This document provides information on breastfeeding. It discusses the importance of breastfeeding for infant health and development. It covers breast anatomy and milk production. It also describes different breastfeeding positions and signs of successful attachment and feeding. The document discusses common breast conditions like engorgement, blocked ducts, mastitis and thrush. It provides guidance on managing these conditions and preventing nipple soreness. The document emphasizes the importance of counseling to support breastfeeding mothers.

1. BREAST FEEDING
Dr KM Parakrama
Registrar in Paediatrics
NICU TH-Mahamodara
13th May 2020

2. Contents
• Introduction
• Positioning and Attachment
• Breast feeding positions
• Indicators of successful breast feeding
• Contraindications
• Breast conditions- Nipple conditions
Breast conditions
• Barriers For Breastfeeding
• Breastfeeding counselling

3. INTRODUCTION
• According to WHO & AAP Breastfeeding is
the normal way of providing young infants with
the nutrients
• Needed for healthy growth and development.
• Breastfeeding helps defend against infections,
• prevent allergies, and
• protect against a number of chronic conditions.

4. ANATOMY AND PHYSIOLOGY
• The breast consists of glandular tissue and supporting
tissue and fat.
• Milk is secreted by the glands and travels through
tubules which drain into lactiferous sinuses.
• The sinuses which store small quantities of milk, lie
below the areola.
• They open out on to the nipple through lactiferous ducts.
• The thin layer of muscle (myo-epithelium) surrounds
each gland.
• The contraction of these muscles causes ejection of milk
from the glands.
4

5. 31.07.201
6
Breast
Feeding
5

6. MILK PRODUCTION AND SECRETION
• Milk is produced as a result of the
interaction between hormones and
reflexes.
• During pregnancy, the glandular tissue is
stimulated to produce milk due to various
hormonal influences.
• Two reflexes, mediated by two different
hormones, come into play during
lactation.

9. Positioning and
Attachment

11. Position of the mother

12. Proper position of baby while
breastfeeding includes
1. Supporting whole of baby’s body.
2. Ensurebaby’s head, neck and back are in
same plane.
3. Entire baby’s body should face mother.
4. Baby’sabdomen touches mother’s abdomen.
• Correct positioning will ensure effective
sucking and prevent sore nipples and breast
engorgement.
35

13. Attachment of baby on mother’s breast
• Four signs of good
attachment are:
1. Baby’smouth wide
open.
2. Lower lip turned
outwards.
3. Baby’schin touches
mother’s breast.
4. Majority of areola
inside baby’smouth.

14. Indicators of good attachment
and positioning:
• mouth wide open
• less areola visible underneath the chin
than above the nipple
• chin touching the breast, lower lip
rolled down, and nose free
• no pain.
Rules of breast
feeding

15. Breastfeeding Positions
Cradle Hold
• This is the most
common position
used by mothers.
• Infant’s head is
supported in the
elbow, the back and
buttock is supported
by the arm and lifted
to the breast.

16. Football Hold Position
• The infant’s is placed under
the arm, like holding a football
• Baby’s body is supported with
the forearm and the head is
supported with the hand.
• Many mothers are not
comfortable with this position
• Good position after operative
procedures
Breastfeeding Positions

17. Side Lying Position
• The mother lies on her side
propping up her head and shoulder
with pillows.
• The infant is also lying down facing
the mother.
• Good position after Caesarean
section.
• Allows the new mother some rest.
• Most mothers are scared of
crushing the baby.
Breastfeeding Positions

18. Cross Cradle Hold Position
• Ideal for early breastfeeding.
• Mother holds the baby crosswise in
the crook of the arm opposite the
breast the infant is to be fed.
• The baby's trunk and head are
supported with the forearm and
palm.
• The other hand is placed beneath
the breast in a U-shaped to guide
the baby's mouth to your breast.
Breastfeeding Positions

19. saddle hold Position
• Usually used for
older infants
• Not commonly used
by mothers.
• Best used in older
infants with runny
nose, ear infection.
Breastfeeding Positions

20.  Indicators of successful feeding in babies:
• Sustained rhythmic suck
• Relaxed arms and hands
• Moist mouth
• Regular soaked/heavy nappies, about 6-8 wet
diapers in a 24 hour.
• Average daily weight gain of 20 -40g.
• Go to sleep and comfort after feeding.
 Indicators of successful breastfeeding in women:
• Breast softening
• No compression of the nipple at the end of the feed
• Woman feels relaxed and sleepy.

21. CONTRAINDICATIONS FOR BREAST FEEDING
Infants : galactosemia
Mothers:
 Mothers infected with HIV ?
 Confirmed or suspected Ebola virus disease
 Infected with T cell lymphotrophic virus type 1 or 2
.

22.  TEMPORARILY SHOUD NOT BF OR EBM
 Mothers taking any of the following medications:
radioactive isotopes,
 Cancer chemotherapy agents, such as antimetabolites, and
 Illegal drugs.
 Untreated brucellosis
 Active HSV in breast
 SHOULD NOT BF CAN GIVE EBM
 Untreated active TB ( can BF after 2 weeks of Rx and
documented not to be contagious)
 Active varicella

23. BREAST CONDITIONS

24. NIPPLE SIZE AND SHAPE

25. FLATNIPPLESAND PROTRACTILITY
 Nipples become protractile /stretchy during pregnancy
 No need to diagnose or treat flat/inverted nipple during
pregnancy
 Makes woman feel that her breasts are not right for BF
 Protractility improves during pregnancy and after delivery
May look flat but baby is able to suckle
 Build her confidence and provide support.
 Attachment and avoiding artificial teats and pacifiers
assist BFto establish.

26. INVERTEDNIPPLES
Not always a problem as babies attach to breast
and nottonipple.
Build mothers’ confidence and provide support.
Supportive practices include :Skin to skincontact,
encourage baby to find own way to breast ,
correct positioning.
Help mothers to attachproperly
Can breastfeedsuccessfully with
help
Really difficult nipples arerare.
9

27. ManagementofFlatandInvertedNipples
• Antenatal treatment
—Probably nothelpful
• Soonafter delivery
—
—
—
—
—
—Buildmother’sconfidence
Explainbaby sucks fromBREASTnotnipple
Letbaby explore breast, skin-to-skin
Help mothertoposition herbaby
Trydifferentpositions
Help hertomake nipple stand outmore- Usesyringe, pump,
massage
• Forfirstweek ortwoifbaby notsuckle effectively
—Expressbreastmilk
— feed withcup
— Expressintobaby’s mouth

28. Syringe method forinverted nipples

29. LONGORBIGNIPPLES
May cause difficulties
baby does not take breast far enough back into
mouth
likely to suck only nipple and not taking breast
with the lactiferous sinuses intomouth.
Be ready to help mother with BF technique
help mother to position and attach correctly

30. LongNipples

31. HelpingMotherWithLongandBigNipples
• Re-assure mother:
Baby’s mouthwillgrowand
lengthen.
Hernipples willnotgrow !!
• Expressbreastmilkand feed
withcup.
• Expressbreastmilkinto
baby’s mouth.

32. ManagementofNippleFissure
(CrackedNipple)
Commonly caused by incorrect positioning
and poor attachment.
Baby pulls on nipple as he sucks and
causing pain
Repeated suckling >>damage nipple skin
>>>fissure.
Help mother for correct positioning.

33. UNICEF/WHO Breastfeeding Promotion and Support in a Baby-Friendly Hospital – 20 hour Course 2006
Sore Nipple
©UNICEFC107-31

34. SORENIPPLES
Breastfeeding shouldn’t hurt
Some find nipples slightly tender at
beginning of feed for few days but
usualy disappears in a few days
• Most causes of nipple soreness are
simple and avoidable
• Ensure all maternity staff know how to
help mothers get babies attached to
breasts
Ifbabies are well attached
Most mothers do not get sore nipples
18

35. Causes of sore nipple:
• Poor attachment
• Baby is pulled off breast to end feed
• Breast pump ( cause stretching of
nipple)
• Candida (from baby’s mouth) infection
of nipple
• Infant’s tongue tie causing friction on
nipple.

36. • Ask mother to describe what she feels:
—Pain at startof a feed that fades when
baby lets go, is most likely related to
attachment.
—Pain thatgets worseduring feed and
continues afterfeed has finished, often
describe as burning/stabbing ismore
likely caused by Candida Albicans.

37. • Look at nipples and breast
— Broken skin is usually caused by poor attachment.
— Skinisred, shiny,itchy, flaky withloss
pigmentation often seen with Candida.
— Candida and trauma from poor attachment can
exists together.
— nipple can have eczema, dermatitis and other
skin condition.

38. Observationandhistorytaking forsorenipples
• Observe a complete breastfeeding
• Check how the baby :
—goes tobreast
—Attachment
—Suckling
—Notice how mother ends feed
—Observe what nipples look like at end
of feed
22

39. ManagementofSoreNipples
Reassurance
sore nipples can be healed and prevented in
future
Treat cause ofsore nipples
Suggest comfort measures while nipplehealing
TreatCause:
•
•
Help mother to improve attachment and positioning
Show mother how to feed in different feeding
position
Treat Candida both on mother and baby
If baby had tongue tie –refer for treatment
•
•
23

40. • .
24

41. Suggestcomfortmeasures
While nipples are healing:-
• Apply expressed breast milk tonipples
after feed.
• Begin each breastfeed on least sore
nipple
• Gently remove baby if baby begin to fall
asleep at breast.
• Wash nipples only once a day.
• Avoid using soap on nipples, as it
removes natural oils.

42. Whatdonothelp
DO NOTstop breastfeeding torest
nipple.
DO NOTlimit frequency or lengthof
breastfeeds.
DO NOTapply any substancesto
nipple.
DO NOTuse nipple shield.

43. Engorged breast

44. COMMONBREASTPROBLEMS
1. Breast engorgement
2.Block duct and mastitis
3. Breast abscess
4.Candidiasis

45. UNICEFC-107-19
BreastEngorgement
12/3

46. Fullbreasts
• NORMAL 48/72 hours
after birth.
• Warm, full andheavy.
•Milk flowing.
• Fever uncommon.
•For the next 10 to 14days
breast fullness often
occurs BEFOREa feed.
Engorgedbreasts
• PATHOLOGICAL
•can occur any time during
breastfeeding.
• Painful, Oedematous.
• Hot andhard.
•Tight and flat especiallynipple
area.
• Shinyand may look red.
• Milk NOTflowing.
• Fever may occur.
•**FIL (FeedbackInhibitor of
Lactation) may causedecrease
in milk supply if engorgement
continues.

47. Causes and Prevention of Breast
Engorgement
•CAUSES
• Plenty of milk.
• Delay starting to
breastfeed.
• Poor attachment to
breast.
•Infrequent removalof
milk.
•Restriction on the
length of feeds.
PREVENTION
• Start breastfeedingsoon
after delivery.
• Ensuregood attachment.
•Encourage unrestricted
BF(feeding day and night with
long duration of feeds).
• Expressin between feeds

48. Management of Breast Engorgement
• If the baby able tosuckle
• If the baby notable to
suckle
• Before feed
(to stimulateoxytocin
reflex)
• After feed
(to reduceoedema)
•Feedfrequently, help with
positioning
• Express milk
• Warm compress or warm
shower.
• Massageneck and back.
• Light massageof breast
• Help mother to relax
• Provide supportive
atmosphere.
• Cold compress on breasts.

49. RELIEFOF ENGORGEMENT
• Removing milk from breast willrelieve
engorgement.
• This will:
• Relieve mother’s discomfort.
• Prevent mastitis and abscessformation.
• Help to ensure continued production of milk.
• Enable baby to receive breastmilk.

50. Blocked milkducts and Mastitis

51. Symptoms of blocked duct and
mastitis
blocked duct milk stasis
non-infective
mastitis
infective
mastitis
• Lump
• Tender
• Localised redness
• No fever
• Feels well
• Hard area
• Feels pain
• Red area
• Fever
• Feels ill
Progresses to
SYMPTOMSOF BLOCKED DUCT AND
MASTITIS

52. MANAGEMENT OF BLOCKED DUCTS,
MASTITIS
Assessment
• important part of treatment is to improve
drainage of milk from affected part of
breast
—Observe a breastfeed
—Notice if her breasts are very heavy
—Ask about frequency of feeds
—Ask about pressure from tight clothes

53. • Explain to mother that she MUSTRemovemilkfrequently
•
•
•
Continue breastfeeding frequently
Check that baby iswellattached
Gently massage blocked or tender area down towards
nipple before and during feeds.
Apply warm cloth to area before feed.
Check that her bra does not have a tight fit.
•
•
38

54. Treatment
• Explain to mother thatshe MUST:
—Rest with baby so that baby can feed often
—Drink plenty of fluids
—Express milk if baby unwilling to feed
frequently
• Infrequent removal >>engorgement
>>abscess
REST THE MOTHER,
NOT THE BREASTS

55. Drugtreatment for Mastitis
• Anti-inflammatory treatment
- Ibuprofen
- Or mild analgesia
Antibiotic therapy isindicated if:
fever for 24 hours ormore
evidence of possible infection eg infected
cracked nipple
symptoms do not subside within 24 hours of
frequent and effective feeding/milk expression
condition worsens
Course of10to14days toavoid relapse

56. BREASTABSCESS
A collection of pus forms in part of breast.
May result fr untreated mastitis
painful swelling
Needs surgical incision ( I&D ) andantibiotic
Continue breastfeedingif
incision far from areola and does not interfere BF
mother tolerate pain
otherwise express milk from affected side
Continue BFfrom unaffected breast
Good management of mastitis should be
preventive

57. CANDIDAINFECTION
Can make skin sore, shiny, red and itchy
Often follow antibiotic use to treat
mastitis/other infections
May be due to/cause baby’s oral thrush
Describe burning/stinging pain which
continues after feed

58. Candida
©UNICEFC107-34
AreolaNipple

59. Oral Candidiasis

60. SIGNSAND TREATMENTFOR THRUSH
•Nystatincream100,000 IU/g
•Applytomother’slesions4x/day,after breastfeedand
• continuetill 7daysafter lesionhealed
Signs Treatment
• Skinlooks red, shinyand
flaky . Nipplesand
areola may lose
pigmentation/ look
normal /red
• Nipples remain sore
between feeds for
prolonged time despite
correct attachment.
• Nystatin suspension100,000
1U/ml:
• Apply 1 ml by dropperto
child’s mouth 4x/dayafter
breastfeed.

61. BARRIERS TO BREASTFEEDING
• Individual: Inadequate knowledge,
embarrassment, social , negative perceptions
• Interpersonal: Lack of support from partner
and family, perceived threat to father-child
bond
• Institutional: Return to work or school,
lack of workplace facilities, unsupportive
health care environments
• Community: discomfort about nursing in
public
• Policy: aggressive marketing by formula
companies

62. COUNSELLING

63. Non-verbal Communication
63
•KEEPyourhead level
•Removebarriers- desk/folders
•Payattention to mother -Avoid getting distracted
•Taketime without hurrying– don’t look at your watch
•Onlytouch in appropriate way (hand/arm)
•Don’t touchher breasts/baby without permission

64. 64
•
Askopen questions
Openquestionsusuallystart with "How?
What?When?Where? Why?"
•
•
•
Eg."How are you feeding your baby?“
Youneed to assessthesituation/difficulty
Askquestionsthat encouragesthe mother to
talk
Closequestionsdonot givemuch info
– Start with “Areyou?Didyou?Hasthe baby?
– Sometimessuggestthe “correct” answer

65. 65
Useresponsesandgestureswhichshow
interest to Encouragemother to talk
• Showwe are interested in what mother is
saying
• Useresponsessuch as
–
–
Nodding/smiling
Simpleresponseeg“Uh““Hmm”, “Goon…”
• Reflectbackwhat the mother issaying
– Canhelp clarify the mother’s statement
• Mix reflecting backwith otherresponses

66. Empathise
• Showyouunderstandher feelings
• Lookingat it from HERpoint ofview
• VsSympathy
• Emphatisewith her goodfeelingstoo, not
just bad feelings
• Findout how shefeelsabout the situation
• Askfor morefacts 12

67. 67
Avoidjudging words
• Judgingwordsinclude:right, wrong,well,
bad, good,problem
• Canmakeawoman feel
–
–
like sheis wrong
Somethingwrongwith the baby

68. 68
• Goodcommunicationskillshelp mother to feel
goodandconfident to carryout her decisions
• Tohelp her build confidence:Acceptwhat a
mother thinksandfeels Recogniseand
acknowledgewhat isright Givepractical help
Providerelevant information usingsuitable
language
Make oneor two suggestions.

69. Acceptwhat amother thinksand feels
69
•
•
•
•
Acceptancewithout disagreeing Does
not meanwe agreesheis right
Acceptwhat she issaying,
givecorrectinfo later
Helpsmother to trust youandencourages
her to continuethe conversation

70. 70
Recognizeandacknowledgewhatis right
• Recognizeandpraisewhat mother andbaby
are achieving
– Tell mother how well babyis attaching
– Point out how cleverthe babyisin
detachinghimselfafter feed

71. 71
Givepractical help
• Milk will flow better if motheris
comfortable
–
–
Offer another pillow
Offer to holdbabywhile shegoesto
wash
• May needclear practical help e.ghow to
expressmilk

72. Provide relevant information usingsuitable
language
72
•
•
•
Findout what sheneedsto knowat this
time
Usesuitable wordsthat mother
understands
Donot overwhelmher with information
Make suggestions,not COMMANDS
Provide choices and let her decide
Do not tell her what she should do
Limitsuggestionsto 1 or 2

73. Scenario..

74. Breastfeeding
Infant Health Benefits
• Allergies, eczema
• Urinary tract infections
• Inflammatory
bowel disease
• Diabetes, type 1
• Gastroenteritis
• Hodgkin's lymphoma
• Otitis media
• Haemophilus
influenzae
meningitis
• Necrotizing
enterocolitis.
• Pneumonia/lower respiratory
tract infection
• Respiratory syncytial
virus infection
• Sepsis
• Sudden infant death
syndrome .
• Provides
immunologic
protection while
the
infant’s immune
system is maturing