
1.0 Why Breastfeeding is Important
Exclusive breastfeeding for the first 6 months after birth is the reference, or normative model, against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.1
Breastmilk is the natural first food for babies, with breastfeeding being the natural means of delivery of this food source. Breastmilk is the only single food that can meet ALL of the nutritional needs of a human for at least 6 months, and this is at a time when that human is growing at the fastest rate he will ever grow after birth.
Breastmilk has many ways to protect the infant's health. These include
- the completeness of its composition and the superiority of each of those components for growth and development (biochemistry); and
- the ability of breastmilk to kill or inactivate pathogens, cause the infant to resist disease and allergies, and stimulate the infant's own immune defences (immunology)
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![]() What would you say?
A mother, pregnant with her second baby, says to you “ |
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Breastmilk is impossible to replicate and infants who don't receive breastmilk cannot grow and develop to their potential. Read on to learn more about the uniqueness of breastmilk.

A kangaroo and her joey - There is no mammal species on earth, other than humans, that would trust the growth, development and health of their young to the milk of another species. .
Image © D.Fisher, IBCLC
Baby Friendly Initiative
The Baby Friendly Hospital Initiative (BFHI) was launched worldwide in 1991, with the goal being to accredit hospitals that apply the best-practice Ten Steps to Successful Breastfeeding.
To continue in the community the best practices initiated in the hospital situation UNICEF/BFI United Kingdom developed the Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services which was subsequently modified and adopted in Australia, New Zealand, Canada, Argentina and Italy.
The Baby Friendly Initiative 10 Steps for hospital facilities and the 7-Point Plan for community health centres are supported by the Innocenti Declaration, the World Health Organisation Code on the Marketing of Breastmilk Substitutes and the Global Strategy for Infant and Young Child Feeding.
The Steps and Points of the Baby Friendly Initiative are the practical 'how-to' guides to ensure clinical practice conforms with these international standards. Throughout this course you will be referring to these Steps and Points as they are applicable to your course.
Notes
- # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
1.1 Biochemistry
The World Health Organisation (WHO) encourages breastfeeding up to and beyond 2 years - after 6 months of exclusive breastfeeding, other nutritionally adequate and safe foods may be introduced.1 Exclusive breastfeeding provides all the nutrients and water that an infant needs to grow and develop in the first six months.
The composition of breastmilk is relatively constant with minimal fluctuations caused by maternal diet. Unlike the nutrition received by the fetus through the placenta, the nutrition received by breastfed infants is not dependent on the status of maternal metabolism. The mechanisms that cause breastmilk to be synthesized are insulated from variations in maternal nutritional intake, ensuring that sufficient milk of adequate composition is available to the infant even during inadequate food intake by the mother.2
The infant will more than double his birth weight during the first 6 months, a time when he is fed on a diet exclusively of his mother's breastmilk. Maternal metabolism is adjusted to redirect nutrients to the breast to meet this additional need. However, for her own well-being a well-nourished woman should aim to consume an additional 500 kcal per day in the form of nutritious snacks.3 Additional fluid requirements are met by recommending drinking sufficient water to avoid thirst. Consuming volumes of water in excess to needs will NOT increase breastmilk production.4,5
a. Protein
Human milk has a low protein content, approximately 9g/L, decreasing as lactation progresses.6 This is less than measured protein in bovine milk, however it is of higher biological value and perfect for a human infant.7
Whey proteins form the predominant proteins in breastmilk - approximately 60%. Casein forms the remaining 40%. These values are approximate... some texts showing the ratio may be between 50:50 (in very late lactation) to 80:20 at different stages of lactation, with whey predominating.
The high concentration of whey proteins are digested quickly and easily in the infant's stomach. Breastmilk casein has a mainly nutritive function, providing minerals and essential amino acids to the infant and forms a soft, flocculent curd during digestion. Bovine casein (the predominant protein in cows' milk) forms a tough, less digestible curd.
You will be aware that proteins have significant nutritional properties. Proteins in breastmilk also have other functions such as:
- essential amino acids for growth
- protective factors (eg. immunoglobulins, lactoferrin, etc.)
- carriers for hormones (eg. thyroxine, cortisone-binding proteins)
- carriers for vitamins (eg folate, Vit D, Vit B12 binding proteins)
- enzymatic activity (eg amylase, lipase)
- growth factors (eg insulin-like growth factor, epidermal growth factor)
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![]() | ![]() Did you know...?The high concentration of whey proteins and the soft, flocculent curds formed by the casein is the reason why breastfed babies do not get constipated. If a mother is concerned her baby might be constipated it is important to investigate the cause, because this is NOT normal for the (exclusively) breastfed baby. | ![]() |
- The proteins of cow's milk, goat's milk and soy beans (all used to make artificial infant formula) are different in structure, quantity and quality to the proteins in breastmilk.
- allergic reactions commonly occur
- any protective factors that remain after manufacture will not function in the same way they do from human milk
- the baby's immune system will not be supported as it gradually matures
Below is the first of your Workbook Activities. Have you printed your Workbook yet? If not, return to the course information page, click on the link and print the Workbook. Fill out the activities as you progress through this course.
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![]() | ![]() Workbook Activity 1.1Complete Activity 1.1 in your workbook. | ![]() |
b. Carbohydrates
Lactose (milk sugar) is the principle carbohydrate in human milk. Lactose is the most stable component of mature breastmilk. Average concentration is 68g/L (some texts report 70g/L). Lactose is synthesized in the mother's breast and broken down by the enzyme lactase in the baby's small intestine. Lactase breaks lactose into glucose and galactose, ready for absorption into the blood stream.
The role of lactose:
- The rapid increase of lactose levels in colostrum at lactogenesis II causes osmotic drawing of water into the breast secretion resulting in copious breastmilk production.
- Provides energy to the body - and particularly to the rapidly growing infant brain.
- Enhances absorption of calcium and iron.
- Galactose is ultimately essential for development of central nervous system.
There have been around 130 different oligosaccharides (short chains of sugar molecules) identified in human milk.8 These important sugars comprise up to 1.2% of mature human milk, compared to only 0.1% of bovine milk. Their role is in protection of the infant from infections.
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![]() | ![]() Food for thought...At a concentration of 70g/L, human milk has the highest concentration of lactose of all the mammalian milks. Have you ever wondered why? Could it be because the human brain has the MOST growth of all mammal species to accomplish over the next two years and lactose contains elements essential to brain growth? Consider what effects a lactose-free artificial infant formula could have on the infant fed on it. Discuss this with your colleagues. | ![]() |
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![]() | ![]() Workbook Activity 1.2Complete Activity 1.2 in your workbook. | ![]() |
c. Milk Lipids (fats)
Properties of milk lipids:
- provide around half of the energy (kilojoules) in breastmilk
- 97 - 98% of milk lipids are triglycerides
- essential for the synthesis and development of retinal and neural tissues
- are a rich source of the essential fatty acids linoleic acid and alpha-linolenic acid and their long-chain derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA). DHA is essential for the developing visual system.
Milk lipids are the most variable constituent of human milk.
The change in fat concentration in breastmilk is directly related to the amount of milk held in the breast at that time. Milk removed when the breast is fullest has a low concentration which increases in a linear fashion as more and more milk is removed. Variations in fat content also occur with time of day, stage of lactation, parity, age, and between women.9

© Dr Jacqueline Kent, Biochemistry and Molecular Biology, The University of Western Australia
Illustrated above is a series of samples from an expression collected in 1mL fractions. The samples are, in order from left to right, a fore-milk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after the expression. The initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat).
The fat is seen as small clumps of white towards the top of each tube - the amount of fat increases as the breast is progressively drained.
For this mother this represents a change in degree of fullness from 0.55 (about half full) to 0.0 (well-drained).10
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![]() | ![]() Workbook Activity 1.3Complete Activity 1.3 in your workbook. | ![]() |
Foremilk vs Hindmilk
Many misunderstandings surround the use of these terms. The milk available at the beginning of a breastfeed is sometimes known as foremilk, and hindmilk is often used to describe the milk consumed by the infant at the end of the breastfeed.
The only difference between foremilk and hindmilk is in fat content, with foremilk having a lower fat content than hindmilk at a given breastfeed. You have just learned that the fat content increases in a linear fashion as milk is removed from the breast during that breastfeed, therefore, the change from foremilk to hindmilk is not defined. Use of the terms 'foremilk' and 'hindmilk' may be misrepresentative.
Breastmilk storage capacity
Breastmilk is stored in the alveoli of the breast, and storage capacity of the breast is unique for every woman and every breast. Some mothers may have a large storage capacity, while others may have a very small capacity, and most women have differing capacity in each breast.11,12,13 You cannot accurately judge a woman's breast capacity visually - don't assume that a large breasted woman has a large capacity.
For a mother who has a large storage capacity the milk received by her baby while the breast is at its fullest will be low in fat. After breastfeeding several times the volume in the breast will be reduced and the fat content of subsequent feeds will be much higher. However, for the mother with a small storage capacity, her baby may remove all or most of the breastmilk at most feeds. The fat content of breastmilk at each feed will be similar.
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![]() | ![]() Clinical TipMothers should follow their baby's feeding cues. The mother with the smaller breastmilk storage capacity will find her baby will cue to feed frequently. The mother with the larger storage capacity may find her baby takes larger feeds and requests fewer feedings. Both babies may consume similar amounts of breastmilk over a 24-hour period and both will grow equally as well. Scheduling feeding may work for some babies but cause other babies to be very unhappy and cause failure to thrive. | ![]() |
Cholesterol
The level of cholesterol in breastmilk remains constant (10-20mg/dL) despite dietary manipulation of the mother's cholesterol intake. There is negligible cholesterol in artificial infant formula.
Cholesterol is required to build and maintain cell membranes. Amongst other important tissues it is involved in laying down the myelin sheath which covers the axons of nerve cells in the rapidly growing brain and spinal cord. Multiple sclerosis, a problem of myelinisation, is much more prevalent in countries where artificial infant feeding is common.14
The high level of cholesterol in breastmilk appears to have a 'programming' effect on infants, protecting them from detrimental effects in later life, with adults who were artificially-fed having significantly higher total cholesterol levels and incidence of coronary heart disease.15,16,17
d. Vitamins
- Vitamin A
- necessary for vision and maintenance of epithelial structures
- adequate stores laid down in the fetal liver during the last trimester
- human milk is an excellent source of vitamin A
- Vitamin D
- synthesized in the skin from cholesterol on exposure to UVB radiation (sunshine)
- stimulates intestinal absorption and renal reabsorption of calcium and phosphorus
- involved in bone resorption and bone formation
- fetal stores of Vitamin D in infants born to mothers with normal status may be depleted by 2 months of age in the absence of any exposure to sunlight
- breastmilk is a negligible source (20 IU/L) for a recommended need of 300 - 400 IU per day
- very dark skinned breastfed infants or those infants not exposed to adequate sunlight may require oral supplementation
- Vitamin E
- mature human milk meets the daily recommended intake
- Vitamin K
- prothrombin, coagulation Factors VII and IX and some plasma proteins are vitamin K-dependent proteins. These are blood clotting factors.
- Vitamin K (phylloquinone) levels in human milk vary considerably depending on maternal diet. Maternal supplementation of 5mg/day increases breastmilk concentration to levels which provide the infant's daily requirement.
- Vitamin K synthesis by bacteria in the large intestine in the first week of life provides insufficient levels for the fully breastfed infant because the predominant gut bacteria (bifidobacteria) does not synthesize Vitamin K.
- Once only intramuscular injection of Vitamin K is recommended for all infants at birth. No other supplementation is required.
- Vitamin B
- Most B vitamins are in appropriate concentrations in breastmilk irrespective of maternal intake. Precaution should be taken with Vitamin B6 as mega-doses (ie 600mg/day) have been shown in some studies to reduce maternal prolactin levels. Usual supplement is 25mg per day. Mothers with a long-term history of oral contraceptive use may be deficient in Vitamin B6.
- A strict maternal vegan diet without B12 supplementation has resulted in serious infant morbidity.18,19 Likewise mothers with gastric bypass surgery are also at risk of Vitamin B12 deficiency.20
- Vitamin C
- Vitamin C levels in breastmilk remain within a normal range, regardless of maternal supplementation.
e. Minerals
Concentration of minerals in human milk appears to be quite low, however they have a very high bioavailability and their interrelationship with other nutrients may affect their absorption, metabolism and excretion.
Calcium
Lactating women are often advised to take a calcium supplement or to increase, above normal, their intake of calcium-rich foods. However, in a large study of a group of women in Cambridge UK21 there was no correlation found between calcium intake (ranging from 600 to 2300mg/day) and the amount of calcium in their breastmilk.
The infant's daily requirement for calcium is adequately met by breastmilk. Bone growth in the infant is unaffected by maternal supplements.
Maternal bone mineral density is not affected adversely by breastfeeding, or enhanced by calcium intake above normal levels. Within 3 months of weaning bone mineral density in breastfeeding women has returned to normal, or is even enhanced21,22. Breastfeeding decreases incidence of osteoporosis in post-menopausal women23 and parity with prolonged total duration of breastfeeding has no detrimental effect on bone mineral density.24
Iron
- levels relatively low but highly bioavailable to infant - five-fold more efficient absorption from human milk than from bovine milk25
- heat treatment of breastmilk does not alter the iron-absorption rate
- the presence of high lactose and Vitamin C levels in breastmilk also aid its absorption
- iron supplements for term infants during the first 6 months of exclusive breastfeeding is unnecessary. Complementary foods after 6 months of age should include iron-rich foods. Some infants who continue to be exclusively breastfed for much longer than 6 months may maintain an adequate iron status - biochemical analysis on an individual basis may be indicated.26
Iodine
- required for synthesis of thyroid hormones that are required for brain development during fetal and early postnatal life
- iodine deficiency is a leading cause of brain damage
- breastmilk levels vary widely according to geographic region and maternal intake
- supplementation of women during pregnancy and lactation in iodine-deficient areas will reverse this leading cause of mental impairment25
f. Water
Breastmilk contains a high percentage of water. When babies have unrestricted access to the breast they DO NOT need additional water, even in hot climates. Giving water or other fluids such as teas, will decrease the infant's desire to breastfeed decreasing nutrient intake and breastmilk synthesis, and increasing the infant's risk of infections.
The taste of breastmilk
The flavour (flavor) of breastmilk is affected by the foods in the maternal diet. This daily variation in flavour can help the infant to become used to the tastes of the family foods and ease the transition to these foods after six months of age. Artificial infant formula tastes the same for every feed. The taste of formula is not related to any foods the baby will eat when older.
Dietary advice
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What should I remember?
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Self-test Quiz
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Notes
- # WHO (2002) Global Strategy on Infant and Younf Child Feeding
- # Neville MC (2001) Anatomy and Physiology of Lactation
- # Picciano MF (2003) Pregnancy and Lactation: Physiological Adjustments, Nutritional Requirements and the Role of Dietary Supplements
- # Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.
- # Dusdieker LB et al. (1985) Effect of supplemental fluids on human milk production.
- # Riordan J (2005) Breastfeeding and Human Lactation
- # Hale TW et al. (2007) Textbook of Human Lactation
- # McVeagh P et al. (1997) Human milk oligosaccharides: only the breast
- # Daly SE et al. (1993) Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk
- # Kent J (2005) Personal communication
- # Engstrom JL et al. (2007) Comparison of milk output from the right and left breasts during simultaneous pumping in mothers of very low birthweight infants.
- # Ramsay DT et al. (2005) Anatomy of the lactation human breast redefined with ultrasound imaging
- # Cox DB et al. (1997) Studies on Human Lactation: The Development of the Computerized Breast Measurement System
- # Pisacane A et al. (1994) Breastfeeding and multiple sclerosis
- # Das UN (2003) A perinatal strategy to prevent coronary heart disease
- # Martin RM et al. (2005) Breastfeeding and atherosclerosis: intima-media thickness and plaques at 65-year follow-up of the Boyd Orr cohort
- # Owen CG et al. (2008) Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence.
- # Codazzi D et al. (2005) Coma and respiratory failure in a child with severe vitamin B12 deficiency
- # Allen LH (2008) Causes of vitamin B12 and folate deficiency.
- # Grange DK et al. (1994) Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass
- # Prentice A (2000) Calcium in pregnancy and lactation
- # Kovacs CS (2005) Calcium and bone metabolism during pregnancy and lactation
- # Schnatz PF et al. (2010) Effects of age at first pregnancy and breast-feeding on the development of postmenopausal osteoporosis.
- # Lenora J et al. (2009) Effects of multiparity and prolonged breast-feeding on maternal bone mineral density: a community-based cross-sectional study.
- # Picciano MF (2001) Nutrient Composition of Human Milk
- # Griffin IJ (2001) Iron and Breastfeeding
1.2 Immunology
At birth, the baby's skin and gut is sterile, but is quickly colonized by the bacterial flora of those with whom he comes in contact.
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![]() Clinical Tip:A simple strategy to ensure the baby's skin is colonized by the flora common to his mother is to limit the handling of the newborn by health care workers until after the mother and baby have been together, in skin-to-skin contact, for a number of hours. Prolonged skin-to-skin contact also reduces the risk of the baby acquiring nosocomial infections. |
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Soon after birth, the infant's gut is colonised by potentially harmful aerobic bacteria. The environment quickly changes as harmless anaerobic bacteria take over. Breastmilk supports this development of a protective anaerobic flora which may function as probiotics. Artificially-fed babies are colonized by aerobes and other anaerobes in addition to bifidobacteria, with a predominance of enterococci and enterobacteria. Clostridia, Enterococci, E. Coli and Bacteroides are also a common part of the gut flora of the artificially fed.1
Protective components of breastmilk
Proteins
Immunoglobulins
Immunoglobulins are present in human milk. The special structure secretory IgA (sIgA) is the main immunoglobulin. Concentration in colostrum is particularly high to provide immediate protection for the infant entering a world of microbes.
- sIgA protection is 'targeted' against organisms with which the mother, and consequently her baby, come into contact, killing the offending pathogen
- sIgA coats the infant's intestine preventing adherence of pathogens, blocking them from getting onto and into the infant's tissues
- sIgA encourages the growth of the normal, non-virulent gut bacteria.
Lactoferrin
- has antibacterial (to gram-positive and gram-negative), antiviral and antifungal (Candida albicans) effects
- promotes the growth of intestinal epithelium
Alpha-Lactalbumin
- antiinfective and immunostimulatory functions
- forms a complex that induces apoptosis (= cell death) of all malignant cells tested, but not normal cells - known as HAMLET (human alpha-lactalbumin made lethal to tumour cells)2
Lysozyme
- this enzyme effectively attacks E. coli in concert with lactoferrin and sIgA
Carbohydrates
Oligosaccharides
- prebiotic effect - produce an increased proliferation of bifidobacteria and lactobacilli (probiotics) which are not digested in the infant's small intestine, but enter the colon as intact, large carbohydrates that are then fermented by the resident bacteria.
- block receptors on epithelial surfaces by resembling binding sites for bacteria, sweeping the bacteria from the gut with them as they are eliminated
- defend infants against pathogens that cause otitis media, respiratory tract infections, urinary tract infections, diarrhoea.
Lipids and milk fat globules
Fatty acids and monoglycerides attack or neutralise G lamblia, Entamoeba, E coli, and Shiga-like toxins.
Cellular components
The neutrophils and macrophages in breastmilk most likely protect the maternal breasts.
Lymphocytes in breastmilk are absorbed and may possibly confer immunological information to the baby.
Other protective factors
Breastmilk contains a myriad of other factors that work to protect and enhance the development of the breastfed child, including nucleotides, defensins, cytokines, hormones and growth factors, anti-secretory factor, anti-inflammatory components, soluble CD14 and soluble Toll-like Receptor, etc.
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![]() Workbook Activity 1.4Complete Activity 1.4 in your workbook. |
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![]() Take a minute to reflect...Breastmilk truly is a living food that is unique to each mother and baby. While artificial infant milk is life-saving for some babies, for the majority, it is an inferior source of food and protection. |
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What should I remember?
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Self-test Quiz
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Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column | ![]() |
1.3 Relative risks
Artificial feeding increases illnesses in infants by:
- denying the infant the many special, unique protective factors, both antibody and non-antibody, found in human milk
- exposing the infant to bacterial pathogens in other food sources
- not providing optimal nutrition, decreasing the infant's ablility to fight infections
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Clinical Note:To obtain true and fair scientifically-relevant results in research studies, the researcher must compare the variable being studied to the norm. For example: compare state of disease in adults who smoke (variable), to state of disease in adults who do not smoke (the norm). Results are then written up as a change from the norm - ie 'incidence of lung cancer is increased in those who smoke by X.' Breastfeeding is normal and breastfed babies enjoy a NORMAL state of health. Studies of infant health are notoriously reported incorrectly, making statements that equate to 'Breastfed babies are healthier' whereas correct breastfeeding language should read 'Artificially-fed babies are sicker'. Whenever you discuss feeding outcomes with your colleagues or with parents, ensure you are speaking factually using breastmilk and breastfeeding as the norm. |
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![]() A little statistics...Relative risk (RR) is a ratio of the probability of a disease, in this case, occuring in the experimental group (ie artificially-fed) versus the control (breastfed) group. The equation to work it out is: RR = Probability in experimental group divided by Probability in control group. For example: If the probability of an infant contracting diarrhoea in the first month of life is 1% when breastfed, but 14% if artificially-fed then the RR=14. An artificially-fed infant has 14 times the risk of getting diarrhoea in the first month of life compared to the risk for a breastfed infant. |
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Acute diseases attributable to artificial feeding
Diarrhoea (diarrhea)
Dewey et al (1995)1 reported twice the incidence of gastrointestinal morbidity in artificially-fed infants in a relatively affluent community in the United States while Kramer et al (2001)2 reported a 66% increase in a socially advantaged group where artificial feeding was predominant.
In countries where poverty and poor hygiene are factors breastfeeding means the difference between healthy normal development, and malnutrition or possibly death.
Otitis media (middle ear infection)
A large literature review concluded that formula-fed infants' risk of otitis media is doubled in the first year.3 It has also been found that they experience a 75% increased incidence of otitis media of 10 or more days duration.1 Saarinen et al (1982)4 followed healthy term infants, noting that no exclusively breastfed infant suffered from otitis media in the first 6 months of life, while 10% of babies who were given any cow's milk did.
Pneumonia
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![]() | ![]() Summary of diarrhoea, otitis media and pneumonia
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Urinary Tract Infection
Marild et al (2004)10 demonstrated a significant increase in UTI amongst artificially-fed infants in Sweden; this protection for the breastfed infant persisted after weaning.
Necrotising Enterocolitis
Septicemia and Meningitis
Neonatal septicemia and meningitis is associated with severe morbidity and high mortality rates. Artificially fed infants in neonatal intensive care units, and artificially fed infants in developing countries, are most at risk.
In a comparison of breastmilk-fed and artificially-fed babies in neonatal intensive care units the incidence of sepsis was:12
Postnatal Age | Breastmilk Fed | Artificial Milk Fed |
---|---|---|
first 10 days | 5% | 10% |
11 - 24 days | 9% | 20% |
25 - 38 days | 0% | 15% |
Chronic diseases attributable to artificial feeding
Type 1 Diabetes Mellitus (Insulin-dependent diabetes)
Type 1 diabetes is an auto-immune disease determined by a combination of genetic and environmental factors.
- general population risk of developing Type 1 diabetes = 0.4%
- when a first-degree relative is affected = 6%
Environmental factors provide the trigger that causes a child to develop diabetes.
There are several hypotheses as to what these environmental factors are:
- early exposure to cow's milk protein
- introduction to solid food before 3 months
- not having all the protective benefits of breastmilk
Meta-analyses of the published research found a strong link between early introduction of artificial milks and the development of Type 1 diabetes:
- exposure to cow's milk in the first 3 months13,14
- children who breastfed <3 months, OR of 1.43 (1.15-1.77)15
- no-breastfeeding increased the risk (OR=1.93 [95% CI: 1.33-2.80]), while breastfeeding for more than 12 months was protective (OR=0.42 [95% CI: 0.22-0.81]).16
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![]() | ![]() The cycle of diabetic riskMothers who have type 1 diabetes are more likely to NOT breastfeed.17 Cesarian section birth, prematurity and unstable baby's condition at birth are among the reasons given for this occurrence. The same author also found that breastfeeding duration is likely to be shorter amongst this group of mothers with breastfeeding <4 weeks being associated with overweight at age 2 years.18
Can you see how the risk of type 1 diabetes can spiral through the generations? The birth and post-birth circumstances and management of the diabetic mother can lead to an intervention (ie. infant being not-breastfed/early exposure to cow's milk protein in artifical infant milk) which triggers the infant to later develop diabetes. Would mothers put their baby at risk if they knew this? What can you do at your workplace to help break this cycle? | ![]() |
Coeliac (Celiac) Disease
Celiac disease is an autoimmune enteropathy. Genetic susceptibility and dietary exposure to gluten are necessary for it to occur. Controlled studies looking at infant feeding have shown an approximately four-fold increased risk, as well as an earlier onset, among artificially fed children. 23
A meta-analysis of the literature 24 reported more than double the incidence of celiac disease in infants who received breastmilk substitutes before 6 months and were not receiving any breastmilk during the introduction of gluten-containing foods.
The current recommendation to prevent the development of celiac disease is for children to be breastfed exclusively for 6 months and for breastfeeding to continue while, and for several months after, gluten is introduced into the diet.
Obesity
Obesity is a serious condition that leads to chronic diseases such as heart disease, diabetes, hypertension, some cancers and an earlier death. Prevention of obesity starts at birth and is greatly influenced by the feeding method chosen.
Breastmilk contains an appetite regulator, leptin. Artifically-fed infants have half the normal serum leptin.25
Artificial feeding is significantly correlated with obesity in childhood and adulthood.26,27,28,3
Closely associated with childhood obesity:
- early weaning to artificial infant formula
- introduction of artificial infant formula before 6 months of age while breastfeeding
- introduction of foods before 6 months of age
Childhood Cancer
Inflammatory Bowel Diseases
- Inflammatory bowel disease
- Ulcerative colitis
- Crohn's disease
The causes of these conditions are multifactorial. However, researchers have been able to link infant feeding method to their development, finding that cases were much more common in those who had been artificially fed.
Allergic Responses
Cow's milk is the most common single allergen affecting infants. The proteins in cow's milk are the allergen, NOT lactose. Standard infant formulas are made from cow's milk.
Compared to breastfed infants, artificially-fed infants have a significantly higher incidence of all forms of atopy.31Feeding soy-based artificial baby milk, compared to standard cow's milk-based artifical baby milk does not reduce the risk.32
Asthma, eczema, urticaria, rhinitis, failure-to-thrive, colic, chronic respiratory disease, gastro-oesophageal reflux and gastro-intestinal disease are all examples of conditions caused by an allergy or intolerance to cow's milk protein.
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![]() Workbook Activity 1.5Complete Activity 1.5 in your workbook. |
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Developmental Deficits
Intelligence
The brain of the newborn infant continues to develop rapidly after full term birth, doubling in size by one year of age. The brain growth in the preterm infant is even more rapid and therefore has an even greater potential to be harmed by inappropriate nutrition.
Since Lucas in 199233 was able to demonstrate an intellectual deficit caused by artificial infant formula feeding, there have been numerous research papers confirming those findings.
Assessment of children at 6.5 years of age reveals:
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exclusive artificial feeding, or early introduction of artificial infant formula, contributes significantly to
- reduced total IQ
- reduced verbal IQ
- reduced performance IQ34
90% of children artificially fed will have an average 7-point IQ deficit that is directly attributable to being artificially fed.35
Sudden Infant Death Syndrome (SIDS)
Artificial feeding at one month of age was associated with double the risk for SIDS.36 The majority of babies older than one month who die of SIDS were infant formula fed. 37,38,39
A meta analysis of 23 SIDS studies revealed 19 studies which favourably supported breastfeeding in protection against SIDS. The combined analysis indicated that artificially-fed infants were twice as likely to die from SIDS.37
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![]() Think about it:Most new parents do not know of the research that clearly demonstrates these poor health and developmental outcomes from artificial feeding. As a health professional do you feel it is fair to withhold this information from parents who generally just want to do the best thing for their children? Who do you think is being protected when this information is not shared with parents? Who stands to lose by withholding this information? Who stands to gain by withholding this information? |
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![]() But we shouldn't make mothers feel guilty!Click on the icon above to read an article about making mothers feel guilty. |
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![]() What would you say?Well, have you thought about what you would say now if a mother said to you, "Is breastfeeding really worth all the effort it takes?"
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In Module 3 you'll learn that discussing specific effects of breastfeeding and artificial infant formula feeding is required of you. However, the next module will help you to see how you can discuss this topic (and many others) giving
- accurate, factual information,
- that the mother will be able to understand in the context of her situation,
- while building the mother's confidence to make decisions that suit her situation, and
- that she feels supported to carry out.
What should I remember?
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Self-test Quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 1 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 1.
Notes
- # Dewey KG et al. (1995) Differences in morbidity between breast-fed and formula-fed infants.
- # Kramer MS et al. (2001) Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus.
- # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries.
- # Saarinen UM (1982) Prolonged breast feeding as prophylaxis for recurrent otitis media.
- # Victora CG et al. (1987) Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil.
- # Wright AL et al. (1989) Breast feeding and lower respiratory tract illness in the first year of life
- # Oddy WH et al. (2003) Breast feeding and respiratory morbidity in infancy: a birth cohort study
- # Bachrach VR et al. (2003) Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis.
- # Heinz (2001-02) Heinz Sight: Infant Nutrition Newsletter
- # Marild S et al. (2004) Protective effect of breastfeeding against urinary tract infection
- # Yeo SL (2006) NICU update: state of the science of NEC.
- # el-Mohandes AE et al. (1997) Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis
- # Kostraba JN et al. (1993) Early exposure to cow's milk and solid foods in infancy, genetic predisposition, and risk of IDDM.
- # Gerstein HC (1994) Cow's milk exposure and type 1 diabetes mellitus. A critical overview of the clinical literature.
- # Perez-Bravo E et al. (1996) Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children
- # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
- # Hummel S et al. (2007) Breastfeeding habits in families with Type 1 diabetes
- # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
- # Lucas A et al. (1980) Breast vs Bottle: endocrine responses are different with formula feeding
- # Salmenperä L et al. (1988) Effects of feeding regimen on blood glucose levels and plasma concentrations of pancreatic hormones and gut regulatory peptides at 9 months of age: comparison between infants fed with milk formula and infants exclusively breast-fed from birth.
- # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
- # Horta BL et al. (2007) Evidence on the long term efects of breastfeeding:systematic review and meta-analyses
- # Davis MK (2001) Breastfeeding and chronic disease in childhood and adolescence
- # Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies
- # Savino F et al. (2004) Breast-fed infants have higher leptin values than formula-fed infants in the first four months of life
- # Baker JL et al. (2004) Maternal prepregnant body mass index, duration of breastfeeding, and timing of complementary food introduction are associated with infant weight gain.
- # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
- # Li C et al. (2005) Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight
- # Shu XO et al. (1999) Breast-feeding and risk of childhood acute leukemia
- # Martin RM et al. (2005) Breast-feeding and childhood cancer: A systematic review with metaanalysis
- # Friedman NJ et al. (2005) The role of breast-feeding in the development of allergies and asthma
- # Ram FS et al. (2002) Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy.
- # Lucas A et al. (1992) Breast milk and subsequent intelligence quotient in children born preterm
- # Gustafsson PA et al. (2004) Breastfeeding, very long polyunsaturated fatty acids (PUFA) and IQ at 6 1/2 years of age.
- # Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism
- # Vennemann MM et al. (2009) Does breastfeeding reduce the risk of sudden infant death syndrome?
- # McVea KL et al. (2000) The role of breastfeeding in sudden infant death syndrome
- # Alm B et al. (2002) Breastfeeding and the sudden infant death syndrome in Scandinavia, 1992-95
- # Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.
2.0 Communication Skills
Information cannot be effectively received, transferred or exchanged without using good communication skills.
The skills you will be learning in this module are skills that can be used in your everyday communication with friends, family, colleagues and the families you work with. Good communication skills will enhance your relationships with other people as you determine accurately what they are saying, and they know they are being listened to.
When working with women good communication means that you respect the women's own thoughts, beliefs, and culture. Telling or advising her what you think she should do or pushing a woman towards a particular action is disrespectful.
Some health care workers may find this difficult as they have been trained to look for problems and fix them. However, once at home with her baby, the mother will benefit most from the information you shared and the confidence she gained from making her own decisions.
You can use communication skills to:
- Listen and learn about the woman's beliefs, level of knowledge and her practices
- Build her confidence and praise practices that you want to encourage
- Offer information
- Suggest changes the woman could consider if changes are needed
Good communication skills results in the person with whom you are having a conversation:
- developing trust in you
- confiding in you
- reflecting on their personal predicament
- problem-solving for themselves
- accepting the outcome of their actions
- being empowered in other spheres of their life
Lack of communication skills results in the person with whom you are having a conversation:
- distrusting you
- treating you as an authority figure (may not disclose crucial information)
- dwelling on the problem
- allowing you to provide a 'solution' to their situation
- being resentful of the outcome of your instructions
- may cause further feelings of 'uselessness' or 'dependence', being unable to deal with future problems
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![]() Workbook Activity 2.1Complete Activity 2.1 in your workbook. |
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![]() Practise makes perfect!Communication skills are not something to be turned on and turned off at particular times. Develop your skills talking with your family and friends - practise them all the time. |
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Personal Qualities
You will need to develop a trusting relationship with the women, men and families you are assisting at this important stage of their life. Carl Rogers, a world-renowned psychotherapist, described three qualities essential to constructive communication: genuineness, non-possessive love and empathy. Communication skills, without the presence of these three factors, are associated with harmful therapist-client interactions.
Genuineness
The first of these is genuineness. Sometimes called congruence, it means being honest and open - what you really are without front or façade. The genuine person knows it is impossible to be completely self-revealing, but is committed to a responsible honesty and openness with others.
Non-possessive love
Also referred to in some texts as 'unconditional positive regard', but probably meaning more than this phrase allows. 'Non-possessive love' refers to your ability to accept, respect and support another person in a non-paternalistic way. This includes all of the client's frailties and weaknesses, as well as their strengths and positive qualities.
The 'love' you exhibit has the characteristics of patience, fairness, consistency, rationality and kindliness. It encourages freedom.
Empathy
Empathy refers to the ability to really see and hear another person and understand that person from their perspective. 'Putting yourself in their shoes.' Psychologists describe the Apathy-Empathy-Sympathy continuum.
Apathy | Empathy | Sympathy |
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"Yes, well mothers are constantly tired." | "Broken nights can be very tiring." | "I don't know how you cope with being woken so often." |
"There's nothing wrong with breastmilk." | "You're worried your breastmilk may be too thin." | "It's so scary when all your baby has is your milk." |
Apathy is a lack of feeling, while sympathy is 'feeling for' another person. Empathy is 'feeling with' the other person. Empathy involves experiencing the feelings of another without losing one's own identity. If you lose the ability to separate your own feelings from the feelings of another person, you are no longer empathetic.
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![]() Implementing Baby FriendlyFor some, the implementation of Baby Friendly Initiative best-practice principles will involve change. The success of any change management strategy is dependent on effectively communicating the benefits of successful implementation as well as the details of the change. The communication skills you use will be the same whether it is explaining the benefits and details of the implementation to the administrators of your organisation, to your colleagues, to mothers or to community-based peer counsellors.
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What should I remember?
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Self-test quiz
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Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column | ![]() |
2.1 Non-verbal
You will have heard the phrase “It's not what you say, it's the way you say it!
”.
Verbal communication allows you to express yourself, while nonverbal communication enhances and reinforces the effect of your spoken word.
Nonverbal communication is a reliable indicator of the real feelings.
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Consider how the mother will interpret these messages.The mother is sitting in a chair breastfeeding her baby. In each situation the health care worker says, “
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What do you want to communicate?
To be a good communicator you must first pay attention to the speaker. Your posture, eye contact, gestures, facial expressions and short responses are all nonverbal cues that help the speaker to understand whether the listener is following their conversation.
Posture
- Relaxed alertness.
- Body leaning slightly forward.
- Face the other squarely and be at eye level.
- Maintain an open posture (no crossed arms or legs).
- Position yourself at an appropriate distance. This is influenced by cultural and individual differences. Both too near and too far positioning causes anxiety. Generally, in Western cultures, about one metre (3 feet) is about right.
Appropriate body motion
Movements should be in response to what the speaker is saying. Lack of movement signifies the listener is controlled, cold, aloof and reserved. Sometimes the listener may be so in tune with the speaker that their gestures synchronise.
Eye contact
Eye contact allows the speaker to appraise your receptiveness and affords you to 'see' if there are deeper meanings than those being expressed. Eye contact involves softly focusing on the speaker's eyes, occasionally shifting the gaze from her face to other parts of her body, a gesturing hand for example, and then back to the face and eye contact once again.
Repeatedly looking away from the speaker, staring at her constantly or blankly, or looking away as soon as she looks at you are examples of poor eye contact.
Consider cultural differences. For example Australian aboriginal people prefer to avoid direct eye contact.
Minimal encouragers
Minimal encouragers are simple responses that indicate you are 'with them'. They aid the speaker to continue speaking, but don't direct the flow of the conversation. They are usually sprinkled throughout a conversation.
Examples are: mm-hmm, yes, right, I see, then?, go on, yeah, etc... They shouldn't imply agreement or disapproval.
Non-distracting environment
- pleasant, uncluttered room
- turn off television or intrusive music
- do not allow phone calls to interrupt the conversation
- in hospital setting, curtain off the mother's bed; put Do Not Disturb sign on door
- in an office: place chairs away from desk, avoid having a desk between you
- be aware of the mother's need for privacy, seeking a private area or asking others to leave if necessary
Time
The way a person perceives time, structures their time and reacts to time is a powerful communication tool. How you and your conversational partner react to punctuality and a willingness to wait will have an impact on your communication. How long are you or they prepared to listen?
Also consider the timing of your conversation as it relates to other activities for both parties.
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![]() Non-verbal communication is two-wayWhile you are ensuring that your nonverbal communication is congruent with your message and demonstrating effective listening, don't neglect to read the communication signs being given by your conversational partner.
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Note all of the aspects of non-verbal communication being exhibited in this photograph. Did you notice the body motion? Note the eye contact between the two.
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![]() Workbook Activity 2.2Complete Activity 2.2 in your workbook. |
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What should I remember?
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Self-test Quiz
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2.2 Listening skills
Listening skills involve
- Reflecting back what you have understood the mother said.
- Appropriate questioning.
Reflective listening
Reflective listening communicates to the mother your interpretation of what she has said and how she feels, and does so in a way that demonstrates understanding and acceptance.
Paraphrasing
Paraphrasing typically explains or clarifies what was said. A good paraphrase is succinct, cutting directly to the message and is restated the way you understood the message. Paraphrasing is not parroting (or copying). Parroting stifles conversation, paraphrasing contributes to the communication between people.
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![]() | An example:Mother: “ Health care worker: “ At this point the mother will either agree or she'll disagree and clarify her intent. | ![]() |
Applying paraphrasing more often in our everyday conversations would improve the fluency and accuracy of what was said and what was understood to have been said.
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![]() | Paraphrasing exercise | ![]() |
Reflecting feelings
You don't have to state the mother's feelings if it isn't appropriate. However, you must be aware of what they are.
How do you correctly interpret her feelings? Try these tips.
- Sometimes they may be spoken and leave you in no doubt: “
I felt so angry when he said that to me.
” - You may need to infer it from the content: “
I spent two hours yesterday when I was really busy helping her to breastfeed. Now she's artificially feeding, and says she was going to when she got home anyway.
” - Observe her body language. Much of your understanding of body language is 'innate'; something you pick up during a lifetime of interpersonal relationships. However, there is still so much you could learn. This is beyond the scope of this course but you will find it very rewarding if you pursue this interesting topic.
- How would you be feeling in that situation? Each person's emotional experience is unique, but by applying the previous points and thinking about how you would feel you can have a fairly good guess. If you reflect that feeling, eg. “
That's so frustrating
”, she will either agree readily or tell you how she actually feels.
Appropriate questioning
Consider the following conversation:
Health worker: | Good morning. Are you feeling well today? |
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Mother: | Yes. I'm well. |
Health worker: | Is baby breasfeeding OK? |
Mother: | Yes. |
Health worker: | Are you having any problems? |
Mother: | No. |
Now consider how it could have been more productive.
Health worker: | Good morning. How are you feeling? |
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Mother: | I'm feeling well. Thank you. |
Health worker: | Tell me about how breastfeeding your baby is going. |
Mother: | I breastfeed often during the day, and give him a bottle at night. |
Health worker: | What made you decide to give a bottle at night? |
Mother: | He wakes up at night, so I don't think my milk is strong enough to satisfy him. |
Do you see how questions that require only a one-word answer (closed questions) limit the amount of information you receive, while open questions encourage more conversation?
We often rely on questions excessively and use them poorly. Questions usually focus on our own intent, perspective, and concerns rather than on the mother's orientation. When that happens, questions are a barrier to communication.
About questioning
- Closed questions
- A closed question can be answered with either a single word or a short reply, eg yes/no. Closed questions direct the conversation, keeping control of the conversation with the questioner, and should therefore rarely be used.
This type of question is used to obtain information on a specific point. “Do you want to keep using the nipple shield?
”; “How old are your other children?
” Because these questions are so directed, the mother may reply with what she thinks you want to hear for fear of getting the question wrong.
Closed questions are useful for starting a conversation while retaining control, “It's great weather, isn't it?
” and for facts, “What was your baby's birth weight?
” -
- Open questions
- Open questions deliberately seek longer answers, asking the mother to think and reflect, before responding with opinions and feelings. The control of the conversation moves to the respondent.
The question should be designed to help her to clarify her own problem, rather than provide information for the interviewer. “How do you feel your baby is latching when you use the nipple shield?
” “Can you describe what your other children do while baby is feeding?
”
Ask only one question at a time - and not too many even then.
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![]() | Converting closed to open questions | ![]() |
What should I remember?
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2.3 Building confidence
In topic 3 you will learn of the importance of nurturing maternal self-efficacy and self-confidence for a mother to breastfeed her infant confidently. Your communication skills can help the mother to feel good about herself and confident in her role as a mother. Confidence can help a mother to carry out her decisions and to resist pressures from other people.
To build confidence the mother must trust that you accept her and her decisions without judgment; that you notice and praise what she is doing right and you offer additional information in an easily understood manner that will allow her to make her own informed decisions.
Acceptance
Acceptance of a person's actions or beliefs is the starting point of any relationship.
Accepting what a mother says helps her to trust you and encourages her to continue the conversation. Accepting what a mother says is not the same as agreeing that she is right. You can accept what she is saying and give correct information later.
Which one of these statements demonstrates acceptance?
- Mother: “
I give my baby a bottle each night because he was waking up.
” - Health worker: “
It's normal for babies to wake at night. That's not a reason to give a bottle.
” - Health worker: “
A bottle just at night will stop him waking so often.
” - Health worker: “
Getting up to settle a baby at night is very tiring.
”
The first response disagreed with the mother. The second response agreed with the mother even though the information was incorrect. The third response demonstrates acceptance of her statement without either agreeing or disagreeing.
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![]() | Acceptance statements quizChoose the response that demonstrates acceptance of the mother's statement. | ![]() |
Avoiding judgmental words
Words that may sound like you are judging include: right, wrong, well, bad, good, enough, properly, adequate, problem, still.
Words like this can make a woman feel that she has a standard to reach or that her baby is not behaving normally. Examples: "Is your baby latching properly?", "Does he have enough wet and dirty nappies/diapers?".
The mother may hide how things are going if she feels she is being judged. In addition, the mother and the health worker may have different ideas about what "properly" or "enough" means. It is more helpful to ask open questions such as "How do you feel he is going with latching now?", "Could you describe his wet and dirty nappies/diapers to me?"
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Acknowledge what is right
Notice and praise what the mother and baby are achieving. An example might be to comment that it is good to see she responds to early feeding cues, or that her baby opens his mouth really well just before latching.
Use language that is easily understood
Regardless of the mother's educational level, using simple language and avoiding medical terms or jargon provides greater clarity and better understanding.
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Provide relevant information
Additional ideas and options can be added to the ones the mother has already tried or knows about. Limit your suggestions to only a few that would be relevant to her. Don't overwhelm her with information. Use phrases such as: “How would you feel about...?
” or “Some recent research shows that... Could this apply in your situation?
”
Your aim is to ensure the mother has enough information to make an informed decision. The mother solves her own problem.
If you've applied the communication skills discussed so far you may find that the mother has already found her own solution. Sometimes just a good listener who can accurately reflect her feelings and provides a well-organized summary is sufficient for her to see her situation in a new light.
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![]() Workbook Activity 2.3Complete Activity 2.3 in your workbook. |
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What should I remember?
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2.4 An example
An example of good communication skills
Mother: | My child won't eat even though she is eight months old. She is only breastfeeding. |
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Health Worker: | It is wonderful that you are breastfeeding - that's still her best food. (approval) But you are right to offer her other food too. (agreement) |
Mother: | I give her porridge in her bottle but she spits it out and cries. |
Health Worker: | I see (acceptance, no criticism). What have you thought of doing? (exploring) |
Mother: | Well, I tried not breastfeeding her so much but she cried too much. |
Health Worker: | She really likes your breastmilk - she's a clever girl! (approval) How does she act when the other children are eating? (open question) |
Mother: | She cries and reaches for their food, but she is still too little for the foods they are eating. |
Health Worker: | So she is eager to eat with the other children (summarising). Have you tried preparing food for her specially? Or feeding her while the others are eating? (offering ideas) |
Mother: | Do you mean cooking her special meals? I am really very busy. |
Health Worker: | Of course you are! (accepting) Some mothers cook all the vegetables and then just take some out, remove the skins and mash them. Then they can spoon feed the baby while the others are eating whole vegetables. (offering ideas) |
Mother: | Well, I could try that. It doesn't sound like a lot of extra work. (mother makes decision) |
Health Worker: | You mentioned using a bottle? (exploring) |
Mother: | I know I shouldn't, but sugar water keeps her quiet when I'm cooking. |
Health Worker: | It's difficult to get everything done (accepting), but I agree that the bottle isn't the best solution. (agreement, no criticism) |
How would you feel about giving her a piece of soft chapati or fruit to try her teeth on while you are cooking? (offering ideas) | |
Mother: | Well, perhaps (mother making decision). But won't she choke on these things? I thought babies needed to drink. |
Health Worker: | You're right, they do need drinks (agreement) but just your breastmilk. That gives all the sugar and water they need (information). Now that she sits alone, she can start learning about your family food, too. |
Mother: | Should I go on giving her porridge? |
Health Worker: | Yes, that's very good food, especially with some mashed pumpkin or mashed banana added. (information). |
Bottles are not the best way to feed babies (correct by giving information, not criticism). | |
She might enjoy porridge more from a spoon or cup (offering ideas). | |
They are easier to keep clean than a bottle anyway (information). | |
So, how do you think you can best feed your daughter now? (checking) | |
Mother: | Well, let's see. I will go on breastfeeding and giving her porridge. I could add some fruit or pumpkin, and mashed beans and vegetables that the others are eating. Did you say I can give her some chapati? (shows understanding) |
Health Worker: | Yes, that's fine. |
Good counselling makes a mother more confident and readier to learn. Notice that the healthworker responded to the mother's concerns. She came back to correct the mistakes of the bottle and the sugar water but gave information in a gentle way that did not criticise the mother. She checked that the mother understood what to continue doing and what to change.
(Counselling scenario adapted from WHO Counselling Course, Helen Armstrong)
Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 2 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 2.
3.0 Pregnancy Care
Baby Friendly Step 3 and Point 3
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Step 3 of the Ten Steps to Successful Breastfeeding, and Point 3 of the Seven-point Plan for Sustaining Breastfeeding in the Community both state:
Australia: Point 3 - Inform women and their families about breastfeeding being the biologically normal way to feed a baby and about the risks associated with not breastfeeding | ![]() |
The prenatal discussion should cover
- the importance of exclusive breastfeeding for the first 6 months,
- the health associations of breastfeeding
- the risks of artificial feeding, and
- basic breastfeeding management.
Pregnant women of 32 weeks or more gestation should confirm that the health associations of breastfeeding and implications of not-breastfeeding have been discussed with them, including at least two of the following:
- infant nutrition,
- disease protection,
- maternal-infant bonding,
- health benefits to the mother, and
- that they have received no group education on the use of infant formula.
They should be able to describe at least two of the following breastfeeding management topics:
- importance of rooming-in,
- importance of feeding on demand,
- how to assure enough milk, and
- positioning and attachment.
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![]() | ![]() Workbook Activity 3.1Complete Activity 3.1 in your workbook. | ![]() |
Some of these topics we've already covered, the remainder will be covered in following modules. Review the Topic 1.3 Relative Risks to ensure that you are confident to talk to mothers about risks of artificial feeding as well as the 'benefits' of breastfeeding.
Broaching the topic
Consider how you would continue the discussion following the mother's reply to the following questions.
Health worker: | How are you going to feed your baby? |
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Mother: | I'm going to bottle feed. |
OR
Health worker: | Are you going to breastfeed? |
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Mother: | Yes. |
These are closed questions and don't allow you to broaden the discussion without it being challenging to the mother, regardless of her response.
Health worker: | What do you know about breastfeeding? |
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This open question will give you the opportunity to discuss any barriers that the woman may see to breastfeeding, or to discuss problems she may have had with previous breastfeeding and to begin discussion of the topics listed above.
It is also implicit in the question and following conversation that you consider breastfeeding to be relevant. The importance of the health care provider's attitude is significant when we find that a woman's attitude to breastfeeding has been shown to correspond closely to that of her health care provider.2
Discussing breastfeeding with pregnant women needn't take more than a few minutes at each visit. For example, at the first visit...
Health worker: | What changes have you noticed in your body so far? |
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Mother: | I have noticed that my breasts seem to have grown. What's causing that? |
Health worker: | Your breasts are preparing themselves for breastfeeding your baby, growing extra milk-making ducts. Look, here's a diagram of what is happening inside your breasts. |
At this point you could give her some more information on how her breasts will make and release her breastmilk according to how often her baby feeds. In just a few minutes you've covered how to assure enough milk and importance of feeding on demand, without it becoming a 'lecture' for the mother.
A little bit of information given like this at each visit normalises breastfeeding as a part of childbearing and motherhood. At a later visit, closer to 32 weeks when you feel you've gradually covered all the information necessary and answered any questions raised, you could spend more time confirming the mother's understanding of breastfeeding.
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![]() Audit tool Does your clinic have a method that records that all the topics listed above have been discussed with all pregnant women? If not, a sample checklist is available from Baby Friendly UK. Clicking on the icon to the left will take you to their checklist. Another sample checklist, developed by WHO/UNICEF is available by clicking |
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![]() Don't force a premature, uninformed decisionMany health units ask the pregnant mother what her feeding intention is early in pregnancy prior to providing education. If this is a practice at your Unit discuss the implications with your colleagues with view to providing the education first. |
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When the mother does not breastfeed
- Infant conditions:
- classic galactosemia
- maple syrup urine disease
- Mother:
- radio-active iodine-131 precludes breastfeeding for about 2 months. This should be avoided given that safer alternatives are available.
- during cytotoxic chemotherapy
- HIV, only if replacement feeding is acceptable, feasible, affordable, sustainable and safe.
- very low birth-weight or very preterm infants
- infants with phenylketonuria; with careful monitoring
- infants with hypoglycemia that does not respond to breastfeeding or breastmilk feeding; though due to the seriousness of this condition intravenous therapy is preferred management.
A mother may also choose not to breastfeed for reasons of her own. It is important that the mother receives the education already mentioned and is aware of the short- and long-term effects of breastmilk substitutes on her child before she makes this decision. A mother who is forewarned about the effects will be in the best position to prevent or seek early treatment of those risks.
Prenatal education
The choice of a breastmilk substitute should be made in conjunction with a pediatrician or other health professional who will have responsibility for the infant's health and growth. Factors such as a family history of allergies, weight gain issues and feeding difficulties with other siblings will guide this choice and the choice of feeding implements. The mother should bring these with her to the hospital or clinic so that she can learn how to prepare them and feed her infant while being supervised.
Infants fed a breastmilk substitute that is not prepared in a safe manner are prone to hypernatremic dehydration, malnutrition, obesity and gastrointestinal infections. 3 A large American study reported more than 3/4 of mothers using breastmilk substitutes did not receive instruction on formula preparation or storage from a health professional. 4 Similarly in the United Kingdom a systematic review of the literature found errors in reconstitution, with a tendency to over-concentrate feeds, though under-concentration also occurred. 5
Because of the frequency and seriousness of these errors, instruction on formula preparation, storage and safe feeding practices must be given individually to the parents by a health professional at the time they need it. This teaching is not effective when given prenatally. Topic 7.5.4 details how to teach this skill.
The WHO Code on the Marketing of Breastmilk Substitutes precludes group instruction of this important skill. Likewise it stipulates that instruction is to occur after the infant is born, at the time of need. 6
What should I remember?
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Notes
- # World Health Organisation et al. (1992) Global Criteria fort he Baby-Friendly Hospital Initiative
- # Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey
- # Egemen A et al. (2002) A generally neglected threat in infant nutrition: incorrect preparation of infant formulae.
- # Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.
- # Renfrew MJ et al. (2003) Formula feed preparation: helping reduce the risks; a systematic review.
- # World Health Organization (2008) The International Code of Marketing of Breast-Milk Substitutes: frequently asked questions. Updated version 2008
3.1 The feeding decision
What is most influential?
Less well known are psychosocial variables. Researchers found that maternal attitudes are better predictors of feeding method than are sociodemographic factors,1 and that a woman's prenatal intention was a stronger predictor than the standard demographic factors combined.2 Fathers' attitudes also influence maternal decisions.3
In a study of women who were already breastfeeding 95.5% gave breastmilk as being better for the baby as the major reason they chose to breastfeed, with convenience for the mother another common reason. Another researcher4 explored why both breastfeeding and artificial formula-feeding mothers chose their method of feeding. They found ...
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Mothers chose to feed artificial infant formula
- not because they embraced artificial infant formula-feeding, rather that they rejected breastfeeding
- found breastfeeding embarrassing
- feared the pain or discomfort
- felt it limits freedom and social life
- were concerned that the father would not be involved
- but acknowledged that human milk is better for the baby
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Mothers who chose to breastfeed had the following in common
- a positive attitude toward breastfeeding and human milk
- considered human milk to be healthier or 'better' for babies than artificial infant formula
- felt breastfeeding was more natural
- felt it resulted in better bonding or closeness with the baby
- and their self-confidence was linked to longer duration of breastfeeding
• breastfeeding in public,
• combining breastfeeding and working, and
• management of breastfeeding by health professionals5
Pregnant women are influenced in their attitude towards breastfeeding and will tend to adopt similar attitudes and opinions to that of their health care provider. Women who are encouraged to breastfeed by their doctor or nurse are more than four times as likely to initiate breastfeeding as women who do not receive encouragement.6
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![]() Play your part...This is an indication of the mother's respect for her health provider's opinion, and the responsibility that rests on your shoulders to be a positive influence on pregnant women at a time when they are so open to receiving information.
You have a very important role to play in encouraging a positive breastfeeding attitude. |
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![]() Influencing attitudes Look again at the reasons mothers have given for them to artificially feed, and what mothers' concerns about breastfeeding are. Be aware that these personal attitudes may exist for some women. |
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Guilt and not breastfeedingThis is a good opportunity for you to re-read about how feelings of guilt develop in the infant feeding decision. Understanding this will assist you to communicate effectively with pregnant women.
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What should I remember?
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Self -test quiz
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Notes
- # Dungy CI et al. (1994) Maternal attitudes as predictors of infant feeding decisions
- # Donath SM et al. (2003) Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study
- # Freed GL et al. (1993) Effect of expectant mothers' feeding plan on prediction of fathers' attitudes regarding breast-feeding
- # Brodribb W et al. (2007) Identifying predictors of the reasons women give for choosing to breastfeed.
- # McIntyre E et al. (2001) Attitudes towards infant feeding among adults in a low socioeconomic community: what social support is there for breastfeeding?
- # Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey
3.2 The barriers
Barriers to breastfeeding can be divided into 3 main categories:
- societal barriers, such as attitudes of the general population, the mother and her support networks. These are influenced by commercial interests, among other things.
- health professionals who lack knowledge, skills and management of breastfeeding
- postnatal perceptions of ability to continue breastfeeding. The mother's lack of knowledge of normal newborn behaviour, breastfeeding management and a need or expectation to work away from her baby influence this perception.
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![]() Workbook Activity 3.2Complete Activity 3.2 in your workbook. |
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Societal barriers
Worldwide campaigns, eg. World Breastfeeding Week, a WABA initiative; the Global Strategy for Infant and Young Child Feeding, a WHO/UNICEF initiative, as well as national and local initiatives attempt to influence community attitudes.

National program to influence community attitudes. The Ad Council, USA

from San Diego County Breastfeeding Coalition
Some countries and States have had to go to the extreme step of legislating for a mother's right to breastfeed her baby wherever she and her baby are when her baby requires feeding.
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![]() | ![]() What can you do to influence community attitudes? Before you can address barriers that mothers will have to overcome, you will need to understand what they are. Surveying the mothers and their relatives and friends that you meet in your unit could give you a starting point. From there, a small but enthusiastic committee could brainstorm ideas for local and community activities to address these concerns. Share your findings in the forum. | ![]() |
Health provider knowledge, skills and management
A common complaint from women is the amount of conflicting advice they receive from their health care providers. Also some of that advice may be detrimental to ongoing breastfeeding success.
Step 1 and Point 1
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Step 1 of the Ten Steps to Successful Breastfeeding and Point 1 of the Seven Point Plan for Sustaining Breastfeeding in the Community both state:
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The policy should be displayed in all areas which serve mothers and babies and should cover all Ten Steps to Successful Breastfeeding in hospitals or all the Seven Point Plan, and prohibits the display or distribution of materials which promote breastmilk substitutes, feeding bottles, teats/artificial nipples and dummies/pacifiers.
Having a written breastfeeding policy
- will eliminate the conflicting advice that is given to mothers; All staff will be aware of what they must do.
- provides a stimulus for discussion for mothers

Display the Policy in the most common languages spoken.
© D.Fisher, IBCLC
Baby Friendly Step 2 and Point 2
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Step 2 of the Ten Steps to Successful Breastfeeding and Point 2 of the Seven Point Plan for Sustaining Breastfeeding in the Community both state:
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Education of health professionals using the curriculum developed for Step 2 of the Baby Friendly Hospitals Initiative produced staff who were significantly more knowledgeable about breastfeeding, had more positive attitudes and were more likely to employ correct practices for the promotion of exclusive breastfeeding.1,2 Another study showed that mothers who birthed in hospitals that had a high compliance to Baby Friendly Steps initiated breastfeeding in greater numbers and breastfed for longer than those in non-Baby Friendly hospitals.3
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![]() Support your colleaguesALL of your colleagues want to do what is best for both mother and baby. Encourage those colleagues who are unsure of current, evidence-based practices to complete an educational program such as this one. It will help them to achieve their goal, and benefit mothers and babies.
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Postnatal perceptions
Educating mothers about maintaining milk supply and normal newborn behaviour will be discussed as you work through this course.
An increasing number of women spend large amounts of time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.
Breastfeeding and separations
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Leaving her baby to go to work can be a highly stressful time for the mother. She will need to consider the physical and emotional effects of separation for long or short periods of time.
Continuing to provide breastmilk can
- present many challenges,
- help her to maintain an emotional connection to her baby, despite her physical absence,
- avoid the acute and chronic illnesses associated with artificial infant formula,
- make breastfeeding when they are reunited a very special and close time.
Your professional role is to
- Educate her on the value of continuing to provide breastmilk for her baby, despite separation.
- Discuss the issues she will need to address to be successful.
- Provide her with contacts for peer-support services, to talk with other women in her situation.
- Inform the mother of her right to breastfeed, and what workplace legislation will protect her right.
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![]() | ![]() Do some action researchAsk your colleagues, friends and the mothers you meet who continued to breastfeed until their baby was at least 12 months old what they did during periods of separation. You are likely to get many unique ideas which you can share with pregnant women. | ![]() |
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![]() | ![]() Workbook Activity 3.3Complete Activity 3.3 in your workbook. | ![]() |
Breastfeeding in special circumstances
Most women will be healthy, having no special needs regarding breastfeeding, and will be able to breastfeed without difficulty.
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![]() | ![]() When a referral is neededIn some of the circumstances described the mother will need the help of other health professionals, such as a psychologist, or a lactation consultant, or a doctor, and perhaps referral to a peer-support group. Does your Unit have a procedure in place to ensure the mother is aware of these other services and able to access them? | ![]() |
What should I remember?
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![]() | ![]() Addressing the following barriers will make breastfeeding possible for more women.
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Notes
- # Gupta A et al. (2002) Training in Baby Friendly Hospital Initiative
- # Owoaje ET et al. (2002) Previous BFHI training and nurses' knowledge, attitudes and practices regarding exclusive breastfeeding
- # Merten S et al. (2005) Do baby-friendly hospitals influence breastfeeding duration on a national level?
3.3 Physical preparation
Nipple preparation
The old texts abound with advice on nipple preparation techniques. Studies from the 1970s all found that any physical preparation of the nipples is entirely unnecessary and should NOT be recommended.
In several large international trials treatment of inverted or non-protractile nipples during pregnancy, the use of Hoffman's nipple stretching exercises and/or breast shells revealed NO difference to the nipples compared to a group who had no intervention. Women in the intervention groups were more likely to not initiate breastfeeding or wean early. Therefore this practice is also not to be recommended.1
Routine expression of colostrum is likewise not necessary and could cause anxiety in women who are not comfortable handling their breasts in this manner, or in those who are unable to express colostrum - a fact which is not related to ability to breastfeed.
However, antenatal expression and collection of colostrum may be recommended for certain maternal or newborn medical reasons.2 This ready supply of colostrum will negate the need for artificial infant milk if a supplement is necessary. It also provides an ideal opportunity to teach mothers how to hand express, a skill they will need to learn anyway.
Prenatal breast examination
While there is no physical preparation necessary for breastfeeding, examination of the breasts during a routine prenatal check-up can reveal information that could assist with the care of the mother and baby postnatally, and it provides an ideal opportunity to discuss breastfeeding and any concerns the mother may have. Have the mother in a sitting position.
The breast is composed of glandular tissue (functional tissue), fibrous tissue and fatty tissue. Breast size is variable between women, and even in the same woman, being mostly dependent on the amount of fatty tissue present. Glandular tissue influences size to a lesser degree.
The glandular tissue begins to function as a milk producing gland during pregnancy. The duct system and terminal milk-producing buds, called alveoli, proliferate during the first half of the pregnancy. Breast size increases for most women during this time.
Under the influence of the hormone prolactin, small amounts of colostrum are produced. Pregnancy progesterone inhibits full milk production. Breastmilk is synthesised and stored in the alveoli and travels through the duct system towards the nipple openings.
The nipple is in the centre of the areola and the least important structure of the breast during breastfeeding, being merely the structure through which the ends of the ductal system pass. Unfortunately, it is often the most commented on by the mother's advisors, forecasting success or failure of breastfeeding on the size and erectile nature of the nipple, which of course is incorrect.
The areola may darken during pregnancy. Montgomery's follicles are tiny glands that have a pimple-like appearance on the areola and become more prominent during pregnancy. These follicles may secrete an oily substance, and some secrete tiny droplets of milk. Maternal areola odor is produced which enhances the newborn's sucking activity.3 Washing the breasts before feeding is not recommended as it washes away these protective secretions, and the important prefeeding stimulus provided by the unique smell.
Inspection
- Size and shape: Breasts and nipples come in an infinite variety of sizes and shapes. Breast size is not related to milk production. Remember, it's breastfeeding, not nipple feeding. A 'different' nipple shape could provide mother and baby with a challenge - the key is to achieve good latch to the breast.
- Asymmetry: Most women have asymmetrical breasts. Marked asymmetry should be noted, but no further action is necessary. If the smaller breast is felt to be hypoplastic, it is helpful to note that one breast can produce sufficient breastmilk for the baby.
- Large breasts: Some women with very large breasts may like to discuss their feelings about their breasts and what breastfeeding is going to mean to them. Knowing how to help this mother to feed easily and discreetly could be the significant factor in her infant feeding decision.
- Skin appearance: The skin should appear smooth without thickening or dimpling, which, while rare in women of child-bearing age, could indicate an underlying tumour. Skin conditions such as psoriasis, dermatitis or bacterial or herpetic lesions should also be noted.
- Scarring: Record the position and reason for surgical or injury scars noting their potential to impact on breastfeeding (eg. breast reduction surgery, areola incision, burns etc).

Nipple, areola and prominent Montgomery's follicles.
© S.Cox, IBCLC
Palpation
This is an ideal health education opportunity to discuss and demonstrate breast self-examination as a routine breast screening technique for breast cancer, but which can also be useful to detect blocked ducts during lactation.
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![]() | ![]() Workbook Activity 3.4Complete Activity 3.4 in your workbook. | ![]() |
Record-keeping
It is important to record the signs and symptoms you noted at this examination. Later in the pregnancy the mother could be referred to a Lactation Consultant to discuss any issues which may impact on breastfeeding, such as breast reduction, augmentation, or if the mother has a concern about her capability to breastfeed. A medical review is indicated for other abnormalities noted.
Markedly small or asymmetrical breasts may, or may not, make breastfeeding difficult. Postnatally, routine procedures should readily identify babies who are receiving insufficient breastmilk. However, a note in the mother's chart will alert staff to remain vigilant.
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![]() The power of words.It's often been commented that the most important organ for successful breastfeeding is the brain. There are essential hormones released here, but of MORE importance is the belief by the mother that she can breastfeed. A positive attitude by all her health care providers is essential to prevent self-doubt limiting the mother's potential. Be aware of the words you use and the impact they have on a mother's self-confidence. |
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What should I remember?
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Self-test Quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 3 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 3.
Notes
- # MAIN Collaborative Group Preparing for Breast Feeding (1994) Treatment of inverted and nonprotractile nipples in pregnancy
- # Cox S (2006) Breastfeeding with Confidence
- # Schaal B et al. (2006) Human breast areolae as scent organs: morphological data and possible involvement in maternal-neonatal coadaptation
4.0 The Birth Experience
The benchmark outcome of pregnancy is the normal vaginal birth of the baby, without any medical or pharmacological intervention and without complication for either mother or baby, followed by the baby being able to latch and breastfeed well. This may not be achievable for some women for whom the availability of skilled medical, nursing and pharmacological assistance is essential, but it is possible for the majority of women in the World.
Normal labor is a fragile entity. Once intervention occurs then a cascade of interventions inevitably follow.1Kroeger, 2004
Health care professionals have a responsibility to support and facilitate normal birthing. What happens to the mother during birthing has far-reaching effects on her relationship with her baby, her ability to breastfeed and the health of the mother and her child.

Poster available for purchase from NHS, UK
Lactation physiology
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Lactogenesis is the making of breastmilk. There are three distinct phases.
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Lactogenesis II
Lactogenesis II will occur when:
- progesterone levels drop as a result of the removal of the placenta, AND
- prolactin levels are high as they are at the time of birthing, in the presence of
- normal insulin, thyroid hormones and glucocorticoids.
- Also, following birth, lactose secretion into colostrum increases, osmotically drawing water with it and increasing the volume of milk.
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![]() | ![]() Workbook Activity 4.1Complete Activity 4.1 in your workbook. | ![]() |
What could delay or inhibit lactogenesis II?
Hint: Remember it's an endocrine function, therefore consider hormonal causes.
Accidents at birthing may cause endocrine disruption. For example, retention of a functional portion of the placenta that continues to secrete progesterone, or a haemorrhage severe enough to cause Sheehan's syndrome (pituitary gland necrosis).
A delay in lactogenesis II occurs after assisted deliveries.2 Finding the cause of this delay and relating it to the physiology of lactogenesis has led researchers to look at the effect of stress.
Stress and breastfeeding
High stress levels are correlated with high cortisol levels. Cortisol, in normal concentrations, is also necessary to initiate lactogenesis II successfully, though what its role is isn't fully understood yet.
- Markers of both fetal and maternal stress during labor and delivery are associated with delayed breast fullness.3
- Maternal stress seems to interfere with the release of oxytocin causing poor milk removal, and a newborn who experienced stress during labor and delivery may be too weak or too sleepy to latch on and suckle effectively.4
- Onset of lactation occurred later in women who had higher cortisol levels. Primiparous women had higher levels than multiparous women. Stress during labor and/or delivery is likely to be a significant risk factor for delayed onset of lactation.5
What should I remember?
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Self-test quiz
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Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column | ![]() |
Notes
- # Kroeger M et al. (2004) Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum
- # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
- # Chen DC et al. (1998) Stress during labor and delivery and early lactation performance
- # Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans
- # Grajeda R et al. (2002) Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women
4.1 The first hours

Promotional poster - from Baby Friendly UK
The benefits to the mother of immediate breastfeeding are innumerable, not the least of which, after the weariness of labour and birth, is the emotional gratification, the feeling of strength, composure, and the sense of fulfillment that comes with the handling and suckling of the baby.1
Ashley Montague, 1978
Baby Friendly Step 4
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Step 4 of the Ten Steps to Successful Breastfeeding states:
"Help mothers to initiate breastfeeding within a half-hour of birth." This step is now interpreted as:
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Immediately following birth
At the time of birth nearly 90% of newborns are vigorous, term babies with no risk factors, who do not need to be separated from their mother in order to receive the initial steps of resuscitation.3
- Immediately move newborn onto mother's abdomen with skin-to-skin contact.
- In this position: Upper airway can be cleared by wiping the mouth and nose, baby can be dried, assigned Apgar scores, visually assessed and vital signs recorded.
- Cover both mother and baby with dry linen.
The first breastfeed
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![]() | ![]() Read this great article!What happens now is truly a miracle to watch! Click on the icon on the left to read this paper, then file it in your Workbook. If you are in contact with colleagues who are with birthing mothers, share it with them too. | ![]() |
Several researchers have described this species-specific set of innate behaviors when baby is placed in skin-to-skin contact with the mother immediately following birth. It is clear that newborn babies are born with the instinct to breastfeed.4,5,6,7

© R.Cantrill, IBCLC
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The role of the birth attendants
This critical period in the relationship between mother and baby is, in some birthing units, a high-intervention time when it should be exactly the opposite. Recall that the AAP Neonatal Resuscitation Program3 states that all observations can take place with infant in skin-to-skin contact with his mother. The role of the birth attendants at this time is to support the mother to provide the ideal environment for her baby to adapt to extrauterine life, orientate to the breast and coordinate suckling.
Appropriate support is given by discussing with the mother, and others present, the importance of uninterrupted skin-to-skin contact. Some birth attendants tell of the mother and her support people being enthralled as they watch the baby move through this sequential pre-feeding behavior, not wishing to interrupt it. A little education can go a long way!
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![]() Workbook Activity 4.2Complete Activity 4.2 in your workbook. |
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Addressing barriers to skin-to-skin
Concern that the baby will get cold.
- Dry the baby and place in skin-to-skin contact on mother's chest.
- Put a dry cloth or blanket over both the mother and the baby.
- If the room is cold cover the baby's head with a bonnet to reduce heat loss.
- Babies in skin-to-skin contact have higher temperature than those dressed and better temperature regulation than those under a heater or in incubator care. 10 11
Baby needs to be examined.
- Most examinations can be conducted with baby on mother's chest.
- There is no need to move the baby to monitor vital signs.
- Weighing can be delayed.
Mother needs to be stitched.
- Baby can stay on mother's abdomen while stitching an episiotomy.
- Baby can stay on mother's chest while stitching a caesarean section.
Baby needs to be bathed.
- Delaying the first bath provides better thermoregulation and allows the vernix to remain on the skin.
Delivery room is busy.
- Mother and baby can be transferred to the postnatal ward while in skin-to-skin contact.
Insufficient staff to remain with the mother.
- A family member can stay with the mother and baby.
- Discuss routine precautions with the family member to ensure their safety.
Baby is not alert.
- If a baby is sleepy due to maternal medications it is even more important that the baby has contact as he/she needs extra support to bond and feed.
Mother is tired.
- A mother is rarely so tired that she does not want to hold her baby.
- Contact with her baby can help the mother to relax.
- Review labor practices such as withholding fluid and foods, and practices that may increase the length of labor.
- Skin-to-skin care and breastfeeding is best when the mother is in a reclined or semi-reclined position; a good position for resting.
Lack of knowledge of health professional wishing to move the baby
- This first step following birthing has far-reaching effects on mother, baby and breastfeeding.
- Train all birthing room staff in the effects of immediate and undisturbed skin-to-skin contact.
- Refer all staff to the hospital policy which they must follow. Hospital breastfeeding policies will reflect the 10 Steps to Successful Breastfeeding, including Step 4.
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![]() | ![]() Just the thing for busy staff!Supporting the mother to care for her baby with skin-to-skin contact will significantly reduce the workload of the health care staff looking after her.
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Maternal-infant bonding
This is the beginning of a loving relationship between the parents and their newborn. The infant appears to play his part in the establishment of these bonds by actively interacting with his parents. Following an initial cry at birth the infant becomes quietly alert and seeks visual contact, massages the mother's chest and breasts and latches and breastfeeds. The high blood levels of beta endorphins, oxytocin and prolactin in both mother and infant facilitate falling in love.14
For this to occur the following factors have to be in place and considered. These are all influenced by the birth attendants.
- the availability of the infant to his/her parents,
- an environment conducive to parent and child interaction, and
- the attitude of those present at the delivery to the appearance of the infant14
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What about a baby to be artificially fed?Skin-to-skin time with mother is equally important for EVERY baby. In Topic 4.3 Postnatal interventions, you will read the effects of separating mothers and newborns - facilitating breastfeeding is only one of many, many benefits of skin-to-skin contact.
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What should I remember?
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Self-test quiz
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Notes
- # Montague A (1978) Touching: The Human Significance of the Skin
- # World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care
- # American Academy of Pediatrics (2000) The Textbook of Neonatal Resuscitation
- # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
- # Widstrom AM et al. (1990) Short-term effects of early suckling and touch of the nipple on maternal behaviour
- # Varendi H et al. (1998) Soothing effect of amniotic fluid smell in newborns
- # Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier
- # Gomez Papi A et al. (1998) Kangaroo method in the delivery room for full-term babies
- # Bergman NJ et al. (2004) Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns
- # Carfoot S et al. (2005) A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding.
- # Fransson AL et al. (2005) Temperature variation in newborn babies: importance of physical contact with the mother.
- # Visscher MO et al. (2005) Vernix caseosa in neonatal adaptation.
- # Bergstrom A et al. (2005) The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial.
- # Attrill B (2002) The assumption of the maternal role: a developmental process
4.2 Labor interventions
The care a mother experiences during labor and birthing can affect breastfeeding and how she cares for her baby. Birth practices that help the mother to feel competent, in control, supported and ready to interact with her baby include:
- Emotional support during labor
- Freedom of movement during labor
- Offering light foods and fluids during labor
- Avoidance of unnecessary caesarean section
- Early mother-infant contact
- Facilitating the first feed
When labor interventions are considered factor in the following information.
Analgesia during labor
The most commonly used intrapartum analgesics are potent narcotics, all of which are known to cause sedation and respiratory depression in the mother and the baby, and also to affect behavior.
- Morphine has a short half-life (1.5 - 2 hrs) and does not have an active metabolite
- Butorphanol (Stadol) has a half-life of 3 - 4 hours.
- Nalbuphine (Nubain) has a half-life of 5 hours.1
- Meperidine (Pethidine/Demerol) is metabolized to the active metabolite normeperidine (norpethidine) which has a long half-life (63 hours in the neonate). Meperidine/Pethidine reaches its highest levels in the fetus 2 to 3 hours after administration, however normeperidine/norpethidine levels continue to rise the longer it is until birth. Normeperidine/norpethidine still has half the pharmacological activity of meperidine/pethidine.
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![]() | ![]() How long will the effects of meperidine/pethidine be experienced by the newborn baby?It takes approximately 5 half-lives for a substance to reach insignificant serum (blood) concentration. How long will it take the newborn baby to clear normeperidine and its effects from his system? Multiply 63 hours by 5 times; then divide by 24 to have your answer in days. | ![]() |
- Shorter-acting opiates such as fentanyl are preferred. Remifentanil is potent and has rapid onset and offset but can be associated with a high incidence of maternal apnea, requiring increased monitoring. Its transfer in utero to the fetus is minimal.
- Meperidine/pethidine generally should not be used except in small doses less than 1 hour before anticipated delivery because of greater incidence and duration of neonatal depression, cyanosis, and bradycardia.
- Nalbuphine, butorphanol, and pentazocine may be used for patients with certain opioid allergies or at increased risk of difficult airway management or respiratory depression. However, these medications may interfere with fetal heart rate monitoring interpretation. Observe the mother and infant for psychotomimetic reactions (3%).
- Multiple doses of intravenous analgesic, and their timing of administration may lead to greater neonatal effects. For example, fentanyl administration within 1 hour of delivery or meperidine/pethidine administration between 1 and 4 hours before delivery is associated with more profound neonatal effects.2
From Academy of Breastfeeding Medicine, Protocol #15. Montgomery A, Hale T, et al. 2006
Other forms of analgesia such as inhaled nitrous oxide, paracervical block, pudendal block and local perineal anaesthesia expose the infant to minimal quantities of medication and may be an alternative to intravenous narcotics or epidural analgesia.
Neuraxial pain relief (epidural/spinal)
Anesthetics such as lignocaine and bupivacaine are commonly administered via the epidural route to mothers in labor to provide pain-free birthing. This local anesthetic is almost always combined with narcotics such as morphine, fentanyl or sufentanil, providing a rapid onset of pain relief while reducing the intensity of immobility for the mother.
While epidurals in labor provide greater pain relief than non-epidural methods, they are also associated with:3
- longer first and second stages of labor,
- maternal fever
- followed by septic work-up of infant, and maternal/infant separation, and possibly antibiotic therapy
- a drop in blood pressure
- fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
- fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
- problems passing urine
- an increased use of oxytocin augmentation
- an increased incidence of fetal malposition,
- an increased need for instrumental vaginal delivery
- the mother being unable to move for a period of time after the birth, and
- the possibility of a postdural puncture headache4 palliatively treated by horizontal bed rest, and usually further medical intervention.
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![]() | ![]() Did you know?Another side effect of epidural administration is the fall in maternal serum beta endorphins.7 Beta-endorphins are a naturally occurring opiate that, like other opiates, act as an analgesic, inducing feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency.
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Cesarean (caesarean) section or vaginal instrumental birth
Cesarean birth is most often associated with delayed skin-to-skin contact between mother and baby and longer time to first breastfeed. Hospitals practicing Step 4 of the 10 Steps to Successful Breastfeeding are, however, diligent at ensuring a minimum disruption to this important bonding and breastfeeding step.
- Rowe-Murray et al (2002)13 reported a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.
- Shawky & Abalkhail (2003)14 found caesarean section delivery to be significantly related to earlier cessation of breastfeeding.
- Leung et al (2002)15 identified caesarean delivery was a risk factor for not initiating breastfeeding, for breastfeeding less than 1 month, and it remained a significant hazard against breastfeeding duration.
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![]() | ![]() Interesting researchAn interesting study16 looked at whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency cesarean section or vaginally, and if those patterns showed any relation to the duration of breastfeeding. They found that the mothers birthing vaginally had significantly more oxytocin pulses on Day 2 than the cesarean section mothers. Furthermore, the cesarean section women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. They were able to link the oxytocin pulsatility on Day 2 to the duration of exclusive breastfeeding.
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Don't forget the effects of the operation itself: an abdominal incision, pain, restricted movement, intravenous therapy, a urinary catheter, analgesics for several days, restricted oral intake and any complications arising from these interventions. Rooming-in is more difficult, at least initially.
The baby has an increased risk of respiratory problems, and is subjected to suctioning of mouth and oropharynx. Some units purposely separate the post-cesarean delivered baby from its mother for "observation" for several hours and may perform routine heel prick blood tests. Due to separation and the desire of the staff to let the mother 'rest', the baby may be given formula supplements.
All of these factors have the potential to limit the frequency, effectiveness and, ultimately, duration of breastfeeding.
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The Natural Caesarean. A wonderful way to support the mother and respect the baby when birth is by caesarean. This 12 minute video is from Youtube. (Some hospitals block youtube - view from a home computer) | ![]() |
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![]() Pregnancy classesWhat is included about birthing interventions in the curriculum of the pregnancy classes where you work? Do all pregnant women know the effects of interventions on themselves and their baby? Do they have to give consent prior to any of these procedures? How well informed is this consent? Form a group to review the pregnancy class curriculum. |
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Assisting a mother following an assisted delivery
- Initiate skin-to-skin contact as soon as possible
- immediately following vaginal delivery if baby does not require advanced life support.
- as soon as possible if caesarean section under epidural or spinal analgesia. Many hospitals facilitate this while the surgeon closes the wound.
- as soon as the mother is responsive if caesarean section under general anaesthetic. Place baby in skin-to-skin contact with father or other close family until mother available.
- If contact must be delayed initiate skin-to-skin contact at the earliest opportunity.
- Assist with breastfeeding as soon as possible.
- The mother does not need to be able to sit up, to hold her baby, or meet other mobility criteria in order to breastfeed.
- It is the baby that is finding the breast and suckling.
- As long as there is a support person with them, the baby can go to the breast if the mother is still sleepy from anesthesia.
- Help the mother find a comfortable position.
- Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anesthesia.
- Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.
- Lying flat with the baby lying on top of the mother.
- Facilitate rooming-in with assistance, until mother is able to care for baby.
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![]() | ![]() Workbook Activity 4.3Complete Activity 4.3 in your workbook. | ![]() |
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What should I remember?
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Self-test quiz
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Notes
- # Hale TW (2002) Medications and Mothers' Milk
- # Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.
- # Anim-Somuah M et al. (2005) Epidural versus non-epidural or no analgesia in labour.
- # Vincent RD et al. (1998) Epidural Analgesia During Labor
- # Rosenblatt DB et al. (1981) The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine
- # Sepkoski CM et al. (1992) The effects of maternal epidural anesthesia on neonatal behavior during the first month
- # Raisanen I et al. (1984) Pain and plasma beta-endorphin level during labor
- # Dabo F et al. (2010) Plasma levels of beta-endorphin during pregnancy and use of labor analgesia.
- # Buckley S (2002) Ecstatic Birth: The Hormonal Blueprint of Labor
- # Ombra MN et al. (2008) beta-Endorphin concentration in colostrums of Burkinabe and Sicilian women.
- # Zanardo V et al. (2001) Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers
- # Zanardo V et al. (2001) Beta Endorphin Concentrations in Human Milk
- # Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding
- # Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia
- # Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery
- # Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route
4.3 Postnatal interventions
Separation of mother and newborn
From an evolutionary perspective skin-to-skin care is the norm. Routine separation of the newborn from its mother soon after birth is unique to the 20th Century. At the risk of laboring the point, separating the mother and baby after birthing for any reason, other than medical emergency, is NOT applying best practice care. All indicators of infant well-being and successful extrauterine adaptation are stabilized better and faster when the newborn is in skin-to-skin contact with its mother from immediately after birth for the first few hours, or at least until after the first breastfeed.
Effect on newborn
A researcher in behavioral neuroscience described the innate behaviors of the newborn that occur when the infant remains with his mother immediately following birth.
When mother and infant are separated the infant exhibits firstly distress cries, followed by what is described as "protest-despair" behavior.1

Note the protest response being exhibited by this newborn.
Photo © T.Young, RM
Separation distress cries have been documented in newborns. Separated newborns make 10 times more crying signals than babies in skin-to-skin care, and their cries have a completely different character.2,3 During the "protest" response there is intense activity seeking the mother, followed by "despair" behavior which sees the baby withdraw with decreased heart rate and temperature, mediated by a massive rise in stress hormones.4

What stage is this newborn exhibiting?
Photo © D.Fisher, IBCLC
Effect on oxytocin
Oxytocin levels are highest around the time of birthing. Oxytocin cannot cross from the peripheral circulation into the brain; therefore it is only naturally occurring oxytocin released by the posterior pituitary gland that will have an effect on the mother's temperament, ie. not oxytocin administered to the mother.
- increased uterine contraction limiting postpartum blood loss,
- the temperature of the mother's breast to rise, providing warmth for the infant,
- an anti-stress effect, reducing maternal blood pressure and cortisol levels and releasing gastrointestinal hormones,
- a state of calmness and social responsiveness,
- bonding with their infant, and enhanced maternal behaviors,
- milk ejection; important at this time prior to it becoming conditioned by the suckling stimulus.
During the time the infant in skin-to-skin contact after birthing is making massage-like movements on the mother's chest and breasts the maternal serum oxytocin levels rise.7 The infant begins these hand movements soon after birth and continues until he self-attaches and suckles.
The work of Michel Odent is well recognized by those involved in obstetrics. Odent's studies of the effects of oxytocin and other hormones of birthing are worthwhile following. In 2001 he wrote:
The age of cesarean sections on request, epidurals and drips of oxytocin is a turning point in the history of childbirth. Until recently women could not give birth without releasing a complex cocktail of 'love hormones'. Today, in many countries, most women have babies without releasing these specific hormones. The questions must be raised in terms of civilization. This turning point occurs at the very time when several scientific disciplines suggest that the way human beings are born has long-term consequences, particularly in terms of sociability, aggressiveness or, in other words, 'capacity to love'. 8Odent, 2001
With this in mind, the importance of skin-to-skin contact for mothers and babies who experience an assisted birthing appears to be even more important.
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![]() | ![]() Falling in Love[link: http://www.health-e-learning.com/resources/articles/34-falling-in-love]Click on the icon on the left and read the article. | ![]() |
Effect on breastfeeding
Learning is a dimension of behavior and physiology, and the human neonate has evolved to learn how to suckle when in skin-to-skin contact.1
Most babies (27 out of 34) who were separated from their mothers after 19 minutes for routine weighing procedures and then returned for feeding either refused to suckle, or demonstrated superficial nipple sucking techniques. The difference between two groups (one group remained in skin-to-skin contact) in ability to attach to the breast and suckle correctly for effective milk removal was significant (p>0.001).9
Washing mother or newborn
Washing the mother and/or baby is also to be discouraged. Infants localize the nipple by smell and have a heightened response to odor cues in the first few hours after birth. When one of the mother's breasts is washed after birthing 22 out of 30 infants preferentially self-attached to the unwashed breast.10
Breast odours from the mother exert a pheromone-like effect at the newborn's first attempt to locate the nipple. Newborns are generally responsive to breast odours produced by lactating women. Olfactory recognition may be implicated in the early stages of the mother-infant attachment process, when the newborns learn to recognize their own mother's unique odour signature.11
Winberg, 1998
Suctioning of the newborn
Oral aversion as an outcome of routine oropharyngeal or gastric suctioning or intubation is often cited by clinicians as a cause of breastfeeding difficulty, but little research is available to confirm this.
Fortunately routine oral and gastric suctioning is no longer recommended, it's effects proving to be harmful to more than just the infant's ability to suck.12
Routine gastric suctioning, involving the passage of a tube into the neonate's stomach and aspiration of the contents has been linked to a delay in infant pre-feeding behaviours13 and an increased prevalence of functional intestinal disorders in later life.14
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![]() Workbook Activity 4.4Complete Activity 4.4 in your workbook. |
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![]() Group ActivityForm a small group to firstly compare your lists of the benefits of keeping mothers and babies together in skin-to-skin contact, then list all the interruptions to this by birthing room staff or others. Together, look at each interruption separately and develop strategies for change to prevent these separations. |
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What should I remember?
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Self-test quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 4 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 4.
Notes
- # Alberts JR (1994) Learning as adaptation of the infant.
- # Michelsson K et al. (1996) Crying in separated and non-separated newborns: sound spectrographic analysis
- # Christensson K et al. (1995) Separation distress call in the human neonate in the absence of maternal body contact
- # Bergman N (2003) Humans and Kangaroos: A Biological Perspective
- # Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier
- # Uvnas-Moberg K (1998) Oxytocin may mediate the benefits of positive social interactions and emotions
- # Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking
- # Odent M (2001) New reasons and new ways to study birth physiology
- # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
- # Varendi H et al. (1994) Does the newborn baby find the nipple by smell?
- # Winberg J et al. (1998) Olfaction and human neonatal behaviour: clinical implications
- # Clifford M et al. (2010) Neonatal resuscitation.
- # Widstrom AM et al. (1987) Gastric suction in healthy newborn infants. Effects on circulation and developing feeding behaviour
- # Anand KJ et al. (2004) Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life
5.0 Breastfeeding the Baby
There is no knowledge or skill more important for you to possess and pass on to mothers than how to position their babies for comfortable latching and efficient milk transfer. If positioning and latching isn't correct then breastfeeding isn't working at all. When a mother is confident her baby is breastfeeding well there's very little else she needs to know to be successful.
Mothers who have the confidence to breastfeed their babies find it an empowering experience. Teaching by 'hands-off' methods will enhance the mother's confidence when her baby achieves good latch.
The best time to commence feeding an infant is when he first exhibits cues that he is ready to feed. When early cues are ignored the infant's behaviour will progressively become more agitated until he is crying, making latching more difficult. If the feed is further delayed the infant may tire quickly and feed poorly once feeding is finally offered.
Early feeding cues
- mouthing and non-nutritive sucking - the infant moves his mouth in a searching or sucking manner
- subtle body movements, wriggling
- rooting when face touched
- hand-to-mouth movements, with or without sucking on hand

Newborn displaying early feeding cue.
© D.Fisher, IBCLC
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![]() Workbook Activity 5.1Complete Activity 5.1 in your workbook. |
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Answering baby's cues |
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It's a team effort!
The team consists of the mother and the baby. Supporters of the team include the baby's father, the mother's other relatives and friends, and her health care providers.
The mother's role is to position the baby to facilitate his breastfeeding reflexes; the baby's role is to be free to respond to the stimulation of those reflexes. If not interfered with the baby's reflexes will cause him to latch perfectly to the mother's breast and suckle effectively. The role of the health professional is to guide the mother to position the baby so that the baby's reflexes are stimulated - not to either do it for the mother and baby, nor to tell the mother how she should latch the baby.
Preparing to guide the mother
Expensive teaching aids aren't necessary to demonstrate good positioning and latch. Common positioning and latching problems can be avoided by using these simple strategies.
- Demonstrate positioning using a doll. This is an effective visual aid.
- Ask the mother to try to swallow when her head is turned to one side, or when her head is tilted forward. This demonstrates how difficult it would be for baby to swallow if he had to turn his head or flex his neck to latch.
- Ask the mother suck on her own thumb. Firstly have her put her thumb midway into her mouth and suck, then move the thumb back to the junction of the soft and hard palate and suck. Ask her to compare the effort required to keep the thumb in her mouth in both positions and the different tongue action necessary in each position. This may help the mother to understand the importance of facilitating a deep latch where her nipple will move to the back of the baby's mouth to prevent undue pressure on the nipple.
- Show the mother a photograph of a baby who is well latched to the breast to demonstrate how wide and deep the latch should be.
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![]() | ![]() What's your practice like?How do you assist a mother to position and latch her baby? How often do you achieve this being totally 'hands off'? Note the number of times the mother latches her baby well herself after your 'hands off' instructions, and the number of times you give hands-on assistance. Think about why you are needing to do it for her, or giving her significant assistance. Reflect on ways to reduce the number of times hands-on assistance is necessary. How would you feel about benchmarking your results against those of several of your colleagues? Get a small group together that you feel 'safe' with and keep your individual statistics for a month, then compare them. Explanations for unsuccessful cases can be discussed together. | ![]() |
What should I remember?
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5.1 Positioning Principles
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![]() It's fundamental!The mother provides the position. The baby does the latching (attaching). |
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Mother's position
Observation of experienced mothers will reveal that they adopt a myriad of positions for breastfeeding throughout the day, even walking. A breastfeed may last from a few minutes up to an hour. And the mother will repeat this many times a day for at least a year. Your guidance to her is simply to adopt a position that will avoid muscle strain and in which she is comfortable.
Lying positions are comfortable and facilitate rest while feeding and are particularly helpful with a newborn baby when the mother is still recovering from the birth experience.
Once the mother's dexterity and confidence increase most breastfeeds will probably occur sitting.
Baby's position
The infant's position refers to two underlying factors:
- the infant's position in relation to his mother eg. baby is lying horizontally/obliquely and mother is sitting vertically, mother and baby are both side lying on bed.
- the infant's own body position eg. straight back (not curved), head aligned with spine (not turned to side), slightly extended head (not flexed), prone or lateral.
From birth until about 3 to 4 months of age a baby's feeding behaviour is instinctive and reflexive. All actions should facilitate the baby's innate abilities rather than mother (or you) controlling the baby.
When he is correctly positioned he will have control of his head and neck. In this position he is able to easily accommodate a suck/swallow/breathe sequence for several minutes at a time without distress when the milk flow is rapid.
Principles of positioning
- Sensory input: Babies depend on smell and skin-to-skin contact to initiate their feeding behaviour. To elicit baby's instincts it is essential to stimulate these two senses.
Skin-to-skin contact (ie baby and mother unrestricted by clothing from the waist up) is best in the early days or when experiencing any latching difficulties. Baby needs firm chest-to-chest contact against the mother's body to allow him to orientate and focus. Chest-to-chest contact will calm the baby and initiate his seeking behaviours. If the baby is clothed remove bulky outer clothing and blankets.
The unwashed breast has a unique and individual odour that stimulates prefeeding activity and delays crying in the baby.1 Only if necessary a drop of milk may be expressed and wiped over the mother's nipple and areola (the infant can smell his mother very easily so don't waste time doing this when the baby is frantically seeking to latch).- Positional stability: Positional stability is necessary for the baby to control his head movements. There are three aspects to this stability...
Proximal stability: infant's head and neck in alignment and supported, and
Midline symmetry: ie. the muscles on either side of the spine are experiencing equal movement.
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![]() | ![]() Workbook Activity 5.2Complete Activity 5.2 in your workbook. | ![]() |
When sensory input and positional stability are achieved the baby will automatically move into the "Instinctive Position". This position is described by Glover (2004)2 as the baby tilting his head back and leading with his jaw and mouth to the breast where his mouth opens wide, tongue down and over bottom gum line ready to take the breast into his mouth.
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![]() | ![]() Applying the principles to practiceInstruct the mother to hold her baby
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For infants affected by prematurity, illness, a difficult birth, dysfunctional or poor muscle tone, positional turns, to name a few, this positioning is crucial to support and strengthen what functions and abilities they do have. Stabilized in this position, each feed has the potential to become a dynamic learning and exercise session for the infant to strengthen and coordinate muscle movement on both sides of the body.
By teaching all mothers and babies this essential positioning I believe you are "treating" all sorts of "normal" anomalies before they have a chance to become a problem. When you see this transform an apparently difficult breastfeeding problem it is pure magic to behold. The simplicity will astound you." (Glover, 2004 p89-90)2
Biological nurturing feeding position
This is achieved when the mother is laid back in a semi-reclined position. The infant lies prone on top of his mother's chest. The combination of these two body positions will release the most primitive neonatal reflexes (PNR) for pre-feeding responses.
Colson (2008)3 describes this as the biological nurturing position. Twenty PNRs for pre-feeding have been identified. Colson's research found that mother and baby pairs who practice full biological nurturing positions released 15.9 PNR compared to only 11.6 PNR in the partial or non-biological nurturing pairs. Biological nurturing posture maximises the baby's sensory input and maintains positional stability as a result of the prone body position of the baby acting as a gravity pull towards the mother. The infant is able to use his hands to knead the breast, his feet to push off his mother's abdomen and thrust himself toward the breast, he will lift his head up into extension to allow his chin to push forward into the breast and prepare for latch.
All of the principles of position are achieved naturally using the mother's body and gravity to stabilize the infant on her. This is a natural position for a mother to assume after birth - semi-reclining with her baby on her chest (it is also an enforced position following a cesarean section). We now know that it is this position in particular which is the stimulus for baby self-attachment, ie. innate responses.
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![]() | ![]() Start at the beginningDo you see some mothers who are struggling with breastfeeding - they feel awkward and unsure how to hold the baby; maybe the baby's responses seem confused?
Rather than rush in with an intervention, suggest that the mother lie back slightly and bring her baby onto her chest. Encourage her to talk to him and hold his back, being ready for him to "bob" his head towards her breast. She can assist to free his arms or support his head if he needs guidance. No interference, maximum opportunity for baby and mother to perform at their best! (This is best in skin-to-skin for a newborn, however, it can be very successful for the older baby who has becomes confused and is also effective when infant clothed, but not restricted by blankets.) | ![]() |
The principles are exactly the same for ALL positions

Laid back encourages prefeeding behaviour.
© B.Ingle IBCLC

Laid back position.
© B.Ingle IBCLC

Laid back position:well-latched.
© B.Ingle IBCLC

Cradle hold.
© D.Fisher, IBCLC

Side lying.
© D.Fisher, IBCLC

Cross cradle hold.
© D.Fisher, IBCLC

Underarm hold.
© D.Fisher, IBCLC
Closely examine each of the photographs above noting:
- Is there adequate sensory input? chest to chest and baby held firmly against mother's body?
- Is base stabilised? check for support across back and between shoulder blades
- Is there proximal stability? neck and head supported NB** NEVER hold the back of the baby's head at any time during positioning, latching and feeding
- Is there midline symmetry? baby's head and neck aligned with his spine; one arm on either side of breast
- Is chin firmly applied to breast, nose free to breathe?
- Is mother relaxed and well supported?
- Is mother's arm supporting baby held comfortably, with relaxed wrist and fingers?
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![]() | ![]() When the baby's head is held....The infant cranium is very sensitive. Pressure on the back of the head (by mother or 'helper') will cause:
Overzealous or misplaced hands can create a struggle or fight with the breast between the mother and baby. Be mindful of this and ensure that all the principles of positioning are always applied. | ![]() |
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![]() | The Principles of Positioning | ![]() |
The well-latched baby
When baby is well positioned he will assume the instinctive position:
- lifts head up,
- brings chin and mouth forward to make contact with the breast and nipple,
- initiating seeking behaviour.
The baby's chin should have first contact with the breast, with the bottom lip placement about 3 - 4cm (1-1.5 inches) from the nipple (about the edge of the 'average-sized' areola). This light touch will stimulate the rooting reflex if baby is not already exhibiting this seeking behaviour. The rooting reflex causes the baby's mouth to open wide, mouth directed to source of stimulation. The tongue comes down and forward to grasp the breast tissue into the mouth.
The firm pressure maintained by the mother on baby's back ensures baby is close to her body allowing him to achieve a wide, deep latch to the breast.
Some mothers need to, or prefer to, shape the breast slightly. If this is needed, simply applying some pressure near to the base of the nipple to create an indent on the side where the infant's nose is pointing, causes the nipple to tilt up at the nose. As the bottom lip is firmly planted at about the edge of the areola well under the nipple, the finger (or thumb) doing the tilting can then fold the nipple so it just brushes under baby's top lip. Refer to photograph below.
Hey presto - one beautifully latched baby, with breast tissue entirely filling his mouth!
This is an asymmetric latch: the mouth will NOT be centred over the nipple.

Note the baby is positioned below the nipple, coming up to it in the 'instinctive position' with head slightly extended, mouth wide, and tongue down and extended over the lower gum. Mother has shaped breast and tilted nipple towards baby's nose.
© Australian Breastfeeding Association
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![]() | ![]() Workbook Activity 5.3Complete Activity 5.3 in your workbook. | ![]() |
What should I remember?
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Self-test Quiz
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Click and drag the missing words below into their correct place The missing words are: above alignment areola bottom chin lip odour pre-feeding prone raise reflexive shoulders smell turned The principles of positioning can be applied to any breastfeeding situation. The mother may adopt a variety of body positions to hold her baby. The baby's body position is designated by the relationship of his body to his mother's body and the lie of his body in relation to the ground.To assist the mother and baby to achieve successful breastfeeding, you will need an understanding of all the factors which facilitate the best circumstances:
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Notes
- # Doucet S et al. (2007) The "smellscape" of mother's breast: effects of odor masking and selective unmasking on neonatal arousal, oral, and visual responses.
- # Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes
- # Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.
5.2 Breastmilk transfer
Obviously the goal of breastfeeding is to achieve milk transfer from mother to baby.
Breastmilk transfer occurs by:
- positive pressure as the milk ejection reflex (MER) forces milk from storage in the alveoli towards the nipple, and
- negative pressure, created in the baby's mouth, drawing the milk from the breast into the oro-pharynx.1
Understanding the anatomy

© Health e-Learning
Imagine the functional tissue of the breast as like a large bunch of grapes. The grapes are linked by thin stalks to thicker stalks and thicker stalks again as more sections of grapes join it, until there is one thick stalk.
A grape represents an alveolus (pl. alveoli) which holds the breastmilk. The stalks are the ductules and lactiferous ducts through which the milk passes, and the whole bunch of grapes represents one lobe of functional breast tissue. Each breast contains about nine lobes.
The lactocytes, columnar epithelial cells that make up the alveolus, synthesise the breastmilk which is then stored in the lumen.
Each alveolus is surrounded by a basket-like weave of myoepithelial cells, muscle cells. Contraction of the myoepithelial cells constricts the alveoli, forcing the breastmilk into the ducts and towards the nipple where the baby can remove it.

© Health e-Learning
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![]() | ![]() Workbook Activity 5.4Complete Activity 5.4 in your workbook. | ![]() |
Positive pressure transfer
The hormone oxytocin causes the milk ejection reflex and the contraction of the myoepithelial cells. A surge of oxytocin is released from the posterior pituitary gland in response to stimulation of the nerves around the nipple. It travels via the blood stream to both breasts causing the myoepithelial cells surrounding the alveoli to contract. Sometimes this can be so forceful as to cause the milk to drip or even squirt from the nipple.

© Health e-Learning

Note the breastmilk squirting from the unused breast while the baby suckles on the other breast.
© B.Ingle, IBCLC
When the MER has been stimulated mothers may describe the sensation as
- a sharp, momentary pain in the breast, or
- a fullness or tightness of the breasts, or
- a tingling sensation inside the breast, or
- there may be no sensation at all.
It can be seen to be functioning when milk drips or squirts from the breast. If the baby is suckling at the time you'll notice a change in suck pattern to a suck / swallow / breathe / suck / swallow / breathe pattern with swallows about every second. This vigorous sucking from increased milk flow may last 1.5 - 2 minutes. You may hear the baby gulping the larger volume of milk too.
As the effect of oxytocin wears off the alveoli and ductal system, milk which is not removed by the infant (or by expressing) moves back up the ductal system to the alveoli once more.
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![]() | ![]() Take home message:Milk transfer is dependent on milk ejection! No MER = Hungry baby | ![]() |
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![]() | ![]() ImportantMany mothers do not feel the milk ejection at all, and rarely is it felt in the first few days postpartum despite it functioning quite well. Prior to the milk 'coming in' the change in the baby's suckling is also not noticeable. In multiparous women involution pain is felt more acutely during milk ejection. (Why?) | ![]() |
Negative pressure transfer
The mouth of the newborn is ideally suited to suckling at the breast. The tongue grasps the breast tissue and the lips create a seal around the areola. Negative pressure in baby's mouth draws the breast into position and maintains it there forming a teat of soft breast which completely fills the mouth. The small mandible fits closely against the breast, allowing the baby's nose to be free for breathing, while the buccal fat pads in their cheeks prevent the cheek from 'collapsing' in during suckling.
Negative pressure is created in the sealed mouth when the back of the tongue drops in response to the increased milk flow at milk ejection. There is a coincident lowering of the soft palate. The intra oral vacuum is at its greatest when the tongue is fully lowered prior to swallowing. It is this negative pressure which draws the breastmilk from the nipple into the baby's mouth.
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![]() Workbook Activity 5.5Complete Activity 5.5 in your workbook. |
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What should I remember?
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Self-test Quiz
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Notes
- # Ramsay D et al. (2004-09-10) Ultrasound imaging of the sucking mechanics of the breastfeeding infant
5.3 Assessing breastfeeding
The five-step process
- Gather information and plan for the visit
- Feeding observation
- Exploration of strategies for improvement
- Develop an action plan
- Communication of results
1. Gather information and plan for the visit
Review pertinent information including mother's/infant's chart, notes from telephone conversations, notes from referral source, etc, prior to meeting with the mother and infant.
Planning includes assembling any items and equipment you expect to use during the assessment (eg. comfortable chair for mother, infant scale, etc.).
2. Feeding observation
- General observation: general interaction between the mother and infant. Health of mother, health of baby, health of the mother's breasts.
- Naturalistic observation: observation of a portion of a usual breastfeeding. This is best performed without intervention from the assessor.
- Elicited observation: observation of the outcome of suggested modifications (eg changes to position, attachment, etc.).
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![]() | ![]() Use your communication skillsIt can help to put the mother at ease if you explain that you would like to watch the baby feeding, rather than saying you are watching what the mother is doing. And don't forget to praise the mother for something she is doing that is good.
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What is involved in a 'naturalistic observation'?
Mother's and baby's position
- Do the mother and baby appear comfortable and relaxed?
- Is the baby well positioned?
- Good sensory input: breast wasn't washed prior to feeding; baby in firm contact with mother chest-to-chest, either no clothing or minimal clothing between them.
- Good positional stability: a stable base; proximal stability; midline symmetry
Latching
- Did mother position baby, then allow baby to latch himself? If not, why not? eg. breast may have needed to be shaped; is the mother controlling the baby's latching?
- Where is baby's chin? Is it firmly applied to the breast? Is the baby's nose free to breathe without the need to hold the breast tissue away? Exceptions only with very large, soft pendulous breasts.
- Is baby's mouth very wide open with both lips flanged outwards? Exceptions to this are in mothers with soft, elastic breast tissue where a baby can achieve a deep latch with lots of breast tissue and not need to continue the wide gape throughout the feed.
- Can you see more areola visible above the top lip than beneath the bottom lip (or, if areola small, another sign that the baby has a large amount of breast tissue in mouth).
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![]() | ![]() Really important!One author 2 viewed the positioning and latching procedures adopted by mothers with painful nipples and concluded that the whole process from pre-feeding behaviors to the suck rhythm need to be assessed.
Observe the moment of latching of the baby to the breast and as much of the feed as you can, then be there again to observe the nipple as it leaves baby's mouth. | ![]() |
Sucking pattern
- When first latched was sucking rapid for up to a minute? This is a stimulation pattern to elicit the milk ejection reflex.
- After about a minute (or less) did sucking settle into a regular, slower suck/swallow/breathe/suck/swallow/breathe pattern with some short pauses? This is a nutritive sucking pattern. You may hear baby swallowing milk; milk may leak from the other breast; or mother may report feeling the milk ejection reflex.
- What are baby's jaw movements like? They should be 'deep' movements visible right up to the temporo-mandibular joint below the ears.
- How long did the nutritive sucking pattern persist? Milk ejection usually lasts about 2 minutes and therefore the nutritive sucking pattern should last about that long.
- What happened after the nutritive sucking pattern stopped? Sucking usually returns to the short, quick stimulation pattern again with smaller jaw movement, fewer swallows and longer resting pauses.
- Was the nutritive pattern repeated? It doesn't have to be, but this cycle may be repeated as baby stimulates a second or more milk ejections during one breastfeed.
How was the breastfeed completed?
- Did the baby fall asleep at the breast being completely satiated, or detach himself contented, or wanting more milk from the other breast, or did the mother remove the baby when she felt he'd had enough?
What did the nipple look like as it came out of the baby's mouth?
- Observe the nipple immediately when it comes out of the baby's mouth. It should look very similar to its pre-feeding state. There should be no ridges or 'squashed' appearance or white compression lines.
How did it feel?
- Of course you will ask the mother how it feels at each stage, and also observe her for signs of anxiety or pain.
- In the first few days for the first minute or less she may describe it as painful, but settles to be pain free quickly. This initial pain is called 'nipple stretch pain' and occurs as the nipple and areola form the teat. Breastfeeding may 'tug' but for the majority of mothers it should not be painful.
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![]() | ![]() Workbook Activity 5.6Complete workbook activity 5.6
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![]() | Observation skillsLook closely at these photos, noting all the details of positioning and latch.
When you are ready, answer the response activity below. ![]() | ![]() |
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3. Exploration of strategies for improvement
- The development of hypotheses for improving the feeding interaction based on history and observations.
- Discussion with mother of hypotheses generated, including pros and cons of various methods for improving the feeding outcome.
- Testing of agreed strategies.
4. Develop an action plan
Record this in the mother's file and give a copy to the mother or write a list for her to refer to at home.
5. Communication of results
- Reiterate findings and action plans for the mother. The language used to describe the situation is extremely important. The assessor should take great care to avoid terminology that blames, negatively characterizes, or labels the mother or infant.
- After learning new skills of how to position her baby to overcome previous breastfeeding difficulties the mother sits and cradles her baby as he feeds and explains to the consultant how she positioned her baby. Cox (2011)3 contends that the consultant is then able to be confident that this mother and baby will now be independent as she has:
- watched the mother position, as suggested, so that the baby could latch comfortably
- written down, in the mothers words, how she positioned her baby
- Document the outcomes of the assessment and evaluation.
- Review plans with the mother to assure that the plan is achievable and agreeable to all parties.
- Communicate findings to key healthcare providers in accordance with mother's consent to release information. Clearly identify and refer any items that need further medical evaluation.1
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Look carefully at this baby breastfeeding and complete the response activity below.
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![]() Workbook Activity 5.7Complete Activity 5.7 in your workbook. |
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![]() Make your work easy!When a mother quickly becomes confident positioning her baby and facilitating his latch baby will be fed well, nipple and breast problems prevented and your workload will be reduced. |
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What should I remember?
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Assessment Quiz
Notes
- # Wolf LS et al. (1992) Assessment and Management: Feeding and Swallowing Disorders in Infancy
- # Blair A et al. (2003) The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples.
- # Cox SG (2011) Planning with the mother to overcome breastfeeding difficulties - manuscript pending publication.
6.0 A time to learn
Currently in developed countries, many mothers have little experience of caring for babies and children before they have their own first child. Health education is an important role for health professionals. Antenatal education and postnatal support significantly increases the incidence of breastfeeding initiation and exclusive breastfeeding to six months.1
How to provide education effectively
The perinatal period is filled with so many new experiences for women, and postnatal hospitalisation is short, therefore it is important to target educational interventions effectively. It is not effective to just give educational materials, either antenatally or postnatally, without a discussion with the mother of their contents.
Asking people direct questions about how they learn leads towards four primary processes being involved in an overlapping way.
These can be summarized as follows:
- wanting to learn (motivation, thirst for knowledge)
- learning by doing (practice, trial and error)
- learning from feedback (midwife/nurse's comments, seeing the results)
- digesting (making sense of what has been learned)
Asking people further questions about where and when they learn reveals that most people consider they learn best:
- at their own pace (allow plenty of time for questions, return demonstrations, etc)
- at times and places of their own choosing (privacy may be important, or when less tired)
- often with other people around, especially fellow learners (a group of new mothers, or her partner)
- when they feel in control of their learning
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![]() | ![]() Workbook Activity 6.1Complete Activity 6.1 in your workbook. | ![]() |
Individuals also have an inclination to a preferred style of learning experience.
- Auditory learners use their sense of hearing as their primary means of absorbing information eg. discussions, hearing of others' experiences, story telling.
- Visual learners relate to pictures, demonstrations, videos and written materials.
- Kinesthetic (kinaesthetic) learners like activities which involve them fully eg. practicing the skill taught, return demonstrations, etc.

Two pregnant woman learn about positioning using dolls.
Photograph © S.Cox, IBCLC
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![]() | ![]() Clinical applicationEducational materials should be presented in a variety of formats. For example: To teach a mother how to position and latch her baby to the breast
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Postnatal education
When all the information required to be covered in Step 3 and Point 3 (see 3.0 Pregnancy Care) is covered during the prenatal period, the emotion-laden postnatal period can be used more effectively for
- practical help - eg. positioning, latching, breast expression
- educational messages about feeding patterns, maintaining exclusive breastfeeding, baby behavior, recognizing abnormalities, and
- psychological support.
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![]() Learning happens best when...
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What should I remember?
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Self-test quiz
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Notes
- # Su LL et al. (2007) Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial
6.1 Practical skills
Baby Friendly Step 5 and Point 4
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Step 5 of the Ten Steps to Successful Breastfeeding, and Point 4 of the Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings both require health care professionals to teach women about the maintenance of breastfeeding.
As well as assisting mothers to breastfeed their infant, as in the previous topic, these Points/Steps require staff to teach mothers the techniques of manual expression of breastmilk.
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Expressing breastmilk
Some mothers may not be aware that they can remove breastmilk from their breasts for feeding to the baby later. In the case of low-birth-weight infants, breastfeeding success may depend on early and effective support with expressing breastmilk. Having the knowledge and skills to do it will encourage them to continue to provide essential breastmilk and for later, knowledge of expressing will encourage continued breastfeeding after a return to work, or during other times of separation.
Hand expressing
Many mothers prefer hand expression rather than using a pump because:
- Hands are always with you, and there are no parts to lose or break.
- Hand expression can be very effective and quick when the mother is experienced.
- Some mothers prefer the skin-to-skin stimulation from hand expression rather than the feel of plastic and sound of a pump.
- Hand expression is usually gentler than a pump, particularly if the mother's nipple is sore.
- There is less risk of cross-infection since the mother does not use equipment that may be also handled by others.
Even a mother who does own a pump may have more success hand expressing
- to collect small volumes of colostrum antenatally, anticipating a postnatal medical problem, or
- to get just a few drops of milk to entice baby to latch, or
- to apply to a damaged nipple, or
- to remove just enough milk to allow her baby to latch to her engorged breast, or
- to relieve the discomfort from an engorged breast, or
- to clear a blocked duct, or
- to obtain milk for her baby who is unable to breastfeed, or
- to obtain milk for her baby when they are separated, or
- to obtain milk to pasteurize for her baby if she is HIV positive.
Many health professionals also find hand expressing more effective and less wasteful for collecting colostrum.
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![]() | ![]() Workbook Activity 6.2Complete Activity 6.2 in your workbook. | ![]() |
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![]() | How to hand express
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Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb.
Photograph © S.Cox, IBCLC
Video © Australian Breastfeeding Association. Used with permission.
Pumping breastmilk
There are many different types of breastpumps available on the market. All staff must be aware of the safety issues surrounding each pump, including adequate cleaning, and its correct use. Either get other competent staff to demonstrate its use, or ask the company representative to give a short educational session for the staff.
Manual and electric pumps can be equally as effective - the mother will need to consider cost and skills required to use each piece of apparatus. For example, some manual pumps can cause wrist strain which may exacerbate carpel tunnel syndrome; other mothers prefer the versatility of carrying a manual pump to work; electric pumps are very efficient for long term expressing circumstances.
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![]() | ![]() Who is best to demonstrate pump usage to mothers?The pump company representative's job is to sell more pumps and encourage as many mothers as possible to use their pumps for as long as possible. Your role is to show a mother how to safely use a pump for only as long as it is absolutely necessary. Do not ask the company representative to speak to mothers about their pump. | ![]() |
Storing breastmilk for a healthy baby
If the mother is not going to use the expressed milk within the next few hours, store it safely. Glass and plastic containers with lids are suitable for use, as are breastmilk storage bags.
There should be a means of noting the time and date of expressing the breastmilk on each container. For hospital use the identity of the mother and baby should also be clearly written.
- All storage equipment will be thoroughly clean.
- Refrigerate milk that will not be used within the next few hours.
- Freeze milk that will not be used within two days.
Storing Breastmilk for a Healthy Baby | |||
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Breastmilk status | Room temperature 26°C or lower | Refrigerator (4°C or lower) | Freezer |
Freshly expressed into container | 6 - 8 hours; when refrigerator available store milk there |
3 - 5 days; store at back where coldest |
2 weeks freezer compartment inside refrigerator; 3 months in freezer section of refrigerator with separate door; 6 - 12 months in deep freeze (-18°C or lower) |
Previously frozen; thawed in refrigerator, but not warmed | 4 hours or less; that is until the next feeding |
24 hours | Do not refreeze |
Thawed outside refrigerator in warm water | For completion of feeding | 4 hours or until next feeding | Do not refreeze |
Infant has begun feeding (ie. contact with baby's mouth) |
Only for completion of feeding | Discard | Discard |
Note: Chilled breastmilk may be safely stored at 15°C for up to 24 hours. This is the temperature maintained in an insulated container with a freezer block, eg blue ice.1
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![]() | ![]() Locate the guidelines to hand expressing and safe breastmilk storage that is provided for mothers in your Unit. Discuss this leaflet with each mother and give her a copy as she is taught this essential skill. Keep a copy of the leaflet in your Workbook. There are no guidelines in your Unit for hand expressing and safe breastmilk storage? Recreate the table of safe storage times and file it in your workbook; form a small group to develop a leaflet that can be presented at a Unit meeting to familiarise the staff with its content. | ![]() |
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![]() | ![]() Hand Expressing CompetencyClick on the icon on the left and print the Hand Expressing Competency. Take this to your course facilitator or mentor and ask them to observe your practice and complete the assessment. | ![]() |
Using the expressed breastmilk
The order in which to use expressed breastmilk is
- First choice: All milk expressed in the first 4 days (colostrum); assures baby receives the antibody-rich colostrum as soon as possible
- Second choice: Freshly expressed milk prior to refrigeration; fresh breastmilk has the most active protective properties
- Third choice: Refrigerated breastmilk, using the oldest first; decreases the need to freeze milk, which has a greater effect on immunological properties
- Finally: Frozen breastmilk that has been stored the longest; to reduce the need to discard milk that has passed the use-by date
What should I remember?
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Self-test quiz
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Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column | ![]() |
Notes
- # Hamosh M et al. (1996) Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk.
6.2 Breastfeeding messages
Baby Friendly Step 8
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Step 8 of the Ten Steps to Successful Breastfeeding summarizes the basis of breastfeeding management in recognising an infant's total needs. It states:
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How often should my baby breastfeed?
Teach parents to recognize and respond promptly to early feeding cues:
- Early cues
- wriggling, moving arms or legs
- rooting, fingers to mouth
- Mid cues
- fussing, squeaky noises
- restless, crying intermittently
- Late cues
- full cry, aversive screaming pitch, turns red

Newborn exhibiting a late feeding cue
A mother's unique breast capacity and rate of milk synthesis dictates how much milk she has available in the breast at each feed, and infant hunger dictates how much the baby will take at each feed. Neither of these factors are amenable to manipulation.
Kent et al (2006) 1 in their study of 71 thriving, exclusively breastfed babies ranging in age from 1 to 6 months, found:
- they averaged 11 feeds (range 6 - 18) per 24 hrs.
- 10 of the babies always fed from both breasts per feed;
- 19 babies always fed from one breast per feed;
- the majority of babies sometimes fed from one and sometimes fed from both breasts;
- 2/3 of babies fed at night, and consumed 20% of their total daily intake at this time.
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![]() | ![]() What should I tell a mother?Responding to her baby's early feeding cues will ensure baby is fed as often as necessary for her baby.
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Is my baby getting enough breastmilk?
Before you can answer this question you need to know how much breastmilk is normal at the various stages of lactation. The average is as follows:1 2 3
Age of baby | 24hr volume | Infant intake |
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Approximate conversion: divide millitres by 30 to obtain volume in ounces | ||
Note:
Individual breastmilk intake (and therefore production) does not significantly change from Week 4 to 6 months of age |
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Day One | 37ml (7 - 123ml) | few drops - 5ml/feed |
Day Two | 84ml (44 - 335ml) | 5 - 15ml/feed |
Day Three | 408ml (98 - 775ml) | 15 - 30ml/feed |
Day Five | 705ml (452 - 876ml) | depends on feeding frequency, volume available and infant appetite |
1 - 6 months | 780ml (500 - 1350ml) | 30ml - 135ml/feed (6 - 18 feeds/day) |
The colostrum received by the baby in the first few days contains highly concentrated immunoglobulins and other protective factors (1.2 Breastmilk Immunology). Also, babies are usually born somewhat 'waterlogged' and therefore a few days of low oral intake assists the infant to clear the excess fluids. The baby is in more need of immunological protection than nutrition in the first few days.
Physiologically the newborn's stomach is not able to hold volumes larger than this. At birth the gastric wall is non-compliant and non-relaxing, which, when combined with the hypomotility of the duodenum, results in early satiety and frequent regurgitation in the first few days.4
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![]() | ![]() Workbook Activity 6.3Complete Activity 6.3 in your workbook. | ![]() |
In the first 3 days postpartum it can be assumed that the intake is adequate if the baby is positioned well, latches well and suckling actively. After lactogenesis II (average range of clinical onset is 50-73 hrs postpartum 5 ) it is essential that mothers know how to recognize signs that their baby is feeding well.
- observe the sucking pattern. Baby should be seen to move from a quick suck:suck:suck pattern (a stimulation pattern) to a slower suck:swallow:breathe:suck:swallow:breathe pattern (the nutritive pattern) which is sustained for 2 to 3 minutes. Baby may pause after this and repeat the pattern again. Observation of this pattern confirms milk transfer is occurring.
- after most feeds the baby will appear satiated
- baby's mucous membranes will be moist
- urine and stool output will indicate adequate intake (If it's coming out, it must have gone in!)
Age | Urine output | Stool output |
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0 - 24 hours | one wet nappy/diaper | one or more meconium stools |
24 - 48 hours | two wet nappies/diapers | one or more meconium stools/possible transitional stool |
48 - 72 hours | three wet nappies/diapers | transitional stool |
from Day 4 onwards | 6 - 8 thoroughly wet nappies/diapers, with clear urine | soft, yellow, curdy (at least daily until about 6 weeks) |
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![]() | ![]() #1 Rule of infant output - If it's coming out it must have gone in!It is important for parents to understand this concept. Teach them that the volumes going in as intake will be reflected in output of urine and bowels. Describe the amounts that are displayed in the chart so that parents have a realistic expectation.
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![]() | ![]() How do mothers receive this information?Is this information routinely given to ALL mothers? It is critical to the well-being of her baby. If you aren't able to identify when a mother has had this information discussed with her, form a group to develop a protocol to ensure this safeguard is put in place as soon as possible. | ![]() |
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![]() | ![]() Is it the same for bottle-fed babies?Yes, on the whole it is. All babies should be fed when they cue to feed, and be allowed to finish the feed when they choose to, ie. not forced to finish all the formula or breastmilk in the bottle.
Urine and stool output is also an excellent guide to intake sufficiency for babies fed with a bottle, though those receiving breastmilk substitutes will have a firmer stool and be prone to constipation. | ![]() |
Twins, or more!
Can mothers produce enough milk for multiples?
Studies7 of milk production in mothers of multiples found that the mothers of exclusively breastfed three-month-old twins were producing between 2.2 - 3.4 litres (73 - 113oz.) of breastmilk per 24 hours, while a mother of exclusively breastfed 2½ month old triplets produced 3.08 litres (~103 oz). This compares with studies of breastmilk production for singletons of 750 to 1100 ml (25 - 36oz.) per 24 hours.8
Assisting breastfeeding
There are several issues that should be addressed, namely education about breastfeeding, working with the mother to find the positions that work for her, discussing how she will cope with fatigue and the extra workload, and increasing her food intake to maintain her health.
- Find an appropriate long couch or bed that provides space on each side of the mother for her to place essentials or place a baby down while she is attending to another baby.
- Use a firm pillow or foam that will not sink during feeds.
- The newborn may perform better with breastfeeding if the mother feeds each baby individually during the early learning phase. This allows her the opportunity to bond and learn about each baby's breastfeeding needs and abilities.
- When breastfeeding two babies at the same time
- initially the mother will require competent assistance to help with positioning her babies, ensuring correct latch and effectiveness of feedings
- the mother can first position and attach the baby who requires the most assistance, supporting him with one hand, then assist the more competent baby to attach
- should one baby have a weaker suck, the milk ejection reflex will be stimulated by the other baby
- For triplets, two babies can be fed at the same time, then the third baby feeds from both breasts. At subsequent feeds the babies are rotated.
- Encourage the mother to ask for and accept help from family and friends who have offered assistance so she can concentrate on her task of breastfeeding and caring for the babies, and herself.

Breastfeeding twins
When should I begin giving baby other foods?
Baby Friendly Point 5
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Point 5 of the Seven-Point Plan is concerned with maintaining exclusive breastfeeding until 6 months, and continued breastfeeding with the addition of appropriate complementary foods after 6 months of age.
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Growth is generally not improved by complementary feeding before six months, even under optimal conditions, i.e., nutritious, microbiologically safe foods. Complementary foods introduced before six months displace the nutritionally superior breastmilk. Replacing even just some breastmilk too soon leads to nutritional deficits and growth faltering, as does not commencing appropriate complementary foods at the appropriate time for his needs. 9
At around 6 months of age, most infant's energy needs for growth and development are beyond the provision of breastmilk alone and appropriate complementary foods will provide additional calories and nutrient for future growth.
Also, developmental milestones also determine that the infant is not functionally ready to take complementary foods earlier than 6 months of age. At, or soon after 6 months, strengthening of the infant's musculature allows him to independently control his head and sit up. The development of fine motor coordination of more distal muscles, including the tongue and lips and their function of bringing in and manipulating more solid food in preparation for swallowing, is indicative of his ability to handle these foods at this age. 9
Between 6 and 24 months of age is a critical time for promotion of optimal growth, health and behavioral development with longitudinal studies demonstrating this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses.
The World Health Organisation 10 recommends the following guiding principles for appropriate complementary feeding to ensure nutritional wellbeing continues once complementary feeding begins:
- continue frequent, on demand breastfeeding until two years old or beyond;
- practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);
- practise good hygiene and proper food handling;
- start at six months with small amounts of foods and increase gradually as the child gets older;
- gradually increase food consistency and variety;
- increase the number of times that the child is fed, 2-3 meals per day for infants 6-8 months of age, and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required;
- feed a variety of nutrient rich foods;
- use fortified complementary foods or vitamin-mineral supplements, as needed; and
- increase fluid intake during illness, including more breastfeeding, and offer soft, favourite foods.
- Meat, poultry, fish or eggs
- Vitamin A-rich fruits and vegetables
- Adequate fat content
Eat daily:
A well-planned vegetarian diet that incorporates all macro- and micro-nutrients would be suitable. 11
Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks. Limit the amount of juice offered to avoid displacing more nutrient-rich breastmilk.
Age | Texture | Frequency | Amount each meal |
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Adapted from: WHO 2005 | |||
From 6 months | soft porridge, well mashed vegetables, fruit, meats | 2 times/day + frequent breastfeeds | 2 - 3 tablespoonfuls |
7 - 8 months | mashed foods | 3 times/day + frequent breastfeeds | Increase gradually to 2/3 of a 250ml cup each meal |
9 - 11 months | finely chopped or mashed foods & foods baby can pick up | 3 meals + 1 snack between meals + breastfeeds | 3/4 of 250ml cup or bowl |
12 - 24 months | Family foods, mashed if necessary | 3 meals + 2 snacks + continued breastfeeding | A full 250ml cup or bowl |
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![]() | ![]() Baby-led or mother-led eating?Developed countries approach to complementary foods tends to be in a structured fashion of food preparation (puree or mash), mother-directed using a spoon.
This is not possible or practical in traditional cultures - the infant is directly involved in food time with the family. Finger foods can be offered to babies so that they can choose their own intake according to ability and needs. This is called Baby-led weaning. A recent study12 showed significantly low levels of food restriction, no association with weight and reported to possibly have a positive effect on later eating habits and weight. | ![]() |
When should I wean my baby from the breast?
Breastfeeding and breastmilk continues to provide protection and growth factors as well as being a quality food source for as long as the child is breastfed. There is no stage of lactation where breastmilk stops having these beneficial effects.
The introduction of complementary foods from 6 months of age is the beginning of the weaning process. The weaning process can take as long as the mother and baby want it to take. The American Academy of Pediatrics recommends breastfeeding continue for at least the first 12 months of life and beyond with the addition of appropriate complementary foods from 6 months.13 The World Health Organisation recommends babies continue to receive breastmilk until at least their second birthday and beyond, with the addition of appropriate complementary foods from 6 months of age.
Despite this knowledge, the number of babies who are being exclusively breastfed at 6 months of age, and the number of babies receiving any breastmilk at 12 months of age is much less than it should be in most countries.
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![]() | ![]() Weaning too earlyHave you thought about how you could influence mothers in your area?
Brainstorm some ideas with your colleagues and implement them. Examples could be a poster that simply states “ | ![]() |
What should I remember?
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Self-test quiz
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Notes
- # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
- # Riordan J (2005) Breastfeeding and Human Lactation
- # Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum
- # Zangen S et al. (2001) Rapid maturation of gastric relaxation in newborn infants
- # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
- # Friedman S et al. (2004) The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants.
- # Saint L et al. (1986) Yield and nutrient content of milk in eight women breast-feeding twins and one-woman breast-feeding triplet.
- # Kent JC et al. (2004) Frequency, volume and fat content of breastfeeds of exclusively breastfed babies
- # World Health Organization (2001) Report of the expert consultation of the optimal duration of exclusive breastfeeding
- # World Health Organisation (2010) Infant and young child feeding - Fact sheet N,.342
- # Amit M (2010) Vegetarian diets in children and adolescents.
- # Brown A et al. (2010) Maternal Control of Child Feeding During the Weaning Period: Differences Between Mothers Following a Baby-led or Standard Weaning Approach.
- # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
6.3 Normal growth
Physical growth is measured by weight, length (height) and head circumference. A 2002 World Health Organization (WHO) survey revealed that regular weighing is part of most Western well-baby care systems and that growth charts are used universally in pediatric care.1 Growth charts are used to plot the expected growth in each of these parameters.
Growth charts plot a curve of the median (50% of children will be equal to and below this curve; likewise 50% of children will be equal to and above this curve), then plot the highest and lowest curves of normal growth on either side. Many growth charts use percentile curves. The 3rd percentile reflects that 3% of children are at and below this line. The 97th percentile indicates that 97% of children will be at and below that line. The 50th percentile is the median.
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![]() Look at the movie not the photoPlotting of a child's data on one occasion in time has limited value. The important information is what happens to that child's data over time - is the child's data continuing to cross through curves?; is the child's data following an upward curve, even if it is the 3rd percentile? |
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Weighing of babies is not an innocuous procedure
Sachs (2006) 2 found that clinic visits focussed around the weighing of the baby with little attention being given to discussing other child care matters. She also noted that the interpretation of an acceptable weight gain was reduced to the expectation that the plotted weight should mirror one of the curves on the growth chart. Mothers in this study, and others, 3 were found to change their feeding practices at the expense of breastfeeding to increase weight gain to stay on or exceed a growth curve.
“ ... the routine of weighing risks becoming a ritual practice with potential to undermine infant nutrition rather than a supportive means to encourage the best care possible for individual babies.
” (p94) 2
Before weighing a baby:
- ask the mother if she has any concerns about her baby.
- discuss the baby's breastfeeding behavior and intake of complementary foods (if age appropriate)
- ask about the baby's output - urine and stooling.
- observe the achievement of age-appropriate developmental skills.
- observe the baby's general condition: skin turgor, color, adipose distribution (particularly as the mother takes the baby's clothes off in preparation for weighing).
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![]() | ![]() Surprised? Absolutely NOT!!! | ![]() |
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![]() | ![]() Workbook Activity 6.4Complete Activity 6.4 in your workbook. | ![]() |

Before weighing this exclusively breastfed Papua New Guinean baby would you anticipate having any concerns?
Photograph © D.Fisher, IBCLC
What influences movement through growth curves?
A variation from a growth curve is only one observation. Further history-taking, other observations, investigations or time may be required before a definitive explanation can be given.
Reasons data may fluctuate:
- Data is plotted on a growth chart based predominantly on artificially-fed children. (Ensure you are using the WHO growth charts) Artificially-fed babies have a markedly different, and therefore abnormal, growth trajectory.
- Child was born large, but is genetically determined to be slighter - or vice versa.
- Child has had a temporary illness, losing weight which will be quickly regained when healthy again.
- Inadequate nutritional sustenance to support growth; or excessive, but poor quality foods causing obesity.
- Chronic illness that prevents normal growth.
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![]() | WHO Child Growth StandardsThe WHO Multicentre Growth Reference Study (MGRS) as undertaken between 1997 and 2003 to generate new growth curves for assessing the growth and development of infants and young children around the world.
The MGRS collected primary growth data and related information from approximately 8500 children from widely different ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA). These growth curves provide a single international standard that represents the best description of physiological growth for all children from birth to five years of age and establish the breastfed infant as the normative model for growth and development. Print a copy of the percentile charts ![]() ![]() | ![]() |
Accurately weighing an infant
In comparing balance, spring and electronic scales most studies found greatest accuracy using electronic scales, with newer scales being more accurate than older scales. Scales should be regularly re-calibrated.
For greatest accuracy:
- weigh the infant on the same set of scales each time
- weighing procedure to be performed by the same person at each visit, using their usual technique
- weigh the baby at approximately the same time of day
- weigh the baby at the same time in relation to a feed, eg. straight after feeding
- weigh the baby naked. Weighing baby with a diaper/nappy or clothed results in larger discrepancies.
- take time to concentrate on accurately plotting the weight. One study4 found >28% of points were plotted inaccurately.
What should I remember?
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Self-test Quiz
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6.4 Sleep
Rooming-in in Hospital
Baby Friendly Step 7
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Step 7 of the Ten Steps to Successful Breastfeeding states:
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In their research to support the inclusion of this Step, UNICEF1 found that when mothers and infants were separated, infants breastfed less frequently, lactogenesis II was evident later and clinical jaundice was more common. Weight gain per day was also statistically less.
Babies cared for in nurseries had more crying episodes (and were therefore more stressed) and were responded to less frequently.
24-hr rooming in resulted in mothers experiencing the same number of hours total sleep as the separated dyads, infants spent 33% of the time in quiet sleep compared with only 25% in the nursery group and there was no difference in daytime alertness in the two groups.
This suggests that rooming-in does not greatly alter maternal sleep and it improves infants' sleep.
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![]() | ![]() Workbook Activity 6.5Complete Activity 6.5 in your workbook. | ![]() |
How long should my baby sleep?
Initially wakefulness and feeding are closely related. During the first 24 hours the newborn spends the first 2 hours awake and alert, and breastfeeding.
After the initial few days most babies will sleep about 16 hours a day, slowly decreasing to 14-15 hours by 3 months and 13-14 hours by 6 months of age.2
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![]() | ![]() InterestingBy 3 weeks of age the average length of the longest sleep is about 3.5 hours. By 6 weeks of age some babies are having up to 6 hrs in one sleep.2 | ![]() |
Neonates will often fall asleep directly in an 'active sleep' or REM (rapid eye movement) stage. It's during the active sleep stage that an infant is most easily roused. Neonates have a 50:50 relationship between active and quiet sleep, with sleep cycles lasting about 50 minutes.2
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![]() | ![]() How can I use this knowledge to help parents?Knowledge of what is normal behaviour is reassuring to parents. Discuss normal breastfeeding and sleep patterns with expectant or new parents. When putting a baby down to sleep suggest they stay with the baby until he moves from the rapid eye movement stage from which he is easily roused, into the deep sleep stage where he is more likely to stay asleep regardless of movement and noises around him. | ![]() |
The natural course of settling seems to proceed over the first 6 months, but even after that age increased waking occurs in up to 42% of children who have already shown the capacity to sleep through the night.2 Two thirds of babies breastfeed at night, and have their biggest feed at this time consuming 20% of their total daily intake.3 For these reasons implementing behavioral therapy for infant and toddler night-waking before 18 months of age is ill-advised.
Where should my baby sleep?
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![]() | DefinitionsCo-sleeping4 encompasses various sleeping situations with “ Bedsharing is sleeping in the same bed. | ![]() |
Where the infant should sleep is a contentious issue. Prior to the 20th Century and the application of rules and regulations to childcare in the Western world, infants and mothers slept together, and still do in countries not influenced by Western customs. A recent UK study found that 72% of breastfeeding mothers consistently co-slept during the first 12 weeks of life.5 Bedsharing and breastfeeding are mutually reinforcing - breastfeeding couples are more likely to bedshare, and bedsharing babies are more likely to breastfeed successfully.4
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![]() | ![]() Now that's significant!Perhaps of even more significance to mothers is the finding of Quillin & Glenn (2004)6 that breastfeeding mothers who co-sleep get more total sleep than bottle feeding mothers or breastfeeding mothers who slept apart from their babies. | ![]() |
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![]() | Research FindingsThe results of fascinating research by McKenna & Mosko (1994)7 suggest that co-sleeping is associated with enhanced infant arousals and striking temporal overlap (synchronicity) in infant and maternal arousals, and that, possibly as a result, co-sleeping mothers and infants spend more time in the same sleep stage or awake condition. This synchronicity assists mothers to cope with broken sleep - the infant isn't rousing them at a time when they are in their quiet sleep phase. | ![]() |
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![]() | ![]() Do you have a bed-sharing policy? Click on the icon to be taken to a sample bedsharing policy produced by UK Baby Friendly. Print the article, read it and file it with your notes from this course. Also read this Guideline for Co-sleeping and Breastfeeding from the Academy of Breastfeeding Medicine. | ![]() |
As it appears that breastfeeding mothers are likely to bedshare with their babies it is important to discuss how to do so safely.
Note this mother and her baby are on a firm mattress, she is turned toward her baby, her lower arm is not restricting infant movement. The bed linen is not covering the infant and he is sleeping safely on his back. This mother will respond immediately to her baby's cues to feed, and he can be easily rolled towards her to breastfeed.

Safe bedsharing with baby includes a firm mattress, supine sleep position and a breastfeeding mother.
Photograph © D.Fisher, IBCLC
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![]() | ![]() Your Hospital Policy on BedsharingYou have a legal responsibility to adhere to your hospital policy on bedsharing and ensure that the mother is aware of this for her hospital stay.
Now that you have read the research about safe bedsharing and co-sleeping, you may feel more confident about the many benefits and even infant safety advantages. If your hospital does not allow bedsharing, you may like to form a group to gather research and present it to the hospital administrators. | ![]() |
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![]() | ![]() What do you tell mothers about bedsharing?You need to inform mothers about your hospital policy on bedsharing. However, it is also important for mothers to be given accurate information on safe bedsharing and co-sleeping at home with their baby. Does your Unit have a leaflet you can discuss with mothers about safe bedsharing? If you don't have one, or it requires updating, form a small group to research the issue, share their findings with other staff, then create a leaflet for the purpose of educating mothers about this important aspect of parenting. | ![]() |
What should I remember?
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Self-test Quiz
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Notes
- # Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding
- # de Weerd AW et al. (2003) The development of sleep during the first months of life
- # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
- # McKenna JJ (2004, July) Examining Sudden Infant Death and Co-sleeping
- # Ball HL (2003) Breastfeeding, bed-sharing, and infant sleep
- # Quillin SI et al. (2004) Interaction between feeding method and co-sleeping on maternal-newborn sleep
- # McKenna JJ et al. (1994) Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine
6.5 Psychological support
Many clinicians will tell you that breastfeeding is a confidence game.
Prof Hartmann in his studies of breast growth and development from preconception to weaning noted one woman in their study had no breast changes during her pregnancy. She went on to successfully breastfeed her baby. Prof Hartmann commented that she was successful because no one at any time suggested to her that she might have a problem.
Similarly a woman who exclusively breastfed her triplets for 6 months said that she did it because no one told her she might not be able to, and that had it been suggested she probably wouldn't have had the confidence to even try.
Maternal self-confidence and self-efficacy
Researchers confirm self-confidence and self-efficacy to be major predictors of breastfeeding success. Women studied in Denmark,1 USA,2,3 Australia,4,5 New Zealand6 and Canada7 have all found mothers who have confidence in their ability to breastfeed and mothers with high breastfeeding self-efficacy significantly more likely to breastfeed.
Influencing self-confidence and self-efficacy
A lack of education about breastfeeding was identified by several of the researchers mentioned above.
Breastfeeding education needs to be included as a part of
- community awareness programs,
- prenatal classes,
- prenatal health care provider visits, and
- postnatally
Health professional attitudes and actions in regard to breastfeeding significantly influences mothers. At 12 weeks postpartum mothers are much more likely to be breastfeeding if they reported having received encouragement from their clinician to breastfeed2. Health care professionals can also have a negative influence if their lack of knowledge results in inaccurate or inconsistent advice. Some hospital routines are also potentially detrimental to breastfeeding7. Blyth et al (2002)5 recommend integrating self-efficacy enhancing strategies, improving the quality of healthcare delivered and increasing a new mother's confidence in her ability to breastfeed.
Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors7.

Never underestimate the role of the father in supporting breastfeeding.
© WIC program, USA
Be aware at all times of how your seemingly innocent comments and actions can affect maternal confidence. For example: mothers have reported losing self-confidence to breastfeed from staff commenting about their 'flat' nipples, or small breasts, or red hair, or fair skin, or ability to hold the baby. Impatience is another factor identified by mothers trying to learn a new skill. Taking the baby from the mother and having him/her settle immediately demonstrates to a mother her lack of skill, and perhaps to an anxious mother, that the baby may 'prefer' someone else.
With such short hospital stays it's important for the mother to assume all care of her infant as soon as she is physically able to, with nurses or midwives available to coach her when needed, providing positive feedback at every opportunity.
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![]() Think positive. Sound positive.It's the little things that count. |
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What should I remember?
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Self-test Quiz
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Notes
- # Kronborg H et al. (2004) The influence of psychosocial factors on the duration of breastfeeding
- # Taveras EM et al. (2003) Clinician support and psychosocial risk factors associated with breastfeeding discontinuation
- # Chezem J et al. (2003) Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices
- # Creedy DK et al. (2003) Psychometric characteristics of the breastfeeding self-efficacy scale: data from an Australian sample
- # Blyth R et al. (2002) Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory
- # Vogel A et al. (1999) Factors associated with the duration of breastfeeding
- # Dennis CL (2002) Breastfeeding initiation and duration: a 1990-2000 literature review
6.6 Discharge planning
The goal of discharge planning is two-fold
- to prevent common problems, and
- to enhance maternal self-esteem and self-confidence1
It is the duty of care of the health professionals caring for the mother-baby dyad to ensure that all mothers, particularly those who have not had prenatal education, know how to recognise wellness in their baby and adequate transfer of milk and to react quickly when anything abnormal occurs.
Preventing common problems
Timing of follow-up
Routine follow-up with a qualified health care provider must be confirmed with the parents prior to discharge. A Clinical Practice Guideline recommends the following appointment schedule (AAP Subcommittee on Hyperbilirubinemia, 2004).
Age of infant at discharge | Should be seen by |
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Before 24hr old | 72 hrs (3 days) |
From 24 - <48 hrs | 96 hrs (4 days) |
From 48 - 72 hrs | 120 hrs (5 days) |
For some newborns discharged before 48 hours, 2 follow-up visits may be required, the first visit between 24 and 72 hours and the second between 72 and 120 hours. |
Critical warning signs
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![]() | ![]() The 3 Red Flags!Optimal birth circumstances and good post natal breastfeeding care will significantly reduce the incidence of infant problems. Each of these signs is an indicator that there may be a breastfeeding problem or something more serious.Any of these signs need immediate medical attention. | ![]() |
#1. Baby's output is less than expected.
Review the table 6.2 Breastfeeding Messages
Do all mothers have a copy of that table to take home? .
Output is a direct indicator of intake - ensure that you can accurately describe normal urine and stool output of the breastfed infant. Ask about the pinkish/rusty stain on a nappy/diaper which is urates in urine. This is normal until baby is 72 hours old (3 completed days). Secretion of urates in urine is a direct function of the serum uric acid concentration (ie blood levels). It is normal to see urates on a nappy/diaper with a scant volume of urine until Day 4. As the milk intake increases on Day 4 urates should no longer be seen.
A note of caution to health professionals who provide only telephone consultations ... your image of a wet nappy/diaper, or a reasonable bowel action may not match the mother's impression. Urine should be clear and each nappy/diaper heavy. Although not a pleasant image, it is helpful to describe a 'handful' size as being a good volume of stooling. This is a very clear picture and will help the mother understand that scant frequent stainings are inadequate.
If there is any doubt at all you must organize for the baby to have medical review urgently.
#2. Breastfeeding is painful.
Breastfeeding should not be painful.
Pain during feeding, misshapen or damaged nipples or pain continuing after the feeding are all indicators that baby is poorly latched and milk transfer will be compromised. A hot or inflamed painful breast is a sign of severe engorgement, or mastitis with reduced milk transfer as a result. Painful breastfeeding is abnormal!
Immediately seek help from an expert in breastfeeding.
#3. Increasing jaundice
Jaundice is a physiological state and is an expected developmental state for the majority of breastfed babies. Jaundice peaks at about Day 3 then gradually fades over the next few weeks. Jaundice should not be seen below the level of the umbilicus.
However, increasing jaundice causes sleepiness and poor feeding; conversely, poor feeding causes increased jaundice.
Teach parents to check for jaundice by observing their baby in natural daylight and putting finger pressure on their baby's forehead, upper chest, arms, abdomen, upper legs and watching for blanching.
Instruct parents that jaundice below the umbilicus is to be reported immediately to their baby's health professional.
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![]() | ![]() Workbook Activity 6.6Complete Activity 6.6 in your workbook. | ![]() |
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![]() | ![]() These symptoms are the most important for the parents to remember and seek help with if they develop. Succinct instructions will more likely be remembered by parents. Ensure they know to seek urgent review by their health care provider whenever any of those points are abnormal. | ![]() |
Contraception
Preventing an unwanted pregnancy is important to women, and adequate child-spacing is important to the mother's health and the health of the new baby. Breastfeeding is also of paramount importance to the health of both mother and baby.
It is preferable for the mother to recover her nutritional status following the demands of pregnancy and lactation. Recovery of these stores prior to a subsequent pregnancy is important for her health - a recuperative period of less than 6 months between the end of breastfeeding and the next pregnancy is associated with depletion of maternal nutrient stores.2
Mothers therefore require counselling on selection of a contraceptive method that is
- highly effective in preventing pregnancy, and
- does not interfere with breastfeeding.
The Lactational Amenorrhea Method (LAM) of contraception has been extensively studied and found to be more effective than the progestin-only contraceptive pill. Additionally all forms of hormonal contraceptive have the potential to adversely affect breastfeeding.
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![]() | ![]() Contraception for breastfeeding mothers[link: http://www.waba.org.my/resources/lam/FBPF.htm]To read more about other contraceptive methods during lactation click on the icon on the left, print the page and file it with your course notes. From this page you'll find further links and references. | ![]() |

Using the Lactational Amenorrhea Method of contraception.
Graphic © Health e-Learning
The quality of contraceptive/fertility counselling given to a woman significantly influences its effectiveness. When giving advice about any contraception ensure you understand it completely.
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![]() | ![]() Workbook Activity 6.7Complete Activity 6.7 in your workbook. | ![]() |
Consolidating learning
Practical skills should be reinforced by educational materials which must be
- accurate,
- consistent within themselves and with previous verbal teaching,
- written at an appropriate reading-age, and
- free from commercial advertising.
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![]() | ![]() Resource materials for mothersForm a group to look at ALL the materials that are given to mothers. Each one should be discussed and explained to the mother as it is given. Are all the materials necessary? Are all staff familiar with the materials? "The critical warning signs" handout is the most important - does it stand out from the brochures? Perhaps you could start a working group to design/update this vital parent information page? | ![]() |
Discharge packs DO influence actions, particularly in regard to breastfeeding. Artificial formula company sponsored packs reduce the likelihood of exclusive breastfeeding3 and therefore for the health and safety of mother and baby they should not be distributed by any health care facilities.
Referral to mother-to-mother support network
Baby Friendly Step 10 and Point 7
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Step 10 of the Ten Steps to Successful Breastfeeding, and Point 7 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
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Attendance at mother-to-mother support groups or follow-up by peer counselors has demonstrated significant increases in maintaining exclusive breastfeeding. 4 Strategies that depend mainly on face-to-face support appear more effective than those that rely primarily on telephone contact. 5 Parents should be given information about the location and availability of these services with encouragement to use the services.
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![]() | ![]() How is the information provided?Does your Unit have a list of all the available breastfeeding support groups and networks in your area? Is it up-to-date with current phone numbers and meeting places and dates? Are representatives from these groups welcome to meet with mothers in your Unit?
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© Australian Breastfeeding Association
What should I remember?
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Self-test Quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 6 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 6.
Notes
- # Friedman MA et al. (2004) Discharge criteria for the term newborn.
- # Merchant K et al. (1990) Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals.
- # Donnelly A et al. (2004) Commercial hospital discharge packs for breastfeeding women
- # Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland
- # Sikorski J et al. (2004) Support for breastfeeding mothers
7.0 Infant Challenges
A knowledge of what conditions or events are linked with decreased initiation or duration of breastfeeding will help you to focus your breastfeeding assistance and education activities to those in most need.
Infant Risk Factors
- birth trauma
- intrapartum analgesics or anaesthetics
- the 'late preterm' (34 to 38 weeks gestation)
- inconsistent ability to latch on
- sleepiness or irritability
- hyperbilirubinemia
- hypoglycemia
- either small (intrauterine growth retardation) or large for gestational age baby
- ankyloglossia (tight lingual frenulum or tongue-tie)
- multiples (twins, triplets or more)
- neuromotor problems (eg Down Syndrome)
- oral abnormalities (ie cleft of lip and/or palate)
- acute or chronic illness
In this course we will only cover the most commonly presenting problems. For some conditions, such as neuromotor problems and oral abnormalities, the mother and baby will require a practitioner with a lot of experience and advanced skills. Early referral to a Lactation Consultant is recommended for these babies and others where the usual management strategies aren't quickly producing the expected results.
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7.1 Late preterm infant; Non-latching
The 'late preterm' baby
Infants born 34 weeks 0 days to 36 weeks 6 days gestational age are categorised as 'late preterm'.1
Late preterm infants with no significant respiratory problems or other problems of prematurity are often cared for on the postnatal ward, with the temptation to treat them as you would a term baby. Often called 'the great pretenders', these infants may present with subtle immaturity that requires a trained eye to detect, and proactive management to prevent subsequent problems.
Some problems these infants may encounter:
- respiratory instability and interrupted lung development2,3
- poor ability to clear normal lung fluid (particularly if delivered by elective, pre-labour caesarean section)
- increased incidence of apnoea
- little respiratory reserve
- temperature instability2
- less glycogen and brown fat stores available to protect against hypoglycaemia4
- reduced ability to conjugate and excrete bilirubin, increasing need for phototherapy to treat jaundice2
- neurological immaturity
- poor state regulation - may go from hyper-alert to deep sleep without intervening stages
- easily overstimulated, then exhausted - may fall asleep before full breastfeed taken
- lower tone
- reduced immunological competence.2 Very important not to separate baby from mother - avoiding nosocomial infections and ensuring extra breastmilk feedings for the immunological protection this gives
- poor breastfeeding establishment and breastfeeding-associated rehospitalisation5,6,7
- higher mortality throughout infancy8
- higher incidence of mental and physical developmental delay at 24 months9,2
Postpartum care
Initial treatment should be no different from any other infant:
- Skin-to-skin contact immediately after birth - drying and observations occuring on mother's chest
- Leave in skin-to-skin contact until after the first breastfeed
Skin-to-skin care will provide
- optimal physiological stability
- temperature stability
- improved oxygen saturation and gas exchange
- enhanced immune protection (colonization with mother's normal flora; maternal antibody development targeted to baby's needs)
- decreased crying
- increased opportunities to breastfeed
- improved breastmilk production
- enhanced maternal-infant bonding
- longer exclusive and total breastfeeding
- Delay all routine procedures (eg. vit K injection, eye prophylaxis, hepatitis B vaccine, weighing) until baby stable, settled and had first breastfeed as these procedures increase crying which depletes metabolic reserves and disrupts breastfeeding behaviours. Most can be carried out while skin-to-skin with mother if hospital routine is not flexible.
Lactation Management
The importance of breastfeeding for a preterm infant is even more significant than for full term infants. Yet it is the very nature of the immaturity of the preterm and late preterm that creates breastfeeding challenges. Poor stamina, low tone, difficulty with latch and suck all contribute. Each infant needs to be assessed on individual needs and abilities and a tailor-made breastfeeding support plan can be established.10,7,11
The mother of the late preterm infant should be instructed to respond immediately to early feeding cues, leaving nappy/diaper changing until after feeding due to baby's low energy reserves. Due to the possibility of poor milk transfer associated with low energy reserves and low tone, encourage mothers to express after every breastfeeding attempt to ensure adequate drainage, or 2-3 hourly, unless baby breastfed vigorously. Small frequent feeds accommodate small stomach capacity and lessen chance of overdistension. A maximum length of 2-3 hours between breastfeeds may need to be set as these babies are sleepier and may not wake for feeds.
Involve experienced lactation support.
A lactation consultant can determine the need for additional lactation support such as:
- special positioning in view of maturity deficits
- jaw support while breastfeeding, if hypotonia present
- breast compression/massage
- determine whether a lactation aid is indicated, eg. nipple shield after lactogenesis II, or tube-feeding device at breast
Note special attention to:
- output - both urine and stool
- weight gain/loss
- level of jaundice
- essential early post-discharge follow-up
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![]() | ![]() Don't be complacentThese babies are NOT term babies. They may initially appear to cope well (remember 'the great pretenders'), but exhibit decreasing stamina and ability after several days so need to be watched carefully. | ![]() |
What should I remember?
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Self-test quiz
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The Non-latching Baby
There are many reasons for a newborn not to latch or latch poorly and breastfeed ineffectively. The following have been associated with sub-optimal breastfeeding behaviors on Day 3 postpartum:
- condition at birth compromised (trauma, intrapartum drugs, resuscitation required)
- pacifier/dummy use
- flat or inverted nipples
- breastfeeding delayed for up to 48 hours, and
- primiparous mothers.12
It has been demonstrated that forcing the baby to the breast can abolish the rooting reflex and disturb placement of the tongue. A healthy baby should have the opportunity of showing hunger and optimal reflexes, and attach to its mother's breast by itself.13
Read this short article[link: http://www.health-e-learning.com/resources/articles/37-when-the-back-of-the-babys-head-is-held-to-attach-the-baby-to-the-breast] that describes the detrimental effects of a hand placed on the back of the baby's head during latching.
Your first responsibility
A newborn who shows no inclination to breastfeed is abnormal until proven otherwise.
The most important concern when a baby is not exhibiting this expected reflex is to rule out infant morbidity. Observe the infant's vital signs and organize a pediatric review if any abnormality is detected. Conditions such as unexpected respiratory distress syndrome, Group B strep infection, sepsis, hypoglycaemia, etc may first present as a baby not exhibiting the normal feeding reflexes. We also know that it could be as a result of intrapartum drugs or the birthing experience, and the baby just needs more time, but don't assume that until you have eliminated the more sinister causes.
Principles of management
The aim of your plan is to:
- protect the baby: this not only means to ensure the physical well-being of the infant (nutrition and warmth), but includes protecting the baby from unnecessary supplementation before it is indicated.
- protect the lactation: until such time as baby is suckling well
Re-establish skin-to-skin care on mother's chest if this had been interrupted. This baby should have A LOT of time in this position. Encourage the mother to adopt the laid back position of Biological Nurturing to stimulate pre-feeding behaviours.
Avoid stressful events/procedures and handle the baby with care ie. definitely don't hold the infant's head in an attempt to hasten latching.
Encourage the mother to respond immediately to baby's earliest feeding cues and instinctive behaviours.
Trickle small amounts of breastmilk into the corner of the infant's mouth as he lies near the breast.
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![]() | ![]() Workbook Activity 7.1Complete Activity 7.1 in your workbook. | ![]() |
The Action Plan
From 0 to 24 hours old
- initiate and maintain skin-to-skin contact with the mother. Utilizing the baby's instinctual reflexes is very important.
- teach the mother about the early feeding cues, ie. wriggling, bringing hand to mouth, rooting; ensure she knows to facilitate feeding immediately the baby shows these cues
- continue to observe the baby's vital signs regularly and observe for symptoms of hypoglycemia (blood testing not indicated if asymptomatic). Initiate pediatric review if outside the range of normal.
- be patient and reassure the mother, providing the baby's condition is satisfactory.
- hand express breastmilk each time baby tries unsuccessfully to breastfeed. Finger-feed, spoon feed or slowly trickle the tiny volumes into the corner of the baby's mouth from a syringe if the baby is swallowing OK.
- hand expressing should have commenced within 6 hours of birthing (preferably earlier) and regularly at least 3 hourly thereafter (up to 5 hour break overnight).14 While the baby's condition should not deteriorate due to lack of feeding in this first 24 hours, giving the baby the expressed milk makes common sense.
From 24 to 48 hours old
- continue in skin-to-skin care
- continue regular observations of vital signs and for signs of hypoglycemia.
- attempt to rouse and interest baby in breastfeeding every 3 hours. If unsuccessful ...
- Feed the baby! Average breastmilk volume taken during the second 24 hours is 5 - 15ml per feed with a 24 hour volume of 84ml. This should be your goal.
- cup, finger or spoon feed the breastmilk to the baby. Giving more than 2 supplements using a bottle can lead to discontinuation of exclusive, and any, breastfeeding.15
- continue regular hand expressing or pumping at least 8 times per 24 hours.
- refer mother and baby to a Lactation Consultant for evaluation.
From 48 to 72 hours old
- Continue all strategies as above
- Average volume of breastmilk taken is 400ml (13.5oz) per day, or about 8 feeds of 50ml/feed - or less volume more frequently depending on the volume the mother is able to express each time.
After 72 hours
- Lactogenesis II should have occurred by now
- Continue all strategies as above
- Average daily volume of breastmilk consumed from Day 5 is 700ml (~24oz). Some babies may settle and thrive on less, some may require more.
(The recommended daily volumes are taken from the average volume taken at the breast by the well, full-term baby. Refer to the table in topic 6.2.) Note: Never underestimate the significance of skin-to-skin contact to trigger instinctive reflexes and enhance recovery.
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![]() | ![]() Does your Unit have a policy on the non-latching baby?Review the policy. Is it current, using up-to-date research to support the recommendations? If not, form a small group to research the topic then draft a policy that you present to your colleagues (midwifery, nursing and medical). Ensure all staff are familiar with the policy to avoid conflicting information and management strategies. | ![]() |
Breast refusal in the older baby
Babies may be fussy at the breast and refuse to breastfeed for a period of time. Before 12 months of age this is rarely due to the infant choosing to wean.
Determine that it actually is breast refusal. Mothers sometimes misinterpret an older baby's quicker more efficient feeding, or a decreased need for breastmilk when complementary foods are introduced, as breast refusal. During very hot weather baby may not feed during the heat of the day, but will feed well in the evening or during the night. Other reasons may be pain, forceful MER/low supply, flavour changes and sucking confusion.
Management strategies for the older baby
- Record a comprehensive history, including specifics on breastfeeding behavior and urine and stool output prior to this episode. Record the change in behavior and baby's current output.
- Do an assessment of the baby including weight, length, head circumference, attainment of appropriate developmental milestones, observation of alertness and general health. If there are signs of delayed growth or ill health, refer the baby to a doctor.
- Observe a breastfeed, or attempted breastfeed. (Review Topic 5.2 Assessing Breastfeeding)
-
If refusal persists for more than one or two missed feeds
- the mother should express her milk to maintain her milk supply, and
- use the expressed milk to feed baby, preferably using a cup. In the absence of donor breastmilk, artificial infant formula will be required if mother's milk volumes are inadequate or baby refuses the breastmilk.
- a medical review of the baby is indicated if baby won't feed at all.
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![]() | ![]() Detective work is needed!This is a distressing time for the mother, who may be feeling variously angry, rejected, worried, disappointed and bewildered. Good counseling skills will help you to empathise with the mother and work together through a comprehensive history-taking to find a reason for the baby's behaviour. If you can determine the cause you can then direct your management strategies more effectively. | ![]() |
General guidelines include:
- patience; avoid trying to force the baby to breastfeed or displaying anxiety or anger during attempts
- encourage lots of skin-to-skin time in bed together or sharing a bath. Don't expect the baby to breastfeed ... but it just might happen
- observe the environment - avoid distractions such as other children, toys, television, etc. Choose a dimly lit room and play some relaxation music.
- attempt breastfeeding when baby is nearly asleep or just beginning to wake up
- offer the breast instead of pacifier/dummy, and when infant starts thumb sucking
- suggest baby be cup fed rather than bottle fed when separated from the mother
- suggest the use of a tube feeding device at the breast if supplements were being given
- give written instructions and supervise the mother using alternative feeding methods until she feels confident doing it herself.
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![]() | ![]() Workbook Activity 7.2Complete Activity 7.2 in your workbook. | ![]() |
What should I remember?
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Self-test quiz
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Notes
- # Engle WA (2006) A recommendation for the definition of "late preterm" (near-term) and the birth weight-gestational age classification system.
- # Baumert M et al. (2011) [Late preterm infants--complications during the early period of adaptation].
- # Resch B et al. (2011) Are late preterm infants as susceptible to RSV infection as full term infants?
- # AAp Committee on Fetus and Newborn (2011) Postnatal glucose homeostasis in lat preterm and term infants
- # Radtke JV (2011) The paradox of breastfeeding-associated morbidity among late preterm infants.
- # Vessière-Varigny M et al. (2010) [Breastfeeding in a population of preterm infants: a prospective study in a university-affiliated hospital].
- # Cleaveland K (2010) Feeding challenges in the late preterm infant.
- # Tomashek KM et al. (2007) Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002.
- # Woythaler MA et al. (2011) Late preterm infants have worse 24-month neurodevelopmental outcomes than term infants.
- # Ahmed AH (2010) Role of the pediatric nurse practitioner in promoting breastfeeding for late preterm infants in primary care settings.
- # Walker M (2008) Breastfeeding the late preterm infant.
- # Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child
- # Widstrom AM et al. (1993) The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle
- # Furman L et al. (2002) Correlates of lactation in mothers of very low birth weight infants
- # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
7.2 Hypoglycemia; Jaundice
Pathologic Neonatal Hypoglycemia
Physiology
There are two times of crisis in the neonates life regarding energy (glucose) needs. Both crises are managed by normal metabolic adaptation which provides alternative fuel sources for the neonate.
- The first crisis occurs when the cord is cut and the maternal supply of glucose to the newborn is abruptly discontinued.1,2
- blood glucose concentration reaches its nadir in the first 1 - 2 hours
- blood glucose concentration then rises to a steady state within 2 - 3 hours
- feeding the infant may cause small transient rises in blood glucose concentration, but it is not feeding that maintains euglycemia
- blood glucose concentration reaches its nadir in the first 1 - 2 hours
- The second crisis will occur if lactation is delayed.3,4,5
- Fat breakdown occurs, releasing ketone bodies that provide glucose-sparing fuel to the neonatal brain, protecting neurologic function.
Transient hypoglycemia in the early neonatal period is a common adaptive phenomenon as the newborn changes from the fetal state of continuous transplacental glucose consumption to intermittent nutrient supply following cessation of maternal nutrition at birth.
Research has demonstrated that in the term, healthy newborn, this dynamic process is self-limiting and is not considered pathologic.6
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![]() | ![]() Do not screen normal, full term neonates.
Unnecessary routine screening results in the misidentification of neonates captured while experiencing the normal, self-correcting physiologic blood glucose nadir, who are then diagnosed with pathologic neonatal hypoglycemia. Research studies indicate that routine hypoglycemia screens, treatments, and interventions in the healthy infant are not evidence-based and result in a serious disruption of the initiation process and duration patterns of lactation.6 | ![]() |
Diagnosing pathologic neonatal hypoglycemia
Diagnosis is made when
- neurological signs are present, and
- blood glucose concentration is low.7
Clinical signs to observe for:
The first observation to make, and the most important, is the infant's level of consciousness. Pick up the infant, talk to him, wake him up. A limp infant you cannot wake is a bad sign.
Other clinical manifestations
- irritability, tremors, jitters
- exaggerated Moro reflex
- high-pitched cry
- lethargy, limpness, hypotonia
- apnea or irregular breathing
- cyanosis
- hypothermia, temperature instability
- poor or inadequate sucking reflex
- vasomotor instability
- seizures
Which infants are at risk?
Infants at risk of symptomatic hypoglycemia include:8
- Infants of diabetic mothers - hyperinsulinemia as a result of poor maternal control during pregnancy will cause hypoglycemia until stabilised.
- Infants who are preterm or late preterm with metabolic immaturity.
- Infants who have few fat reserves, eg small for gestational age infants
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![]() | ![]() Workbook Activity 7.3Complete Activity 7.3 in your workbook. | ![]() |
Preventing pathologic hypoglycemia
- stabilise the infant's temperature (no requirement to burn fat for heat)
- stabilise the infant's cardio-respiratory system
- stimulate metabolic adaptation
- initiate the first phase of the enteric nervous system (facilitating intestinal function)
- reduce stress (release of cortisol initially causes a surge in blood glucose concentration, then a fall)
- facilitate early and frequent breastfeeding, preventing a delay in lactation
- and prevent other factors, such as nosocomial infections and hypothermia that cause hypoglycemia.
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![]() | ![]() This is really important!It's worthwhile repeating: The BEST way for you to prevent hypoglycaemia in the infants you care for is by placing baby in skin-to-skin contact with his mother immediately after birth, and for as long as possible.
Share your thoughts in the forum about how this simple, no-cost practice helps prevent hypoglycemia. | ![]() |
What about early feeding?
Healthy, full-term infants do not develop symptomatic hypoglycemia in the first 24 hours simply as a result of underfeeding.9
Frequent, effective breastfeeding will, however, be protective after the first 24 hours. Beginning breastfeeding soon after birthing will ensure the infant is breastfeeding well and maternal lactation is becoming established by the time the infant is dependent on this source of energy.![]() | ![]() | ![]() |
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![]() | ![]() Workbook Activity 7.4Complete Activity 7.4 in your workbook. | ![]() |
Clinical management of pathologic hypoglycaemia
Inadequately treated symptomatic hypoglycemia has such a serious outcome that pediatricians agree that
“ the clinician should not rely on oral feeding (eg breastmilk or infant formula) for the correction of symptomatic hypoglycemia
” 9 and “ symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose.
” 8
However, during this medical management, breastfeeding should continue uninterrupted. The goal is to have an infant who suckles effectively at the breast and a mother's milk supply that is able to meet his needs when IV therapy is discontinued.
- continue breastfeeding, and skin-to-skin contact during treatment
- do not give water, glucose water or formula to the breastfed infant
- continue breastfeeding while weaning baby from IV glucose, monitoring carefully
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![]() | ![]() Extend your knowledgeGo to the
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![]() | ![]() Unit ActivityAccess your Unit policy on the management of hypoglycemia. Compare it to the literature published in peer-reviewed journals. Is it up-to-date and evidence-based? If not, form a working group to review it, present it at a Unit meeting and implement it.
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What should I remember?
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Self-test quiz
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Jaundice
The most common paediatric condition encountered in the first week is hyperbilirubinaemia. It is so common that it is termed "Physiological Jaundice" and reflects the normal physiological changes that occur as the neonate adapts to extrauterine life.
Normal serum bilirubin levels
The neonate is more susceptible to high serum bilirubin levels because
- there is increased breakdown of fetal erythrocytes. This is the result of the shortened lifespan of fetal erythrocytes and the greater number of erythrocytes in neonates.
- liver excretory ability is low because of the relative immaturity of the liver.
At birth neonates have a low serum bilirubin. The normal pattern is for a rise to a peak by the third day of life, followed by a plateau and drop in levels, or, for â…” of babies, a gradual rise to another peak on about the 10th day. After this the levels gradually drop until about the third week of life. (An exception to this is found in babies of Asian origin whose Day 3 levels peak nearly twice as high as found in non-Asian babies).
In some mothers, unidentified factors present in her breastmilk may contribute to increased enterohepatic circulation of bilirubin with harmless jaundice persisting for many weeks. This is an extension of physiologic jaundice known as breastmilk jaundice. No special treatment is required and continued breastfeeding is recommended.10

Diagram © Health e-Learning
An explanation of why newborns have elevated bilirubin levels could be that the antioxidant effects of bilirubin compensate for the relative deficiency of endogenous antioxidants in newborns. It is another protective effect denied the artificially fed infant.
Causes of abnormal bilirubin levels
- Abnormal weight loss : A weight loss of more than 7% in both artificially fed and breastfed infants is associated with higher serum bilirubin concentrations. Inadequate intake causes
- retention of meconium and reabsorption of previously excreted bilirubin back into the blood stream.
- Hemolytic processes : Blood group incompatibilities (Rh, ABO, and others) may increase bilirubin production through increased haemolysis. Nonimmune haemolytic disorders (spherocytosis, G-6-PD deficiency) also may cause increased jaundice through increased haemolysis.
- Non-hemolytic processes : A number of other nonhaemolytic processes can increase serum bilirubin levels. Accumulation of blood in extravascular compartments (cephalhaematomas, bruising, occult bleeding) may increase bilirubin production as the blood is absorbed and degraded. Increased bilirubin production also is seen in infants with polycythemia and in infants of mothers with diabetes. Increased reabsorption of bilirubin from the bowel leading to elevated bilirubin levels is seen in infants with bowel obstruction or ileus.
Physical appearance
Jaundice has a cephalocaudal (or cephalopedal) ie head to toe progression; it is evident first in the face, gradually becoming visible on the trunk. Jaundice seen below the level of the umbilicus and on the extremities reflects increasingly higher serum bilirubin levels. Jaundice disappears in the opposite direction.
Daylight on a clear day provides the best lighting for evaluation. Pressure applied on the skin using the finger pad will blanch the skin revealing the underlying colour.
Non-invasive transcutaneous measurement of bilirubin is a reliable screening method for identifying infants who need additional work-up.11 Laboratory measurement of bilirubin is indicated if jaundice involves the lower body and extremities.10
Management of hyperbilirubinemia
Prevention of hyperbilirubinemia due to inadequate intake involves early recognition of risk factors, good teaching and supervision of breastfeeding, and mothers who are able to recognize that good transfer of breastmilk to the infant is occurring.
Low serum bilirubin concentrations in the first 5 days are characterised by optimal breastfeeding behaviours: 10
- initiation of breastfeeding in the first hour after birth
- continuous rooming-in with unlimited access to the breast
- a breastfeeding frequency of 10 to 12 times per day
- prompt responses to early hunger cues, and
- absence of all supplementation.
Ensure adequate intake for the infant:
- assess breastfeeding effectiveness
- stimulate and support an adequate milk supply
- frequent breastfeeds; 8-12 per 24 hrs
- offer supplemental feeds of expressed breastmilk
- artificial infant formula is given only in the absence of adequate breastmilk volumes
- continue all of the above
- offer emotional support to the mother while her baby is receiving treatment
- Contraindicated: water supplementation
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![]() | ![]() Workbook Activity 7.5Complete Activity 7.5 in your workbook. | ![]() |
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![]() | ![]() Extend your knowledgeRead and print the Note that the first two recommendations are to:
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![]() | ![]() Unit activityWhat is your Unit's policy on recognition, prevention and management of jaundice? Discuss the Unit policy with your colleagues, comparing it to the AAP recommendations and other evidence-based articles. Would the algorithm in the AAP guidelines be useful to reproduce for your Unit? | ![]() |
What should I remember?
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Self-test quiz
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Click and drag the missing words below into their correct place The missing words are: breastfeeding breastmilk physiological supplementation tenth third __________ jaundice is normal in most newborns. Bilirubin rises to a peak on the __________ day of life, followed by a further rise until the __________ day for most breastfed infants. A harmless form of jaundice that persists for many weeks is termed __________ jaundice.Prevention of hyperbilirubinemia is focused on frequent, effective __________ and the absence of all __________. | ![]() |
Notes
- # Hawdon JM (2010) Best practice guidelines: Neonatal hypoglycaemia.
- # Cornblath M et al. (2000) Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds
- # Hawdon JM et al. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week.
- # Edmond J et al. (1985) Ketone body metabolism in the neonate: development and the effect of diet.
- # Cotter DG et al. (2011) Obligate role for ketone body oxidation in neonatal metabolic homeostasis.
- # Haninger NC et al. (2001) Screening for hypoglycemia in healthy term neonates: effects on breastfeeding
- # Hawdon JM (1999) Hypoglycaemia and the neonatal brain.
- # Jain A et al. (2010) Hypoglycemia in the newborn.
- # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
- # Gartner LM (2001) Breastfeeding and jaundice
- # Panburana J et al. (2010) Accuracy of transcutaneous bilirubinometry compare to total serum bilirubin measurement.
7.3 Supplementation
Exclusive breastfeeding
Baby Friendly Point 5 and Step 6
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Step 6 of the Ten Steps to Successful Breastfeeding, and Point 5 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
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Pre-lacteal feeds
Pre-lacteal feeds are any feeds given to the newborn before breastfeeding is established and the milk 'comes in', often within 0-2 hrs of birth. Honey, teas, pastes and herbal preparations are cultural and religious choices.1 Water, glucose water, milk-based substitutes are common pre-lacteal feeds given in hospital.2 3
Prelacteal feeds have been given in some cultures since ancient times in the belief that colostrum is harmful to infant, stale, and that it is not considered to be 'true breastmilk'.4 Colostrum may be expressed and discarded or replaced with the prelacteals.5 The prelacteals are believed to moisten the mouth and cleanse the gastrointestinal tract and aid expulsion of the meconium.4
Effect on mother and infant
- increasing diarrhea and infections,6
- increasing breastfeeding problems,7
- decreases exclusive breastfeeding and duration of breastfeeding,7,6,8,3 and
- the cycle of delayed initiation of lactation has the propensity to cause further use of prelacteal feedings.9
The practice of giving pre-lacteal feeds is a key determinant of early cessation of full breastfeeding.3With education and support for breastfeeding, the acceptance of exclusive breastfeeding from birth has become more widespread.
Supplementation
Even more common than giving pre-lacteal feeds has been the routine giving of post-breastfeed supplements, or additional bottles of water, glucose water or artificial infant milk.
The reasons sometimes given for this practice include:
- to give the mother a rest
- because the mother doesn't have her milk 'in' yet
- to calm a crying infant
- to prevent hypoglycemia
- to prevent or reduce jaundice
None of these reasons are indications for giving supplements, with some having the opposite effect to the result desired.
Medical indications for supplementation
The World Health Organization states that there are few medical indications that may require individual infants to be given fluids or food in addition to, or in place of, breastmilk. Whenever stopping breastfeeding is considered, the risks of infant formula feeding and the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific condition listed. The following circumstances may be considered:
Infant conditions:
- These infants should receive only specialized infant formula:
- an infant with certain inborn errors of metabolism; eg classic galactosemia, maple syrup urine disease, phenyloketonuria (some breastfeeding possible with careful monitoring)
- These infants should continue to receive breastmilk, but may require other food in addition for a limited time:
- infants with very low birth weight (<1500g) or who are born preterm (before 32 weeks gestational age)
- infants with potentially severe hypoglycemia, or who require therapy for hypoglycemia, and who do not improve through increased breastfeeding or by being given breastmilk.
Maternal conditions:
- HIV infection. Individualized assessment required that includes the availability of counseling and support, and that infant formula feeding will be acceptable, feasible, affordable, sustainable and safe (AFASS). Antiretroviral therapy and exclusive breastfeeding for 6 months must be supported if the mother breastfeeds.
- Temporary infant formula feeding may be necessary when
- the mother is taking medication which is contraindicated when breastfeeding, and for which there is no safe alternative. Rarely are there no safe alternatives, however cytotoxic chemotherapy is one.
- the mother abuses drugs such as heroin, cocaine, amphetamines, cannabis, alcohol etc. Seek individual counseling for mothers in these instances to assess their dependency and the needs of their infant.
Adapted from WHO/UNICEF: Baby-Friendly Hospital Initiative. Hospital level Implementation 1992.
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![]() | ![]() Protect breastfeedingWhile breastfeeding is temporarily delayed or interrupted for any reason, the mother should be given instructions to maintain her milk supply (or increase it as the case may be) by regular expression of milk.
Encourage the mother to be with her baby as much as possible. Explain to her about the importance of her breastmilk for her baby and discuss strategies for the infant's return to breastfeeding. Review the literature which you can give to the mother about expressing, storage of breastmilk and maintaining milk supply. | ![]() |
Supplements in order of preference
- The mother's own expressed breastmilk
- Donor breastmilk - from another healthy mother or human milk bank
- Infant formula. The type chosen requires careful consideration of maternal preference and family history of allergies. A pediatrician should guide the choice according to infant need.
Effect on infant health
As mentioned earlier, prelacteal feeds and supplements change the normal flora of the intestine, decreases gut mobility, increases jaundice, etc. Artificial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection. Protective properties such as lactoferrin are inactivated by artificial infant milk.11
Effect on breastfeeding
As with pre-lacteal feeds, researchers using randomized, controlled trials and prospective studies found the use of supplements during the hospital stay (and afterwards) is associated with
earlier cessation of exclusive breastfeeding and earlier weaning.
Breastfeeding is negatively affected when formula is used, even in hospitals where educational materials, counseling, support and policies are generally favorable to breastfeeding. Research was conducted in a unit where nursing staff's attitudes regarding breastfeeding were very positive with more than 80% reporting discussing the advantages of breastfeeding routinely with mothers.12 However, 77% of mothers had started bottle-feeding 2 to 3 weeks after birth, the majority (93%) remembered which brand of formula was used to supplement their baby in hospital and most were using that brand.
Parents may interpret the use of formula as an endorsement by hospital staff, despite clear verbal messages promoting breastfeeding.
Effect on the mother
The reduced breast stimulation and reduced milk removal that occurs as a result of the infant being given supplements results in
- an increased incidence of breast engorgement, and
- more severe engorgement, which can cause breast involution and the failure of adequate lactation. Early, frequent milk removal is pivotal to the success of breastfeeding in the coming weeks.
- shorter duration of lactational amenorrhoea13
Effect on infant serum glucose levels
Serum glucose levels normally drop to their lowest levels at about 2 hours of age, then rise to remain normal for up to 24 hours, irrespective of feeding.15 Giving babies glucose water or artificial infant formula only serves to interfere with this normal physiological process and is poor clinical practice.
Effect on hyperbilirubinemia
Likewise the pathophysiology of hyperbilirubinemia does NOT respond to giving water. Reduced breastfeeding frequency and supplementation with water or glucose water have been associated with increased serum bilirubin concentrations in the first 5 days of life.16 Lack of early feeding delays passage of meconium and increases enterohepatic re-absorption of bilirubin.
Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is instituted.17
Effect on atopic disease
Effect on infant digestion and absorption
Artificial infant formula is poorly digested and absorbed compared to breastmilk as
- there is a normal immaturity of digestion and absorption at birth
- breastmilk contains enzymes to aid digestion (eg lipase)
- breastmilk macronutrients are in easily digested form
- absorption of minerals is enhanced by breastmilk 'transporters'
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![]() | ![]() Let's solve this problem...Lack of understanding of normal newborn behavior and maternal fatigue appear to be the major reasons mothers give their infants supplements. Time for some brainstorming! Brainstorm with your colleagues ways of supporting a tired mother in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change her baby's behavior. | ![]() |
Human Immunodeficiency Virus (HIV)
- Exclusive breastfeeding, combined with antiretroviral therapy has a low risk of mother-to-child transfer of HIV. 20 21 22
- Mixed feeding (ie breastfeeding and giving supplements) significantly increases the risk of mother-to-child (MTC) transfer of HIV.
Exposure to cow's milk protein and other foods damages the permeable infant gut allowing transfer of the HIV virus. 23 Unless it is known, without doubt, that a mother is HIV negative then there is a likelihood the baby may suffer serious morbidity and eventual mortality from giving a breastfed infant just one supplementary bottle.
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![]() | ![]() Workbook Activity 7.6Complete Activity 7.6 in your workbook. | ![]() |
Legal implications
The effects discussed above are just a few of the many detrimental effects of infant formula on babies. The knowledge of these detrimental effects has been available in mainstream medical, nursing and midwifery literature for many years.
Consider the liability of introducing an inferior product (ie artificial infant formula) to an infant, particularly as it is known to cause breastfeeding failure and acute and chronic illness for infants. Should the parents, or affected child, take legal action it would be very difficult to defend.
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![]() | ![]() Unit Activity Review your Unit's policy on supplementation AND common practices of the staff. Ensure that there are very clear policy guidelines for when a supplement is medically indicated. Discuss with your colleagues the implications for them, the mother and the baby should they not follow this policy. Do you have an "Informed Consent" form to ensure mothers are aware of the dangers of infant formula? | ![]() |
What should I remember?
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Self-test quiz
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Notes
- # Laroia N et al. (2006) The religious and cultural bases for breastfeeding practices among the Hindus.
- # Akuse RM et al. (2002) Why healthcare workers give prelacteal feeds.
- # Lakati AS et al. (2010) The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.
- # Ingram J et al. (2003) South Asian grandmothers' influence on breast feeding in Bristol.
- # Rogers NL et al. (2011) Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in rural Northern Ethiopia.
- # Hossain MM et al. (1992) Prelacteal infant feeding practices in rural Egypt.
- # Isenalumhe AE et al. (1987) Prelacteal feeds and breast-feeding problems.
- # Pérez-Escamilla R et al. (1996) Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras.
- # Ahmed FU et al. (1996) Prelacteal feeding: influencing factors and relation to establishment of lactation.
- # World Health Organisation (2003) Global Strategy for Infant and Young Child feeding
- # Wharton BA et al. (1994) Faecal flora in the newborn. Effect of lactoferrin and related nutrients
- # Reiff MI et al. (1985) Hospital influences on early infant-feeding practices.
- # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
- # Gagnon AJ et al. (2005) In-hospital formula supplementation of healthy breastfeeding newborns
- # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
- # Gartner LM (2001) Breastfeeding and jaundice
- # de Carvalho M et al. (1981) Effects of water supplementation on physiological jaundice in breast-fed babies
- # Wegienka G et al. (2006) Breastfeeding history and childhood allergic status in a prospective birth cohort
- # MacIntyre EA et al. (2010) Early-life otitis media and incident atopic disease at school age in a birth cohort.
- # Horvath T et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV.
- # Iliff PJ et al. (2005) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival.
- # Coovadia HM et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.
- # Smith MM et al. (2000) Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?
7.4 Crying baby
My baby cries a lot. What should I do?
Babies cry to express a need, and the cry of the baby causes the parent to respond.
Breastfeeding is often the first thing that is blamed when the baby is perceived to have problems. Babies who cry frequently are at higher risk of being given foods and drinks inappropriately 1 or a pacifier/dummy and infants who are perceived as 'fussy' are more likely to be fed solid foods before 4 months. 2
Using counseling skills techniques, listen to what the mother is saying, and try to determine a cause. Observe her interaction with her baby and what settling techniques she is using. Watch the baby breastfeeding and examine the baby. If necessary, refer to a doctor for further assessment.
Build the mother's confidence
- Listen and accept the mother's feelings
- Reinforce what the mother and baby are doing right; what is normal
- Give information relevant to this mother
- Give practical help
Some suggestions that may help
- Hold her baby skin-to-skin against her chest; her warmth, smell and heartbeat will help to soothe him.
- Offer her breast to her baby: he may be hungry, thirsty or in need of suckling for a sense of security; some babies will settle quickly when offered a 'nearly-empty' breast when not hungry.
- Attend to baby's comfort: change nappy/diaper; check baby is not too warm not too cold; etc
- Talk to, sing, rock the baby while holding close. Gently swinging the baby sideways (ie from ear to ear) helps settle quicker than backwards and forwards movement.
- Stroking or baby massage with oil may help.
- Involve the mother's support people in the discussion so they understand that supplements aren't the solution to this problem.
- Suggest use of a baby sling/pouch for the mother to be able to continue other tasks or ask that someone else carry and comfort the baby for some time, giving the mother a break.
- Encourage the involvement in a mother-to-mother support group for the mother to share experiences and concerns.
- Investigate the mother's intake of caffeinated drinks and smoking - both of which are associated with crying and unsettled babies.
- Suggest a 24-48 hr diary of the infant's behaviour - this may help you determine a link to a time of day or activity and help the mother's perception of the crying.
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![]() | ![]() To Swaddle or not to swaddle?A crying baby needs comfort and reassurance - do you like to be ignored when you are upset?
Some cultures use swaddling methods and this practice has disseminated into many modern parenting styles. The adult observes that the infant becomes calm, quiet and less likely to disturb themselves with jerky movements.
Be cautious not to look for a quick fix. A 'good' baby is not a sleeping baby. Be a detective to help determine the existence of an underlying organic cause of the unsettled behaviour and reassure the mother. Some babies may benefit from gentle swaddling. Carefully explain the correct application of this technique to ensure it isn't used as a first method of settling or used inappropriately. | ![]() |
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![]() | ![]() Be alert!A crying baby causes strong emotional responses in people so be alert to the mother's state of mind and ability to cope. This may be a desperate plea for more professional help, not just settling tips. | ![]() |
Pacifiers/Dummies
Baby Friendly Step 9 and Point 4
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Step 9 of the Ten Steps to Successful Breastfeeding, and Point 4 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
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Sucking and breastfeeding
- The suckling technique used during breastfeeding is completely different to the action of sucking used on a bottle teat or non-nutritive sucking on a pacifier/dummy.
Babies are thought to 'imprint' latching and suckling skills from their earliest experiences.5 When artificial teats/dummies are their predominant feeding experience, learning to latch and use a correct sucking technique is difficult. - Pacifiers/dummies stifle early feeding cues and are often used to delay breastfeeding and reduce the time spent at the breast. This will have a significant impact on the control of milk synthesis and potential to decrease milk supply.
Studies of full term newborns and preterm infants demonstrate reduced duration of exclusive breastfeeding when pacifiers are used extensively and/or more than a few supplements are given using bottles.6,7 - Teats and pacifiers are reservoirs for infection which adheres easily to the surface.8,9
- Pacifiers are associated with an increase in otitis media and dental malocclusion.
- Some studies recommend the use of pacifiers for the prevention of sudden infant death syndrome (SIDS).10 The explanation offered, that an infant sucking on a pacifier during the night has more spontaneous arousals, has been shown not to occur.11 However, breastfeeding and co-sleeping have been shown to reduce the risk of SIDS, and pacifier use reduces the incidence of breastfeeding.
Should a mother wish to use a pacifier it's use should be guided by ...
- do not commence use until breastfeeding well established, eg 4 - 6 weeks or longer
- only use it at the time the infant is put down to sleep - if rejected by infant do not force
- when the pacifier falls out during the infant's sleep it is not to be reinserted.
When crying is excessive
The most common causes of excessive crying are
- immaturity in the first 7-8 weeks of life
- lactose malabsorption,
- colic, and
- gastroesophageal reflux disease
Lactose malabsorption/overload
Presentation
Onset is usually in the first few weeks of life, but could present later if mother changes her feeding style.
- Baby
- usually thriving baby, putting on weight very well
- frequently distressed and has inconsolable crying
- short sleeps followed by waking in pain
- frequently sucking fist for comfort
- draws knees up to chest while crying
- flatulence ++
- many nappies/diapers per day soaked with clear urine
- frequent, watery, copious, green-ish and/or frothy stools
- Mother
- has a copious breastmilk supply and a large breastmilk storage capacity
- offers baby both breasts at most breastfeeds, taking baby off first breast after a measured amount of time, rather than when it feels 'drained'
- may feel the baby's 'fist sucking' indicates hunger and breastfeeds baby again; usually from breast not (or least) suckled at the previous feed
- may feel she has an inadequate supply because of his frequent feeding and crying
- may be concerned baby has a gastrointestinal infection because of the unusual stool appearance
Management
- Reassure mother of the volume and suitability of her breastmilk for her baby.
- Discuss with her the signs that indicate the infant is in good health.
- Encourage breastfeeding from only one breast over a period of time, determined individually. eg. One mother may repeatedly breastfeed from only her left breast for a 2-4 hours time period. Every time baby indicates a need to suckle during that time he will be put to the left breast and receive breastmilk that has an increasing fat content as that breast is progressively drained. This will slow the gastric emptying, and usually the infant will take less breastmilk when the breast is less full; both factors resulting in less lactose being transferred rapidly into the small intestine. For the next 2-4 hour block of time, the infant may only feed from the right breast, and so on until the problem is resolved. Mothers will be able to determine by trial and error the most appropriate time period for each breast.
- Frequency of breastfeeding is not restricted. All feeding cues during the set time period are responded to with the same breast.
- Care of the breast not being suckled may involve gentle expressing or releasing enough milk for comfort and applying ice packs to prevent engorgement. This can be done while the infant is feeding on the other breast.
- Resolution of the infant's symptoms is usually rapid - within 48 hours, although it could take up to a week.
- A return to two-sided breastfeeding may be indicated in time as milk volume settles and gut maturity improves, either for most feeds or perhaps only evening feeds.
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![]() | ![]() Workbook Activity 7.7Complete Activity 7.7 in your workbook. | ![]() |
Colic
One study12 noted that infants who have colic cry excessively without an identifiable need. They are difficult to console and provoke much parental anxiety. Sleep is interrupted for both infant and caregiver, and mothers experience increased risks of breastfeeding failure, postpartum depression, and marital conflict. When infants cry excessively, they are at a much greater risk of child abuse. Parents become desperate for resolution and accept advice and therapies from a wide variety of resources. The authors estimate that between 16% and 26% of all infants experience colic.
Reviews of the research13,14 examining pharmaceutical, naturopathic and behavioral techniques for their effectiveness in reducing colic are only able to recommend a low-allergen maternal diet as having any effect on the breastfed baby. Only one pharmaceutical agent (dicyclomine) was found to be any more effective than a placebo, and due to serious side effects it is no longer recommended.
A tea containing camomile and other herbs had a degree of effectiveness, however the volume required to be given to the infant to obtain this effect was excessive and therefore not recommended.
A pilot study15 found a significant decrease in crying and increase in sleeping in colicky infants receiving cranial osteopathic manipulation. Larger studies are required to confirm the effectiveness of this intervention.
Eglash13 considers pure colic to be a patterned daily behavior of crying that a parent can predict will occur and stop at certain times, and the baby is fine at other times of day. This health care provider does not expect a change in maternal diet to help, the condition being self-limiting by about age 3 months.
Management
- Refer for medical review to exclude pathology
- Low-allergen diet for the mother may result in some improvement
- Infant and parent support measures
Gastroesophageal Reflux
Gastroesophageal reflux occurs when stomach contents reflux into the esophagus/oesophagus and out the mouth, resulting in regurgitation, or spitting up, and vomiting. This condition is very common and is caused by the sphincter at the top of the infant's stomach having not yet become efficient at retaining the stomach contents. Most babies with this condition are happy and continue to thrive, outgrowing the worst of it around 6 months of age.
Gastroesophageal Reflux Disease
Gastroesophageal Reflux Disease (GERD, GORD) occurs when the constant refluxing of stomach contents causes burning and ulceration of the esophagus and sometimes aspirates into the lungs. This medical condition will be diagnosed and treated by the infant's doctor.
Breastfeeding Management
- Breastfeed the infant in an upright position, at least 30o elevation of the head above the stomach.
- Some babies will want to breastfeed very frequently, as the breastmilk eases the pain by neutralizing stomach acid.
- Cow milk protein allergy is frequently associated with GERD. A trial of maternal low-allergen diet is recommended.16
What should I remember?
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Self test quiz
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Notes
- # Karacam Z (2007) Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women
- # Wasser H et al. (2011) Infants perceived as fussy are more likely to receive complementary foods before 4 months.
- # Thach BT (2009) Does swaddling decrease or increase the risk for sudden infant death syndrome?
- # Richardson HL et al. (2010) Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants.
- # Woolridge MW (1986) The 'anatomy' of infant sucking.
- # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
- # Collins CT et al. (2004) Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial
- # Comina E et al. (2006) Pacifiers: a microbial reservoir
- # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
- # Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
- # Hanzer M et al. (2009) Pacifier use does not alter the frequency or duration of spontaneous arousals in sleeping infants.
- # Fireman L et al. (2006) Colic
- # Crotteau CA et al. (2006) Clinical inquiries. What is the best treatment for infants with colic?
- # Garrison MM et al. (2000) A Systematic Review of Treatments for Infant Colic
- # Hayden C et al. (2006) A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic
- # Heine RG (2006) Gastroesophageal reflux disease, colic and constipation in infants with food allergy
7.5 Inadequate weight gain
Inadequate weight gain, or failure to thrive (FTT) is a sign of poor health that is caused by other factors. It's not a condition in its own right.
Definition of failure to thrive (FTT)
In the younger baby weight loss of >7 - 10% of birthweight, or failure to regain birthweight by the second week is considered abnormal.
In the older baby it may be defined in several ways
- an infant whose weight or height for age is less than the 3rd or 5th percentile
- an infant whose weight for age falls through 2 major percentile curves on their growth chart
- weight less than 80% of ideal body weight for age
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![]() | ![]() Review the WHO Child Growth Standards as covered in Topic 6.3 . It is important to have a good understanding of normal growth and to be competent to recognise sub-optimal growth patterns.
All infant measurements should be plotted on these charts only. | ![]() |
Cause of failure to thrive
- poor absorption and/or the inability to use absorbed nutrients, or
- increased metabolic demands, (eg heart disease, undiagnosed infection, etc) or
-
inadequate energy intake from
- an insufficient supply of breastmilk, or
- regulation of breastfeeding such that the baby is unable to take sufficient breastmilk, or
- inability of the baby to suckle effectively at the breast.
What to do when you suspect FTT
Record a thorough history
Your routine history intake form should allow you to identify issues that may be significant, eg. gestational age at birth, weight at birth, weight at hospital discharge, interventions in birthing, early postnatal breastfeeding history, jaundice, ill health since birth, maternal medical, surgical, obstetric and lactation history, etc. [Discuss in the forums or with your colleagues why each of these could be significant.]
- If the mother has been concerned about her baby's growth, ask her what actions she has taken to date; eg. doctor review, pumping additional breastmilk, using breast compression, taking a galactagogue, giving supplements, etc.
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Ask the mother to describe typical breastfeeding behavior.
If necessary prompt the mother to include:
- type of feeding cues and her response to them,
- describe when the baby feeds, not just how many times per day or night,
- baby's behavior before, during and after breastfeeds,
- the mother's active involvement, eg. waking baby to feed, delaying feeding to fit a schedule or her busy lifestyle, stimulating baby to continue to breastfeed, stopping baby after a time-limit, etc.
- Ask the mother about complementary foods, or other fluids given to baby, or the use of a pacifier - How much? How often? Why? ...
- Ask her to describe her baby's urine and stool output in a typical day. It would be an advantage if you could see a wet and a dirty diaper/nappy.
- Ask her to describe her baby's temperament. If crying behavior sounds excessive, ask for a more detailed description of frequency and type.
- Ask her about her baby's recent state of health.
- Does she give the baby any medications (prescription or non-prescription), vitamins, 'tonics', etc?
- If you don't already have it, plot as many weight and length measurements onto the WHO Growth Chart as the mother is able to provide you with. From this you will be able to determine a trend.
- Ask about her recent state of health, medications (prescription and non-prescription) and postpartum recovery, particularly her lochia. [Why ask about lochia?]
- Ask her about the growth patterns of her other children, if applicable. If they followed a similar growth pattern did she do anything to try to influence it? Was it successful?
- Social issues could be significant: if appropriate, ask about the family structure, their living conditions, stressors, other children. Observe the interaction between mother and baby during your consultation - also other relationships if someone else has accompanied the mother.
Examination of the baby
Observe the baby naked.
Ask the mother to lie the infant down and undress him/her (reducing chance of distress caused by unfamiliarity). Observation should include the infant lying flat on his back (if tolerated), turned gently from one side to the other, and laid prone with head turned to face both sides.
- Behavioral state, and transition between states. Reaction to being undressed, laid down flat, picked up and cuddled/soothed by mother.
- Muscle tone and position that the infant assumes (well flexed, partially flexed, extended, hyperextended, head turned one particular direction exclusively)
- Shape of the infant's head particularly noting presence of forceps or vacuum marks (first few weeks), cephalhaematoma, asymmetry.
- Skin: turgor, subcutaneous fat, rashes, integrity, bruises; color - jaundice (extent); pale; mottled; cyanosis - where, what precipitated it
- Mucous membranes: color, moisture, inflammation, integrity, infection
- Respiratory effort, presence of sweating; response to exertion
- Does the infant feel hot (febrile), or unusually cool to touch?
- If you have received instruction on how to assess for intact cranial nerves, note your findings. Note facial movement and symmetry.
- Weigh the infant. (Review the information in Topic 6.3 ) - Length and head circumference could also be recorded if you have an accurate means of doing so.
- Response to stimulation of rooting reflex
- Visual examination - size, shape of tongue; uvula (bifid or not); intact palate, labial and lingual frenulum, condition of mucous membranes (moist/dry; candida; etc)
- Suck assessment - (only perform after instruction and supervision by experienced practitioner) feeling for intact palate (hard and soft), notches on palate, shape of palate, grooving of tongue, tongue action during sucking (or preventing sucking)
- Note position adopted by mother and how she holds her baby
- Note sucking pattern and ability - Note: Sucking will be sub-optimal and with notable non-nutritive sucking. Observing the feeding process will help determine whether poor sucking caused the failure to thrive or whether the failure to thrive is the end result of another cause. Milk supply is usually compromised too due to the poor feeding, so this needs to be assessed and addressed.
As the mother prepares to breastfeed ask permission to examine her breasts, looking for marked differences in size, hypoplasia, state of health of the breasts and nipples and surgical scars.
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![]() | ![]() Modelling observational skillsBy following the flow of the consultation above, (until you assessed the cranial nerves or performed the oral assessment) you were modelling to the parents good general observational skills. | ![]() |
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![]() | ![]() RED FLAGIf the infant appears ill (pale, lethargic, sunken fontanelle, poor skin turgor, minimal urine output, hot or cool to touch) organise for the infant to be seen by a doctor urgently or for immediate transfer to hospital. | ![]() |
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![]() | ![]() Workbook Activity 7.8Complete Activity 7.8 in your workbook. | ![]() |
Test weighing
Some practitioners find test weighing a baby to determine the volume of breastmilk received at a single breastfeed to be beneficial, while other practitioners do not.
This procedure must be used sensitively and its limitations explained to the mother:
- From one test weigh it is not possible to conclude how much milk the baby is consuming in a 24-hour period,
- nor how much milk is available for the baby in the breast either at this feed or for the 24-hour period.
Accuracy is dependent on attention to weighing technique.
What do you see?

© B.Ingle, IBCLC
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Management
Management of failure to thrive in a breastfed baby requires a multidisciplinary team approach. The ultimate goal is to have baby exclusively breastfeeding and gaining weight normally.
Parent education and counseling
While the management below is focussed on clinical issues, your communication skill and care and understanding for the parents is as important an aspect of the consultation as getting nutrients into the baby. You must build trust and understanding between you and the parents.
Step 1
The first action you will take is to discuss with the mother the importance of having her baby reviewed by the baby's doctor. This is important, even if you think it is a feeding problem that you can resolve that has caused the problem. The infant has been compromised and needs a medical review.
Step 2
Next, feed the baby! The normal range of daily intake of breastmilk by healthy infants aged from 1 month to 6 months is 500ml - 1350ml (17oz - 44oz), with the average being 780ml (26oz) irrespective of the infant's weight or age. This volume is consumed over 11 feeds a day (range 6-18). Infants generally consume significantly more breastmilk during the morning and nighttime breastfeeds than during the day and evening breastfeeds.1
The baby will need supplementation. Determining how much milk to supplement will depend firstly on the infant's condition, and secondly on how much is required to produce a normal urine and stool output and consistent weight gain.
The infant's stomach will be unaccustomed to large volumes of milk. Introducing frequent small volumes of supplement will prevent overdistention and possible vomiting. Bear in mind the very wide range of normal - being pedantic about a set volume to be consumed at a predetermined number of feeds without considering what is normal is not helpful to the mother or baby. Individualize your care!
Be very careful that you don't jeopardise breastfeeding completely with a management plan that doesn't take normal breastfeeding physiology into consideration.
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![]() | ![]() A quick calculationLet's look at that from a practical viewpoint.
Total daily intake = approx 800ml 8 feeds/24 hrs = 100ml/feed 11 feeds/24 hrs = 70ml/feed 12 feeds/24 hrs = 65ml/feed The volume of supplement will be a portion of these total feed amounts. Some babies wake frequently because they are hungry. Other babies have no energy reserves so they are very difficult to rouse and will feed poorly when woken. The supplement is to enhance the infant's current intake, not to act as a total replacement feed. | ![]() |
What supplement shall I use?
The aim is for the infant to have as much of his mother's breastmilk as is available, while ensuring the infant receives sufficient nutrition to correct the deficit and permit normal growth. Sometimes the mother's milk supply is still adequate to meet her baby's needs - correcting poor positioning may be all that is required.
In order of preference: 2
- mother's own expressed breastmilk
- donor breastmilk from a trusted, infection-free source, eg a milk bank
If neither of those are available: - artificial infant formula. Discuss with the mother whether a regular or a hypoallergenic formulation is required.
- ONLY if baby is >6 months - commence complementary foods, replacing nutrient-poor foods with nutrient-dense, high calorie foods if necessary.
How will the supplement be given to the infant?
Different circumstances dictate different methods of supplementation. (Click on supplement feeding method below for additional information and technique)
- A tube-feeding device at the breast is the method of choice when the infant is willing and able to suck at the breast - he has good underlying sucking ability but the suck may be weak and/or the mother has insufficient milk supply.
- Cup-feeding is the preferred choice for an alert baby who cannot suckle for any reason (absence of mother, suck abnormality, etc)
- Finger-feeding is a useful technique to help teach an infant to suck. When small quantities are to be given (ie colostrum) using this technique with just a syringe containing the milk is convenient.
- Bottle feeding is the least preferred method, but may be the method of choice of the parents. Bottle feeding should not be used for infants while still in the hospital setting.
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![]() | ![]() Workbook Activity 7.9Complete Activity 7.9 in your workbook. | ![]() |
When to supplement
With the information you have gained during your history-taking and clinical examination you should be able to decide whether the baby needs supplementing after all breastfeeds, or only from the afternoon, or even just the evening feeds as most mothers have fuller breasts in the morning.
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![]() | ![]() Individualise your careNo two babies will be in the same situation therefore every strategy you and the parents devise will be unique. Don't look for a 'solution' you can apply in every situation. | ![]() |
Step 3
You must also determine and treat the cause, if possible. Is the cause maternal or infant in origin?
- Protect the milk supply - insufficient breastmilk supply is addressed in Topic 8.4
- Inability of the infant to suckle effectively at the breast could be caused by poor positioning and poor latching, or by ineffective suckling. Positioning and latch is well within your area of expertise, however you may need to refer the infant with poor suckling ability to a lactation consultant, pediatric speech therapist or other appropriate specialist.
- Restrictive scheduling of breastfeeding, excessive non-nutritive sucking (pacifier or dummy use), denial of night-feeding, etc is addressed by education and discussion of normal behavior with the parents. Encourage the mother to join mother-to-mother support groups.
- The management of the infant with poor absorption of nutrients or increased metabolic demands will be managed by a medical specialist.
Step 4
Follow-up. It is absolutely essential that the parents are competent, and feel confident, to observe their infant, recognise a problem early and seek assistance at any time.
To this end you will discuss with them ...
- Observation of infant's output. Baby must have at least 5 thoroughly wet with clear urine nappies (diapers) per day; stooling should be regular and copious. Keeping a feeding and output diary will provide them and you with accurate information on which to base changes to the management plan.
- Observation of infant's appearance. Baby should be bright-eyed and alert, and skin should not be pale.
- Observation of infant's behavior. Baby should be active, alert and happy for some time each day, waking for feeds and feeding enthusiastically.
How soon and frequently you follow-up will depend on the baby's condition. Daily phone follow-up could be indicated to get reports on feeding and output, with a weight check again in two or three days if output was satisfactory until then. Revise the plan as necessary with the ultimate goal to have the baby fully breastfed and thriving.
What should I remember?
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Self-test quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 7 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 7.
7.5.1 Feeding-line device at the breast
There are various types of feeding-line devices commercially available; they can also be improvised. The supplemental milk is contained in a soft pouch or bottle, and a length of fine, soft tubing reaches from the milk receptacle to the breast at the nipple/areolar complex.
As the baby suckles at the breast, milk is removed from both the breast and the feeding-line device. This is an excellent method of providing supplemental milk. It avoids any possibility of suck confusion, stimulates the mother's breastmilk production, enhances the infant's suck vigor by creating a steady milk flow and lessens the likelihood of breast refusal when supplementation becomes necessary.
Unlike any other form of supplemental feeding method, the at-breast supplementer will never compromise the mother's milk supply and in most circumstances, it will enhace milk supply or stimulate supply to achieve the highest possible production in the individual mother.
When to choose an at-breast feed line
- newborn requiring supplementation for medical reasons
- mothers with a chronic low supply (ie. due to infant poor feeding or conditions such as hypoplasia)
- failing to thrive infants who are still willing to breastfeed
- infants with low tone (primary hypotonia or secondary due to underfeeding)
- some cases of breast refusal in the older infant who is frustrated with a slow milk flow
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![]() | ![]() Clinical tipInsufficient milk flow will very quickly cause the infant to lapse into non-nutritive sucking or display breast refusal behaviour.
Newborns imprint that the breast is the place which provides all their needs. An at-breast feed line can rescue a breastfeeding relationship which is threatened by poor infant-breast association. Consider a feed line as a first choice rather than a last resort. Become proficient with it's use so that you can confidently assist mothers. Does your unit use any feed lines? Practice with a 'home-made' version using a syringe and naso-gastric feedling tube and organise to purchase a demonstartion kit which mothers would use at home for longer term supplementing. | ![]() |
Equipment
- the feeding line device, ready-to-use
- hypoallergenic tape
Preparation
- Warm the milk to be used as a supplement.
- Prime the tubing with the supplement milk, either by gravity or by vacuum (suction).
- Tape the distal end of the tubing to lie alongside the mother's nipple, with tape away from where baby will latch. The tubing is best placed on the breast to be just above the corner of the infant's mouth, not in the middle of the top lip.
Technique
- Latch the baby as usual, ensuring the soft tubing passes into baby's mouth as he latches to the breast. (Instruct the mother to visualise that the tubing will be running alongside the length of the nipple so it sits in the groove of the tongue during sucking.
- Breastfeed as usual.
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Milk flow can be controlled by
- raising the milk container; the flow of the supplement is easier to initiate and requires less suction to maintain flow,
- lowering the milk container; the flow will be slower, requiring greater suction from the baby, or
- clamping the tubing off initially, encouraging baby to remove as much breastmilk from the breast as possible before unclamping the supplement.

At-breast supplemental feeding line.
© B.Ingle IBCLC
7.5.2 Cup feeding
When to choose cup feeding
Equipment
- A small cup with a smooth edge
- a plastic cup can be shaped slightly during feeding
- a small glass, eg. a sherry glass, is also quite suitable
- cups for the purpose of cup-feeding babies are available commercially
Preparation
- Two thirds fill cup with slightly warmed breastmilk or artificial infant formula
- Baby must be alert and showing an interest in feeding
- Wrap baby well to prevent cup being knocked by his hands
- Sit baby comfortably upright on your lap
Technique
- Rest the rim of cup on baby's bottom gum
- Tip the cup until milk just reaches rim of cup
- DO NOT pour milk into baby's mouth
- Leave cup in position when baby pauses and is not drinking
- Continue to tip cup to keep milk at rim of cup
Baby will quickly learn to sip or lap milk from the cup.

Infant supported for cup feeding.
© B.Ingle IBCLC
Notes
- # Marinelli KA et al. (2001) A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed
7.5.3 Finger Feeding
Finger feeding may be used by the health professional and parents can very ably continue at home. It is seen as an alternative to cup feeding1 and a hospital study in Australia used finger feeding to substitute bottlefeeding in preterm infants who displayed faulty sucking techniques and found that it increased breastfeeding rates at discharge by 30% to 71%.2
When to consider finger feeding
- the infant is unable to grasp the breast - affected by maternal medications during birth, trauma impairing cranial nerve function, tongue-tie, low tone conditions
- the infant is refusing the breast
- mother has severely damaged nipples requiring rest during healing process - this is helpful to the mother and may also serve as a suck therapy for the infant during this time
- as a 'pre-breastfeed' enticer for infants suffering from confusion or dysfunctional suck problems.
The feeder is able to feel the tongue action and respond with milk flow accordingly or stimulate the palate or tongue as required. The infant should be able to efficiently coordinate breathing and sucking if using this method.
Preparation
Infant supported on a pillow or on the lap of the feeder person.
Equipment
- Syringe - regular or periodontal curved-tip OR soft feeding bag and feed line
- Breastmilk or substitute at room temperature
- Pillow or towel roll
- Gloves (for all except infant's own parents)
Finger feeding technique
Be consistent in the technique used for finger placement, and utilize the same positioning principles as used when feeding at the breast:
- Infant well supported down the back
- Infant's body in alignment with his head; neck slightly extended
The feeder washes hands - Note: health professionals to use a gloved finger:
- The feeder uses their finger with nail-side down and soft pad of finger to the palate.
- The feeder's finger begins curled and uses the knuckle to stimulate the top lip and encourage tongue extension and gap.
- Uncurl the finger under the top lip and introduce it along the palate.
- Keep finger directly down midline during feeding.
- Once sucking has commenced, insert syringe in corner of infant's mouth against the feeder's finger. Push very small aliquots of milk (approx 0.5ml) into infant's mouth to stimulate continued sucking.
- Follow infant's lead with sucking bursts - only push milk in when infant is sucking, or stimulate suck recommencement by massaging the palate.
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![]() | ![]() Important tip!The infant oral cavity is very sensitive. Fingers come in all different shapes and sizes so to avoid confusion and desensitization of the infant, limit the number of different people who perform this procedure. Parents are very capable of taking on this task and teaching them will give them confidence.
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![]() | ![]() Finger feeding instruction sheetClick on this
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Teach finger feeding
7.5.4 Bottle feeding
The physical act of bottle feeding is very different to the normal action which occurs during breastfeeding. Artificial nipples/teats are less elastic than a mother's breast. The infant's tongue works in an up-and-down piston motion during bottlefeeding1 and overuses the buccinator and orbicularis muscles.2,3 Bottle feeding creates repeated airway closure during swallowing. Rapid milk flow results in more frequent swallowing and less opportunities for breathing.4
When to use bottle feeding
- is unable to breastfeed for medical reasons or her infant's medical condition precludes breastfeeding ability.
- chooses to use a bottle for supplementation - with adequate education about impact on breastfeeding and health risks associated with bottle use.
- weans her infant when milk is still a major part of the diet.
Considerations when bottlefeeding a breastfed infant
- Use a straight bottle rather than a bent bottle.
- Choosing a teat/artificial nipple:
- Use a long teat/artificial nipple, with a rounded end and a medium-wide base. 5
- Use a slow-flow artificial nipple/teat. This requires the baby to suck well to obtain the milk. A full feed, bottle-fed, should take about 15 - 20 minutes. Babies with low tone who take longer than this to be fed may require a medium-flow artificial nipple.
- Choose a soft artificial nipple/teat if possible.
- Rationale :
- When the artificial nipple is taken into the baby's mouth the tip of the artificial nipple is well back in the mouth, close to the junction of the hard and soft palate. The baby is reminded that something is always supposed to be towards the back of his mouth as he feeds, as occurs during breastfeeding.
- The medium-wide base, up to the screw cap, causes the baby to have a wide mouth when he makes a seal around the base of the artificial nipple, similarly to how he holds his mouth for breastfeeding.
- Don't use artificial nipples that have a short, narrow shaft and a very wide base. They force the baby to make a tight mouth around the narrow shaft. This short shaft is forward in the baby's mouth changing the tongue position and action.
Bottle feeding technique
- Position the baby so that he is sitting upright. Support the baby's back, neck and base of head with the forearm and hand. Hold the bottle horizontally removing the pressure from gravity. Without gravity helping to pour milk into the baby's mouth, baby will have better control of the volume taken at each mouthful and will suck a little harder. Kassing (2002) 6 cautions against the mother and/or caregiver using an arm or the crook of an elbow to support the baby's neck, because there is a greater tendency for the baby to lean back a bit rather than remaining upright.
- Using the tip of the artificial nipple brush the baby's lips gently, stimulating the rooting reflex. When baby opens his mouth very wide slide the tip of the teat under the top lip, wait for the baby to grasp and draw the entire artificial nipple into his mouth right up to the cap. By stimulating the rooting reflex and waiting for a wide gape, you are simulating what will occur when breastfeeding.
- Keeping baby upright, tilt the bottle just enough to keep the artificial nipple filled with milk. As the bottle empties take care not to hyper-extend the baby's neck.
- Closely observe baby for full duration of the feeding. Slow the feed, or pause it if the baby is showing early signs of distress. These signs can be very subtle: frowning, wide-eyed, fist clenching, etc. Baby should not get to the stage where he is gulping, or not pausing to take a breath, or becoming cyanosed.
Assess a bottle feed

© B.Ash, IBCLC

© B.Ash, IBCLC
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Good bottle feeding practices are essential
Positive nurturing and infant feeding are closely aligned. Encourage the bottle feeding mother to make the feeding experience an enjoyable one for her infant by responding to feeding cues promptly, holding her infant during feeding, using an appropriate nipple/teat for milk flow and not forcing the infant to consume more than he wants. Discuss observations the mother can make that indicate:
- early feeding cues,
- infant pleasure (or stress) during the feed,
- adequate intake such as
- signs of satiety
- normal bowel actions,
- expected urine output, and
- appropriate weight gain (neither excessive, nor inadequate).
- signs of satiety
Preventable dangers
In a 2008 study 7 more than 3/4 of mothers reported they did not receive instruction on artificial formula preparation from a health professional. Consequently many mothers did not follow safe practices when preparing their infant's formula feeds.
- Dangers of incorrect preparation
- gastrointestinal infection, serious illness and death from:
- contamination from unhygienic practices contaminating feeding implements
- contamination from bacteria found in the powdered formula when purchased (eg enterobacter sakazakii)
- contaminated water supply.
- gastrointestinal infection, serious illness and death from:
- Incorrect reconstitution - a commonly found error:
- over-dilution causes poor weight gain and inadequate intake of calories and nutrients
- under-dilution causes hypernatremic dehydration, diarrhea and excessive intake of calories.
- Over-feeding and under-feeding by caregivers must also be addressed.
Volume of intake guidelines are available from various sources, however parents should be encouraged to use these as only a guide. Encourage feeding to be initiated when the infant cues and ended by the infant when satiety is indicated. A responsive caregiver is able to observe the infant's behavior so that the infant remains comfortable. The focus is on reading the infant's needs rather than consuming a predetermined volume of milk.- Over-feeding causes 'food battles' and obesity,
- under-feeding causes poor growth and development
- both under- and over-feeding cause failure to thrive and malnutrition
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![]() | ![]() Preparing breastmilk substitutes safelyClick on the title above. This links to a leaflet produced by the Department of Health in the UK for mothers that describes, with very good graphics, how to safely prepare breastmilk substitutes. Read this leaflet, print it out and file it in your Workbook.
Go through this leaflet, or a similar one that your hospital or clinic may use, as you demonstrate to a mother how to prepare the formula. Then, most importantly, ask her to show you how she would do it by making up another bottle of formula, confirming that she understands each step of the process. | ![]() |
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Notes
- # Weber F et al. (1986) An ultrasonographic study of the organisation of sucking and swallowing by newborn infants.
- # Inoue N et al. (1995) Reduction of masseter muscle activity in bottle-fed babies.
- # Gomes CF et al. (2006) Surface electromyography of facial muscles during natural and artificial feeding of infants
- # Mathew OP (1991) Breathing patterns of preterm infants during bottle feeding: role of milk flow.
- # Noble R et al. (1997) Therapeutic teat use for babies who breastfeed poorly
- # Kassing D (2002) Bottle-Feeding as a Tool to Reinforce Breastfeeding
- # Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.
8.0 Maternal Challenges
A knowledge of the conditions or events which are linked with decreased initiation or duration of breastfeeding will help you to focus your breastfeeding assistance and education activities to those in most need.
Maternal Risk Factors
- acute or chronic disease
- maternal obesity
- hypertension during pregnancy
- intrapartum analgesics or anaesthetics
- assisted or surgical delivery of baby
- breast or nipple abnormality
- history of breast surgery or trauma
- previous breastfeeding difficulty
- persistent breast pain
- severe engorgement
- cracked/bleeding nipples
Mothers with persistent breast pain, acute or chronic disease and previous breast surgery will require ongoing management and should receive an early referral to a lactation consultant who can continue care in the community.
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8.1 Engorgement
Breast fullness
Secretory activation (lactogenesis II) occurs biochemically at about 30 - 40 hours postpartum.1 The clinical onset is heralded by the maternal experience of 'the milk coming-in' and the breasts making a copious volume of milk. Across studies the average timing of this is reported to be 50 to 73 hours postpartum, with wide individual variation (1hr to 148 hrs).2
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![]() | Why does this happen?Several hormonal and biochemical changes occur which contribute to copious milk production: 3
Review this in Topic 4.0 | ![]() |
Signs and Symptoms
Women report knowing their milk is 'in' by the following cues:
- breast fullness
- milk leakage
- physical appearance of the milk
- breast tingling
- change in infant cues.
Engorgement
...the swelling and distension of the breast, usually in the early days of initiation of lactation, caused by vascular dilatation as well as the arrival of the early milk.5,
Breast engorgement is not an inevitable part of early lactation.
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![]() | Why does this happen?Hormonal and biochemical changes combine to create a 'traffic jam' in the breast.
There is a combination of
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If normal breast fullness progresses to engorgement the signs and symptoms include:
- swollen breasts; tight, shiny skin
- generalized redness of both breasts
- mild to severe pain
- increased heat of both breasts
- difficulty latching baby effectively and achieving milk removal
- mild pyrexia (fever)
Prevention

Engorgement.
© S.Cox, IBCLC
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![]() | ![]() Don't be fooledBreast fullness is normal. Engorgement is a warning sign. Engorged, large breasts are not a sign of a good milk supply. It indicates that breastfeeding practices are suboptimal and proactive management is required to retrieve normality. Breast engorgement is preventable in most cases. | ![]() |
Milk engorgement can occur at any point in the progression of breastfeeding. The cause is milk stasis from oversupply, inadequate drainage and long gaps between feeds rather than reasons of interstitial odema, and increased venous congestion.
Unresolved or repeated episodes of engorgement risks blocked ducts, mastitis and low supply.
Severe engorgement (initial or with established lactation) begins the process of involution of the breast due to poor milk drainage. The mother will progress from painful engorgement with perceived adequate/excessive amounts of milk, to an inadequate supply. Poor milk supply and nipple damage have been identified by mothers as reasons for premature weaning of their babies.14
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![]() Workbook Activity 8.1Complete Activity 8.1 in your workbook. |
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Clinical Management
Frequent, effective removal of milk from the breast until it is comfortable is the mainstay of management.
- Encourage the mother to breastfeed her baby often. If baby feeding well, but breasts still uncomfortably tight, expressing enough to maintain comfort is essential. This can be done after and between feeds as often as is necessary.
- Ensure baby is latched on to breast well. If breasts are very firm but there is no areolar edema, hand expressing for a few minutes to soften the nipple/areola area may be required. Re-latching the baby after suckling for several minutes will result in an even deeper latch.
- Allow the baby to feed as long as he will on one side to optimize drainage. Firm, but gentle massage of lumpy areas while baby feeds helps drainage. Allow the other breast to drip freely. If baby doesn't want the second side, express enough milk to make that breast comfortable. Repeat this process each feed.
- When breasts are particularly full it can be effective to stimulate a milk ejection by soft massage or short-time application of a warm compress. Then apply gentle compression anywhere on the breast with the palm of the hand - this gentle pressure may help the milk flow freely from the nipple without having to hand express or use a pump which may be too uncomfortable.
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![]() | ![]() Will expressing increase milk supply?The emphasis is on frequent removal of milk to prevent milk stasis.
Milk volume is increasing daily until peak milk volume between 2-3 weeks post-partum. Extra expressing and breastfeeding will promote better breast drainage but it will not increase milk volume further. Reassure the mother that this management will assist faster resolution of her engorgement. Failure to diligently attend to these strategies will prolong the discomfort, initiate involution and risk a resultant low supply. | ![]() |
- Reduce tissue swelling
- A Cochrane Review of management of breast engorgement 15 examined trials of breast engorgement treatments:
- There is no difference between treatment with cold packs or cabbage leaves. Both were equally effective in relieving pain but there was no strong evidence that interventions resolved symptoms faster than with no treatment.
- Acupuncture gave greater improvement in symptoms in the days immediately after the treatment.
- The underlying principle is the use of cold to initiate vasoconstriction to decrease venous congestion and help reduce interstitial oedema.
- Depending on degree of engorgement, the cold compresses may need to be replaced frequently (e.g. 20 mins on, 20 mins off and repeat several times)
- Apply cold compresses to both breasts immediately after breastfeeding.
- Certain non-steroidal anti-inflammatory drugs are very effective. 15
- A Cochrane Review of management of breast engorgement 15 examined trials of breast engorgement treatments:
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![]() | ![]() Heat or cold?Heat increases blood flow to the breast and movement of fluid into the tissues to further exacerbate the engorgement.17 Avoid standing under a hot shower or soaking the breasts in warm water during this period of engorgement.
Mothers usually prefer the feeling of cold on their hot breasts, but it is important to individualise your management and be responsive if a mother finds this to be unpleasant. | ![]() |
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![]() Workbook Activity 8.2Complete Activity 8.2 in your workbook. |
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![]() Unit ActivityRevise your unit's policy on the management of engorgement. Develop a teaching plan for a 15-minute educational session you could lead on the prevention and management of engorgement for your colleagues. |
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Areolar oedema/edema
When areolar edema is present latching the baby onto the breast for effective breastfeeding is impossible. Methods have been described to assist the movement of this interstitial fluid to make latching possible. 10,8
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![]() | ![]() Read this excellent practical article[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]Click on the icon on the left to be taken to a description of Reverse Pressure Softening for the treatment of areolar edema. Print the paper for filing in your Workbook. Share this paper with your colleagues who may be working with women experiencing this type of engorgement. Ask the mothers about their feelings of the usefulness of this technique. When you are proficient at it you will be able to describe its application over the phone to mothers in difficulty at home. | ![]() |
Additional strategies include
- lie mother on her back and massage the breast away from the nipple, towards the axilla; aiding lymphatic drainage
- baby has to be ready to feed immediately after massage because the fluid will return very quickly
- hand express if baby not available to suckle. DO NOT use a breast pump ... this increases the edema.
What should I remember?
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Self-test quiz
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Notes
- # Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships
- # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
- # Pang WW et al. (2007) Initiation of human lactation: secretory differentiation and secretory activation.
- # Neville MC et al. (1991) Studies in human lactation: Milk volume and nutrient composition during weaning and lactogenesis
- # Lawrence R (2010) A Breastfeeding guide for the Medical Profession
- # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
- # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
- # Miller V et al. (2004) Treating Postpartum Breast Edema With Areolar Compression
- # Hunter D (2004) Oedema and its impact on breastfeeding outcome: Assessment and management of the mother and her breastfeeding baby during the postpartum period.
- # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement
- # Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention
- # Academy of Breastfeeding Medicine (2009) Clinical Protocol #20: Engorgement
- # Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic
- # Wight NE (2001) Management of common breastfeeding issues
- # Mangesi L et al. (2010) Treatments for breast engorgement during lactation.
- # McLachlan Z et al. (1993) Ultrasound treatment for breast engorgement: A randomised, double-blind trial
- # Robson BA (1990) Breast engorgement in breastfeeding women
8.2 Nipple Pain
Nipple pain is a common early postpartum concern.
It causes mothers
- to wean early 1 2 3 4 (is a reason given by one third of mothers who wean prior to 6 weeks postpartum)
- emotional distress 1 (women with nipple pain experience high levels of emotional distress, which resolves once the pain resolves)
Nipple pain can be caused by several factors:
- Technical issues:
- poorly latched baby
- baby with incorrect sucking technique
- incorrect use of lactation aids, eg. a breast pump, nipple shields, breast shells, etc.
- Maternal anatomy issues
- non-protractile nipples - not always resulting in nipple pain/damage
- firm, dense breast tissue
- Dermatological conditions of the nipple
- dermatitis (atopic and contact)
- psoriasis, and other skin conditions
- Infections
- fungal overgrowth, eg. candidiasis
- bacterial infections, eg. staph aureus
- viral infections, eg. herpes simplex
- Neurovascular conditions
- vasospasm of the nipple
- Raynaud's phenomenon
- nerve response to damaged nipples
- Infant anatomy issues
- high arched palate or a bubble palate
- short lingual frenulum
- receding/small mandible
- teething
Transient nipple pain is common during the first week postpartum, peaking at day 3 and decreasing by day 7. 5 There is no damage evident and the pain disappears within a short time of commencing the feed (ie, about 30 seconds).
Technique factors
Historically, an intervention to try to prevent nipple damage was to limit the number of feeds and length of time on the breast. A Cochrane Review 6 concluded that this practice was associated with an increased incidence of sore nipples, engorgement and the need to give additional (formula) feeds, and is therefore not recommended.
One study noted that 94% of women with breastfeeding problems had babies who had a "superficial, nipple-sucking" technique. 7
Many authors implicate a poorly latched baby as being the major culprit of nipple damage. 8 9 10
It has also been noted that there is a correlation between the early use of bottles and/or pacifiers and a disorganized suck and nipple damage. 7 11
From this body of work it is clear that the most common cause of nipple pain and nipple damage is preventable by:
- teaching correct positioning and latching techniques, and
- avoiding artificial nipples (teats/pacifiers/dummies) during the learning period.
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![]() | ![]() Back to basicsPoor latch (whether from maternal technique or infant ability) may exist in the presence of other factors mentioned above.
In assisting the mother, go back to basic principles of position and latch FIRST to obtain a clearer picture of the other factors. | ![]() |
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![]() | ![]() Quality assurance activityWould you and a small group of colleagues be able to organize an audit of all cases of nipple damage on discharge from your maternity unit over a one-month period?
It may be as simple as just an incident report, though trying to determine a cause for each would be useful. You may like to discuss with your colleagues the significance of this data once collected. Together you could work on ways to reduce the incidence before surveying again. | ![]() |
Maternal anatomy issues
General tips:
- Always start any 'difficulty latching' attempt to breastfeed with a well positioned baby in skin-to-skin contact with mother.
- Gentle touch or massage, or a cold cloth over the nipple will stimulate the erectile tissue.
- Compress the breast to hold the shape, ensuring the compression points on the breast coincide with where the baby's bottom and top jaws will be. Some mothers find it helpful to maintain this hold for a minute or two until sucking well established.
- While the breast is still soft prior to lactogenesis II is the best time for the baby to learn to breastfeed from his mother's breasts. If an artificial teat, whether it be a bottle nipple or a nipple shield, is introduced before giving the baby this opportunity the baby is more likely to require the 'super' stimulation of a formed shape at the posterior hard palate to stimulate sucking for all future feeds.
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![]() | ![]() Workbook Activity 8.3Complete Activity 8.3 in your workbook. | ![]() |
Inverted or non-protractile nipples
Some devices may assist:

Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.
Photograph © Health e-Learning
Devices such as the modified syringe, or commercially available devices have assisted mothers to draw their nipples out to enhance baby's ability to latch. Using a hand pump for a minute or so can also draw out the nipple. Some mothers may find it more comfortable if her partner is able to suck the breast/nipple into a teat shape immediately before feeding the baby.
These techniques are not always necessary though as many babies latch well to the breast regardless of nipple protractility.
Remember it is breastfeeding, not nipple feeding.

Infant well-latched to nipple shield.
© B. Wilson-Clay IBCLC
Sometimes a nipple shield may be successful. A risk:benefit assessment needs to be thoroughly explored first. Short-term benefits may lead to long-term complications for the breastfeeding dyad. In the past, nipple shields have been associated with decreased milk transfer, infant weight loss and decreased milk supply.12 13 14 Even with modern, thin nipple shields their use has been associated with premature weaning15 yet one study of preterm infants showed increased milk transfer over two consecutive feeds.16
Milk transfer via a shield, before lactogenesis II, will be negligible and therefore shields are not started until mother has established a good milk supply.
Note: Once a nipple shield has been introduced, observe for a good deep latch and nutritive sucking pattern. Follow-up assessment of infant condition and maternal milk supply is very important with the aim to weaning off the shield when the initial problem has resolved.
Infant anatomy issues
Ankyloglossia (tongue tie)
Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.
© Dr E. Jain
Ankyloglossia is a membranous attachment between the inferior aspect of the tongue and the anterior floor of the mouth, just beneath or directly onto the posterior alveolar ridge. This short or tight lingual frenulum may prevent the baby from extending the tongue over the bottom gum line or elevating the tongue (a very essential action for breastfeeding).
Presentation
80% of cases of poor latch as a result of ankyloglossia presented at 2 days postpartum; whereas 60% of women with nipple pain from ankyloglossia presented after day 2.17
If not treated the most common outcomes include:
- poor latch
- nipple pain
- severe nipple damage
- constantly feeding
- infant failure to thrive (inadequate milk transfer)
Treatment
Frenotomy
This is a simple surgical procedure to release the restriction and provide greater movement.
The following outcomes of frenotomy have been achieved:
- Where poor latch was their major complaint, 100% of women found latch was improved.17
- Of those presenting with nipple pain, mean pain score reduced from 6.9 to 1.2 immediately after the procedure.17
- A significant decrease in nipple pain score reported after frenotomy compared to after sham procedure.18
- Ultrasound post-frenotomy demonstrated less nipple compression by the tongue and was associated with "better attachment, increased milk transfer and less maternal pain".19
Nipple infections
Fungal overgrowth (candidiasis, thrush, yeast)
Candida albicans is a fungus (a form of yeast), which exists normally on the mucous membranes of the gut and vagina and usually presents no problems to a healthy individual. Factors that cause an imbalance of the normal flora of the body often result in candidiasis - the condition caused by an overgrowth and change in form of the fungus as it infects the host tissue.
Factors often associated with nipple candidiasis are:
- presence of vaginal candidiasis - up to 25% of women are affected by end of pregnancy 20
- use of antibiotics 1
- break in skin integrity of nipple
- infant who has oral candidiasis (acquired during birthing or being introduced on fingers, etc)
- infant use of pacifiers/dummies 21 22 - may also contribute to persistence of infant oral infection
- use of bottles - 23% of lactating women who used bottles tested positive for Candida and 20% had nipple candidiasis. A risk factor for colonization of the mother was bottle use in the first 2 weeks postpartum. Of these women 57% had weaned by 9 weeks postpartum, compared to 31% who were negative for Candida . 23
Presentation
Nipple candidiasis commonly presents with the following signs and symptoms
- acute breast/nipple pain after a period of pain-free feeding
- deep shooting, burning, or stabbing pain in the breast
- burning nipple pain, during and for some time after a breastfeed
- nipple and/or areola may be red, shiny or flakey; though may show no changes
- Candida may be obvious in the baby's mouth

Note the dry, flakey area at base of nipple.
© B.Ingle IBCLC

Note the shiny, red areola.
© B. Ingle, IBCLC
Management
Observe a breastfeed to ensure latch is optimal, preventing further nipple damage.
Candida branches and multiples rapidly and exists in many different stages at the same time. Management is aimed at eradicating the pathogen and preventing re-infection. The mother's doctor will confirm the diagnosis and may prescribe a pharmaceutical antifungal agent.
Antifungal agents that have been found to be effective in treating nipple candidiasis include:
- Gentian violet - painted on the nipples. This purple dye kills Candida on contact. (not readily available in some countries)
- Pure coconut oil - rubbed into nipples and ingested for candida in other sites. 100% effective against candida albicans 25
- Miconazole - cream applied sparingly to nipples, oral gel, and powder. Effective in 99% of cases. 26
- Fluconazole - systemic agent, usually administered orally.
- Nystatin cream, tablets and pessaries. Not usually the drug of first choice. Resistance has developed to this drug, only being effective in 54% of cases. 26
Educate the mother about the following supportive strategies that will enhance the antifungal treatment and prevent re-infection.
- Meticulous attention to hygiene.
- wash hands in warm, running soapy water before and after breastfeeding and any time when potentially infected areas have been touched, drying hands on a paper towel.
- discard reusable gel breast pads if they were being used and don't recommence until infection is cured, and preferably not at all.
- wash bras and cloth nursing pads daily and dry in direct sunlight if possible.
- boil pacifiers or artificial teats/nipples daily and replaced frequently.
- wash and thoroughly dry all toys, etc the baby puts in his mouth.
- Rinse the nipples in a bicarbonate of soda solution to create an alkaline skin environment. Nipples may respond differently to traditional vaginal thrush soothing treatments.
- Consider and treat all possible sources of recurring infection
- trim the baby's finger nails to prevent Candida being harbored under the nail and transferred to the mouth.
- the moist fold under the breasts of large breasted women
- other children, maternal vaginal infection, sexual partner, a pet
- Some women have reported faster resolution of symptoms when they eliminate simple sugars and yeasts from their diet and consume pure coconut oil, acidophillus and/or bacillo bifidus either in yoghurt form or in a commercially prepared capsule.
The infant may be a source of a re-infection cycle. Check the infant's mouth mucosa carefully. It may be necessary to treat the mouth with an appropriate infant preparation such as miconazole gel.
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![]() | ![]() Workbook Activity 8.5Complete Activity 8.5 in your workbook. | ![]() |
Bacterial infection

Look closely at the nipple, noting the exudate.
© B.Ingle IBCLC
Staphylococcus aureus is the most common causative organism of bacterial infections on the nipple, though streptococcus may also be implicated.
Diagnosis is usually made following careful history taking:
- pain described as stinging,
- observation of nipple damage,
- presence of an exudate that could be yellow to red and crusting,
- a delay in wound healing
- Treat the original cause of the break in nipple skin integrity.
- Clean the nipple wound in a saline solution.
- Apply antibiotic ointment as ordered by the doctor. A compound many find useful is a combination of betamethasone ointment, mupirocin ointment and miconazole powder making an anti-inflammatory, antibiotic and antifungal ointment. 27 A doctor may prescribe this and a compounding pharmacy supply it.
- It has been suggested that prophylactic oral antibiotics when nipple bacterial infection is diagnosed will prevent subsequent mastitis. 28 However, in an unsuccessful attempt to replicate that study, the authors reported a significant number of women reluctant to take antibiotics prophylactically.29
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![]() | ![]() Be vigilantA bacterial nipple infection is a strong risk factor for the development of infective mastitis.
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Treatment of nipple damage
There is nothing to be achieved by treating sore or damaged nipples if you don't simultaneously treat the cause.
After identifying the cause and initiating an appropriate action plan, the mother may also benefit from some other supportive measures to give added relief.
Breastmilk contains anti-infective agents and epidermal growth factor to prevent infections and heal any damage, as well as the hindmilk being high in fat to soothe the nipple. When you remove the cause of the damage, the nipple will heal quickly even while the mother continues to breastfeed on the affected breast.After performing a meta-analysis30 on the available research on treatment methods for nipple damage best practice is to
- apply warm water compresses to relieve pain, and
- apply breastmilk to hasten healing of cracked nipples.
None of the following are recommended: lanolin, ointments, aerosol sprays, film dressing and hydrogel dressings.
You can read the whole Best Practice information sheet on Management of nipple pain and/or trauma associated with breastfeeding.[link: http://www.jbiconnectplus.org/ViewSourceFile.aspx?0=500]
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![]() | ![]() What about resting the nipple?Severely damaged nipples may need to be rested for 24 hours or longer for initial healing to occur. During this time regular expressing of breastmilk will be required.
We live in a time of technology and gadgets. A breast pump (electric or manual) is often the only option considered for milk removal. Just as infants who exert a stronger baseline peak and pause vacuum will cause more pain for their mothers compared to infants with vacuum within normal range31 so too the vacuum of breast pumps has been associated with increased nipple pain and damage.32 If a pump is to be used careful instruction to mothers about the correct use will prevent a bad situation becoming worse. Hand expressing breastmilk may be a better option for many mothers. | ![]() |
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![]() | ![]() Group ActivityReview your unit's Breastfeeding Policy for the management of nipple damage. Is it up-to-date and evidence-based? Is this the procedure all your colleagues follow? | ![]() |
What should I remember?
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Self-test quiz
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Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column | ![]() |
Notes
- # Amir LH et al. (1996) Candida albicans: is it associated with nipple pain in lactating women?
- # Schwartz K et al. (2002) Factors associated with weaning in the first 3 months postpartum.
- # Lewallen LP et al. (2006) Breastfeeding support and early cessation.
- # Amir LH et al. (2005) Why do women stop breastfeeding? A closer look at not enough milk among Israeli women in the Negev Region.
- # Morland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review.
- # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
- # Righard L (1998) Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?
- # Gunther M (1945) Sore Nipples: Causes and Prevention
- # Prachniak GK (2002) Common breastfeeding problems
- # Wight NE (2001) Management of common breastfeeding issues
- # Centuori S et al. (1999) Nipple care, sore nipples, and breastfeeding: a randomized trial
- # Woolridge MW et al. (1980) Effect of a traditional and of a new nipple shield on sucking patterns and milk flow.
- # Jackson DA et al. (1987) The automatic sampling shield: a device for sampling suckled breast milk.
- # Auerbach KG (1990) The effect of nipple shields on maternal milk volume.
- # Pincombe J et al. (2008) Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.
- # Meier PP et al. (2000) Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding.
- # Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad
- # Griffiths DM (2004) Do Tongue Ties Affect Breastfeeding?
- # Geddes DT et al. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.
- # Cotch MF et al. (1998) Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy
- # Comina E et al. (2006) Pacifiers: a microbial reservoir
- # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
- # Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women
- # Andrews JI et al. (2007) The yeast connection: is Candida linked to breastfeeding associated pain?
- # Ogbolu DO et al. (2007) In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.
- # Hoppe JE et al. (1996) Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group
- # Newman J et al. (2005) Dr Jack Newman's Guide to Breastfeeding (The Ultimate Breastfeeding Book of Answers)
- # Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study
- # Amir LH et al. (2004) A failed RCT to determine if antibiotics prevent mastitis: Cracked nipples colonized with Staphylococcus aureus: A randomized treatment trial
- # Johanna Briggs Institute et al. (2009) The management of nipple pain and/or trauma associated with breastfeeding.
- # McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums
- # Clemons SN et al. (2010) Breastfeeding womens experience of expressing: a descriptive study.
8.3 Breast Problems
Blocked (Plugged) Duct
Blocked ducts are a common occurrence for breastfeeding mothers at any stage of lactation. Milk ducts become blocked and distended and are palpable as a tender, small lump in the breast. The skin over the lump may be reddened and warm to touch.
Blockage may occur as a result of
- occlusion of a duct from pressure applied by an ill-fitting bra, a strap or clothing or mother compressing the breast during feeds
- excessive movement of the breasts such as running or aerobics
- poorly drained breast - mechanical causes of infant/mother, poor positioning or unfinished feeds
It has been noted that some mothers who experience repeated duct blockages have thicker milk, or the blockage may contain more fatty material than usual. 1 2 (Note: this should not be your first assumption - always investigate other causes first)
Management involves
- identification of the cause
- meticulous attention to position and latch
- warm compresses to the affected area or a soak in warm water prior to gentle, but firm massage
- massage the lump towards the nipple as the baby suckles, or when hand or pump expressing
- feed more frequently until lumps clears
- massage and hand expressing under a warm shower
If a blocked duct fails to be cleared it may progress to mastitis from the milk backed up; infective mastitis may follow.
Mastitis
Lactational mastitis most commonly occurs during the second and third weeks of the puerperium, either as a result of hospital management or the infective organism having been hospital-acquired 3 2however it may occur at any stage of lactation.
Aetiology
Mast -itis (inflammation of the breast) is a general term which encompasses different aetiology. The inflammatory process in lactational masitis is caused by either milk stasis or infection.
One author 4 found evidence that " without effective removal of milk, non-infectious mastitis was likely to progress to infectious mastitis... "
Milk stasis is non-infective, but may progress to an infective state if good clinical management is not implemented. Milk stasis is most commonly associated with:
- engorgement
- infrequent feeds, or scheduling the frequency and/or duration of feeds
- poor latching leading to inefficient removal of milk
- rapid weaning
- missing feeds, eg. overnight or because baby has received a bottle feed
- pressure on the breast (eg. tight bra, car seatbelt)
- a blocked nipple pore or duct
Associated factors which increase incidence of mastitis
- nipple damage - especially if colonised with Staphylococcus aureus
- illness in mother or baby
- oversupply of milk
- maternal stress or fatigue
- anaemia or malnutrition
Infection
- usually by a penicillin-resistant Staphylococcus aureus
- less commonly the organism is a streptococcus or Escherichia coli
(Sources: WHO 5 ABM protocols 6 )
Milk stasis and mastitis causes movement of sodium and chloride into the milk space 7 and milk supply will fall as synthesis temporarily slows in the affected area. The infant may fuss during breastfeeds as a result of these factors.
Preventing Mastitis
Educate mothers about the importance of good breastfeeding management, caring for themselves and their breasts.
- A well-latched baby who breastfeeds according to his needs will help to regulate the mother's milk supply and avoid nipple damage.
- Teach mothers to hand express to prevent engorgement.
- Encourage rest and a healthy diet to support her immune system.
- Encourage an awareness of breast lumps or areas of milk stasis and discuss treatment with massage, extra feeding, expressing and heat packs.
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![]() | ![]() Be fore-armedWhilst we need to be very familiar with appropriate diagnosis and treatment of mastitis, prevention is a better approach.
During pregnancy, and as you educate mothers about effective breastfeeding, try not to focus your talk about mastitis in a way which will make mothers fear breastfeeding. Emphasise good position and latch, and effective breast drainage as the basis for all markers of good breastfeeding. Then the mother will understand that problems such as mastitis can be avoided - she can aim for success rather than presume that mastitis always comes with breastfeeding. | ![]() |
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![]() | ![]() Workbook Activity 8.6Complete Activity 8.6 in your workbook. | ![]() |
Diagnosis
Diagnosis is usually made by clinical presentation.
- inflamed area of the breast
- a painful wedge-shaped lump
- associated with fever of 38.5ºC (101.3ºF) or greater, and
- chills, flu-like aching and systemic illness.
One researcher8 desribes her criteria for mastitis as "at least 2 breast symptoms (pain, redness or lump) AND at least one of fever or flu-like symptoms."
Laboratory cultures of the breastmilk are rarely performed unless it does not respond to classical management strategies, or the mother has repeated episodes.

© B.Ingle, IBCLC
Management
Knowing that milk stasis is the most common predisposing factor to mastitis, it stands to reason that the first management strategy will be to ensure frequent and effective milk drainage from the affected breast.
Effective milk removal
- measures to support return of milk supply
- ensure baby latching and suckling well. Observe the baby breastfeeding!
- warm breast soak or applying warm compresses prior to breastfeeding may help milk ejection
- massage the breast gently during the breastfeed
- review the frequency of breastfeeding; most babies will feed 6 to 18 times in 24 hours, and feeding should not be regulated by the mother 9
- hand expressing, or pumping after a breastfeed may be necessary
Supportive measures
- bed rest
- adequate fluids and nutrition
- practical help at home
- vitamin E-rich sunflower oil, echinacea and vitamin C supplements have been suggested to assist immune and inflammatory responses. 10
Pain relief
Researchers and clinicians have yet to conclude whether heat or cold is preferred, most suggesting both with heat being used prior to breastfeeding or expressing and cold afterwards.
-
Use of moist heat...
- soak a cloth in warm water and apply to affected breast
- immerse the breast in a container of warm water. Some mothers have obtained relief from putting magnesium sulphate (Epsom Salts) into the water.
- limit use of heat if significant inflammation is present
- Application of cold - either a chilled moist cloth or a covered ice pack.
Paracetamol (acetaminophen) and ibuprofen are both safe analgesics to use during lactation; paracetamol (acetaminophen) having better antipyretic properties, while ibuprofen has better anti-inflammatory properties.
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![]() | ![]() Will weaning help?The mother may be planning to wean her baby - this is not the time to do it!
Weaning now (as tempting as it may seem) will increase milk stasis (and yes, begin to reduce milk supply), however the milk stasis increases the inflammatory response, further increasing risk of worsening mastitis and possible development of a breast abscess. It is important to clear the milk and allow the time for the breast to recover. | ![]() |
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![]() | ![]() Workbook Activity 8.7Complete Activity 8.7 in your workbook. | ![]() |
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![]() | ![]() Educational materialDevelop an information sheet to be discussed with mothers who have a blocked duct or mastitis, outlining the supportive measures they can take to facilitate a speedy recovery. This should be suitable for them to take home with them. | ![]() |
Complications
- reduced milk supply
- early weaning
- candida overgrowth
- breast abscess
What should I remember?
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Self-test quiz
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Click and drag the missing words below into their correct place The missing words are: Staph antibiotic before blocked breastfeeds cold damaged drainage ducts express fever flu-like frequency infection inflammation inflammation lactational latch less lump massage position pressure rest stasis towards warm Mastitis is __________ of the breast. When it occurs during breastfeeding it is called __________ mastitis. This condition may have its origin from milk __________ or __________.Initially, __________ __________ may be the result of the milk stasis. The recommended management of this situation would include:
Milk stasis may be the result of externally applied __________ from tight bra or clothing. However, the main reason for milk stasis is ineffective __________ of the breast. This can be achieved by meticulous attention to __________ and __________ of the infant to the breast. If unresolved, milk forced into the tissues causes __________ and resultant further milk stasis. Infection with organisms such as __________ aureus is the most common cause of infective mastitis. A strong risk factor for infective mastitis is __________ nipples. The mother will display breast symptoms such as a red, inflamed area over the site of a hard __________ and the mother may also have a __________ and __________ symptoms. You can assist the mother to recover by suggesting supportive management such as __________, good fluid and nutritional intake. During this time, the most important management is frequent drainage of the breast - this can be achieved by:
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Notes
- # Eglash A (1998) Delayed milk ejection reflex and plugged duct. Lecithin therapy
- # Fetherston C (1998) Risk factors for lactation mastitis
- # Kinlay JR et al. (1998) Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study
- # Thomsen AC et al. (1984) Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women
- # World Health Organisation (2000) Mastitis: causes and management
- # Academy of Breastfeeding Medicine (2008) Clinical Protocol 4
- # Nguyen DA et al. (1998) Tight junction regulation in the mammary gland.
- # Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants.
- # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
- # Riordan J (2005) Breastfeeding and Human Lactation
- # World Health Organisation (WHO) (2001) The optimal duration of exclusive breastfeeding. Results of a WHO systematic review.
- # Saiman L et al. (2003) Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among postpartum women
8.4 Insufficient breastmilk
Perceived breastmilk insufficiency
Along with nipple pain, this is the most common breastfeeding problem which women experience and a reason mothers give for introducing artificial infant formula and weaning prematurely. "Not enough milk" is reported by women, but usually their perception does not match reality.1,2
Education about normal infant behavior, normal infant breastfeeding frequency, good latch and normal infant output will prevent this misunderstanding and unfortunate outcome.
Output is the most obvious and reassuring way for a mother to know her baby is being well fed. Remind the mother: If it's coming out, it must have gone in!
How is breastmilk production regulated?
You will recall
- Secretory differentiation (Lactogenesis I)
- commences during pregnancy
- regulates production of colostrum
- is an endocrine function dependent on hormonal control
- Secretory activation (Lactogenesis II)
- commences soon after birthing, when serum prolactin is high and progesterone is suddenly removed
- is seen clinically as a copious production of breastmilk
- is an endocrine function
Lactogenesis III
Lactogenesis III is the maintenance of milk synthesis .
This is an autocrine function, meaning the control is under local control at the breast. Simply explained, milk must be removed from the breast for more milk to be made. Each breast is independent of the other in regards to milk production.
Researchers have described the following mechanisms, which both work together.
-
Feedback Inhibitor of Lactation (FIL)
FIL is a small whey protein that is found in breastmilk. It works on an inhibitory basis. The more milk present in the breast, the more FIL is present to be absorbed and exert its inhibitory effect on milk production. Conversely, as the breastmilk volume in the breast drops there is less inhibitory protein and production of breastmilk is more rapid.
Prolactin receptors:
Prolactin receptors on the alveolus control how much prolactin can move into the milk. (Imagine the prolactin receptors to be like keyholes, and prolactin is the key. The keyhole must be the perfect shape to allow the key to fit into it.) As the alveoli become increasingly distended, such as occurs as the breast is filling, less prolactin is found in the alveolus so milk production slows.3 As the alveolus empties of milk, the cells flatten allowing prolactin to bind to the receptors, pass through them and into the milk increasing the rate of milk production again.4 5
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![]() | ![]() What was that again?Simply put: full breast = lots of milk in alveoli = lots of FIL = slow breastmilk production full breast = distorted receptors = slow passage of prolactin = slow breastmilk production Two very good reasons to ensure frequent, effective milk removal for adequate milk production. | ![]() |
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![]() | ![]() Workbook Activity 8.8Complete Activity 8.8 in your workbook. | ![]() |
Breast storage capacity and rate of breastmilk production
Breastmilk storage capacity is unique to each mother, and each breast.
- A mother who has a small storage capacity will find that her baby feeds frequently, removing most milk at each breastfeed. This mother's rate of breastmilk production will be high most of the time. It would be inappropriate to suggest that her baby should be feeding less frequently, or expect him to sleep through the night, as this is most likely to result in failure to thrive and an insufficient milk supply.
- A mother with a large storage capacity will have higher degree of breast fullness for longer. Her infant made need only one breast per feed or may feed less frequently. Breastmilk production during this time will be slow, increasing as the available milk is removed.
Over a 24-hour period both babies may take very similar amounts of milk, but one baby may have to breastfeed many more times per day to achieve it.
Insufficient breastmilk
Diagnosis
Diagnosis of insufficient breastmilk supply is generally made by observing the condition of the baby. As mentioned in Topic 7.2 , it may not be low supply that has caused failure to thrive, which is why a pediatric review is always indicated.
Your thorough history-taking and excellent assessment and observational skills may reveal the reason for insufficient milk. These can be summarised as:
Maternal:
- medical conditions such as polycystic ovary syndrome, retained placenta, obesity, diabetes, large blood loss
- breast conditions - surgery (reduction mammoplasty, augmentation), hypoplasia
- other - contraceptive pill, subsequent pregnancy
Infant:
any medical condition or temporary circumstance which prevents adequate sucking strength and drainage of the breast.
Delayed onset
The infant's needs are increasing daily, so without adequate milk volume, the infant is at risk of dehydration, weight loss, hyperbilirubinemia, loss of energy and breast refusal.
Refer back to your notes about the biochemical changes which occur after birth to initiate secretory activation. Progesterone drops, prolactin remains high, lactose increases in colostrum. Insulin, thyroxine and glucocorticoids are also involved, but the role is uncertain.
Medical conditions which impair any of the chemical and hormonal changes are associated with delay of secretory activation. Your further study in Topic 8.5 will assist your further understanding of the potential impact on delayed onset of secretory activation.
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![]() | Being proactiveWhat measures will you take when you are caring for a mother-to-be/new mother who falls into one of these risk categories?
How can you help to reduce the impact of her risk on delayed secretory activation? | ![]() |
Management
A team approach may be required depending on the cause. Insufficient milk may be temporary of permanent, however, your role will be to guide the mother and assist her to effectively and regularly remove breastmilk to encourage rapid breastmilk production.
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The breastfeed - be a detective, examine the infant and assess a breastfeed as discussed in Topic 5.3
- Observe for good positioning, deep latch, effective suckling, swallowing. Believe it or not this very first step is one often neglected, particularly by health professionals whose specialty is not breastfeeding.
- Correcting a poor latch may be all that's required to solve the mother's lactation insufficiency.
- Breast compression during breastfeeding increases milk transfer. Breast compression involves holding the breast in the hand and gently squeezing it. Hold the compression until the baby's sucking pattern changes then release. Repeat.
- Switch feeding can also be effective. When the infant stops nutritive sucking on the first breast, swap to the other breast. Repeat this on each breast to encourage infant's interest and promote milk synthesis.
- Use a tube-feeding device at the breast for supplements. If possible commence the breastfeed without the supplement flowing to encourage good drainage of the breast first. When nutritive sucking stops allow the supplemental milk to flow. Review Topic 7.5.1
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Breastfeeding frequency
- Unfortunately many mothers are told they must feed 'X' number of times per day for 'X' number of minutes. They believe that long gaps between the feeds are a sign of a good baby and that frequent feeding will spoil the baby or create 'bad' habits, etc.
- Educate the mother about milk synthesis and breast storage capacity so that she can feel confident about the optimal breastfeeding practices to promote her milk supply.
- Frequent and effective breastmilk removal from the breast at each feed, by a well-latched baby or breast expression, will produce more milk in each breast.
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Additional stimulation - milk removal between breastfeeds
- Fact: The more frequently milk is removed from the breast the more rapidly the breast will produce breastmilk. The fuller the breast, the slower the breast will make breastmilk.
- Additional milk removal between breastfeeds will increase total breastmilk produced in that period. Use this milk as a supplement later.
- Express immediately after breastfeeding IF the baby does not remove all breastmilk from the breast each breastfeed, as may happen in the mornings when volume contained in the breast is greater, or the baby has an ineffectual suck. (And pump again in another hour)
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Galactagogues - discuss the pros/cons and types available
- A galactagogue is a substance that increases the volume of breastmilk produced.
- Effective galactagogues include domperidone and metoclopramide, as well as the herbals fenugreek, blessed thistle and goat rue.
- Galactogogues will only be successful if combined with clinical measures that ensure frequent, effective milk removal.
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Counselling the mother - sensitivity and caring will be needed to assist this mother.
- Reassure her that your recommendations won't be detrimental to the baby (and make sure they aren't - ensure the baby receives adequate nutrition, which may include artificial infant formula.) .
- Educate the mother about how milk production is controlled in her breast. This knowledge can be very empowering, particularly if mother had been limiting feeds based on erroneous advice.
- Be sensitive to her feelings; some people have probably criticised her decision to breastfeed, and she may see this problem as justification of their criticism.
- Be careful that she doesn't perceive you to be unapproachable if she does decide to artificially feed. She's still going to need lots of support to help her through possible emotional and guilt reactions.
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![]() | ![]() When is the best time to express?Assume a mother has an insufficient milk supply. Her baby latches effectively and drains both breasts well each breastfeed. When will you tell her to pump? Immediately after breastfeeding?? This is what is frequently advised. Mother breastfeeds, then pumps and gets only a few mls, or maybe nothing. That's understandable: the baby had just breastfed effectively. Mother feels disheartened - it proves her inability to provide for her baby. Breastmilk production will not be enhanced because the breast was already as empty as possible. However, if she waits for an hour then pumps, breastmilk production would have been at maximum for the majority of that time, beginning to slow now as more milk accumulates in the breast. Pumping may produce 30ml (1 ounce) from each breast (depends on individual rate of milk production). The breast will be emptied again, milk production will be back to maximum rate once again enhancing overall volume produced, and the mother will feel positive about her ability to produce breastmilk. This is an example of applying your knowledge of physiology to a problem. | ![]() |
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![]() | ![]() Workbook Activity 8.9Complete Activity 8.9 in your workbook. | ![]() |
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![]() Did you know?Women are able to relactate having prematurely weaned their baby, and also induce lactation, if they did not previously go through pregnancy. Always offer this as an option for mothers who weaned prematurely or are adopting a baby. |
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What should I remember?
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Self-test quiz
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Notes
- # Amir LH (2006) Breastfeeding--managing supply difficulties.
- # Lamontagne C et al. (2008) The breastfeeding experience of women with major difficulties who use the services of a breastfeeding clinic: a descriptive study.
- # Cregan MD et al. (2002, March) Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period
- # DeCarvalho MD (1983) Effect of frequent breastfeeding on early milk production and infant weight gain
- # Zappa AA (1988) Relationship between maternal parity, basal prolactin levels and neonatal breast milk intake
- # Nommsen-Rivers LA et al. (2010) Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding.
8.5 Medical, Surgical Issues
Diabetes mellitus
Gestational diabetes mellitus (GD)
- mothers who had GD and suppress lactation have higher serum glucose than had they breastfed
- suppressing lactation has an immediate detrimental effect on their glucose tolerance and lasting effects on maternal metabolic profiles 1
- mothers who had GD and suppress lactation will significantly increase their risk of developing Type 2 diabetes 1 2
- Being artificially fed in infancy is associated with an increased risk of Type 2 diabetes. 3
- Due to their decreased glucose metabolism and altered metabolic profiles women who suppress lactation do not receive the protection that delays or prevents Type 2 diabetes mellitus in women who breastfeed their babies.
- Being obese and suppressing lactation significantly increases the risk of developing Type 2 diabetes mellitus. 2
- Onset of secretory activation (lactogenesis II) may be delayed. 4
- Being artificially fed as an infant significantly increases the risk of developing Type 1 diabetes mellitus. 5 6 7
- Glucose use increases during lactation; lactating mothers can reduce their insulin by 25% or more of pre-pregnancy dose, while increasing their carbohydrate intake. Insulin requirements of mothers who suppress lactation is greater. 8 9 10
Impact on lactation
- women who are diabetic are more likely to birth preterm, have a caesarean section or assisted birth and experience other obstetric complications, all of which increase the risk of lactation difficulty
- mothers who are diabetics are more likely to NOT breastfeed or have a shorter breastfeeding duration 11
- separation of mother and baby is more likely due to preterm birth, Caesarean section and blood glucose testing
- maternal diabetes delays the onset of lactogenesis II 12
- in some units the baby is at greater risk of being given artificial infant formula, causing various breastfeeding difficulties
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![]() | ![]() RecommendationsIt is unfortunate that mothers with diabetes are at increased risk of breastfeeding difficulties which not only impacts on their own health but also on the health of their child who then becomes at risk of developing the same diabetic condition. For the present and future health of the mother with diabetes and her baby:
In light of the increased risk to the health of this woman and her child practices which interfere with breastfeeding, such as separation and giving artificial infant formula should be reviewed. | ![]() |
Maternal overweight and obesity
- being artificially-fed correlates to obesity in childhood and adulthood 13 14 15
- overweight and obesity increases obstetric complications and is associated with a greater risk of operative delivery
mothers who artifically feed compared to those who breastfeed (>6 months) have
- a 2 kg greater weight gain by 1 year postpartum
- larger waist girth
- greater weight gain 10-15 years later
- Lactation difficulty
- lactogenesis II may be delayed 16
- positioning the baby to facilitate good latching is more difficult
- the greater the BMI the greater the risk of early cessation of breastfeeding compared to women with normal BMI
- overweight and obese women are less likely to plan to breastfeed, initiate breastfeeding and wean earlier 17
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![]() | ![]() RecommendationsGive additional education and support to breastfeed to overweight and obese mothers -
Social measures that increase breastfeeding will result in less overweight and obese adults. Pre-conception education should provide help for women to achieve a normal BMI before pregnancy. Urgently needed are qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour. | ![]() |
Thyroid disease
Autoimmune thyroid dysfunctions are a common cause of both hyper- and hypo-thyroidism.
Graves' disease (hyperthyroid) and postpartum thyroiditis are two major causes of thyrotoxicosis in the postpartum period. Antithyroid drugs, propylthiouracil or methimazole, are the mainstay of the treatment of postpartum thyrotoxicosis and both are safe to take while breastfeeding. Radioiodine treatment is contraindicated during lactation. 18
There is a relatively high prevalence of hypothyroidism, especially subclinical hypothyroidism. Hypothyroidism is associated with insufficient breastmilk supply and may be one of the symptoms which alerts you to this condition. Thyroxine replacement therapy is safe for the breastfeeding baby and milk levels will improve once the mother becomes euthyroid.
Thyroid status varies considerably postpartum. Medication dosage may need adjusting during the postpartum months. Be mindful of symptoms such as fatigue, palpitations, weight loss, loss of concentration and depression. Facilitate medical review of the mother.
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![]() | ![]() RecommendationsAll women with diagnosed thyroid disease should have their therapy re-evaluated frequently during pregnancy and lactation and medication dosage adjusted as necessary. This is particularly necessary for women who are being treated for hypothyroidism because of the impact on breastmilk sufficiency. Evaluate all mothers who have breastmilk insufficiency for hypothyroidism. | ![]() |
Hepatitis
- Hepatitis B (HBV)
- With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breastfeeding does not contribute to mother-to-child transfer of HBV. 19 20
Prior to vaccination, concern of transmission of HBV via cracked nipples was speculated but not recorded. - Hepatitis C (HCV)
- There is no evidence of mother-to-infant transmission of hepatitis C from breastfeeding.
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![]() | ![]() RecommendationsWomen who are hepatitis B or C positive should be encouraged to breastfeed their babies. | ![]() |
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![]() Workbook Activity 8.10Complete Activity 8.10 in your workbook. |
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HIV
Note: Before giving a supplement to ANY breastfed baby consider the risk you are submitting the baby to should the mother unknowingly be HIV positive.
WHO Recommendations for infant feeding
- exclusive breastfeeding for the first 6 months, then
- introduce complementary foods while continuing to breastfeed for 24 months and beyond.
- commence anti-retroviral therapy (ARV) during pregnancy and continue for the duration of breastfeeding
- infants to receive ARV therapy
- exclusive breastfeeding for 6 months, then
- introduce complementary foods while continuing to breastfeed for 24 months and beyond
- continue ARV therapy for the duration of breastfeeding. 21
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![]() | HIV and NOT breastfeedingSafe alternatives to exclusive breastfeeding are heat-treated mother's own breastmilk,22 donor breastmilk from a safe source, or artificial infant formula.
Support the mother in her choice of infant feeding, ensuring that whatever she chooses is as safe as possible.
Issues to discuss with the mother who is NOT breastfeeding:
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![]() | ![]() Workbook Activity 8.11Complete Activity 8.11 in your workbook. | ![]() |
In a study in Botswana24, breastfeeding with zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission, but was associated with a lower mortality rate at 7 months. Both breastfed and artificially-fed had comparable HIV-free survival at 18 months.
Breast surgery
Reduction mammoplasty surgery which has involved severing large numbers of lactiferous ducts, removal of large amounts of glandular tissue, or severing the 4th intercostal nerve innervating the nipple/areola, will affect breastfeeding ability to varying degrees. (The 4th intercostal nerve is the stimulus for the milk ejection reflex, some severed ducts will re-anastomose)
Breast augmentation also has the potential to negatively affect breastfeeding because of severed 4th intercostal nerve and ducts with peri-areola incision method, and compression of glandular tissue with sub-glandular placement of implant.
Breastfeeding, milk transfer and the baby's condition should be closely monitored to ensure the baby continues to thrive. An antenatal consultation with a Lactation Consultant followed by close supervision of initial and ongoing breastfeeding management and early interventions to increase supply is important.
Breastfeeding and medication usage
Some women need to take medications while breastfeeding. It is important to ensure the baby will not be harmed via breastmilk transfer of the medication. It is equally as important not to forfeit breastfeeding when there are safe, effective medications. In most cases, it is far preferable to continue breastfeeding with small amounts of drug present in milk rather than risk many more hazardous effects of infant formula feeding.
All medications transfer into breastmilk to some degree but very, very few medications are contraindicated during breastfeeding. As a general rule of thumb less than 1% of the maternal dose passes via the breastmilk to the baby. Up to 10% of maternal dose is usually considered to be safe. 25
Several factors influence the ultimate medication dose which the infant will receive via breastmilk:
- the transfer of the drug into the breastmilk - influenced by specific drug properties such as maternal drug level reached, molecular weight, protein binding capacity.
- the uptake of the drug by the infant from the breastmilk - daily intake of infant, stomach acidity, gut absorption.
Everyone who prescribes medications for breastfeeding women should have access to a recent text that specifically reviews medications for mothers. This is the link to an excellent online resource. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT[link: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT] . Bookmark this resource for future reference.
The known detrimental effect of artificial infant formula feeding for both mother and baby needs to be seriously considered prior to ceasing breastfeeding due to maternal medication use. An alternative drug should be sought if the one usually prescribed is contraindicated.
What should I remember?
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Self-test quiz
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Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column | ![]() |
Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 8 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 8.
Notes
- # Kjos SL et al. (1993) The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes
- # Gunderson EP (2007) Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring
- # Das UN (2007) Breastfeeding prevents type 2 diabetes mellitus: but, how and why?
- # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
- # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
- # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
- # Tenconi MT et al. (2007) Major childhood infectious diseases and other determinants associated with type 1 diabetes: a case-control study
- # Illingworth P et al. (1989) Insulin requirements during breast feeding
- # Davies HA et al. (1989) Insulin requirements of diabetic women who breast feed
- # Riviello C et al. (2009) Breastfeeding and the basal insulin requirement in type 1 diabetic women.
- # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
- # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
- # von Kries R et al. (1999) Breast feeding and obesity: cross sectional study.
- # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
- # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
- # Rasmussen KM et al. (2004) Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum.
- # Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration
- # Azizi F (2003) Thyroid function in breast-fed infants is not affected by methimazole-induced maternal hypothyroidism: results of a retrospective study
- # Hill JB et al. (2002) Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers
- # Zhongjie Shi (2011) Breastfeeding of newborns by mothers carrying Hepatitis B virus
- # World Health Organisation and UNICEF (2010) HIV and infant feeding
- # Israel-Ballard K et al. (2007) Flash-heat inactivation of HIV-1 in human milk: a potential method to reduce postnatal transmission in developing countries.
- # Bland RM et al. (2007) Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice
- # Thior I et al. (2006) Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study
- # Hale T (2010) Medications and Mothers Milk
9.0 Promotion, Protection and Support
You may wonder how this module is relevant for your practice. An understanding of the history of artificial infant formula promotion and the impact it has had on breastfeeding will help you to understand how your values, the values of the mothers you assist and the community in which you live have been formed.
Artificial infant formula manufacturers are businesses, large businesses with shareholders whose concern is profit. Even though a LOT of evidence exists that artificial infant formula causes serious acute and chronic diseases and developmental and neurological insult to babies and children, and that in developing countries it is deadly, it is still marketed unethically to those who don't need it with the aim being to limit breastfeeding and increase profits, at the expense of the World's children. The World's first international code that regulates the practices of trans-national corporations had to be developed specifically to curb the marketing practices of artificial formula manufacturers.
The formula industry puts corporate profits before child health by subtle and less subtle marketing to parents, wooing of health professionals and disregard for national and international conventions. Artificial infant formula does have a role to play in infant feeding, but a professional will acquire the knowledge needed from unbiased published research, not from salesmen or saleswomen. Mothers who need to use infant formula can receive accurate, unbiased information from their health professional.
When you are aware of their practices you will realise that free lunches, pens, diaries or other give-aways are only given to you for one purpose - so that you will promote their product - and it works! A similar problem exists with pharmaceutical companies and the medical profession. Evidence is very clear that accepting their give-aways does influence the medical and nursing professional even when they don't think it does.1,2,3
Notes
- # Erlen JA (2008) Conflict of interest: nurses at risk!
- # Civaner M (2008) [A proposal for the prevention of ethical problems related to drug promotion: a national network for drug information].
- # Sarikaya O et al. (2009) Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential.
9.1 The International Code of Marketing of Breastmilk Substitutes
Aim of the WHO Code
The safe and adequate nutrition of all infants.
The WHO Code aims to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
- Protect, promote and support breastfeeding.
- Ensure that breastmilk substitutes are used properly when they are necessary.
- Provide adequate information about infant feeding
- Prohibit the advertising or any other form of promotion of breastmilk substitutes.
The WHO Code is clear that the manufacture and availability of safe and appropriate products is not prohibited, but promoting them in the way most consumer products are marketed is unacceptable.
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![]() Workbook Activity 9.1Complete Activity 9.1 in your workbook. |
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What's covered by the WHO Code?
Breastmilk substitute
- breastmilk substitutes, including bona fide artificial infant formula
- other milk products, foods (cereals) and beverages (teas and juices for babies), when marketed or otherwise represented to be suitable for use as a partial or total replacement of breastmilk before 6 months
- anything that replaces the milk part of the child's diet after 6 months, which would ideally be fulfilled by breastmilk, is a breastmilk substitute, for example 'follow-on' milks or cereals promoted to be offered by bottle
- feeding bottles and teats/artificial nipples
- the quality of these, the availability and information concerning their use
The scope of the WHO Code does not include any food, solid or semi-solid intended to be given to infants after 6 months. Such foods are complementary or weaning foods and can not be considered breastmilk substitutes.
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![]() Workbook Activity 9.2Complete Activity 9.2 in your workbook. |
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Promotion and product information
- Product labels must clearly state their inferiority to breastfeeding, the need for the advice of a health care worker, and a warning about health hazards. They may not show pictures of babies, or other pictures or text idealising the use of infant formula.
- Advertising of breastmilk substitutes to the public is not permitted.
- Companies can provide necessary information to health workers on the ingredients and use of their products. This information must be scientific and factual, not marketing materials. This product information should not be given to mothers.
- No financial or material inducements (pens, lunches) which promote products within the WHO Code should be provided for health workers or accepted by health workers.
Free samples
- No free or low-cost breastmilk substitutes can be supplied in any part of the health care system.
- The small amount of infant formula needed for any babies who are not breastfeeding should be bought through regular purchasing channels.
- Free samples should not be given to mothers, their families or health care workers. Small samples of artificial formula may not be given to mothers either from hospital or in the community, as these are samples to encourage mothers to use those products.
- Supplies of breastmilk substitutes to be given by the institution for free or at a reduced price to mothers or caregivers for social welfare purposes must continue to be provided for each baby for as long as the baby needs them. (ie, the responsibility of continued cost)
What can you do?
- Remove posters that advertise formula, teas, juices or baby cereal, as well as any that advertise bottles and teats and refuse any new posters.
- Refuse to accept free gifts from companies.
- Refuse to allow free samples, gifts, or leaflets to be given to mothers.
- Give individual private teaching of artificial infant formula use postnatally when a baby has a need for it. Do not allow group teaching of artificial formula preparation to pregnant women.
- Accept only product information from companies that is scientific and factual, not marketing materials.
- Report breaches of the Code to the appropriate authorities.
As a health care worker who cares about the health of mothers and babies it is up to each individual to uphold the WHO Code, regardless of your country's commitment to it. If your hospital intends to seek Baby Friendly accreditation it must comply with the WHO Code in its entirety, including the WHA Resolutions.
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![]() | ![]() Workbook Activity 9.3Complete Activity 9.3 in your workbook. | ![]() |
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![]() | ![]() Violation spotting[link: http://www.ibfan.org/code_watch-monitoring.html]
Click on the icon to be taken to the IBFAN site, which gives you a quick and easy summary called Alternative download: | ![]() |

The WHO Code
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![]() A copy of the WHO Code[link: http://www.who.int/nutrition/publications/code_english.pdf] Click on the icon above to be taken to a site where you can download and print a copy of the International Code of Marketing of Breastmilk Substitutes (it's a .pdf document which will open your Acrobat Reader). If that website is 'down' it's also available at the Your workplace should have a copy (or several copies) of this document. It can be purchased inexpensively. |
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What should I remember?
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Self-test quiz
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9.2 The Baby Friendly Initiative
Innocenti Declaration
Some 10 years after the WHO Code was first signed a group of high-level policy-makers convened; the outcome was the release of the Innocenti Declaration. The Innocenti Declaration was endorsed by the World Health Assembly in 1991, giving it world-wide status and acceptance. It is the most concise international statement on breastfeeding and covers all three facets of protection, promotion and support.
The Innocenti Declaration set 4 targets for all governments:
- To appoint a national breastfeeding coordinator and a multi-sectoral national breastfeeding promotion committee. This target put accountability directly in the hands of each nations' government.
- That governments would have taken action to implement the International Code of Marketing of Breastmilk Substitutes.
- That maternity facilities should practice the recently published Ten Steps to Successful Breastfeeding. This came at just the right time historically. The launching of the Baby Friendly Hospital Initiative has been the most important and powerful step ever taken on behalf of breastfeeding. It has put breastfeeding on the health policy map in almost every country in the world.
- To enact imaginative legislation to protect the breastfeeding rights of working women.
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![]() | ![]() Reaching the targetsIn 2005, 15 years after setting the original goals, a celebration was held to evaluate progress and re-affirm commitment to the targets.
The targets were ambitious and although they were not fully achieved by the projected date, great progress was made:
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The Baby Friendly Initiative
The thought process began more than 20 years ago to set targets and implement steps to increase world breastfeeding trends.
Baby Friendly hospitals

A proud hospital!
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![]() | ![]() Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should:
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Baby Friendly communities
Community facilities who acquire the Seven-Point Plan Award are often referred to a "mother-child friendly" or "breastfeeding-friendly".
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![]() | ![]() Seven-Point PlanThe 7 points in summary are:
1. Have a written breastfeeding policy that is routinely communicated to all health-care staff. 2. Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Support mothers to initiate and maintain breastfeeding. 5. Encourage exclusive and continued breastfeeding, with appropriately-timed introduction of complementary foods. 6. Provide a welcoming atmosphere for breastfeeding families. 7. Promote cooperation between health-care staff, breastfeeding support groups and the local community. Source: 2001 UNICEF/BFI UK | ![]() |
Does Baby Friendly Work?
- UNICEF, in 1999, reported widespread increases in rates of breastfeeding in urban areas, reductions in respiratory infections and diarrhea in infants, and savings in terms of both costs and staff time when BFHI is implemented.
- USA - Baby-Friendly designated hospitals have elevated rates of breastfeeding initiation and exclusivity. Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates. 1
- China - after 2 years of implementation of the Ten Steps, exclusive breastfeeding rates doubled in rural areas and improved from 10% to 47% in urban areas.
- Cuba - exclusive breastfeeding rates increased from 25% in 1990 to 72% in 1996. 2
- Scotland - babies born in a Baby-Friendly accredited hospital were 28% more likely to be exclusively breastfed at 7 days of postnatal age than those born in other maternity units. 3
- UK - in a 2 year period of mandatory BFI training of health visitors and nursery nurses resulted in a 1.57 times increased likelihood of an infant being breastfed at 8 weeks. 4
Becoming accredited
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![]() | ![]() Workbook Activity 9.4Complete Activity 9.4 in your workbook. | ![]() |
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![]() | ![]() Poster PromotionGather a small working group to collect appropriate photos (or obtain permission from mothers to photograph them and their babies) which could be made into a poster for each of the Ten Steps or each of the Seven Points.
Display the posters in strategic areas in your workplace. | ![]() |
What should I remember?
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Self-test quiz
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Notes
- # Merewood A et al. (2005) Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey
- # Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.
- # Broadfoot M (2005) The Baby Friendly Hospital Initiative and breast feeding rates in Scotland
- # Ingram J et al. (2011) The effects of baby-friendly iniatiative training on breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health care staff.
9.3 Young Child Feeding
The Global Strategy for Infant and Young Child Feeding was endorsed by the World Health Assembly in 2002. The aim of this strategy is to improve, through optimal feeding, the nutritional status, growth and development, health, and thus the survival of infants and young children.
"Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths, which are often associated with inappropriate feeding practices, occur during the first year of life.....malnourished children who survive are more frequently sick and suffer the life-long consequences of impaired development."
The strategy's specific objectives are:
- to raise awareness of the main problems affecting infant and young child feeding, identify approaches to their solution, and provide a framework of essential interventions;
- to increase the commitment of governments, international organisations and other concerned parties for optimal feeding practices for infants and young children;
- to create an environment that will enable mothers, families and other caregivers in all circumstances to make, and implement, informed choices about optimal feeding practices for infants and young children.
- Inappropriate feeding practices and their consequences are major obstacles to sustainable socioeconomic development and poverty reduction.
- Mothers and babies form an inseparable biological and social unit; the health and nutrition of one group cannot be divorced from the health and nutrition of the other.
- Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; infants should be exclusively breastfed for the first 6 months to achieve optimal growth, development and health.
- Infants are vulnerable during the transition period when complementary feeding begins. Nutritional status needs to be maintained by complementary foods which are timely, safe, adequate and properly-fed.
- Infants and children are among the most vulnerable victims in natural and human-induced emergencies. Interrupted breastfeeding and inappropriate complementary feeding heighten the risk of malnutrition.
Source: Global Strategy for Infant and Young Child Feeding, WHO 2003
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![]() Does your Unit have a copy of this document?[link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=510]If your Unit does not have a copy of this document it can be obtained, for a small cost, from the World Health Organisation website. Click on the icon to be taken to the order form. While at the website order Implementing the Global Strategy for Infant and Young Child Feeding at the same time - it is a free publication.
Alternatively, you could download the Strategy for no cost from |
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Global Strategy for Infant and Young Child Feeding
What should I remember?
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9.4 Local initiatives
Breastfeeding in public
Baby Friendly Point 6
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Point 6 of the Seven-point Plan for Sustaining Breastfeeding in the Community states:
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The health care facility should welcome breastfeeding in all public areas and this should be indicated by appropriately worded signs. Suitable facilities should be available for mothers who prefer to feed in privacy.
Reception staff should be aware that mothers are welcome to breastfeed in all public areas and be able to describe how they would advise a mother who wished to feed in privacy.
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![]() | ![]() The normal act of breastfeeding seen in publicAustralia now has a law passed in Federal Parliament under the Sex Discrimination Act which makes it illegal for anyone to discriminate against breastfeeding mothers! Does your community health unit make it explicitly clear that breastfeeding is welcomed in all public areas? Do you have an area set aside should a mother prefer to breastfeed in privacy? | ![]() |

© Australian Breastfeeding Association

© BFI UK Breastfeeding Welcome
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![]() Take a walkGo for a walk around your hospital or community health centre. Are there obvious signs in all the public areas making it clear that mothers may breastfeed in any them, AND referring her to a private area should she prefer it? If not design your own signs and display them until the organisation develops 'official' signs. |
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Supporting mothers in the community
Baby Friendly Step 10 and Point 7
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Step 10 of the Ten Steps to Successful Breastfeeding, and Point 7 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
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A Cochrane database systematic review 1 on the effect of lay health workers in the community found them to be "promising" in breastfeeding promotion. Attendance at mother-to-mother support groups or follow-up by peer counsellors has demonstrated significant increases in maintaining exclusive breastfeeding. 2 The peer counsellor role is unique from a health professional role in that it brings a mother together with another mother - the experienced can share with the new, the new can be supported and learn from the experienced.
A report on the effects of implementation of the Baby Friendly Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates indicated an increase in breastfeeding initiation to one month of age in the BFHI group compared to the control.3 However, once breastfeeding support groups activity increased, breastfeeding at 6 months and 12 months was significantly increased. They concluded that activities aiming to promote breastfeeding in maternity hospitals had limited success on long-term breastfeeding. For far-reaching effect postnatal support is also required.
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![]() | ![]() Workbook Activity 9.5Complete Activity 9.5 in your workbook. | ![]() |
UK Baby Friendly requires Community Health Units to address each of the following to meet the requirements of this point.
- All breastfeeding mothers should know which professional(s) to contact for breastfeeding support and how to access this help.
- All breastfeeding mothers should know how to contact a breastfeeding counsellor or support group for help with breastfeeding.
- All breastfeeding mothers should know how to access help with breastfeeding outside surgery/office hours.
- Relevant staff should be able to describe a procedure which ensures that information on the progress of breastfeeding is passed on during the handover of care between midwife and health visitor.
- Mothers should demonstrate an awareness that such a procedure exists.
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![]() | ![]() What procedures does your unit have in place to meet this standard?How is the availability of professional support and peer support communicated to mothers? Do you have a method of recording that mothers have received this information? How does your Unit encourage mothers to attend peer support organisations? If you are unsure of this could you form a group to look at what is done now, improve the procedure if necessary, and ensure the procedure is communicated to all staff at your Unit? If applicable, what handover procedures are in place between the birthing service and the community service? | ![]() |
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![]() | ![]() Peer support in unusual circumstancesAs a sign of the changing times Gribble (2001)4 found that Internet breastfeeding support groups can provide mother-to-mother support to those breastfeeding in unusual circumstances. Consider forming a small group to research online support groups with the goal being to produce reference material for staff when counselling a mother whose situation may be unique (eg. adoptive breastfeeding, breastfeeding after reduction mammaplasty, etc). Contacting the facilitator of the group to determine their goals and the way the group functions would help to determine if their goals are consistent with those of your organisation. | ![]() |
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![]() | ![]() You can't do it alone!Peer support offers mothers a different type of support to what she receives from health professionals. Both are needed by mothers and, working together, both will help her to give her baby the healthiest start in life. Engage the peer breastfeeding support organisations in your community. | ![]() |
Engaging the Community
Each year the World Alliance for Breastfeeding Action (WABA) promotes World Breastfeeding Week. World Breastfeeding Week (WBW) is the greatest outreach vehicle for the breastfeeding movement, being celebrated in over 120 countries. Officially it is celebrated from 1-7 August. However, groups may choose other dates to make it a more successful event in their countries.
Each year a theme is chosen and WABA produces resource materials to assist groups and individuals to celebrate this event, raising community and media awareness of breastfeeding. This is an ideal opportunity for your Unit to celebrate breastfeeding and use the occasion to educate your community about breastfeeding.
You will be able to get ideas and download resources from their website when they become available: WABA World Breastfeeding Week[link: http://worldbreastfeedingweek.org/].

Logo for WBW 2007

Logo for WBW 2010
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![]() Have fun this year! Start now! Get a group together to plan activities and promotions (of breastfeeding and your wonderful unit!) during Breastfeeding Awareness Week. The theme for this year is very modern and topical. There are lots of resources available on the Internet and you could think up many others. Don't forget to involve the media in your celebrations. |
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What should I remember?
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Self-test quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 9 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 9.
Notes
- # Lewin SA et al. (2005) Lay health workers in primary and community health care.
- # Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland
- # Bosnjak AP et al. (2004) The effect of baby friendly hospital initiative and postnatal support on breastfeeding rates - Croatian experience
- # Gribble KD (2001) Mother-to-mother support for women breastfeeding in unusual circumstances: a new method for an old model.
9.5 Infant feeding in emergencies
The problem
Some emergency nutrition situations can be anticipated, eg famine and war; however, the majority can not. Earthquakes, floods, tsunami, fire, cyclones, hurricanes and tornadoes happen quickly and with little warning or time to prepare. During or following such an event there may be:
- no clean drinking water
- no clean area for food preparation
- no supplies to clean or sterilize feeding utensils
- no refrigeration
Donations of baby foods and breastmilk substitutes in situations such as this is dangerous and can do more harm to the infants than good.
The solution for the breastfed infant
Some frequently asked questions
Question: | Does a mother lose her milk supply when she is in a stressful situation? |
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Answer: | Stress will not stop the mother producing milk; however it may delay her milk ejection. If a quiet area can be set aside for mothers to breastfeed, with reassurance and support offered, the suckling of the infant will elicit the milk ejection. |
Question: | Won't stress or trauma cause the mother's milk to be unsuitable? |
Answer: | The composition of a mother's milk will always be perfect - it is not possible to make 'weak' or 'spoiled' breastmilk. |
Question: | Could a mother's milk become contaminated? |
Answer: | If the infant is suckling directly from the breast there will be no contamination from infectious organisms in the environment. Even if the mother has diarrhea or other infections acquired as a result of the emergency situation these will not be passed via breastfeeding to her infant. |
The solution for the artificially fed infant
- an ongoing source of a safe breastmilk substitute, and safe storage for it
- utensils for the preparation of the infant formula, and bottles and teats for feeding
- an ongoing source of clean drinking water
- fuel to heat the water to a safe temperature for formula preparation
- the ability to thoroughly clean all the preparation and feeding utensils
In crisis affected areas where an imminent end is not in sight, assisting mothers to relactate could be the only solution.
What can you do to help?
- Protect, promote and support breastfeeding for all infants for at least the first two years of life, with the addition of suitable complementary foods from six months of age. Breastfed infants are in a much more secure situation should an emergency strike.
- Discourage the public from donating infant formula at these times as it is likely to cause more morbidity than it prevents.
- If you are in a position to, volunteer your services to provide support, encouragement and information to the breastfeeding mothers caught in the emergency; and education to the other relief workers.
- Know how to assist a mother to relactate should it become necessary.
- Discuss with ALL parents emergency preparedness for themselves and their children. Encourage them to have an emergency plan and kit always ready.
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![]() | ![]() Emergency preparations parents can make[link: http://www.internationalbreastfeedingjournal.com/content/6/1/16]Click on the icon, save and print the paper, "Emergency preparedness for those who care for infants in developed country contexts".
Read the paper, provide copies of it for your colleagues at your place of work, and discuss how you can ensure that this very important message is given to all parents who access your care. | ![]() |
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![]() What should I remember?
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10.0 Closing session
Thank you for participating in Breastfeeding Essentials. We hope you have found it thought provoking and interesting, and that it has revitalised your desire to provide the best care for mothers and babies.
The key points of the course are
- Breastfeeding is important for mother and baby.
- Most mothers and babies can breastfeed.
- Mothers and babies who are not breastfeeding need extra care to be healthy.
- Hospital and community health practices can help (or hinder) the success of breastfeeding.
- Implementing the Ten Steps to Successful Breastfeeding or the Seven Point Plan to Protect, Promote and Support Breastfeeding helps good practices to happen.
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![]() Your certificate.
Have you passed the Assessment Quizzes yet? If you have “ |
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