3 Exclusive breastfeeding

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When you have completed this chapter you should be able to:

  1. Understand why exclusive breastfeeding is the best way of feeding a baby
  2. List the advantages of exclusive breastfeeding
  3. Explain the dangers of formula or mixed feeding
  4. Support a mother to exclusively breastfeed
  5. Prevent and manage common breastfeeding problems
  6. Promote exclusive breastfeeding
  7. Explain why HIV positive women should be encouraged to breastfeed

Choice of feeding method

3-1 What are the three common ways of feeding a baby?

3-2 What is the best way to feed a baby?

Exclusive breastfeeding.

Exclusive breastfeeding is the best way to feed a baby.

3-3 What does exclusive breastfeeding mean?

Exclusive breastfeeding means that the baby is only given breast milk and no other fluids (such as water, formula, tea or juice) or solid foods (such as porridge or vegetables).

Exclusive breastfeeding means feeding the baby only breast milk.

3-4 Which children should be exclusively breastfed?

All children should be exclusively breastfed even if the mother is HIV positive.

3-5 What is formula feeding?

Formula feeding is feeding babies with powdered milk formula which has to be correctly prepared by adding it to water.

3-6 What is mixed breastfeeding?

Mixed breastfeeding means that the baby receives both breast milk and other food such as formula or solid food. Exclusive breastfeeding is much better than mixed breastfeeding for the baby. Exclusive breastfeeding rather than mixed breastfeeding should be encouraged.

3-7 Why is exclusive breastfeeding best?

Exclusive breastfeeding is best because it is safe and provides many benefits to both the baby and the mother. These benefits are the same for babies born to HIV positive or HIV negative women.

Exclusively breastfeed is best for both mothers and their babies.

3-8 What are the benefits of exclusive breastfeeding for a baby?

Exclusive breastfeeding helps the baby grow and develop normally and prevents infections.

3-9 What are the benefits of exclusive breastfeeding for the mother?

Exclusive breastfeeding is cheap, always available, emotionally satisfying and helps the mother recover from her pregnancy and delivery.

3-10 What are the problems with formula feeding?

Feeding babies with formula has many problems such as:

3-11 Can incorrect formula feeding cause the death of a baby?

Yes. Two important causes of death in formula fed babies are:

Therefore formula feeding of young babies can be dangerous, especially in poor communities.

Formula feeding is expensive and can be dangerous especially in poor communities without clean water.

3-12 What are the problems with mixed breastfeeding?

Because these babies are receiving both breast milk plus other forms of food such as formula, many of the benefits of exclusive breastfeeding are lost. Mixed breastfeeding causes many of the problems found with formula feeding.

Mixed breastfeeding also increases the risk of HIV crossing from the mother to the baby in the breast milk if they are not getting HIV medicines (ARVs).

Mixed breastfeeding is not as good as exclusive breastfeeding for both mother and baby.

Managing exclusive breastfeeding

3-13 When should a mother start breastfeeding?

As soon as possible after delivery. The newborn baby should be put to the breast and the mother should start exclusive breastfeeding within a half an hour after the baby is born. Once the baby is born and well dried and if the baby appears well and active, the baby can be put to the mother’s breast.

3-14 How often should a mother breastfeed her baby?

Babies should be fed on demand. This means the mother should put her baby to the breast whenever the baby wants to feed during the day and night. Most babies feed 8 to 10 times in 24 hours (a day and a night).

3-15 Do mothers have very little breast milk in the first few days after birth?

For the first few days after delivery the mother produces only small amounts of breast milk which may look yellow and weak. However this is normal and enough to meet the baby’s needs. The breast milk that is produced in the first few days after the baby is born is called colostrum. It is full of cells and antibodies to help protect the baby from infections.

Each day the mother will produce more milk and her breasts will start to feel full. The more the baby feeds the more breast milk the mother will produce. Most babies lose weight for the first few days. This is normal. By day 5 after birth the mother’s milk supply would have increased a lot and the baby should be gaining weight.

3-16 Should mothers with little milk give their baby formula feeds?

No. Many mothers think they do not have enough milk and so they start giving formula feeds. This is a common mistake. Most mothers are able to produce enough milk to meet the fluid and nutritional needs of their baby. It is important that babies do not receive formula feeds as this will reduce the mother’s milk supply.

These mothers should be encouraged and supported to breastfeed frequently. They should be shown how to hold the baby correctly so that it can latch well onto her breast.

If a baby is getting enough milk, the baby will have a wet nappy 6 or more times in 24 hours.

3-17 Can mothers with small breasts feed successfully?

Yes. Breast size is no indication of a woman’s ability to breastfeed. The size of a woman’s breasts depends on the amount of fat present and not on the parts of the breast that produce milk.

3-18 Should an exclusively breastfeeding mother give her baby water if the weather is very hot?

No. There is no need to give the baby extra fluid. It is best to breastfeed more frequently if the weather is very hot. In many rural areas water is not always safe to drink and can cause diarrhoea.

3-19 Is it safe for exclusively breastfed babies to be given medicine by mouth?

Yes. It is safe to give these babies medicine, such as antibiotics or vitamins, by mouth if it has been prescribed by a nurse or doctor. Babies should not have any over the counter medicines or traditional medicines as these can be dangerous.

3-20 Should exclusively breastfed babies receive vitamin or iron supplements?

No. Healthy babies that weigh more than 2500 g at birth do not need vitamin and iron drops. Breast milk provides all they need. However babies that weigh less than 2500 g at birth may need vitamin and iron drops from the clinic.

3-21 How can the baby be given breast milk if the mother is away?

If the mother cannot be with her baby all day she can express breast milk. This should be given to the baby using a cup and not a bottle. A cup is easy to clean and therefore is much safer than a bottle. A cup will also not stop the baby wanting to breastfeed which can happen when bottle feeds are given.

These mothers should be shown how to express breast milk into a clean cup. Expressed breast milk can be safely stored up to 6 hours in a cool place or for 48 hours in a fridge. There is no need to warm cold milk. Just allow it to stand for a few minutes at room temperature after taking it out of the fridge. Some working mothers can breastfeed when they are home and express milk for when they are away.

Cup feeding is the best alternative feeding method for exclusively breastfed babies when the mother is away or unable to breastfeed.

3-22 What is the correct method to express breast milk?

Figure 3-1: How to express breast milk

Figure 3-1: How to express breast milk

3-23 How would you demonstrate cup feeding?

Figure 3-2: How to cup feed a baby

Figure 3-2: How to cup feed a baby

3-24 For how long should a mother exclusively breastfeed?

It is best for both mother and baby if exclusive breastfeeding is continued for 6 months after the baby is born. During this time the baby needs no other fluid or solid food. Breast milk provides all the food that a baby needs up to the age of 6 months.

Mothers should exclusively breastfeed their babies for 6 months.

3-25 Why is it important to exclusively breastfeed for 6 months?

Because formula feeds and solid foods are not as good as breast milk for the baby. If the baby is also given formula feeds the baby will take less breast milk.

Cow’s milk is not suitable for small babies and can cause many problems.

3-26 Should mothers stop breastfeeding at 6 months?

No. They should continue breastfeeding as well as starting the baby on solid foods. It is best for an HIV negative mother to continue breastfeeding until her baby is about 2 years old.

At 6 months mothers need to introduce solid foods while continuing with breastfeeding. This is called complementary feeding.

Solid foods should be started at 6 months but mothers should be encouraged to continue breastfeeding as well until her baby is 2 years old.

3-27 Should mothers start formula feeds after 6 months?

Some mothers do give formula as well as breastfeed (mixed feeding) after 6 months. However most mothers will start giving the baby solid foods as well as continuing to breastfeed.

It is best if formula is not used unless:

It is therefore best for mothers to continue breastfeeding after six months but give the baby solid foods as well.

Helping mothers to breastfeed

3-28 How do you know if the baby is not getting enough breast milk?

3-29 How can you improve a mother’s milk supply?

If you think the baby is still not getting enough milk you should refer the mother and her baby to the clinic so that the baby can be weighed to assess whether it is gaining weight. The baby can also be weighed before and after a feed to find out how much milk the baby is taking.

The best way to increase milk production is frequent feeding.

3-30 What is the best position to hold a baby while feeding?

Holding the baby correctly while feeding is important. The mother should be warm and comfortable. Usually she sits up and holds her baby across her body in front of her. The baby is held in one arm and should lie on its side with its mouth facing the nipple. The breast is held in the other hand to offer the nipple to the baby. Mothers should be encouraged to try different feeding positions in order to find which is most comfortable. Some mothers prefer to lie down while they feed. Other mothers prefer to tuck the baby under an arm like a rugby ball.

Figure 3-3: How to hold a baby while breastfeeding

Figure 3-3: How to hold a baby while breastfeeding

3-31 How should the mother attach her baby to her breast?

One of the most common mistakes made when breastfeeding is that the baby is not attached correctly at the breast. The baby must take the whole nipple and most of the pigmented areola into the mouth. Sucking or chewing on the nipple causes pain and damages the nipple.

Good attachment prevents many of the difficulties of breastfeeding. Always observe a mother breastfeeding and make sure she positions and attaches the baby correctly to her breast.

3-32 What are the signs of good attachment?

With poor attachment the baby will suck on the nipple and not on areola. The baby will make rapid shallow sucks and the chin will not touch the breast.

Figure 3-4: Good breast attachment

Figure 3-4: Good breast attachment

The baby must take the whole nipple and most of the areola into the mouth when attaching at the mother’s breast.

3-33 What should a mother do if her baby chokes during a feed?

The mother may have a lot of milk and the milk may flow too fast, causing the baby to choke, gag or cough when starting to breastfeed. As a result, the baby may refuse to feed, or overfeed, and become restless. Teach the mother to take the baby off the breast if this happens and wait until the baby can breathe well again. Then start feeding once more. Make sure the baby does not have a blocked nose. It may help for the mother to lie back at the start of the feed with the baby across her chest so that the milk has to flow upwards against gravity. The mother may have to express a bit before starting the feed or feed the baby more frequently.

3-34 Should the baby always feed on both breasts?

For the first few days it is useful to allow the baby to feed on both breasts to stimulate the milk production. Thereafter it is best to empty one breast first before putting the baby to the opposite breast. This makes sure that the baby gets the rich hind milk at the end of the feed. Start each feed on the opposite breast to the previous feed.

Difficulties with exclusive breastfeeding

3-35 Is exclusive breastfeeding always easy?

No. Breastfeeding is an art which has to be learned. The best way to learn how to breastfeed successfully is to be helped by other women who have breastfed or by nurses who have been trained in breastfeeding.

The mother should take the decision to exclusively breastfeed before her baby is born. If the woman is still undecided at delivery, she should be encouraged to breastfeed.

3-36 What preparation does a mother need for breastfeeding?

No routine preparation of breasts and nipples before delivery is necessary. A good, supportive bra should be worn. If a woman’s nipples appear flat or inverted during pregnancy, they can be corrected by the baby taking the breast after delivery.

3-37 Why do some mothers not breastfeed successfully?

Some mothers do not breastfeed or fail to breastfeed successfully because:

3-38 How do you prevent painful nipples?

Correct attaching of the baby at the breast will help to prevent painful nipples.

3-39 What are cracked nipples?

The mother may develop cracked nipples if the baby does not attach properly. The nipples are then very painful and may bleed. As a result the mother will be afraid of breastfeeding resulting in engorged breasts and a very hungry baby. It is not dangerous to the baby if some blood is swallowed.

3-40 How can you help a mother with painful nipples?

3-41 What are the causes and management of painful breasts?

3-42 How do you manage leaking breasts?

When a baby is put to the breast the mother may leak milk from the other breast. This is completely normal but may cause a wet area on her clothing. Soon after delivery the mother may also have abdominal cramps when she starts breastfeeding. Both leaking and cramps are due to the “let down reflex” which is a sign of a good milk supply. Leaking of the opposite breast during feeding can be stopped by pressing on that nipple. Cotton handkerchiefs or breast pads can be used for leaking between feeds. These should be changed frequently as dampness may cause painful nipples.

3-43 What should you do if a baby refuses the breast?

Some babies may reject the breast and refuse to attach on the nipple. Common causes are a sore mouth due to thrush, the baby is ill or upset, or the milk flow is too fast. These problems should be looked for and treated.

The mother should not hold the baby’s head or push the face towards the breast, as the baby will turn towards her hand instead of the nipple. It may help to squeeze a little breast milk onto the nipple before placing it in the baby’s mouth.

3-44 Can inverted nipples cause problems with breastfeeding?

Some women have inverted nipples which are flat rather than sticking out. Babies will pull the nipples forward when they attach at the breast and feed normally. There is no need treat or try to correct inverted nipples as they do not cause problems with breastfeeding.

Promoting exclusive breastfeeding

3-45 How can breastfeeding be promoted?

Breastfeeding should be promoted as the normal, natural method of feeding a baby. This can be achieved by:

Community healthcare workers can play an important role in promoting exclusive breastfeeding.

The advantages of breastfeeding must be taught in homes, schools and clinics.

3-46 How can exclusive breastfeeding be encouraged in clinics?

3-47 What is the value of a breastfeeding support group?

More experienced mothers can help new mothers breastfeed. The best way to learn how to breastfeed successfully is to watch other women breastfeed. Some clinics form a support group where mothers help other mothers.

Case study 1

An unmarried, unemployed woman is pregnant with her first baby. She is planning to bottle feed her baby but is worried that she may not be able to afford formula. She believes that bottle feeding is the modern and best way to feed babies. All her friends are bottle feeding.

1. Why should she not bottle feed her baby?

Because breastfeeding is best for both mother and baby. She will probably not be able to formula feed correctly as she will not be able to buy enough formula. She should not follow the incorrect example of her friends who bottle feed.

2. What are the main two dangers of formula feeding?

Infections, such as diarrhea, and malnutrition due to the baby receiving too little formula. The risk for both infection and malnutrition is high in poor communities.

3. How should you encourage her to breastfeed?

Carefully explain all the advantages of breastfeeding and the dangers of bottle feeding.

4. When should she start breastfeeding?

As soon as possible after birth. Breastfeeding should start within half an hour of delivery.

5. Would it help to also give the baby a few bottle feeds of formula for the first week so that the mother can get some sleep?

No. It is important to practice exclusive breastfeeding. Most of the benefits of exclusive breastfeeding are lost if the mother practises mixed feeding.

6. When should she stop breastfeeding?

Women should exclusively breastfeed for 6 months. Solid foods should then be started but breastfeeding should continue until their infant is 2 years old. This will help her baby to grow and develop normally.

Case study 2

A woman starts to exclusively breastfeed her newborn baby but develops very painful nipples and her baby cries all the time. It is her first baby and she has no one at home to help or advise her. She phones her grandmother who suggests she stop breastfeeding and bottle feed instead.

1. Why do you think she has painful nipples?

She probably has cracked nipples.

2. What would be the cause of the problem?

The baby is not latching to the breast correctly. Instead the baby is sucking on the mother’s nipples.

3. Why is the baby crying all the time?

Because the baby is hungry. Babies that do not latch properly cannot get any milk out of the breasts. The mother’s breasts will soon get full and become engorged and painful.

4. How should you manage this problem?

Support the mother and reassure her that the problem can be corrected. Show her how to latch the baby correctly onto the breast. Change the position of the baby on the breast so that the baby does not suck on the tender area. If her nipples are very painful it may help to express some milk and cup feed the baby for a day or two until her breasts heal.

5. Would it have helped if she had prepared her breasts correctly during pregnancy?

No. There is no need to prepare a woman’s breasts before delivery. After each feed the mother should leave a few drops of milk on her nipples.

6. What should you do if the mother’s one breast becomes painful and swollen and she feels ill and develops a fever?

The mother needs to be taken to the clinic as she is probably developing mastitis and needs treatment with antibiotics.

Case study 3

A young mother is having problems breastfeeding and asks you to show her how to hold and attach her baby to the breast. Her 3 day old baby has lost weight and she thinks she does not have enough milk. She was discharged from hospital a few hours after delivery and received no breastfeeding advice before going home. She read an article about the benefits of breastfeeding in a women’s magazine and is very keen to breastfeed successfully.

1. Where should mothers get advice on breastfeeding?

Young girls should see breastfeeding in the family and learn about the importance of breastfeeding at school. All pregnant women should receive breastfeeding education at antenatal clinics and be assisted to breastfeed after delivery. As with this mother, the media have an important role to play in promoting breastfeeding.

2. What is the role of a Community Healthcare Worker in promoting breastfeeding?

They should educate pregnant women and new mothers about the benefits of exclusive breastfeeding. They can also support and teach mothers how to hold and attach their babies to the breast correctly.

3. How important is help with breastfeeding immediately after delivery?

Very important as this is the first time the mother has a chance to put her baby to the breast. She should be taught how to hold and attach her baby correctly from the first feed. No mother should be discharged from a delivery clinic or hospital without receiving this important demonstration.

4. Do breastfed babies lose weight in the first few days?

Yes. It is normal for breastfed babies to lose weight in the first few days after birth when the mother’s breast milk is still increasing in amount. There is no need to give extra water or formula. By day 5 the baby should start gaining weight. This early breast milk is called colostrum and is full of antibodies to protect the baby from infection. Putting the baby to the breast frequently is the best way to improve the milk supply.

5. Do normal, healthy babies who are exclusively breastfed need iron and vitamin drops?

No. Only preterm babies who are born too soon or who weight less than 2500 g at birth need iron and vitamin drops.

6. If this mother has to return to work can the baby still get breast milk while she is away?

Yes. The mother can express her breast milk and the carer can give this to the baby by cup while the mother is at work. It is important that a cup rather than bottle is used to give expressed breast milk.

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