The Baby Friendly Hospital Initiative aims to promote and support breastfeeding in hospitals according to 10 steps. These include having a written breastfeeding policy, training staff, informing pregnant women of benefits, helping initiate breastfeeding within 30 minutes of birth, showing mothers breastfeeding techniques, exclusively breastfeeding, practicing rooming-in, on-demand breastfeeding, avoiding pacifiers for breastfed infants, and referring mothers to support groups. The goal is establishing optimal practices for supporting breastfeeding mothers and babies.

1. BABY FRIENDLY HOSPITAL
INITIATIVE AND EXCLUSIVE
BREAST FEEDING

2. BABY FRIENDLY HOSPITAL
INITIATIVE

3. Definition:
• The Baby Friendly Hospital Initiative was
introduced in 1991 by the World Health
Organization/United Nations Children's Fund
(WHO/UNICEF) to promote, protect and support
breastfeeding in the hospital or birth setting. A
key element in this promotion and support is
outlined in their
Ten Steps to Successful Breastfeeding. To date,
approximately 19,000 hospitals and birth centers
in about 125 countries have received the "Baby
Friendly" designation.

4. CRITERIA
Ten steps to successful breastfeeding recommended by code of
practice of WHO/ UNICEF :-
• 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 one half-hour of birth.
• Show mothers how to breastfeed and maintain lactation,even if they
should be separated from their infants.

5. • Give newborn infants no food or drink other than
breastmilk, unless medically indicated.
• Practice rooming in - that is, allow mothers and
infants to remain together 24 hours a day.
• Encourage 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.

6. Step 1. Have a written
breastfeeding policy that is
routinely communicated to all
health care staff.

7. Breastfeeding policy
Why have a policy?
• Requires a course of action and provides
guidance
• Helps establish consistent care for
mothers and babies
• Provides a standard that can be evaluated

9. Breastfeeding policy
What should it cover?
• At a minimum, it should include:
– The 10 steps to successful breastfeeding
– An institutional ban on acceptance of free or low cost
supplies of breast-milk substitutes, bottles, and teats
and its distribution to mothers
– A framework for assisting HIV positive mothers to
make informed infant feeding decisions that meet
their individual circumstances and then support for
this decision
• Other points can be added

10. Breastfeeding policy
How should it be presented?
It should be:
• Written in the most common languages
understood by patients and staff
• Available to all staff caring for mothers and
babies
• Posted or displayed in areas where
mothers and babies are cared for

12. Step 2. Train all health-care staff in
skills necessary to implement this
policy.

15. Areas of knowledge
• Advantages of breastfeeding
• Risks of artificial feeding
• Mechanisms of lactation and suckling
• How to help mothers initiate and sustain
breastfeeding

16. • How to resolve breastfeeding difficulties
• How to assess a breastfeed
• Hospital breastfeeding policies and
practices
• Focus on changing negative attitudes
which set up barriers

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

18. Antenatal education should
include:
• Benefits of breastfeeding
• Early initiation
• Importance of rooming-in (if new concept)
• Importance of feeding on demand
• Importance of exclusive breastfeeding
• How to assure enough breastmilk
• Risks of artificial feeding and use of bottles and
pacifiers (soothers, teats, nipples, etc.)

19. • Basic facts on HIV
• Prevention of mother-to-child transmission of
HIV (PMTCT)
• Voluntary testing and counselling (VCT) for HIV
and infant feeding counselling for HIV+ women
• Antenatal education should not include group
education on formula preparation

22. Step 4. Help mothers initiate
breastfeeding within a half-hour of
birth.

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

24. Early initiation of breastfeeding
for the normal newborn
Why?
• Increases duration of breastfeeding
• Allows skin-to-skin contact for warmth and
colonization of baby with maternal organisms
• Provides colostrum as the baby’s first
immunization
• Takes advantage of the first hour of alertness
• Babies learn to suckle more effectively
• Improved developmental outcomes

25. Early initiation of breastfeeding
for the normal newborn
How?
• Keep mother and baby together
• Place baby on mother’s chest
• Let baby start suckling when ready
• Do not hurry or interrupt the process
• Delay non-urgent medical routines for at
least one hour

28. Protein composition of human
colostrum
and mature breast milk (per litre)
Constituent Measure Colostrum Mature Milk
(1-5 days) (>30 days)
Total protein G 23 9-10.5
Casein mg 1400 1870
α-Lactalbumin mg 2180 1610
Lactoferrin mg 3300 1670
IgA mg 3640 1420

29. • Step 5. Show mothers how to
breastfeed and how to maintain
lactation, even if they should be
separated from their infants

30.  Contrary to popular belief, attaching the
baby on the breast
• is not an ability with which a mother is
[born…]; rather it is a learned skill which
she must acquire by observation and
experience.

33. Supply and demand
 Milk removal stimulates milk production.
 The amount of breast milk removed at each
feed determines the rate of milk production in
the next few hours.
 Milk removal must be continued during
separation to maintain supply.

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

38. • Decreased frequency or effectiveness of
suckling
• Decreased amount of milk removed from
breasts
• Delayed milk production or reduced milk supply
• Some infants have difficulty attaching to breast if
formula given by bottle

39. Acceptable medical reasons for
supplementation or replacement
Infant conditions:
• Infants who cannot be BF but can receive BM include
those who are very weak, have sucking difficulties or oral
abnormalities or are separated from their mothers.
• Infants who may need other nutrition in addition to BM
include very low birth weight or preterm infants, infants at
risk of hypoglycaemia, or those who are dehydrated or
malnourished, when BM alone is not enough.
• Infants with galactosemia should not receive BM or the
usual BMS. They will need a galactose free formula.
• Infants with phenylketonuria may be BF and receive
some phenylalanine free formula.

40. Maternal conditions:
• BF should stop during therapy if a mother is taking anti-metabolites,
radioactive iodine, or some anti-thyroid medications.
• Some medications may cause drowsiness or other side effects in
infants and should be substituted during BF.
• BF remains the feeding choice for the majority of infants even with
tobacco, alcohol and drug use. If the mother is an intravenous drug
user BF is not indicated.
• Avoidance of all BF by HIV+ mothers is recommended when
replacement feeding is acceptable, feasible, affordable, sustainable
and safe. Otherwise EBF is recommended during the first months,
with BF discontinued when conditions are met. Mixed feeding is not
recommended.

41. Maternal conditions
(continued):
:
• If a mother is weak, she may be assisted to position her baby so
she can BF.
• BF is not recommended when a mother has a breast abscess, but
BM should be expressed and BF resumed once the breast is
drained and antibiotics have commenced. BF can continue on the
unaffected breast.
• Mothers with herpes lesions on their breasts should refrain from BF
until active lesions have been resolved.
• BF is not encouraged for mothers with Human T-cell leukaemia
virus, if safe and feasible options are available.
• BF can be continued when mothers have hepatitis B, TB and
mastitis, with appropriate treatments undertaken.

42. Step 7. Practice rooming-in —
allow mothers and infants to
remain together —
24 hours a day.

43. • Rooming-in
• A hospital arrangement where a
mother/baby pair stay in the same room
day and night, allowing unlimited contact
between mother and infant

46. Rooming-in
Why?
• Reduces costs
• Requires minimal equipment
• Requires no additional personnel
• Reduces infection
• Helps establish and maintain
breastfeeding
• Facilitates the bonding process

47. Step 8. Encourage breastfeeding
on demand.

48. • Breastfeeding on demand:
• Breastfeeding whenever the baby or
mother wants, with no restrictions on the
length or frequency of feeds

49. On demand, unrestricted
breastfeeding
Why?
• Earlier passage of meconium
• Lower maximal weight loss
• Breast-milk flow established sooner
• Larger volume of milk intake on day 3
• Less incidence of jaundice

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

55. Alternatives to artificial teats
• cup
• spoon
• dropper
• Syringe

56. • Cup-feeding a baby

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

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

60. Support can include:
• Early postnatal or clinic checkup
• Home visits
• Telephone calls
• Community services
– Outpatient breastfeeding clinics
– Peer counselling programmes

61. • Mother support groups
– Help set up new groups
– Establish working relationships with those
already in existence
• Family support system

64. EXCLUSIVE BREAST FEEDING

65. Definition:
The feeding of an
infant or young child
with breast milk
directly from female
human breasts rather
than from a baby
bottle or other
container.

66. Benefits to the Baby
Perfect nutrition
Higher IQ
Complete food for the first
six months
Emotional bonding
Prevents infections
Prevents chronic diseases
Easily digested

67. Benefits to the Mother
Reduces post delivery
bleeding and anemia
Helps delay next pregnancy
Protective effect against
breast and ovarian cancer
Helps to loose weight
Emotional bonding
Needs no preparation

68. Breastfeeding in the Correct Position
Milk producing glands
Lactiferous canaliculi
Lactiferous sinuses
Myoepithelial tissue
Adipose tissue

69. Signs of Correct Attachment
Mouth wide open
Lower lip is turned outside
Chin touching the breast
Black part of the breast not
visible below the lower lip
Large black portion of breast
and nipple including milk
collecting ducts are inside
baby’s mouth
Tongue under the teat

70. Incorrect Sucking Position
Mouth is not wide open
Chin is away from the breast
Baby is sucking only nipple
Most black portion of the
breast is outside the baby’s
mouth
Tongue away from the teat

71. Causes of Incorrect Attachment
• Use of feeding bottles. Leads to nipple
confusion
• Inexperienced mother
• Functional difficulty with the mother or the
baby
• Lack of skilled support

72. Breastmilk Production
The Prolactin reflex
Sensory Impulses
Prolactin in blood from nipple
More prolactin secreted at
night
Secreted after feed to
Baby sucking
produce next feed
Suppresses ovulation

73. The Feeling of “Not Enough Milk”
Not True. Just a perception
Reinforce mothers:
Self confidence is must
Ensure frequent suckling
Ensure effective suckling

74. Conclusion
Exclusive Breastfeeding for First Six
Months
Being Successful-
• Initiate breastfeeding as early as possible within one hour of birth.
• Do not give the baby any prelacteal feeds
• No bottles, artificial teats or pacifier
• Breastfeeding on demand at least 8-10 times in a day and at night a
• Breastfeed in a correct position
• Build mother’s confidence to sustain good milk supply and alleviate
feeling of not enough milk.

75. • Newborn deserves
the best Nutrition,
Improved Survival,
Optimum
Development and
Healthy Life
• Breastfeeding can do
this miracle !!!

76. INDICATORS OF ADEQUACY :-
Adequacy of breast feeding is indicated and established by
the following:-
• Audible feeding sound while swallowing
• Let down sensation in mother’s breast
• Breast is full before the feed and soft after feed
• Wet nappies 6 or more in 24 hrs
• Frequant soft bowel movements 3 to 8 times in 24 hrs
• Average weight gain of 18-30 gm/day
• Baby sleeps well and doesnot cry frequently
• Baby has good muscle tone and healthy skin

77. IMMUNOLOGIC SPECIFICITY
• Protection against
pathogens & allergens
• Kills pathogenic
organisms or modifies
their growth
• Stimulates epithelial
maturation for future
defence
• First immunization
• Protection against
common respiratory
and intestinal diseases

78. IMMUNOLOGIC SPECIFICITY
• Colostrum = Baby’s
first vaccination
• Less risk of illness
such as:
Ear infections,
pneumonia, crohn’s
disease and other
bowel illnesses,
stomach flu and other
intestinal illnesses, ear
infections, childhood
cancers, diabetes,
arthritis, allergies,
asthma and eczema

79. PERFECT FOOD FOR BABIES
• Just the right amount of nutrients in the
right proportions
• Over 200 components in human milk
• Composition of breast milk:
-Live cells, fat, carbohydrates, proteins,
vitamins, minerals
-Less fat than most other mammals
-More lactose than other mammals

80. BREAST MILK COMPOSITION
• Fat (4% concentration
provides up to 50% of
caloric needs, cholesterol
levels constant, lipolytic
enzymes aid in fat digestion)
• Carbohydrates (lactose =
milk sugar predominantly in
human milk, 7%
concentration provides up to
40% caloric needs, essential
for development of CNS,
enhances calcium & iron
absorption)

81. BREAST MILK COMPOSITION
• Carbohydrates (Bifidus
factor = growth factor
present only in human milk
required for establishing an
acidic environment in the
gut to inhibit growth of
bacteria, fungi and
parasites)
• Protein
-Lactoferin => Isolates
external iron
-Secretory IGA => Most
important immunoglobulin,
breast milk = only source for
first 6 weeks

82. BENEFITS OF BREASTFEEDING
• Ecological:
-Saves resources
-Less waste
-No refrigeration
-No manufacturing
-No bottles, cans
-No trucking
-No handling

83. BENEFITS OF BREASTFEEDING
• For Society
-Smarter
-Healthier
-Less cost to
healthcare
system
-Stronger families

84. BENEFITS OF BREASTFEEDING
• To Families
-Less trips to
doctors, hospitals
-Less prescriptions
-Less stress
-Less illness
-More bonding
-Inexpensive

85. BENEFITS OF BREASTFEEDING
• Benefits to baby:
-Better dental health
-Increased visual
acuity
-Decreased duration
and intensity of
illnesses
-Less allergies
-Better health & less
risk of illnesses

86. BENEFITS OF BREASTFEEDING
• Benefits to mother:
-Psychological (Attachment,
bonding, security, skin to
skin, fulfillment of basic
needs, relationship)
-Easier weight loss
-Decreased risk of illness
(breast cancer,
osteoperosis, hemmorhage,
ovarian cancer)
-Birth control
-Pride, empowerment,
fulfillment

87. HARMFUL EFFECTS OF
FORMULA MILK

88. Why some mothers choose formula
vs. breast milk
• Distressed by physical
discomfort of early
breastfeeding problems.
• Convenience issues
• Pressures of
employment/school
• Worries that breast shape will
change
• Formula manufacturers
manipulate people through their
ads
• Doctors and nurses need more
lactation training

89. Why some mothers choose formula
vs. breast milk
• Moms given very little time
to adjust to changes of
postpartum
• Family demands
• Non-supportive family/health
professionals
• Embarrassment
• Lack of confidence in self
• Feeling that one cannot
produce enough milk

90. Mother’s milk vs. formula milk
• Human milk is designed
to support the
development of large
brains, capable of
processing and storing
lots of information.
• Cows milk is designed
to support functions,
like constant grazing.

91. Illness Relative risk
• Allergies, eczema 2 to 7
times
• Urinary tract infections 2.6
to 5.5 times
• Inflammatory bowel disease
1.5 to 1.9 times
• Diabetes, type 1 2.4 times
• Gastroenteritis 3 times
• Hodgkin's lymphoma 1.8 to
6.7 times
• Otitis media 2.4 times
• Haemophilus influenzae
meningitis 3.8 times
• Necrotizing enterocolitis 6 to
10 times

92. Illness Relative risk
• Pneumonia/lower
respiratory tract
infection 1.7 to 5 times
• Respiratory syncytial
virus infection 3.9 times
• Sepsis 2.1 times
• Sudden infant death
syndrome 2.0 times
• Industrialized-world
hospitalization 3 times