Subject Pediatrics 1

Topic Nutrition 1: Breastfeeding

Date November 20, 2009
Lecturer Dr. R. Espos, Jr.
Batch 2012 (AY 2009-2010) Transcriber Marissa Golla Pages 14
Subj. Head Marissa Golla
Editor Emil Balitaan

NUTRITION 1: BREASTFEEDING
A. THE BENEFITS OF BREASTFEEDING
B. ADVANTAGES OF BREASTFEEDING FOR THE BABY
C. ANATOMY AND PHYSIOLOGY DURING PREGNANCY
1. CHANGES SEEN IN PREGNANCY
2. HOW DOES THE BREAST PRODUCE MILK?
3. LACTOGENESIS
4. BEFORE DELIVERY: PREPARATION FOR BREASTFEEDING
D. MECHANICS OF BREASTFEEDING
1. TIPS AND TROUBLESHOOTING
2. BREAST ABNORMALITIES AND BREAST CARE
3. ISSUES FOR THE BABY
4. FAMILY CONCERNS
5. SOCIAL CONCERNS
E. BREASTFEDING: GETTING STARTED
1. INFANT FEEDING CUES
2. PREPARING FOR BREASTFEEDING
3. PROPERPOSITIONING
4. THE PROCESS OF BREASTFEEDING
a. MILK EJECTION REFLEX
b. OFFERING YOUR BREAST TO THE BABY
c. ROOTING REFLEX AND LATCH-ON
d. OPEN WIDE
e. COMING OFF THE BREAST
f. IS THE BABY GETTING ENOUGH TO EAT
F. NURSING MOTHER
G. REASONS TO SUSPEND OR AVOID BREASTFEEDING
H. WEANING
I. MOTHER-BABY FRIENDLY HOSPITAL INITIATIONS (MBFHI)
J. TEN STEPS TO SUCCESSFUL BREATFEEDING
K. COMBINED STEPS: THE IMPACT OF BABY-FRIENDLY PRACTICES: THE PROMOTION OF BREASTFEEDING INTERVENTION
TRIAL (PROBIT)
L. BREASTFEEDING AND CHILD SURVIVAL

A. THE BENEFITS OF BREASTFEEDING:

1. Nutrition:
o containing ideal proportions of fats, vitamins, sugar, and water for infant development.
o Human breast milk is the most complete source of nutrition for babies
o It is easier to digest than formula and causes less unnecessary weight gain.

2. Immunity:
o Immunoglobulins found in breastmilk help protect against infectious diseases caused by viruses,
bacteria, and parasites, until the baby’s immune system has more fully developed

3. Reduce disease risk: may decrease risk of chronic childhood diseases (such as types 1 and 2 DM, celiac
disease, inflammatory bowel disease, childhood cancer, allergies, and asthma)

4. Brain development and growth: long-chain polyunsaturated fatty acids (PUFAs) are important for brain
development; these are found in breastmilk and may lead to early visual acuity and cognitive function

5. Mother’s health: breastfeeding increases oxytocin levels, which minimizes postpartum blood loss and
induces a more rapid uterine involution. It can also facilitate mother-child bonding

6. Economic: breastmilk is many times cheaper than any baby formula. Breastfed babies typically require
fewer sick medical appointments, hospitalizations, and prescriptions than non-breastfed babies.
Breastfeeding mothers must stay home with a sick baby less often and thus miss less days of work.

B. ADVANTAGES OF BREASTFEEDING FOR THE BABY

1. Less illnesses, diseases, and disorders
2. Antibodies in breast milk
3. Always the right temperature
 4. Nurturing benefits from skin-to-skin contact
5. Aids in development of baby’s brain and nervous system

- Breastfeeding has been associated with reduced rates of allergies to cow’s milk and other allergies,
asthma, diabetes, high cholesterol, obesity, ear infections, dental caries, infections, constipation,
vomiting, diarrhea, deaths from respiratory infections, sudden infant death syndrome (SIDS), and cancers
(such as leukemia and lymphomas).
- Infants also benefit from appropriate jaw, teeth, and speech development as well as overall facial
development.
- Breastmilk contains all the nutrients a baby needs, regardless of whether the baby was preterm or term at
birth.

C. ANATOMY AND PHYSIOLOGY DURING PREGNANCY

- The breast is formed by skin, chest muscles, blood vessels, nerves, fatty tissue, and milk-producing
tissue
o The areola is the dark, circular area surrounding the nipple
o Montgomery glands: located under the areola; secretes a protective lubricant which prepares the
breast for breast feeding.
Prolactin levels increase
1. Changes seen in pregnancy ↓
o Breast, areola, and nipple increase in size Prolactin stimulates milk
o Veins may be more noticeable cells in the alveoli to
o Milk glands and ducts increase produce and secrete milk
o Colostrum is produced in the second trimester ↓
o Montgomery glands become more numerous and prominent Milk reservoirs store the
milk
2. How does a breast produce milk? ↓
o Milk is made in grape-like structures deep in the breast Special nerves in the nipple
o When milk is ‘let down’, it travels out of the ‘grapes’ (alveoli) are stimulated as the baby
down the ‘stems’ (ducts) and collects in the sinuses under sucks
the areola behind the nipple ↓
o Baby;s gums press the areola to release the milk The impulse is sent to the
o Milk production of the mother begins at birth of the baby brain
Once the baby is delivered,
hormones stimulate the
3. Lactogenesis
alveoli to produce milk
a.Nipple stimulation and sucking stimulates nerve endings in
↓
the areola and sends messages to the brain
Breasts become engorged
b.The pituitary gland then secretes the hormone, prolactin,
which stimulates milk production, and oxytocin, which causes the release of milk

4. Before Delivery: Preparing for Breast feeding

a.Massage the breasts and rub nipples gently
b.Avoid using soap on the nipples
c. Expose nipples to air and briefly to sunlight
d.Let nipples rub against clothing

D. MECHANICS OF BREAST FEEDING

- The mother should be comfortable and support the baby’s neck and shoulders with her arms or a pillow
- Move nipple gently back and forth across the baby’s mouth until the mouth opens wide. Move the baby
toward the mother’s breast so that baby can close mouth around the nipple.
- Make sure that the baby’s chin (not the nose) is in contact with the mother’s breast to allow the baby to
breathe.
- The mother may need to hold or support her breast while nuring.
- The baby’s mouth will usually detach automatically when the baby is finished.
- If the mother or baby is not comfortable or relaxed, it’s ok to start ocver.
- Reassure the mother that it is ok to ask for help!

1. Tips and Troubleshooting:

a.Epidurals rather than general anesthetics to allow mothers to be more alert immediately after
giving birth. Typically, the pain medications and antibiotics given after undergoing a caesarian
section are compatible with breastfeeding.
b.Partners, midwives, or doulas can help position mother to breastfeed after birth.
Doula: person experienced in childbirth who provides advice, information, and emotional
support to a mother before, during, and just after child birth
Midwife: person skilled in assisting women during childbirth and skilled in delivering
babies

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c. Colostum: thick, yellowish milk produced initially during breastfeeding. Colostrum is low in fat and
high in carbohydrates, proteins, and antibodies. It is easy to digest and helps flush out baby’s
stool, preventing jaundice. Most mothers should ‘save colostrum’ and feed it indirectly to infants if
direct breastfeeding is unsuccessful. Thin, pale, ‘normal’ breast milk seen after a few days.

d.Schedules: mothers should watch for signs of hunger in their baby, such as crying or the rooting
reflex (sucking on hands or fingers), rather than watching the clock. Healthy babies should feed
every 2-3 hours. Frequent feedings keeps the baby healthy and breasts stimulated produce an
adequate milk supply. As the baby ages and the baby’s stomach grows, feedings naturally
become less frequent.

e.Leaking: sometimes, milk leaks from one breast while a baby feeds from the other. A nursing pad
or towel can be used to clean up. Leaking can be minimized by not missing a feeding. If a mother
feels a leak but cannot nurse at the moment, apply slight pressure (i.e., by crossing arms), to help
stop milk ejection.

f. Fullness: when the mother’s milk supply adjust to the baby’s needs, the feeling of ‘fullness’ may
decrease (but does not indicate inadequate production)

g.It is normal to have one breast that produces more milk than the other; it is also normal for the
baby to prefer one breast over the other.

h.Inverted or flat nipples: mothers with either of these can still breastfeed

i. A cross-body sling: is recommended to carry the baby. It provides constant tactile contact,
promotes healthy child development, helps baby transition from calm womb to outside
environment, encourages non-verbal communication and bonding, often calms the babies,
facilitates discreet nursing, and frees the mother’s hands.

j. Breast feeding should not hurt if done safely and correctly. Soreness is usually caused by
improper positioning, blocked milk flow, stress, or infection. Changing position, applying a hot
water bottle for warmth, getting rest, and frequent feedings can reduce pain.

k. Mastitis: breast infection with tender breast(s), in which the mother may feel achy, tired, and
feverish; may require antibiotic treatment.

 Continue to breastfeed the baby: the antibacterial properties of human milk protect the
baby from infection and the speedy recovery of the mother. If symptoms persist after 24
hours, the mother should consult with the physician. Prescribed medication should be
compatible with breastfeeding. Encourage mothers to take entire antibiotic course to help
avoid infection recurrence.

l. Thrush: yeast infection of the nipples that may cause sudden, persistent breast or nursing pain,
itching, redness, burning, cracked or flaky nipples. Thrush can be transmitted from mother to
infant. Mothers with nipple thrush should consult doctor for treatment immediately and wash all
bras, pads, shirts, blankets, nightgowns, and other items that contact their breasts.

m. Use lotion/soap or towel to ‘rough up’ the nipples as a preparation for a feeding is no
longer recommended. The breasts produce protective substances that may be removed by
these synthetic materials. Patients with skin conditions should consult a doctor.

n.Thinning milk, less frequent feeding, decreasing stool and slowing of baby growth after first few
weeks are normal changes and typically do not indicate inadequate milk supply

o.Biting: often occurs when babies are teething and does not necessarily mean that they want or
need to be weaned. Protect nipple from biting by sliding finger into the baby’s mouth. If a baby
bites while nursing, lightly latch on to your nipple and position the baby closer to the breast.

p.Sudden changes in baby’s feeding behavior may indicate illness or reaction to something the
mother ate. Mothers should pay attention to their diets while breastfeeding.

q.Reflux: return of stomach contents into the esophagus. Breastfed babies have less severe reflux
at night. Continue to breastfeed babies with reflux.

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2. Breast abnormalities prevention and breast care:
a.Flat or inverted nipple:
 Begin treatment late in pregnancy, stop if it causes uterine contractions
 Breast shells: wear 1 hour a day and gradually increase to several hours; dry area under
nipple often

b.Sore or cracked nipples:

 Properly position the infant (use pillows, check good latch on)
 Do not use ointments or creams
 Express a few drops of milk onto nipple after feeding (has antibacterial properties), allows
nipple to air dry

c.Engorgement
 May occur between second and sixth day when your milk ‘comes in’
 Occurs more frequently in first-time mothers
 This is caused by additional blood that has rushed to the breast in order to assure
adequate nourishment for the new baby, and some swelling of tissues. Breasts may feel
like they will burst.
 Hang in there! This will go away after a day or so…

 Treatment (engorgement)
• Nurse baby frequently: emptying the breasts will relieve the congestion
• Use warm showers: may alternate between hot and cold packs
• Gentle breast massage: with the palm of your hand, gently stroke the breast
downward toward the nipple. This is the most effective when done under a
shower or while leaning over a bowl of warm water.
• If engorgement causes the nipples to flatten and you are having difficulty latching
the baby on, you may try pumping or hand expressing some milk first to relieve
the fullness
• Breast shells can also be used between feedings to draw out flat nipples.
• Sometimes, placing a cold washcloth or ice pack on your nipple will help bring it
out.

d.Plugged ducts
 Tender spot, redness, or sore lump in the breast
 Milk is unable to flow through the ducts and this leads to inflammation
 Change feeding positions from time to time
 May be caused by improper positioning, infrequent nursings, supplementary bottles,
overuse of pacifiers, bras that are too tight, or other restrictive clothing

 Treatment
• Change positions at each nursing: lie down, sit up,, switch from the rocking chair
to the sofa to a lounge chair. A variety of positions will give your baby a better
change to reach all of the milk ducts and keep them emptied.
• Lean over to nurse: get up on your hands and lean over to nuerse, with your
breasts hanging freely from the rib cage. This allows a plugged duct to be
opened more easily. While this position may not be the most comfortable to you,
it can allow a plugged duct to be opened and keep the inflammation from
progressing to mastitis.

e.Mastitis
 Occurs when a plugged duct is not treated
 Flu-like symptoms (tired, aches, fever)
 Start treatment immediately
• Contact physician for antibiotics
• Apply heat
• Breastfeed frequently
• Rest
• Nurse frequently – mastitis will not harm the baby and the infection will clear up
more quickly when the breast is kept empty
• Antibiotics in your milk will protect the baby from the bacteria that may be
causing the infection

3. ISSUES FOR THE BABY

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 a.Weaning: the American Academy of Pediatrics recommends that a women and her baby should,
as long as they wish to, at least 12 months. Solid foods can be introduced at 6 months as well. In
many societies, children continue to breastfeed up to 3-4 years. Weaning should ideally happen
gradually.
b.Co-sleeping: contrary to popular opinion, co-sleeping (sleeping with baby in the parents’ bed or
room) promotes independence and bonding, regulates parent and child sleep patterns, and
facilitates continued breast feeding on demand.
c. Frequent nursing: will not ‘spoil’ the baby. Research indicates that breastfeeding provides
nutrition, protection, and security that aid in child development.

4. FAMILY CONCERNS
a.Role of the Mother’s Partner: important for the child and partner. Partner can become attuned
to child’s needs and personaility. The partner can hold the baby, support the mother during times
of stress and fatigue, encourage healthy parental lifestyile, and help deflect negative comments
or criticism from others about childrearing methods. In addition, the partner can provide mother
with the desired affection and intimacy.
b.Breastfeeding reduces but does not eliminate the probability of becoming pregnant. If a
baby is less than 6 months old, the mother is amenorrheic, and the baby breast feeds around the
clock, a woman’s chances of becoming pregnant are less than 2%.
c. Breastfeeding multiple births (twins, etc.) and multiple children (‘tandem nursing’) is possible
(and common in many societies) with advanced planning and adequate support. Self-confidence
is an important factor in producing enough milk; mothers should ignore or deflect critical remarks
questioning the ability to supply adequate milk. For more information, consult a doctor or La
Leche League.

5. SOCIAL CONCERNS
o Discretion is possible with loose clothes, specialized or easy-to-adjust bras, and small light
blankets. Even when the nursing mother does not feel a personal need for modesty, such
considerations may make others more comfortable, especially in public places.

E. BREASTFEEDING: GETTING STARTED

1. Infant Feeding Cues
o Watch for signs that your infant is hungry. When crying occurs, earlier feeding cues have
been missed and it is much difficult to feed an infant who is crying.
 Bringing hands to mouth or check and trying to suck on them
 Rooting
 Lips smaking, mouthing, tongue protrusion
 Crying is a late feeding cue

2. Preparing for Breast feeding

o Wash your hands
o Position yourself comfortably and correctly
o Use pillows or towels for support
o Uncover the breast you wish to offer first
o Be comfortable
 It’s easiest to try breastfeeding first sitting up
 Sit in a bed, arm chair, or rocking chair
 Place pillows behind your back, under your elbow, or in your lap to support your baby
 You may find that a footstool brings your knees up and makes you more comfortable
 Hold baby at breast level
o Support your breasts if they are large and support the baby’s head. Support keeps your nippls
from pulling away from the baby, making your nipple sore. You should not feel tugging. Use your
elbow and forearm on the side the baby will breastfeed from to will support baby’s head, neck and
back. Use that same hand to hold the baby’s bottom or thigh.
o Correct holds: Cradle hold, Cross Cradle hold, Football hold, Side-Lying
o Holding the bottom of the thigh will help mom to roll baby inward to wrap around her trunk in a C-
shape
o Baby’s ear, shoulder, and hips will be aligned with his/her legs
o Baby’s chin and the tip of the nose should be touching the breast
o Improper positioning
 Can cause nipple soreness
 Restricts milk flow
 Presses back on the areola and breast
o Incorrect breast support: ‘V-hold’ or ‘cigarette hold’
o Incorrect body positioning:
 Baby lies on his back

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  Baby’s head tipped back away from the breast
-These positions cause pulling and tugging on the nipple which can lead to nipple
soreness and injury

Side Lying Position Football Position Cradle Position

3. Proper Positioning
a.Side Lying Position – good position for C-section moms or to doze off while breastfeeding
 Make mother lie on her side with pillows to support her head
 Position the baby such that the mother and the baby are ‘tummy-to-tummy’
 Baby’s mouth should be in line with the nipple

b.‘Football’ Position – good position for mothers who had C-section

 Baby’s legs are under your arm
 Use pillows
 Helpful for babies who are having trouble latching on

c.Cradle Position
 Tummy-to-tummy
 Baby’s head in the crook of the mother’s elbow
 Level with the breast
 Pillow in the lap will help

4. The Process of Breastfeeding

a.Milk Ejection Reflex (“Let Down”)

 Tingling sensation in the breast and a relaxed feeling occurs

 The ‘let down’ reflex can occur between feedings
 Milk comes in on average 3-4 days postpartum. Prior to this the infant is suckling
antibody-rich colostrum
 Milk will come in faster by nursing as soon as possible postpartum and nursing
frequently.
 Engorgement – when the milk comes in and the breast becomes hard and painful. This
is relieved by breastfeeding
 The ‘let down’ reflex is stimulated by infant suckling. This can be inhibited by hear,
embarrassment, and anxiety. The reflex releases a calorie-rich milk essential for infant
weight gain.
Foremilk is produced between feedings and is high in protein.
Calorie-rich hindmilk is released with ‘let down’ and as breast feeding continues.
 Using both breasts at every feeding allows maximum nutrition and continued milk
production
 During let down, milk may drip from second breast and uterine cramping may occur
 If you feel your ‘let down’ between feedings, press inward on the areola to stop the
release of milk. (Breasts pads worn in the nursing bra are helpful to catch milk that leaks
out between feedings).

b.Offering your breast to the baby

 Fingers underneath, thumb on top of the breast; fingers well behind areola
 Always alternate the breast you start with.
• Babies usually nurse more vigorously at the first breast.
• This will make sure that both breasts get an equal amount of stimulation.

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 • You may use a safety pin on your bra strap to remind you which side to begin
with, or palpate your breasts and begin with the side that feels more full.
 Cup your breasts with your free hand, supporting it with your fingers underneath and
thumb on top.

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 c.Rooting Reflex and Latch-On
1. Position the baby correctly at the breast with mouth directly in front of the nipple.
2. Use the nipple to tickle baby’s lips until mouth opens wide.
3. Support the baby’s head
4. Baby’s mouth is open wide enough to take in nipple and most of areola.

Special Information
- Babies are bone with a reflex that causes them to open their mouths wide when properly stimulated. To
stimulate the rooting reflex, brush the baby’s lips gently. If your baby does not open her mouth
wide, be patient and keep brushing her lips.

Some babies respond more quickly if their bottom lip is lightly brushed or tickled. Be patient. The baby
is learning about breastfeeding just like you are.

- Wait until the baby’s mouth is wide open. Center your nipple in her mouth and quickly pull her to the
the breast. It is very important that your bay opens her mouth wide and takes in as much of the nipple
as possible. This will prevent pain and nipple soreness.

- Latch-on occurs when the baby compresses the areola and draws nipple into mouth. The infant
needs to compress the milk sinuses under the areola to release the milk. If the baby grasps the nipple
only, the milk sinuses will not be compressed to release milk. Swallowing occurs in response to the
presence of milk.

d.Open Wide
 Quickly center your nipple in his mouth and pull him toward you
 Baby’s lower jaw far back from the nipple
 Baby’s chin on breast
 Nose may be on breast

- When your baby opens his mouth WIDE (like a yawn) quickly center your nipple in his
mouth and pull him toward you with the arm that is holding him.
- With a good latch-on, your baby’s lower jaw (which does most of the work of nursing)
should be as far back from the nipple as possible.
- The baby should be pulled in so close that his chin is pressed into the mother’s
breast. His nose may be on the breast as well.
- Some mothers are afraid to pull their babies this close, because they worry that the
baby won’t be able to breathe. But a baby’s nostrils are flared so that he can breathe
even when his nose rests against the breast.

e.‘Coming Off’ the Breast

 Watch the baby for cues that he is finished
 The baby may come off the breast in his own
 May fall asleep
 Allow baby to determine when he is done

- If you need to stop the feeding early, break suction by inserting finger into corner of
baby’s mouth
- Babies usually nurse for a total of twenty to thirty minutes at a feeding – 10 to 15
minutes on each breast. But all babies are different -- some nurse for shorter periods,
others for longer periods.
- The same baby may nurse longer at one feeding than at another
- Watery foremilk contains protein while hindmilk contains fat and calories. Only the
baby knows if he’s had the right amount of both and is satisfied.
- If you need to take you baby off the breast before he is finished, break the suction to
avoid damage to sensitive breast tissue.

f. Is the baby getting enough to eat?

 She eats 8-12 times in 24 hours
 During each feeding, she actively sucks on each breast for 10-15 minutes
 Adequate wet diapers
 2-3 per day by day 3; 6 or more/day by day 6 after birth
 Adequate Stools
 Baby’s stools will be meconium first day or two
 After 3rd or 4th day, should have about 3 bowel movements per day for the first few
months. Appearance is generally loose, yellow, and seedy with mild smell
 As baby gets older stools may decrease in frequency
 Weight gain
 Initially, all babies a bit of birth weight (5-7%) but should regain it by 2 weeks

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  Baby should gain about 1 pound a month
 Ask pediatrician about Vitamin D supplementation.

 The size of a women’s breast have nothing to do with how much milk her body can make.
To maintain your milk supply, empty your breast at regular intervals. Toeno maintain milk
supply, you must have repeated stimulation of the nipple and areola to produce prolactin
and oxytocin. The more you breastfeed, the more milk you will produce.

F. THE NURSING MOTHER

- Stay well-nourished
o Follow same healthy diet you ate while pregnant
o Breast feeding burns 300-400 additional calories per day
o If you are not well nourished, your supply of breast milk may decrease

G. REASONS TO SUSPEND BREAST FEEDING

- Treatment with a medication that transfers into the breast milk
- Level of risk to environmental exposures at duty station or in the field (such as solvents, chemicals, fuels)

H. WEANING
- Wean gradually
- Substitute a bottle or serve drinks in a sippy cup
- Ensure adequate nutrition for baby
- Be firm in your decision

I. MOTHER-BABY FRIENDLY HOSPITAL INITIATIONS (MBFHI)

- It is a program transforming hospitals with maternity and newborn services and facilities which fully
protect, promote and support breastfeeding and rooming-in practices.

1. What is a Mother-Baby Friendly Hospital?

o Promotes, protects and supports breastfeeding and rooming-in practices.
o Empowers the mother to successfully breastfeed.
o Upholds the right of the infant for breastmilk.
o Does not accept free supply of infant formula.
o Does not maintain a nursery for newborn normal cases.
o Follows the principle of breastmilk “first and foremost”.
o Follows the principle of absolutely no milk formula for the newborn.
o Follows the WHO-UNICEF, 10 steps to successful breast feeding.

2. What are the goals of MBFHI?

a.Program Goal - all hospitals rendering maternity and newborn services that are mother and baby
friendly will adopt the MBFHI program.
b.Mid-Decade Goal - all hospitals rendering maternity with newborn services and having at least 10
deliveries will be a mother-baby friendly by the year 1995.

3. Republic Act 7600

o An act providing incentives to all government and private health institutions with rooming-in and
breastfeeding practices and for other purposes. This act shall be known as the “ROOMING-IN
AND BREASTFEEDING ACT OF 1992”

a.Normal spontaneous deliveries- The following newborn infants shall be put to the breast of the
mother immediately after birth and forthwith roomed-in within thirty (30) minutes
1. well infants regardless of age of gestation.
2. infants with low birth weights but who can suck.
b.Deliveries by caesarian- Infants delivered by caesarian section shall be roomed-in breastfed
within three (3) to four (4) hours after birth.
c. Deliveries outside health institutions- Newborns delivered outside health institutions whose
mothers have been admitted to the obstetrics department/unit and who both meet the general
conditions stated in Section 5 of this Act, shall be roomed-in and breastfed immediately.
d.Exemptions- Infants whose conditions do not permit rooming-in and breastfeeding as determined
by the attending physician, and infants whose mothers are either:
1. seriously ill;
2. taking medications contraindicated to breastfeeding,
3. violent psychotics; or

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4. whose conditions do not permit breastfeeding and rooming-in as determined by the
attending physician. Provided, that these infants shall be fed expressed breastmilk or
wet-nursed as may be determined by the attending physician.

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 e.The following acts shall be considered as violations under this rule:
1. Prescription of infant formula to neonates without valid acceptable medical indication.
2. Acceptance of gifts, samples, donation of milk and other supplies from milk companies.
3. Display of posters related to infant formula and milk substitutes by milk companies
anywhere in the health facility.
4. Conduct of continuing education activities sponsored by companies manufacturing milk
or related products as covered by E.O.51 w/o prior approval.
5. Giving of samples of milk formula, other than milk substitutes and related products like
feeding bottles and teats in the facility.
6. Selling infant formula and breastmilk substitutes and related products in the hospital
pharmacy.

4. EXECUTIVE ORDER 51 (MILK CODE)

o Protection and promotion of breastfeeding to ensure the safe, adequate nutrition of infants thru
regulation of marketing of infant foods, related products (e.g. Breastmilk substitutes, infant
formula, feeding bottles, teats etc.)
o Imposition of restrictive upon health workers, health care system, manufacturers and distributors
of regulated products and the general public. These details are examined by assessors when
they assess the hospital for mother and baby friendliness.
o Adopting a national code of marketing of breastmilk substitutes, breastmilk supplements and
related products, penalizing violations thereof and for other purposes.
o This Code shall be known and cited as the “National Code of Marketing of Breastmilk Substitutes,
Breastmilk Supplement and Other Related Products.”

o The aim of the Code is 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 and breastmilk supplements when these are necessary, on the basis of adequate
information and through appropriate marketing and distribution.

J. TEN STEPS TO SUCCESSFUL BREASTFEEDING

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 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 breast milk unless medically-indicated.
7. Practice rooming-in — allow mothers and infants to remain together — twenty-four hours
a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies and soothers) to breastfeeding
infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic.

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
o Requires a course of action and provides guidance
o Helps establish consistent care for mothers and babies
o Provides a standard that can be evaluated

o What should it cover?

 At a minimum, it should include:
• The 10 Steps to Successful Breastfeeding
• An institutional ban on acceptance of free or low-cost supplies of breastmilk
substitutes, bottles, teats, and its distribution to mothers
• A framework for assisting HIV-positive mothers to make informed infant feeding
decisions that meet their individual circumstances and then support for this
decision.
 Other points can be added

o How should it be represented?

 Written in the most common languages understood by patients and staff
 Available to all staff caring for mothers and babies
 Posted or displayed in areas where mothers and babies are cared for

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2. Train all health-care staff in skills necessary to implement this policy.
o Areas of Knowledge
 Advantages of breastfeeding
 Risks of artificial feeding
 Mechanisms of lactation and suckling
 How to help mothers initiate and sustain breastfeeding
 How to assess a breastfeed
 How to resolve breastfeeding difficulties
 Hospital breastfeeding policies and practices
 Focus on changing negative attitudes which set up barriers

o Additional topics for BFHI training in the context of HIV

 Basic facts on HIV and on Prevention of Mother-to-Child Transmission (PMTCT)
 Voluntary testing and counselling (VCT) for HIV
 Locally appropriate replacement feeding options
 How to counsel HIV+ women on risks and benefits of various feeding options and how to
make informed choices
 How to teach mothers to prepare and give feeds
 How to maintain privacy and confidentiality
 How to minimize the “spill over” effect (leading mothers who are HIV - or of unknown
status to choose replacement feeding when breastfeeding has less risk)

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

Antenatal Education should include:
o Benefits of breastfeeding
o Early initiation
o Importance of rooming-in (if new concept)
o Importance of feeding on demand
o Importance of exclusive breastfeeding
o How to assure enough breastmilk
o Risks of artificial feeding and use of bottles and pacifiers (soothers, teats, nipples, etc.)
o Basic facts on HIV
o Prevention of mother-to-child transmission of HIV (PMTCT)
o Voluntary testing and counselling (VCT) for HIV and infant feeding counselling for HIV+ women
o Antenatal education should not include group education on formula preparation

4. Help mothers initiate breastfeeding within a half-hour of birth. New interpretation of Step 4 in the
revised BFHI Global Criteria (2006): “Place babies in skin-to-skin contact with their mothers immediately
following birth for at least an hour and encourage mothers to recognize when their babies are ready to
breastfeed, offering help if needed.”

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 Early initiation of breastfeeding for the normal newborn:
Increases duration of breastfeeding
Allows skin-to-skin contact for warmth and colonization of baby with maternal
organisms
Why? Provides colostrum as the baby’s first immunization
Takes advantage of the first hour of alertness
Babies learn to suckle more effectively
Improved developmental outcomes
1. Keep mother and baby together
2. Place baby on mother’s chest
How? 3. Let baby start suckling when ready
4. Do not hurry or interrupt the process
5. Delay non-urgent medical routines for at least one hour

Protein Composition of Human Colostrum and Mature Milk (per litre)

Constituent Colostrum Mature Milk
(1-5 days) (>30 days)
Total Protein 23 g 9 – 10.5 g
Casein 1400 mg 1870 mg
Alpha-lactalbumin 2180 mg 1610 mg
Lactoferrin 3300 mg 1670 mg
IgA 3640 mg 1420 mg

5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated
from their infants.
o Milk removal stimulates milk production.
o The amount of breast milk removed at each feed determines the rate of milk production in the
next few hours.
o Milk removal must be continued during separation to maintain supply.

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

The perfect match: quantity of colostrum per feed and the newborn stomach capacity

Impact of routine formula supplementation:

Decreased frequency or effectiveness of suckling
↓
Decreased amount of milk removed from the breasts
↓
Delayed milk production or reduced milk supply
↓
Some infants have difficulty attaching to the mother’s breast if formula given by bottle

o Determinants of lactation performance across time in an urban population from Mexico

 Milk came in earlier in the hospital with rooming-in where formula was not allowed

 Milk came in later in the hospital with nursery (p<0.05)

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  Breastfeeding was positively associated with early milk arrival and inversely associated
with early introduction of supplementary bottles, maternal employment, maternal body
mass index, and infant age.

Summary of Studies on the Water Requirements of Exclusively-Breastfed Infants

Country Temperature Relative Humidity Urine osmolarity

(Celcius) (%) (mOsm/L)
Argentina 20-39 60-80 105-199
India 27-42 10-60 66-1234
Jamaica 24-28 62-90 104-468
Peru 24-30 45-96 30-544

o Medically-indicated
 There are rare exceptions during which the infant may require other fluids or food in
addition to, or in place of, breast milk. The feeding programme of these babies should be
determined by qualified health professionals on an individual basis.

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  Acceptable Medical Reasons for Supplementation or Replacement :

Infant - Infants who cannot be BF but can receive BM include those

Conditions who are very weak, have sucking difficulties or oral
abnormalities or are separated from their mothers.
- Infants who may need other nutrition in addition to BM include
very low birth weight or preterm infants, infants at risk of
hypoglycaemia, or those who are dehydrated or malnourished,
when BM alone is not enough.
- Infants with galactosemia should not receive BM or the usual
BMS. They will need a galactose free formula.
- Infants with phenylketonuria may be BF and receive some
phenylalanine free formula.
Maternal - BF should stop during therapy if a mother is taking anti-
Conditions metabolites, radioactive iodine, or some anti-thyroid
medications.
- Some medications may cause drowsiness or other side effects
in infants and should be substituted during BF.
- BF remains the feeding choice for the majority of infants even
with tobacco, alcohol and drug use. If the mother is an
intravenous drug user BF is not indicated.
- Avoidance of all BF by HIV+ mothers is recommended when
replacement feeding is acceptable, feasible, affordable,
sustainable and safe. Otherwise EBF is recommended during
the first months, with BF discontinued when conditions are met.
Mixed feeding is not recommended.
- If a mother is weak, she may be assisted to position her baby
so she can BF.
- BF is not recommended when a mother has a breast abscess,
but BM should be expressed and BF resumed once the breast
is drained and antibiotics have commenced. BF can continue
on the unaffected breast.
- Mothers with herpes lesions on their breasts should refrain from
BF until active lesions have been resolved.
- BF is not encouraged for mothers with Human T-cell leukaemia
virus, if safe and feasible options are available.
- BF can be continued when mothers have hepatitis B, TB and
mastitis, with appropriate treatments undertaken.

7. Practice rooming-in — allow mothers and infants to remain together — 24 hrs/day.

o Rooming-In
 A hospital arrangement where a mother/baby pair stay in the same room day and night,
allowing unlimited contact between mother and infant
 Why?
• Reduces costs
• Requires minimal equipment
• Requires no additional personnel
• Reduces infection
• Helps establish and maintain breastfeeding
• Facilitates the bonding process

8. Encourage Breastfeeding on-demand

o Breastfeeding on-demand
 Breastfeeding whenever the baby or mother wants, with no restrictions on the length or
frequency of feeds.

o On demand, unrestricted breastfeeding, why?

 Earlier passage of meconium
 Lower maximal weight loss
 Breast-milk flow established sooner
 Larger volume of milk intake on day 3
 Less incidence of jaundice

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

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 o Alternatives to artificial teats: cup, spoon, dropper, or syringe

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

"The key to best breastfeeding practices is continued day-to-day support for the breastfeeding
mother within her home and community."

o Support can include:

 Early postnatal or clinic checkup
 Home visits
 Telephone calls
 Community services (outpatient breastfeeding clinics, peer counseling programs)
 Mother support groups (help setup new groups, establish working relationships with
those already in existence)
 Family support system

 Types of Breastfeeding Mothers’ Support Groups

• Traditional
o Extended family
o Culturally-defined doulas
o Village women
• Modern, non-traditional
o Self-initiated: by mothers and concerned health professionals
• Government-planned
o Network of national development groups, clubs, etc.
o Health services – especially primary health care (PHCs) and trained
traditional birth attendants (TBAs)

K. Combined Steps: The impact of baby-friendly practices: The Promotion of Breastfeeding Intervention
Trial (PROBIT)
- In a randomized trial in Belarus 17,000 mother-infant pairs, with mothers intending to breastfeed, were
followed for 12 months.
- In 16 control hospitals & associated polyclinics that provide care following discharge, staff were asked to
continue their usual practices.
- In 15 experimental hospitals & associated polyclinics staff received baby-friendly training & support.

Control Hospitals Experimental Hospitals

Routine separation of mothers and babies at Mothers and babies together from birth
birth
Routine tight swaddling
Routine nursery-based care
Incorrect latching and positioning
techniques
Scheduled feedings every 3 hours
Routine use of pacifiers
No BF support after discharge
No swaddling – skin-to-skin contact
encouraged
Rooming-in on a 24-hour basis
Correct latching and positioning techniques
Breastfeeding on demand
No use of pacifiers
BF support in polyclinics

L. BREASTFEEDING AND CHILD SURVIVAL

1. The institution shall incorporate the breastfeeding policy with the orientation, continuing medical education
programs, on-going staff development activities, as well as the evaluation and promotion criteria.
2. The institution shall continue to attract and give priority to health personnel who shall encourage,
promote, protect, and sustain breastfeeding.
3. Breastfeeding, the breastfeeding policy, as well as the other five survival programs, shall be integrated
into the medical, nursing, midwifery, and other paramedical curricula of the De La Salle University Health
Sciences Campus.
4. The appointments of all health personnel shall only be awarded after the applicant/s has/have undergone
training in lactation management and after having demonstrated satisfactory knowledge, attitude and
skills in the promotion, protection and support of breastfeeding.

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 5. The waiting room of the Pre-natal Clinic of the Out-Patient Department shall be provided with all the
necessary audio-visual equipments, reading materials and the like to ensure that all pregnant mothers are
properly informed of the advantages and management of breastfeeding.
6. All OB-Gyne and Pediatrics Consultants shall provide their patients with ample and appropriate reading
materials and leaflets which promote, protect and sustain breastfeeding.
7. A Mothers’ Class shall be held daily by either the residents, interns, clinical clerks, or the nurse at the
OPD.
8. The husband and any other person/s who are in close contact with the pregnant mother and who play/s a
significant role in the promotion, protection and support of breastfeeding are encouraged to actively
interact during the pre-natal visit.
9. All clinics and other strategic places in this institution shall display at least one poster that promotes
breastfeeding.
10. All posters and other similar materials which promote the contrary shall therefore be removed.
11. The security guard shall perform routine and thorough inspection of all persons entering the hospital. The
following are being banned from being taken into the hospital:
a.Artificial milk formula
b.Milk substitutes
c. Teats, soothers and pacifiers
12. Patients’ visiting time for the OB Ward shall be limited to 9:00 am-11:00 am and 3:30 pm-6:30 pm.
13. All newborns shall be put to their mother’s breast immediately after delivery. All healthcare personnel
shall assist the mothers in order to ensure a successful latching-on process.
14. The hospital shall strictly implement the rooming-in practice.
a.The Nursery shall be converted into Neonatal Intensive Care Unit only.
b.Obstetricians shall inform all their patients about this policy and rooming-in practice at all times
during the pre-natal consultation.
c. The OB-Gynecological ward shall be improved.
d.All pregnant women admitted to the hospital are routinely and adequately informed of the
breastfeeding and rooming-in policies.
15. A breastfeeding room shall be provided at the NICU.
16. The NICU staff shall always ensure that the mothers are constantly reminded of the advantages, properly
taught and professionally supported about breastfeeding.
17. A properly equipped and functioning breast milk bank shall be available at the NICU.
18. The hospital pharmacy shall no longer display, dispense or sell artificial formula, milk substitutes, teats
and soothers and other similar or related materials.
19. All health personnel shall see to it that the babies are fed on demand.
20. A linkage shall be established with GO’s and NGO’s who promote and protect breastfeeding.
21. Obstetricians and Pediatricians are encouraged to routinely check and follow-up the status of
breastfeeding during the post-partum period for at least 4-6 months.
22. The institution shall establish its own breastfeeding support group in the near future.
23. The hospital shall provide a breastfeeding room for the personnel/employees, where they can breastfeed
even during working hours.
24. Obstetricians and Pediatricians, and members of the health staff shall encourage their patients to ask
questions about breastfeeding and make themselves available at any time for similar queries.
25. Mothers who have stopped breastfeeding shall be motivated to relactate.
26. Problems relevant to the policy shall be discussed during the monthly medical staff meeting.
27. Mothers shall be encouraged to give their opinions and suggestions on how the hospital can improve the
practice of breastfeeding and rooming-in.
28. Non-compliance of any member of the staff of this policy shall make them subject to appropriate
disciplinary action.

END OF TRANSCRIPTION

Walang pabati sorry. Pagod na ako mag-type… -editor

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