TIME SPECIFIC CONTENT TEACHING LEARNING AV EVALUATION

OBJECTIVES ACTIVITIES ACTIVITIE AIDS

S
2
MIN INTRODUCTION
Breastfeeding is the best natural feeding and breast
milk is the best milk. Breastfeeding is the most
effective way to provide the baby with caring
environment and complete food.
It meets the nutritional as well as emotional and
psychological needs of infants.
Breast milk is universally endorsed by the World
Health Organization (WHO) as the best feed for
newborn. Years of research have focused light on the
vast dimensions of benefits not only for children but
also for mothers and society.

DEFINITION
Define and BREASTFEEDING Lecture Listen LCD
2min explain Breastfeeding is the process of feeding a mother's
anatomy of milk to her infant, either directly from the breast or by
breast and expressing the milk from the breast and bottle feeding
physiology of it to an infant.
breast feeding
Anatomy of Breast
Breast is composed of glandular tissue, supporting
tissue and fat. Glandular tissue contains milk-

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producing sacs which are surrounded by
myoepithelial cells helping drainage of milk through
lactiferous ducts. These ducts form lactiferous
sinuses, which lie below the junction of the areola and
remaining breast tissue to store milk. Areola and
nipples are rich in nerve supply. Montgomery's glands
are present in the areola, and they produce oily
substance to keep the nipple soft.

Physiology of Lactation

 Mammogenesis (growth of the breasts):

During pregnancy, the breasts enlarge; the
nipple pigment darkens; the skin becomes
thinner and thus veins in the breast become
more prominent. Ductal system grows
stimulated by the estrogens, growth hormone,
prolactin, insulin and the adrenal corticoids.
Secretary properties of alveoli also develop in
this phase.
 Lactogenesis (the functional change of the
breasts so that they can secrete milk): It is
subdivided in two phases. Lactogenesis, I
begins from mid-pregnancy till 2 days after
birth. It involves the differentiation of alveolar
epithelial cells and the stimulation of milk
synthesis by prolactin. Lactogenesis II begins
from 3rd day of postpartum to day 8. It is

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 precipitated by the reduction of progesterone.
The breasts become full, warm and produce
large amounts of milk.

 Galactokinesis (ejection of milk): In this

phase, milk is ejected due to active suckling
by the baby and contractile mechanism to
express milk from alveoli into ducts.

 Galactopoiesis (maintaining the production

of milk): It is the maintenance of milk
secretion controlled by mainly prolactin.

Explains Reflexes of Breastfeeding

reflexes of
breast feeding Reflexes in Mother

 Prolactin reflex: Prolactin, produced by the

anterior pituitary gland is key hormone for
milk secretion by the mammary gland cells.
As soon as the baby sucks, the nerve endings
in the nipple carry messages to the anterior
pituitary, which in turn, releases prolactin and
promotes milk secretion from breast. This
reflex is known as milk secretion reflex.
Earlier the baby sucks, sooner the reflex is
initiated.

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  Oxytocin reflex: Oxytocin is a hormone
produced by the posterior pituitary. It helps in
contraction of the myoepithelial around the
glands leading to ejection of the milk from the
glands into the lacteal sinuses and the lacteal
ducts. This is known as milk ejection reflex
(Fig.

Reflexes in Baby

 Rooting reflex: It helps to find the nipple and

proper attachment to the breast.

 Sucking reflex: Helps drawing out milk from

mother's breast.

 Swallowing reflex: When mouth is filled with

breast, it the milk.
List out
benefits of Benefits of Breastfeeding
breast feeding
Benefits to the Baby

Nutrition: Breast milk contains all the nutrients in the

right proportion required for optimum growth and
development of the infant during the first six months.

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Other benefits are:

 It contains amino acids, like taurine and

cysteine which are important
neurotransmitters and fats-mostly
polyunsaturated fatty acids that are essential
for the myelination of the central nervous
system.
 Galactose which is significant for brain
growth is also present in high percentage.
 Breast milk also has adequate amount of
vitamins, minerals and electrolytes along with
various hormones and growth factor.
 It enhances calcium absorption.

Digestion: Breast milk is easily digestible as it

contains lactoglobulin and lactalbumin protein, which
are easy to digest. Lipase helps to enhance fat
digestion
Infection and disease prevention: Breast milk
contains immunoglobulins, like IgA, macrophages,
lymphocytes, lactoferrin, interferon and bifidus
factors which add to the protective value. Other
benefits are:
 Breast-fed babies usually suffer less from
infectious illnesses and their symptoms (e.g.,
diarrhea, ear infections, respiratory tract
infections, meningitis).

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  They have a lower risk of the two most
common inflammatory bowel diseases
(Crohn's disease, ulcerative colitis).
 They are less prone to develop some forms of
cancer (e.g Hodgkin's disease, childhood
leukemia).
 Babies have a reduced risk of juvenile onset
diabetes, if they have a family history of the
disease and are breastfed exclusively for at
least 4 months.

 Babies are significantly safeguarded against

asthma and eczema, if at risk for allergic
disorders and exclusively breastfed for at least
4 months.
 They may have a lower risk of obesity in
childhood and in adolescence.
 They also have fewer caries and are less likely
to require braces.
 These babies have a lower risk of sudden
infant death syndrome (SIDS).

Intellectual Growth: Breastfed babies score higher

on cognitive and IQ tests at school age, and on tests
of visual acuity.

Psychological benefits are:

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  Breastfed babies are better bonded with
mother than formula fed babies.
 Benefits to the preterm babies.
 It significantly shortens length of hospital
stay.
 It minimizes hospital costs.
 Breastfeeding enhances brainstem maturation.
 It reduces the risk of life-threatening disease
of the gastrointestinal system and other
infectious diseases.
 They have future IQs that are 8-15 points
higher than those who receive formula.

Benefits to the Mother

 Breastfeeding mothers experience a quicker

recovery after childbirth, with less chance of
postpartum bleeding.
 Mothers who practice breastfeeding are more
likely to return to their pre-pregnancy weight
than those mothers who practices formula
feeding. Breastfeeding reduces the risk for
long-term obesity.
 Exclusive breastfeeding minimizes the risk of
anaemia by delaying the return of the
menstrual cycle for 20-30 weeks.
 Exclusive breastfeeding for the first 6 months
postpartum, in the absence of menstruation, is

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 98% effective in preventing pregnancy.
 Women who practice breastfeeding, are less
likely to develop ovarian and premenopausal
breast cancers.
 Breastfeeding reduces osteoporosis.
 Breastfeeding mothers are reported to be more
confident and less anxious than those mothers
who do bottle feeding.

Benefits to the Society

 Breastfeeding saves money and time and

conserves energy. The estimated cost of
artificial feeding is four times more than that
of breastfeeding. Concentrated and ready-to-
feed formulas are even more expensive than
powdered formula.

 Breastfeeding reduces the number of sick days

that families have to spend to care for their
sick children.

 Breastfeeding is the cheapest source of

optimum nutrition It reduces the cost of health
services that must be paid for by insurers,
government, agencies, or families.

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Describes types Types of Breast Milk
of breast milk
Breast milk changes its composition as periods of
lactation passes to cater to the needs of the infant.

Colostrum: Colostrum is the first milk for newborn

secreted during initial 3-4 days after delivery. It is
yellow thick and rich in large quantity of antibodies,
vitamins, immune factors and growth factors but
secreted in small quantity. This milk is highly
essential for the baby.

Transitional milk: This milk is secreted after 3-4

days and continues up to two weeks. This milk has
less protein and immunoglobulin but more sugar and
fat than colostrum

Mature milk: After transitional milk, mature milk is

secreted which is thin and watery but contains all
nutrients in appropriate quantity for optimal growth
of the baby.

Preterm milk: It is secreted from the mother who

delivers preterm baby. It is rich in protein, sodium,
iron, immunoglobulin and calories than term milk to
fulfil the need of the preterm baby.

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Fore milk: It is secreted at the beginning of any feed.
It is watery but enriched with proteins, sugar,
vitamins, minerals and water; and satisfies the baby's
thirst.

Hind milk: It is secreted toward the end of the feed

and rich in fat which provides energy and satisfies
baby's hunger.

Both fore milk and hind milk should be given to the

baby. Hence, baby should be allowed to empty one
breast before moving to the other breast.

Techniques of Breastfeeding

Positions of Breastfeeding
 Characteristics
 Correct versus incorrect positioning
 Proper position of baby while breastfeeding
include Supporting whole of baby's body.
 Ensure baby's head, neck and back are in same
place
 Entire baby's body should face mother
 Baby's abdomen touches mother's abdomen.

 Side lying position

This allows mothers to rest or sleep while baby nurses
especially who have had caesarean births.

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  Mother lies on her side using pillows under
head and back Head and neck should be
comfortably propped up.
 Put a small, rolled blanket behind the baby's
back
 Pull baby close and guide his/her mouth to the
nipple

 Cradle position
 This is a commonly used comfortable position
 Mother holds her baby with his head on her
forearm and his/her whole body facing her.
 Place baby across her stomach, with her face
and knees close-in facing mother's body.

 Cross cradle position

This is good for premature babies or babies who are
having trouble latching on:
 Mother holds her baby along the opposite arm
from the breast she is using.
 Support baby's head with the paim of her hand
at the bar of his/her head.

 Clutch or football position

 Good for mothers with large breasts or
inverted nipples
 Mother holds her baby at her side, lying on

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 his/her back with his/her head at the level of
nipple.
 Support baby's head with the palm of mother's
hand at the base of his/her head.

 Twin football or clutch position

Nursing in the football/clutch-hold is common for
twins.
 Each baby is nursing while his stomach wraps
around mother's and feet extend around her
body to the side.
 With supportive pillows underneath babies, it
is easy to use her hands to help babies latch.

 Twin cross cradle position

 Support one baby's head in each of mother's
arms
 Babies heads may rest in the bend of her arm
near her elbow.
 Babies bodies will be in her lap turned toward
her abdomen

 Football and cradle hold combination

Mother holds one baby using the football hold and the
other baby using the cradle hold.

Latching

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After proper positioning, baby's mouth should be
properly attached to the breast for effective suckling.
Poor latching may result in sore or painful nipple and
poor milk supply to the baby.

 Signs of Good Attachment

 Baby's mouth wide open.

 Lower lip turned outward.
 Baby's chin touches mother's breast.
 Majority of areola inside baby's mouth.

Burping

1. Over the shoulder: This is the most commonly

used position when burping is essential to get rid of
some of the air that babies tend to swallow during
feeding. To burp a baby mother should gently pat
baby on the back and put some pressure on the
tummy area. Burping should be done after feeding at
each breast. There are three easy techniques to do
burping since it's the easiest technique. Put the baby
in an upright position then pat its back gently. Make
sure to support its head and neck. It would also be
good to have a burping towel over mother's shoulder
to protect clothing if baby spits up.

2. Sitting: Mother puts her baby in a sitting position

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and gently rubs its back until baby burps.

3. Over the lap: Place the baby in a lying position

with its back toward the mother. Lay it on your lap
and gently tap its back until its burps. The baby would
feel more comfortable, if a pillow is placed on its lap

Adequacy of Feeding
The following signs indicate adequacy of
breastfeeding
 Baby passes urine 6-8 times in 24 hours.
 Goes to sleep for 2-3 hours after the feeds
 Gains weight @20-40 g/day
 Crosses birth weight by 2 weeks

FREQUENCY OF FEEDING

 Time schedule: Breastfeeding should start

after 2-3 hours interval during first 24 hours.

 Demand feeding the baby should be breastfed

the moment it shows the signs of hunger

 Night feeding: Feeding should be given

during night to avoid long interval between
feeding and disturbed sleep of the baby.

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Exclusive breastfeeding should be given for first 6
months. Additional water is not necessary even in
summer

PROBLEMS IN BREASTFEEDING

1. Engorged Breast
Breast engorgement is characterized by painful
overfilling of the breasts when the amount of milk
produced is more than the amount of milk removed
from the breast. It is an imbalance between the milk
production and milk demand Breast engorgement
usually occurs on the 3rd or 4th day of the postpartum
period when the milk production in the breast’s
changes from colostrum in mature milk.
Signs and symptoms include pain and tenderness in
one or both the breasts, low rise of temperature,
oedematous and flushed nipples and general malaise.
Treatment includes cold application, massage of breat
and analgesics for pain. Accumulated milk should be
gently expressed out. Mother is encouraged to breast
feed baby frequently with correct latching to prevent
breast engorgement.

2. Inverted Nipple and Flat Nipple

Flat nipple can be pulled out easily and does not

cause any difficulty in breastfeeding. Inverted nipple

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causes difficulty in attachment. Treatment includes
stretching and rolling out the nipple many times a day
soon after birth of the baby. Plastic syringe is put into
the nipple and milk is drawn out to correct the nipple
before putting the baby to breast.

3. Sore Nipple

Sore nipple occurs due to incorrect latching when

baby sucks only the nipple not areola or frequent
washing of breast with soap and water. Treatment
includes correct technique of latching, cleaning breast
not more than once a day, application of hind milk on
the affected breast and allowing it to heal in- between
feeds.

4. Breast Abscess

Untreated engorged breast, cracked nipple, blocked

duct or mastitis can lead to breast abscess. The
mother gets high grade fever and raised blood count.
It can be treated with analgesics, antibiotics and
sometimes incision and drainage.

5. Not Enough Milk

If indications of adequate feeding are not seen,
mother may perceive about insufficient milk. There
are various reasons for insufficient milk supply which

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are as follows:
Breastfeeding factor: Delayed start, feeding at fixed
times, infrequent feeds, no night feeds, short feeds,
poor attachment, use of bottles, pacifiers, offering
other fluids (water, tea).
Maternal factor: Lack of confidence, illness,
unwilling for breastfeeding worries, stress, pain,
smoking, tiredness. Reason should be identified and
treated accordingly

Encourage rooming in, relieve mother's stress and

provide adequate rest and fluids. Teach the mother
appropriate technique as well as frequency and
duration of feeding her baby

CONTRAINDICATIONS OF BREASTFEEDING

HIV infection if alternate milk is safe, affordable,

sustainable and feasible.

Mother on antimetabolite/anticancer/radioactive
drug till the period of treatment.

Expressed Breast Milk

Breast milk can be expressed if mother is sick or

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working, preterm baby, etc. Mother should express
milk at least 8-10 times a day to maintain lactation
(Fig. 8.8).
Breast milk can be expressed by:
 Expressing by hand
 Expressing by manual pump
 Expressing by electric pump

 Expressing by Hand

I. Gently massage the breast and hold the clean

container under the nipple and areola. Place
the thumb on the top of the breast at least 4
cm from tip of the nipple and the first finger
on the undersurface of the breast opposite the
thumb.
II. Press straight in toward chest wall about 1
inch.
III. Roll thumb and fingers toward the areola.
IV. Repeat rhythmically and collect the milk.
V. When the stream of milk slows, change the
position of hand. Rotate around the areola to
reach more milk ducts. Change hands and
repeat. After 5-7 minutes, change breast.

How to store breast milk for home use

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  Expressing by Manual Pump

 Follow the direction for use.

 Massage the breast toward the pump. This
helps the breast milk to flow.

Breast milk --
Freshly expressed into a closed container. If kept in
room temperature can keep 6-8 hours (26°C or
lower), if refrigeration is available store milk there. If
Refrigerator
Not >72 hours, Store in back, where it is coldest. If
Freezer - 2 weeks in freezer compartment inside
refrigerator (-15°C), 3 months in freezer section of
refrigerator with separate door (-18°C), 6-12 months
in deep freeze (-20°C).

 Expressing by Electric Pump

 Electric breast pumps are powerful which

provide hospital grade suction to produce
more milk in less time.
 A huge number of mothers express the amount
they require quickly and effectively with an
electric pump.

WARMING THE FROZEN MILK

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  Frozen breast milk can be thawed in the
refrigerator. This takes approximately 12
hours.
 A quicker way to thaw and warm the milk to
body temperature is to place it under cool,
then gradually warmer running water until the
breast milk is thawed and warmed to room
temperature. Test temperature of the breast
milk on the inside of mother's wrist before
offering it to baby.
 Never microwave the breast milk. This may
alter its nutrients and cause hot spots which
can burn the mouth of the baby.
 Discard any remaining breast milk that was
not used at the feeding.

BABY-FRIENDLY HOSPITAL INITIATIVE

The Baby-Friendly Hospital Initiative (BFHI) was

launched by World Health Organization (WHO) and
United Nations Children's Fund (UNICEF) in 1991,
following the Innocenti Declaration of 1990. This is a
global effort to implement practices that protect,
promote and support breastfeeding. The process is
under control of national breastfeeding authorities,
using global criteria that can be applied to maternity

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care in every country. Implementation guides for the
BFHI have been developed by UNICEF and WHO.
To help in the implementation of the initiative,
different tools and materials were developed, field-
tested and provided, including a course for maternity
staff, a self-appraisal tool and an external assessment
tool.

The global BFHI materials have been revised,

updated and expanded for integrated care. The
materials include new research and experience which
reinforce the International Code of Marketing of
Breast-milk Substitutes, support mothers who are not
breastfeeding, provide modules on HIV and infant
feeding and mother-friendly care, and give more
guidance for monitoring and reassessment.

KEY DATES IN THE HISTORY OF

BREASTFEEDING AND BHFI

 1991-Launching of Baby-friendly Hospital

Initiative
 2000- WHO Expert Consultation on HIV and
Infant Feeding
 2001-WHO Consultation on the optimal
duration of exclusive breastfeeding
 2002- Endorsement of the Global Strategy for
Infant and Young Child Feeding by the WHA

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  2005- Innocenti Declaration 2005
 2006- Revision of BFHI documents

The program, launched in Kerala in March 1993, in

hospital.
Manoncourt said of the 1,372-baby friendly hospital
in India 65% are in Tamil Nadu and Kerala.

Dr. Elsie Philip, state coordinator of BFHI, said the

rate of breast-feeding initiation within a day is 92% in
Kerala (compared to 78.7% in Tamil Nadu and the
national average of 37.1%)

DEFINITION:

The feeding of an infant or young child with breast

milk directly from female human breasts rather than
from a baby bottle or other container.

Goals of BFHI:

 To transform hospitals and maternity facilities

into breastfeeding conductive environments.
 To end the practice of distribution of free and
low cost supplies of breast- milk substitutes to
maternity ward and hospital.

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 Aims of BFHI

 To initiate global assessment and

accreditation.
 To enable the mother to acquire the skills
needed for breastfeeding.
 To assist the mothers who are not
breastfeeding.
 To implement BFHI in the curriculum for the
health worker.

Revised Package of BFHI

The revised package of BFHI materials includes five

sections:

1. Background and implementation.

2. Strengthening and sustaining the BFHI: A
course for decision-makers.
3. Breastfeeding promotion and support in a
baby-friendly hospital: A 20-hour course for
maternity staff.
4. Hospital self-appraisal and monitoring.
5. External assessment and reassessment.

According to BFHI, a maternity facility can be

termed 'baby- friendly' when it does not accept free or
low-cost breast milk substitutes, feeding bottles or

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teats, and has implemented 10 specific steps to
support successful breastfeeding.

Ten Steps of Successful Breastfeeding

Every facility providing maternity services and care

for newborn infants should:
1. Have a written breastfeeding policy that is
routinely communicated to all health care
staff.
2. Train all health care staff in skills necessary
to implement this policy.
3. Inform all pregnant women about the
benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within
half-hour of birth.
5. Show mothers how to breastfeed, and how
to maintain lactation even if they are separated
from their infants.
6. Give newborn infants no food or drink
other than breast milk, unless medically
indicated.
7. Practice rooming-in. Allow mothers and
infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also
called dummies or soothers) to breastfeeding
infants.

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

Since its launching, BFHI has grown with >152

countries around the world implementing the
initiative. The initiative has measurable and proven
impact, increasing the likelihood of babies being
exclusively breastfed for the first 6 months.

The BFHI in India was launched in 1993.

Breastfeeding Promotion Network of India (BPNI) is
monitoring the program in India and has
recommended the following actions for successful
implementation of BFHI.

 Training in breastfeeding and lactation

management should be made a priority for all
health professionals, especially nurses.
 Breastfeeding and lactation management
should be incorporated in basic training of
existing peripheral workers.
 A strong link through NGOs involvement
should be established between the hospital and
the community to achieve success in
promotion of breastfeeding in the community.
 Periodic evaluation to document effectiveness
and progress of BFHI program should be

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 done.
 Counselling on women's behaviours to adopt
exclusive breastfeeding.

THE ROLE OF THE HOSPITAL

ADMINISTRATOR IN BFHI:

 Becomes familiar with the BFHI processes.

 Decide where responsibility lies within the
hospital structure. This can be coordinating
committee, working group, multidisciplinary
team etc.
 Establish the process within the hospital of
working with the identified responsible body.
 Work with key hospital staff to fill in the self-
appraisal tool using the global criteria and
interpret results.
 Support staff in decision taking to achieve
baby friendliness.
 Facilitate any BFHI related training that may
be needed.
 Collaborate with national BFHI coordination
group and ask for an external assessment team
when the hospital is ready for assessment.
 Encourage staff to sustain adherence to the ten
steps arraigning for refresher training and
periodic monitoring and reassessment.

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 BENEFITS TO THE BABY

 Perfect nutrition
 Higher IQ
 Complete food for the first six months
 Emotional bonding
 Prevents infection
 Prevents chronic diseases.
 Easily digested

BENEFITS TO THE MOTHER

 Reduces post-delivery bleeding and anaemia

 Helps delay next pregnancy
 Protective effect against breast and ovarian
cancer
 Helps to lose weight
 Emotional bonding
 Needs no preparation

CONCLUSION
Breastfeeding is widely recognized as the optimal
method for infant feeding due to its numerous health
benefits for both the baby and the mother. It provides
essential nutrients, strengthens the immune system,
and promotes bonding, while reducing risks of
infections, chronic diseases, and maternal health

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issues like breast cancer. Baby friendly Hospital
Initiative (BFHI) seeks to provide mothers and babies
with good start for breastfeeding, increasing the
likelihood that babies will be breastfed exclusively
for the first six months and then given appropriate
complementary foods while breastfeeding continues
for two years or beyond. It has served as a motivating
force for maternity facilities around the world to
implement policies and practices that support
breastfeeding.

REFERENCE
 Beevi Assuma. Concise Textbook for
Paediatric Nursing. Elsevier Health Sciences;
2019.
 Datta Parul. Paediatric Nursing. Jaypee
Brothers Medical Publishers (P) Ltd; 2009.
 Sharma Rimple. Essentials of paediatric
nursing: for BSc, post basic nursing students.
New Delhi: Jaypee Brothers Medical
Publishers (P) Ltd; 2013.

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