art and science of breastfeeding

Dr. Harivansh Chopra,Dr. Harivansh Chopra,D.C.H.,M.DD.C.H.,M.D

Professor,Professor,

Department of Community Medicine,Department of Community Medicine,

LLRM Medical College, Meerut.LLRM Medical College, Meerut.

FAQs

• I do not know how to feed ?• No milk production?• Milk is not enough/ sufficient?• Asking milk every half to one hr.?• Frequent motions?• No motion for 3-5 days?• Why should I breast feed?• How long should I breast feed

04/13/23 DR HARIVANSH CHOPRA

Objectives

1. To study the composition of breast milk and its advantages to the infant and mother.

2. To study exclusive breast feeding and complimentary feeding.

3. To study the baby friendly hospital initiative.


Breast Milk – The best milk for Infant

Under any circumstances, “Breast Milk” is the ideal food for infant. No other food is required till 6 months of age.


Breast Milk

1. Average volume of secretion (Indian Mothers) = 450 – 600 ml per day.

2. Constituents (per 100 gm):1. Fat 3.4 gm.

2. Protein 1.1 gm.

3. Lactose 7.4 gm.


Breast Milk

2. Constituents (per 100 gm):5. Calcium 28 mg.

6. Vitamin C 3 mg.

7. Minerals 0.1 gm.

8. Water 88 gm

9. Energy 65 Kcal.


Colostrum

1. Colostrum is thick yellow to orange colour milk produced in late pregnancy and 1st week of lactation in low volumes.

2. Colostrum is low in fat, and high in carbohydrates, protein, and antibodies.


Colostrum

3. Benefits of colostrum feeding:1. Perfect food for infants in initial days.

2. Laxative effect – clears infant’s intestines of initial stools; prevents jaundice.

3. Contains leukocytes which prevent infection.

4. Contains IgA which also provides immunity.


When mothers hear that colostrum is measurable in teaspoons rather than ounces, they often wonder if that can really be enough for their babies. The short answer is that colostrum is the only food healthy, full-term babies need. The following is an explanation:


A 1 day old baby's stomach capacity is about 5-7 ml, or about the size of a marble. Interestingly, researchers have found that the day-old newborn's stomach does not stretch to hold more. Since the walls of the newborn's stomach stays firm, extra milk is most often expelled (spit up). Your colostrum is just the right amount for your baby's first feedings04/13/23 DR HARIVANSH CHOPRA

By day 3, the newborn's stomach capacity has grown to about 0.75-1 oz, or about the size of a "shooter" marble. Small, frequent feedings assure that your baby takes in all the milk he needs


Around day 7, the newborn's stomach capacity is now about 1.5-2 oz, or about the size of a ping-pong ball. Continued frequent feeding will assure that your baby takes in all the milk he needs, and your milk production meets his demands.04/13/23 DR HARIVANSH CHOPRA

Around day 7, the newborn's stomach capacity is now about 1.5-2 oz, or about the size of a ping-pong ball. Continued frequent feeding will assure that your baby takes in all the milk he needs, and your milk production meets his demands.


Timing of breast feeding

1. Breast feeding should be started as early as possible after delivery:

1. Within half hour of normal delivery.

2. Within three hours of Caeserian Section delivery.

2. Infant feeding must be “Feeding on Demand”.


Care of lactating woman

1. Good health.

2. Proper balance of rest and exercise.

3. Freedom from worry.

4. Early & sufficient treatment of any incurrent disease.


Care of lactating woman

5. Adequate nutrition:1. +600 to +520 Kcal/day.

2. +19 to +13 gm protein/day.

3. About 30 gm fat per day.

4. Other foods rich in minerals and vitamins.


Exclusive Breast Feeding

The infant only receives breast milk without any additional food or drink, not even water.

WHO has recommended that the duration of exclusive breast feeding should be 6 months.


Technique of breastfeeding – Prerequisites

Infant should be:

1. Hungry.

2. Dry.

3. At comfortable temperature.

4. Supported in semi-sitting position.


Helping mother to attach infant

1. Touch her infant’s lips with her nipple.

2. Wait until her infant’s mouth is opening wide.

3. Move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple.


Positioning of Infant

1. Infant’s neck is straight or bent slightly back.

2. Infant’s body is turned towards the mother.

3. Infant’s body is close to the mother.

4. Infant’s whole body is supported.


Signs of Proper Attachment

1. Infant’s mouth is wide open.

2. Infant’s chin is touching the breast.

3. Infant’s lower lip is turned outwards.

4. More of areola is visible on the Upper side.


One Breast or Both Breasts

1. Infants must empty at least one breast at a time.

2. During initial weeks of lactation, both breasts must be offered.

3. During later months of lactation, one breast at a time, and alternated in the successive cycle.


Foremilk and Hindmilk

Foremilk, the thinner milk the baby gets first, which has a lower fat content; and Hindmilk, the high-fat, creamier milk that follows.


Foremilk and HindmilkBaby starts feeding

ForemilkLow fat, High Lactose milk

MILK EJECTION REFLEX

Milk & sticking fat on ducts squeezed

Hindmilk High fat milk04/13/23 DR HARIVANSH CHOPRA

Breast Feeding

1. The best stimulus to refill breast is “Empty Breast”. That is why, alternative breast must be offered to the infant.

2. Infant must suckle the breast at least for 10 minutes to empty it completely.


Common problems of breast feeding

1. The newborn is a very rapid sucker and will normally sleep within 2 – 3 minutes of sucking the breast, so the mother has to wake up the newborn by gently tickling at the sole of the newborn, and force the child to suckle at least for 10 minutes.



2. While feeding the newborn, every precaution must be taken not to touch the cheek of other side because this will distract the newborn from the breast of the mother due to rooting reflex.



3. Gastrocolic reflex:

Normally the child will pass motion after taking the breast milk, and there is a great variation in the defecation habits of the newborn children – the child may pass 10-14 motions a day or may pass 1 motion in five days while on breast feeding.


Post-breastfeeding

Infant should be held erect over mother’s shoulder or in lap, and patted in back for expelling swallowed air (burping).


Adequate feeding

1. Infants suckle breast for 5 – 20 minutes.

2. With the exception of sore nipple, infants must be allowed to suckle till satisfied.


Adequate feeding

3. Signs of adequate feeding:1. Infant satisfied after feeds.

2. Sleeps 3 – 4 hrs after feeds.

3. Adequate urination.

4. Adequate weight gain.


Expressed Milk

1. Breast milk may be expressed manually, or through use of a breast pump.

2. Useful in cases of engorged breasts, working mothers, or sore nipples.

3. Expressed milk must be brought to adequate temperature before feeding infant.04/13/23 DR HARIVANSH CHOPRA

Advantages of Breast Feeding

1. The breast milk:1. Always available – No preparation time.

2. Proper temperature.

3. Clean & Fresh.

4. Free of contaminating agents.

5. Cheap.



2. To the infant:1. Meets the full nutritional requirement of infant.

2. Less incidence of allergy & intolerance.

3. Contains antimicrobials factors against various diseases.



2. To the infant:4. Suckling helps in development of jaws and teeth.

5. Protects against obesity.



3. To the mother:1. Helps building of a bond with her child.

2. Helps spacing of children by prolonging period of infertility.


Baby Friendly Hospital Initiative

1. BFHI created and promoted by WHO and UNICEF.

2. Lists ten steps for hospitals to fulfill.

3. Correct breast feeding practices alone can prevent 1 million deaths world wide.


10 steps of BFHI

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


10 steps of BFHI

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


10 steps of BFHI

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


10 steps of BFHI

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


10 steps of BFHI

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


10 steps of BFHI

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


10 steps of BFHI

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


10 steps of BFHI

8. Encourage breastfeeding on demand.


10 steps of BFHI

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


10 steps of BFHI

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


Solution – Storing breast milk

1. Breast milk may be stored in hard sided plastic/glass containers with tight lid, or specially designed bags.

2. About 2 – 4 oz stored at a time to minimize wastage.


Solution – Storing breast milk

3. Maximum storage time:1. Room temperature Up to 10 hrs.

2. Refrigerator (2 – 8 oC) Up to 8 days.

3. Freezer 2 weeks to 3 months.

4. Deep freezer (0 – -19oC) Up to 6 months.

4. Milk must not be heated for reuse. The container should be held under running tap water.


MCQs

1. According to the WHO, Exclusive breast feeding should be practiced till the age of:

1. 2 months.

2. 4 months.

3. 6 months.

4. 1 year.

Ans. – 304/13/23 DR HARIVANSH CHOPRA

MCQs

2. Colostrum, in comparison to normal breast milk, has:

1. More fats.

2. More proteins.

3. Is lighter in colour.

4. More constipating effect on neonate.


MCQs

4. Which of the following is not a component of WHO’s BFHI:

1. Early initiation of breast feeding.

2. Foster establishment of breastfeeding support groups.

3. Breastfeeding on demand.

4. Establishment of human milk-banks.


MCQs

5. Expressed breast milk can be stored in deep freezer at -19oC for:

1. Up to 24 hours.

2. Up to 10 days.

3. Up to 1 month.

4. Up to 6 months.


Contraindications to Breast feeding

1. Markedly inverted or cracked nipples.


Maternal infection contraindication to breast feeding

Contraindications

Mastitis / Staphylococcus aureus When breast abscess is present

Active Mycobacterium Tuberculosis Because of aerosol spread

HIV In developed countries

HTLV-1 In developed countries

HTLV-2 In developed countries

Herpes simplex virus When breast vesicles are present


Drugs contraindicated during breast feeding

• Amphetamines• Antineoplastic agents• Bromocriptine• Chloramphenicol• Cimetidine• Cocaine• Cyclophosphamide• Cyclosporine• Diethylstilbestrol

• Doxorubicin , Ergots• Gold salts, Heroin• Immunosuppressants• Iodides, Lithium• Methimazole• Methylamphetamine• Nicotine (smoking)• Radiopharmaceuticals• Tetracycline



2. Mothers with any active infection with the infant having no infection:

1. HIV +ve mothers.

2. Mothers with septicemia, active tuberculosis, typhoid fever, breast cancer, or malaria.



3. Substance abuse by mother.



4. Severe neurosis or psychosis in mother.


Solution – Inverted or Flat nipples

1. Use of breast shells in the brassiere, massaging exercises (Hoffman Technique), breast pumps, or nipple shields may be one.


Solution – Inverted or Flat nipples

2. Use of a cut syringe inverted to draw out nipple or milk may be done.


Solution – Sore nipple

1. Proper positioning of infant while breast feeding.

2. Offer baby short, frequent feeds for less vigorous suck.

3. Feed on other side, if possible.



4. Pull baby’s chin or corner of mouth to break suction before removing him from breast.



5. Keep nipples moist (lanolin, etc) as moist healing is better for them. Nipple shields may be used.


Solution – Leaking breasts

1. Mothers leaking with one breast while feeding on other should use towel, or cotton diaper to catch the flow.

2. Disposable, or washable cotton pads may be used in brassiere; avoid ones with plastic lining.


Solution – Leaking breasts

3. Not to miss the feeds or going longer between feeds solves problem.

4. Slight pressure against breasts stops sudden leaking or let down.


Solution – Twin feeding

1. Think positive. Negative thoughts hinder milk production.

2. Babies may be fed at the same time positioned like X in front of the mother, or held on sides.


Solution – Twin feeding

3. Adequate diet, rest & exercise for the mother.

4. If supplements required, feed with cup, finger, dropper, or syringe – Avoid bottle feeding.


Solution – Breast feeding an adopted child

1. Most mothers may produce enough milk for an adopted child, whether they have ever been pregnant or not.


Solution – Breast feeding an adopted child

2. The key to lactation is breast stimulation by:

1. Breast pump before the arrival of baby.

2. Continued suckling by child.

3. Use of pump while baby is suckling.


Complimentary Feeding

When breast milk alone is unable to suffice the needs of the infant, transition from exclusive breast feeding to family foods is known as complimentary feeding.



1. It is both “science” and “art”.

2. Only home available foods should be used.

3. Market preparations are best to be avoided.

4. Home available foods help in the development of taste buds of the child.

5. Thus, it helps to prevent the occurrence of feeding problems later in childhood.


Supplementary feeding

1. Feeding formula feeds to a previously exclusively breastfed child.

2. Useful for working mothers.


Complimentary Feeding during 6-12 months of age – What should be given?

1. Breastfeed as often as child wants.

2. Offer banana/ biscuit/ cheeko/ mango/ papaya.


Complimentary Feeding during 6-12 months of age – What should be given?

3. Give at least “one katorie” at a time of:1. Mashed roti/ rice/ bread/ biscuit mixed in sweetened

undiluted milk, OR

2. Mashed roti/ rice/ bread mixed in thick dal with added ghee/ oil. Add cooked vegetables also in the servings, OR

3. Sevian/ dalia/ halwa/ kheer prepared in milk or any cereal porridge cooked in milk, OR

4. Mashed boiled/ fried potatoes.


Complimentary Feeding during 6-12 months of age – When and How?

• 3 times per day if breastfed; 5 times per day if not breastfed.

• Remember:• Keep the child in your lap and

feed with your own hands.• Wash your own and child’s

hands with soap and water every time before feeding.


Complimentary Feeding during 12 mths- 2 yrs of age – What should be given?

1. Breastfeed as often as child wants.

2. Offer food from the family pot.

3. Offer banana/ biscuit/ cheeko/ mango/ papaya.


Complimentary Feeding during 12 mths- 2 yrs of age – What should be given?

4. Give at least “1 ½ katorie” at a time of:1. Mashed roti/ rice/ bread/ biscuit mixed in sweetened

undiluted milk, OR

2. Mashed roti/ rice/ bread mixed in thick dal with added ghee/ oil. Add cooked vegetables also in the servings, OR

3. Sevian/ dalia/ halwa/ kheer prepared in milk or any cereal porridge cooked in milk, OR

4. Mashed boiled/ fried potatoes.


Complimentary Feeding during 12 mths- 2 yrs of age – When and How?

• 5 times per day if not breastfed.

• Remember:• Sit by the side of child and

help him to finish the serving.

• Wash your child’s hands with soap and water every time before feeding.


Complimentary Feeding – Timing

1. The complimentary feeding should be started at least half an hour before the scheduled time of feeding.

2. If this fact is not kept in mind, and if one starts feeding complimentary feeding when the child is hungry, then the child is not going to accept and will start crying.


Complimentary Feeding – Timing

3. Thus it will result in non-acceptance of the complimentary feeds.

4. The reason behind starting complimentary feeding earlier than the scheduled time is that the child is a rapid sucker. While on breast feeding, the child is able to suckle 50% of the breast feed in the first 2 minutes, and this rate cannot be matched by spoon or any other method.


1. The mother should fix one time in the morning or evening in the beginning.

2. Initially, a very small amount of liquids should be offered to the infant.

3. Every day there should be an increment of 2 – 3 tsf.

4. Initially, the breast feeding is to be offered at the scheduled time.

Complimentary Feeding – Timing and Amount


4. In 10 – 15 days time the amount will be adequate so that the mother can miss the scheduled breast feeding.

5. Then another time is fixed and the same process is repeated.

Complimentary Feeding – Timing and Amount


1. Initially only liquids in the form of fruit juices and soups and milk preparations should be offered to the child.

2. Then semi-solids like mashed banana, boiled and mashed potato, etc should be offered to the child.

3. Later on, the young toddler must learn to eat from the “Family Pot”.

Complimentary Feeding – Type of Feeds


1. Mother should prepare the complimentary feeds herself in proper hygienic conditions.

2. Before giving feeding to the child, she must wash her hands, and clean the utensils after feeding the child to minimize the risk of weaning induced diarrhea.

Complimentary Feeding – Hygiene


1. This way the child will learn to eat the home cooked food, as well as will be able to fulfill his/her nutritional requirements except iron.

2. For this the child needs to be given either food fortified with iron or iron supplementation under the supervision of a doctor.



Requisites of Complimentary Feeding

1. Timely – started at 6 months.

2. Adequate – good nutritive value.

3. Safe – free from contamination.

4. Appropriate – in sufficient amount.


MCQs

3. Which of the following is a contraindication for breast feeding:

1. Elderly gravida.

2. Preterm delivery.

3. Mother with active tubercuosis.

4. Nulliparous mother of adopted child.


Conclusion

1. Breast milk is the best food for the infant up to 6 months of age.

2. After 6 months complimentary feeding should be started.

3. These two are the best practices for the attainment of normal growth in children.


art and science of breastfeeding

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