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Participants Manual - World Health Organization

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1. Signs in brackets refer only to newborn not to older babies Signs that breastfeeding is going well BODY POSITION Mother relaxed and comfortable Baby s body close facing breast Baby s head and body straight Baby s chin touching breast Baby s bottom supported OOoOOdO RESPONSES O0 Baby reaches for breast if hungry O0 Baby roots for breast O0 Baby explores breast with tongue O Baby calm and alert at breast O Baby stays attached to breast O Signs of milk ejection leaking afterpains EMOTIONAL BONDING O Secure confident hold O Face to face attention from mother O Much touching by mother ANATOMY O Breasts soft after feed O Nipples stand out protractile O Skin appears healthy O Breast looks round during feed SUCKLING Mouth wide open Lower lip turned outwards Tongue cupped around breast Cheeks round More areola above baby s mouth Slow deep sucks bursts with pauses Can see or hear swallowing OOOOOOHO TIME SPENT SUCKLING O Baby releases breast Baby suckled for ___ minutes Signs of possible difficulty OShoulders tense leans over baby OBaby s body away from mother s OBaby s neck twisted OBaby s chin not touching breast C Only shoulder or head supported ONo response to breast O No rooting observed OBaby not interested in breast OBaby restless or crying OBaby slips off breast ONo signs of milk ejection ONervous or limp hold ONo mother baby eye contact OLittle touching o
2. The commonest bacterium found in breast abscess is Staphylococcus aureus Therefore it is necessary to treat breast infections with a penicillinase resistant antibiotic such as either flucloxacillin or erythromycin Drug Dose Instructions Flucloxacillin 250 mg orally Take dose at least 30 6 hourly minutes before food for 7 10 days Erythromycin 250 500 mg orally 6 hourly for 7 10 days Table 2 TREATMENT OF CANDIDA OF THE BREAST Gentian violet paint To baby s mouth 0 25 apply daily or alternate days for 5 days or until 3 days after the lesions have healed To mother s nipples 0 5 apply daily for 5 days OR Nystatin cream 100 000 IU g Apply to nipples 4 times daily after breastfeeds Continue to apply for 7 days after lesions have healed Nystatin suspension 100 000 IU ml Apply 1 ml by dropper to child s mouth 4 times daily after breastfeeds for 7 days or as long as mother is being treated Stop using pacifiers teats and nipple shields MANAGEMENT OF SORE NIPPLES Look for a cause e Check attachment e Examine breasts engorgement fissures Candida e Check baby for Candida and tongue tie Give appropriate treatment Build mother s confidence Improve attachment and continue breastfeeding e Reduce engorgement suggest feed frequently express e Treat for Candida if skin red shiny flaky if there is itchiness or deep pain or if soreness persists Advise the mother to e Wash breasts on
3. Explain what might help and ask if she would like you to show her Make sure that she is comfortable and relaxed Sit down yourself in a comfortable convenient position Explain how to hold her baby and show her if necessary The four key points are with his head and body straight with his face facing her breast and his nose opposite her nipple with his body close to her body supporting his bottom if newborn Show her how to support her breast with her fingers 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 his lower lip below the nipple Notice how she responds and ask her how her baby s suckling feels Look for signs of good attachment If the attachment is not good try again Session 11 Back to CONTENTS BUILDING CONFIDENCE AND GIVING SUPPORT Introduction The third and fourth counselling skills sessions are about building confidence and giving support A breastfeeding mother easily loses confidence in herself This may lead her to give unnecessary artificial feeds and to respond to pressures from family and friends to give artificial feeds You need the skill to help her to feel confident and good ab
4. Poor attachment Good attachment Attachment outside appearance Fig 13 Overhead 3 9 RESULTS OF POOR ATTACHMENT l Sore nipples E Pain and damage to nipples ae E Breastmilk not removed effectively gt Apparent poor milk supply Breasts make less milk Fig 14 Overhead 3 10 _ Engorgement we Baby unsatisfied wants to feed a lot Baby frustated Leer e es refuses to suckle S Baby fails to gain weight CAUSES OF POOR ATTACHMENT Use of feeding bottle Inexperienced mother Functional difficulty Lack of skilled support gt Fig 15 Overhead 3 11 before breastfeeding established for later supplements first baby previous bottle feeder small or weak baby breast poorly protractile engorgement late start less traditional help and community support doctors midwives nurses not trained to help Rooting reflex When something touches lips baby opens mouth puts tongue down and forward Skill Mother learns to position Sucking reflex When something touches baby palate baby sucks Baby learns to take breast Swallowing reflex When mouth fills with miik baby swallows Fig 16 Overhead 3 12 Reflexes in the baby Summary Breastmilk flow depends partly on the mother s thoughts feelings and sensations It is important to keep mothers and babies together day and night and to help mothers to feel good about breastfeeding Ma
5. Session 1 WHY BREASTFEEDING IS IMPORTANT Introduction Back to CONTENTS Before you learn how to help mothers you need to understand why breastfeeding is important and what its benefits are You need to know the differences between breastmilk and artificial milks and the dangers of artificial feeding Breastmilk Perfect nutrients m Easily digested Efficiently used m Protects against infection Fig l Overhead 1 1 ADVANTAGES OF BREASTFEEDING m Costs less than artificial feeding Breastfeeding Helps bonding and development Helps delay a new pregnancy Protects mothers health Fig 2 Summary of differences between milks HUMAN MILK ANIMAL MILK FORMULA Bacterial likely when mixed contaminants Anti infective not present not present factors Protein correct amount too much partly easy to digest difficult to digest corrected Fat enough essential lacks essential lacks essential _ fatty acids fatty acids fatty acids lipase to digest no lipase no lipase iron small amount small amount extra added well absorbed not well absorbed not well absorbed war ee mayna Protection against infection White cells in mother s body make antibodies to protect mother Mother infected ete a Some white cells go mother in api ae to breast and make secreted in milk to antibodies there protect baby Fig 3 Overhead 1 7 Variations in the com
6. The stories of Mrs T Mrs U and Mrs V are optional to do if you have time When you have finished discuss your answers with the trainer Example Mrs M says that she does not have enough milk Her baby is 3 months old and crying all the time A nurse told her that he had not put on enough weight he gained 200 g last month Mrs M manages the family farm by herself so she is very busy She breastfeeds her baby about 2 3 times at night and about twice a day whenever she has time She does not give her baby any other food or drink What could you say to empathize with Mrs M You are very busy it is difficult to find time to feed a baby What do you think is the cause of Mrs M s baby not getting enough milk Mrs M is not breastfeeding him often enough Can you suggest how Mrs M could give her baby more breastmilk Could she take her baby with her so that she could breastfeed him more often Could someone bring her baby to her where she is working Could she express her breastmilk to leave for her baby To answer Mrs N says that her baby is always hungry in the evenings Since the age of 2 weeks he has cried and doesn t want to settle Her sister told Mrs N that she probably does not have enough milk when she is tired in the evening Her sister suggested that Mrs N give a bottle feed in the evening so that she can save up her milk for the night feeds Mrs N drinks tea once or twice a day She does not smoke cigarettes an
7. Celia brings her 14 week old baby for his third DPT and polio immunizations He is exclusively breastfed and has gained 2 5 kg since birth Praise Inform Suggest 2 Ines brings her 12 month old child with fever and diarrhoea He has no weight chart but today weighs 8 5 kg He has lost his appetite and does not want to eat much food He still breastfeeds mostly at night You have given appropriate advice and treatment for fever and diarrhoea What will you say to Ines about breastfeeding Praise Inform Suggest Optional to do if you have time 3 Mona brings her 15 month old son for treatment of a cough and difficult breathing He has a fever and is not eating well He breastfeeds but pulls away to breathe before he has suckled for long After you have examined the child counted his breathing and given appropriate treatment what would you do to support breastfeeding Praise Inform Suggest EXERCISE 21 Breastfeeding and growth charts How to do the exercise Study the growth charts of the following babies and the short notes that go with them Then answer the questions briefly When you are ready discuss your answers with the trainer Example Baby 1 is exclusively breastfed He slept with his mother until 8 weeks ago Now he sleeps in a separate bed 13 What is Baby I s mother doing that you could praise ae His mother has breastfed exclusively all this time NEN N EEN EEE What
8. Cover them both with a clean cloth or put them in a covered pan Teach the baby s carer to mix the milk powder and water when she is going to feed the baby She must mix and use the formula immediately because it spoils quickly after it is mixed Note There are many different ways to leave milk for a baby These are satisfactory methods You may find that a different method is better for you in your situation Teach the carer properly and carefully Teach her to feed your baby with a cup and not to use a bottle Cups are cleaner and they do not satisfy the baby s need to suckle So when you come home your baby will want to suckle at the breast and this will stimulate your breastmilk supply Teach her to give all of one feed at one time She must not keep it to give later and she must not give a small amount every now and again Teach her not to give the baby a dummy but to calm him with other attention While you are at work express your breastmilk 2 3 times about 3 hourly If you do not express your breastmilk supply is more likely to decrease Expressing also keeps you comfortable and reduces leaking If you work where you can use a refrigerator keep your expressed breastmilk there Carry a clean jar with a lid to store your breastmilk and to take it home for the baby If you can keep it cold at home it will be safe to use the next day Ifyou cannot keep your EBM throw it away Your baby has not lost anyth
9. If she has fever If she feels too unwell or unwilling to breastfeed If extremely ill If mentally ill When mother recovers Mother s medications Ask Do you have a_ breastfeeding baby Encourage her to continue Admit baby with her Give her plenty to drink Help her to express her breastmilk 3 hourly Feed baby her EBM by cup Consider expressing her breastmilk for her Feed baby by cup Find a helper to care for mother and baby together Help her to increase her breastmilk or to relactate Most drugs pass into breastmilk in only small amounts Few of them affect the baby In most cases to stop breastfeeding is more likely to be dangerous than the medicine There are a few drugs which may cause side effects Problems are more likely in babies less than 1 month old and less likely in older babies However it is usually possible to give the mother an alternative which is less likely to cause a problem It is rarely necessary to stop breastfeeding because of a mother s medication Ina very few situations breastfeeding is contraindicated If a mother is taking anticancer drugs it may be necessary to stop breastfeeding If she is treated with radioactive substances she should stop breastfeeding temporarily These drugs are not used commonly A few drugs can cause side effects which sometimes makes it necessary to stop breastfeeding If a mother is taking psychiatric drugs or anticonvulsants these sometimes m
10. Overhead 3 1 Anatomy of the breast PROLACTIN Sensory Secreted AFTER feed impulses from nipple to produce NEXT feed Prolactin in blood NY E More prolactin secreted at night o lt Baby suckling Fig 8 Overhead 3 2 E Suppresses ovulation OXYTOCIN REFLEX Works BEFORE or DURING feed to make milk FLOW Oxytocin Sensory in blood impulses TET T trom nipple W Makes uterus contract Baby suckling gt Fig 9 Overhead 3 3 OXYTOCIN REFLEX Vo Thinks lovingly of baby Sound of baby Sight of baby CONFIDENCE These HELP reflex These HINDER reflex Fig 10 Overhead 3 4 Helping and hindering the oxytocin reflex SIGNS AND SENSATIONS OF AN ACTIVE OXYTOCIN REFLEX A mother may notice e A squeezing or tingling sensation in her breasts just before she feeds her baby or during a feed Milk flowing from her breasts when she thinks of her baby or hears him crying Milk dripping from her other breast when her baby is suckling Milk flowing from her breasts in fine streams if her baby comes off the breast during a feed Pain from uterine contractions sometimes with a rush of blood during feeds in the first week Slow deep sucks and swallowing by the baby which show that breastmilk is flowing into his mouth INHIBITOR IN BREASTMILK If breast remains full of milk secretion stops Fig 11 Overhead 3 5 Control of breastmilk
11. Try not to ask questions about facts which either the mother or the growth chart has told you already If you do need to repeat a question first say Can make sure that have understood clearly and then for example You said that name had both diarrhoea and pneumonia last month e Take time to learn about more difficult sensitive things Some things are more difficult to ask about but they can tell you about a woman s feelings and whether she really wants to breastfeed What have people told her about breastfeeding Does she have to follow any special rules What does the baby s father say Her mother Her mother in law Did she want this pregnancy at this time Is she happy about having the baby now About the baby s sex Some mothers tell you these things spontaneously Others tell you when you empathize and show that you understand how they feel Others take longer If a mother does not talk easily wait and ask again later or on another day perhaps somewhere more private BREASTFEEDING HISTORY FORM Mother s name Baby s name Date of birth Reason for consultation 1 Baby s feeding Breastfeeds now How often Day Night ask all these Length of breastfeeds points Longest time between feeds time mother away from baby One breast or both breasts Complements and water Pacifier What given Yes no When started How much How given 2 Baby s health Birth weight Weight now Growth and behaviour Premature
12. of the female urban wage GLOSSARY afterpains allergy alveoli amenorrhoea anaemia antenatal preparation anti infective factors antibodies appropriate touch areola artificial feeds artificially fed asthma attachment baby led feeding bedding in bilirubin blocked duct bonding breast pumps breast refusal breastfeeding history breastfeeding supplementer breastfeeding support group breastmilk substitutes Calories Candida casein cleft lip or palate closed questions colic cold compress colostrum complementary foods confidence contaminated counselling Back to CONTENTS contraction of the uterus during breastfeeding in the first few days after childbirth due to oxytocin released symptoms when fed even a small amount of a particular food so it is not dose related small sacs of milk secreting cells in the breast absence of menstruation lack of the red cells or lack of haemoglobin in the blood preparing a mother for the delivery of her baby factors which prevent or which fight infection proteins in the blood and in breastmilk which fight infection touching somebody in a socially acceptable way dark skin surrounding the nipple any kind of milk or other liquid given instead of breastfeeding receiving artificial feeds only and no breastmilk wheezing illness the way a baby takes the breast into his mouth a baby may be well attached or poorly attached to the breast see demand feeding
13. B R E A S T FEED Observation Form pencil and paper to make notes How to do the clinical practice Talk to and observe mothers and babies as for Clinical Practice 1 Continue to practise assessing a breastfeed and listening and learning In addition practise as many of the six confidence and support skills as possible Try to do these things praise two things that the mother and baby are doing right give the mother two pieces of relevant information that are useful to her now Be careful not to give a lot of advice The participant who observes marks a W on the list of CONFIDENCE AND SUPPORT SKILLS for every skill that her partner uses Ifthere is an opportunity practise helping a mother to position her baby at the breast or to overcome any other difficulty Inform the trainer so that she can demonstrate how to help the mother and help you to do it the first time Session 14 Back to CONTENTS BREAST CONDITIONS Introduction There are several common breast conditions which sometimes cause difficulties with breastfeeding Flat or inverted nipples and long or big nipples Engorgement Blocked duct and mastitis Sore nipples and nipple fissure Diagnosis and management of these breast conditions are important both to relieve the mother and to enable breastfeeding to continue Fig 27 There are many different shapes and sizes of breast Babies can breastfeed from almost all of them MANAG
14. Breastfeeding factors e Delayed start infrequent feeds No night feeds Short feeds Mother psychological factors Lack of confidence eWorry stress Dislike of breastfeeding Rejection of baby Poor attachment Tiredness Bottles pacifiers Complementary feeds These are COMMON Mother physical condition Baby s condition Contraceptive pill diuretics lIness Pregnancy Abnormality e Severe malnutrition Alcohol Smoking Retained piece placenta rare Poor breast development very rare These are NOT COMMON The reasons in the first two columns Breastfeeding factors and Mother psychological factors are common Psychological factors are often behind the breastfeeding factors for example lack of confidence can cause a mother to give bottle feeds Look for these common reasons first The reasons in the second two columns Mother physical condition and Baby s condition are not common So it is not common for a mother to have a physical difficulty in producing enough breastmilk Think about these uncommon reasons only if you cannot find one of the common reasons HOW TO HELP A MOTHER WHOSE BABY IS NOT GETTING ENOUGH MILK e Look for a cause Steps to take What you may learn about Listen and learn Psychological factors how mother feels Take a history Breastfeeding factors contraceptive pill diuretics Assess a breastfeed Baby
15. FEED Observation Form one copy of LISTENING AND LEARNING SKILLS pencil and paper to make notes You do not need to take books or manuals If you are the one who talks to the mother Introduce yourself to the mother and ask permission to talk to her Introduce the group and explain that you are interested in infant feeding Try to find a chair or stool to sit on If necessary and if allowed in the facility sit on the bed If the baby is feeding ask the mother to continue as she is doing If the baby is not feeding ask the mother to give a feed in the normal way at any time that the baby seems ready Ask the mother s permission for the group to watch the feed Before or after the breastfeed ask the mother some open questions about how she is how the baby is and how feeding is going to start the conversation Encourage the mother to talk about herself and the baby Practise as many of the listening and learning skills as possible If you are observing Stand quietly in the background Try to be as still and quiet as possible Do not comment or talk among yourselves Make general observations of the mother and baby Notice for example does she look happy Does she have formula or a feeding bottle with her Make general observations of the conversation between the mother and the participant Notice for example who does most of the talking Does the mother talk freely and seem to enjoy it Make specific observations
16. Light massage of breast Stimulate nipple skin Help mother to relax After feed Cold compress on breasts to reduce oedema SYMPTOMS OF BLOCKED DUCT AND MASTITIS Blocked gt Milk gt Non infective gt Infective duct Stasis mastitis mastitis Lump progresses Hard swelling Tender gt Severe pain Localized redness to No fever Feels well Red area Fever Feels ill Symptoms of blocked duct and mastitis Mastitis may develop in an engorged breast or it may follow a condition called blocked duct Blocked duct occurs when the milk is not removed from part of a breast The duct to that part of the breast is sometimes blocked by thickened milk The symptoms are a lump which is tender and sometimes redness of the skin over the lump The woman has no fever and feels well When milk stays in part of a breast because of a blocked duct or because of engorgement it is called milk stasis If the milk is not removed it can cause inflammation of the breast tissue which is called non infective mastitis Sometimes a breast becomes infected with bacteria and this is called infective mastitis It is not possible to tell from the symptoms alone if mastitis is non infective or infective If the symptoms are all severe however the woman is more likely to need treatment with antibiotics CAUSES OF BLOCKED DUCT AND MASTITIS e Poor drainage of part due to infrequent breastfeeds or all of breast ineffecti
17. a baby sleeping in bed with his mother instead of in a separate cot yellow breakdown products of haemoglobin which cause jaundice a milk duct in the breast becoming blocked with thickened milk so that the milk in that part of the breast does not flow out mother and baby developing a close loving relationship devices for expressing milk a baby not wanting to suckle from his mother s breast all the relevant information about what has happened to a mother and baby and how their present breastfeeding situation developed a tube through which a baby can drink artificial milk or expressed breastmilk while suckling at a breast a group of mothers who help each other to breastfeed any food or drink that is used to replace breastmilk and breastfeeding kilocalories or Calories measure the energy available in food yeast which can infect the nipple and the baby s mouth and bottom causing thrush protein in milk which forms curds abnormal division of the lip or palate questions which can be answered with yes or no regular crying sometimes with signs suggesting abdominal pain at a certain time of day the baby is difficult to comfort but otherwise well cloths soaked in cold water to put on the breast the special breastmilk that women produce in the first few days after delivery it is yellowish or clear in colour solid foods given from the age of 4 6 months believing in yourself and your ability to do things containing harmful b
18. and that is on your breastmilk alone c Just let him suckle more often that will soon build up your milk supply Story G A 15 month old child is breastfeeding and having thin porridge and sometimes tea and bread He has not gained weight for 6 months and is thin and miserable a He needs to eat a more balanced diet b It is good that you are continuing to breastfeed him at this age as well as giving him other food c You should be giving him more than breastmilk and thin porridge at this age Story H A 4 month old baby is completely bottle fed and has diarrhoea The growth chart shows that he weighed 3 5 kilos at birth and that he has only gained 200 grams in the last two months The bottle smells very sour Story l Neera comes to the clinic to learn how to take her 3 month old baby Ravi off the breast She is going back to work soon But Ravi is refusing bottles so she asks you to advise her Ravi is alert and active How to do the exercise EXERCISE 9 Giving a little relevant information Below is a list of six mothers with babies of different ages Beside them are six pieces of information a b c d e and f that those mothers may need but the information is not opposite the mother who needs it most Match the piece of information with the mother and baby in the same set for whom itis MOST RELEVANT AT THAT TIME After the description of each mother there are six letters Put a circle round the letter whi
19. breastfeed This should be at least every 3 hours including during the night If she expresses only a few times or if there are long intervals between expressions she may not be able to produce enough milk To keep up her milk supply to feed a sick baby She should express as much as she can as often as her baby would feed at least every 3 hours To build up her milk supply if it seems to be decreasing after a few weeks Express very often for a few days every 12 1 hour and at least every 3 hours during the night To leave milk for a baby while she is out at work Express as much as possible before she goes to work to leave for the baby It is also very important to express while at work to help keep up the supply see Session 32 Women and work To relieve symptoms such as engorgement or leaking at work Express only as much as is necessary To keep nipple skin healthy Express a small drop to rub on her nipple after a bath or shower Fig 32 Rubber bulb breast pump These are not very efficient and they are easily contaminated Breast pumps If hand expression is difficult a mother can use a hand breast pump RUBBER BULB PUMP Rubber bulb pumps see Fig 32 are not very efficient especially when the breasts are soft They are not suitable for collecting milk to feed a baby They are difficult to clean properly Milk may collect in the rubber bulb and it is difficult to clean out The milk which collects is ofte
20. breastfeed him Ifa baby can suckle well Encourage his mother to breastfeed more often She can increase the number of feeds up to 12 times a day or more for her child when he is sick Sometimes a baby loses his appetite for other foods but continues to want to breastfeed This is quite common with children who have diarrhoea Sometimes a baby likes to breastfeed more when he is ill than before and this can increase the supply of breastmilk Ifa baby suckles but less than before at each feed Suggest that his mother gives more frequent feeds even if they are shorter Ifa baby is not able to suckle or refuses or is not suckling enough Help his mother to express her milk and give it by cup or spoon Let the baby continue to suckle when he is willing Even babies on intravenous fluids may be able to suckle or to have expressed breastmilk Ifa baby is unable to take expressed milk from a cup It may be necessary to give the EBM through a nasogastric tube for a few feeds Ifa baby cannot take oral feeds Encourage his mother to express her milk to keep up the supply for when her baby can take oral feeds again She should express as often as her baby would feed including at night see Session 20 Expressing breastmilk She may be able to store her milk or donate it to another baby As soon as her baby recovers she can start to breastfeed again If he refuses at first help him to start again see Session 16 Refusal to breas
21. build Mrs I s confidence What could you suggest that she does to breastfeed again if she decides to try Mrs J has a baby who is 1 month old The baby was born in hospital and was given three bottle feeds before he started to breastfeed When Mrs J went home her baby wanted to breastfeed often and he seemed unsatisfied Mrs J thought that she did not have enough milk She continued to give bottle feeds in addition to breastfeeding and hoped that her breastmilk supply would increase Now her baby is refusing to breastfeed When Mrs J tries to breastfeed he cries and turns away Mrs J wants very much to breastfeed and she feels rejected by her baby What could you say to empathize with Mrs J Why is Mrs J s baby refusing to breastfeed What relevant information might be helpful to Mrs J What four things would you offer to help Mrs J to do so that she and her baby can enjoy breastfeeding again Optional Mrs K had her baby 3 days ago She says that he is refusing to breastfeed and she will have to bottle feed A nurse is helping her to try to position the baby The nurse puts the baby to face Mrs K s breast The nurse then holds Mrs K s breast with one hand and the back of the baby s head with her other hand The nurse then tries to push the baby onto the breast The baby pushes his head back and cries What could you say to praise the nurse Why does Mrs K s baby refuse to breastfeed What would you suggest that the nurse
22. can do it herself Your aim is to help her to position her own baby It does not help if you can get a baby to suckle if his mother cannot WEA et re oe Fig 23 The mother s nipple is touching her baby s lips He is opening his mouth and putting his tongue forward ready to take the breast HOW TO HELP A MOTHER WHOIS SITTING Greet the mother introduce yourself and ask her name and her baby s name Ask her how she is and ask one or two open questions about how breastfeeding is going Assess a breastfeed Ask if you may see how her baby breastfeeds and ask her to put him to her breast in the usual way If the baby has had a feed recently you may have to arrange to come back later Observe the breastfeed If you decide that the mother needs help to improve her baby s attachment First say something encouraging like He really wants your breastmilk doesn t he Then explain what might help and ask if she would like you to show her For example say something like Breastfeeding might be more comfortable for you if baby s name took a larger mouthful of breast when he suckles Would you like me to show you how If she agrees you can start to help her Make sure that she is sitting in a comfortable relaxed position Sit down yourself so that you also are comfortable and relaxed and in a convenient position to help Explain to the mother how to hold her baby Show her what to do if necessary Make these fo
23. come in and it is more difficult to establish breastfeeding If a baby has even a few prelacteal feeds his mother is more likely to have difficulties such as engorgement Breastfeeding is more likely to stop early than when a baby is exclusively breastfed from birth ADVANTAGES OF ROOMING IN AND DEMAND FEEDING Rooming in and demand feeding help both bonding and breastfeeding Advantages of rooming in Mother can respond to baby which helps bonding Babies cry less so less temptation to give bottle feeds Mothers more confident about breastfeeding Breastfeeding continues longer Advantages of demand feeding Breastmilk comes in sooner Baby gains weight faster Fewer difficulties such as engorgement Breastfeeding more easily established Fig 21 Bedding in allows a mother to rest while breastfeeding HOW TO HELP A MOTHER WITH AN EARLY BREASTFEED Avoid hurry and noise Talk quietly and be unhurried even if you have only a few minutes Ask the mother how she feels and how breastfeeding is going Let her tell you how she feels before you give any information or suggestions Observe a breastfeed Try to see the mother when she is feeding her baby and quietly watch what is happening If the baby s position and attachment are good tell her how well she and the baby are doing You do not need to show her what to do Help with positioning if necessary If the mother is having difficulty or if her bab
24. days should it take from when you start to reduce the amount to when you stop giving EBM altogether Session 28 Back to CONTENTS SUSTAINING BREASTFEEDING Introduction Health care practices have an important influence on breastfeeding throughout the first two years of life It is important for all health facilities to support breastfeeding It is not only maternity wards which have a responsibility Health workers can do a lot to support and encourage women who want to breastfeed their babies They can help to protect remaining good practices If they do not actively support breastfeeding they may hinder it by mistake Every contact that a health worker has with a mother may be an opportunity to encourage and sustain breastfeeding Every time you see a mother try to build her confidence Praise her for what she and her baby are doing right Give relevant information and suggest something appropriate Praise Inform Suggest It is especially important to discuss breastfeeding when you weigh a baby Growth monitoring is a helpful way to know if a baby is getting enough breastmilk Poor growth is an important sign that a mother and baby need help If a mother does not have a growth chart or if you cannot weigh a baby you can still talk about breastfeeding You should have a good idea if breastfeeding is going well or not from the baby s appearance and behaviour You can ask about his urine output HOW HEALTH SERVICES CAN S
25. does differently What could you suggest that Mrs K does Mrs L says that her 6 month old baby suddenly refused to breastfeed He was born in hospital and started to breastfeed within an hour He has never had any bottle feeds but he recently started solids from a spoon Last month the family moved to stay with relatives in town while the father looked for a job There is an aunt in the house who likes to take care of the baby and who criticizes Mrs L What might be the cause of Mrs L s baby refusing to breastfeed What can you suggest that Mrs L does to breastfeed again What practical help can you give Session 17 Back to CONTENTS TAKING A BREASTFEEDING HISTORY Introduction If a mother asks for your help you need to understand her situation You cannot learn everything that you need to know by observing and listening and learning You need to ask some questions Taking a history means asking relevant questions in a systematic way You will use a special form the Breastfeeding History Form to help you to remember what questions to ask When you first learn to use the form you need to ask all the questions As you become more experienced you learn which questions are relevant for which mothers Then you do not need to ask all the questions every time SUMMARY HOW TO TAKE A BREASTFEEDING HISTORY Use the mother s and baby s names if appropriate Ask her to tell you about herself and her baby in her own way Look at t
26. each Even 2 cup or less is enough for one feed Leave about 1 2 cupful 100 ml for each feed that the baby will need while you are out If you cannot express as much as this express what you can Whatever you can leave is helpful Cover the cup of expressed breastmilk with a clean cloth or plate Leave the milk in the coolest place that you can find in a refrigerator if you have one or in a safe dark corner of the house Do not boil or reheat your breastmilk for your own baby Heat destroys many of the anti infective factors EBM stays in good condition longer than cow s milk because of the anti infective factors in it Germs do not start growing in EBM for at least 8 hours even in a hot climate and outside the refrigerator It is safe to give to the baby at least throughout one working day Breastfeed your baby after you have expressed Suckling is more efficient than expressing so he will get breastmilk that you cannot express including some hindmilk Ifyou decide to use cow s milk for some or all of the feeds To make 1 cup 200 ml of feed boil 3 4 cup 150 ml of cow s milk and 1 4 cup 50 ml of water Add 1 level spoonful of sugar 15 g Leave 1 2 to 1 cup 100 200 ml of mixture for each feed Leave the mixture in a clean covered container Ifyou decide to use formula Measure the powder for a feed into one clean cup or glass Measure the water to make up the feed into another clean glass
27. glucose water before he is at least 4 months old Suggestion 2 Command Feed him more often whenever he is hungry then your milk supply will increase Suggestion 3 Command You should feed him from a cup Don t give him any feeds from a bottle or he will refuse to breastfeed Suggestion Optional 4 Command You must hold him closer or he won t take enough of the breast into his mouth Suggestion 5 Command You must sit on a lower chair to breastfeed or you will not be able to relax Suggestion Session 13 Back to CONTENTS CLINICAL PRACTICE 2 Building confidence and giving support Positioning a baby at the breast These notes are a summary of the instructions that the trainer will give you about how to do the clinical practice Try to make time to read them to remind you about what to do during the session During the clinical practice you work in small groups or pairs and take turns to talk to a mother while your partner or other members of the group observe You practise the building confidence and giving support skills from Session 11 and helping a mother to position her baby at the breast from Session 10 After the clinical practice record the mothers and babies that you have seen on your CLINICAL PRACTICE PROGRESS FORM on page 186 What to take with you one copy of the list of CONFIDENCE AND SUPPORT SKILLS one copy of the list of LISTENING AND LEARNING SKILLS two copies each of the
28. growing eyes and brain which are not present in cow s milk or most brands of formula breastfed only with no other food or drink or water expressed breastmilk is allowed to squeeze or press out milk which has been pressed out of the breasts break in the skin sometimes called a crack a nipple which sticks out less than average the watery breastmilk that is produced early in a feed artificial milks for babies made out of a variety of products including sugar animal milks soybean and vegetable oils They are usually in powder form to mix with water the tissue below the tongue which joins it to the floor of the mouth breasts which are full of milk and hot heavy and hard but from which the milk flows sucking out a baby s stomach immediately after delivery the number of weeks the baby has completed in the uterus substances in breastmilk which promote growth and development of the intestine and which probably help the intestine to recover after an attack of diarrhoea sudden increased hunger for a few days loud swallowing sounds due to swallowing a lot of fluid babies who seem to need to be carried and comforted more than other babies the fat rich breastmilk that is produced later in a feed chemical messengers in the body those parts of the body and blood including lymph glands and white blood cells which fight infection suckling in a way which removes milk from the breast inefficiently or not at all mastitis due
29. interested in breast OBaby restless or crying OBaby slips off breast ONo signs of milk ejection ONervous or limp hold ONo mother baby eye contact OLittle touching or OShaking or poking baby OBreasts engorged ONipples flat or inverted OFissures or redness of skin OBreast looks stretched or pulled OMouth not wide open points forward OLower lip turned in OBaby s tongue not seen OCheeks tense or pulled in OMore areola below baby s mouth ORapid sucks only OCan hear smacking or clicking OMother takes baby off breast Notes Adapted with permission from B R E A S T Feeding Observation Form by H C Armstrong Training Guide in Lactation Management New York IBFAN and UNICEF 1992 B R E A S T FEED OBSERVATION FORM Mother s name Date Baby s name Slide 5 14 Age of baby Signs in brackets refer only to newborn not to older babies Signs that breastfeeding is going well BODY POSITION Mother relaxed and comfortable Baby s body close facing breast Baby s head and body straight Baby s chin touching breast Baby s bottom supported OOoOOdO RESPONSES O Baby reaches for breast if hungry O0 Baby roots for breast O0 Baby explores breast with tongue O Baby calm and alert at breast O0 Baby stays attached to breast O Signs of milk ejection leaking afterpains EMOTIONAL BONDING O Secure confident hold O Face to face attention from mother O Much touching by mother ANATOMY O
30. is aged 3 12 months He suddenly refuses several breastfeeds This behaviour is sometimes called a nursing strike Possible causes 4 Separation from his mother for example when she starts a job A new carer or too many carers A change in the family routine for example moving house visiting relatives Illness of his mother or a breast infection His mother menstruating A change in his mother s smell for example different soap or different food Is it apparent and not real refusal Sometimes a baby behaves in a way which makes his mother think that he is refusing to breastfeed However he is not really refusing When a newborn baby roots for the breast he moves his head from side to side as if he is saying no However this is normal behaviour Between 4 and 8 months of age babies are easily distracted for example when they hear a noise They may suddenly stop suckling It is a sign that they are alert After the age of 1 year a baby may wean himself This is usually gradual Fig 29 Sometimes a baby refuses because breastfeeding has become unpleasant or frustrating CAUSES OF BREAST REFUSAL Illness pain or sedation Difficulty with breastfeeding technique Change which upsets baby especially aged 3 12 months Apparent refusal Infection Brain damage Pain from bruise vacuum forceps Blocked nose Sore mouth thrush teething Bottle feeds dummies Not getting much mil
31. milk all day at work it is so embarrassing I have bad stomach pains when he is breastfeeding 6 Optional Short Story Exercise Edna brings baby Sammy to see you She looks worried She says Sammy breastfeeds very often but he still looks so thin What would you say to Edna to empathize with how she feels EXERCISE 5 Translating judging words JUDGING WORDS Well Normal Enough Problem Crying too much good correct adequate fail unhappy bad proper inadequate failure happy badly right satisfied succeed fussy wrong plenty of success colicky sufficient USING AND AVOIDING JUDGING WORDS English Local Judging question Non judging question language Well Does he suckle well Normal Are his stools normal Enough Is he gaining enough Repa weight Problem Do you have any alein problems breastfeeding Does he cry too much at Crying too night much gt Session 8 Back to CONTENTS HEALTH CARE PRACTICES Introduction Health care practices can have a major effect on breastfeeding Poor practices interfere with breastfeeding and contribute to the spread of artificial feeding Good practices support breastfeeding and make it more likely that mothers will breastfeed successfully and will continue for a longer time Maternity facilities help mothers to initiate or start breastfeeding at the time of delivery and they help them to establish breastfeeding in the post natal period Other parts of the health care service can p
32. mouth a baby opening his mouth and turning to find the nipple the part of a feeding bottle from which a baby sucks holding the breast between the index and middle fingers while the baby is feeding produce a fluid in the body a baby more than one year old deciding by himself to stop breastfeeding messages in nerves which are responsible for feeling drops put into a baby s eyes to prevent infection with gonococcus or chlamydia a mother holding her naked baby against her own skin pain in the nipple and areola when the baby feeds using negative pressure to take something into the mouth the baby automatically sucks something that touches his palate the action by which a baby removes milk from the breast drinks or artificial feeds given in addition to breastmilk help continuing to breastfeed up to 2 years or beyond helping mothers to continue to breastfeed the baby automatically swallows when his mouth fills with fluid show that you are sorry for a person from your point of view stretched out breast tissue from which a baby suckles infection caused by the yeast Candida in the baby s mouth thrush forms white spots the tongue cannot stick out far because of a short frenulum see demand feeding the vitamin that prevents blindness due to xerophthalmia the vitamin in fruits and vegetables that prevents scurvy there are several different vitamin Bs they help to control the working of the body a method of expressing breastmilk u
33. not you find a cause advise the mother to do these things Breastfeed frequently The best way is to rest with her baby so that she can respond to him and feed him whenever he is willing Gently massage the breast while her baby is suckling Show her how to massage over the blocked area and over the duct which leads from the blocked area right down to the nipple This helps to remove the block from the duct She may notice that a plug of thickened milk comes out with her milk It is safe for the baby to swallow the plug Apply warm compresses to her breast between feeds Sometimes it is helpful to do these things Start the feed on the unaffected breast This may help if pain seems to be preventing the oxytocin reflex Change to the affected breast after the reflex starts working Breastfeed the baby in different positions at different feeds This helps to remove milk from different parts of the breast more equally Show the mother how to hold her baby in the underarm position or how to lie down to feed him instead of holding him across the front at every feed However do not make her breastfeed in a position that is uncomfortable for her If breastfeeding is difficult help her to express the milk Sometimes a mother is unwilling to feed her baby from the affected breast especially if it is very painful Sometimes a baby refuses to feed from an infected breast possibly because the taste of the milk changes In
34. of the participant s listening and learning skills including her non verbal communication Mark a Y on your list of LISTENING AND LEARNING SKILLS when she uses a skill to help you to remember for the discussion Notice if she makes a mistake for example if she uses a judging word or if she asks a lot of questions to which the mother says yes and no Stay quietly watching the mother and baby as the feed continues While you observe fill in a B R E A S T FEED Observation Form Write the name of the mother and baby mark a W beside each sign that you observe add the time that the feed takes Thank the mother for her time and cooperation and say something to praise and support her MISTAKES TO AVOID e Do not say that you are interested in breastfeeding The mother s behaviour may change She may not feel free to talk about bottle feeding You should say that you are interested in infant feeding or in how babies feed Do not give a mother help or advice In Clinical Practice 1 if a mother seems to need help you should inform your trainer and a member of staff from the ward or clinic Be careful that the forms do not become a barrier The participant who talks to the mother should not make notes while she is talking She needs to refer to the forms to remind her what to do but if she wants to write she should do so afterwards The participants who are observing can make notes WHO CDR 93 5 UNICEF NUT 93 3 Dis
35. possible Most other commonly used medicines are safe in the usual dosage If a breastfeeding mother is taking a drug that you are not sure about Check the list in your manual or a more detailed list if available Encourage the mother to continue to breastfeed while you try to find out more Watch the baby for side effects such as abnormal sleepiness unwillingness to feed and jaundice especially if the mother needs to take the drug for a long time Try to ask the advice of a more specialized health worker for example a doctor or pharmacist e Ifyou are worried try to find an alternative drug that you know is safe e If a baby has side effects and you cannot change his mother s medication consider an alternative feeding method temporarily if possible BREASTFEEDING AND MOTHERS MEDICATION Breastfeeding contraindicated Continue breastfeeding Side effects possible Anticancer drugs antimetablites Radioactive substances stop breastfeeding temporarily Psychiatric drugs and anticonvulsants Monitor baby for drowsiness Use alternative drug if possible Monitor baby for jaundice Use alternative drug Chloramphenicol tetracyclines metronidazole quinolone antibiotics eg ciprofloxacin Sulphonamides cotrimoxazole Fansidar dapsone Estrogens including estrogen containing contraceptives may decrease milk supply Thiazide diuretics Safe in usual dosage Monitor baby Most commonl
36. reduces her confidence If you accept that she is upset it makes her feel that it is alright to feel the way she does so it does not reduce her confidence Empathizing is one useful way to show acceptance of how a mother feels Skill 2 Recognize and praise what a mother and baby are doing right As health workers we are trained to look for problems We see only what we think people are doing wrong and we try to correct them As counsellors we must learn to look for and recognize what mothers and babies do right Then we should praise or show approval of the good practices Praising good practices has these benefits It builds a mother s confidence It encourages her to continue those good practices It makes it easier for her to accept suggestions later Skill 3 Give practical help Sometimes practical help is better than saying anything For example When a mother feels tired or dirty or uncomfortable When she is hungry or thirsty When she has had a lot of advice already When you want to show support and acceptance When she has a clear practical problem Some ways to give practical help are these Help to make her clean and comfortable Give her a warm drink or something to eat Hold the baby while she gets comfortable No have not breastfed him yet My breasts are empty ant i i aid it is too panfu to sit up A VOAR DAENS Fig 26 Overhead 11 3 Which response is more appropriate You
37. reduces their worries They can give a mother the extra help that she needs from women like herself that health services cannot give WHAT TO DO BEFORE A MOTHER LEAVES A MATERNITY FACILITY Find out what support she has at home If possible talk to family members about her needs Arrange a postnatal check in the first week to include observation of a breastfeed in addition to a routine check at 6 weeks Make sure that she knows how to contact a health worker who can help with breastfeeding if necessary If there is a breastfeeding support group in her neighbourhood refer her to that Fig 22 Talk to family members about a new mother s needs Fathers can be an important source of support for breastfeeding Session 9 Back to CONTENTS CLINICAL PRACTICE 1 Listening and learning Assessing a breastfeed These notes are a summary of the instructions that the trainer will give you about how to do the clinical practice Try to make time to read them to remind you about what to do during the session During the clinical practice you work in small groups and take turns to talk to a mother while the other members of the group observe You practise observing and assessing a breastfeed and the six listening and learning skills from Session 6 After the clinical practice record the mothers you have seen on your CLINICAL PRACTICE PROGRESS FORM on page 186 What to take with you two copies of the B R E A S T
38. should begin as soon as the baby tolerates them Babies who are less than about 30 32 weeks gestational age usually need to be fed by nasogastric tube Give expressed breastmilk by tube The mother can let her baby suck on her finger while he is having the tube feeds This probably stimulates his digestive tract and helps weight gain Babies between about 30 32 weeks gestational age can take feeds from a small cup or from a spoon You can start trying to give cup feeds once or twice a day while a baby is still having most of his feeds by tube If he takes cup feeds well you can reduce the tube feeds Babies of about 32 weeks gestational age or more are able to start suckling on the breast Let the mother put her baby to her breast as soon as he is well enough He may only root for the nipple and lick it at first or he may suckle a little Continue giving expressed breastmilk by cup or tube to make sure that the baby gets all that he needs When a baby starts to suckle effectively he may pause quite often during feeds to breathe It is important to leave him on the breast so that he can suckle again when he is ready Offer a cup feed after the breastfeed Or offer alternate breast and cup feeds Make sure that the baby suckles in a good position Good attachment may make effective suckling possible at an earlier stage The best positions to hold the baby are across the mother s body holding the baby with the arm opposite to the brea
39. should let the baby suckle now to help your breastmilk to come in Let me try to make you more comfortable and then I ll bring you a drink Skill 4 Give a little relevant information Relevant information is information which is useful for a mother NOW When you give a mother information remember these points Tell her things that she can do today not in a few weeks time Try to give only one or two pieces of information at a time especially if she is tired and has already received a lot of advice Wait until you have built her confidence by accepting what she says and praising what she and her baby do right You do not need to give new information or to correct a mistaken idea immediately Give information in a positive way so that it does not sound critical This is especially important if you want to correct a mistaken idea Skill 5 Use simple language Use simple familiar terms to explain things to mothers Remember that most people do not understand the technical terms that health workers use Skill 6 Make one or two suggestions not commands Be careful not to tell or command a mother to do something This does not help her to feel confident Instead when you counsel a mother suggest what she could do differently Then she can decide if she will try it or not This leaves her feeling in control and helps her to feel confident CONFIDENCE AND SUPPORT SKILLS O Accept what a mother thinks and feels O Rec
40. sooner ovarian and breast cancer Fig 6 Overhead 1 14 RECOMMENDATIONS Start breastfeeding within 2 1 hour of birth Breastfeed exclusively from 0 4 months of age Complementary foods can begin between 4 6 months exact age varies Give complementary foods to all children from 6 months of age Continue breastfeeding up to 2 years of age or beyond TERMS FOR INFANT FEEDING Exclusive breastfeeding Exclusive breastfeeding means giving a baby no other food or drink including no water in addition to breastfeeding except medicines and vitamin or mineral drops expressed breastmilk is also permitted Predominant breastfeeding Predominant breastfeeding means breastfeeding a baby but also giving small amounts of water or water based drinks such as tea Full breastfeeding Full breastfeeding means breastfeeding either exclusively or predominantly Bottle feeding Bottle feeding means feeding a baby from a bottle whatever is in the bottle including expressed breastmilk Artificial feeding Artificial feeding means feeding a baby on artificial feeds and not breastfeeding at all Partial breastfeeding Partial breastfeeding means giving a baby some breastfeeds and some artificial feeds either milk or cereal or other food Timely complementary feeding Timely complementary feeding means giving a baby other food in addition to breastfeeding when it is appropriate after the age of 4 6 months Session 2 Back to C
41. that she has enough to eat and drink If you know of a locally valued lactogogue encourage her to take that Encourage her to rest more and to try to relax when she breastfeeds Explain that she should keep her baby near her give him plenty of skin to skin contact and do as much as possible for him herself Grandmothers can help if they take over other responsibilities but they should not care for the baby at this time Later they can do so again Explain that the most important thing is to let her baby suckle more at least 10 times in 24 hours more if he is willing She can offer her breast every two hours She should let him suckle whenever he seems interested She should let him suckle longer than before at each breast She should keep him with her and breastfeed at night Sometimes it is easiest to get a baby to suckle when he is sleepy Make sure that her baby attaches well to the breast Discuss how to give other milk feeds while she waits for her breastmilk to come and how to reduce the other milk as her milk increases For amounts see box AMOUNT OF MILK FOR BABIES WHO CANNOT BREASTFEED on page 139 Show her how to give the other feeds from a cup not from a bottle She should not use a pacifier If her baby refuses to suckle on an empty breast help her to find a way to give the baby milk while he is suckling For example with a dropper or a breastfeeding supplementer see next page To start with she sho
42. the baby How does the baby respond How does the mother put her baby onto her breast How does the mother hold her breast during a feed Does the baby look well attached to the breast Is the baby suckling effectively How does the breastfeed finish Does the baby seem satisfied What is the condition of the mother s breasts How does breastfeeding feel to the mother Fig 17 How does the mother hold her baby a Baby s body close facing breast b Baby s body away from mother neck twisted Face to face attention from mother No mother baby eye contact Fig 18 How does the mother hold her breast a Resting her fingers on her chest wall b Holding her breast too near the so that her first finger forms a nipple support at the base of the breast B R E A S T FEED OBSERVATION FORM Mother s name Date Baby s name Age of baby Signs in brackets refer only to newborn not to older babies Signs that breastfeeding is going well BODY POSITION Mother relaxed and comfortable Baby s body close facing breast Baby s head and body straight Baby s chin touching breast Baby s bottom supported OOoOOdO RESPONSES O Baby reaches for breast if hungry O0 Baby roots for breast O0 Baby explores breast with tongue O Baby calm and alert at breast O0 Baby stays attached to breast O Signs of milk ejection leaking afterpains EMOTIONAL BONDING O Secure confident hold O Face to face attention fr
43. to bacterial infection to reduce or stop something examining by looking inability to tolerate a particular food symptoms are dose related that is worse when more food is eaten a nipple which goes in instead of sticking out or which goes in jaundice judging words lactation Lactation Amenorrhoea Method LAM lactiferous sinuses lactose lipase low birth weight LBW mastitis mature milk milk ejection reflex milk stasis mistaken idea Montgomery s glands nipple confusion nipple sucking non infective mastitis non verbal communication not enough milk nutrients oedema open questions oversupply oxytocin pacifier palpation partially breastfed persistent diarrhoea pneumonia poorly protractile positioning postnatal check predominantly breastfed prelacteal feeds premature preterm prolactin protein protractile when the mother tries to stretch it out yellow colour of eyes and skin words which suggest that something is right or wrong good or bad the process of producing breastmilk using the period of amenorrhoea after childbirth as a family planning method wide part of milk ducts in which breastmilk collects the special sugar present in all milks enzyme to digest fat weighing less than 2 5 kg at birth inflammation of the breast see also infective and non infective mastitis the breastmilk that is produced after a few days milk flowing from the breast due to oxytocin rel
44. what they could do better COUNSELLING SKILLS CHECKLIST Listening and learning Helpful non verbal communication Ask open questions Respond showing interest Reflect back Empathize Avoid judging words Confidence and support O Accept what mother says Praise what is right Give practical help Give relevant information Use simple language Make one or two suggestions Assessing a breastfeed o E E E O E Body position Responses mother and baby Emotional bonding Anatomy of breast Suckling Time spent suckling Taking a history Baby s feeding now Baby s health behaviour Pregnancy birth early feeds Mother s condition and FP Previous infant feeding Family and social situation Session 26 Back to CONTENTS LOW BIRTH WEIGHT AND SICK BABIES Introduction The term low birth weight LBW means a birth weight of less than 2 500 grams A LBW baby may be premature or small for gestational age or both In many countries 15 20 of all babies are low birth weight In this country of all babies are low birth weight LBW babies need breastmilk even more than larger babies The best milk for a LBW baby is his own mother s milk Preterm milk is specially adapted to the needs of a preterm baby It contains extra protein and extra anti infective factors Methods of feeding LBW babies For the first few days a baby may not be able to take any oral feeds He may need to be fed intravenously Oral feeds
45. which does not sound critical Example A mother says I don t have enough milk because my breasts are so small Accept what she says Mm Mothers often worry about the size of their breasts Give correct information in a positive way You know bigger breasts only contain more fat The part of the breast that makes the milk is the same in all breasts To answer 1 A mother says I don t let him suckle for more than 10 minutes because it would make my nipples sore Accept what she says Yes that can be a worry Give correct information in a positive way 2 A mother says I give him drinks of water the weather is so hot now Accept what she says You feel that he needs more to drink sometimes Give correct information in a positive way 3 A mother says I will give him a bottle in the evening and save up my breastmilk for the night Accept what she says You feel that he is not satisfied in the evening Give correct information in a positive way EXERCISE 11 Using simple language How to do the exercise Below are five pieces of information that you might want to give to mothers including some from Exercise 9 The information is correct but it uses technical terms that a mother who is not a health worker might not understand Rewrite the information in simple language that a mother could easily understand Example Information Colostrum is all that a baby needs in the first few day
46. Breasts soft after feed O Nipples stand out protractile O Skin appears healthy O Breast looks round during feed SUCKLING Mouth wide open Lower lip turned outwards Tongue cupped around breast Cheeks round More areola above baby s mouth Slow deep sucks bursts with pauses Can see or hear swallowing OOOOOOO TIME SPENT SUCKLING O Baby releases breast Baby suckled for ___ minutes Signs of possible difficulty OShoulders tense leans over baby OBaby s body away from mother s OBaby s neck twisted OBaby s chin not touching breast C Only shoulder or head supported ONo response to breast O No rooting observed OBaby not interested in breast OBaby restless or crying OBaby slips off breast ONo signs of milk ejection ONervous or limp hold ONo mother baby eye contact OLittle touching or OShaking or poking baby OBreasts engorged ONipples flat or inverted OFissures or redness of skin OBreast looks stretched or pulled OMouth not wide open points forward OLower lip turned in OBaby s tongue not seen OCheeks tense or pulled in OMore areola below baby s mouth ORapid sucks only OCan hear smacking or clicking OMother takes baby off breast Notes Adapted with permission from B R E A S T Feeding Observation Form by H C Armstrong Training Guide in Lactation Management New York IBFAN and UNICEF 1992 B R E A S T FEED OBSERVATION FORM Mother s name Date Baby s name Slide 5 15 Age of baby
47. ED EXERCISE I Using the B R E A S T FEED Observation Form In this exercise you practise recognizing the signs of good and poor positioning and attachment in some slides of babies breastfeeding With Slides 5 12 to 5 15 use your observations to practise filling in one of the B R E A S T FEED Observation Forms on the following pages There are four forms Fill in one form for each slide Ifyou see a sign make a in the box next to the sign Ifyou do not see a sign leave the box empty Ifyou see something important but there is no box for it make a note in the space Notes at the bottom of the form Most of the signs that you will see are in the sections for BODY POSITION and SUCKLING For this exercise you do not have to fill in the other sections Fig 19 a A baby well attached b A baby poorly attached to his mother s breast to his mother s breast B R E A S T FEED OBSERVATION FORM Mother s name Date Baby s name Slide 5 12 Age of baby Signs in brackets refer only to newborn not to older babies Signs that breastfeeding is going well BODY POSITION Mother relaxed and comfortable Baby s body close facing breast Baby s head and body straight Baby s chin touching breast Baby s bottom supported OOoOOdO RESPONSES O Baby reaches for breast if hungry O0 Baby roots for breast O0 Baby explores breast with tongue O Baby calm and alert at breast O Baby stays attached to breast O Sign
48. EMENT OF FLAT AND INVERTED NIPPLES Antenatal treatment Probably not helpful Soon after delivery Build mother s confidence breasts will improve Explain baby suckles BREAST not nipple Let baby explore breast skin to skin Help mother to position baby early Try different positions e g underarm Help her to make nipple stand out more Use pump syringe For first week or two Express breastmilk and feed with cup if necessary Express breastmilk into baby s mouth Management of flat and inverted nipples Antenatal treatment is probably not helpful For example stretching nipples or wearing nipple shells does not help Most nipples improve around the time of delivery without any treatment Help is most important soon after delivery when the baby starts breastfeeding Build the mother s confidence Explain that it may be difficult at the beginning but with patience and persistence she can succeed Explain that her breasts will improve and become softer in the week or two after delivery Her baby s suckling will help to pull her nipples out Explain that a baby suckles from the breast not from the nipple Her baby needs to take a large mouthful of breast Explain also that as her baby breastfeeds he will pull the breast and nipple out Encourage her to give plenty of skin to skin contact and to let her baby explore her breasts Let him try to attach to the breast on his own whenever he is interested Some babies learn be
49. ENTS Additional sessions Session 31 Women s nutrition health and fertility Session 32 Women and work Session 33 Commercial promotion of breastmilk substitutes Glossary Session 31 Additional session Back to CONTENTS WOMEN S NUTRITION HEALTH AND FERTILITY Introduction When you help a mother to breastfeed it is important to remember her own health and to care for her as well as her baby You need to think about the mother s nutrition because this affects her health energy and well being You need to know how to help a mother to breastfeed if she becomes sick You may be concerned about whether her illness or the drugs that she is taking can affect her baby Breastfeeding and family planning help each other You need to be able to give mothers the information that they need about breastfeeding and family planning SOURCE OF ENERGY IN BREASTMILK Calories 700 Calories a day Fig 39 Overhead 31 1 EFFECT OF MOTHERS NUTRITION ON BREASTMILK PRODUCTION _ Lactose Lactose Lactose WELL MODERATE SEVERE NOURISHED MALNUTRITION MALNUTRITION Fig 40 Overhead 31 2 EXAMPLE OF EXTRA FOOD NEEDED EACH DAY BY A BREASTFEEDING WOMAN 60g rice 1 fistful 240 Calories 30g dahl fistful 120 Calories Vegetables 1 fistful 2 banana 90 Calories 5 mi oil 1 teaspoonful 50 Calories Fig 41 overhead 31 3 HELPING A SICK MOTHER TO BREASTFEED Any sick woman lf admitted to hospital
50. ONTENTS LOCAL BREASTFEEDING SITUATION Try to answer the following questions for the area where you work For each question put a circle round the answer few half or most whichever is closest to what you have observed How many babies start to breastfeed few half most How many breastfeed within 1 hour of delivery few half most How many have other foods or drinks before they few half most start to breastfeed How many breastfeed exclusively for 4 6 months few half most How many have other foods or drinks before 1 month few half most 2 months few half most 3 months few half most How many children continue to breastfeed more than 6 months few half most 12 months few half most 24 months few half most Session 3 Back to CONTENTS HOW BREASTFEEDING WORKS Introduction In this session you will learn about the anatomy and physiology of breastfeeding In order to help mothers you need to understand how breastfeeding works You cannot learn a specific way of counselling for every situation or every difficulty But if you understand how breastfeeding works you can work out what is happening and help each mother to decide what is best for her oxytocin makes them muscle cells contract prolactin makes them milk secreting cells secrete milk ducts milk lactiferous sinuses collects here areola Montgomery s glands ae alveoli supporting tissue and fat Fig 7
51. So it is important to discuss family planning with breastfeeding mothers Make sure that the method a mother chooses is suitable to use with breastfeeding All non hormonal methods are suitable They have no effect on lactation The IUD is very suitable Condoms diaphragms and spermicides are also suitable provided the couple can use them correctly They may help to supplement the partial protection provided by breastfeeding after the baby is 6 months old The progestogen only hormonal methods are also suitable with breastfeeding These include depo provera and the newer norplant or the progestogen only pill These have either no effect on lactation or they possibly increase the breastmilk supply slightly The least suitable group are the combined estrogen progestogen hormonal methods such as the combined pill or the newer monthly injection These methods sometimes decrease the breastmilk supply so it is best to avoid them during breastfeeding if possible Avoid them at any time including after the baby has started complementary foods However if no other method of family planning is available it is better for both mother and child if the mother uses the combined pill than that she risks an early pregnancy Encourage her to continue breastfeeding frequently to make sure that her breastmilk supply does not decrease No hormonal method should be used during the first 6 weeks after delivery EXERCISE 23 Breastfeeding and family p
52. Twin ask all these Urine output more less than points 6 times per day 3 Pregnancy birth early feeds 4 Mother s condition and family planning 5 Previous infant feeding experience 6 Family and social situation Stools soft and yellow brown or hard or green frequency Feeding behaviour appetite vomiting Sleeping behaviour Illnesses Antenatal care attended not Delivery Rooming in Prelacteal feeds What given Formula samples given to mother Postnatal help with breastfeeding Age Health Family planning method Number of previous babies How many breastfed Any bottles used Work situation Economic situation Father s attitude to breastfeeding Other family members attitude to breastfeeding Help with child care What others say about breastfeeding Abnormalities Breastfeeding discussed Early contact first 12 1 hour Time first breastfeed How given Breast condition Motivation to breastfeed Alcohol smoking coffee other drugs Experience good or bad Reasons Literacy Session 18 Back to CONTENTS HISTORY PRACTICE These notes are a summary of the instructions that the trainer will give you about how to do the exercise Try to make time to read them to remind you about what to do during the session During the exercise you work in small groups taking turns to practise as a counsellor taking a history from a mother using the history form You will be given a card
53. USTAIN BREASTFEEDING Praise all mothers who are breastfeeding Encourage them to continue and to help other mothers Remember to praise mothers who breastfeed through the second year Help mothers to breastfeed in the most healthy way For example to breastfeed exclusively for 4 6 months Help them to improve practices which may cause problems Encourage mothers to come for help before they decide to start artificial feeds For example if they are worried about their breastmilk supply Or if they have a breastfeeding difficulty or question Refer mothers to a breastfeeding support group if appropriate See Session 8 Health care practices Provide appropriate family planning advice for women who are breastfeeding Encourage a mother not to start a new pregnancy until this child is 2 years old or more Remember to encourage breastfeeding when you see a mother for her postnatal check in the first week and at 6 weeks family planning growth monitoring especially poor weight gain of baby nutrition education immunization including for measles at 9 months At the 9 months visit encourage her to continue breastfeeding the child with complementary foods for another 12 15 months or more Help mothers to continue breastfeeding in these difficult situations because they have to return to work with twins or low birth weight babies with a disabled baby if a mother is ill or disabled Help mothers to breas
54. WHO CDR 93 5 UNICEF NUT 93 3 Distr General Original English BREASTFEEDING COUNSELLING A TRAINING COURSE PARTICIPANTS MANUAL PART ONE Sessions 1 9 WORLD HEALTH ORGANIZATION CDD PROGRAMME UNICEF CONTENTS Introduction Session 1 Why breastfeeding is important Session 2 Local breastfeeding situation Session 3 How breastfeeding works Session4 Assessing a breastfeed Session5 Observing a breastfeed Session 6 Listening and learning Session 7 Session 8 Session 9 Listening and learning exercises Health care practices Clinical Practice 1 INTRODUCTION Back to CONTENTS Why this course is needed Breastfeeding gives children the best start in life It is estimated that over one million children die each year from diarrhoea respiratory and other infections because they are not adequately breastfed Many more children suffer from unnecessary illnesses that they would not have if they were breastfed Breastfeeding also helps to protect mothers health The Programme for the Control of Diarrhoeal Diseases has long recognised the need to promote breastfeeding to prevent diarrhoea in young children More recently it has become clear that breastfeeding is important also in the management of diarrhoea to prevent dehydration and to promote recovery The World Health Organization and UNICEF recommend exclusive breastfeeding from birth for the first 4 6 months of life and sustained breastfeeding together with adequa
55. What has happened to Mrs G s breasts What are Mrs G and her baby doing right What practical help can you give Mrs G Session 16 Back to CONTENTS REFUSAL TO BREASTFEED Introduction Refusal by the baby is a common reason for stopping breastfeeding However it can often be overcome Refusal can cause great distress to the baby s mother She may feel rejected and frustrated by the experience Sometimes a baby attaches to the breast but then does not suckle or swallow or suckles very weakly Sometimes a baby cries and fights at the breast when his mother tries to breastfeed him Sometimes a baby suckles for a minute and then comes off the breast choking or crying He may do this several times during a single feed Sometimes a baby takes one breast but refuses the other You need to know how to decide why a baby is refusing to breastfeed and how to help the mother and baby enjoy breastfeeding again Fig 28 A baby may be unable to suckle because he is sick This baby has tetanus WHY A BABY MAY REFUSE TO BREASTFEED 1 Is the baby ill in pain or sedated Illness The baby may attach to the breast but suckles less than before Pain Pressure on a bruise from forceps or vacuum extraction The baby cries and fights as his mother tries to breastfeed him Blocked nose Sore mouth Candida infection thrush an older baby teething The baby suckles a few times and then stops and cries Sedation A baby m
56. a cup glass jug or jar with a wide mouth e Wash the cup in soap and water She can do this the day before e Pour boiling water into the cup and leave it for a few minutes Boiling water will kill most of the germs When ready to express milk pour the water out of the cup HOW TO EXPRESS BREASTMILK BY HAND Teach a mother to do this herself Do not express her milk for her Touch her only to show her what to do Be gentle Teach her to Wash her hands thoroughly Sit or stand comfortably and hold the container near her breast Put her thumb on her breast ABOVE the nipple and areola and her first finger on the breast BELOW the nipple and areola opposite the thumb She supports the breast with her other fingers Press her thumb and first finger slightly inwards towards the chest wall She should avoid pressing too far because that can block the milk ducts Press her breast behind the nipple and areola between her finger and thumb She must press on the lactiferous sinuses beneath the areola see Fig 7 on page 12 Sometimes in a lactating breast it is possible to feel the sinuses They are like pods or peanuts If she can feel them she can press on them Press and release press and release This should not hurt if it hurts the technique is wrong At first no milk may come but after pressing a few times milk starts to drip out It may flow in streams if the oxytocin reflex is active Press the areola in the s
57. a little more than this if possible for example 30 ml This also allows for spillage To answer Question 1 optional Baby Anna was born at 31 weeks gestation and cannot yet suckle She weighs 1 5 kg and you are tube feeding her with her mother s EBM This is the second day she has taken oral feeds You are feeding her 2 hourly How much will you give at each feed Question 2 Mona has just delivered a baby 6 weeks before her expected date He weighs 1 500 grams and is being observed in the special care unit Mona wants to breastfeed but she is worried that her baby will not be able to What could you say to empathize with Mona What could you say to build her confidence Question 3 Sammy is 8 months old He was exclusively breastfed until 5 weeks ago Now his mother gives him 3 feeds of enriched porridge a day in addition to breastfeeding He has had diarrhoea for 2 days and does not want to eat porridge Sammy is not dehydrated You explain to his mother about giving ORS and about when to come back for follow up What could you say to praise what Sammy s mother is doing right What two things would you advise her about feeding Sammy Question 4 Tsitsi is 4 months old and is being treated in hospital for severe pneumonia Before she was ill she was exclusively breastfed Now she is unable to suckle and has to be fed by nasogastric tube What would you ask Tsitsi s mother to do to feed Tsitsi How often would you
58. a mother thinks that she does not have enough breastmilk her baby is in fact getting all that he needs Sometimes a baby does not get enough breastmilk But it is usually because he is not suckling enough or not suckling effectively see Session 3 How breastfeeding works It is rarely because his mother cannot produce enough So it is important to think not about how much milk a mother can produce but about how much milk a baby is getting SIGNS THAT A BABY MAY NOT BE GETTING ENOUGH BREASTMILK RELIABLE e Poor weight gain Less than 500 g a month Less than birth weight after 2 weeks Passing small amount Less than 6 times a day of concentrated urine yellow and strong smelling POSSIBLE Baby not satisfied after breastfeeds Baby cries often Very frequent breastfeeds Very long breastfeeds Baby refuses to breastfeed Baby has hard dry or green stools No milk comes when mother tries to express Breasts did not enlarge during pregnancy Milk did not come in after delivery How to find out if a baby is getting enough breastmilk or not Check the baby s weight gain This is the most reliable sign For the first stx months of life a baby should gain at least 500 g in weight each month or 125 g each week One kilogram per month is not necessary and not usual If a baby gains less than 500 g in a month he is not gaining enough weight Look at the baby s growth chart if available or at any othe
59. a number of questions On the last page there are two blank forms First go through the questions Answer YES or NO for each question as it applies to your health facility Write a few words about what is done well or what needs to be improved Write your answers on the loose copy of the form to hand in to the course organizers If several members of the groups are from the same health facility fill in one form together to hand in Otherwise each of you should fill in your own form If some questions are not relevant to your facility for example you are not a maternity facility and do not deliver babies leave the questions about that activity blank Then look at the short forms on the last page Inthe top form list 5 10 changes that you could make immediately by changing your own practice In the bottom form list 1 4 useful changes that require an administrative decision If you wish to keep a personal copy copy the answers onto the form in your manual ASSESSING AND CHANGING PRACTICES FORM Practice Policy e Does your health facility have a breastfeeding policy e Is this a written policy Does it cover the Ten Steps to Successful Breastfeeding Antenatal preparation e Do you inform all pregnant women about the benefits of breastfeeding the management of breastfeeding Initiating breastfeeding if normal vaginal e Are women routinely sedated during normal labour e Do you give mother
60. aby help a baby to attach to a full breast express breastmilk directly into a baby s mouth prevent the nipple and areola from becoming dry and sore It is a good idea for all mothers to learn how to express their breastmilk so that they know what to do if the need arises The most useful way for a mother to express milk is by hand It needs no appliance so she can do it anywhere and at any time With a good technique it can be very efficient It is easy to hand express when the breasts are soft It is more difficult when the breasts are engorged or tender So teach a mother how to hand express on the first or second day after delivery Many mothers are able to express plenty of breastmilk using rather strange techniques If a mother s technique works for her let her do it that way But if a mother is having difficulty expressing enough milk teach her a more effective technique Stimulating the oxytocin reflex The oxytocin reflex may not work as well when a mother expresses as it does when a baby suckles A mother needs to know how to help her oxytocin reflex or she may find it difficult to express her milk HOW TO STIMULATE THE OXYTOCIN REFLEX Help the mother psychologically Build her confidence Try to reduce any sources of pain or anxiety Help her to have good thoughts and feelings about the baby Help the mother practically Help or advise her to Sit quietly and privately or with a supportive friend Some mothers
61. acteria or other harmful substances a way of working with people so that you understand their feelings and help them to develop confidence and decide what to do dehydration demand feeding distraction ducts milk ducts dummy early contact eczema effective suckling empathize engorgement essential fatty acids exclusively breastfed express expressed breastmilk EBM fissure flat nipple foremilk formula frenulum full breasts gastric suction gestational age growth factors growth spurt gulp high needs babies hindmilk hormones immune system ineffective suckling infective mastitis inhibit inspection intolerance inverted nipple lack of water in the body feeding a baby whenever he shows that he is ready both day and night This is also called unrestricted or baby led feeding a baby s attention easily taken from the breast by something else such as a noise small tubes which lead milk to the nipple artificial nipple made of plastic for a baby to suck a pacifier a mother holding her baby during the first hour or two after delivery skin condition often associated with allergy suckling in a way which removes the milk efficiently from the breast show that you understand how a person feels from her point of view swollen with breastmilk blood and tissue fluid Engorged breasts are often painful and oedematous and the milk does not flow well fats which are essential for a baby s
62. aditional ideas may be mistaken Many women especially in cities have little support Or they may have friends or relatives who encourage them to bottle feed An early postnatal check within I week of discharge from hospital This check should include observation of a breastfeed and discussion of how breastfeeding is going You can help mothers with minor difficulties before they become serious problems A routine postnatal check at 6 weeks This check also should include observation of a breastfeed as well as discussion of family planning see Session 31 Women s nutrition health and fertility Continuing help from health care services At any time that a health worker is in contact with a mother and child under 2 years of age she should support breastfeeding See Session 28 Sustaining breastfeeding Help from community health workers Community health workers are often in a good position to help breastfeeding mothers as they may live nearby They may be able to see a mother more often and give more time than facility based health workers It may be helpful to train community health workers in some breastfeeding counselling skills A breastfeeding support group BREASTFEEDING SUPPORT GROUPS A group may be started by a health worker by an existing women s group by a group of mothers who feel that breastfeeding is important or by mothers who meet in the antenatal clinic or maternity facility and w
63. ake her breastfed baby drowsy or weak This is especially likely with barbiturates and diazepam and if the baby is less than one month old Sometimes it is possible to change to an alternative drug which is less likely to affect the baby However it can be dangerous to change a mother s treatment quickly especially for conditions such as epilepsy If there is no alternative continue breastfeeding and observe her baby If side effects occur it may be necessary to stop breastfeeding Some antibiotics should be avoided if possible Most antibiotics given to a breastfeeding mother are safe for her baby It is better to avoid chloramphenicol and tetracycline if possible and also metronidazole However if one of these antibiotics is the drug of choice for treating a mother continue breastfeeding and observe her baby In most cases there will be no problem Avoid giving a mother sulphonamides especially if her baby is jaundiced If treatment with cotrimoxazole Fansidar or dapsone is necessary give the drug and continue breastfeeding Consider an alternative method of feeding if the baby is jaundiced especially if he becomes jaundiced while his mother is taking the drug Drugs which decrease breastmilk should be avoided if possible Avoid using contraceptives which contain estrogens but see also Overhead 31 8 Avoid using thiazide diuretics such as chlorthiazide These drugs may reduce the breastmilk supply Use an alternative if
64. ame way from the SIDES to make sure that milk is expressed from all segments of the breast Avoid rubbing or sliding her fingers along the skin The movement of the fingers should be more like rolling Avoid squeezing the nipple itself Pressing or pulling the nipple cannot express the milk It is the same as the baby sucking only the nipple Express one breast for at least 3 5 minutes until the flow slows then express the other side and then repeat both sides She can use either hand for either breast and change when they tire Explain that to express breastmilk adequately takes 20 30 minutes especially in the first few days when only a little milk may be produced It is important not to try to express in a shorter time Fig 31 How to express breastmilk a Place finger and thumb each side of the areola and press inwards towards the chest wall b Press behind the nipple and areola between your finger and thumb c Press from the sides to empty all segments How often a mother should express milk To establish lactation to feed a low birth weight LBW or sick newborn She should start to express milk on the first day within six hours of delivery if possible She may only express a few drops of colostrum at first but it helps breastmilk production to begin in the same way that a baby suckling soon after delivery helps breastmilk production to begin She should express as much as she can as often as her baby would
65. and use it as a source of reference as you put what you have learnt into practice Your manual also contains copies of the key overheads that you might want to memorise forms lists and checklists for exercises and clinical practice written exercises that you will be asked to do individually You will receive separate copies of the forms lists and checklists to use for clinical practice sessions so that you do not have to carry your manual at these times You will receive Answer Sheets for each written exercise after you have done the exercise This enables you to check your answers later and to study any questions that you may not have had time to complete You will also receive a copy of the following reference materials The book Helping Mothers to Breastfeed AMREF Revised Edition 1992 Protecting Infant Health A Health Workers Guide to the International Code of Marketing of Breastmilk Substitutes Protecting Promoting and Supporting Breastfeeding The Special Role of the Maternity Services A joint WHO UNICEF Statement 1989 Annex to the Global Criteria for Baby Friendly Hospitals Acceptable Medical Reasons for Supplementation Annex on Breastfeeding and Maternal Medication Recommendations for drugs in the Essential Drugs List The Course Director will recommend parts of these reference materials for you to read in preparation for some sessions or after sessions to help you to remember what you have learned
66. ask her to do this Question 5 Baby Zora is 3 days old and today her eyes and skin look slightly yellow Her mother breastfeeds her 3 4 times a day and she also gives Zora glucose water between breastfeeds What relevant information would you give to Zora s mother How would you advise her mother to feed Baby Zora now Session 27 Back to CONTENTS INCREASING BREASTMILK AND RELACTATION Introduction If a mother s breastmilk supply is reduced she needs to increase it If a mother has stopped breastfeeding she may want to start again This is called relactation The situations in which mothers may want to relactate include when A baby has been sick and has not suckled for a time A baby has been artificially fed but the mother wants now to try breastfeeding A baby becomes ill or fails to grow on artificial feeds The mother has been sick and stopped feeding her baby A woman adopts a baby The same principles and method apply for increasing a reduced supply and for relactation However relactation is more difficult and takes longer The mother must be well motivated and she needs a lot of support to succeed Sometimes it is also necessary to use the methods described in MANAGEMENT OF REFUSAL TO BREASTFEED see Session 16 Refusal to breastfeed How to help a mother to increase her milk She must et her baby suckle often to stimulate her breast If her baby does not suckle often her breastmilk will not increa
67. ast if her baby does show an interest He may be more willing to suckle when he is sleepy or after a cup feed than when he is very hungry She can offer her breast in different positions If she feels her ejection reflex working she can offer her breast then Help her baby to breastfeed in these ways Express a little milk into her baby s mouth Position him well so that it is easy for him to attach to the breast She should avoid pressing the back of his head or shaking her breast Feed her baby by cup until he is breastfeeding again She can express her breastmilk and feed it to her baby from a cup or cup and spoon If necessary use artificial feeds and feed them by cup She should avoid using bottles teats and pacifiers dummies of any sort HELPING A MOTHER AND BABY TO BREASTFEED AGAIN Help the mother to do these things Keep her baby close no other carers Give plenty of skin to skin contact at all times not just at feeding times Sleep with her baby Ask other people to help in other ways Offer her breast whenever her baby is willing to suckle When sleepy or after a cup feed In different positions When she feels her ejection reflex working Help her baby to take the breast Express breastmilk into his mouth Position him so that he can attach easily to the breast Avoid pressing the back of his head or shaking her breast Feed her baby by cup Give her own expressed breastm
68. at he is breastfeeding less often and for a shorter time than before she started cereal feeds Mrs Q is at home all day and her baby sleeps with her at night Why do you think that Mrs Q s breastmilk seems to be decreasing What are Mrs Q and her baby doing right What could you suggest to Mrs Q so that she continues to breastfeed Mrs R s baby is 7 weeks old She says that her breastmilk is not good Her baby does not seem satisfied after breastfeeds He cries and wants to feed again very soon sometimes in half an hour or an hour He cries and wants to breastfeed often at night too and Mrs R is exhausted He passes urine about 6 times a day When he breastfeeds you notice that his lower lip is turned in and there is more areola visible below his mouth than above it The baby weighed 3 7 kilos at birth He now weighs 4 8 kilos Is Mrs R s baby getting as much breastmilk as he needs What may be the reason for his behaviour What could you praise to build Mrs R s confidence What practical help would you offer to Mrs R Mrs S says that she is exhausted and will have to bottle feed her 2 month old baby He does not settle after breastfeeds and wants to feed very often she cannot count how many times in a day She thinks that she does not have enough breastmilk and that her milk does not suit her baby While she is talking to you her baby wants a feed He suckles in a good position After about two minutes he pauses and Mrs S qu
69. at you might want to say to the mother Mark with a V the response which praises what the mother and baby are doing right to build the mother s confidence You may give her some of the other information later For Stories H and I make up your own response which praises what the mother and baby are doing right Example A mother is breastfeeding her 3 month old baby and giving drinks of fruit juice The baby has slight diarrhoea Mark the response which praises what she is doing a You should stop the fruit juice that s probably what is causing the diarrhoea Y b It is good that you are breastfeeding breastmilk should help him to recover c It is better not to give babies anything but breastmilk until they are about 6 months old To answer Story E A mother has started bottle feeding her baby by day while she is at work She breastfeeds as soon as she gets home but the baby does not seem to want to suckle as much as he did before a You are very wise to breastfeed whenever you are at home b It would be better if you gave him artificial feeds by cup and not by bottle c Babies often do stop wanting breastfeeds when you start giving bottles Story F The mother of a 3 month old baby says that he is crying a lot in the evenings and she thinks that her milk supply is decreasing The baby gained weight well last month a Many babies cry at that time of day it is nothing to worry about b He is growing very well
70. ay be sleepy because of drugs that his mother was given during labour drugs that she is taking for psychiatric treatment 2 Is there a difficulty with the breastfeeding technique Sometimes breastfeeding has become unpleasant or frustrating for a baby Possible causes Feeding from a bottle or sucking on a pacifier dummy Not getting much milk because of poor attachment or engorgement Pressure on the back of the baby s head by his mother or a helper positioning him roughly with poor technique The pressure makes him want to fight His mother holding or shaking the breast which interferes with attachment Restriction of breastfeeds for example breastfeeding only at certain times Too much milk coming too fast due to oversupply The baby may suckle for a minute and then come off choking or crying when the ejection reflex starts This may happen several times during a feed The mother may notice milk spraying out as he comes off the breast Early difficulty coordinating suckling Some babies take longer than others to learn to suckle effectively Refusal of one breast only Sometimes a baby refuses one breast but not the other This is because the problem affects one side more than the other 3 Has a change upset the baby Babies have strong feelings and if they are upset they may refuse to breastfeed They may not cry but simply refuse to suckle This is commonest when a baby
71. ays Yes you can follow up with an open question to learn more For example What made you decide to do that or What are you giving him Skill 3 Use responses and gestures which show interest Another way to encourage a mother to talk is to use gestures such as nodding and smiling and simple responses such as Mmm or Aha They show a mother that you are interested in her Skill 4 Reflect back what the mother says Reflecting back means repeating back what a mother has said to you to show that you have heard and to encourage her to say more Try to say it in a slightly different way For example if a mother says My baby was crying too much last night You could say Your baby kept you awake crying all night Skill 5 Empathize show that you understand how she feels Empathy or empathizing means showing that you understand how a person feels For example if a mother says My baby wants to feed very often and it makes me feel so tired you could say You are feeling very tired all the time then This shows that you understand that she feels tired so you are empathizing If you respond with a factual question for example How often is he feeding What else do you give him you are not empathizing Skill 6 Avoid words which sound judging Judging words are words like right wrong well badly good enough properly If you use these words when you ask questions you may make a mother feel that she is wro
72. breastfeeding on demand Give no artificial teats or pacifiers also called dummies or soothers to breastfeeding infants Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic ANTENATAL PREPARATION FOR BREASTFEEDING With mothers in groups e Explain benefits of breastfeeding Give simple relevant information on how to breastfeed Explain what happens after delivery Discuss mothers questions With each mother individually e Ask about previous breastfeeding experience Ask if she has any questions or worries Examine her breasts if she is worried about them Build her confidence and explain that you will help her The dangers of prelacteal feeds Prelacteal feeds are artificial feeds or drinks given to a baby before breastfeeding is initiated They are dangerous because They replace colostrum as the baby s earliest feeds The baby is more likely to develop infections such as diarrhoea septicaemia and meningitis He is more likely to develop intolerance to the proteins in the artificial feed and allergies such as eczema They interfere with suckling The baby s hunger is satisfied so that he wants to breastfeed less If he is fed from a bottle with an artificial teat he may have more difficulty attaching to the breast sucking confusion or nipple confusion The baby suckles and stimulates the breast less Breastmilk takes longer to
73. can express easily in a group of other mothers who are also expressing for their babies Hold her baby with skin to skin contact if possible She can hold her baby on her lap while she expresses If this is not possible she can look at the baby If this is not possible sometimes even looking at a photograph of her baby helps Take a warm soothing drink The drink should not be coffee Warm her breasts For example she can apply a warm compress or warm water or have a warm shower Stimulate her nipples She can gently pull or roll her nipples with her fingers Massage or stroke the breasts lightly Some women find that it helps if they stroke the nipple and areola gently with finger tips or with a comb Some women find that it helps to gently roll their closed fist over the breast towards the nipple Ask a helper to rub her back The mother sits down leans forward folds her arms on a table in front of her and rests her head on her arms Her breasts hang loose unclothed The helper rubs down both sides of the mother s spine She uses her closed fist with her thumbs pointing forwards She presses firmly making small circular movements with her thumbs She works down both sides of the spine at the same time from the neck to the shoulder blades for two or three minutes Fig 30 Fig 30 A helper rubbing a mother s back to stimulate the oxytocin reflex HOW TO PREPARE A CONTAINER FOR EXPRESSED BREASTMILK EBM e Choose
74. ch corresponds to the information which is most relevant for her As an example the correct answer for Mother 1 is already marked in brackets For Mothers 7 and 8 make up a sentence with relevant information To answer Mothers 1 6 1 Mother returning to work abcd e f 2 Mother with 12 month old baby abcdef 3 Mother who thinks that her milk is too thin abcdef 4 Mother who thinks that she does not have enough breastmilk abcdef 5 Mother with 2 month old baby who is exclusively breastfed abcdef 6 A newly delivered mother who wants to give her baby prelacteal feeds abcdef Information a Foremilk normally looks watery and hindmilk is whiter b Exclusive breastfeeding is best until a baby is 4 6 months old c More suckling makes more milk d Colostrum is all that a baby needs at this time e Night breastfeeds are good for a baby and help to keep up the milk supply f Breastfeeding is valuable for two years or more Mother 7 A mother one day after delivery with soft breasts who wants her milk to come in Mother 8 A mother with a healthy 5 6 month old baby who is exclusively breastfed EXERCISE 10 Giving information in a positive way How to do the exercise Below are some mistaken ideas including some from Exercise 7 and what you might say to accept what the mother thinks Write what you would say to the mother later to correct the mistaken idea Give the information in a positive way
75. ck but he may have real pain The crying will become less when the baby is 3 4 months old Medicines for colic are not now recommended They can be harmful Complements are not necessary and often do not help Artificially fed babies also have colic They may develop cow s milk intolerance or allergy and become worse Suckling at the breast for comfort is safe but bottles and pacifiers are not safe Make one or two suggestions What you suggest depends on what you have learnt about the cause of the crying Common causes may be different in different countries If she has an oversupply of breastmilk Help her to improve her baby s attachment to the breast Suggest that she lets him suckle from one breast only at each feed Let him continue at the breast until he finishes by himself Give the other breast at the next feed Explain that if her baby stays on the first breast longer he will get more fat rich hindmilk see also Session 16 Refusal to breastfeed It might help if she takes less coffee and tea and other drinks which contain caffeine such as colas If she smokes suggest that she reduces her smoking and that she smokes after breastfeeds not before or during them Ask other members of the family not to smoke in the same room as the baby It might help if she stops taking cow s milk and other milk products or other foods which can cause allergy soy peanuts eggs She should stop taking the food for a w
76. d she does not drink milk or coffee Mrs N s baby is 5 weeks old and weighs 4 5 kilos He weighed 3 7 kilos when he was born Why do you think Mrs N s baby is crying What are Mrs N and her baby doing right that you could praise What three pieces of information would you give to her What could you suggest that Mrs N might do to help her baby Mrs O is 16 years old Her baby was born 2 days ago and is very healthy She has tried to breastfeed him twice but her breasts are still soft so she thinks that she has no milk and will not be able to breastfeed Her young husband has offered to buy her a bottle and some formula What could you say to accept what Mrs O says about her breastmilk Why does Mrs O think that she will not be able to breastfeed What relevant information would you give her to build her confidence What practical help could you give Mrs O Mrs P s baby is 3 months old She says that for the last few days he has suddenly started crying to be fed very often She thinks that her milk supply has suddenly dried up He has breastfed exclusively until now and has gained weight well What can you say to empathize with Mrs P What can you praise to build Mrs P s confidence What relevant information can you give Mrs P Mrs Q says that her breastmilk seems to be decreasing Her baby is 4 months old and has gained weight well from when he was born Last month she started giving him cereal three times a day She says th
77. do you think about Baby I s recent weight gain IH of A 7 KEDAH His growth is slowing down 2 3 ERA s LEHAHTI Why may this have happened a JA At bE He stopped having night feeds i i angeeece What would you suggest to his mother about feeding him now Let her baby sleep with her again to breastfeed at night Soon she should add complementary foods To answer Baby 2 has come for immunization His mother says 13 that he is well He is a very good baby and cries very little He only wants to feed about 4 5 times a day which his mother finds helpful because she is very 1 busy 10 CNET What could you say to show that you accept how Baby 2 s mother feels 8 What do you think of Baby 2 s weight gain ie lt E N aa es a H PA KILOGRAMS What is the reason i La Rake What would you like to suggest to Baby 2 s mother ry about feeding him 3 13 Baby 3 was exclusively breastfed until last month Now his mother gives him drinks of water because the weather is hot and he seems so thirsty 11 ree CEN ae What do you think of Baby 3 s weight gain What is the reason for his weight this month Ne NEN eb CEES eee ce Cae ae What relevant information could you give to Baby 3 s mother Try to give positive information 6 Pt N What would you suggest to his mother oo Pe NE cl Pe a a a a De pees ee eke eee Baby 4 has come for measle
78. e What could you suggest that Mrs U could do to continue breastfeeding Mrs V s baby is 10 weeks old She says that her breastmilk is decreasing She has given her baby juice from a bottle and one cereal feed a day since he was 4 weeks old A midwife recommended this because the baby was crying a lot Mrs V breastfeeds about 4 5 times a day and sometimes once in the night The baby still cries a lot but usually settles when he suckles on a pacifier He weighed 2 8 kg at birth 3 4 kg at one month and now weighs 3 8 kg Is Mrs V s baby getting enough breastmilk Why What three things would you suggest that Mrs V does Session 24 Back to CONTENTS CLINICAL PRACTICE 3 Taking a breastfeeding history These notes are a summary of the instructions that the trainer will give you about how to do the clinical practice Try to make time to read them to remind you about what to do during the session Work in the same way as in previous clinical practice sessions Practise taking a history from the mother using the skills from Session 17 Continue to practise the skills from previous clinical practice sessions After the clinical practice record the mothers and babies that you have seen on your CLINICAL PRACTICE PROGRESS FORM on page 186 What to take with you one copy of the Breastfeeding History Form one copy of the COUNSELLING SKILLS CHECKLIST see Session 25 page 134 pencil and paper to make notes If you are the
79. e breast Ifthe baby is able to suckle he should feed frequently This is the best way to remove milk Help the mother to position her baby so that he attaches well Then he suckles effectively and does not damage the nipple Ifthe baby is not able to suckle help his mother to express her milk She may be able to express by hand or she may need to use a breast pump or a warm bottle see Session 20 Expressing breastmilk Sometimes it is only necessary to express a little milk to make the breast soft enough for the baby to suckle Before feeding or expressing stimulate the mother s oxytocin reflex These are things that you can do to help her or that she can do puta warm compress on her breasts or take a warm shower massage her neck and back massage her breast lightly stimulate her breast and nipple skin help her to relax Sometimes a warm shower or warm bath makes milk flow from the breasts so that they become soft enough for the baby to suckle After a feed put a cold compress on her breasts This may help to reduce oedema Build the mother s confidence Explain that she will soon be able to breastfeed comfortably TREATMENT OF BREAST ENGORGEMENT Do not rest the breast If baby able to suckle Feed frequently help with positioning If baby not able to suckle Express milk by hand or with pump Before feed Warm compress or warm shower to stimulate oxytocin Massage to neck and back reflex
80. ease when the baby suckles milk staying in the breast and not flowing out an idea that is incorrect small glands in the areola which secrete an oily liquid a term sometimes used to describe the way babies who have fed from a bottle may find it difficult to suckle effectively from a breast when a baby takes only the nipple into his mouth so that he cannot suckle effectively mastitis due to milk leaking out of the alveoli and back into the breast tissues with no bacterial infection showing your attitude through your posture and expression the common complaint of mothers who think that they do not have enough breastmilk for their babies components of food swelling due to fluid in the tissue questions which can only be answered by giving information and not with just a yes or a no too much milk produced by the breasts sometimes flowing from the breast faster than the baby can take it the hormone which makes the milk flow from the breast artificial nipple made of plastic for a baby to suck a dummy examining by feeling with your hand breastfed and given some artificial feeds diarrhoea which starts like an acute attack but which continues for more than 14 days infection of the lungs difficult to stretch out to form a teat how a mother holds her baby at her breast the term usually refers to the position of the baby s whole body routine visit to a health facility after a baby is born breastfed as the main source
81. eek If the baby cries less she should continue to avoid the food If the baby continues to cry as much as before then that particular food is not the cause of the crying She can take the food again Do not suggest that she stops these foods if her diet is poor Make sure that she can eat another energy and protein rich food instead for example beans Give practical help Explain that the best way to comfort a crying baby is to hold him close with gentle movement and gentle pressure on his abdomen Offer to show her some ways to hold and carry her baby Sometimes it is easier for someone not the mother to carry the baby so that he cannot smell the breastmilk Show her how to bring up her baby s wind She should hold him upright for example in a sitting position or upright against her shoulder It is NOT necessary to teach winding routinely only if the baby has colic Offer to discuss the situation with her family to talk about the baby s needs and about her need for support It is important to try to help to reduce family tensions so that she does not start giving unnecessary complements HOW TO HELP WITH A BABY WHO CRIES ALOT Look for a cause Listen and learn Take a history Assess a breastfeed Examine baby Help mother to talk about feelings guilt anger Empathize Learn about baby s feeding and behaviour Learn about mother s diet coffee smoking drugs Pressures from family and others Position at b
82. em to sleep in separate cots HOW TO HELP A FAMILY WITH A BABY WHO CRIES A LOT Look for a cause Listen and learn Help the mother to talk about how she feels Empathize with her feelings She may feel guilty and a poor mother She may feel angry with her baby Other people may make her feel guilty or they may make her feel that her baby is bad or naughty or undisciplined Other people may advise her to give the baby complements or pacifiers Take a history Learn about the baby s feeding and behaviour Learn about the mother s diet and if she drinks a lot of coffee or smokes or takes any drugs Learn about the pressures that she is under from the family and other people Assess a breastfeed Check the baby s suckling position and the length of a feed Examine the baby Make sure he is not ill or in pain Check his growth Ifthe baby is ill or in pain treat or refer as appropriate Build confidence and give support Accept Accept what the mother thinks about the cause of the problem Accept what she feels about the baby and his behaviour Praise what the mother and baby are doing right Explain that her baby is growing well he is not sick Her breastmilk is providing all that her baby needs there is nothing wrong with it or with her Her baby is fine he is not bad or naughty or in need of discipline Give relevant information Her baby has a real need for comfort He is not si
83. ents by mothers There are no responses beside them Your trainer will read out each mistaken idea Take turns to make up a response which accepts what the mother says without disagreeing or agreeing Examples 4 10 Trainer reads 4 need to give him formula now he is two months old My breastmilk is not enough for him now 5 I am pregnant again so shall have to stop breastfeeding immediately 6 cannot breastfeed for the first few days because will have no milk 7 The first milk is not good for a baby cannot breastfeed until it has gone 8 I cannot eat spicy food it will upset my baby 9 I don t let him suckle for more than ten minutes because it would make my nipples sore 10 I don t have enough milk because my breasts are so small EXERCISE 7 Accepting what a mother FEELS How to do the exercise After the Stories A B and C below there are three responses Mark with a VW the response which shows acceptance of how the mother feels For Story D make up your own response which shows acceptance Example Purla s baby boy has a cold and a blocked nose and is finding it difficult to breastfeed As Purla tells you about it she bursts into tears Mark with a YW the response which shows that you accept how Purla feels a Don t worry he is doing very well b You don t need to cry he will soon be better Y c It s upsetting when a baby is ill isn t it To answer S
84. ery well She says that her nipples are inverted and she cannot breastfeed You examine her breasts and notice that her nipples look flat You ask Mrs E to use her fingers and to stretch her nipple and areola out a short way You can see that the nipple and areola are protractile What could you say to accept Mrs E s idea about her nipples How could you build her confidence What practical help could you give Mrs E Mrs F s baby is 3 months old She says that her nipples are sore They have been sore on and off since an attack of mastitis several weeks ago The mastitis cleared up after a course of antibiotics This new pain feels like needles going deep into her breast whenever her baby suckles You watch her baby breastfeeding His mouth is wide open his lower lip is turned back and his chin is close to the breast He takes some slow deep sucks and you see him swallow What might be the cause of Mrs F s sore nipples What treatment would you give to her and her baby How would you build Mrs F s confidence Optional Mrs G says that her breasts are painful Her baby is 5 days old Both Mrs G s breasts are swollen and the skin looks shiny There is a fissure across the tip of her right nipple You watch her breastfeeding her baby She holds him loosely with his body away from hers His mouth is not wide open and his chin is not near the breast He makes smacking sounds as he suckles After a few sucks he pulls away and cries
85. family planning advice to breastfeeding mothers do you make sure that the method they choose is suitable with breastfeeding e Are you able to give extra help and support to mothers and babies with special needs so that they can continue to breastfeed For example low birth weight babies twins babies with disabilities _ if the mother is sick or disabled e Are you able to help women who work away from home but who wish to continue breastfeeding e Do you inform your colleagues about breastfeeding so that they also know that it is important Health education e ls breastfeeding included in your health education talks and materials e Is breastfeeding included in your talks on nutrition and in your talks on the introduction of complementary foods to children e Do you encourage women to breastfeed exclusively for at least 4 and if possible 6 months e Do you encourage women to continue to breastfeed for up to 2 years of age and beyond YES NO What is done well and or main needed improvement CHANGES THAT HEALTH WORKERS COULD MAKE THEMSELVES Make 5 10 practical suggestions 1 CHANGES THAT NEED ADMINISTRATIVE HELP List 1 4 helpful administrative changes 1 WHO CDR 93 5 UNICEF NUT 93 3 Distr General Original English BREASTFEEDING COUNSELLING A TRAINING COURSE PARTICIPANTS MANUAL PART FOUR Sessions 31 33 WORLD HEALTH ORGANIZATION CDD PROGRAMME UNICEF CONT
86. he child s growth chart Ask the most important questions Be careful not to sound critical Try not to repeat questions Take time to learn about difficult sensitive things HOW TO TAKE A BREASTFEEDING HISTORY e Use the mother s name and the baby s name if appropriate Greet the woman in a kind and friendly way Introduce yourself and ask her name and the baby s name Remember and use them or address her in whatever way is culturally appropriate e Ask her to tell you about herself and her baby in her own way Let her tell you first what she feels is important You can learn the other things that you need to know later Use your listening and learning skills to encourage her to tell you more e Look at the child s growth chart It may tell you some important facts and save you asking some questions e Ask the questions that will tell you the most important facts You will need to ask questions including some closed questions but try not to ask too many The Breastfeeding History Form is a guide to the facts that you may need to learn about Decide what you need to know from each of the six sections Be careful not to sound critical Ask questions politely For example Do not ask Why are you bottle feeding It is better to say What made you decide to give name some bottle feeds Use your confidence and support skills Accept what the mother says and praise what she is doing well e Try not to repeat questions
87. he does about family planning What would you suggest that she does to keep up her milk supply Lisa has a 7 month old baby whom she breastfeeds exclusively Her menstruation has not returned She sells fruit in the market and takes her baby with her all the time so that she can breastfeed frequently She could not cope with another baby until this one can walk and no longer needs to be carried What information would you give Lisa about breastfeeding and family planning What could you say to praise what she is doing well What information would you give about feeding What would you suggest to her about family planning Session 32 Additional session Back to CONTENTS WOMEN AND WORK Read and discuss ADVICE TO GIVE TO MOTHERS WHO WORK AWAY FROM HOME ADVICE TO GIVE TO MOTHERS WHO WORK AWAY FROM HOME If possible take your baby with you to work This can be difficult if there is no creche near your work place or if the transport is crowded If your work place is near to your home you may be able to go home to feed him during breaks or ask someone to bring him to you at work to breastfeed If your work place is far from your home you can give your baby the benefit of breastfeeding in the following ways Breastfeed exclusively and frequently for the whole maternity leave This gives your baby the benefit of breastfeeding and it builds up your breastmilk supply The first two months are the most important Do not start othe
88. he mother When her baby is willing to breastfeed again you can help her more with her technique Oversupply This is the usual cause of too much milk coming too fast Oversupply can result from poor attachment If a baby suckles ineffectively he may breastfeed frequently or for a long time and stimulate the breast so that it produces more milk than he needs Oversupply may also result if a mother tries to make her baby feed from both breasts at each feed when he does not need to To reduce oversupply Help the mother to improve her baby s attachment Suggest that she lets him suckle from only one breast at each feed Let him continue at that breast until he finishes by himself so that he gets plenty of the fat rich hindmilk At the next feed give him the other breast Sometimes a mother finds it helpful to express some milk before a feed lie on her back to breastfeed if milk flows upwards it is slower hold her breast with the scissor hold to slow the flow see Session 10 Positioning a baby at the breast However these techniques do not remove the cause of the problem Changes which upset a baby Discuss the need to reduce separation and changes if possible Suggest that she stops using the new soap perfume or food Apparent refusal If it is rooting Explain that this is normal She can hold her baby at her breast to explore her nipple Help her to hold him closer so that it is easier for h
89. ho want to continue to meet and help each other A group of breastfeeding mothers meets together every 1 4 weeks often in one of their homes or somewhere in the community They can have a topic to discuss such as The advantages of breastfeeding or Overcoming difficulties They share experiences and help each other with encouragement and with practical ideas about how to overcome difficulties They learn more about how their bodies work The group needs someone who is accurately informed about breastfeeding to train them They need someone who can correct any mistaken ideas and suggest solutions to difficulties This helps the group to be positive and not to complain This person could be a health worker until someone in the group has learnt enough to play this role The group needs a source of information whom they can refer to if they need help This could be a health worker trained in breastfeeding whom they see from time to time The group also needs up to date materials to educate themselves about breastfeeding The health worker can help them to get these Mothers can also help each other at other times and not only at meetings They can visit each other when they are worried or depressed or when they don t know what to do Breastfeeding support groups can provide an important source of contact for socially isolated mothers They can be a source of support which builds mother s confidence about breastfeeding and which
90. ickly takes him off her breast The baby s growth chart shows that he gained 250 g last month What could you say to show that you accept Mrs S s ideas about her milk Is Mrs S s baby getting enough breastmilk What is the reason for this What can you suggest to help Mrs S Optional Mrs T s baby is 6 weeks old He wants to feed about every 2 3 hours sometimes after 1 2 hours sometimes he sleeps for 5 hours He has gained 800 g since he was born Mrs T s mother says that the baby is crying too much and looks too thin She says that Mrs T does not have enough milk and should give some bottle feeds What are the good things that are happening Do you think that Mrs T s baby is getting enough milk What would you do to help Mrs T Mrs U says that her milk is drying up and she will have to stop breastfeeding She would like to continue Her baby is 6 months old and she has been back at work for three months Mrs U s sister cares for the baby during the day Mrs U breastfeeds morning and evening She expresses her breastmilk before she goes to work but she doesn t usually get more than half a cupful Her baby needs 1 or 2 bottles of formula during the day Mrs U is very tired when she gets home and her sister often gives him another bottle during the night The baby weighed 3 0 kilos at birth and now weighs 6 5 kilos Why do you think Mrs U s breastmilk may be drying up What is Mrs U doing right that you would prais
91. ig 4 Overhead 1 9 Psychological benefits of breastfeeding Breastfeeding helps a mother and baby to form a close loving relationship which makes mothers feel deeply satisfied emotionally Close contact from immediately after delivery helps this relationship to develop This process is called bonding Babies cry less and they may develop faster if they stay close to their mothers and breastfeed from immediately after delivery Mothers who breastfeed respond to their babies in a more affectionate way They complain less about the baby s need for attention and feeding at night They are less likely to abandon or abuse their babies Some studies suggest that breastfeeding may help a child to develop intellectually Low birth weight babies fed breastmilk in the first weeks of life perform better on intelligence tests in later childhood than children who are artificially fed BREASTMILK IN SECOND YEAR ENERGY PROTEIN VitA Vit C 193 95 daily needs provided by 50 500mi breast milk 45 38 WE Fig 5 Overhead 1 13 DANGERS OF ARTIFICIAL FEEDING E interferes with bonding E More diarrhoea and respiratory infections More allergy and milk intolerance E Increased risk of some chronic diseases Persistent diarrhoea E Malnutrition Vitamin A deficiency E Overweight More likely to die Lower scores on intelligence tests Mother E May become E Increased risk of anaemia pregnant
92. ilk if possible if necessary give artificial feeds Avoid using bottles teats pacifiers EXERCISE 14 Breast refusal How to do the exercise Read the stories and write your answers to the questions in pencil in the following space When you have finished discuss your answers with the trainer The stories of Mrs K and Mrs L are optional to do if you have time To answer Mrs H s baby was delivered by vacuum extraction 2 days ago He has a bruise on his head When Mrs H tries to feed him he screams and refuses She is very upset and feels that breastfeeding will be too difficult for her You watch her trying to feed him and you notice that her hand is pressing on the bruise What can you say to empathize with Mrs H What praise and relevant information can you give to build Mrs H s confidence What practical help can you give her Mrs I says that her 3 month old baby is refusing to breastfeed He was born in hospital and roomed in from the beginning He breastfed without any difficulty Mrs returned to work when her baby was 2 months old Her baby has 2 3 bottle feeds while she is at work For the last week he has refused to breastfeed when she comes home in the evening She thinks that her milk is not good because she works hard and feels hot all day What could you say to accept Mrs I s ideas about her milk What might be the cause of her baby s refusal to breastfeed What praise and relevant information could you give to
93. im to attach If it is distraction Suggest that she try to feed him somewhere more quiet for a while The problem usually passes If it is self weaning Suggest that she makes sure that the child eats enough family food gives him plenty of extra attention in other ways continues to sleep with him because night feeds may continue This is valuable at least up to the age of 2 years 2 Help the mother and baby to enjoy breastfeeding again This is difficult and can be hard work You cannot force a baby to breastfeed The mother needs help to feel happy with her baby and to enjoy breastfeeding They have to learn to enjoy close contact again She needs you to build her confidence and to give her support Help the mother to do these things Keep her baby close to her all the time She should care for her baby herself as much of the time as possible Ask grandmothers and other helpers to help in other ways such as doing the housework and caring for older children She should hold her baby often and give plenty of skin to skin contact at times other than feeding times She should sleep with him If the mother is employed she should take leave from her employment sick leave if necessary It may help if you discuss the situation with the baby s father grandparents and other helpful people Offer her breast whenever her baby is willing to suckle She should not hurry to breastfeed again but offer the bre
94. in and there is no evidence that they are helpful Suggest that after breastfeeding she rubs a little expressed breastmilk over the nipple and areola with her finger This promotes healing Session 15 Back to CONTENTS BREAST CONDITIONS EXERCISE EXERCISE 13 Breast conditions How to do the exercise Read the stories and write your answers to the questions in pencil in the following space When you have finished discuss your answers with the trainer Example Mrs A says that both her breasts are swollen and painful She put her baby to her breast for the first time on the third day when her milk came in This is the sixth day Her baby is suckling but now it is rather painful so she does not let him suck for very long Her milk is not dripping out as fast as it did before What is the diagnosis Engorged breasts What may have caused the condition Delay starting to breastfeed How can you help Mrs A Help her to express her milk and help her to position her baby at her breast so that he can attach better To answer Mrs B says that her right breast has been painful since yesterday and she can feel a lump in it which is tender She has no fever and feels well She has started to wear an old bra which is tight because she wants to prevent her breasts from sagging Her baby now sometimes sleeps for 6 7 hours at night without feeding You watch him suckling Mrs B holds him close and his chin is touching he
95. ing your breasts will make more milk If you are a health worker make sure that your patients know and see how you manage Then they can follow your example Role play Helping a mother who works away from home Sophie had her third baby 4 weeks ago Sophie works in a shop She will have to return to work when her baby is 2 months old She stopped breastfeeding her other children at 6 weeks and bottle fed them because of returning to work They were often ill and she missed the closeness of breastfeeding Sophie would prefer to breastfeed this baby and a friend said that some women do but Sophie does not know how She is worried about leaking and smelling at work it would be embarrassing and might upset her employers and customers She is worried about trying to breastfeed work and care for her other children and their father She will be away from home for about 10 hours altogether five days a week Her younger sister will be caring for the baby and is quite reliable There is no refrigerator Sophie has bought two new feeding bottles Session 33 Additional session Back to CONTENTS COMMERCIAL PROMOTION OF BREASTMILK SUBSTITUTES The International Code of Marketing of Breastmilk Substitutes Breastmilk and breastfeeding need to be protected from formula promotion activities This requires regulation of the promotion and sale of formula In 1981 the World Health Assembly WHA adopted The International Code of Market
96. ing feels Look for all the signs of good attachment If the attachment is not good try again HOW TO HELP A MOTHER WHO IS LYING DOWN Help the mother to lie down in a comfortable relaxed position It is better if she is not propped up on her elbow as this can make it difficult for the baby to attach to the breast Show her how to hold her baby Exactly the same four key points are important as for a mother who is sitting She can support her baby with her lower arm She can support her breast if necessary with her upper arm If she does not support her breast she can hold her baby with her upper arm Other positions in which a mother can breastfeed Mothers breastfeed in many different positions for example standing up It is important for the mother to be comfortable and relaxed and for her baby to take enough of the breast into his mouth so that he can suckle effectively Some useful positions that you may want to show mothers are the underarm position holding the baby with the arm opposite the breast Fig 24 a A mother holding her baby in b A mother holding her baby with the underarm position the arm opposite the breast Useful for Useful for twins very small babies blocked duct sick babies difficulty attaching the baby Fig 25 A mother breastfeeding her baby lying down HOW TO HELP A MOTHER TO POSITION HER BABY Greet the mother and ask how breastfeeding is going Assess a breastfeed
97. ing of Breastmilk Substitutes which aims to regulate promotion and sale of formula This Code is not extreme it is a minimum requirement to protect breastfeeding The Code is a code of marketing It does not ban infant formula or bottles or punish people who bottle feed The Code allows baby foods to be sold everywhere and it allows every country to make its own specific rules The Code covers both breastmilk substitutes and bottles and teats used to feed babies Breastmilk substitutes include infant formula any other milks or foods which mothers perceive or use as breastmilk substitutes SUMMARY OF THE MAIN POINTS OF THE INTERNATIONAL CODE No advertising of breastmilk substitutes and other products to the public No free samples to mothers No promotion in the health service No company personnel to advise mothers No gifts or personal samples to health workers No pictures of infants or other pictures idealizing artificial feeding on the labels of the products Information to health workers should be scientific and factual Information on artificial feeding including that on labels should explain the benefits of breastfeeding and the costs and dangers associated with artificial feeding Unsuitable products such as sweetened condensed milk should not be promoted for babies NO MORE FREE SUPPLIES In May 1986 governments at the World Health Assembly urged a ban on donated supplies of baby milk They urged m
98. ing supplementer HOW TO HELP A MOTHER TO USE A BREASTFEEDING SUPPLEMENTER Show the mother how to e Use a fine nasogastric tube or other fine plastic tubing and a cup to hold the milk If there is no very fine tube use the best available Cut a small hole in the side of the tube near the end of the part that goes into the baby s mouth this is in addition to the hole at the end Prepare a cup of milk expressed breastmilk or artificial milk containing the amount of milk that her baby needs for one feed see page 139 Put one end of the tube along her nipple so that her baby suckles the breast and the tube at the same time Tape the tube in place on her breast Put the other end of the tube into the cup of milk Tie a knot in the tube if it is wide or put a paper clip on it or pinch it This controls the flow of milk so that her baby does not finish the feed too fast Control the flow of milk so that her baby suckles for about 30 minutes at each feed if possible Raising the cup makes the milk flow faster lowering the cup makes the milk flow more slowly Let her baby suckle at any time that he is willing not just when she is using the supplementer Clean and sterilise the tube of the supplementer and the cup or bottle each time she uses them Other ways to give supplements to a baby How to use a syringe Use a 5 ml or 10 ml syringe Fix a length of fine tubing to the adaptor about 5 cm in length For examp
99. inistries of health To ensure that the small amounts of breastmilk substitutes needed for the minority of infants who require them in maternity wards and hospitals are made available through the normal procurement that is purchasing channels and not through free or subsidized supplies WHA 39 28 Ending of free supplies in all countries is a target of the WHO UNICEF Baby Friendly Hospital Initiative A hospital cannot be Baby Friendly if it receives free supplies of breastmilk substitutes How health workers can resist commercial promotion of breastmilk substitutes Remove from the health facility and destroy any advertisements and or promotional literature or other items bearing a brand name including old formula tins used for other purposes Refuse to accept free samples of formula or of equipment such as bottles dummies and toys Refuse to accept or to use other gifts for example pens calendars or diaries Avoid using growth charts and other equipment with a brand name on it especially if mothers may see it Avoid eating meals provided by formula companies Do not give free samples or promotional material to mothers Make sure that any formula that is used in the hospital for example for orphans is kept out of sight of other mothers Role play Choosing the best formula Pearl and Stan are parents of 4 week old baby Andy Stan has a job in town Stan comes home from work and Pea
100. ion Give her whatever help you decide is necessary Try to use at least one example of each of the skills from the COUNSELLING SKILLS CHECKLIST You do not need to practise observation of a breastfeed All that you need to know is in the story In a real situation you should always observe If you are the mother You are the only one in the group who has a copy of your story Conceal it from the others especially from your counsellor Give yourself and your baby a name either your own real name or another if you prefer Answer the counsellor s open questions with your reason for coming This is the sentence at the top of the story Then respond to what your counsellor says answering her questions from your story If you cannot answer a question from what is written make up an answer to fit with your story If your counsellor uses good listening and learning skills and makes you feel that she is interested you can tell her more If you are observing Observe which skills the counsellor uses and which she does not use Mark in pencil on your COUNSELLING SKILLS CHECKLIST EACH SKILL THAT you observe the counsellor using correctly Try to decide if the counsellor understands the mother s situation correctly Decide if she asks the most relevant questions and gives appropriate help During discussion be prepared to praise what the players do right and to suggest
101. k poor attachment engorgement Pressure on back of head when positioning Mother shaking breast Restricting feeds Oversupply of breastmilk Difficulty coordinating suckle Separation from mother New carer too many carers Change in family routine Mother ill or mastitis Mother menstruating Change in smell of mother Newborn rooting Age 4 8 months distraction Above 1 year self weaning MANAGEMENT OF REFUSAL TO BREASTFEED If a baby is refusing to breastfeed 1 Treat or remove the cause if possible 2 Help the mother and baby to enjoy breastfeeding again 1 Treat or remove the cause if possible Illness Treat infections with appropriate antimicrobials and other therapy Refer if necessary Ifa baby is unable to suckle he may need special care in hospital Help his mother to express her breastmilk to feed to him by cup or by tube until he is able to breastfeed again see Session 20 Expressing breastmilk Pain For a bruise help the mother to find a way to hold her baby without pressing on a painful place For thrush treat with gentian violet or nystatin see Table 2 page 78 For teething encourage her to be patient and to keep offering him her breast For a blocked nose explain how she can clear it Suggest short feeds more often than usual for a few days Sedation If the mother is on regular medication try to find an alternative Breastfeeding technique Discuss the reason for the difficulty with t
102. l the counselling skills that you have learnt in the previous sessions After the clinical practice record the mothers and babies that you have seen on your CLINICAL PRACTICE PROGRESS FORM on page 186 What to take with you one copy of the COUNSELLING SKILLS CHECKLIST pencil and paper to make notes copies of the B R E A S T FEED Observation Form and the Breastfeeding History Form to refer to if necessary How to do the clinical practice Work in the same way as in Clinical Practice 3 Practise all your clinical and counselling skills using the COUNSELLING SKILLS CHECKLIST If a mother has a difficulty with breastfeeding offer to help her Discuss what you plan to do with your trainer If possible ask a responsible member of the health facility staff to be present while you help the mother When you have completed Clinical Practice 3 and 4 you will have seen mothers in as many of these situations as possible after normal deliveries after Caesarian section with difficulty breastfeeding with different breast conditions with low birth weight babies and twins with sick children who have brought a baby for immunization or growth monitoring in family planning clinics in antenatal clinics Session 30 Back to CONTENTS CHANGING PRACTICES EXERCISE 22 Assessing and changing practices How to do the exercise Go through the ASSESSING AND CHANGING PRACTICES FORM The first four pages contain
103. lanning How to do the exercise Read the following short stories about women who have come for help with family planning After each story discuss with the group how to answer the questions When you are ready discuss your suggestions with the trainer Stories to discuss Meena had her second baby two weeks ago Her firstborn son Arun is 12 months old Meena breastfed Arun partially but also gave him 3 bottles of formula a day from the age of 1 month because she thought that she did not have enough milk She wants a rest now and does not want to get pregnant again for a long time But her husband is unwilling to use family planning She does not have a job and stays at home What could you say to empathize with how Meena feels What information would you give Meena about how to delay another pregnancy What could you say to give her confidence that she has enough breastmilk What would you suggest that she does about family planning at the end of 6 months or if her menstruation returns Donna has to go back to work in 2 weeks time Her baby will then be 8 weeks old She will be away from her baby for 9 10 hours each day She will breastfeed when she is at home Her helper will give the baby expressed breastmilk and some formula feeds by cup while Donna is at work She wants another baby one day but not for at least 3 years What information would you give Donna about breastfeeding and family planning What would you suggest that s
104. lay a very important part in helping to sustain breastfeeding up to 2 years or beyond see Session 28 Sustaining breastfeeding In 1989 WHO and UNICEF issued a Joint Statement called Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services This describes how maternity facilities can support breastfeeding The Ten Steps are a summary of the main recommendations of the Joint Statement They are the basis of the Baby Friendly Hospital Initiative For a maternity facility to be designated baby friendly it must put the Ten Steps into practice ene Fig 20 Skin to skin contact in the first hour after delivery helps breastfeeding and bonding THE TEN STEPS TO SUCCESSFUL BREASTFEEDING 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 Train all health care staff in skills necessary to implement this policy Inform all pregnant women about the benefits and management of breastfeeding Help mothers initiate breastfeeding within a half hour of birth Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants Give newborn infants no food or drink other than breastmilk unless medically indicated Practise rooming in allow mothers and infants to remain together 24 hours a day Encourage
105. le a piece cut from a fine feeding tube including the adaptor end of the feeding tube Explain that the mother measures the milk for a feed into a small cup She fills the syringe with milk from the cup She puts the end of the tube into the corner of her baby s mouth and presses out the milk slowly as he suckles She refills the syringe and continues until her baby has had the complete feed She should try to make the feed continue for 30 minutes about 15 minutes at each breast How to use a dropper The mother measures the milk for a feed into a cup She drops the milk into her baby s mouth from the dropper as he suckles How to drip milk down the breast Drip expressed breastmilk down the breast and nipple using a spoon or small cup Position the baby at the breast so that he licks the milk drops Slowly put the nipple into his mouth and help him to attach to the breast You may need to continue for 3 4 days before he can suckle strongly EXERCISE 19 Relactation How to do the exercise Use the information in the box AMOUNT OF MILK FOR BABIES WHO CANNOT BREASTFEED to calculate the total amount of milk the baby needs Use the information in the box HOW TO HELP A WOMAN TO INCREASE HER BREASTMILK SUPPLY to decide how to decrease the milk as the mother relactates see second point from the bottom in the box Example Ada died soon after her baby was born Ada s mother will look after the baby and she wants to breastfeed hi
106. ll encourage her to tell you more She will be less likely to turn off and say nothing Notes about the skills for listening and learning Skill 1 Use helpful non verbal communication Non verbal communication means showing your attitude through your posture your expression everything except through speaking Helpful non verbal communication makes a mother feel that you are interested in her so it helps her to talk to you Skill 2 Ask open questions Open questions are very helpful To answer them a mother must give you some information Open questions usually start with How What When Where Why For example How are you feeding your baby Closed questions are usually less helpful They tell a mother the answer that you expect and she can answer them with a Yes or No They usually start with words like Are you Did he Has he Does she For example Did you breastfeed your last baby If a mother says Yes to this question you still do not know if she breastfed exclusively or if she also gave some artificial feeds To start a conversation general open questions are helpful For example How is breastfeeding going for you To continue a conversation a more specific open question may be helpful For example How many hours after he was born did he have his first feed Sometimes it is helpful to ask a closed question to make sure about a fact For example Are you giving him any other food or drink If she s
107. ly once a day and avoid using soap Avoid medicated lotions and ointments Rub hindmilk on areola after feeds Management of sore nipples First look for a cause Observe the baby breastfeeding and check for signs of poor attachment Examine the breasts Look for signs of Candida infection look for engorgement look for fissures Look in the baby s mouth for signs of Candida and for tongue tie and baby s bottom for Candida rash Then give appropriate treatment Build the mother s confidence Explain that the soreness is temporary and that soon breastfeeding will be completely comfortable Help her to improve her baby s attachment Often this is all that is necessary She can continue breastfeeding and need not rest the breast Help her to reduce engorgement if necessary She should breastfeed frequently or express her breastmilk Consider treatment for Candida if the skin of the nipple and areola is red shiny or flaky or if there is itchiness or deep pain or if the soreness persists see Table 2 Then advise the mother Advise her not to wash her breasts more than once a day and not to use soap or rub hard with a towel Breasts do not need to be washed before or after feeds normal washing as for the rest of the body is all that is necessary Washing removes natural oils from the skin and makes soreness more likely Advise her not to use medicated lotions and ointments because these can irritate the sk
108. m She breastfed all her own children The youngest is 12 Ada s baby is now 4 weeks old and weighs 4 5 kilos Ada s mother will let the baby suckle and she will feed the baby formula with a supplementer while she waits for her breastmilk to come back How much artificial milk should Ada s mother give to the baby in total each day at the beginning Each day the baby needs 150 ml kg So she needs 150 x 4 5 675 ml milk in total each day After a few days when Ada s mother starts to produce a little milk she will start to reduce the amount of artificial milk by 30 ml each day How much milk will she give on the first day that she reduces the amount She will give 675 30 ml 645 ml How much milk will she give the next day She will give 645 30 ml 615 ml To answer A baby of 2 months has been bottle fed for one month He has become very ill with diarrhoea and formula feeds make the diarrhoea worse His mother breastfed satisfactorily for the first 4 weeks and wants to relactate The baby seems willing to suckle at the breast You will feed the baby donated EBM by cup while his mother s breastmilk supply builds up You will reduce the volume of EBM by 30 ml per day The baby weighs 4 0 kilos How much EBM will you give the baby by cup each day at the beginning How much EBM will you give the baby on the first day that you reduce the amount How much EBM will you give on the tenth day of reducing the amount How many
109. n other babies If someone else in the family smokes that also can affect the baby Oversupply This can occur when a baby is poorly attached He may suckle too frequently or for too long and stimulate the breast too much so that the milk supply increases Oversupply can occur if a mother takes her baby off the first breast before he has finished and makes him take the second breast The baby may get too much foremilk and not enough hindmilk He may have loose green stools and a poor weight gain or he may grow well but cry and want to feed often Even though she has plenty of milk the mother may think that she does not have enough for her baby Colic Some babies cry a lot without one of the above causes Sometimes the crying has a clear pattern The baby cries continuously at certain times of day often in the evening He may pull up his legs as if he has abdominal pain He may appear to want to suckle but it is very difficult to comfort him Babies who cry in this way may have a very active gut or wind but the cause is not clear This is called colic Colicky babies usually grow well and the crying usually becomes less after the baby is 3 months old High needs babies Some babies cry more than others and they need to be held and carried more In communities where mothers carry their babies with them crying is less common than in communities where mothers like to put their babies down to leave them or where they put th
110. n contaminated They are useful mainly to relieve engorgement when hand expression is difficult They are often called breast relievers SYRINGE PUMP Syringe pumps are more efficient than rubber bulb pumps They are easier to clean and sterilize How to use a syringe pump Put the plunger inside the outer cylinder Make sure that the rubber seal is in good flexible condition Put the funnel over the nipple Make sure that it touches skin all round to make an airtight seal Pull the outer cylinder down The nipple is sucked into the funnel Release the outer cylinder and then pull down again After a minute or two milk starts to flow and collects in the outer cylinder When milk stops flowing break the seal pour out the milk and then repeat the procedure Fig 33 Syringe breast pump The warm bottle method for the expression of breastmilk This is a useful technique to relieve severe engorgement when a breast is very tender and the nipple is tight so that hand expression is difficult You need a suitable bottle made of glass not plastic 1 3 litres in size not smaller than 700 ml with a wide neck at least 2 cm diameter if possible 4 cm so that the nipple can fit into it easily You also need apan of hot water to warm the bottle some cold water to cool the neck of the bottle a thick cloth to hold the hot bottle Pour a little of the hot water into the bottle to start warming it u
111. ng or that there is something wrong with her baby However sometimes you need to use the good judging words to build a mother s confidence see Session 11 Building confidence and giving support OOOOOod HELPFUL NON VERBAL COMMUNICATION Keep your head level Pay attention Remove barriers Take time Touch appropriately LISTENING AND LEARNING SKILLS Use helpful non verbal communication Ask open questions Use responses and gestures which show interest Reflect back what the mother says Empathize show that you understand how she feels Avoid words which sound judging Session 7 Back to CONTENTS LISTENING AND LEARNING EXERCISES EXERCISE 2 Asking open questions How to do the exercise Questions 1 3 are closed and it is easy to answer yes or no Write a new open question which requires the mother to tell you more Question 4 is an Optional Short Story Exercise to do if you have time Example Do you breastfeed your baby How are you feeding your baby To answer 1 Does your baby sleep with you 2 Are you often away from your baby 3 Are your nipples sore 4 Optional Short Story Exercise Joseph and Mabel bring 3 month old Johnny to the clinic They want to talk to you because he is not gaining weight Write two open questions that you would ask Joseph and Mabel The questions must be ones that they cannot say just yes or no to EXERCISE 3 Reflecting back what a mother says H
112. ng some of it DO NOT POUR the milk into the baby s mouth Just hold the cup to his lips and let him take it himself When the baby has had enough he closes his mouth and will not take any more If he has not taken the calculated amount he may take more next time or you may need to feed him more often Measure his intake over 24 hours not just at each feed Fig 37 Feeding a LBW baby by cup Jaundice Jaundice is not a reason to stop breastfeeding or to give supplements Early jaundice occurs between the 2nd and 10th days of life It is more common and worse among babies who do not get enough breastmilk Extra fluids such as water or glucose water do not help because they reduce breastmilk intake To help prevent jaundice from becoming severe babies need more breastmilk They should start to breastfeed early soon after delivery They should have frequent unrestricted breastfeeds Babies fed on expressed breastmilk should have 20 extra EBM Early feeds are particularly helpful because they provide colostrum Colostrum has a mild purgative effect which helps to clear meconium the baby s first dark stool Bilirubin is excreted in the stool so colostrum helps to both prevent and clear jaundice How to help breastfeeding if a baby is sick Babies who are sick recover more quickly if they continue to take breastmilk during the illness Ifa baby is in hospital Admit his mother too so that she can stay with him and
113. ning Guide in Lactation Management New York IBFAN and UNICEF 1992 B R E A S T FEED OBSERVATION FORM Mother s name Date Baby s name Slide 5 13 Age of baby Signs in brackets refer only to newborn not to older babies Signs that breastfeeding is going well BODY POSITION Mother relaxed and comfortable Baby s body close facing breast Baby s head and body straight Baby s chin touching breast Baby s bottom supported OOoOOdO RESPONSES O0 Baby reaches for breast if hungry O0 Baby roots for breast O0 Baby explores breast with tongue O Baby calm and alert at breast O Baby stays attached to breast O Signs of milk ejection leaking afterpains EMOTIONAL BONDING O Secure confident hold O Face to face attention from mother O Much touching by mother ANATOMY O Breasts soft after feed O Nipples stand out protractile O Skin appears healthy O Breast looks round during feed SUCKLING Mouth wide open Lower lip turned outwards Tongue cupped around breast Cheeks round More areola above baby s mouth Slow deep sucks bursts with pauses Can see or hear swallowing OOOOOOHO TIME SPENT SUCKLING O Baby releases breast Baby suckled for ___ minutes Signs of possible difficulty OShoulders tense leans over baby OBaby s body away from mother s OBaby s neck twisted OBaby s chin not touching breast C Only shoulder or head supported ONo response to breast O No rooting observed OBaby not
114. nly a small amount of breastmilk be sure to give it all to her baby Help her to feel that this small amount is valuable especially to prevent infection This helps her confidence and will help her to produce more milk Supplement if necessary with donated breastmilk If a mother expresses more than her baby needs let her express the second half of the milk from each breast into a different container Let her offer the second half of the EBM first Her baby gets more hindmilk which helps him to get the extra energy that he needs EXERCISE 18 Feeding low birth weight and sick babies How to do the exercise For Question 1 optional use the information in the box AMOUNT OF MILK FOR BABIES WHO CANNOT BREASTFEED to calculate how much milk the baby needs Read the Example For Questions 2 3 and 4 explain briefly how you would advise the mother about feeding her baby Example optional Mabel s baby was born 8 weeks early and cannot yet suckle strongly Mabel is expressing her milk and feeding her baby 3 hourly by cup He weighs 1 6 kilos and it is the 5th day How much milk should Mabel give at each feed A LBW baby needs 60 ml per kg on the first day On the fifth day he will need 60 20 20 20 20 ml kg 140 ml kg Mabel s baby weighs 1 6 kg so he will need 1 6 x 140 224 ml on the Sth day He feeds 3 hourly so he has 8 feeds each day So at each feed he needs 224 ml divided by 8 28 ml of EBM Mabel should offer
115. ny common difficulties can be caused by poor attachment to the breast These difficulties can be overcome by helping a mother to correct her baby s position They can be prevented by helping a mother to position her baby in the first few days The amount of milk that the breasts produce depends partly on how much the baby suckles and how much milk he removes More suckling makes more milk Most mothers can produce more milk than their babies take and they can produce enough for twins BREASTFEEDING WILL BE SUCCESSFUL IN MOST CASES IF The mother feels good about herself The baby is well attached to the breast so that he suckles effectively The baby suckles as often and for as long as he wants The environment supports breastfeeding Session 4 Back to CONTENTS ASSESSING A BREASTFEED Introduction Assessing a breastfeed helps you to decide if a mother needs help or not and how to help her You can learn a lot about how well or badly breastfeeding is going by observing before you ask questions This is just as important a part of clinical practice as other kinds of examination such as looking for signs of dehydration or counting how fast a child is breathing There are some things you can observe when a baby is not breastfeeding Other things you can only observe if a baby is breastfeeding HOW TO ASSESS A BREASTFEED What do you notice about the mother How does the mother hold her baby What do you notice about
116. of nourishment but also given small amounts of non nutritious drinks such as tea water and water based drinks artificial feeds given before breastfeeding is established born before 37 weeks gestation the hormone which makes the breasts produce milk nutrient necessary for growth and repair of the body tissues easy to stretch out The nipple and underlying tissue needs to be psychological reflect back reflex rejection of baby relactation restricted breastfeeds retained placenta rooming in rooting rooting reflex rubber teat scissor hold secrete self weaning sensory impulses silver nitrate drops skin to skin contact sore nipples sucking sucking reflex suckling supplements support sustaining breastfeeding swallowing reflex sympathize teat thrush tongue tie unrestricted feeding vitamin A vitamin C vitamin B warm bottle method warm compress whey protractile for a baby to suckle effectively mental and emotional repeat back what a person says to you in a slightly different way an automatic response through the body s nervous system the mother not wanting to care for her baby a mother starting to breastfeed again and producing breastmilk after she has stopped when the frequency or length of breastfeeds is limited in any way a small piece of the placenta remaining in the uterus after delivery a baby staying in the same room as his mother a baby searching for the breast with his
117. ognize and praise what a mother and baby are doing right O Give practical help O Give alittle relevant information O Use simple language O Make one or two suggestions not commands Session 12 Back to CONTENTS BUILDING CONFIDENCE EXERCISES EXERCISE 6 Accepting what a mother THINKS Examples 1 3 are mistaken ideas which mothers might hold Beside each mistaken idea are three responses One agrees one disagrees and one accepts the idea without agreeing or disagreeing Your trainer will read out each mistaken idea Taking turns read out each response and say if it agrees disagrees or accepts the idea Examples 1 3 Trainer reads Participant reads 1 I give him drinks of water Oh that is not necessary Breastmilk contains because the weather is so hot plenty of water now Yes babies may need extra drinks of water in this weather You feel that he need drinks of water sometimes 2 have not been able to Breastmilk is not very nice after a few days breastfeed for two days so You are worried that your breastmilk may be my milk is sour sour But milk never goes sour in the breast 3 My baby has diarrhoea so You do not like to give him breastmilk just now it is not good to breastfeed It is quite safe to breastfeed a baby when he now has diarrhoea It is often better to stop breastfeeding a baby when he has diarrhoea Examples 4 10 are some more mistaken ideas written as statem
118. om mother O Much touching by mother ANATOMY O Breasts soft after feed O Nipples stand out protractile O Skin appears healthy O Breast looks round during feed SUCKLING Mouth wide open Lower lip turned outwards Tongue cupped around breast Cheeks round More areola above baby s mouth Slow deep sucks bursts with pauses Can see or hear swallowing OOOOOOO TIME SPENT SUCKLING O Baby releases breast Baby suckled for ___ minutes Signs of possible difficulty OShoulders tense leans over baby OBaby s body away from mother s OBaby s neck twisted OBaby s chin not touching breast C Only shoulder or head supported ONo response to breast O No rooting observed OBaby not interested in breast OBaby restless or crying OBaby slips off breast ONo signs of milk ejection ONervous or limp hold ONo mother baby eye contact OLittle touching or OShaking or poking baby OBreasts engorged ONipples flat or inverted OFissures or redness of skin OBreast looks stretched or pulled OMouth not wide open points forward OLower lip turned in OBaby s tongue not seen OCheeks tense or pulled in OMore areola below baby s mouth ORapid sucks only OCan hear smacking or clicking OMother takes baby off breast Notes Adapted with permission from B R E A S T Feeding Observation Form by H C Armstrong Training Guide in Lactation Management New York IBFAN and UNICEF 1992 Session 5 Back to CONTENTS OBSERVING A BREASTFE
119. one who talks to the mother Take a full breastfeeding history using the Breastfeeding History Form Try to ask the most relevant questions and ask something from each section of the form Practise all your other counselling skills using the COUNSELLING SKILLS CHECKLIST to remind you Use your listening and learning skills and try not to ask too many questions Use your confidence and support skills and avoid giving a lot of advice Assess a breastfeed If a mother has a breastfeeding difficulty try to decide the reason and how to help her However before you give the mother any help or suggest what she could do talk to the trainer Session 25 Back to CONTENTS COUNSELLING PRACTICE These notes are a summary of the instructions that the trainer will give you about how to do the exercise Try to make time to read them to remind you about what to do during the session During the exercise you work in small groups taking turns to practise as a counsellor talking with a mother about her situation using the COUNSELLING SKILLS CHECKLIST You will be given a card with a mother and baby s story to follow when you are the mother How to do the counselling practice If you are the counsellor Greet the mother and introduce yourself Use her name and her baby s name Ask one or two open questions to start the conversation Use your counselling skills to learn about the mother and her situat
120. out herself Confidence can help a mother to succeed with breastfeeding Confidence also helps her to resist pressures from other people It is important not to make a mother feel that she has done something wrong She easily believes that there is something wrong with herself or with her breastmilk or that she is not doing well This reduces her confidence It is important to avoid telling a breastfeeding mother what to do Help each mother to decide for herself what is best for her and her baby This increases her confidence Notes about the skills for building confidence and giving support Skill 1 Accept what a mother thinks and feels Sometimes a mother has a mistaken idea that you do not agree with If you disagree with her or criticise you make her feel that she is wrong This reduces her confidence If you agree with her it is difficult later to suggest something different It is more helpful to accept what she thinks Accepting means responding in a neutral way and not agreeing or disagreeing Reflecting back and responses and gestures which show interest are both useful ways to show acceptance as well as being useful listening and learning skills Sometimes a mother feels very upset about something that you know is not a serious problem If you say something like Don t worry there is nothing to worry about you make her feel that she is wrong to feel the way that she does This makes her feel that you do not understand and it
121. ow to do the exercise Statements 1 5 are some things that mothers might tell you Beside 1 3 are three responses Mark the response that reflects back what the statement says For statements 4 and 5 make up your own response which reflects back what the mother says Number 6 is an Optional Short Story Exercise to do if you have time Example My mother says that I don t have a Do you think you have enough enough milk b Why does she think that Y c She says that you have a low milk supply To answer 1 My baby is passing a lot of stools a He is passing many stools each sometimes 8 in a day day b What are the stools like c Does this happen every day or only on some days 2 He doesn t seem to want to suckle a Has he had any bottle feeds from me b How long has been refusing c He seems to be refusing to suckle 3 I tried feeding him from a bottle a Why did you try using a bottle but he spat it out b He refused to suck from a bottle c Have you tried to use a cup 4 Sometimes he doesn t pass a stool for 3 or 4 days 5 My husband says that our baby is old enough to stop breastfeeding now 6 Optional Short Story Exercise You meet Cora in the market with her 2 month old baby You say how well the baby looks and ask how she and the baby are doing She says Oh we re doing fine But he needs a bottle feed in the evening What do you say to reflect back what Cora says and to encourage her to tell you mo
122. p Then almost fill the bottle with hot water Do not fill it right up too quickly or the glass will crack Let the bottle stand for a few minutes to warm the glass Wrap the bottle in the cloth and pour the hot water back into the pan COOL THE NECK OF THE BOTTLE with cold water inside and outside If you do not cool the neck of the bottle you may burn the nipple skin Put the neck of the bottle over the nipple touching the skin all round to make an airtight seal For the demonstration use the soft part of your hand or forearm Hold the bottle steady After a few minutes the whole bottle cools and makes gentle suction which pulls the nipple into the neck of the bottle Sometimes when a woman first feels the suction she is surprised and pulls away You may have to start again The warmth helps the oxytocin reflex and milk starts to flow and collects in the bottle Keep the bottle there as long as the milk flows Pour out the breastmilk and repeat if necessary or do the same for the other breast After some time the acute pain in the breasts becomes less and hand expression or suckling may become possible Fig 34 The warm bottle method a Put hot water into a bottle b Pour out the water c The mother holds the warm bottle over her nipple Session 21 Back to CONTENTS NOT ENOUGH MILK Introduction Almost all mothers can produce enough breastmilk for one or even two babies Usually even when
123. ple a sudden blow or an accidental kick by an older child If there is a nipple fissure it provides a way for bacteria to enter the breast tissue This is another way in which poor attachment can lead to mastitis TREATMENT OF BLOCKED DUCT AND MASTITIS FIRST THEN e Improve drainage of breast If any of these Look for cause and correct symptoms severe or poor attachment fissure or pressure from clothes or fingers no improvement large breast draining poorly after 24 hours Advise Treat in addition with frequent breastfeeds gentle massage towards nipple e Antibiotics warm compresses Complete rest Suggest if helpful start feed on unaffected side Analgesics vary position paracetamol Treatment of blocked duct and mastitis The most important part of treatment is to improve the drainage of milk from the affected part of the breast Look for a cause of poor drainage and correct it Look for poor attachment Look for pressure from clothes usually a tight bra especially if worn at night or pressure from lying on the breast Notice what the mother does with her fingers as she breastfeeds Does she hold the areola and possibly block milk flow Notice if she has large pendulous breasts and if the blocked duct is in the lower part of her breast If so suggest that she lifts the breast more while she feeds the baby to help the lower part of the breast to drain better Whether or
124. position of breastmilk Colostrum is the breastmilk that women produce in the first few days after delivery It is thick and yellowish or clear in colour Mature milk is the breastmilk that is produced after a few days The quantity becomes larger and the breasts feel full hard and heavy Some people call this the breastmilk coming in Foremilk is the milk that is produced early in a feed Hindmilk is the milk that is produced later in a feed Hindmilk looks whiter than foremilk because it contains more fat This fat provides much of the energy of a breastfeed This is an important reason not to take a baby off a breast too quickly He should be allowed to continue until he has had all that he wants Foremilk looks bluer than hindmilk It is produced in larger amounts and it provides plenty of protein lactose and other nutrients Because a baby gets large amounts of foremilk he gets all the water that he needs from it Babies do not need other drinks of water before they are 4 6 months old even in a hot climate If they satisfy their thirst on water they may take less breastmilk COLOSTRUM Property importance E Antibody rich protects against infection and allergy E Many white cells protect against infection E Purgative clears meconium helps to prevent jaundice m Growth factors help intestine to mature prevents allergy intolerance Vitamin A rich reduces severity of infection prevents eye disease F
125. production within the breast You may wonder why sometimes one breast stops making milk while the other breast continues to make milk although oxytocin and prolactin go equally to both breasts This diagram shows why There is a substance in breastmilk which can reduce or inhibit milk production If a lot of milk is left in a breast the inhibitor stops the cells from secreting any more This helps to protect the breast from the harmful effects of being too full It is obviously necessary if a baby dies or stops breastfeeding for some other reason If breastmilk is removed by suckling or expression the inhibitor is also removed Then the breast makes more milk This helps you to understand why If a baby stops suckling from one breast that breast stops making milk If a baby suckles more from one breast that breast makes more milk and becomes larger than the other It also helps you to understand why For a breast to continue to make milk the milk must be removed If a baby cannot suckle from one or both breasts the breastmilk must be removed by expression to enable production to continue Poor attachment Good attachment FHM tty S f N N wa Sal pyri t yt me PAH An aN I ain TN NNN wo WSS Poor attachment Good attachment Good and poor attachment Fig 12 Overhead 3 8 Good attachment Poor attachment fyi aN fi a wy SNY AW Sa Wo
126. r OShaking or poking baby OBreasts engorged ONipples flat or inverted OFissures or redness of skin OBreast looks stretched or pulled OMouth not wide open points forward OLower lip turned in OBaby s tongue not seen OCheeks tense or pulled in OMore areola below baby s mouth ORapid sucks only OCan hear smacking or clicking OMother takes baby off breast Notes Adapted with permission from B R E A S T Feeding Observation Form by H C Armstrong Training Guide in Lactation Management New York IBFAN and UNICEF 1992 Session 6 Back to CONTENTS LISTENING AND LEARNING Introduction Counselling is a way of working with people in which you understand how they feel and help them to decide what to do In these sessions you will discuss mothers who are breastfeeding and how they feel Breastfeeding is not the only situation in which counselling is useful Counselling skills are useful when you talk to patients or clients in other situations You may also find them helpful with your family and friends or your colleagues at work Practise some of the techniques with them you may find the result surprising and helpful The first two counselling skills sessions are about listening and learning A breastfeeding mother may not talk about her feelings easily especially if she is shy and with someone whom she does not know well You need the skill to listen and to make her feel that you are interested in her This wi
127. r breast His mouth is wide open and he takes slow deep sucks What could you say to empathize with Mrs B s worries about her figure What is the diagnosis What may be the cause What three suggestions would you give Mrs B Mrs C has had a painful swelling in her left breast for three days It is extremely tender and the skin of a large part of the breast looks red Mrs C has a fever and feels too ill to go to work today Her baby sleeps with her and breastfeeds at night By day she expresses milk to leave for him She has no difficulty in expressing her milk But she is very busy and it is difficult for her to find time to express milk or to feed her baby during the day What could you say to empathize with Mrs C What is the diagnosis Why do you think that Mrs C has this condition How would you treat Mrs C Mrs D complains of nipple pain when her 6 week old baby is suckling You examine her breasts while her baby is asleep and can see no fissures When he wakes you watch him feeding His body is twisted away from his mother s His chin is away from the breast and his mouth is not wide open He takes rapid shallow sucks As he releases the breast you notice that the nipple looks squashed What is the cause of Mrs D s nipple pain What could you say to build Mrs D s confidence What practical help could you give her Mrs E s baby was born yesterday She tried to feed him soon after delivery but he did not suckle v
128. r feeds before you really need to Do NOT think I shall have to go back to work in 12 weeks so I might as well bottle feed straight away It is not necessary to use a bottle at all Even very small babies can feed from a cup Wait until about a week before you go back to work Leave just enough time to get the baby used to cup feeds and to teach the carer who will look after him Continue to breastfeed at night in the early morning and at any other time that you are at home This helps to keep up your breastmilk supply It gives your baby the benefit of breastmilk even if you decide to give him one or two artificial feeds during the day Many babies learn to suckle more at night and get most of the milk that they need then They sleep more and need less milk during the day Learn to express your breastmilk soon after your baby is born This will enable you to do it more easily Express your breastmilk before you go to work and leave it for the carer to give to your baby Leave yourself enough time to express your breastmilk in a relaxed way You may need to wake up half an hour earlier than at other times If you are in a hurry you may find that you cannot express enough milk Express as much breastmilk as you can into a very clean cup or jar Some mothers find that they can express 2 cups 400 500 ml or more even after the baby has breastfed But even 1 cup 200 ml can give the baby 3 feeds a day of 60 70 ml
129. r record of previous weights If no weight record is available weigh the baby and arrange to weigh him again in one week s time If the baby is gaining enough weight he is getting enough milk However if no weight record is available you cannot get an immediate answer Check the baby s urine output This is a useful quick check An exclusively breastfed baby who is getting enough milk usually passes dilute urine at least 6 8 times in 24 hours A baby who is not getting enough breastmilk passes urine less than 6 times a day often less than 4 times a day His urine is also concentrated and may be strong smelling and dark yellow to orange especially in a baby more than 4 weeks old Ask the mother how often her baby is passing urine Ask her if the urine is dark yellow or strong smelling Ifa baby is passing plenty of dilute urine he is getting enough breastmilk Ifhe is passing concentrated urine less than 6 times a day then he is not getting enough breastmilk This can tell you quickly if an exclusively breastfed baby is getting enough milk However if he is having any other drinks you cannot be sure THESE DO NOT AFFECT THE BREASTMILK SUPPLY Age of mother Sexual intercourse Menstruation Disapproval of relatives and neighbours Returning to a job if baby continues to suckle often Age of baby Caesarian section Many children Simple ordinary diet REASONS WHY A BABY MAY NOT GET ENOUGH BREASTMILK
130. re EXERCISE 4 Empathizing to show that you understand how she feels How to do the exercise Statements 1 5 are things that mothers might say Next to statements 1 3 are three responses which you might make Underline the words in the mother s statement which show something about how she feels Mark the response which is most empathetic For statements 4 and 5 underline the feeling words and then make up your own empathizing response Number 6 is an Optional Short Story Exercise to do if you have time Example My baby wants to feed so often at night that I feel exhausted To answer 4 gt 1 My nipples are so painful I will have to bottle feed 2 My breastmilk looks so thin I am sure it cannot be good 3 I do not have any milk in my breasts and my baby is a day old already a How many times does he feed altogether b Does he wake you every night c You are really tired with the night feeding a The pain makes you want to stop breastfeeding b Did you bottle feed any of your previous children c Oh don t do that it s not necessary to stop just because of sore nipples a That s the foremilk it always looks rather watery b You are worried about how your breastmilk looks c Well how much does the baby weigh a You are upset because your breastmilk has not come in yet b Has he started suckling yet c lt always takes a few days for breastmilk to come in My breasts leak
131. reast length of feed Illness or pain treat or refer as appropriate Check growth e Build confidence and give support Accept Praise as appropriate Give relevant information Suggest as appropriate Practical help Mother s ideas about the cause of the crying Her feelings about baby and his behaviour Her baby is growing well not sick Her breastmilk provides all that baby needs Her baby is fine not naughty or bad Baby has real need for comfort Crying will decrease when baby is 3 4 months old Medicines for colic not recommended Complements not necessary or helpful artificially fed babies also have colic Comfort suckling at breast is safe bottles and pacifiers not safe Give only one breast at each feed give other breast next feed Reduce coffee and tea Smoke after not before or during breastfeeds Stop milk eggs soy peanuts 1 week trial if mother s diet adequate Show mother and others how to hold and carry baby with close contact gentle movement gentle abdominal pressure Offer to discuss situation with family Fig 36 Some different ways to hold a colicky baby Session 23 Back to CONTENTS NOT ENOUGH MILK AND CRYING EXERCISE EXERCISE 16 Not enough milk and Crying How to do the exercise Read through the following short stories about mothers who feel that they do not have enough milk or whose babies are crying too much Write in pencil a brief answer to the questions which follow
132. rl tells him that she wants to buy some formula She thinks that her breastmilk is not enough for Andy Andy was given bottle feeds at night in hospital so that Pearl could rest Pearl saw some tins of formula in the nurses office Pearl wants to buy the same brand because it is likely to be good and safe if the hospital uses it Stan does not know much about breastfeeding or formula He is mainly worried about the cost because his wages are low He would prefer Pearl to breastfeed because it is cheaper If she does buy formula he wants her to buy the cheapest brand because he thinks they are all the same Stella is the shop assistant who is selling the formula She is a friend of Pearl s She has the brand that they use in the hospital She also has a different brand that the local doctor recommends to his patients She says that he gives them free samples There is also a cheaper locally made brand that Stella gave to her baby and he is now a healthy child And there is a more expensive brand that is for children with diarrhoea Stella tells Pearl and Stan the prices and tries to point out advantages of each brand that it is sweeter or that it is easier to mix in cold water She points to the lovely picture of a smiling baby the attractive label or the convenient ant proof tin or the measuring scoop that has so many uses Pearl and Stan discuss which would be best for Andy and forget all about breastmilk They wonder if they sho
133. rn To understand why she lacks confidence empathize Take a history To learn about pressures from other people Assess a breastfeed To check baby s attachment at breast Examine mother Breast size may cause lack of confidence e Build confidence and give support Accept Her ideas and feelings about her milk Praise Baby growing well her milk supplies his needs as appropriate Good points about her breastfeeding technique Good points about baby s development Give practical help Improve attachment if necessary Give relevant Correct mistaken ideas do not sound critical information Explain about babies normal behaviour Explain how breastfeeding works what you say depends on her worries Use simple language Some babies do like to suckle a lot Suggest Ideas for coping with tiredness Offer to talk to family Fig 35 If a baby passes plenty of urine it usually means that he is getting plenty of breastmilk Session 22 Back to CONTENTS CRYING Introduction Many mothers start unnecessary complements because they think that their baby cries too much They think that their babies are hungry and that they do not have enough milk However complements often do not make a baby cry less Sometimes a baby cries more A baby who cries a lot can upset the relationship between him and his mother and can cause tension among other members of the family An important way to help a breastfeeding mother is to counsel her about her baby
134. s Using simple language The first yellowish milk that comes is exactly what a baby needs for the first few days To answer 1 Information Exclusive breastfeeding is best up to 4 6 months of age Using simple language Information Foremilk normally looks watery and hindmilk is whiter Using simple language Information When your baby suckles prolactin is released which makes your breasts secrete more milk Using simple language Information To suckle effectively a baby needs to be well attached to the breast Using simple language EXERCISE 12 Making one or two suggestions not commands How to do the exercise Below are some commands which you might want to give to a breastfeeding mother Rewrite the commands as suggestions Questions 4 and 5 are optional to do if you have time Example Command Keep the baby in bed with you so that he can feed at night Suggestion It might be easier to feed him at night if he slept in bed with you Some alternative examples of how to make a suggestion In your answer you only need to give ONE answer Suggestion in the form of a question Would it be easier to feed him at night if he slept with you Have you thought about letting him sleep in bed with you Question followed by some information How would you feel about letting him sleep in bed with you It might be easier to feed him that way To answer 1 Command Do not give your baby any drinks of water or
135. s immunization He breastfeeds frequently by day and sleeps with his mother and breastfeeds at night Two months ago his mother started to give him thin cereal porridge once a day What is Baby 4 s mother doing right What do you think of Baby 4 s weight gain What do you think is the reason for the change What two things would you suggest to his mother Baby 5 s mother has come for help with family planning When you have given her this help you ask about the baby He was exclusively breastfed until the age of 6 months Since then he has had complementary food at first twice and more recently four times a day He continues to breastfeed at night and several times during the day What do you think about Baby 5 s growth What can you say to praise his mother What would you suggest to his mother about breastfeeding KILOGRAMS KILOGRAMS iY y 7 E M a m oe a FE Pe NN See EERE SRA ood Od Oe ee Ee le a 2 eS a A ia EE ee ENL ANE E E JAS PEET A ee AAA ENAN a Session 29 Back to CONTENTS CLINICAL PRACTICE 4 Counselling mothers in different situations These notes are a summary of the instructions that the trainer will give you about how to do the clinical practice Try to make time to read them to remind you about what to do during the session During the clinical practice you work in pairs and take turns to talk to a mother while your partner observes You practise al
136. s crying REASONS WHY BABIES CRY Discomfort Tiredness Illness or pain Hunger Mother s food Drugs mother takes Oversupply of breastmilk Colic High needs babies dirty hot cold too many visitors changed pattern of crying not getting enough milk growth spurt any food sometimes cow s milk caffeine cigarettes other drugs CAUSES OF CRYING Hunger due to growth spurt A baby seems very hungry for a few days possibly because he is growing faster than before He demands to be fed very often This is commonest at the ages of about 2 weeks 6 weeks and 3 months but can occur at other times If he suckles often for a few days the breastmilk supply increases and he breastfeeds less often again Mother s food Sometimes a mother notices that her baby is upset when she eats a particular food This is because substances from the food pass into her milk It can happen with any food and there are no special foods to advise mothers to avoid unless she notices a problem Babies can become allergic to the protein in some foods in their mother s diet Cow s milk soy egg and peanuts can all cause this problem Babies may become allergic to cow s milk protein after only one or two prelacteal feeds of formula Drugs mother takes Caffeine in coffee tea and colas can pass into breastmilk and upset a baby If a mother smokes cigarettes or takes other drugs her baby is more likely to cry tha
137. s of milk ejection leaking afterpains EMOTIONAL BONDING O Secure confident hold O Face to face attention from mother O Much touching by mother ANATOMY O Breasts soft after feed O Nipples stand out protractile O Skin appears healthy O Breast looks round during feed SUCKLING Mouth wide open Lower lip turned outwards Tongue cupped around breast Cheeks round More areola above baby s mouth Slow deep sucks bursts with pauses Can see or hear swallowing OOOOOOO TIME SPENT SUCKLING O0 Baby releases breast Baby suckled for ___ minutes Signs of possible difficulty OShoulders tense leans over baby OBaby s body away from mother s OBaby s neck twisted OBaby s chin not touching breast C Only shoulder or head supported ONo response to breast O No rooting observed OBaby not interested in breast OBaby restless or crying OBaby slips off breast ONo signs of milk ejection ONervous or limp hold ONo mother baby eye contact OLittle touching or OShaking or poking baby OBreasts engorged ONipples flat or inverted OFissures or redness of skin OBreast looks stretched or pulled OMouth not wide open points forward OLower lip turned in OBaby s tongue not seen OCheeks tense or pulled in OMore areola below baby s mouth ORapid sucks only OCan hear smacking or clicking OMother takes baby off breast Notes Adapted with permission from B R E A S T Feeding Observation Form by H C Armstrong Trai
138. s position at breast bonding or rejection Examine the baby Illness or abnormality growth Examine the mother Her nutrition and health and her breasts Any breast problem Build confidence and give support Help the mother to give her baby more breastmilk and to believe that she can produce enough Accept Her ideas about breastmilk supply Her feelings about breastfeeding and her baby Praise She is still breastfeeding as appropriate Her breasts are good for making milk Give practical help Improve baby s attachment to breast Give relevant Explain how baby s suckling controls milk supply information Explain how baby can get more breastmilk Use simple language Breasts will make more milk if baby takes more Suggest Breastfeed more often longer at night as appropriate Stop using bottles or pacifiers use cup if necessary Reduce or stop other feeds and drinks if baby aged less than 4 6 months Ideas to reduce stress anxiety Offer to talk to family e Help with less common causes Baby s condition If ill or abnormal treat or refer Mother s condition If taking estrogen pills or diuretic help her to change Help as appropriate with other conditions e Follow up See daily then weekly until baby gaining weight and mother confident It may take 3 7 days for the baby to gain weight see Session 27 HOW TO HELP A MOTHER WHO THINKS THAT SHE DOES NOT HAVE ENOUGH BREASTMILK Understand her situation Listen and lea
139. s their babies to hold with skin to skin contact within half an hour of delivery e Do the babies stay with their mothers at this time for at least 30 minutes e Does a member of staff offer mothers help to initiate breastfeeding within 1 hour of delivery if Caesarian Section e Do mothers hold and breastfeed their babies within 4 6 hours of the operation or as soon as they are conscious YES NO What is done well and or main needed improvement Practice Establishing breastfeeding e Do nursing staff offer all mothers further assistance with breastfeeding within 6 hours of delivery e Do you make sure that mothers are able to position and attach their babies well e Do you show breastfeeding mothers how to express their breastmilk e Do you help mothers of babies in special care to establish and maintain lactation by frequent expression of breastmilk from the first day Do mothers and infants remain together 24 hours a day e Do you restrict the frequency or length of breastfeeds e Do you encourage mothers to breastfeed their babies on demand e Do babies receive food or drink other than breastmilk except when medically indicated formula glucose water or water e Do you use feeding bottles for babies whose mothers intend to breastfeed e Do you allow breastfed babies to use pacifiers e Are free supplies of formula available e Do you check on the support that mo
140. se whatever else she does Eating more does not by itself increase a woman s milk supply However if she is undernourished she needs to eat more to build up her strength and energy If she is not undernourished food and warm nourishing drinks may help her to feel confident and relaxed Many mothers notice that they are more thirsty than usual when they are breastfeeding especially near the time of a feed They should drink to satisfy their thirst However taking more fluid than they feel they need does not increase their breastmilk supply In most communities experienced women know of some form of actogogue Lactogogues are special foods drinks or herbs which people believe increase the breastmilk supply They do not work like drugs but may help a woman to feel confident and relaxed HOW TO HELP A WOMAN TO INCREASE HER BREASTMILK SUPPLY Try to help the mother and baby at home if possible Sometimes it is helpful to admit them to hospital for a week or two so that you can give enough help especially if the mother may feel pressure to use a bottle again at home Discuss with the mother the reason for her poor milk supply Explain what she needs to do to increase her supply Explain that it takes patience and perseverance Use all the ways you have learnt to build her confidence Help her to feel that she can produce breastmilk again or increase her supply Try to see her and talk to her often at least twice a day Make sure
141. sing a bottle warmed with hot water cloths soaked in warm water to put on the breast liquid part of milk which remains after removal of casein curds
142. st the underarm position In both of these positions the mother can support and control the baby s head as she holds him to her breast see Session 10 Positioning a baby at the breast Babies from about 34 36 weeks gestational age or more sometimes earlier can usually take all that they need directly from the breast Supplements from a cup are no longer necessary Continue to follow babies up and weigh them regularly to make sure that they are getting all the breastmilk that they need Why cup feeding is safer than bottle feeding Cups are easy to clean with soap and water if boiling is not possible Cups are less likely than bottles to be carried around for a long time giving bacteria time to breed A cup cannot be left beside a baby for the baby to feed himself The person who feeds a baby by cup has to hold the baby and look at him and give him some of the contact that he needs A cup does not interfere with suckling at the breast HOW TO FEED A BABY BY CUP Hold the baby sitting upright or semi upright on your lap Hold the small cup of milk to the baby s lips Tip the cup so that the milk just reaches 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 The baby becomes alert and opens his mouth and eyes A LBW baby starts to take the milk into his mouth with his tongue A full term or older baby sucks the milk spilli
143. st by themselves Help her to position her baby If a baby does not attach well by himself help his mother to position him so that he can attach better Give her this help early in the first day before her breastmilk comes in and her breasts are full Help her to try different positions to hold her baby Sometimes putting a baby to the breast in a different position makes it easier for him to attach For example some mothers find that the underarm position is helpful see Fig 24 in Session 10 Help her to make her nipple stand out more before a feed Sometimes making the nipple stand out before a feed helps a baby to attach Stimulating her nipple may be all that a mother needs to do Or she can use a hand breast pump or a syringe to pull her nipple out Sometimes shaping the breast makes it easier for a baby to attach To shape her breast a mother supports it from underneath with her fingers and presses the top of the breast gently with her thumb She should be careful not to hold her breast too near the nipple See Fig 18 in Session 4 If it is acceptable to both partners the woman s husband can suck on her breasts a few times to pull out the nipples If a baby cannot suckle effectively in the first week or two help his mother to Express her milk and feed it to her baby with a cup Expressing milk helps to keep breasts soft so that it is easier for the baby to attach to the breast and it helps to keep up
144. t necessary to do so WHO CDR 93 5 UNICEF NUT 93 3 Distr General Original English BREASTFEEDING COUNSELLING A TRAINING COURSE PARTICIPANTS MANUAL PART THREE Sessions 20 30 WORLD HEALTH ORGANIZATION CDD PROGRAMME UNICEF CONTENTS Session 20 Session 21 Session 22 Session 23 Session 24 Session 25 Session 26 Session 27 Session 28 Session 29 Session 30 Expressing breastmilk Not enough milk Crying Not enough milk and Crying exercise Clinical Practice 3 Counselling practice Low birth weight and sick babies Increasing breastmilk and relactation Sustaining breastfeeding Clinical Practice 4 Changing practices Session 20 Back to CONTENTS EXPRESSING BREASTMILK Introduction There are many situations in which expressing breastmilk is useful and important to enable a mother to initiate or continue breastfeeding Expressing milk is useful to relieve engorgement relieve blocked duct or milk stasis feed a baby while he learns to suckle from an inverted nipple feed a baby who has difficulty in coordinating suckling feed a baby who refuses while he learns to enjoy breastfeeding feed a low birth weight baby who cannot breastfeed feed a sick baby who cannot suckle enough keep up the supply of breastmilk when a mother or baby is ill leave breastmilk for a baby when his mother goes out or to work prevent leaking when a mother is away from her b
145. te complementary foods up to 2 years of age or beyond However the majority of mothers in most countries start giving their babies artificial feeds or drinks before 4 months and many stop breastfeeding long before the child is 2 years old The common reasons for this are that mothers believe that they do not have enough breastmilk or that they have some other difficulty breastfeeding Sometimes it is because a mother is employed outside the home and she does not know how to breastfeed at the same time as continuing with her job Sometimes it is because there is no one to give a mother the help that she needs or because health care practices and the advice that she receives from health workers does not support breastfeeding Health workers such as you can help the mothers and children for whom you care to breastfeed successfully It is important to give this help not only before delivery and during the perinatal period but also during the whole of the first and second year of a child s life You can give mothers good advice about feeding their babies at all times when they are well and when they are sick You can help mothers to ensure that their milk supply is adequate You can help with breastfeeding difficulties and you can help employed mothers to continue breastfeeding You may feel that you have not been adequately trained to give this kind of help In the past breastfeeding counselling and support skills have seldom been included in the c
146. tfeed Encourage his mother to breastfeed often to build up her breastmilk supply see Session 27 Increasing breastmilk and relactation AMOUNT OF MILK FOR BABIES WHO CANNOT BREASTFEED What milk to give Choice 1 Expressed breastmilk EBM if possible from the baby s mother Choice 2 Formula made up according to the instructions Choice 3 Animal milk Dilute cow s milk with 1 cup of water to 3 cups milk and add 1 level teaspoon of sugar to each cup of feed Amount of milk to give Babies who weigh 2 5 kg or more 150 ml milk per kg body weight per day Divide the total into 8 feeds and give 3 hourly Babies who weigh less than 2 5 kg Low birth weight Start with 60 ml kg body weight Increase the total volume by 20 ml per kg per day until the baby is taking a total of 200 ml per kg per day Divide the total into 8 12 feeds to feed every 2 3 hours Continue until the baby weighs 1 800 g or more and is fully breastfeeding Check the baby s 24 hour intake The size of individual feeds may vary Volume of milk for babies The amount of milk that a baby takes at each feed varies with all methods of feeding Let the baby decide when he has taken enough If a baby takes a very small feed offer extra at the next feed or give the next feed early especially if the baby shows signs of hunger Assess a baby s 24 hour intake Give extra by nasogastric tube only if the 24 hour total is not enough If a mother produces o
147. tfeed sick babies and young children A mother can increase her breastfeeds to 12 or more per day If her baby cannot suckle help her to express her breastmilk to feed him see Session 20 Expressing breastmilk Inform your colleagues about what you are trying to do Make sure that health workers in other sectors understand about breastfeeding Ask for their support and offer to help them if they are caring for mothers and babies EXERCISE 20 Sustaining breastfeeding How to do the exercise The mothers in these stories are coming to see you for some reason other than breastfeeding First you will help them for the other reason then think what you can say about breastfeeding In the space after the case details write something to praise the mother give some relevant information and suggest something useful Number 3 is optional to do if you have time When you are ready discuss your answers with the trainer Example Linnet brings her 9 month old baby for measles immunization He has started eating complementary foods about 4 times a day and still breastfeeds He has no weight chart but today weighs 8 0 kg Praise It is good that you are continuing to breastfeed at the same time as giving other foods Inform Breastfeeding up to 2 years of age or beyond is recommended these days Suggest At this age it is a good idea to breastfeed before you give a meal of food then he gets plenty of breastmilk To answer 1
148. the supply of breastmilk She should not use a bottle because that makes it more difficult for her baby to take her breast Express a little milk directly into her baby s mouth Some mothers find that this is helpful The baby gets some milk straight away so he is less frustrated He may be more willing to try to suckle Let her baby explore her breasts frequently She should continue to give him skin to skin contact and let him try to attach to her breast STEP ONE Cut along this line with blade STEP TWO Insert Plunger from Cut End STEP THREE Mother gently pulls the Plunger Fig 28 Preparing and using a syringe for treatment of inverted nipples SUMMARY OF DIFFERENCES BETWEEN FULL AND ENGORGED BREASTS FULL BREASTS ENGORGED BREASTS Hot Painful Heavy Oedematous Hard Tight especially nipple Shiny May look red Milk flowing Milk NOT flowing No fever May be fever for 24 hours CAUSES AND PREVENTION OF BREAST ENGORGEMENT CAUSES PREVENTION e Plenty of milk Delay starting to breastfeed e Start breastfeeding soon after delivery Poor attachment to breast Ensure good attachment Infrequent removal of milk Encourage unrestricted breastfeeding Restriction of length of feeds Treatment of breast engorgement To treat engorgement it is essential to remove milk If milk is not removed mastitis may develop an abscess may form and breastmilk production decreases So do not advise a mother rest th
149. thers will have when they go home Are you able to refer mothers to a breastfeeding support group YES NO What is done well and or main needed improvement Practice Sustaining breastfeeding e ls there a follow up visit for mothers within 1 week of delivery to make sure that breastfeeding is going well and to give early help with any difficulties e Do you check on breastfeeding and observe a breastfeed at the 6 week postnatal visit e Do you praise and support all mothers who are breastfeeding e Do you praise and support mothers who are breastfeeding in the child s second year e Do you help mothers to improve practices which may cause problems e Do you help mothers who have questions about breastfeeding even if they have no serious difficulty e Are you able to help mothers who are worried about their breastmilk supply so that they continue to breastfeed without unnecessary complements e Are you able to help mothers with breast conditions and common breastfeeding difficulties so that they continue to breastfeed e Do you remember to discuss breastfeeding when mothers and babies come to you for another reason growth monitoring immunization including measles at 9 months treatment when baby is ill family planning e Do you help mothers to continue breastfeeding if the child is sick YES NO What is done well and or main needed improvement Practice e When you give
150. these situations it is necessary to express the milk If the milk stays in her breast an abscess is more likely Usually blocked duct or mastitis improves within a day when drainage to that part of the breast improves A mother needs additional treatment if there are any of these severe symptoms when you first see her OR a fissure through which bacteria can enter OR no improvement after 24 hours of improved drainage Treat her or refer her for treatment with the following Antibiotics Give either flucloxacillin or erythromycin see Table 1 for dosage Other commonly used antibiotics such as ampicillin are not usually effective Explain that it is very important to complete the course of antibiotics even if she feels better in a day or two If she stops the treatment before it is complete the mastitis is likely to recur Complete rest Advise her to take sick leave if she is employed or to get help at home with her duties Talk to her family if possible about sharing her work If she is stressed and overworked encourage her to try to take more rest Resting with her baby is a good way to increase the frequency of breastfeeds to improve drainage Analgesics Give her paracetamol for the pain Explain that she should continue with frequent breastfeeds massage and warm compresses If she is not eating well encourage her to take adequate food and fluids Table 1 ANTIBIOTIC TREATMENT FOR INFECTIVE MASTITIS
151. tory A Marion is in tears She says that her breasts have become soft again so her milk must be less but the baby is only three weeks old a Don t cry l m sure you still have plenty of milk b You are really upset about this know c Breasts often become soft at this time it doesn t mean that you have less milk Story B Dora is very bothered Her baby sometimes does not pass a stool for one or two days When he does pass a stool he pulls up his knees and goes red in the face The stools are soft and yellowish brown a You needn t be so bothered this is quite normal for babies b Some babies don t pass a stool for 4 or 5 days c It really bothers you when he does not pass a stool doesn t it Story C Susan is crying She takes off her baby s clothes and shows you a rash on the baby s buttocks which looks like a nappy rash a You are really miserable about this rash aren t you b Lots of babies have this rash we can soon make it better c Don t cry it is not serious Story D Marta looks very worried She is sure that her baby is very ill His tongue is covered in white spots which you see are thrush You know that this is not serious and it is easy to treat Write down what you would say to her to show that you accept how worried she is EXERCISE 8 Praising what a mother and baby are doing right How to do the exercise For Stories E F and G below there are three responses They are all things th
152. tr General Original English BREASTFEEDING COUNSELLING A TRAINING COURSE PARTICIPANTS MANUAL PART TWO Sessions 10 19 WORLD HEALTH ORGANIZATION CDD PROGRAMME UNICEF CONTENTS Session 10 Session 11 Session 12 Session 13 Session 14 Session 15 Session 16 Session 17 Session 18 Session 19 Positioning a baby at the breast Building confidence and giving support Building confidence exercises Clinical Practice 2 Breast conditions Breast conditions exercise Refusal to breastfeed Taking a breastfeeding history History practice Breast examination Session 10 Back to CONTENTS POSITIONING A BABY AT THE BREAST Introduction Always observe a mother breastfeeding before you help her Take time to see what she does so that you can understand her situation clearly Do not rush to make her do something different Give a mother help only if she has difficulty Some mothers and babies breastfeed satisfactorily in positions that would make difficulties for others This is especially true with babies more than about 2 months old There is no point trying to change a baby s position if he is getting breastmilk effectively and his mother is comfortable Let the mother do as much as possible herself Be careful not to take over from her Explain what you want her to do If possible demonstrate on your own body to show her what you mean Make sure that she understands what you do so that she
153. uld buy the brand that the doctor recommends However they have not been to that doctor and do not know him Pearl wonders if they should buy the brand that is good for diarrhoea It is expensive so may be very good It might prevent Andy from getting diarrhoea Stan continues to argue that the cheap one is just the same Stella used it In the end Pearl insists on buying the brand that they use in the hospital Pearl says that she will use the formula slowly and that she will make one tin last for two months EXERCISE 24 The cost of formula How to do the task On average to feed a baby artificially for the first 6 months you need 44 x 500g tins of formula You need about 5 tins in the first month 7 tins in the second month and 8 tins a month for the next 4 months From the price on your tin calculate the cost of 44 x 500g tins of the formula Compare the cost of 44 tins with the minimum wage for 6 months for a female agricultural worker and for a female urban labourer or domestic worker Discuss your answers with the trainer and the group To answer Brand of formula Cost of one 500g tin of formula Cost of 44 x 500g tins of formula Minimum wage Agricultural Urban 1 month 6 months Cost of 44 x 500g tins formula ee X 100 Sneon Agricultural wage for 6 months eeeeee To feed a baby on eeeeeeeeeeeeeeeeeeeeeeees formula costs late e ets of the female agricultural wage PS EAE
154. uld give the full amount of artificial feed for a baby of his weight or the same amount that he has been having before As soon as a little breastmilk comes she can reduce the daily total by 30 60 ml each day Check the baby s weight gain and urine output to make sure that he is getting enough milk If he is not getting enough do not reduce the artificial feed for a few days If necessary increase the amount of artificial milk for a day or two Some women can decrease the amount by more than 30 60 ml each day Length of time for relactation The length of time that it takes for a woman s breastmilk supply to increase varies very much It helps if the mother is strongly motivated and if her baby is willing to suckle frequently But the mother should not worry if it takes longer than expected If a baby is still breastfeeding sometimes the breastmilk supply increases in a few days If a baby has stopped breastfeeding it may take 1 2 weeks or more before much breastmilk comes It is easier to relactate if a baby is very young less than 2 months than if he is older more than 6 months However it is possible at any age It is easier if a baby stopped breastfeeding recently than if he stopped a long time ago However it is possible at any time A woman who has not breastfed for years can produce milk again even if she is post menopausal For example a grandmother can breastfeed a grandchild Fig 38 Using a breastfeed
155. ur key points clear 1 The baby s head and body should be in a straight line 2 His face should face the breast with his nose opposite the nipple 3 His mother should hold his body close to hers 4 If her baby is newborn she should support his bottom and not just his head and shoulders Show her how to support her breast with her hand to offer it to her baby She should rest her fingers on her chest wall under her breast so that her first finger forms a support at the base of the breast see Fig 18 page 20 She can use her thumb to press the top of her breast slightly This can improve the shape of the breast so that it is easier for her baby to attach well She should not hold her breast too near to the nipple Explain how she should touch her baby s lips with her nipple so that he opens his mouth see Fig 23 Explain that she should wait until her baby s mouth is opening wide before she moves him onto her breast His mouth needs to be wide open to take a large mouthful of breast Explain or show her how to quickly move her baby to her breast when he is opening his mouth wide She should bring her baby to her breast She should not move herself or her breast to her baby She should aim her baby s lower lip below her nipple so that his chin will touch her breast Notice how the mother responds Does she seem to have pain Does she say Oh that feels better If she says nothing ask her how her baby s suckl
156. urricula of either doctors nurses or midwives This course aims to give you training in basic breastfeeding counselling skills which should enable you to give mothers in your care the support and encouragement that they need to breastfeed successfully During the course you will be asked to work hard You will be given a lot of information and you will be asked to do a number of exercises and clinical practices to develop your breastfeeding counselling skills Hopefully you will find the course interesting and enjoyable and the skills that you learn will make your work with mothers and babies in future more helpful for them and more rewarding for you The course and the manual Breastfeeding counselling A training course consist of 33 sessions which can be arranged in different ways to suit the local situation Your Course Director will plan the course that is most suitable for your needs and will give you a time table This book the Participants Manual is your main guide to the course and you should keep it with you at all times except during clinical practice sessions In the following pages you will find a summary of the main information from each session including descriptions of how to do each of the skills that you will learn You do not need to take detailed notes during the sessions though you may find it helpful to make notes of points of particular interest for example from discussions Keep your manual after the course
157. ve suckling pressure from clothes pressure from fingers during feeds large breast draining poorly Stress overwork reduce frequency length of feeds Trauma to breasts damages tissues e Nipple fissure allows bacteria to enter Causes of blocked duct and mastitis The main cause of blocked duct and mastitis is poor drainage of all or part of a breast Poor drainage of the whole breast may be due to Infrequent breastfeeds For example when a mother is very busy when her baby starts feeding less often because he sleeps through the night or feeds irregularly because of a changed feeding pattern for any other reason for example a journey Ineffective suckling if the baby is poorly attached to the breast Poor drainage of part of the breast may be due to Ineffective suckling because a baby who is poorly attached may empty only part of the breast Pressure from tight clothes usually a bra especially if she wears it at night or from lying on the breast which can block one of the ducts Pressure of the mother s fingers which can block milk flow during a breastfeed The lower part of a large breast draining poorly because of the way in which the breast hangs Another important factor is stress and overwork of the mother probably because it causes her to breastfeed her baby less often or for shorter times Trauma to the breast which damages breast tissue sometimes causes mastitis for exam
158. what they could do better Session 19 Back to CONTENTS BREAST EXAMINATION HOW TO EXAMINE A WOMAN S BREASTS Not necessary as a routine only if you or the woman are concerned If postnatal examine before breastfeed or wait until baby finishes Do the examination gently and modestly e Explain what you want to do Ask the mother s permission Inspect her breasts without touching Look for size and shape of breast may affect confidence size and shape of nipple may affect attachment dripping milk sign of active oxytocin reflex full soft engorged fissures white spots redness inflammation or infection at end of feed protracted or squashed scars breast surgery previous abscess Ask if she has noticed anything wrong If yes ask her to point to the place If it is necessary to palpate ask her permission Palpate gently all parts of both breasts Use the flat of your hand fingers together and straight Do not pinch or poke Watch mother s face for signs of pain or tenderness Feel for generalized fullness hardness engorgement localized hardness hot areas lumps Ask mother to show how easily her nipples stretch out protract She places her finger and thumb on the areola either side of her nipple and tries to stretch the nipple out Talk to the mother about what you have found Use confidence and support skills Do not say anything critical and do not tell her things that will worry her when it is no
159. with the history of a mother and baby to follow when you are the mother How to practise taking a history If you are the counsellor Greet the mother Ask how she is Use her name and her baby s name Ask one or two open questions about breastfeeding to start the conversation Ask questions from all six sections of the Breastfeeding History Form and look at the baby s growth chart to learn about the situation You can make brief notes on the form but try not to let it become a barrier Use your listening and learning skills Do not give information or suggestions or give any advice If you are the mother Read out the Reason for visit in response to the counsellor s open questions Answer the counsellor s questions from the information in your history If the information to answer a question is not in your history make up information to fit with the history If your counsellor uses good listening and learning skills give her the information more easily If you are observing Follow with your Breastfeeding History Form and observe if the counsellor takes the history correctly Notice if she asks relevant questions if she misses important questions and if she asks questions from all sections of the form Try to decide if the counsellor has understood the mother s situation correctly During discussion be prepared to praise what the players do right and to suggest
160. y is not well attached give her appropriate help Give her relevant information Make sure that she understands about demand feeding about the signs that a baby gives that show that he is ready to feed and explain how her milk will come in Answer the mother s questions She may have some questions that she wants to ask or as you talk to her you may learn that she is worried about something or not sure about something Explain simply and clearly what she needs to know Step 10 of the Ten Steps to Successful Breastfeeding This step says Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic Many mothers give up breastfeeding or start complementary feeds in the early weeks Difficulties arise most often during this time However many mothers are discharged within a day or two after delivery before their breastmilk has come in and before breastfeeding is established Even good hospital practices cannot prevent all the difficulties They cannot make sure that mothers will continue to breastfeed exclusively So it is important to think about what happens to mothers after they go home Possible sources of help for breastfeeding mothers include Supportive family and friends This is often the most important source of support Community support is often good where breastfeeding traditions are strong and family members live near However some tr
161. y used drugs analgesics and antipyretics short courses of paracetamol acetyl salicylic acid ibuprofen occasional doses of morphine and pethidine most cough and cold remedies antibiotics ampicillin cloxacillin and other penicillins erythromycin anti tuberculars anti leprotics see dapsone above antimalarials except mefloquine antihelminthics antifungals bronchodilators eg salbutamol corticosteroids antihistamines antacids drugs for diabetes most antihypertensives digoxin nutritional supplements of iodine iron vitamins Breastfeeding and family planning BREASTFEEDING TO DELAY A NEW PREGNANCY While no menstruation Up to age 6 months Good protection From 6 12 months Partial protection After menstruation returns At any time No protection Breastfeed fully Breastfeed frequently day and night Breastfeed frequently day and night with complementary feeds e Use another family planning method LACTATIONAL AMENORRHOEA METHOD LAM No other family planning method Use other family planning method needed if e No menstruation AND if Menstruation returned OR Baby LESS than 6 months old Baby MORE than 6 months old AND OR Baby fully breastfed Complementary feeds started Other methods of family planning and breastfeeding Family planning is important to help breastfeeding to continue Many mothers stop breastfeeding if they become pregnant again

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