it is an important topic in today's world. it is a good topic for future mothers.

1. BREASTFEEDING

2. INTRODUCTION
• The rate of growth of the infants during the first 6
months of life is greater and faster than any period of
the life.
• Its weight is doubled by the age of 5 months and tripled
by the end of one year.
• Keeping this in mind, the baby should be nursed
adequately which allows easy digestion and
absorption.

3. NUTRITIONAL REQUIREMENTS IN
NEONATES
• The infant should get sufficient fluid. Fluid intake should be 150-
175ml/kg body weight per day.
• The infant should get adequate calorie. A term healthy infant needs
100-110 kcal/kg of body weight per day.
• Low birth weight infant needs about 105- 130kcal/kg/day. Each 30mL
of breast milk gives 20 calories.
• Calorie needs are primarily dependent on oxygen consumption.
• The food should have a balanced composition of protein(2-
4g/kg/day), carbohydrates( 10-15g/kg/day), minerals and vitamins
and it should be easily digestible.

4. BREASTFEEDING
• The two vital consideration for the infants in tropical countries are
breastfeeding and avoidance of infection.
• All the babies, regardless of the type of delivery, should be given
early and exclusive breastfeeding up to 6 months of age.
• Exclusive breastfeeding means giving nothing orally other than
colostrum and breast milk. Medicines and vitamins are allowed.
• Breastfeeding is “ Gold Standard” for infant feeding.
• Obstetricians and midwives should educate the mother during
prenatal and postnatal care for the usefulness of breastfeeding.

5. BABY- FRIENDLY HOSPITAL INITIATIVE
• Baby friendly hospital initiative with 10 steps to successful
breastfeeding ( WHO/ UNICEF 1992: Protecting, promoting and
supporting breastfeeding). These are:
i. There must be a written breastfeeding policy.
ii. All healthcare staff must be trained to implement this policy
iii. All pregnant women should be informed about the benefits of
the breastfeeding.
iv. Mothers should be helped to initiate breastfeeding within half
an hour of birth.

6. v. Mothers are shown the best way to breastfeed.
vi. Unless medically indicated, the newborn should be given no food
or drink other than breast milk.
vii. To practice ‘rooming- in’ by allowing mothers and babies to
remain together 24 hours a day.
viii. To encourage demand breastfeeding.
ix. No artificial teats to the babies should be given
x. Breastfeeding support groups are established and mothers are
referred to them on discharge.
A baby friendly hospital should also provide other preventive health
cares, e.g. infant immunization, rehydration salts against diarrheal
dehydration and child’s growth and development surveillence.

7. ADVANTAGES OF
BREASTFEEDING

8. COMPOSITION
• Breast milk is an ideal food with easy digestion and low osmotic
load.
o CARBOHYDRATES: Mainly lactose, stimulates growth of intestinal
flora, produces organic acids needed for synthesis of vitamin B.
o FATS: Smaller fat globules, better emulsified and digested.
o PROTEINS: Rich in lactalbumin and lactoglobulin, less in casein.
o MINERALS: Low osmotic load, less burden on kidney.

9. PROTECTION AGAINST INFECTION
AND DEFICIENCY
• VITAMIN D: It promotes bone growth, protects the baby against
rickets.
• Leukocytes, lactoperoxidase: It prevent the growth of infective
agents.
• Lyzozyme, lactoferrin, interferon protect against infection.
• Immunoglobulins IgA( secretory), IgM, IgG protect against
infection.
• Long chain omega-3- fatty acids essential for neurological
development.

10. OTHERS
• Breast milk is readily available food to newborn at body
temperature and without any cost.
• Breastfeeding acts as a natural contraception to the mother.
• It has laxative action
• No risk of allergy
• Psychological benefit to mother- child bonding.
• Helps involution of the uterus.
• Lessens the incidence of the sore buttocks, GI infection and
atopic eczema.
• The incidence of rickets and scurvy is significantly reduced.

11. PREPARATION OF BREASTFEEDING
• The preparation of the breastfeeding should be actually be
started from the middle of pregnancy.
• Any abnormality in the nipple, like cracked or depressed nipple
should be adequately treated.
• Massaging the breasts, expression of the colostrum and
maintenance of the cleanliness should be carried out during the
last four weeks of pregnancy.

12. MANAGEMENT OF FEEDING
• The modern practice is to reduce nipple cleansing to a minimum
and to wash the breasts once daily.
• A clean, soft, supporting brassiere should be worn.
• The mother should wash her hands prior to feeding.
• Mother and the baby should be in a comfortable position during
feeding.
• Frequent feedings, 8-12 feeds/24 hours are encouraged.

13. FIRST FEED
• In the absence of the anatomical or medical
complications, a healthy baby is put to the breast
immediately or at most 1/2 – 1 hour following normal
delivery.
• Following caesarean delivery, a period of 4-6 hours
may be sufficient for the mother to feed her baby.

14. MILK TRANSFER
• Milk transfer to an infant is a physiological process. It starts with
good latch on.
• The nipple is slightly tilted downward using a “ C- hold”.
• The milk is extracted by the infant not by negative pressure but
by a peristaltic action from the tip of the tongue to the base.
• The latent period between latch on to milk ejection is about 2
minutes.
• Nearly 90% of the milk is obtained in first 5 minutes. The calorie-
rich hind milk is obtained at the end part of suckling.

15. FREQUENCY OF FEEDING
• TIME SCHEDULE: During the first 24 hours, the mother
should feed the baby at an interval of 2-3 hours.
Gradually, the regularity becomes established at 3-4
hours pattern by the end of first week. Baby should be
fed more on demand.
• DEMAND FEEDING: The baby is put to the breast as
soon as the baby becomes hungry. There is no
restriction of the number of feeds and duration of
suckling time.

16. DURATION OF FEED
• The initial feeding should last for 5-10 minutes at each breast.
• This helps to condition the letdown reflex. Thereafter, time spent
is gradually increased.
• Baby is fed from one breast completely so that baby gets both
the foremilk and the hind milk. Then the baby is put to the other
breast if required.
• Hind milk is richer in fat and supplies more calories and satiety to
the infant.
• The next feed should start with other breast.

17. NIGHT FEED AND AMOUNT OF FEED
NIGHT FEED
In the initial period, night feed is
required to avoid long interval
between feeds of over 5 hours.
It not only eliminates excessive
filling and hardening of breasts
but also quietens and ensures
sound sleep for the baby.
As the days progress, the baby
becomes satisfied with the
rhythmic 3-4 hourly feeding.
AMOUNT OF FEED
The average requirement of
milk is about 60ml/ kg/24 hours
on first day, 100mL/kg/24 hours
on the third day and is
increased to 150mL/kg/24 hours
on 10th day.
However, baby can take as
much as he/ she wants.

18. TECHNIQUE
• The mother and baby should be in a comfortable position.
• Feeding in the sitting position, the mother holds the baby in an
inclined upright position on her lap, the baby’s head on her
forearm on the same side close to her breasts, the neck is slightly
extended.
• Good attachment means the infant’s mouth is wide open and
chin touches the breast.
• The mother should guide the nipple and areola into the baby’s
mouth for effective milk transfer.
• The milk transfer to the infant begins with good latch on and by
peristaltic action of the tip of the tongue to the base.

19. • The proper position for milk transfer is chest- to chest contact of
the infant and mother.
• The infant’s ear, shoulder and hip are in one line. Baby sucks the
areola and the nipple holding between the tongue and palate.
• Feeding in lateral position following cesarean delivery or with
painful perineum is carried out by placing the baby along her
side between trunk and arm.
• The failure to develop good milk transfer is the major cause of
lactation failure and breast pain.
• Inhibition of let- down reflex and failure to empty the breasts
leads to ductal distortion, parenchymal swelling and breast
engorgement.
• Normally, the breast is washed with clean waterand allowed to
dry.

20. NIPPLE CONFUSION
• If the baby is fed with an artificial nipple of bottle, he cannot
suck the mother’s nipple effectively due to nipple confusion.
• In case of artificial nipple, he has to press the nipple only.
• But in case of mother’s nipple, he has to press the areola and
suck the nipple.
• The baby is confused between these two procedures and
lactation failure develops.
• So, artificial nipple is strictly discouraged.
• If at all, needed the artificial feed is given by spoon or jhinuk.

21. BREAKING THE WINDIKKK
• All babies swallow varied amount of air during sucking.
• To break up the wind, the baby should be held upright against
the chest and the back is gently patted till the baby beches out
the air.
• It is better to break up the wind in the middle of sucking so as to
make the stomach empty, enabling the baby to take more food
and at the end of sucking to prevent hiccough and abdominal
colic.

22. FACTORS FOR SUCCESSFUL
LACTATION
1) Positioning
2) Attachment to breast
3) Nursing technique
4) A rotation of positions is helpful to reduce focal pressure on the
nipple and to ensure complete emptying.
5) To break the suction, a finger is inserted between the baby’s lips
and the breast.
6) Otherwise it can injure nipple by forceful disengagement.

23. DIFFICULTIES IN BREASTFEEDING AND
THE MANAGEMENT
• At times, breastfeeding poses some problems
and if it is not promptly detected and rectified, it
may lead to adverse consequences.
• The causes may be classified as those:
DUE TO MOTHER
DUE TO INFANT

24. DUE TO MOTHER
• Reluctance or dislike to breastfeeding- careful listening to
mother and intelligent counseling can solve the problem.
• Infant’s attachment to breast- when poor, it leads to quick
shallow sucks instead of slow and deep. Areola remains outside
the lips. This causes nipple pain. Skilled support from healthcare
provider can improve the technique of breastfeeding. Prelacteal
feeds inhibit lactation process and should be avoided.
• Anxiety and stress: Previous history of failed lactation or elderly
primipara- the mother fails to relax during feeding and such as,
baby refuses to suck. Reassurance and practical support is
helpful.

25. • Following operative delivery such as cesarean section or
following prolonged and exhaustive labor often there is delay. So
mother should be helped to feed the baby in a comfortable
position as early as possible.
• Milk secretion is inadequate- unrestricted feeding, well-
positioned infant, practical and emotional support to mother –
all are important. Dopamine antagonist (metoclopramide) may
be useful.
• Breast ailments such as engorgement of breast, cracked nipple,
depressed nipple and mastitis need treatment. Previous breast
surgery and circumareolar incision have unsuccessful
breastfeeding. Loss of breast sensation may be the cause.

26. DUE TO INFANT
• LOW BIRTH WEIGHT BABY- The baby is too small or feeble to suck.
• TEMPORARY ILLNESS: such as respiratory tract infection, nasal
obstruction due to congestion, lethargy due to jaundice and
oral thrush.
• OVERDISTENSION OF STOMACH WITH SWALLOWED AIR
• CONGENITAL MALFORMATION: such as cleft palate needs
surgical correction.

27. DRUGS AND BREASTFEEDING
• Most drugs taken by mother appear in the breast milk .
• Fortunately, drug level in the breastfed infant ranges
from 0.001 to 5% of the therapeutic doses.
• The infant tolerates the drug without toxicity.
• Very few drugs are absolutely contraindicated. These
are: anticancer drugs, chloramphenicol, radioactive
materials, phenylbutazone and atropine.

28. MATERNAL NUTRITION DURING
LACTATION
• A healthy mother while breastfeeding will produce about 500- 900mL
breast milk per54 day. This will give her baby about 75kcal/dL.
• This requires additional 750 kcal/day for the mother. This amount is either to
be supplemented through her diet or is made up from her body stores.
• A store of 5 kg of fat throughout pregnancy is adequate to make up the
nutritional deficit.
• There is additional need of folic acid, iron, calcium and protein during
pregnancy.
• Mother should drink at least 1 extra liter of fluid per day to make up the
fluid loss through milk.

29. ASSESSMENT OF WELL BEING OF THE
INFANT
• General condition- The baby is happy, sleeps between feeds
and at night, does not vomit and passes urine at least six times in
24 hours.
• Good vigor which is manifested by movements of the limbs and
cry
• Infants has stopped losing weight
• Has yellow seedy stools and no more meconium stools
• Expected level of weight curve.

30. UNDERFEEDING
• It is commonly seen in artificially fed babies. The features are:
 Failure of the infant to gain weight as per schedule, evidenced
from the weight curve.
 The infant appears dissatisfied with the feeds evidenced by cry
between feeds and at night disturbing the sleep.
 The baby has constipation
 The urinary output becomes scanty and high colored
 Test feeding is the only reliable method of diagnosis.

31. MANAGEMENT OF UNDERFEEDING
• The deficient amount of milk should be substituted by artificial
milk.
• The required deficit of 24 hours as calculated from test feeding is
to be divided by the number of feeds to be given in 24 hours.
• The amount of deficit for each feed, so calculated , should be
given after each feed.
• As soon as sufficient milk comes to the breast , the
supplementary feed is withdrawn.

32. CARE OF BREASTS
• Daily washing of the breasts with clean water is
essential.
• The nipple should be cleaned with clean water
before and after each feed.
• Brassieres are to be worn for support and
comfort.

33. FEEDING DIFFICULTIES DUE TO NIPPLE
• BREAST ENGORGEMENT usually occurs on day 3-5 postpartum. There is
copious milk production.
• Breasts are swollen and hard. There is difficulty to latch on for the infant.
• TREATMENT:
o Gentle hand expression of milk to make the breasts soft so that the infant
can latch on.
o Application of moist heat and cold compress to relieve edema
o Gentle breast massage during feeding or milk expression
o Pain relief to reduce inflammation( ibuprofen)

34. • LONG NIPPLES: It may cause poor feeding due to
improper latch on to the nipple without areola. Mother
has to help the baby to draw the areola also.
• SHORT NIPPLES: It usually cause no problem. Mother is
reassured.
• INVERTED AND FLAT NIPPLES attachment to the breasts
is possible and babies are able to feed adequately. In
difficult cases, lactation is initiated by expression. Baby
is then attached to breast as breast tissue becomes soft
and protractile gradually. it can be corrected by
suction with syringe or breast pump.

35. EXPRESSION OF BREAST MILK
• Expression of breast milk or artificial removal of breast milk is not
generally needed where breastfeeding is normal.
• The indications of expressing breast milk are:
 Where the baby is separated from the mother due to prematurity or
illness.
 Where there are difficulties in breastfeeding as in attaching the baby
to the breast, e.g. cleft palate.
 When the mother is separated from the baby because of work.
 Colostrum should be expressed and given to the babies if they
cannot suck properly.

36. METHODS OF MILK EXPRESSION
• MANUAL EXPRESSION: It is advantageous over the
mechanical pumping,. It increases the level of
prolactin that helps to maintain lactation for longer
period. It can be practiced anywhere and costs
nothing.
• BREAST PUMPS: A breast pump is a mechanical device
that lactating women use to extract milk from their
breasts. They may be manual devices powered by
hand or foot movements or automatic devices
powered by electricity.

37. DONOR BREAST MILK
• Historically, it has been used for centuries. Currently its use is
limited.
• Transmission of infection(HIV, CMV, Hepatitis B, TB) is the concern
for its safety.
• If the donor breast milk or milk banks are used, donor screening,
pasteurization of milk and parental counseling are
recommended.
• Breast milk can be stored frozen at −200
C for upto 6 months,
refrigerated at 40C for 24 hours and at room temperature for 4
hours. Fresh, unrefrigerated milk can be used within 4 hours of
expression.

38. METHODS OF ESTABLISHMENT OF
LACTATION
FOR THE BABY
• To discontinue bottle
feedings
• To put the baby to the
breast at frequent
intervals
• Baby should suck in a
well- attached manner.
FOR THE MOTHER
• To encourage plenty of
fluid( 1L extra) and milk
intake.
• Drugs like
metoclopramide or
oxytocin( nasal spray)
are of help.