Breast feeding disorders

NORMAL BREASTFEEDING

INTRO

uGives the baby the best possible start in life

uAlthough it is natural, mothers often experience difficulties in BF

uThe aim of this session is the give you the knowledge to help you to help these mothers

Physiology and preparation for breast feeding

uDuring pregnancy changes take place in the mother to facilitate breast feeding

uBreast enlarge, the nipple and the areola enlarge and darken and the nipple becomes soft

uTwo hormones which are involved in BF

uProlactin – milk secretion

uOxytocin – milk ejection

uThese are influenced greatly by mothers emotions

uThe sight, sound and the touch of baby all have a positive effect on the mother

uWhen the baby starts suckling milk which has been produced already will be ejected to the baby’s mouth

uBreast feeding is an active process

uThe baby when latched on properly creates a vacuum by active sucking into which milk will flow

uThis sucking is coordinated with swallowing

Enhancing factors♣ Early initiation of breastfeeds ♣ Good attachment & effective suckling ♣ Frequent feeds including night feeds ♣ Emptying of breast o

Hindering factors ♣ Delay in initiation of breastfeeds, Pre-lacteal feeds, Bottle feeding, Incorrect positioning, Painful breast

Why is breastfeeding important?

υ Improves bonding with baby

υ Provide adequate nutrition for the baby

υ Provide protection against illness

υ Beneficial for maternal health

υ Importance for family

υ No cost

υ Convenient (no preparation)

υ Fresh Why is breastfeeding important? 1Importance for baby • Ideal composition biochemically / nutritionally • Protects from infections – diarrhoea, otitis media, UTI • Optimises neurodevelopment (more lactose than cow’s milk) • Better intelligence than formula-fed babies • Protects from chronic diseases eg: diabetes (type 1 & 2), childhood cancers, obesity, inflammatory bowel disease, asthma and allergies • Preterm – breastmilk reduces risk of sepsis, NEC

2 Importance for mother • Reduces risk of hypercholesterolaemia, diabetes, hypertension, cardiovascular disease • Breast and ovarian cancer are reduced • Hip fractures and osteoporosis are reduced • Faster return to pre-pregnancy weight • Lactational amenorrhea – contraception (partial) • Stops bleeding after birth of the baby (Oxytocin) • Stabilizes endometriosis

3Importance for family • Improves bonding with baby • No cost • Convenient (no preparation) Fresh ------------------------------------

Baby friendly hospital initiative

uPlacing the baby skin to skin with mother and initiation of breast feeding within 30 minutes of delivery (golden hour)

For normal successful breastfeeding

1 Mother’s needs to be happy and settled - position

2 The baby’s latch has to be correct

3 The baby needs to suck vigorously

4 Sucking and swallowing has to be coordinated

For successful breastfeeding :

o A willing and motivated mother

o An active and sucking newborn

o A motivator who can bring both mother and newborn together (health professional or relative)

FAQ

uHow often to feed?

uHow long to feed?

uWhat is the best position to feed?

uCan I feed in the lying down position?

uShould I feed with one or both breasts at one time?

uHow do I know that the baby is getting enough milk?How often to feed

uFeed on demand

uWhen a baby is hungry it will indicate the need to feed

uMakes the baby more likely to take a good feed

uReduces the stress on the mother

uAfter a few days the demand and supply will match

How long to feed

uWhen a baby is sucking vigorously, it will empty 85% of the breast within 5 minutes

uWhen the baby is getting full, it slows feeding

uWhen full and satisfied will let go of the nipple and fall asleep

uLet the baby decide on the duration of a feed

uThe reverse is a baby who is hungry will not let go of the breast

u

uSucking for hours, crying when taken off the breast and poor sleep are indicators that the baby is not getting fullOne or both breasts?

uDepends on the baby

u

uWhen the baby slows feeding and stops take off that breast

u

uOffer the other breast and see

What is the best position to feed 1. Poition 2. Attachment 3 suckling

uWhat is best for that mother and baby

u

uDepends on the size and shape of the breast too >Football hold position > Cradle hold position > Lying down postion

whatever position the following rules Correct position

1The babies head and body should be in one line

2The babies face and body should be turned towards the mother

uThe baby has to be held securely against the mothers body 3. Babys whole body is supported, even back

4 Mother should keep the back straight (don’t lean forward to feed)

Correct latching/attachment

uProper latching is essential for successful feeding

uTo latch effectively the babies mouth has to open fully, take the entire nipple into the mouth and close the gums over the areola

- Chin is touching the breast, Mouth is wide open, Lower lip is curled outwards, More areola above baby’s upper & less areola below lower lip Key points of good attachment

o Baby’s mouth is wide open

o Baby’s chin touches the breast

o Baby’s lower lip is curled outward

o There is more areola visible above than below the baby’s mouth

Causes of poor attachment

o Use of an artificial teat on a feeding bottle –before breastfeeding established

o Inexperienced mother – first baby or previous baby bottle fed

o Functional disability – small or weak baby, breast engorged, large, delay in first feed / skin-to-skin care

o Lack of skilled support – less traditional help and community support, doctors, midwives, nurses not trained to help

o Pain and damage to nipples – sore nipple and fissures o Breast milk not removed effectively - breast engorgement

o Poor milk supply (make less) – baby unsatisfied, frustrated, refuse to suckle, wants to feed a lot, baby fails to gain weight 3. Effective suckling υ You can see the baby taking slow, deep sucks υ The baby is relaxed, happy and satisfied at the end of the feed υ The mother does not feel nipple pain υ You may be able to hear the baby swallowing The baby should sleep afterwards...not cry when taking awar nd put to cot and not suck on for hours. Be alert and active at other times and have weight gain.

How do I know the baby is getting enough milk

1 Feeding behavior

uSucks vigorously during a feed

uDoes not suck for hours

uStops a feed and sleeps for 1-2 hours

uA baby who cries when taken off the breast and does not settle to sleep after feeding is most probably hungry

2 Urine output -

6 wet cloth nappies/day (after day 5); pale in-offensive

3 Regular bowel motions - Loose unformed bowel motions; yellow to greenish gold (about 3-5 initially; later less) 4 Alert with bright eyes, good skin colour and tone

5 Weight gain / loss

uMost breast fed babies loose some weight in the first week

uUsually not > 10% of the BW

uBy second week they should regain BW

uGain at 30g/d from then on If weight gain is adequate baby is getting enough milk

o Adequate weight gain (or acceptable weight loss) and urine frequency ≥6 times a day (after day 5) are reliable signs of enough milk intake --------------------------------------------------------------

Indications for alternative feeding methods

Methods of giving expressed breast milk

♣ Hold a wide necked, clean container under the mother’s nipple and areola ♣ Place her thumb and first finger behind the nipple (at least 4 cms from the tip of the nipple) ♣ Apply pressure inward toward the chest wall ♣ Compress and release the breast between finger and thumb using a rolling motion rather than sliding the fingers on the breast ♣ Compress and release all the way around the breast,keepingthe fingers the same distance from the nipple ♣ Express one breast until the milk just drips, then express the other breast until the milk just drips. ♣ Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes ♣ Stop expressing when the milk no longer flows but drips from the start

Back massage ♣ Mother sits down, leans forward, folds her arms on a table in front of her, rests her head on her arms ♣ Her breasts hang loose and unclothed ♣ The helper works down both sides of the spine at the same time from the neck to just below the shoulder blades ♣ She uses her closed fist with her thumbs pointing forwards ♣ She presses firmly making small slow circular movements with her thumbs and continues for 2-3 minStoring expressed breastmilk 1. Room temperature : 4 hours 2. Refrigerator : 72 hours (5°C or lower) 3. Freezer : 2 weeks (-150C) to 3 months (-180C)

Options available: Cup Spoon Gastric tube

Cup Feeding • Cup and spoon are easy to clean with soap and warm water • An ideal cup can hold 50 to 90 mL of milk • It can be glass or plastic and easily washable • Edge should be rounded and smooth • A cup with a lid is useful for storing expressed breast milk • Variations of cups with lips and spouts can easily be found • They should be used with extreme caution • It is DANGEROUS to POUR milk into a baby’s mouth

Cup Feeding Steps Put a measured amount of milk in the cup (do not fill more than 2/3 at a time ) Infant should be awake and held sitting semi-upright on caregiver's lap with the care giver’s arm supporting the baby’s shoulders and neck Put a small cloth on his or her chest to catch drips of milk Wrap the carer’s arm gently around the baby’s middle to keep his/her own hands down and away from the cup Hold the cup so that it just touches the baby's mouth. It should reach the corners of her/his mouth and rest lightly on her/his bottom lip Tip the cup so that the milk reaches the baby’s upper lip Do NOTpour the milk into the infant's mouth Allow the infant to take the milk himself (upon smelling the breastmilk, the baby becomes alert, opens its mouth, and puts its tongue into the milk to start the feed) Feed the infant slowly; some milk may spill from the infant's mouth When the infant has had enough, he or she will close his or her mouth and will not take any more. Do not force-feed the infant. Pouring the milk into baby’s mouth can cause aspiration

Advantages of cup feeding Simple equipment ; easy to clean Baby can take what it needs in its own time Mother can do it herself Good eye contact between mother and baby

Measuring the correct amount of milk

To measure 30 mL

Use a desert spoon which holds approx. 10 mL Take 3 spoonful of milk Put a mark on the outside of the cup to guide the mother as to how much milk is needed each time If the baby does not take the required amount: feed more often or for longer

Spoon feeding

Advantages ◦ Useful for collecting small amounts of colostrum in the first days of life ◦ Useful in a baby with cleft lip/palate

Disadvantages ◦ Slow method of feeding ◦ Often difficult to manage a spoon and a milk container while holding the infant semi-upright

Feeding milk by gastric tube

uConvinced that BF gives the best possible start in life to a baby

uHelp the mother to achieve successful breast feeding before discharge from hospital

uMost mothers have been given information on BF during the AN period which is helpful.

uHowever, having the knowledge alone is not sufficient

uHelp mothers who experience problems with lactation

uEmpathy

uNot judgmental / critical

uSupportive

uTrouble shoot

uEncourage

uPraise υ Address mother’s issues with regards to breast feeding

υ Make her aware that it is very common

υ Assess psychological status

υ Stress the importance of feeding to the baby

υ Provide positive reinforcement

υ Solve the problem when possible

υ Treat painful local lesions

υ Medical management of problems when necessary

υ Encourage adequate fluid intake

υ Educate that the support is available and from where to seek help When you counsel a mother, - You help her to decide what is best for her, and you help her to develop confidence - You listen to her, and to try to understand how she feelsWay forward to overcome issues υ Rooming-in υ Mother baby units υ Lactation management centers

υ Public health staff --------------------------------------------------------Why do babies stop feeding when they are ill? • Blocked nose due to respiratory infection (common cold) • Sore mouth (candida infection) • Loss of appetite • Feeding may be withheld in babies who undergo surgeryMisconceptions held by mother or health worker • Breastfeeding during diarrhoea is harmful • Breastfeeding should be stopped if stools are positive for reducing substances. • Formula supplementation is indicated in babies who present with dehydration fever and early neonatal jaundice. • All babies with cleft palate need bottle feeds These misconceptions can significantly interfere with establishment and exclusivity of breastfeeding.

Breastfeeding should be continued for sick babies due to the following reasons: • Baby continues to get the best nourishment • Looses less weight • Recovers more quickly • Baby receives more anti-infective agents via breast milk to fight any infection • Comforted by suckling • Breast milk production continues • Baby is more likely to continue breastfeeding when he/ she is well • Supporting establishment of lactation (positioning, attachment, suckling pattern) and giving cup feeds where indicated is helpful in alleviating dehydration fever and early neonatal jaundice.Extra points Initiate breastfeeding soon after (within one hour of) birth in all babies who are born in good condition (who do not require resuscitation at birth) and have a sucking reflex along with coordinated swallowing (more than 32- 34 weeks gestation). Preterm babies more than 32-34 weeks should be breast fed before they are sent to the neonatal unit as soon as they are stabilized. • Babies who are resuscitated can be breast fed as soon as the baby is stabilized. • Ensure exclusive breastfeeding (feeding only breast milk and not even water; but medications are allowed) during first 6 months of life. • Do not introduce kalke, gripewater, honey or animal milk as prelacteal feeds, supplements or as a home remedy. They will introduce infection and allergies, reduce the breast milk intake by the baby (stomach volume is very small about 5ml at birth), and thereby reduce the breast milk production. • Breastfeed day and night on demand by responding to early hunger cues from the baby. The number of times a baby feeds will vary. A baby who takes a large feed will sleep for longer and feed less frequently than a baby who takes smaller feeds more frequently. A baby will fall into a regular pattern of feeding about 8 to 12 times a day once the milk production increases after 48 to 72 hours. • Allow baby to feed at one breast till the baby stops sucking and releases the breast. Then offer him the other breast if the baby is still hungry. However, if he does not feed from this breast now, offer this breast first at the next feeding session. National Guidelines for Newborn Care - Volume I 43 • The adequacy of milk intake can be assessed by counting the number of wet nappies per day (≥6times/day) after the milk comes in (i.e after 72 hours postpartum), and weight gain (babies may take up to 2 weeks to regain the birth weight and thereafter gain 10-15g/kg/day in the first 2 months). • If a sick baby or small baby sleeps for more than 4 hours at a stretch more than once a day, baby may need to be woken up for feeds. Undressing the baby can be used for waking up. • Babies may tend to sleep at the breast when sick. They may also pull off the breast frequently when they have a blocked nose etc. Mothers should be advised to give shorter feeds more frequently to overcome these problems. The normal pattern of breastfeeding should be re-established as soon as the baby is better. • If a baby falls asleep as soon as the baby is put to the breast some of the things that can be used to wake up the baby are – undressing (leaving only the nappy on) and holding skin- to-skin, holding in a different manner (eg:- football hold rather than cradle hold) or switching sides. Do not tickle the ear, rub on the cheek or stimulate the sole in this situation. • The baby may refuse to suckle at the breast or suckle less efficiently when sick or preterm. In this instance mothers should be advised to express the milk and feed preferably via a cup, failing which a gastric tube may need to be used. • If the baby cannot take oral feeds due to medical reasons advice mothers to empty their breasts by expression 3 hourly to maintain the milk supply until the baby is able to resume oral feeds.

PROBLEMS DURING BREAST FEEDINGMaternal

υ Normal breast fullness υ Breast engorgement

υ Blocked duct

υ Mastitis / abscess

υ Sore / cracked nipples

υ Inverted nipples

υ Not enough milk

υ Sleepy baby

Infant problems

υ Preterm

υ Anatomical - Cleft palate / lip - Micrognathia - Tongue tie (rarely causes problems with feeding)

υ Other - Hypotonia - Poor coordination -----------------------------------------------Normal breast fullness

Normal breast fullness - when milk is coming-in

υ breast may feel hot, heavy and hard

υ There will be a free flow of milk which is normal

υTo relieve fullness: - Feed frequently - Cool compresses between feeds - The breast will adjust milk production to the baby’s need

------------------------------------------

Engorged breasts

Features

υ Breasts feel hot, heavy and hard

υ Painful and tender

υ No free flow of milk from breasts

υ May have maternal fever lasting less than 48 hours

υ Causes - Delay in starting to breast feed

Infrequent feeding, not feeding at night or short duration of feeds

• Treatment ♣ Give analgesics to relieve pain ♣ Apply cold packs locally; do NOT apply warm compresses ♣ Put the baby frequently to the breast ♣ Do NOT express and empty the breast fully; if very uncomfortable express just enough to minimise severe discomfort ♣ If tightness around areola is preventing the baby from attaching express a small amount to soften the area

Mastitis and absess

υ Part of breast becomes red, hot, swollen & tender.

υ Fever, chills & generalized unwellness

υ Fluctuant if an abscess is formed

υ Symptoms are same for noninfective & infective mastitisManagement

υ Remove milk frequently by allowing baby to breast feed (if not, an abscess will form) or by expression

υ Good attachment

υ Offer the baby the affected breast first (if not too painful) υ Wear a loose bra

υ Rest with the baby, so that the baby can feed often

υ Paracetamol/ibuprofen for pain

υ Antibiotics if fever >24 hours, infected cracked nipple, not improving (or worsening) with above measures within 24 hrs

υ Antibiotics for 7-10 days

υ An abscess may need surgical drainage ------------------------------------------Sore / cracked nipples Painful when sucking υ Skin may be normal

υ Pale lines (compression) on nipple immediately after suckling Cause? o Check the baby’s attachment at the breast

o Check the baby’s position if the attachment is satisfactory

o Examine the breasts – engorgement, fissures, candida o Ask if mother washes the breasts after each feed (frequent washing leads to sore nipple)

o Check the baby’s oral cavity for candida

o If all of above are ok consider tongue tie in the baby as a probable cause

υ Treatment -

Correct attachment

Give appropriate treatment:Improve the baby’s attachment and continue breastfeeding o Manage engorgement o Express breast milk and give to the baby if sucking is very painful o Treat candida o Build mother’s confidence o Wash breasts only once a day; avoid using soap o Avoid medicated lotions and ointments o Gently apply hind milk onto nipple and areola after each feed

-------------------------------------------------

Inverted nipples

υ Can BF, therefore reassure

υ No antenatal discussion with mother required

υ Most improve naturally and when baby sucks it will evert

υ Early initiation of breastfeeding

υ Extra support to establish attachment

υ Once breasts are full – - reverse pressure softening / little hand expression - Draw nipple out by touch - Nipple-shield may help o Treatment should begin after birth. o Ensure early opportunity for breastfeeding andextra support in positioning and attachment. o Manually stretch and roll the nipple between the thumb and finger several times a day. o Teach the mother to grasp the breast tissue so that areola forms a teat, and allows the baby to feed. o Syringe suction method.

υ Occurs when an occlusion occurs in a milk passage ways

υ This plug either prevents milk from passing through or slows passage of milk

υ Management

- Correct attachment

- Warm massage

- Pain relief

---------------------------------------------------------

Not enough milk

υ Mostly perceived

υ It might take 15-30 minutes of expression to produce 1 drop initially! (First few days volume of milk is small)

υ Causes

- - Maternal ill health

υ Treatment - Reassure if perceived - Find out the cause and correct a

Assess adequacy of brreast feeds♣ Kangaroo mother care ♣ Put baby to breast frequently ♣ Baby to be correctly attached to breast ♣ Build mother’s confidence ♣ Back massage and relaxation can help ♣ Use galactogogues (metaclopropamide) judiciously -------------------------------------------------Sleepy baby υ Baby falls asleep on the breast

υ Cries when baby is kept in cot

υ Mostly because baby gets too comfortable

υ Management • Undress baby • Position in football hold • Try switching sides ----------------------------------------Breastfeeding may need to be delayed in the following

υ Sick babies

υ Preterm babies

υ Babies with a GI surgical problems

υ Rarely for babies with metabolic problems Breast feedinf not intiiated in: • Antenatally (or immediate post-natally) diagnosed or suspected: - Congenital diaphragmatic hernia - Oesophageal atresia / trachea-oesophageal fistula - Intestinal obstruction - Imperforate anus - Gastroschisis / omphalocele • Mother on chemotherapeutic medication or recent / current use of radioactive substances • Mother having human T-cell lymphotropic viral infection, untreated brucellosis • Mother having untreated (not yet sputum negative) open tuberculosis (can express and feed)

BURPING A BABY

Even if your baby falls asleep, try burping them for a few minutes before placing them back down to sleep. Otherwise, they make wake up in pain with trapped gas.

Not all babies burp, though, no matter if it’s on their own or with your help. If your baby is one that needs to be burped, read on for ways to do so even when they’re asleep. As babies become older its not that important!

Put pressure on the babies belly to release gas

Takes only a few minutes and then okay.

If colicky even after that check other causes? Or maybe just a colicky baby.

NORMAL BREASTFEEDING

INTRO

uGives the baby the best possible start in life

uAlthough it is natural, mothers often experience difficulties in BF

uThe aim of this session is the give you the knowledge to help you to help these mothers

Physiology and preparation for breast feeding

uDuring pregnancy changes take place in the mother to facilitate breast feeding

uBreast enlarge, the nipple and the areola enlarge and darken and the nipple becomes soft

uTwo hormones which are involved in BF

uProlactin – milk secretion

uOxytocin – milk ejection

uThese are influenced greatly by mothers emotions

uThe sight, sound and the touch of baby all have a positive effect on the mother

uWhen the baby starts suckling milk which has been produced already will be ejected to the baby’s mouth

uBreast feeding is an active process

uThe baby when latched on properly creates a vacuum by active sucking into which milk will flow

uThis sucking is coordinated with swallowing

Enhancing factors♣ Early initiation of breastfeeds ♣ Good attachment & effective suckling ♣ Frequent feeds including night feeds ♣ Emptying of breast o

Hindering factors ♣ Delay in initiation of breastfeeds, Pre-lacteal feeds, Bottle feeding, Incorrect positioning, Painful breast

Why is breastfeeding important?

υ Improves bonding with baby

υ Provide adequate nutrition for the baby

υ Provide protection against illness

υ Beneficial for maternal health

υ Importance for family

υ No cost

υ Convenient (no preparation)

υ Fresh Why is breastfeeding important? 1Importance for baby • Ideal composition biochemically / nutritionally • Protects from infections – diarrhoea, otitis media, UTI • Optimises neurodevelopment (more lactose than cow’s milk) • Better intelligence than formula-fed babies • Protects from chronic diseases eg: diabetes (type 1 & 2), childhood cancers, obesity, inflammatory bowel disease, asthma and allergies • Preterm – breastmilk reduces risk of sepsis, NEC

2 Importance for mother • Reduces risk of hypercholesterolaemia, diabetes, hypertension, cardiovascular disease • Breast and ovarian cancer are reduced • Hip fractures and osteoporosis are reduced • Faster return to pre-pregnancy weight • Lactational amenorrhea – contraception (partial) • Stops bleeding after birth of the baby (Oxytocin) • Stabilizes endometriosis

3Importance for family • Improves bonding with baby • No cost • Convenient (no preparation) Fresh ------------------------------------

Baby friendly hospital initiative

uPlacing the baby skin to skin with mother and initiation of breast feeding within 30 minutes of delivery (golden hour)

For normal successful breastfeeding

1 Mother’s needs to be happy and settled - position

2 The baby’s latch has to be correct

3 The baby needs to suck vigorously

4 Sucking and swallowing has to be coordinated

For successful breastfeeding :

o A willing and motivated mother

o An active and sucking newborn

o A motivator who can bring both mother and newborn together (health professional or relative)

FAQ

uHow often to feed?

uHow long to feed?

uWhat is the best position to feed?

uCan I feed in the lying down position?

uShould I feed with one or both breasts at one time?

uHow do I know that the baby is getting enough milk?How often to feed

uFeed on demand

uWhen a baby is hungry it will indicate the need to feed

uMakes the baby more likely to take a good feed

uReduces the stress on the mother

uAfter a few days the demand and supply will match

How long to feed

uWhen a baby is sucking vigorously, it will empty 85% of the breast within 5 minutes

uWhen the baby is getting full, it slows feeding

uWhen full and satisfied will let go of the nipple and fall asleep

uLet the baby decide on the duration of a feed

uThe reverse is a baby who is hungry will not let go of the breast

u

uSucking for hours, crying when taken off the breast and poor sleep are indicators that the baby is not getting fullOne or both breasts?

uDepends on the baby

u

uWhen the baby slows feeding and stops take off that breast

u

uOffer the other breast and see

What is the best position to feed 1. Poition 2. Attachment 3 suckling

uWhat is best for that mother and baby

u

uDepends on the size and shape of the breast too >Football hold position > Cradle hold position > Lying down postion

whatever position the following rules Correct position

1The babies head and body should be in one line

2The babies face and body should be turned towards the mother

uThe baby has to be held securely against the mothers body 3. Babys whole body is supported, even back

4 Mother should keep the back straight (don’t lean forward to feed)

Correct latching/attachment

uProper latching is essential for successful feeding

uTo latch effectively the babies mouth has to open fully, take the entire nipple into the mouth and close the gums over the areola

- Chin is touching the breast, Mouth is wide open, Lower lip is curled outwards, More areola above baby’s upper & less areola below lower lip Key points of good attachment

o Baby’s mouth is wide open

o Baby’s chin touches the breast

o Baby’s lower lip is curled outward

o There is more areola visible above than below the baby’s mouth

Causes of poor attachment

o Use of an artificial teat on a feeding bottle –before breastfeeding established

o Inexperienced mother – first baby or previous baby bottle fed

o Functional disability – small or weak baby, breast engorged, large, delay in first feed / skin-to-skin care

o Lack of skilled support – less traditional help and community support, doctors, midwives, nurses not trained to help

o Pain and damage to nipples – sore nipple and fissures o Breast milk not removed effectively - breast engorgement

o Poor milk supply (make less) – baby unsatisfied, frustrated, refuse to suckle, wants to feed a lot, baby fails to gain weight 3. Effective suckling υ You can see the baby taking slow, deep sucks υ The baby is relaxed, happy and satisfied at the end of the feed υ The mother does not feel nipple pain υ You may be able to hear the baby swallowing The baby should sleep afterwards...not cry when taking awar nd put to cot and not suck on for hours. Be alert and active at other times and have weight gain.

How do I know the baby is getting enough milk

1 Feeding behavior

uSucks vigorously during a feed

uDoes not suck for hours

uStops a feed and sleeps for 1-2 hours

uA baby who cries when taken off the breast and does not settle to sleep after feeding is most probably hungry

2 Urine output -

6 wet cloth nappies/day (after day 5); pale in-offensive

3 Regular bowel motions - Loose unformed bowel motions; yellow to greenish gold (about 3-5 initially; later less) 4 Alert with bright eyes, good skin colour and tone

5 Weight gain / loss

uMost breast fed babies loose some weight in the first week

uUsually not > 10% of the BW

uBy second week they should regain BW

uGain at 30g/d from then on If weight gain is adequate baby is getting enough milk

o Adequate weight gain (or acceptable weight loss) and urine frequency ≥6 times a day (after day 5) are reliable signs of enough milk intake --------------------------------------------------------------

Indications for alternative feeding methods

Methods of giving expressed breast milk

♣ Hold a wide necked, clean container under the mother’s nipple and areola ♣ Place her thumb and first finger behind the nipple (at least 4 cms from the tip of the nipple) ♣ Apply pressure inward toward the chest wall ♣ Compress and release the breast between finger and thumb using a rolling motion rather than sliding the fingers on the breast ♣ Compress and release all the way around the breast,keepingthe fingers the same distance from the nipple ♣ Express one breast until the milk just drips, then express the other breast until the milk just drips. ♣ Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes ♣ Stop expressing when the milk no longer flows but drips from the start

Back massage ♣ Mother sits down, leans forward, folds her arms on a table in front of her, rests her head on her arms ♣ Her breasts hang loose and unclothed ♣ The helper works down both sides of the spine at the same time from the neck to just below the shoulder blades ♣ She uses her closed fist with her thumbs pointing forwards ♣ She presses firmly making small slow circular movements with her thumbs and continues for 2-3 minStoring expressed breastmilk 1. Room temperature : 4 hours 2. Refrigerator : 72 hours (5°C or lower) 3. Freezer : 2 weeks (-150C) to 3 months (-180C)

Options available: Cup Spoon Gastric tube

Cup Feeding • Cup and spoon are easy to clean with soap and warm water • An ideal cup can hold 50 to 90 mL of milk • It can be glass or plastic and easily washable • Edge should be rounded and smooth • A cup with a lid is useful for storing expressed breast milk • Variations of cups with lips and spouts can easily be found • They should be used with extreme caution • It is DANGEROUS to POUR milk into a baby’s mouth

Cup Feeding Steps Put a measured amount of milk in the cup (do not fill more than 2/3 at a time ) Infant should be awake and held sitting semi-upright on caregiver's lap with the care giver’s arm supporting the baby’s shoulders and neck Put a small cloth on his or her chest to catch drips of milk Wrap the carer’s arm gently around the baby’s middle to keep his/her own hands down and away from the cup Hold the cup so that it just touches the baby's mouth. It should reach the corners of her/his mouth and rest lightly on her/his bottom lip Tip the cup so that the milk reaches the baby’s upper lip Do NOTpour the milk into the infant's mouth Allow the infant to take the milk himself (upon smelling the breastmilk, the baby becomes alert, opens its mouth, and puts its tongue into the milk to start the feed) Feed the infant slowly; some milk may spill from the infant's mouth When the infant has had enough, he or she will close his or her mouth and will not take any more. Do not force-feed the infant. Pouring the milk into baby’s mouth can cause aspiration

Advantages of cup feeding Simple equipment ; easy to clean Baby can take what it needs in its own time Mother can do it herself Good eye contact between mother and baby

Measuring the correct amount of milk

To measure 30 mL

Use a desert spoon which holds approx. 10 mL Take 3 spoonful of milk Put a mark on the outside of the cup to guide the mother as to how much milk is needed each time If the baby does not take the required amount: feed more often or for longer

Spoon feeding

Advantages ◦ Useful for collecting small amounts of colostrum in the first days of life ◦ Useful in a baby with cleft lip/palate

Disadvantages ◦ Slow method of feeding ◦ Often difficult to manage a spoon and a milk container while holding the infant semi-upright

Feeding milk by gastric tube

uConvinced that BF gives the best possible start in life to a baby

uHelp the mother to achieve successful breast feeding before discharge from hospital

uMost mothers have been given information on BF during the AN period which is helpful.

uHowever, having the knowledge alone is not sufficient

uHelp mothers who experience problems with lactation

uEmpathy

uNot judgmental / critical

uSupportive

uTrouble shoot

uEncourage

uPraise υ Address mother’s issues with regards to breast feeding

υ Make her aware that it is very common

υ Assess psychological status

υ Stress the importance of feeding to the baby

υ Provide positive reinforcement

υ Solve the problem when possible

υ Treat painful local lesions

υ Medical management of problems when necessary

υ Encourage adequate fluid intake

υ Educate that the support is available and from where to seek help When you counsel a mother, - You help her to decide what is best for her, and you help her to develop confidence - You listen to her, and to try to understand how she feelsWay forward to overcome issues υ Rooming-in υ Mother baby units υ Lactation management centers

υ Public health staff --------------------------------------------------------Why do babies stop feeding when they are ill? • Blocked nose due to respiratory infection (common cold) • Sore mouth (candida infection) • Loss of appetite • Feeding may be withheld in babies who undergo surgeryMisconceptions held by mother or health worker • Breastfeeding during diarrhoea is harmful • Breastfeeding should be stopped if stools are positive for reducing substances. • Formula supplementation is indicated in babies who present with dehydration fever and early neonatal jaundice. • All babies with cleft palate need bottle feeds These misconceptions can significantly interfere with establishment and exclusivity of breastfeeding.

Breastfeeding should be continued for sick babies due to the following reasons: • Baby continues to get the best nourishment • Looses less weight • Recovers more quickly • Baby receives more anti-infective agents via breast milk to fight any infection • Comforted by suckling • Breast milk production continues • Baby is more likely to continue breastfeeding when he/ she is well • Supporting establishment of lactation (positioning, attachment, suckling pattern) and giving cup feeds where indicated is helpful in alleviating dehydration fever and early neonatal jaundice.Extra points Initiate breastfeeding soon after (within one hour of) birth in all babies who are born in good condition (who do not require resuscitation at birth) and have a sucking reflex along with coordinated swallowing (more than 32- 34 weeks gestation). Preterm babies more than 32-34 weeks should be breast fed before they are sent to the neonatal unit as soon as they are stabilized. • Babies who are resuscitated can be breast fed as soon as the baby is stabilized. • Ensure exclusive breastfeeding (feeding only breast milk and not even water; but medications are allowed) during first 6 months of life. • Do not introduce kalke, gripewater, honey or animal milk as prelacteal feeds, supplements or as a home remedy. They will introduce infection and allergies, reduce the breast milk intake by the baby (stomach volume is very small about 5ml at birth), and thereby reduce the breast milk production. • Breastfeed day and night on demand by responding to early hunger cues from the baby. The number of times a baby feeds will vary. A baby who takes a large feed will sleep for longer and feed less frequently than a baby who takes smaller feeds more frequently. A baby will fall into a regular pattern of feeding about 8 to 12 times a day once the milk production increases after 48 to 72 hours. • Allow baby to feed at one breast till the baby stops sucking and releases the breast. Then offer him the other breast if the baby is still hungry. However, if he does not feed from this breast now, offer this breast first at the next feeding session. National Guidelines for Newborn Care - Volume I 43 • The adequacy of milk intake can be assessed by counting the number of wet nappies per day (≥6times/day) after the milk comes in (i.e after 72 hours postpartum), and weight gain (babies may take up to 2 weeks to regain the birth weight and thereafter gain 10-15g/kg/day in the first 2 months). • If a sick baby or small baby sleeps for more than 4 hours at a stretch more than once a day, baby may need to be woken up for feeds. Undressing the baby can be used for waking up. • Babies may tend to sleep at the breast when sick. They may also pull off the breast frequently when they have a blocked nose etc. Mothers should be advised to give shorter feeds more frequently to overcome these problems. The normal pattern of breastfeeding should be re-established as soon as the baby is better. • If a baby falls asleep as soon as the baby is put to the breast some of the things that can be used to wake up the baby are – undressing (leaving only the nappy on) and holding skin- to-skin, holding in a different manner (eg:- football hold rather than cradle hold) or switching sides. Do not tickle the ear, rub on the cheek or stimulate the sole in this situation. • The baby may refuse to suckle at the breast or suckle less efficiently when sick or preterm. In this instance mothers should be advised to express the milk and feed preferably via a cup, failing which a gastric tube may need to be used. • If the baby cannot take oral feeds due to medical reasons advice mothers to empty their breasts by expression 3 hourly to maintain the milk supply until the baby is able to resume oral feeds.