TEN STEPS TO SUCCESSFUL BREASTFEEDING

(Session 1 : THE BABY-FRIENDLY2 HOSPITAL INITIATIVE:A PART OF THE GLOBAL STRATEGY)

A Joint WHO/UNICEF Statement (1989)

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to

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

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Job-Aids (Handout)

10. Foster the establishment of breastfeeding support groups and refer

mothers to them on discharge from the hospital or clinic.

Communication Skills Worksheet 2.1 (for participants copy)

Open questions:
For each closed question, write a new question that is an open question.
Example
Are you breastfeeding your baby? (closed)

How are you feeding your baby? (open)

Re-write these questions as an open question:

Does your baby feed often?
Are you having any feeding problems?
Is your baby gaining weight?
Empathising with the mothers feelings:
The statements below are made by a mother. Pick the response that you might make to show
empathy and understanding of the mothers feelings.
Example:
My baby feeds all night and I am exhausted.

- How many times does she feed?

- Does this happen every night?
- You really feel tired.

Pick the response that shows empathy:

My breastmilk looks thin it cannot be good.

- Breastmilk always looks thin.

- You are worried about your milk?
- How much does your baby weigh?

I am afraid to breastfeed in case I have HIV.

- You are concerned about HIV?

- Have you had a test?
- Then use formula instead.

Avoid judging words:

Re-write each question to avoid a judging word and to also ask an open question.
Example:

Does your baby cry too much at night?

Do you have any problems with breastfeeding?
Is the babys weight gain good?

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Change to avoid a judging word:

How is your baby feeding?

Job-Aids (Handout)

Is your baby feeding well?

Accepting what a mother thinks:

Draw a line to link which response is accepting, agreeing or disagreeing with the mothers statement.

Example:
Mother: I give drinks of water if the day is hot.

Answer:

Type of response

That isnt necessary! Breastmilk has enough water.

Agreeing

Yes, babies need water in hot weather.

Disagreeing

You feel the baby needs some water if it is hot?

Accepting

Link with the answer with the type of response:

Mother: My baby has diarrhoea, so I am not breastfeeding until it is gone.
Answer:
You dont like to give breastmilk now?

Type of response
Agreeing

It is quite safe to breastfeed when he has diarrhoea.

Disagreeing

It is best to stop breastfeeding during diarrhoea.

Accepting

Mother: The first milk is not good, so I will need to wait until it has gone.
Answer:
First milk is very important for the baby.

Type of response
Agreeing

You think the first milk is not good for the baby.

Disagreeing

It will only be a day or two before the first milk is gone.

Accepting

Provide relevant information using suitable language:

Re-write the statement to use words that are easy for the mother to understand.
Example:
You can tell that the hormone oxytocin is working if you notice the milk ejection reflex.

The immunoglobulins in human milk provide your baby with protection from viral and bacterial
infections.

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Change these statements to words easy to understand:

Exclusive breastfeeding provides all the nutrients that your baby needs for the first 6 months.

Job-Aids (Handout)

Change to words easy to understand:

You may notice the opposite breast leaks when the baby is suckling. This is a sign that the milk is
flowing well.

Offer suggestions, not commands:

Re-write each command changing it to a suggestion rather than a command.

Example:
Do not give your baby drinks of water. (command)
Change to a suggestion:
Have you thought of only giving breastmilk? (suggestion)
Change each command to a suggestion:
Hold him close so that he takes enough of the breast into his mouth. (command)

Feed her more often, then your milk supply will increase. (command)

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Job-Aids (Handout)

Do not give any foods to your baby until after 6 months. (command)

Antenatal Checklist Infant Feeding

(SESSION 3: PROMOTING BREASTFEEDING DURING PREGNANCY STEP 3)

All of the following should be discussed with all pregnant women by 32 weeks of pregnancy. The
health worker discussing the information should sign and date the form.
Name:
Expected date of birth:
Topic

Discussed or note
if mother declined
discussion

Signed

Date

Importance of exclusive breastfeeding to the baby

(protects against many illnesses such as chest infections,
diarrhea, ear infections; helps baby to grow and develop well;
all baby needs for the first six months, changes with babys
needs, babies who are not breastfed are at higher risk of
illness)
Importance of breastfeeding to the mother
(protects against breast cancer and hip fractures in later life,
helps mother form close relationship with baby, artificial
feeding costs money)
Importance of skin-to-skin contact immediately after birth
(keeps baby warm and calm, promotes bonding, helps
breastfeeding get started)
Importance of good positioning and attachment
(Good positioning and attachment helps the baby to get lots
of milk, and for mother to avoid sore nipples and sore
breasts. Help to learn how to breastfeed is available from )
Getting feeding off to a good start
- Baby-led feeding
- Knowing when baby is getting enough milk
- Importance of rooming-in / keeping baby nearby
- Problems with using artificial teats, pacifiers
No other food or drink needed for the first 6 months
only mothers milk
Importance of continuing breastfeeding after 6 months
while giving other foods

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- loss of protection from illness and chronic diseases

- contamination, errors of preparation,
- costs,
- difficulty in reversing the decision not to breastfeed
Other points discussed and any follow-up or referral needed:

Job-Aids (Handout)

Risks and hazards of not breastfeeding

Breastfeeding Positions
SESSION 7 HELPING WITH A BREASTFEED - STEP 5

Lying down on side position

Helps a mother to rest. Comfortable after a

caesarian section. Take care that the babys
nose is on a level with mothers nipple, and
that baby does not need to bend his or her
neck to reach the breast.

Lying down on side position

Cradle position

The babys lower arm is tucked around the

mothers side. Not between the babys chest
and the mother. Take care that the babys
head is not too far into the crook of the
mothers arm that the breast is pulled to one
side making it difficult to stay attached.

Cradle position

Cross Cradle (Cross arm position)

Useful for small or ill baby. Mother has good

control of babys head and body, so may be
useful when learning to breastfeed. Take care
that the babys head is not held too tightly
preventing movement.

Cross Cradle (Cross arm position)

Football Hold (Underarm position)

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Useful for twins or to help to drain all areas of

the breast. Gives the mother a good view of
the attachment. Take care that baby is not
bending his or her neck forcing the chin down
to the chest.

Job-Aids (Handout)

Football Hold (Underarm position)

Breastfeed Observation Job Aid

(SESSION 7 HELPING WITH A BREASTFEED - STEP 5)

Mother's name _______________________________

Date ___________________

Baby's name _________________________________

Baby's age ______________

Signs that breastfeeding is going well:

Signs of possible difficulty:

GENERAL
Mother:

Mother looks healthy

Mother relaxed and comfortable

Signs of bonding between mother and baby

Mother:

Mother looks ill or depressed

Mother looks tense and uncomfortable

No mother/baby eye contact

Baby:

Baby looks healthy

Baby calm and relaxed

Baby reaches or roots for breast if hungry

Baby:

Baby looks sleepy or ill

Baby is restless or crying

Baby does not reach or root

Nipple flat, not protractile

Babys neck and head twisted to feed

Baby not held close

Baby supported by head and neck

Baby approaches breast, lower
lip to nipple

BABYS ATTACHMENT

More areola seen above babys top lip

Babys mouth open wide

Lower lip turned outwards

Babys chin touches breast

More areola seen below bottom lip

Babys mouth not open wide

Lips pointing forward or turned in

Babys chin not touching breast

SUCKLING

Slow, deep sucks with pauses

Cheeks round when suckling

Baby releases breast when finished

Mother notices signs of oxytocin reflex

Rapid shallow sucks

Cheeks pulled in when suckling

Mother takes baby off the breast

No signs of oxytocin reflex noticed

Notes:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________

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BABYS POSITION

Babys head and body in line

Baby held close to mothers body

Babys whole body supported

Baby approaches breast, nose opposite nipple

Breasts look red, swollen, or sore

Breast or nipple painful

Breasts held with fingers on areola

Job-Aids (Handout)

BREASTS

Breasts look healthy

No pain or discomfort

Breast well supported with fingers
away from nipple

Nipple stands out, protractile

HELPING A MOTHER TO POSITION HER BABY

(SESSION 7 HELPING WITH A BREASTFEED - STEP 5)

Greet the mother and ask how breastfeeding is going.

Sit down yourself in a comfortable, convenient position.

Observe a breastfeed.

Notice something positive and say something to encourage the mother.

If you notice a difficulty, explain what might help, and ask the mother if she would like you
to show her.

Make sure that she is in a comfortable and relaxed position.

Explain how to hold her baby, and show her if necessary. The four key points are:

with babys body close to her body,

supporting babys whole body (if newborn),

with babys face facing her breast, and babys nose opposite her nipple,

Show her how to support her breast:

-

with her fingers flat against her chest wall below her breast;

with her first finger supporting the breast;

with her thumb above.

Her fingers should not be too near the nipple.

Explain or show her how to help the baby to attach:

- touch her baby's lips with her nipple;
-

wait until her baby's mouth is opening wide;

move her baby quickly onto her breast, aiming babys lower lip below the nipple.

Notice how she responds and ask her how she feels during the baby suckle .

Look for signs of good attachment more areola seen above babys top lip, wide mouth,
lip turned outwards, chin touching breast

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with babys head and body straight,

Job-Aids (Handout)

ACCEPTABLE MEDICAL REASONS FOR SUPPLEMENTATION TO THE

BABIES AGED BELOW SIX MONTHS OLD.
(SESSION 10: INFANTS WITH SPECIAL NEEDS)

Infant Conditions
1.

Infant who should not receive breast milk or any other milk except specialized formula

o
o
o

Classic galactosemia : a special galactose-free formula is needed

Maple syrup urine disease : a special formula free of leucine, isoleucine and valine is needed;
Phenylketonuria : a special phenylalanine-free formula is needed (some breasfeeding is
possible, under careful monitoring)

2.

Infants for whom breast milk remains the best feeding options but who my need other food in
addition to breast milk for a limited period

o
o
o

Very low birth weight infants (those born weighing less than 1500g);
Very preterm infants, I.e. those born less than 32 week gestational age;
Newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adapaition
or increased glucose demand (such as those who are preterm, small for gestational age or
who have experienced significant intrapartum hypoxic/ischaemic stress, those who are ill and
those whore mother are diabetic) if their blood sugar fails to respond to optimal breasfeeding
or breast milk feeding;
Infants younger then 6 month who, in spite of frequent and effective suckling and in the
absence of illness, show persitent growth faltering (as demonstrated by a flat or downward
growth curve).

Maternal Conditions
Mother who is affected by any of the conditions mentioned below should receive treatment according to
standard guidelines.
Mother who should avoid breastfeeding PERMANENTLY
o
o

Mother who should avoid breastfeeding TEMPORARILY

o
o

3.

Severe illness that prevent a mother from caring for her infant, for example sepsis;
Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mothers breasts
and the infants mouth should be avoided until all active lesions have resolved;

Mother who CAN CONTINUE BREASTFEEDING, although the health problems may be of concern
o

Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the
affected breast can resume once the abscess has been drained and antibiotic treatment
has started;
Hepatitis B : infants should be given hepatitis B vaccine, within the first 48 hours or as
soon as possible thereafter;

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2.

HIV infection : if replacement feeding is accepteble, feasible, affordable, sustainable and safe
(AFASS);
HTLV-I (Human T-cell Leukaemia virus): if safe and feasible options for replacement feeding
are available.

Job-Aids (Handout)

1.

o
o
o

4.

Hepatitis C;
Mastitis : If breastfeeding is very painful, milk must be removed by expression to prevent
progression of the condition;
Tuberculosis : mother and baby should be managed according to national tuberculosis
guidelines;

Medications and other subtances that can adversely affect the breastfed infant
Maternal medication. Risks are greater during the first 2 month and with high doseges (as therapy or
with abuse) of medications. Monitor infants for adverse effects. Use in older infants and the use of
low doses usually require no special precautions.
o

Sedating psychotherapeutic drugs, anti apileptic drugs and opioids and the combinations
may course side effects such as drowsiness and respiratory depression in neonates; use
less sedating alternative and low dosages whenever possible;
Radioactive iodine -131 in therapeutic doses should be avoided given that safer
alternatives are available; a mother my resume breastfeeding about two month after
receiving this substance with measured low milk radioactivity;
Excessive use of topical iodine or iodophors (e.g., povidone-iodine, especially on open
wounds or mucous membranes, can result in thyroid suppression or electrolyte
abnormalities in the breastfed newborn and should be avoided;
Cytotoxic chemotherapy requires that a mother stop breastfeeding during therapy. Some
non cytotoxic chemotherapy can be used with continued nursing.

Substances use. Mother should be encouraged not to use these substances and given opportunities and
support to abstain. Mother who chooses not to cease their use of these substances or who are unable to do
should seek individual advice on the risk and benefits of breastfeeding depending on their individual
circumstances. For mother who use these substances in short episodes, consideration may be given to
avoiding breastfeeding temporarily during this time.

* Adapted from the Acceptable Medical Reasons for Use of Breast-milk Substitutes, WHO 2009

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Maternal use of nicotine often decrease the duration of breastfeeding, and can adversely
affect the infant, but breastfeeding is preferable to formula feeding in smoking mothers.
Infants should not be exposed to tobacco smoke.
Alcohol taken before breastfeeding can course infants sedation and reduced milk intake;
Abuse of amphetamines, cocaine and related stimulants may produce harmful effects on
breastfeeding babies, especially if the infant is additionally exposed to the drugs by inhalation
of smoked drugs.

Job-Aids (Handout)

(SESSION 11: IF BABY CANNOT FEED AT THE BREAST STEP 5)

Your milk is very important to your baby. It is useful to express your milk if:
your baby cannot feed at the breast
you are away from your baby
you want drops of milk to encourage your baby to suck,
your breasts are overfull or you have a blocked duct,
you want some hind milk to rub on sore nipples, and other reasons.

You can help your milk to flow by:

sitting comfortably, relaxed and thinking about your baby,
warming your breast,
massaging or stroking your breast, and rolling your nipple between your fingers
having your back massaged.

Expressing and storing breastmilk:

1.

Wash your hands with soap and water.

2.

Prepare a clean container that can be covered for storing the milk. The container should be washed
in hot soapy water & rinsed in hot clear water.

3.

Feel back from your nipple to find a place where your

breast feels different. This may feel like knots on a
string or like peas in a pod. This is usually a good place
to put pressure when expressing. Put your thumb on one
side of the breast and 2-3 fingers opposite.

4.

Compress the breast over the ducts. Try pressing your thumb and fingers back
towards your chest, and then press your thumb
and fingers towards each other, moving the milk towards the nipple.
Release and repeat the pressure until the milk starts to come.

5.

Repeat in all parts of the breast. Move your fingers around the breast to compress different ducts.
Move to the other breast when the milk slows. Massage your breast occasionally as you move your
hand around. If you are expressing to clear a blocked duct, you only need to express in the area that is
blocked.

6.

Each container should be labeled with the date. First come first serve.

It takes practice to get large volumes of milk. First milk (colostrum) may only come in drops. These
are precious to your baby.

How often to express depends on the reason for expressing. If your baby is very young and not
feeding at the breast, you will need to express every 2-3 hours.

It is important to have clean hands and clean containers for the milk. Discuss milk storage if
needed.

These points are suggestions not rules.

Find what works best for you.
Expressing should not hurt and to ask for help if it does.
Ask if you have any questions. You can get information or help from:

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Job-Aids (Handout)

Milk Expression

(SESSION 11: IF BABY CANNOT FEED AT THE BREAST STEP 5)

Cup Feeding a Baby

Why cup feeding is recommended
It is pleasant for the baby there are no invasive tubes in his or her mouth.
It allows the baby to use his or her tongue and to learn tastes
It stimulates the babys digestion,
It encourages coordinated breathing/suck/swallow,
The baby needs to be held close and eye-contact is possible,
It allows baby to control the amount and rate of feeding,
A cup is easier to keep clean than a bottle and teat,
It may be seen as a transitional method on the way to breastfeeding rather than as a failure of
breastfeeding.

HOW TO FEED A BABY BY CUP

Sit the baby upright or semi-upright on your lap; support the babys back, head and neck. It helps to
wrap the baby firmly with a cloth, to help support his or her back, and to keep his or her hands out of
the way.
Hold the small cup of milk to the baby's lips.
The cup rests lightly on the baby's lower lip, and the edges of the cup touch the outer part of the
baby's upper lip.
Tip or tilt the cup so that the milk just reaches the baby's lips.
The baby becomes alert, and opens his or her mouth and eyes.
A preterm baby starts to take the milk into his or her mouth with his or her tongue.
A full term or older baby sucks the milk, spilling some of it.

Measure the babys intake over 24 hours - not just at each feed.

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When the baby has had enough, the baby closes his or her mouth and will not take any more. If the
baby has not taken the calculated amount, he or she may take more next time, or you may need to
feed the baby more often.

Job-Aids (Handout)

DO NOT POUR the milk into the baby's mouth. Just hold the cup to the babys lips and let him or her
take it himself or herself.