeding Medicine 4(2) 111-113American Academy of Pediatrics (2004). the Newborn Infant 35or MoreWeeks of Gestation. Pediatrics July; 114(1): 297-316.(3)American Academy of Pediatrics (2012) Breastfeeding and the use ofhuman milk. Pediatrics.Vol129: 3, e827-841. (1, 2)American Academy of Pediatrics (2009) Red Book: TheReport of the Committeeon Infectious Diseases, 28American Academy of Pediatrics (2008) Prevention of Rickets and vitamin D(1)Deficiency in Infants, Children and Adolescents. Pediatrics 122(5) 1142-American Academy of Pediatrics andthe AmericanCollege of Obstetricians andGynecologists (2006) BreastfeedingHandbook for Physicians. AAP, Elk Grove Village, IL andACOG,WDC. (2,3)American Academy of Pediatrics, Committee on Drugs (2001) The transfer of drugs andother chemicals into human milk,AndersonPO, Knoben JE, eds.(1999)Handbook ofclinical DrugData, 9Drugs inPregnancy and Lactation, Fifth Edition,Baltimore, MD: Williams & Wilkins.(1)Bachrach,V, Schwartz, E, Backrach, L(2003) Breastfeeding and the risk of hospitalization for respiratory disease ininfancy,Arch Pediatr Adolesc Balkam, JAJ,Cadwell,K, Fein,S (2011).Effect ofcomponents of a workplace lactation program on breastfeeding duration among employess of a public-sectoremployeer.Black,RE,Morris, SS,Bryce, J. Where and why are 10 million children dying every year? (2003) The Lancet; 316;2226-2234(F,1)Briggs, GG, Freeman, RK, Yafee SJ (2005). Drugs inPregnancy and Lactation Edition.BaltimoreLippincott Williams andWilkins. (1,3)CDC (2000) CDC Growth Charts:United States, AdvanceData #314, May 30http://www.hhs.gov/news/ Chen, A and Rogan, W.J.(2004) Breastfeeding and the risks of post neonatal death inthe United States. Pediatrics, 113:e435-e439. (1) GColson,SD, Meek, JH,Hawdon, JM. (2008). Optimalposof primitiveneonatalreflexes stimulatingbreastfeeding. Early Hum Dev (2008), doi:10.1016/j.earlhume WHO childgrowth standards and the National Center forHealth Statistics/WHO international growth reference: Implications for childhealthprograms. Public Health Nutrition: 9(7), 942-947.de Onis, M, Garza,C, Onyango, AW, Martorell, R. (2006) WHO Child Growth Standards. Acta Paediatrica Supplement 450, April 2006, 95:7-101(1)de Onis, M, Garza,C,Onyango, AW, Borghi (2007) Comparisonof theWHO childgrowth standards and the CDC 2000 growth charts. J.Nutr. 137:144-Declercq, E et al (2009). Hospital practices and women’s likelihood of fulfilling their intentionto exclusively breastfeed. AJPH 99 (5) 929-935.(2)Dewey K, Heinig J, Nommsen-Rivers L (1995) Differences inmorbidity between breast-fed and formula-fed infants, J Pediatr126(5), Part1: 696-702.National Research CounciSciences: RecommendedDietaryAllowances, 10ed.Washington, DC, U.S. Government Printing Office,1989. (1)Geddes, DT, Langton, DB, Gollow, I Jacobs, LA, Hartmann, PE, Simmer, K (2008) Freulotomy forbreastfeeding Infants with ankyloglossia: effect on milk removaland sucking mechanism as imagedby ultrasound. Pediatrics 2008; Geddes, DT,Kent, JC,Mitoulas,LR, Hartmann,PE. Tongue movement and intra-oral vacuum inbreastfeeding infants. (2008) Early 471-477. (2)HaleT (2012)Medications andMothers’Milk, Thirteenth EditHalePublishing. LP(1,3)Hale, TW. Hartman, PE. (2007)Textbook of Human Lactation, FirstEditionAmarillo, TX. Hale Publishing, L.P. (1,2,3)Hamosh M (2001) BioactiveFactors in Human Milk,America48(1): 69-86.(1)Himelright, I etal (2002)infections associated with the use of powdered infant formula ---Tennessee, 2001. CDC MMWR Weekly April 12, 2002/51(14);298-300(1)Horta, BL.Bahl, R, Martines, J, Victora, CG. (2007)Evidence on the long-term effects ofbreastfeeding: Systematic Reviews and Meta-analyses. WHO, Geneva. (F,1)Ip. S,Chung, M, etal. (2007) Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.EvidenceReport/Technology Assessment No153. AHRQ PublicationNo 07-E007. Agency for Healthcare Research and Quality.(F,1)an, A.(2009)Code Essentials 3: Responsibilities of Health Workers under the InternationalCodeof Marketingof Breastmilk Substitutes andsubsequentWHA resolutions.ICDCPenang, Malaysia.Kramer, MS et al BreastfeedMcClellaningandchild cognitivedevelopment: newevidence froma large randomized trial (2008) Arch Gen Psychiatry 65 Labbok, M. Cooney, K, Coly S (1994) Guidelines: Breastfeeding, family planning, and the LactationalAmenorrheaMethod–LAM. Washington,DC:Institutefor Reproductive Health, GeorgetownUniversity (3)LactMed, National Library of Medicine data base. (A free frequently updated internet serviceaccessed at:www.toxnet.nlm.nih.gov/egi- bin/sis/html.gen?LACT ) (3) LawrenceRAand LawrenceRM (2011)Breastfeeding, a guide for the medical profession,Seventh Edition, St. Louis, MO:Mosby, Inc.(1,2,3)McClellan, HL,Hepworth, AR, etal.2012Breastfeeding frequency, milkvolume, duration inmother-infant dyads with persistent nipplepain.Naylor, AJ. (2001)Baby-Friendly Hospital Initiative: SupportingBreastfeeding in the Twenty-First Century. Pediatric Clinics of North Noonan,M.(2011)Breastfeeding: is my babygetting enough milk?BJ Midwifery19(2)pp82-89.Perez, A, et al. (1992) Clinical study of the lactationalamenorrheamethod for family planning.Lancet Ramsay DT, Kent JC,HartmannRA, HartmannPE. Anatomy of the lactating human breast redefinedwith ultrasound imaging. (2005) J.Anat206, pp525-534. (2)Remington JS andKlein JO (2001)Infectious Diseasesof the Fetus and Philadelphia: WB Saunders Co. (1)Riordan J and Wambach K(2010)Breastfeeding and Human Lactation, Fourth : Jones and Bartlett Publishers, Inc.Boston (1,2)Impact of Birthing Practices on Breastfeeding,Second Edition Strathearn,L, Mamun,AA, Najman, MJ,O’Callaghan(2009) Does breastfeeding protect against childabuseand neglect? A 15-Year cohort study.Pediatrics (2),123; 483-493.(1)Truitt ST, Fraser AB, Grimes DA, Gallo MF,Schulz KF. Cochrane Database Syst Rev. 2003; (2):CD003988. Coversus progestin-onlycontraception inlactation. (3)Walker, M.(2014)ment for the Clinician: Using the Evidence3EditionJones and Bartlett Publishers, Inc. Boston (2)Wellstart International andthe University of California San Diego (1999).LactationManagement Curriculum: A FacultyGuide forSchools of Medicine, rth Edition. San Diego, California; Wellstart International. (F)Infantand Young Child Feeding: ModelChapter for Textbooks for MedicalStudents and Allied Health Professionals. WHO Geneva.WHO Working Group on Infant Growth (1994)AnEvaluation of Infant GrowthGeneva: World HealthOrganization. WHO/NUT/94.8. (1)WHO, UNICEF, UNAIDS,UNFPA (2008).HIVtransmission through breastfeeding: a reviewof the availableevidence–an update from 2001 to 2007. WHO Geneva(1)WHO/UNICEF (2006) Promotion and Support ina Baby-Friendly Hospital, 20 hour Course WHO Geneva(2)WHO/UNICEF(1989), Protecting, Promotingan Supporting Breastfeeding: The Special Role of Maternity Services. A Joint Statement.WHO GenevaFood, Nutrition, Physical Activity, andthePrevention of Cancer: AGlobalPerspective. 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The NationalAcademy Press.K,Jaffe,AC,Phillipi,CA.Pacifierrestriction and exclusive breastfeeding. Pediatrics 131 (4) e1101-e1107.Maisels,MJ,Bhutani,VK,Bogen,D,Newman,TB,Stark,AR,Watchko,JF. Hyperbirubinemiainthenewborninfant� 35weeks’gestation:Anupdatewith clarifications. Pediatrics 124(4) 1193-1198, 2009The OxytocinFactor:TappingtheHormone ofCalm,Love,and DaCapoPress (2003).Mohrbacher,N.(2010)BreastfeedingAnswersMadeSimple:AGuideforHelpingMothers.HalePublishing Co. Amarillo, TexasMulder,PJ, Johson,TS,Baker, LC. (2010) Excessiveweight loss in breastfed lization.JOGNN39(1): pp15-26.Noel-Weiss,J,Woodend,AK,Perterson,WE,Gibb,W,Groll,DL.Anobservational study of associationsamong maternalfluidsduring parturition, neonatal output andbreastfed newborn weight loss. Internat. Breastfeeding Journal 2011, 6:9.Ramsay,DT,Kent,JC,Hartmann,RA,Hartmann,PE.Anatomy of thelactating human breast redefined with ultrasoundimaging. J.Anat. (2005) 206, pp 525-SavetheChildren.SurvivingtheFirstDay:StateoftheWorld’sMothersThe2013 annual report of Save the Children. Shealy,KR,Li,R,Benton-Davis,S,Grummer-Strawn,LM.TheGuideto BreastfeedingInterventions.Atlanta:U.S.DepartmentofHealthandHuman Services, Centers forDiseas e Control and Prevention,2005.. Improving Child Nutrition: An achievable imperativefor global UNICEF2013.Winberg,J. Mother and Newborn baby: Mutual regulation of physiology and behavior-a selective review. DevelWorldHealthOrganizationandUNICEF.HIVandInfantFeeding:PrinciplesandRecommendationsforInfantFeedingintheContextofHIVandaSummaryof Evidence(2010).