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Breast feeding

The sessions are arranged into seven modules. Each has a common theme.

Module 1:

Why breastfeeding is important

Observation of the breast

How breastfeeding works

Attachment to the breast

Positioning the baby at the breast

Module 2:

Communication skills

Assessing and observing a breastfeed

Taking a breastfeeding history

Module 3:

Expressing breast milk

Helping a mother to overcome breastfeeding difficulties: breast conditions Insufficient milk supply


Module 4:

Refusal to breastfeed and the crying baby

The baby with special needs

Module 5:

The International Code of Marketing of Breast milk Substitutes

Module 6:

Introduction to the Ten Steps to Successful Breastfeeding

The Baby Friendly Hospital Initiative and the implementation of the Ten Steps

Module 7:

Clinical Practice 1 : Listening & learning; Assessing a breastfeed

Clinical Practice 2: Positioning the baby at the breast; Building confidence and giving support.

Clinical Practice 3: Hand expression of breastmilk (optional)

Clinical Practice 4: The Ten Steps to Successful Breastfeeding (optional)

Breastfeeding Management: A Modular Course

Worksheets and additional information

At the end of some of the sessions, there is a worksheet and/or an additional information sheet relating to the sessions material.


At the end of several of the sessions is a list of references.

The following list provides a guide to the main books and other materials which are of most use to health professionals and other people interested in lactation management.

1 Successful Breastfeeding. Royal College of Midwives, Churchill Livingstone, 2nd Edition 1991. ISBN: 1-870822-01-3

2 Best Feeding. Renfrew M, Fisher C, Armes S, Celestial Arts, 1990. ISBN: 0- 889087-571-5

3 Breastfeediflg in Practice. Helsing E, Savage-King F, OUP 1985. ISBN: 0-19- 261485-1

4 The Politics of Breastfeeding. Palmer G, Pandora Press 1988. ISBN: 0-86358- 220-6

5 A Practical Guide to Breastfeeding. Riordan J. Jones & Bartlett 1991 . ISBN: 0- 86720-448-6

6 Infant Feeding — The Physiological Basis. Ed James Akre, Suppl. to Volume 67, 1989 of the Bulletin of the WHO. ISBN: 92-4-068670-3

7 The Breastfeeding Answer Book. La Leche League International 1992. ISBN: 0-912500-336

8 Breastfeeding and Human Lactation. Riordan J, Auerbach K. Jones & Bartlett 1993. ISBN. 0-86720-3439

9 Breastfeeding: A guide for the medical profession. Lawrence R. Mosby 4th edition 1994.

10 An Evaluation of Infant Growth. WHO Working Group on Infant Growth, Nutrition Unit, WHO, Geneva 19’

11 Breastfeeding A guide for midwives. Henschel D, Inch S. Books for Midwives Press 1996. ISBN: 1 898507 12 0

12 Protecting Infant Health: A health worker’s guide to the International Code of Marketing of Breast milk Substitutes. IBFAN Penang 1996. ISBN: 983 9075 01 2

13 Protecting, promoting and supporting breastfeeding: the special role of maternity services. A Joint WHO/UNICEF Statement, Geneva 1989. ISBN: 92 4 156130 0

14 Evidence for the Ten Steps to Successful Breastfeeding. CHD/WHO, Geneva, in production.

15 Hypoglycaemia of the Newborn: Review of the Literature. CHDNVHO, Geneva 1997.

16 Breastfeeding Special Care Babies. Lang S. Bailliere Tindall, London 1997. ISBN: 0-7020-2020-6

Other useful literature

1 Breastfeeding Abstracts. Published quarterly by La Leche League International. Obtained from the national organisation for a small annual subscription.

2 Breastfeeding Briefs. Published quarterly by GIFA, Box 157, 1211 Geneva 19, Switzerland at UNICEF n offices. A small subscription is charged.

Module 1

Session A

Why Breastfeeding is Important


At the end of this session, you should be able to:

Define the terms used to describe infant feeding.

Describe recommended infant feeding practices.

State the benefits of breast milk and breastfeeding, and the dangers of

artificial feeding.

Describe the main differences between breast milk and artificial milks.

Materials required Information Sheets 1— 5

Worksheet 1


A nation’s infant feeding practices have significant short and long term consequences for the health and wellbeing of its population. What these consequences are and the question of ‘why’ breastfeeding is important are evident from an examination of:

1 The benefits of breastfeeding and breast milk, and

2 The differences between breast milk and artificial milks, and the dangers of artificial feeding.

Breastfeeding defined

Before examining the benefits of breastfeeding or the composition of the milk, the term ‘breastfeeding’ needs to be defined.

This is not straightforward for it is a term which is often used imprecisely both verbally and in the literature. A more accurate definition can be achieved

by the use of various prefixes, e.g. exclusive, predominant, full, partial. ‘Exclusive’ breastfeeding, for example, can mean the baby feeding only from the

breast, but in some texts it can also include the use of expressed breast milk, in which case no distinction is made between breastfeeding and the giving of expressed breastmilk.

Is this an important difference to make? There is no easy answer to this because it depends upon the context in which the definitions are to be used.

Research is beginning to highlight some of the benefits to the baby of the ‘physical’ action of breastfeeding (e.g. a reduced incidence of otitis media in childhood). It may, therefore, be important in the future to distinguish between a baby feeding only from the breast and a baby receiving his mother’s own milk via an alternative method of feeding. It is apparent, therefore, that definitions can change as our levels of knowledge also change.

For the purposes of carrying out a hospital audit, and to ensure consistency in the terminology used throughout the BFHI programme, some precise definitions are required. The following 3 terms are currently used in the UNICEF assessment of hospitals for the BFHI award. These define and categorise the type of breastfeeding taking place at the time of discharge from a hospital. They are:

Exclusive breastfeeding:

a Nothing is given to the baby other than breastmilk, or

b Nothing is given to the baby apart from breastmilk and vitamins, mineral supplements or medicine (which are NOT given by bottle)


A baby who has been breastfed in the past or is still breastfeeding and is receiving anything in addition to breast milk (except vitamins, mineral supplements or medicine), such as plain water, dextrose water, fruit juice, tea or infant formula.

Bottle feeding:

Giving a baby any drink from a bottle, including expressed breast milk or a vitamin preparation.

Therefore using the BFH1 terminology some mothers may be both breastfeeding and bottle feeding at discharge, for example, in the case of a baby who has a cleft lip and palate. It is important that all carers working with mothers and babies should be using the same definitions, and know how the definitions are used for the purposes of the BEHI.

The terms used for the BFHI may still be too general in some situations. Therefore, it may be useful to break the ‘breastfeeding’ category into:

Predominant breastfeeding —Most of the baby’s feeds are at the breast but the baby also receives small amounts of water or water based drinks. Partial breast feeding — Only some of the baby’s feeds are at the breast and some are artificial feeds such as formula.

While these terms are not used in the BFHI assessment as measures of outcome at discharge, they may be useful in an audit which is examining the practices in a health facility up to the time of discharge or to define breastfeeding practice in the community, as they are important indicators of breastfeeding rates.

WHO recommendations for breastfeeding

It is evident from the following WHO recommendations that ‘exclusive’ breastfeeding is the main aim in the first few months of a baby’s life.

The following points summarise the present recommendations for feeding infants and young children.

Babies should have the opportunity of going to the breast within half an hour of birth. They should not have any food or drink before they start to breastfeed unless medically indicated.

Research carried out in Sweden indicates that a term healthy baby, when placed on the mother’s chest, is able to find the nipple and suckle without help in ‘attachment’. The time period varies according to each individual baby, but it may be longer than 1 hour.

Therefore, mothers should be given their babies to hold for an unlimited period with skin-to-skin contact within 30 minutes of delivery (or within 30 minutes of the mother being able to respond in the case of caesarian deliveries). They should be encouraged to initiate the first breastfeed as soon as the baby is receptive.

Babies should be exclusively breastfed for at least the first four and if possible six months of life and should not receive any other foods or drinks unless medically indicated

WHO recommends that a baby between 4-6 months of age should be given complementary foods only if he is not growing adequately or if he appears hungry despite adequate breastfeeding . Children above six months of age should receive complementary feed

Children should continue to breastfeed up to 2 years of age or beyond.

The benefits of breastfeeding

It is useful to consider the benefits of both breast milk and breastfeeding separately, because the benefits breastfeeding are more than simply the advantages of feeding a baby on breast milk. It is becoming evident that the physical action of breastfeeding has a long term role in child health. Moreover, breastfeeding to protect a mother’s health in several ways, and therefore benefit the whole family, emotionally and economically.

The benefits of breastfeeding to a baby

The action of breastfeeding helps to develop muscles which keep the eustachian tube open the effects of this are often not apparent until child is 5 to 7 years old

Possible effects on the clarity of speech.

Increased protection against dental caries, and possibly less malocclusion.

The benefits of breastmilk for a baby

It is nutritionally balanced to meet the baby’s needs

It is easily digested and efficiently used by the baby’s body

A reduced incidence of gastrointestinal and respiratory infections during the neonatal period

A lower incidence of otitis media

A lower incidence of juvenile onset diabetes

Recent research indicates that breastmilk given to a preterm baby may contain factors important in the development of the brain, central nervous system and sight

A reduced incidence of necrotising enterocolitis among preterm babies

Growth factors enhance the baby’s gut development and maturation

There is increasing evidence of other important benefits to the baby:

It is suggested that the incidence of some childhood cancers is reduced (Lymphoma and Hodgkin’s disease).

Certain allergic conditions may be less severe

Some studies show a lower incidence of sudden infant deaths

Benefits to the mother

There is increasing evidence of long term health benefits from breastfeeding to the mother. These include:

A reduction in the incidence of pre-menopausal breast cancer, and some forms of ovarian cancer

A lower incidence of hip fractures in women over the age of 65

A delay in the return of fertility

Short term benefits of breastfeeding for the mother

It helps the mother to lose weight naturally

Night feeds and travelling are made easier.

The psychological benefits of breastfeeding for both mothers and babies

It helps a mother and baby to form a close, loving relationship, which makes mothers feel deeply satisfied emotionally. Close contact immediately after delivery helps this relationship to develop. This process is called bonding, and refers to the development of close affectionate ties between a mother and her baby: skin-to-skin contact and breastfeeding are two activities which are thought to contribute to ‘bonding’. This would seem to suggest that a mother who bottle feeds, or the baby’s father are unable to ‘bond’ with the child to the same extent. This may or may not be true, but it is likely that the mother is ‘programmed’ through evolution to develop a special affectionate relationship through breastfeeding, (in other mammals oxytocin and prolactin are the principal hormones directing maternal behaviour), and by choosing not to breastfeed, a natural process may be poorly developed in humans. There may be other ways in which the father is ‘programmed’ to develop these ties and not by assuming the mother’s role through bottle feeding — for example, through physical play and contact

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 on breast milk in the first weeks of life perform better on intelligence tests in later childhood than children who are artificially fed.

Some of the social gains of breastfeeding

The cost of an adequate diet for the mother costs less than buying artificial formula to feed to a baby. The mother is able to feed her baby wherever and whenever required.


A mother’s milk is especially suited to her own baby. It is obviously more than simply a form of nutrition. It is also a living fluid, which protects a baby against infections.

Protection against infection

For the first year or so of life, a baby’s immune system is not fully developed, and cannot fight infections as well as an older child’s or adult’s. Breastfeeding is the natural way to protect against infection. This is because the breast milk contains white blood cells, and a number of anti-infective factors. It also contains antibodies against infections which the mother has had in the past, and against new infections she comes into contact with on a ‘day-to-day’ basis. This happens in the following way:

1 A mother becomes infected

2 white cells in her body become active, and make antibodies against the infection to protect her

3 Some of these white cells go to her breasts and make antibodies

4 These are secreted in her breast milk to protect her baby.

It is for this reason that a baby should not be separated from his mother when she has an infection, because her breast milk will protect him against it. This helps the baby to build up a ‘bank’ of antibodies for the future.

Artificial feeds, in contrast, contain no living cells, antibodies or live anti-infective factors. Some constituents of the lipids of artificial milk may have a chemical action against certain bacterial viruses, but they provide much less protection against infection than human breast milk

The main immunoglobulin in breast milk is gA — often called ‘secretory’ immunoglobulin A (sIgA). It is secreted within the breast into the milk, in response to the mother’s infections. This is different from other immunoglobulins (such as IgG) which are carried in the blood.

b The composition of breast milk

The composition of breast milk is not always the same.

It varies with:

The stage of lactation.

Colostrum is present before delivery and is produced in the first few days after delivery. thicker than breast milk and yellowish or clear in colour. After a few days, i.e. 24 — 72 hours a birth, the breasts start to secrete breast milk. The milk produced up to approximately 1 0 to 14 called ‘transitional milk’ and thereafter, is ‘mature breast milk’. The volume of milk steadily increases, and the breasts may feel full, hard heavy (this is sometimes referred to as the milk ‘coming-in’).

The time of day.

During the course of a breastfeed, from the beginning to the end of the feed.

Foremilk is the milk that is produced early in a feed which may look watery and bluish in colour. Hind milk is the milk that is produced later in a feed and looks denser and whiter. This part of the milk is particularly rich in fat and provides much of the energy of a breastfeed. ‘Fore’ and ‘hind’ milk do not suddenly appear. The fat levels in the milk gradually increase throughout the duration of the feed. These words therefore, describe the milk at either end of the process of milk production.

The extra fat in the hind milk provides much of the energy from a breastfeed. This is why it is important not to take a baby off the breast too quickly.

He should be allowed to continue until he has had all that he wants, so that he gets plenty of the fat-rich hindmilk.

Foremilk is produced in larger amounts, and it provides plenty of protein, lactose, and other nutrient. Because a baby gets large amounts of foremilk, he gets all the water that he needs from it. Babies do not need other additional fluids before they are 4-6 months old, even in a hot climate. If they satisfy their thirst on water supplements (or other fluids), they may take less breast milk. lt is important for a baby to have both foremilk and hind milk to get a complete ‘meal’, and all the water that he needs.

Mothers sometimes worry that their milk is ‘too thin’. Breastmilk is never ‘too thin’ and cannot be compared to the colour or consistency of other mammalian milks.


The following points illustrate the special properties of colostrum, and why it is important

Colostrum provides a high density and low volume feed in the first few days, ideal for the needs of the newborn infant.

It contains high levels of immunoglobulins, more antibodies and other anti-infective proteins than mature milk. This is part of the reason why colostrum is richer in protein than mature milk.

Colostrum contains more white blood cells than mature milk. These anti-infective proteins and white cells provide the first immunization against the diseases that a baby meets after delivery.

Colostrum has a mild purgative effect, which helps to clear the baby’s gut of meconium (the first rather dark stools). This clears bilirubin from the gut, and helps to prevent jaundice developing

Colostrum (and mature breast milk) contains growth factors, which help a baby’s immature intestine to develop after birth.

Colostrum is richer than mature milk in some vitamins — especially vitamin A which helps to reduce the severity of any infections the baby might have. It also has higher levels of Vitamin K than mature milk, though hind milk contains more Vitamin K than fore milk

So it is very important for babies to have colostrum for their first few feeds.

Colostrum is ready in the breasts when a baby is born. It is all that most babies need before the mature milk comes in. Therefore babies should not be given any drinks or foods before they start breastfeeding.

The constituents of milk

All mammalian milks contain water, fat, protein, carbohydrate, minerals and vitamins. The proportions of these nutrients vary in the different milks.

Human milk contains other important factors that are absent from artificial formulae, these include hormones, enzymes, growth factors, essential fatty acids, immunological and non-specific protective factors

Colostrum and mature breast milk contain many hormones and growth factors. The function of all of them is not certain. However, epidermal growth factor, which is present in both, has been shown to stimulate the growth and maturation of the intestinal villi. Undigested cow’s milk proteins can pass through the immature infant gut into the blood, and may cause intolerance and allergy to milk protein. Epidermal growth factor helps to prevent the absorption of large molecules by stimulating rapid development of the gut. This ‘seals’ the baby’s intestine, so that it is more difficult for proteins to be absorbed without being digested. Antibodies probably help to prevent the development of allergies by coating the intestinal mucosa and preventing the absorption of larger molecules, it may also help to prevent intolerance to other foods


Fat is the principle source of energy for infants and in human milk is very easily digested. This is because of the combined action of several lipases, the infant’s own lingual and gastric lipases and another found only in human milk, called bile salt stimulated lipase (BSSL). Some of the infants own lipases are poorly developed at term (eg pancreatic lipase) making the lingual lipases and BSSL of particular importance to the newborn infant

Human milk contains essential fatty acids in different proportions to those present in cows’ milk and includes some which are commonly absent in artificial formula. These essential fatty acids are needed for a baby’s.

growing brain and eyes, and for healthy blood vessels. There is evidence to suggest that preterm babies fed on artificial feeds, which lack these essential fatty acids, may have less satisfactory mental development and eyesight.


The protein in different milks varies in quality, as well as in quantity. It is an important nutrient, and it might be thought to be advantageous for a baby to receive large amounts of it. However, all other mammals grow faster than humans, so they need milk with a higher concentration of protein (humans have the slowest rate of growth and development). It is difficult for a human baby’s immature kidneys to excrete the extra waste from the protein in animal milks.

Much of the protein in cow’s milk is casein which, because of its molecular structure, forms thick, indigestible curds in a baby’s stomach. There is less casein in human milk, and its structure means that it forms softer curds which are easier to digest.

The soluble or whey proteins are also different. In human milk, much of the whey protein consists of anti - infective proteins, which help to protect a baby against infection Animal milks do not contain the same kinds of anti-infective protein and so do not protect human babies.

Babies fed on artificial formula may develop intolerance to protein from animal milks. They may develop diarrhoea, abdominal pain, rashes and other symptoms when they have feeds which contain the different kinds of protein. Babies who are fed animal milks or formula may be more likely than breastfed babies to develop allergies which may sometimes cause eczema and respiratory wheeze

The anti-infective proteins in human milk include lactoferrin (which binds with iron, and prevents the growth of bacteria which need iron) lysozymes (which kills bacteria), and antibodies (immunoglobulin, mostly gA). Other important anti-infective factors include the bifidus factor (which is thought to promote the growth of Lactobacillus bifidus. L. bacillus may inhibit the growth of harmful bacteria, and gives breastfed babies’ stools their yoghurty smell).

A baby may develop intolerance or allergy after only a few artificial feeds given in the first few days of life.


The sugar lactose is the main carbohydrate in milk, readily breaking down into glucose for immediate energy needs and galactose for liver storage to meet future energy needs. The lactose content of human milk is higher than in the milk of other mammals, reflecting the human baby’s needs for glucose as a source of energy for the brain.


Vitamins can be fat or water soluble. The fat soluble vitamins are A, D, E, and K. These may vary in breast milk. They are present in higher amounts in the fat rich hind milk. It is therefore very important to ensure that babies are able to feed for as long as they wish on the breast so that they get the hind milk.

The water soluble vitamins are the B complex, C an folic acid.

The breastmilk of a well nourished mother contains plenty of vitamin A, which is important for the babys sight and reduces the severity of infections. Breastmilk can supply much of the vitamin A that a child needs even in the second year of life. Health workers may recommend giving babies multi-vitamins from a very early age, to provide vitamin C. This may be necessary for artificially fed babies, but it is not necessary for breastfed babies.

If a mother consumes a balanced and a varied diet it will be rich in vitamins and then her breast milk will contain sufficient vitamins to meet all her infant’s needs. The only concern is for women on an impoverished diet, lacking fresh foods, or if they have to adhere to a certain specialised diet low in particular vitamins. Dietary recommendations for supplementing babies with vitamins are intended to embrace all those’ at risk groups, although for the majority of the healthy population they are not necessary.


The levels of sodium, calcium, phospherous and magnesium in breast milk are considered ideal for a term baby. While breast milk may contain significantly lower concentrations of minerals than formula m absorption may be more complete in breastfed babies because of the presence of specific transport factors in the milk.


Iron is important for formation of blood. Different milks contain similar very small amounts of iron. But there is an important difference. Babies switched too early to unmodified cows milk are at risk of anaemia. Breastmilk has a relatively low iron content but the iron is bound inside the lactoferrin molecule. This makes it inaccessible to pathogenic iron-seeking bacteria, which limits their proliferation. Also the iron is more ‘bio available’ to the infant. Formula has 5-6 times as much iron in it as breastmilk. lt is present as ‘free iron’ and not bound within another compound. Free iron has less bioavailability and supports the growth of iron-seeking bacteria. It is less well absorbed by the infant which may cause infections.

Exclusively breastfed babies do get enough iron, and they are protected against iron deficient anaemia until at least 6 months of age, and often longer.


Breast milk is water-rich. It also has a low electrolyte

concentration, which ensures sufficient free water is available to a baby even in very dry hot weather.

Other differences between breast and formula milks

Artificial formula milks are very different from breast milk, although the constituents have been added in quantities which are adjusted to make them approximate to those in breastmilk. Formula milks are made from a variety of products, including animal milks, soybean and vegetable oils. While they may be nutritionally comparable in broad terms, they are unable to duplicate the vast array of functional constituents that make breastmilk a living, interactive fluid. In the past, several problems have arisen from inappropriate amounts of some of the constituents in formulae.

The artificial formula milks currently used are different to those which were used in the past, and those which will be used in the future will be different to those which are used now. They will never be totally comparable to human breast milk. The faeces of an artificially fed baby are different from those of a breastfed baby. This is partly because an artificially fed baby’s faeces contain more unused food. Its reduced digestibility is responsible for prolonging the intervals between feeds. The faeces of a breastfed baby appear quite loose and may be passed at irregular intervals.

The dangers of artificial feeding

Artificial feeding can be defined as feeding a baby on artificial feeds, including formula milk, and not breastfeeding at all.

Artificial feeding is potentially harmful for children and their mothers. Breastfeeding is fundamental to child health and survival, and important for the health of women.

Several studies relate feeding methods to disease

The following points indicate the dangers of artificial feeding both to the mother and to her baby:

An artificially fed baby is more likely to become ill with diarrhoeal, respiratory, and other infections.

Diarrhoea may become persistent.

The risk of otitis media is increased, because the physical action of bottle feeding does not enhance the development of certain oral muscles to the same extent as breastfeeding.

In some parts of the world the baby may get too little milk and may become malnourished, because he gets too few feeds, or because the artificial feeds are too dilute.

An artificially fed baby is more likely to die from infections and malnutrition than a breastfed baby.

He is more likely to develop allergic conditions such as eczema and possibly asthma or to develop respiratory wheeze.

He may become intolerant of animal milk, developing diarrhoea, rashes and other symptoms.

The risk of some chronic diseases in the child, such as diabetes mellitus, is increased.

A baby may get too much artificial milk, and become overweight

He may not develop so well mentally, and may score lower on intelligence tests

Bottle fed babies have a higher body temperature than breastfed babies

A mother who does not breastfeed is more likely to become fertile again and can become pregnant more quickly.

She has a higher risk of developing cancer of the ovary and possibly premenopausal cancer of the breast.

Artificial feeding may interfere with bonding. The mother and baby may not develop such a close, loving relationship, because many people may be involved in the feeding of the baby, which makes it more difficult for the mother and baby really to get to know one another.

The Dundee study

In 1990 study took place in Dundee, in Scotland. It compares the prevalence of gastrointestinal disease at 13 weeks postpartum among infants who were partially and fully breastfed, when compared to those who were bottle fed. It was found that there was a significant reduction of gastrointestinal disease among the breastfed infants compared to the bottle-fed infants. This protection was observed to last beyond the period of breastfeeding. Follow-up studies in 1995 from this study show that this protection has continued into childhood.

A range of studies show that breastfeeding protects babies against other infections These studies consistently add to our knowledge of the benefits of breastfeeding and are a constant reminder that the benefits have a long term effect on the health of our nation.


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34 Klaus MH, Jerauld R, Kreger NC, McAlpine W, Steffa M, Kennell iH. Importance of the first post-partem days. New Enginl Med 1972. 286;9:400-462.

35 Kjellmer I Winberg J. The neurobiology of infant-parent interaction in the newborn: An introduction. In: The Neurobiology of Infant-Parent Interaction in the Newborn Period. An International Wenner-Gren Centre Symposium. (Eds) Winberg J, Kjellmar I. Acta Paediatr 1994. (Suppl 397) (All the articles in this supplement are relevant to the section on the psychological benefits of breastfeeding for both mothers and babies)

36 Christensson K, Cabrera T, Christensson E, Uvnas-Moberg K, Winberg i. Separation distress call in the human neonate in the absence of maternal body contact. Acta Paediatr 1995. 84:468-473.

37 Buranasin B. The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia-Pacific jnl Public Health 1991 . 5:3;21 7-220.

38 Filteau S, Tomkins A. Infant feeding and infectious disease. (Chapter 6) from: Infant Nutrition: Issues in Nutrition and Toxicology 2. Ed. Walker AF, Rolls BA. Pubi. Chapman & Hall London,1994.

39 Nathavitharana D, Catty D, McNeish AS. lgA Antibodies in human milk: epidemiological markers of previous infections? Arch Dis Child 1994. 71:F192-197.

40 Isaacs CE Kashyap S, Heird WC, Thormar H. Antiviral and antibacterial lipids in human milk and infant formula. Arch Dis Child 1990. 65:861-864.

41 Almroth S, Bidinger PD. No need for water supplementation for exclusively breast-fed infants under hot and arid conditions, Transactions for the Royal Society of Tropical Medicine and Hygiene 1 990, 84:602-604.

42 Martinez JC, Rea M, De Zoysa L. Breastfeeding in the first six months. No need for extra fluids. BMJ 1992. 304:1068-1069.

43 Ashraf RN, Zalil F, Aperia A, Lindblad BS. Additional water is not needed for healthy breastfed babies in a hot climate. Acta Paediatr 1993. 82:1007-1011.

44 De Carvalho M, Klaus MH, Merkatz RB. Frequency of breast-feeding and serum bilirubin, Am ml Dis Child 1982, 136:737-738.

45 von Kries R et al. Vitamin K deficiency in breast-fed infants. In: Goldman AS et al. Human Lactation 3. Effects on the recipient infant. New York. Plenum Press 1987.

46 Ichiba H, Kusada 5, Itagane Y, Fujita K, Issiki G. Measurement of growth promoting activity in human milk using a fetal small intestinal cell line. Biol Neon (Switzerland) 1992. 61:1;47-53.

47 Smith U, Kaminsky 5, D’Souza SW. Neonatal Fat Digestion and Lingual Lipase. Acta Paediatr Scand 1986. 75:913 918.

48 Neuringer M. Cerebral Cortex docosahexaenoic acid is lower in formula-fed than in breast-fed infants. Nutrition Reviews 1993. 51;8:238-241.

49 Forsyth JS. The relationship between breastfeeding and infant health and development. In: Proceeding of the nutrition society 1 995. 54:407-418.

50 Burr ML, Limb SE, Maguire Mi, Amarah L, et al. Infant Feeding, Wheezing and allergy: a prospective studyArch Disd Child 1993. 68:724-728.

51 Barclay SM, Lloyd Di, Duffy P, Aggett Pi. Iron Supplements for preterm or low birthweight infants. Arch Dis 1989. 64:1621-1628.

52 Minchin M. Infant Formula: A Mass, Uncontrolled trial in Perinatal Care. Birth 1987. 14:1;25-35.

53 Sievers E, Oldigo HD, Schulz-Lell G, Schaub J. Fecal excretion in infants. Eur jnl Pediatr 1993. 152:454

54 Pisacane A, Impagliazzo N, Russo M, Valiani R, Florio C, Vivo P. Breast feeding and multiple s Brit Med Jnl 1994. 308:1411-1412.

55 Pisacane A, Grazano L, Mazzearella G, Scarpellin G. Breast-feeding and urinary tract infection. Jnl Pediatr 1992. 120:1;87-89.

56 Cunningham AS, Jelliffe DB, Jelliffe EFP. Breast feeding and health in the 1980s: A global epidemiological re’ Pediatr 1991. 118:659-666.

57 Working group on cows’ milk protein and Diabetes Mellitus (American Academy of Pediatric Infant practices and their relationship to the etiology of diabetes Mellitus. Pediatrics 1 994. 94;5:752-754.

58 Lucas A Lockton 5, Davies P. Randomised trial a to-feed compared with powdered formula. Arch Dis Child 1992.

59 Rogan WJ, Gladen BC. Breast-feeding and cognitive development. Early Hum Devel 1993. 31:181-193

60 Garza C, Butte NE Energy intakes of human milk fed infants during the first year. jnl Pediatr 1990. 117; 2 5124-5131.

61 Victoria CG, Fuchs SC, Flores AJC, Fonseca W, B. Risk factors for pneumonia among children Brazilian metropolitan area. Pediatrics 1994. 9985.

62 Aniaasson G, AIm B, Andersson B et al. A prospective cohort study on breastfeeding and otitis media in Sweden infants. Pediatr lnfect Dis Jnl 1994. 13:183-188.

Terms for infant feeding

Full breastfeeding:

Full breastfeeding means breastfeeding either exclusively or predominantly.

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.

Partial breastfeeding:

Partial breastfeeding means giving a baby some breastfeeds, and some artificial feeds, either milk or cereal, or other food.

Bottle feeding:

Bottle feeding means feeding a baby from a bottle, whatever is in the bottle, including expressed breast milk.

Artificial feeding:

Artificial feeding means feeding a baby on artificial feeds, and not breastfeeding at all.

From: Breastfeeding Counselling: A Training Course. WHO/UNICEF 1993.

Module 1

Session B

Observation of the breast


At the end of this session, you should be ; able to: Recognise the normal appearance of the breast during pregnancy, in the first few

days after delivery and after breastfeeding has become established.

Recognise any abnormal features of the lactating breast

Worksheet 2


It is useful to consider the appearance of the normal breast at different stages of lactation.

Using the following headings, make a list of the normal observations which may be made. Make a separate list of any abnormal observations which may be made:

In the antenatal period

In the first few days after delivery

After breastfeeding has been established

When you have completed this exercise, check your answers with those on the following page.

Your lists should contain the following normal observations:

The antenatal period

The appearance of Montgomery’s tubercles.

Increased pigmentation of the areola

The size and shape of the nipple and areola may alter

The breasts may become larger, changing their size and shape

Striae (stretch marks)

Marbling (visible veins)

Colostrum may leak from either breast

In the first few days after delivery

The breasts may become fuller and firmer so

altering the size and shape of the breasts again



Colostrum/milk may drip from either breast

Protractility of the nipple may be enhanced

Flat, inverted nipples may be more apparent

After breastfeeding has become established

The breasts look softer

Milk may leak from the breasts

Abnormal or unusual observations during these periods


Scars from breast surgery, e.g. if the mother has had an abscess previously, breast reduction, cosmetic surgery, implants, lumpectomy (some of these will indicate that she has had breast or lactation problems in the past)

Any obvious swellings and lumps

Fissures (sometimes called cracks) on the nipple or areola

Redness, suggesting inflammation or possible infection

Traumatised nipples

Auxilliary nipple

Pierced or tattooed nipples or breasts

Important point:

It is not necessary to examine the breasts routinely antenatally or postnatally unless a potential breast problem is suspected, or if the woman is worried about her breasts.

Module 1

Session C

How breastfeeding works


At the end of this session, you will be able to:

Name the main parts of the breast, and describe their function.

Describe the hormonal control of breast- milk production and ejection.

Materials required

Worksheet 3


This session describes the anatomy and physiology of breastfeeding. This is important in understanding how best to help a mother attach her baby to her breast.

Understanding how breastfeeding works means that any problems of attachment (and many other problems) can be recognised and the mother helped to overcome them.

Anatomy of the breast

The breasts are secretory glands whose primary role is to provide the source of a baby’s nourishment, their size is unrelated to the amount of milk they can produce.

The areola is the darker area surrounding the nipple which contains small glands called Montgomery’s glands. These secrete an oily fluid to keep the skin healthy. The oily secretions may be the source of the mother’s characteristic scent which helps the baby recognise its own mother

Inside the breast are 1 5-25 lobes of glandular tissue surrounded by supportive tissue. It is the fat and supportive tissue which gives the breasts their shape, and which makes most of the difference between small and large breasts.). These lobes contain alveoli — minute sacs of milk-secreting cells around a lumen; they are clustered together in microscopic grape-like bunches emptying into a ductal system. A hormone called prolactin makes these cells produce milk. Not all lobes are equally productive in each lactation or for the duration of the lactation.

Around the alveoli are networks of tiny thread-like myoepithelial or muscle cells which contract and make the milk flow. A hormone called oxytocin makes these muscle cells contract.

Small ducts carry the milk from the alveoli, they merge into a smaller number of larger distensible ducts usually referred to as lactiferous sinuses. This is where milk collects due to the action of oxytocin, and from where it is removed by the baby’s suckling. The ducts then become narrower and merge terminating in 10-15 openings at the nipple surface.

Sensory impulses pass from the nipple to the brain.

In response, the anterior part of the pituitary gland at the base of the brain secretes prolactin.

Prolactin is transported in the blood to the breast, where it directs the milk secreting cells to produce milk.

Prolactin levels in the blood remain high for up to 90 minutes after the feed — and make the breast produce milk for the NEXT feed. For this feed, the baby takes the milk already synthesised and stored in the breast.

Therefore if a baby suckles more, the mother’s breasts will make more milk.

Most women can produce more milk than their babies need or take. If a mother has twins, and both suckle, her breasts will make enough milk for both babies. Most mothers can produce enough milk for at least two babies, and may also be able to feed triplets.

If a baby suckles less, her breasts make less milk. If a baby stops suckling, the breasts soon stop making milk.

The following points are important for the mother to know:

Prolactin levels are higher at night, and a breast feed given at night causes a greater prolactin surge than the one given during the day — therefore nightfeeding is important for keeping up the milk supply.

Prolactin makes a mother feel relaxed and sometimes sleepy, so she will usually rest well after feeding at night.

Another hormone, Gonadotrophin Releasing Hormone — GnRH has been identified as the trigger responsible for directing ovulation and the menstrual cycle. Suckling (possibly via prolactin release) supresses GnRH release and so in ovulation, thereby, delaying a new pregnancy. the mechanism of fertility control can be reliable for up to six months post-partem - if the baby is fully breastfeeding on demand, and menstruation has not returned. The maintenance of breastfeeds at night with no intervals longer than 6 hours has been shown to be important for sustaining lactation and infertility.

b The Oxytocin Reflex or ‘Let-down Reflex’

Works before or during a feed to make milk flow.

Sensory impulses go from the nipple to the brain.

In response, the posterior part of the pituitary gland at the base of the brain secretes the hormone oxytocin.

The oxytocin is carried to the breast in the blood and makes the myo-epithelial cells around the alveoli contract.

This makes the milk which has collected in the alveoli flow along the ducts to the lactiferous sinuses.

Oxytocin also makes myoepithelial cells in the walls of the ducts contract which opens the ducts and helps milk flow easily.

Sometimes the milk is spontaneously ejected from the nipple. This is the ‘oxytocin reflex’ or ‘milk ejection reflex’.

Oxytocin is produced more quickly than prolactin. It makes the milk stored in the breast flow for this feed. This is an unconditioned response to suckling.

Oxytocin can start working before a baby suckles, when a mother learns to anticipate a feed. This is an example of a conditioned response.

If the oxytocin reflex does not work well, the baby may only receive a proportion of the milk available. It may seem that the breasts have stopped producing milk, when it is more a case that the milk is not flowing out.

Oxytocin also causes a mother’s uterus to contract after delivery. This helps to reduce bleeding, but sometimes causes uterine pain and a rush of blood during a feed in the first few days. The pains can be quite strong — they are called ‘after-pains’ and are more common in multiparous women.

There is a suggestion that dopamine may be involved in the mechanism of oxytocin release This possibly explains why mothers feel sleepy after a breastfeed and may also be able to go back to sleep easily at night

Helping and Hindering The Oxytocin Reflex

The oxytocin reflex is easily affected by a mother’s thoughts, feelings and sensations. Positive feelings, such as feeling pleased with the baby, thinking lovingly, and feeling confident that her milk is best for him, helps the oxytocin reflex to work and the milk to flow.

Sensations such as:


Seeing her baby

Hearing him cry

Can also help the reflex.

This means it is important to consider a mother’s feelings and her self-confidence. DO NOT say things which make her worry or doubt her milk supply.

Negative feelings, such as:

Pain, soreness

Worry, anxiety, stress

Doubt that she has enough milk

Can all hinder the reflex and stop the milk flow. This effect is usually temporary.

A mother should have her baby near her all the time, so that she can see and touch and respond to him. This helps her body to prepare for a breastfeed, and it helps the breastmilk to flow. If a mother is separated from her baby between feeds, her oxytocin reflex may not work so easily. Therefore, rooming-in is very important.

Positive signs and sensations of the oxytocin reflex

A mother is often aware of the following:

A squeezing or tingling sensation in her breasts just before feeding or during a feed.

Milk leaking from breasts when she thinks of her baby, or hears him crying, Milk leaking from the other breast, when her baby is suckling, Milk flowing from her breasts in fine streams if her baby suddenly comes off the breast during a feed, Pain from uterine contractions, sometimes with a rush of blood, during feeds in the first week after delivery,

Slow deep sucks and swallowing by the baby, showing breast milk is flowing into his mouth.

If any of these signs or sensations are present, then a mother can be sure that her oxytocin reflex is active, and that her breastmilk is flowing. However, even if her reflex is functioning, she may not always feel the sensations, and the signs may not be obvious.

In addition to the signs and sensations listed a mother may sometimes report feeling thirsty, though it is not clear if this is related to oxytocin.

d The inhibitor in breastmilk.

Breastmilk production is controlled not only by hormones centrally released from the pituitary, but possibly also within the breast itself.

Sometimes one breast may stop making milk, while the other breast continues to do so, although the central hormones oxytocin and prolactin go equally to both breasts. It is thought that this is because, in addition to its hormonal control, milk secretion is controlled locally in each breast.

Breastmilk contains a protein which can reduce or inhibit milk secretion. If the breast contains a lot of milk, this inhibitor may build up, and slow down further milk production. This would protect the breast from the harmful effects of being too full. Conversely, if breast milk is removed, by suckling or expression, the level of the inhibitor in milk may fall, so that the breast makes more milk. Thus, frequent suckling removes the inhibitor, speeding up milk secretion. In the same way, if suckling is infrequent, or the baby leaves milk in the breast, the inhibitor may accumulate, slowing down milk secretion.

This may explain why:

If a baby prefers one breast, it makes more milk than the other breast.

If a mother suckles her baby often, or the baby takes most of the milk at each feed, that breast makes more milk.

It may also explain why:

For a breast to continue to make milk, the milk must be removed frequently and as completely as possible.

If a baby cannot suckle from one or both breasts, the breast milk must be removed by expression to enable production to continue.

Various names have been given to the ‘inhibitor’. Therefore, in the literature you may see it referred to as: the feedback inhibitor of lactation (FIL), an inhibitory factor, or an autocrine factor. The correct name is the ‘Feedback Inhibitor of Lactation’.

Important point:

It is important for a mother to eat and drink sufficient amounts, but these activities do not help her produce milk if her baby does not suckle. For a mother to produce enough milk, her baby must suckle often enough, and he must also suckle in the correct way.


1 Porter RH, Makin JW, Davis LB, Christensen K Breast-fed infants respond to olfactory cues from their own mother and unfamiliar lactating females.Infant Behav Dev 1992. 15:86-93.

2 Infant Feeding: The Physiological Basis. Ed by James ,A.Suppl to Vol 67 of Bulletin, 1989, WHO. Ch 2 pp 20.

3 Noel GL, Suh HK, Fnantz AG. Prolactin release during nursing and breast stimulation in postpartum and nonpostpartum subjects. jnl Clin Endocrinol 1974


4 Howie PW. A new Understanding. Midwives chronicle and Nursing Notes, July 1985. 184-192.

5 Riordan J. Anatomy and physiology of lactation, chapter 4, from ‘Breastfeeding and Human Lactation Riordan and Aurbach KG, Publ, Jones & Bartlett Publishers London 1993.

6 McNeilly AS, Glasier AF, Howie PW, et al. Fertility after childbirth: pregnancy associated with breastfeeding. Endocrinol 1983. 18:167.

7 Clark G, Lincoln DW, et al. Dopaminergic control of Oxytocin Release in Lactating Rats. jnl of Endocrinol 83: 409-420.

8 Royal College of Midwives. Successful Breast feeding From Chapter 4 — ‘Factors which have been shown to help’, pp 33. Publishers, Churchill Livingstone.

a This section has been contributed by Dr Cohn Wilde. See also: Wilde CJ, Prentice A, Peaker M. Breast-feeding: matching supply with demand in human lactation. Proceedings of the Nutrition Society (1995), 54:401-406.

Attachment to the breast


At the end of this session, you will be able to:

Describe the difference between good and poor attachment of a baby at the breast.

Describe the difference between effective and ineffective suckling.

Materials required

Worksheet 4


Having looked at how breastfeeding works it is now possible to relate it to the mechanics of breastfeeding.

He has taken much of the areola and the underlying tissues into his mouth.

The lactiferous sinuses are included in these underlying tissues.

He has stretched the breast tissue out to form a long ‘teat’.

The nipple forms only about one-third of the ‘teat’. The baby is suckling from the breast, not the nipple.

Notice the position of the baby’s tongue:

His tongue is forward, over his lower gums, and beneath the lactiferous sinuses.

His tongue is in fact cupped round the ‘teat’ of breast tissue. This cannot be seen in the drawing, though it may be observed when a baby is feeding at the breast.

If a baby takes the breast into his mouth in this way, he can suckle correctly and is well attached to the breast.

This diagram shows what happens to the baby’s tongue when he suckles.

This shows a ‘wave’ going along the baby’s tongue from the front to the back. The ‘wave’ presses the ‘teat’ of breast tissue against the baby’s hard palate. This presses milk out of the lactiferous sinuses into the baby’s mouth, from where he swallows it.

A baby does not suck milk out of a breast, as if he was drinking through a straw — Instead:

He uses suction to pull out the breast tissue to form a teat, and to hold the breast tissue in his mouth.

The oxytocin reflex makes breast milk flow to the lactiferous sinuses.

The action of his tongue presses the milk from the lactiferous sinuses into his mouth.

When a baby suckles in this way, his mouth and tongue do not damage the skin of the breast and nipple.

Good and poor breast attachment

In this diagram, good and poor attachment at the breast can be seen

In picture 2 only the nipple is in the baby’s mouth, not the underlying breast tissue.

The lactiferous sinuses are outside the baby’s mouth, where his tongue cannot reach them. It is back inside his mouth.

The baby in picture 2 is poorly attached. He is ‘nipple sucking’.

These pictures shows what may be observed when watching a baby breastfeed.

In picture one

More of the areola can be seen above his mouth than below. (This shows that he is reaching with his tongue under the lactiferous sinuses to press out the milk).

His mouth is wide open.

His lower lip is turned outwards.

The baby’s chin touches the breast.

These are the four key signs which can be observed and indicate that a baby is well attached to the breast.

In picture 2:

The same amount of areola can be seen above and below his mouth, which shows that he is not reaching the lactiferous sinuses.

His mouth is not wide open, and it points forwards.

His lower lip is not turned outwards.

The baby’s chin does not touch the breast.

These are some of the signs which can be seen and indicate that a baby is poorly attached to the breast.

Important point

Seeing a lot of areola is not a reliable sign of poor attachment. Some mothers have a very large areola much of which is visible even when the baby is well attached. It is more reliable to compare how much areola you see above and below a baby’s mouth.

Results of poor breast attachment

If a baby is poorly attached, and he ‘nipple sucks’, it is painful for his mother. Poor attachment is the most important cause of sore nipples. As the baby sucks hard to try to get milk, he pulls the nipple in and out. This makes the skin of the nipple rub against his mouth. If a baby continues to suck in this way, he can damage the delicate tissue of this area and cause cracks. Suction on the tip of the nipple can cause a crack across the tip. Rubbing the skin at the base of the nipple can cause a crack around the base.

If a baby is poorly attached, he does not remove breast milk effectively, with the following results:

The breasts may become engorged.

The baby may be unsatisfied, because the breast milk comes slowly.

He may cry a lot, and want to feed often, or for a very long time at each feed.

The baby may not get enough breast milk. He may fail to gain weight.

He may be so frustrated that he refuses to feed altogether.

If the oxytocin reflex works well, he may get enough breast milk at least for a few weeks, by feeding very often. But it can exhaust his mother.

The breasts may make less milk, because the milk is not removed.

Poor attachment can make it SEEM as though a mother is not producing enough milk. In other words she has an apparent poor milk supply. Then, if the situation continues, her breasts may really make less milk. In either situation, the result may be poor weight gain in her baby and breastfeeding failure.

A baby who is suckling effectively may not want to feed very often, though the interval between feeds may be irregular. If a baby wants to feed more than about every 1—1 ½ hours it is likely that he either not well attached, or that he is having very short feeds, so that he is not removing much milk. Increased frequency of suckling will not make more milk for him until the other conditions are corrected.

The point about frequent suckling being a result ineffective suckling may seem to contradict what was stated about ‘more suckling makes more milk’ . More suckling makes more milk if a baby is well attached, and allowed to finish a feed, so that he removes the milk. In this case if he suckles more often, the breasts will make more milk.

The causes of poor breast attachment

The common causes of poor attachment to the breast are:

(i) Use of a feeding bottle.

If a baby feeds from a bottle before breastfeeding is established, he may have difficulty suckling effectively. Some babies who start bottle feeds after a few weeks may also begin to suckle ineffectively.

The action of sucking from a bottle is different suckling at the breast. Babies who have had some bottle feeds may try to suck on the breast as if it were bottle, and this makes them ‘nipple suck’ . When this happens, it is sometimes called ‘sucking confusion" or ‘nipple confusion’ . So giving bottle feeds can interfer with breastfeeding (similarly giving dummies or pacifier can also encourage an inappropiate sucking action).

(ii) An inexperienced mother.

If a mother has not had a baby before, or if she bottle fed or had difficulties breastfeeding previous babies she may have difficulty getting her baby well attached to her breast (however, even mothers who have previously breastfed successfully sometimes have difficulties.)

(iii) Functional difficulty.

Some situations can make it more difficult for a baby attach well to the breast.

For example:

If a baby is very small or weak;

If a mother’s nipples and the underlying tissue is poorly protractile (difficult to stretch out to ‘teat’).

If her breasts are engorged;

If there has been a delay in starting to breastfeed. Mothers and babies can breastfeed in all these situations, but they may need extra skilled help to succeed.

(iv) Lack of skilled support.

A very important cause of poor attachment is lack of skilled help and support.

Some women are isolated, and lack support from the community. They may lack help from experienced women such as their own mothers; or from traditional birth attendants, who often are very skilled at helping with breastfeeding.

Women in ‘bottle feeding’ cultures may be unfamiliar with how a breastfeeding mother holds and feeds her baby. They may never have seen a baby breastfeeding.

Health workers who look after mothers and babies, for example doctors and midwives, may have received no practical training to help mothers to breastfeed.

A baby has three main reflexes which are important to successful breastfeeding — the rooting reflex, the sucking reflex, and the swallowing reflex.

When something touches a baby’s lips or cheek, he opens his mouth and may turn his head to find it. He puts his tongue down and forward. This is the ‘rooting’ reflex. It should normally be the breast that he is ‘rooting’ for. This reflex is usually present from approximately 32 weeks gestation or post-conception age.

When a nipple or bottle teat touches the baby’s palate, he starts to suck it, and when his mouth fills with milk, he swallows. These reflexes happen automatically in a term healthy baby, without him having to learn them. The action of swallowing has been observed in the fetus from approximately 11 to 16 weeks gestation and sucking from between 18 to 24 weeks Therefore in a baby these reflexes are quite mature at the time of birth and are usually coordinated well enough for successful feeding to take place within a very short time of birth. It has been shown that a baby placed on his mother’s chest at birth can find the nipple and areola by himself, and begin to suckle within approximately 1 hour

But there are some things that a mother and baby have to learn. A mother has to learn how to hold her breast and position her baby, so that he can attach well. A baby has to learn how to take the breast into his mouth to suckle effectively. Many mothers and babies do this easily. But some may need help.


1 McBride MC, Danner SC. Sucking Disorders in Neurologically Impaired Infants: Assessment and Facilitation of Breastfeeding — from: Clinics in

Perinatology, March 1 987, ‘Breastfeeding’ 14: 1 ; 109-130.

2 Lebenthal E, Heitlinger L, Milla P J. Prenatal and Perinatal

Development of the Gastrointestinal Tract, from ‘Harries

Paediatric Gastroenterology’, Edited by Milla Pi, Muller

DPR, Publ. Churchill Livingstone; 1988 2nd Ed. Ch.1.

3 Widstrom A-M, Thingstrom-Pausson J. The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle. Acta Paediatr Scand 1993. 82:281 - 283.

Additional references

1 Woolridge MW. The anatomy of infant sucking. Midwifery

1986. 2:164-171

2 Widstrom A-M, Ransjo-Arvidson A-B, Christensson K,

Matthiesen A-S, Winberg J, Uvnas-Moberg K.

Gastric suction in healthy newborn infants. Acta Paediatr

Scand 1987. 76:566-572.

3 Righard L, Alade Mo. Sucking technique and its effect on success of breastfeeding. Birth 1992. 19:185-189.

Assessing a Breastfeed - Attachment

The two pictures below show good and poor attachment.

Read each statement and decide whether it is a sign of good or poor attachment.

Good attachment

Poor attachment

a The babys chin is touching the breast

b The baby’s lower lip turns in

c The baby’s lower lip is turned outwards

d The baby’s mouth is wide open

e There is more areola above the upper lip that below it

Some signs cannot be seen in pictures — only at the time the baby is breastfeeding. Which of the following would apply to the babies above?

g The baby takes quick, small sucks

h The mother feels nipple pain

i The baby’s cheeks are pulled in.

j You can hear or see the baby swallowing

k The baby is relaxed and happy and releases the breast at the end of the feed.

Positioning the baby at the breast


Help a mother to position her baby correctly at the breast so that he is well attached and can suckle effectively.

Suggest alternative positions for mothers and babies.

The position of the baby at the breast is of paramount importance to the success of breastfeeding and to the prevention of potential problems, both to the mother and to her baby.

Mothers who need help

There are several groups of mothers who may need to be helped with breastfeeding.

First time mothers

Mothers who currently have difficulty with breastfeeding

Mothers who were previously unsuccessful.

Mothers who previously bottle fed but now want to breastfeed

Mothers with special needs (e.g. disabled or blind)

Mothers of babies with special needs .

Mothers with multiple births

All mothers have the same basic needs when preparing for a breastfeed:

They must be comfortable,

They need to wear appropriate clothing,

They need ready access to items which ensure their

personal comfort, e.g. a drink, They need to have any pillows/small blankets/towels necessary for support of the baby within easy reach

The key points to positioning and attachment of the baby

There are four key points which apply to all mothers, when positioning and attaching their babies to the breast.

1 The baby’s head and body should be in a

straight line.

A baby cannot suckle or swallow easily if his head is

twisted or bent.

2 His mouth should face the breast, with his top lip opposite the nipple.

The baby’s whole body should almost face his mother’s body.

3 His mother should hold his body close to hers.

4 If her baby is newborn, she should support his whole body, and not just his head and shoulders.

(These four key points are on the B-R-E-A-S-T-feed Observation Form under ‘Body Position’ see session 2B).

Positioning a baby at the breast

There are four main ways of positioning a baby for a breastfeed which are illustrated in the following pictures.

The first mother is holding her baby in the most commonly used position for:

A term, healthy baby, Twins.

The second mother is holding her baby in an underarm position, where the baby is held secure by the mother’s forearm and elbow.

This position is useful for:

Very small and preterm babies, Twins, A sick, weak baby of any size, If the mother has had difficulty in attaching her baby to the breast, Clearing a blocked lobe, After a Caesarian section.

The third mother is holding her baby with the opposite the breast from which her baby is suckling. Her hand is supporting his head. This is a very helpful position for:

Weak babies Small and preterm babies.

The fourth mother is laying down on her back or

on her side using a position which allows her to rest

while breastfeeding. It is a particularly valuable position for:

A mother who has had a Caesarian section

A mother who is uncomfortable because of

vaginal or vulval stitches, or from perineal


A mother who is unwell,

A mother with a disability.

Babies who also benefit from this position include.

Those with oral defects, such as cleft-lip palate, Babies who need frequent feeds at night.

Although the different positions are themselves to the particular situations already mentioned, any one of them may be used by a who finds it suits her best.

A mother who has had a Caesarian section may

following sequence of positions for breastfeeding

For the first 24 hours, lying on her back with baby across her chest;

For the second 24 hours, turning on to her side with her baby on his side facing her.

From the third day onwards, sitting up with pillows for support, with her baby in one of the first three positions.

Mothers with twins (multiple births)

A mother who has twins may have some initial difficulties with their positions at the breast, and in being comfortable herself. Initially it may help to position them and even feed them separately, trying out different positions in which she can feed them simultaneously — when the babies are fed and settled. She may position one twin in the underarm position with the other in the traditional position, or both babies in the underarm position or both in the traditional position. Whichever position she is most comfortable in and can manage herself should be used. A V’ shaped pillow placed around her with the ‘V in front of her may help in supporting the twins.

It is not uncommon for each twin to feed only from one breast. Each breast is able to provide sufficient milk to sustain their nutritional needs. It sometimes happens that one twin is bigger than the other, or that one twin puts weight on more quickly than the other. If this happens, it is beneficial to let the babies feed from the breast they do not usually fed from. This may help stimulate the breast which may not be producing as much milk as the other breast.

There are many other positions in which a mother can breastfeed, all are acceptable if they work for that mother and her baby. In any position, the important thing is for the baby to take enough of the breast tissue into his mouth so that he can suckle effectively, and to follow the four ‘key points’ previously mentioned.

The different groups of mothers who will need help with positioning (and their different emotional needs).

The practical skills required by the different groups of mothers may be very similar, but the psychological approach adopted by the health care workers who are caring for the mothers may need to be subtly different.

The first time mother

It is quite possible for many first time mothers to have had no previous experience with babies. For these mothers the feelings of responsibility for a new and

fragile baby can often be very frightening and stressful. The baby will need to feed within a comparatively short time of birth, but as yet the mother has not had the experience of holding him long enough to get to know him, or to have confidence in her own mothering skills.

The approach of the carer to the mother at this emotional time should be aimed at helping her become more confident. Assistance with breastfeeding needs to be given from the first day but too much information at this stage may be confusing. It is practical help she requires now, particularly making sure her baby is attached correctly and in an appropriate position. More information can be given over the next few days in hospital or in the community.

Mothers who currently have some difficulty with breastfeeding

Difficulty with breastfeeding can have various causes. The mother may have been given confusing advice, or have received none at all and developed her own position for feeding. It may be the baby who has the problem, thrush or an undiagnosed soft cleft palate, for example. He may even have nappy rash causing him general discomfort. Time must be taken to talk to the mother and observe her and her baby during a feed so that the problem can be identified and appropriate advice and assistance can be given.

Mothers who were previously unsuccessful

If a mother was previously unsuccessful at breastfeeding it is important to find out as early as possible (preferably in the ante-natal period) what her experiences were. It is important to identify her reasons for the lack of success so that her breastfeeding management can address these particular factors. This mother may experience a number of conflicting feelings, including guilt and apprehension. She may feel guilty at not breastfeeding a previous baby successfully and apprehensive that it will not succeed this time either. She will need a lot of support and needs all the information that would be given to a first time mother. It is vital to this mother’s success that she is given practical help which will enable her to be independent of the carer as soon as possible.

Mothers who bottle fed a previous baby but now want to breastfeed

Mothers who have bottle fed a previous baby need to be given the same practical advice as a first time mother. Her previous experience may interfere with good positioning for breastfeeding, but she needs to understand that proper attachment and good positioning are the key to success in feeding.

Mothers with special needs

A mother who is unable to pick her baby up, or to support his weight will need the help of a second person. It is important to give the mother and her helper a range of practical suggestions for positioning her baby. She may find any of the positions already discussed possible if she has secure physical support for her baby or for herself from shaped pillows, rolled up towels, small blankets or even a sling (which she can wear).

This mother may require physical help, not only in positioning, but also in attachment of the baby at the breast. She may be very anxious or embarrassed about her situation.

Mothers of babies with special needs

Mothers of preterm babies, babies with congenital malformations, or babies who are sick shortly after birth may not be able to feed in a conventional way. If the mother has breastfed before she might not realise that her new baby may have to be fed in a different position; or if the baby is preterm, she might not realise that he is immature and may take several days or weeks to establish effective breastfeeding.

These mothers have special emotional needs of their own. They may feel frightened, nervous, disappointed or guilty. There may even be an element of rejection in their relationship with their baby. These points should be taken into consideration when helping the mother with attachment and positioning of her baby for breastfeeding.

Mothers with twins (multiple births)

A mother who has given birth to two or more babies

may feel totally overwhelmed by the thought of having

to be responsible for more than one small baby at the

same time.

Helping a mother to position her baby for a breastfeed

Taking account of the above considerations the following instructions provide a basic guide to positioning the baby at the breast. Many of these points apply to a mother, even if she is not holding her baby in the ‘traditional’ position.

1 Make the mother comfortable and relaxed

2 Sit down yourself in a comfortable and convenient position

3 Show or tell the mother how to hold her baby

With his head and body straight,

With his body almost facing her, and close to her,

With his upper lip opposite the nipple — not too high, too low or too far away,

Supporting his whole body with her hand and arm.

4 Show or tell her how to support her breast if necessary, with her fingers against her chest wall under her breast, and with her thumb at right angles along the side of her breast.

5 Show or tell her how to touch or tease her baby’s lips with her nipple (by gently moving the nipple against the baby’s lips)

6 Explain that she should wait until the baby’s mouth is wide open.

7 She should then move the baby quickly onto the breast with his head slightly extended, aiming his top lip towards her nipple so that his lower lip is in contact with the underside c the areola.

8 Ask her how this feels and notice how she responds.

9 Look for the signs of good attachment.

10 Try again if necessary (the mother can take the baby off the breast by inserting her little finger into the side of his mouth to break the seal — thus avoiding any damage to the breast tissue).

What sort of seating is appropriate for mothers who are breastfeeding?

Wherever the mother is sitting, her back needs to be well supported.

A low chair, allowing the mother’s feet to be flat on the floor is usually best. Some mothers may find it useful to use a chair with arms which provides support for the baby. The chair needs to be wide enough for them both to sit comfortably. If the seat is high, a footstool is useful. In this case, care should be taken not to make her knees so high that her baby is above the level of her breast. If she needs extra support, small soft pillows, small blankets or towels will be more helpful than bulky or hard pillows. Make sure they are on a table/stool within easy reach.

If she is sitting in bed she will need to be well supported, for example, by pillows behind her. Soft pillows, small blankets, towels or pieces of cloth may also be useful to give her or the baby additional support.

If she is sitting on the floor she needs some support for her back. Pillows, blankets or towels can be used to raise the baby to the level of her breasts, so that she does not have to lean forward to position him properly.

It is also important for any one helping the mother to be sitting comfortably as well. Back problems can result if the person helping a mother is standing or sitting in an awkward position or leaning over or leaning too far forward.

The mother should do as much as possible for herself. It is important not to "take over’ from her. Explain what she is required to do. If necessary the helper should demonstrate on her own body what she wants the mother to do. The mother must understand what is done so that she can do it herself. The aim is to help her to position her own baby. It does not help if the carer can get the baby to suckle but the mother cannot.

Therefore, if possible, avoid touching the baby or mother. If assistance needed helps the mother to understand what is required, then the helper should put her hand over the mother’s hand or arm so that the helper holds the baby through the mother. Hold the baby at the base of his neck or by his shoulders, not the back of his head. Take care not to push the baby’s head forward. Try to let the head extend slightly.

If the mother is having difficulty with one position, show her a different position.

General principles

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 breast milk effectively and his mother is comfortable.

The underarm position

The four key points are important. The mother may need to support the baby with pillows, small blankets or towels at her side. In this position, the baby’s head rests in the mother’s hand, but she does not push it at the breast.

If the mother needs help initially to position her baby under her arm, ask her to stand up, and then position her baby. The baby is supported in the crook of the mother’s waist and with the length of her forearm. The baby’s head rests in her hand. When she sits down with the baby already positioned the mother will find she is in an upright sitting position with her back straight, and will not get a stiff neck or backache. As she becomes more used to this position she will find it easier to position her baby when she is sitting down, without being uncomfortable.

Holding the baby across the mother’s body, using the arm opposite to the breast.The four key points are again important. If the mother needs to support her breast she can use the hand on the same side as the breast. The mother’s forearm supports the baby with her hand supporting his head at the level of his ears or below. She should not push at the back of the baby’s head.

The lying down position

The mother needs to lie down in a position in which she can sleep. Being propped up on one elbow is not relaxing for most mothers. A pillow under her head

and another under her chest may help. Exactly the same four key points are important. 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.

A common reason for difficulty attaching when lying down is that the baby’s mouth is not in line with the nipple. The mother has to correct her own body position. The baby may need to be supported at the back with a small rolled blanket.

Some common mistakes

The following ways a mother holds her baby make it difficult for him to attach to her breast and suckle effectively.

If a baby is positioned:

Too high (e.g. sitting with her knees very high)

Too low (e.g. with the baby unsupported so the mother has to lean forward)

Too far to the side (e.g. supporting the head of a small baby in the ‘crook’ of the elbow, instead of on the forearm. This can happen if the mother holds her baby’s whole body in the hand on the same side as the breast he is feeding from, instead of using both arms to support him.

The following ways a mother holds her breast make it difficult for her baby to attach and suckle effectively.

Holding the breast with fingers and thumb close to the areola.

Pinching up the nipple or areola between the thumb and fingers, and trying to push the nipple into a baby’s mouth.

Holding the breast in the ‘scissor’ hold (index finger above and middle finger below the nipple).

Holding the breast back from the baby’s nose with a finger. This is not necessary, and can result in the nipple coming out of the baby’s mouth. A baby can breathe quite well without the breast being held back.

Mistakes which can be made when trying to help a mother.

The helper has tried to put the baby on to the breast instead of helping the mother to attach and position him herself The mother will not learn how to position her baby herself and will not gain confidence in her ability to be successful.

If pressure is put on to the baby’s head, he may react by pushing his head back. The natural reaction is to push the baby onto the breast with more force. baby may continue to fight back, and this may cause him to refuse to breastfeed. The back of the head is more likely to be ‘pushed’ on to the breast by someone helping the mother than by the mother herself.

Module 2

Communication Skills


At the end of this session, you should be able to:

Use non-verbal and verbal techniques to encourage a mother to talk.

Respond to a mother’s feelings with empathy.

Avoid using words which suggest judgement of the mother and baby.

Materials required

Worksheet 6

confidence and give her support whenever she needs it. Listening and learning skills are important counselling skills.

A breastfeeding mother may not talk about her feelings easily, especially if she is shy, and with someone whom she does not know well.

The skills of listening, and of making a mother feel that you are interested in her, are of prime importance. They will encourage her to talk.

Non-verbal communication

There are different ways of communicating with a mother without talking. Body language gives signals that many of us are unaware of.


Body language is a very important part of communication though we are not always aware of what it reveals about ourselves and our feelings in particular situations or with particular people.

In the situation of counsellor/care-giver, listening to what people say and watching what they do can give us a wealth of valuable information. Equally important is being aware of the influence on other people of what we say and how we say it and the body language we use. It is therefore vital to look at various aspects of communication which can make our relationship with mothers and their babies more effective, as well as to help us understand why in some situations mothers react as they do.

The skills of communication

The skills of listening and learning are important elements of communication which help us to understand a situation. This enables us to use other communication skills to help build a mother’s

The following list indicates the main features of non- verbal communication:






Use helpful non-verbal communication

Non-verbal communication means showing your attitude through posture, expression and gesture; everything in fact, except through speaking.


Sit at the mother’s level

Pay attention

Remove barriers Take time

Touch appropriately

A friendly smile

Verbal communication

Ask open questions

There are several ways of asking questions, some only allow a yes’ or ‘no’ reply. It is often helpful to encourage the mother to speak more freely.

Open questions are usually the most helpful. To answer them, a mother must give 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 almost tell a mother the answer that you expect, because she can only answer them with a " Yes" or "No"

Closed questions usually start with words like " Are you?" or "Did he?" or "Has he?" or "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 or if she experienced any problems. The person asking the questions can become quite frustrated, and think that the mother is not willing to talk openly.

The following two dialogues are examples of open and

closed questions.

1 Closed questions

Midwife "Good morning, (name) I am (name), the community midwife. Is (name of baby) well

Women "Yes, thank you

Midwife "Are you breastfeeding him

Woman "Yes"

Midwife " Are you having any difficulties ?

Woman " No"

Midwife "Is he breastfeeding very often "

Woman "Yes"

Open questions

Midwife " Good morning (name). I am (name), the community midwife. How is (name of baby)?"

Woman "He’s very well, but he’s very hungry"

Midwife "How are you feeding him?"

Woman "I’m breastfeeding and I give him a bottle in the evening."

Midwife "Why did you do that?"

Woman " He seems so hungry; he wants to feed all the time so I thought my milk wasn’t enough for him".

In the first dialogue, the health worker got only " yes" and " no" for answers and did not learn any details in this situation. It can be difficult to know what to say next.

In the second dialogue, the health worker asked open questions. The mother could not answer with a " yes or a " no" , she had to give additional information, the health worker learnt much more.

Use responses and gestures which show interest -

To encourage a mother to continue talking, she must know that you are listening and interested in what she is saying. Important ways to show this are with gestures such as nodding, and simple responses, such as "aha"

Reflect back what the mother says

? Health workers sometimes ask mothers a lot of factual questions. However, the answers to factual questions do not allow the mother to talk freely. She may say less and less in reply to each question

For example if a mother says " My baby was crying all night, ‘ you might want to ask " How many times did he wake you up ‘ But this question does not encourage her to express she feels about the situation which would be more relevant.

It is more useful to repeat back or reflect what a mother says.It shows that you understand her, and encouraqes her to say more about what is important to her. It is best to say it in a slightly different way so that it does not sound as though you are copying her.

For example, if a mother says " My baby was crying all niqht"

You could say "Crying all night, did you get any sleep?"

the mother continues: "I really don’t know what’s wrong with him, perhaps I haven’t got enough milk."

Empathize — show that you understand how she feels

When a mother says something which shows how she feels, it is helpful to respond in a way which indicates that you heard what she said, and that you understand her feelings from her point of view.

For example, if a mother says:

My baby wants to feed very often and it makes me feel so tired!"

You respond to what she feels, perhaps like this:

"You must feel exhausted?"

Empathy is different from sympathy. When you sympathize you are sorry for a person, but you look at it from YOUR point of view.

If you sympathize, you might say: "Oh, I know how you feel. My baby wanted to feed often too, and I felt exhausted. " This brings the attention back to you, and does not make the mother feel that you necessarily understand her.

You might ask for more facts. For example, you might

ask: ,, How often does he feed? What else are you giving


But these questions also do not help a mother to feel that you understand her, though they may help you solve her problem at a later point in time. Therefore, other questions and responses should always be included which show that you empathise with her.

You could reflect back what the mother says about the baby.

For example: "He wants to feed very often?" But this reflects back what the mother said about the baby’s behaviour, and it misses what she said about how "exhausted" she feels.

So empathy is more than reflecting back what a mother says to you.

It is also helpful to empathise with a mother’s good feelings as well as her bad feelings.

Avoid words which sound judgmental

Judgmental words are words like: right, wrong, well, badly, good, enough, properly. If judgmental words are used when talking to a mother about breastfeeding, especially when she is asked questions, it may make her feel that she is wrong, or that there is something wrong with the baby.

For example: Do not say: " Does the baby sleep well?"

Instead say: "How is the baby sleeping?"

Sometimes judgemental words may be useful especially the positive words, for example, when building a mother’s confidence. But practise avoiding them as much as possible, unless there is a really important reason to use one.

Judgmental questions, such as the one used in the example, are often closed questions. Using open questions will help to avoid using a judging word.

Building confidence and giving support

In addition to the communication skills of listening and learning covered in this session it is often necessary to help build a mother’s confidence and give her support as well.

To achieve this we need to:

Accept what a mother thinks and feels

Praise what the mother and her baby are doing correctly.

Give practical help

Give the mother relevant information

Use simple, non technical language

Make suggestions, rather than give commands.

Assessing a Breastfeed


At the end of this s you will be able to:

Assess a breastfeed by observing a mother and baby.

Identify a mother who may need help.

Materials required

B-R-E-A-S-Tfeed Observation Form

Information Sheet 6

Worksheet 7


When assessing and observtng a breastfeed there are a number of points which need to be considered. Some of these relate to the way the mother and child interact and some to the mechanics of breastfeeding. There are also a number of general observations which can be made about both the mother and baby.

These include

1 The mother’s age, general appearance, and nutritional state. Appropriateness of clothing, evidence of other feeding methods, her preparation for the feed, support from other family members/friends

2 The mother’ expression whether she is comfortable and relaxed in the way she handles her baby.

3 The baby’s position, the baby’s breast attachment, the mother’s and her baby’s reaction to his breastfeed.

Important note

There are inevitably a number of other general factors which cannot immediately be seen, but which affect , the mothers overall ability to care for her baby and her relationship ‘ with him These factors may only be apparent after a good relationship has been built up between the care-giver and the mother.

These factors include:

Her detailed physical health and her mental health.

Her socio-economic position.

Her family situation.


All these factors will influence the way she cares for her baby. Therefore, care should be taken to avoid making any quick assumptions of her circumstances based only on what can be observed.

If a mother is nervous and lacks confidence, she may handle her baby in an inappropriate manner during feeding. This can upset her baby and interfere with suckling and breast milk flow.

The baby’s breastfeeding behaviour

A baby’s well-being may be influenced by his gestation general health, emotional bonding and nutrition .His ability to breastfeed successfully has an important role in maintaining his own well-being and that of his mother.

In observing a breastfeed and assessing whether it is going well or not there are a number of sign’s which are important. These are:

The baby’s responses to the breast initially and during a feed.

Rooting — in the first few weeks a baby roots for the breast when he is ready for a feed (i.e " he opens his mouth and turns towards the breast when the side of his mouth or cheek are touched) As the baby matures, he also reaches for the breast with his hand.

The baby being calm during a feed, and relaxed and contented afterwards. These are signs that he is getting breast milk.

The baby crying or pulling back or turninq away, from his mother. This response shows that a baby.

does not want to breastfeed, and that there is a problem.

The baby being restless and slipping off the breast or refusing to feed. This may mean that he is not well attached and is not getting the breastmilk.

Signs or conditions which may interfere with the baby’s positive responses at the breast?

Short term conditions

Blocked nose



Oral thrush

Respiratory infection

Long term and congenital conditions

Tongue tie

Cleft lip or palate

Cardiac abnormality

How the mother holds her baby at her breast and maintains his attachment

For a young infant, it is easier to attach him to the breast if his whole body is supported and not just his head and shoulders. For older babies, support of the upper part of the body is usually enough.

The mother may support the weight of her breast with her hand and if necessary shape her breast by putting her thumb on the upper part of it, so that the nipple and areola are pointing towards the baby’s mouth. Alternatively she may support the breast by placing her fingers flat against the chest wall. She then brings the baby to her breast to suckle. This way of holding the breast usually helps ensure good attachment. This support is especially important if she has large breasts.

The following practices interfere with successful attachment of the baby to the breast:

a The mother may ‘pinch-up’ her nipple and areola and try to push them into her baby’s mouth, perhaps at the same time leaning forward. This does not make it easy for the baby to attach to the breast and usually makes it more difficult.

b The mother holding her breast with her fingers very close to the areola makes it more difficult for a baby to take an adequate mouthful of breast. If the fingers press into the breast the milk ducts may become blocked so that it is more difficult for the baby to get the breast milk.

c The mother pressing her breast away from her baby’s nose with her finger is not necessary, babies have flat noses and are able to breath without difficulty at the breast. On the rare occasions when a baby is not able to do so it will pull off the breast itself. It is difficult for a mother to see that her baby is able to breathe easily, as she cannot see his nostrils, she may therefore, need reassurance on this point.

d The mother holding her breast with the ‘scissor hold’ (i.e. the nipple and areola are held between her index finger above and middle finger below the breast).

e She may have large breasts which need support throughout the feed. If she stops supporting them, the baby’s good attachment may not be maintained. She may have small breasts which she may not need to support at all.

Attachment at the breast

Consider these two pictures.

In picture 1.

There is more areola above the baby’s mouth than below it

His mouth is wide open (this is important with large breasts, but less important with thin breasts)

His lower lip is turned outwards

The baby’s chin is touching the breast

In addition:

His cheeks are rounded, or flattened against his mother’s breast

The breast looks rounded during a feed

In picture 2.

The baby is poorly attached to the breast. What signs of poor attachment can be seen?

There is more areola below the baby’s mouth than above it, or the same amount above and below.

His mouth is not wide open (especially breast).

His lips are pointing forwards or his by turned in.

The baby’s chin is not touching the breast

In addition:

His cheeks are tense or pulled in as he suckles

The breast looks stretched or pulled during the feed

The following ways of demonstrating poor attachment can be used to illustrate main differences.

To demonstrate good attachment:

Suck on your forearm, with mouth wide tongue forward, and lower lip curled back slow deep sucks, about 1 per second.

To demonstrate poor attachment:

Suck your thumb or on a straw, with your month almost closed, lips pointing forwards, a pulled in. Give quick, small sucks.

Signs of effective and ineffective suckling

Slow deep sucks, often with visible or audible swallowing indicate that the baby is getting breastmilk. From time to time the baby pauses. This pattern shows that he is well attached to the breast and effectively. If the baby takes quick shallow sucks he is probably getting less breastmilk. He is not well attached, and not suckling effectively. A baby making ‘smacking’ sounds as he sucks is another sign of poor attachment.

Swallowing can usually be both seen and heard. When a baby swallows, it means that he is getting breast milk. Gulps are very loud swallowing sounds, which occur when a lot of fluid is being swallowed at once. It may mean that his mother has an oversupply, is getting too much milk too fast. Over supply is sometimes the cause of breastfeeding difficulties. A baby usually takes a few quick sucks to start the oxytocin reflex. Then as the milk begins to flow and the mouth fills, his sucks become deeper and slower. He then pauses, and starts again with a few quick sucks.

How the baby finishes his breastfeed

A baby should release the breast himself and look sleepy and satisfied at the end of his breastfeed.

A mother sometimes takes her baby off her breast quickly, as soon as he pauses, because she thinks he has finished; or because she wants to make sure that he suckles from the other side as well. A baby who comes off the breast too quickly may not get enough hindmilk. He may want to feed again within a short time of his last feed.

The exact length of time of a feed is not important. Feeds normally vary in length, they may be anywhere between 4 to 40 minutes in length (per breast). If they are routinely taking over 45 minutes for each breast there may be a problem. In the first few days, or with a low-birth-weight baby, it is common for breastfeeds to be very long.

Additional Information

Breasts which are full before and soft after a feed, show that the baby is removing breastmilk. Breasts which are very full or engorged all the time, show that the baby is probably not removing breastmilk effectively.

The skin of the nipple and areola should look healthy. There should be no sign of red skin or cracks. If the nipple looks ‘squashed’ or has a line across the tip or down the side of it, when the baby releases the breast it is a sign of poor attachment.

Ask the mother how breastfeeding feels to her. If she says it is comfortable, her baby is probably well attached; if she says uncomfortable and painful, the baby is probably not well attached.

It is important to look and ask the mother for signs of an active oxytocin reflex, though if they are not apparent the reflex may still be active. Uterine pains, associated with this reflex, may also occur during breastfeeds in the first few days after birth. Multiparous women may sometimes complain that the pains are as bad or worse than labour pains.

B-R-E-A-STfeed Observation forms

This form summarizes the key points for assessing a breastfeed. It is used to practise observing breastfeeds with mothers and babies. It is divided into 6 sections, each of which lists signs that breastfeeding is going well or signs of possible difficulty.

The sections are:

Body position


Emotional bonding



Time spent suckling.

(The initial letters make up the word BREAST which can be used as a reminder in clinical practice).

How to assess a breastfeed

1 What do you notice about the mother?

2 How does the mother hold her baby?

3 What do you notice about the baby?

4 How does the baby respond?

5 How does the mother put her baby onto her breast?

6 How does the mother hold her breast during a feed?

7 Does the baby look well attached to the breast?

8 Is the baby suckling effectively?

9 How does the breastfeed finish?

10 Does the baby seem satisfied?

11 What is the condition of the mothers breasts?

12 How does breastfeeding feel to the mother?

B-R-E-A-S-.T-feed Observation Form

Session 26

This form has been designed to help in the assessment of breastfeeding technique through the observation of a feed and as a learning tool for health professionals and mothers. It is suggested that you familiarise yourself with the form by sharing your observations with one or more mothers who are NOT experiencing difficulties before using it where problems are suspected. A tick should be marked on the line if a sign is observed during a breastfeed.

Signs that breastfeeding is going well:

Body position

— Mother fully relaxed and comfortable

— Close body contact between baby and mother

— Baby’s head and body in line

— (Baby’s whole body supported)

— Baby’s upper lip opposite nipple before attachment

— Baby’s chin touches the breast during the feed


— Baby reaches or roots for the breast

— Baby explores the breast with tongue

— Baby calm and alert at the breast

— Baby stays attached to the breast

— Signs of milk release (e.g. leaking)

Emotional bonding

— Secure, confident hold

— Face-to-face attention from mother

— Baby touched a lot by mother


— Breasts soft and full

— Nipples prominent and protractile

— Skin appears healthy

__ Breasts look round during a feed

— If visible, more areola above baby’s top lip


— Baby’s mouth wide open

— Lower lip turned outwards

— Cheeks rounded

— Slow, deep sucking bursts with pauses

— Can see or hear swallowing

— Rhythmic swallowing seen

Termination of feed

— Baby releases the breast spontaneously Time spent feeding ______ minutes

Signs of possible difficulty:

— Mother not relaxed, e.g. shoulders tense

— Baby’s body not held close to the mother

— Baby’s has to twist head and neck to feed

— (Only shoulder or head supported)

— Baby’s lower lip opposite nipple before attachment

— Baby’s chin does not touch the breast

— No response to the breast

— Baby not interested in the breast

— Baby restless or fussy

— Baby slips off the breast

_No sign of milk release

— Nervous, shaking or limp hold

— No mother/baby eye contact

— Little touching of baby by mother

— Breasts hard and full/engorged

— Nipples flat or inverted, or very long or very big

— Skin damaged

— Breasts look stretched or pulled

— If visible, more areola below baby’s bottom lip

— Baby’s mouth pursed, lips point forward

— Lower lip turned in

— Cheeks tense or pulled in

— Rapid shallow sucks

— Can hear smacking or clicking sounds

— Occasional swallowing seen throughout feed

-- Mother takes baby off the breast

Module 2

Taking a breastfeeding history


At the end of this session, you should be able to:

Take a breastfeeding history to help them to diagnose a breastfeeding difficulty.

Materials required

The Breastfeeding History Form.


A breastfeeding history may be useful in a number of different situations because it is not possible to learn everything from observation alone.

How to take a breastfeeding history

There are some important points about taking a history, which ensures that the relevant and correct information is obtained:

Questions should be asked in a systematic way

The accompanying Breastfeeding History Form provides a format or guide which contains 6 sections. Each section contains word or sentence prompt: for information that may be required, though not all the ‘prompts’ will be needed.

Many of the points on the information sheet seem to be very obvious. It is, however, very easy to forget how important our own attitudes are towards breastfeeding and how these may influence the way we ask mothers for information when they have breastfeeding problems. Therefore, in taking a history we have to use all of our skills of communication to persuade the mother that she really does want to tell us what the problem is, for it may not be straight forward.

The following points may help to obtain the information required:

Use the mother’s name and the baby’s name (if appropriate).

Ask her to tell you about herself and her baby in her own way.

Look at the child’s growth chart. This may give some important information about the baby’s progress

Ask the questions that will tell you the most important facts.

The Breastfeeding History Form is a guide to the facts that may be useful in obtaining accurate assessment of the mother’s feeding situation.

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 These include:

— What other people have told her about breast feeding

— Does she have to follow any special religious/cultural rules.

What dose the baby’s father say? His mother? Her mother?

Did she want this pregnancy at this time?

Is she happy about having the baby now?

Is she happy about the babys sex.

Some mothers will tell you these things spontaneously. Others will tell you when you empathize, and show that you understand how they feel. Others take much longer. If a mother does not talk easily, wait, and ask again at a later meeting.

The Breastfeeding History Form

The first two sections are about the baby and how he is feeding now.

The third section is about the mother’s pregnancy and delivery.

The fourth section is about the mother and her health and family planning.

The fifth section is about any previous experience of infant feeding.

The sixth section is about the family and its social situation.

Often, questions about points in the first two sections provide the answer to a problem. Sometimes more information is required from the mother, about her pregnancy and delivery, her previous babies, or the family’s situation, before her difficulties can be understood.

Start with the first two sections. They are the most important. If the problem is still not clear then continue through the other sections until the problem has been identified.

However, it is a good idea to ask a mother something from each section because it helps to give a full picture of the mother’s background. It is worth looking quickly through all the six sections, and making a mental note of which points might be important for this family.

If at any time a mother wants to talk about something that is important to her, let her talk about that first.

Breastfeeding History Form

Mother’s name Baby’s name

Date of birth Baby’s age in months

Reason for consultation

1.Current feeding situation

Breastfeeds Day Night

How often

Length of breastfeeds

Longest time between feeds

Time mother away from baby

One breast or both breasts

Supplements (and water) Dummy

What given yes/no

When started

How much

How given

2 The babys health and behaviour

At birth Birth centile Present centile

Weight Weight


Circumference H C

Length Length

Gestation Multiple birth

Feeding behaviour ( appetite,vomiting)

Sleeping behaviour

Urine output (more/less than 6 times per day)

Stools (soft and yellow/brown; or hard or green;frequency)

Illnesses Any abnormalities

3. Pregnancy, birth, early feeds.


Antenatal care (attended/not) Antenatal classes

Breastfeeding discussed?

When? With whom?

Labour and Delivery

Baby’s position at delivery

Type of delivery

Analgesia used during labour

Blood loss

Intact placenta


Early skin-to-skin contact (first 0—1 hour)

Time of first breastfeed


Prelacteal feeds

What given How given

Formula samples given to mother

Postnatal help with breastfeeding

4 Mother’s condition and family planning



Family planning method

Alcohol, smoking, coffee, other drugs

5 Previous infant feeding experience

Number of previous babies

How many breastfed

Experience good or bad

Any bottles used Reasons

6 Family and social situation

Father employed/not

Father’s occupation

Mother intending to return to work/not

Mother’s occupation

First language

Father’s attitude to breastfeeding

Other family members attitude to breastfeeding

Help with child care


Own home/living with other family members.

How to take a breastfeeding history

Use the mother’s name and the baby’s name (if appropriate)

Ask her to tell you about herself and her baby in her own way

Look at the child’s growth chart

This may give some important information about the baby’s progress

Ask the questions that will tell you the most important facts

The Breastfeeding History Form is a guide to the facts that may be useful in obtaining an accurate as the mother’s feeding situation

Take time to learn about more difficult, sensitive things

Some things are difficult to ask about, but they can tell you about a woman’s feelings, and whether

wants to breastfeed.

These include:

What have other people told her about breastfeeding?

Does she have to follow any special religious/cultural 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?

Is she happy about the baby’s sex?

Some mothers will tell you these things spontaneously. Others will tell you when you empathise and you understand how they feel. Others take much longer. If a mother does not talk easily, wait, and a later meeting.

Module 3

Session A

Expressing breastmilk


At the end of this section, you will be able to:

Explain when it is useful for a mother to express breastmilk.

Help a mother to stimulate her oxytocin reflex.

Teach a mother the principles of hand expression and an effective technique.

Teach a mother how to use a hand and electric breast pump.

Materials required

Worksheet 8


The expression of breast milk is useful in a number of situations. All health workers who care for breastfeeding mothers should be able to teach the skills of both manual and mechanical expression of breast milk.

Situations when the expression of breastmilk is useful or necessary

The expression of breast milk can be useful for a variety of reasons, these include:

General breast care;

Relief and prevention of potentially serious breast conditions;

Stimulation of the milk supply.

Maintaining the milk supply.

Helping a baby to breastfeed

General breast care

To prevent the nipple or areola from becoming dry or sore. This can be achieved by gently smoothing a small drop of expressed milk onto the skin after a bath or shower.

To prevent leaking when a mother is away from her baby. (express only as much as is necessary).

Relief and prevention of potentially serious breast conditions

To relieve engorgement(express only as much as is necessary);

To relieve a blocked duct or milk stasis;

To relieve breasts while the mother is at work or away from her baby.

Stimulation of the milk supply

To feed a sick or weak baby, who cannot suckle for long without tiring.

Maintaining the milk supply

To maintain the mother’s breast milk supply when she is ill;

To feed a baby who cannot breastfeed because he is preterm, sick or has an abnormality;

To feed a baby who, for a variety of reasons may require expressed breast milk.

Such as:

A baby learning to suckle from an inverted nipple;

A mother who is returning to work or is

temporarily away from home;

To feed a baby who has difficulty coordinating suckling;

To feed a baby who ‘refuses’ the breast, while he earns to enjoy breastfeeding.

Helping a baby to breastfeed

To express breast milk directly into a baby’s mouth.

To help a baby to attach to a full breast;

The oxytocin reflex and milk expression

Before breast milk can be expressed, the oxytocin reflex has to function, so that milk will flow from the mother’s breasts. The emotional feelings of the mother, when she thinks about her baby, help the oxytocin reflex to work and this is strengthened when she puts her baby on to her breast. When a mother is expressing breast milk it is therefore necessary to stimulate this reflex. This can be achieved by the mother being confident in herself, free from pain and anxiety, and having positive thoughts about her baby.

The reasons a mother may need to express her milk vary a great deal, as already indicated. The amount of psychological help and support she will require depends upon why she has to express (e.g. to help a baby to attach to a full breast or to feed a preterm baby not yet able to breastfeed).

Practical ways of stimulating the oxytocin reflex prior to or during expression

1 Sitting quietly and privately with a supportive friend or relative, or sitting with a group of other mothers who are also expressing milk for their babies.

2 Holding her baby, skin-to-skin, even if the baby is ventilated or very small. Holding her baby on her lap during expression or, if this is not possible, looking at the baby who is in an incubator or cot. Even looking at a photograph of her baby may help.

There are other practical ways a mother can be helped

1 Give her a warm soothing drink (coffee is best avoided).

2 She can warm her breasts with a warm compress, warm water, or by having a warm shower.

3 She can stimulate her nipples by gently pulling or rolling them with her fingers.

4 She can stroke or massage her breasts lightly with her finger tips or with a comb, or gently rolling her closed fist over her breast, towards the areolas and nipples.

5 Massaging her back. To do this the mother sits down, leans forward, folds her arms on a table in front of her, and rests her head on her arms. The top part of her body may be clothed or unclothed, but it is best if her breasts can hang loosely. The helper uses her closed fist with her thumbs pointing forwards. She places her thumbs on either side of the vertebral column, at the base of the neck, at the top of the back. She presses firmly making small circular movements with her thumbs. She works down both sides of the upper spine, from the neck to the bottom of the shoulder blades, at the same time, for two or three minutes. This can be repeated according to the wishes of the mother. Milk may begin to drip spontaneously after this has been repeated a few times.

If the woman’s husband or partner gives this help the psychological benefits to her are increased.

Methods of milk expression

There are three main methods of expressing breast milk:

Hand expression.

A hand pump.

An electric pump.

A mother often finds that one of these methods suits her best. Some mothers develop their own technique of hand expression. Providing this works for her, she should be encouraged to continue with it. When a mother is having difficulty expressing enough milk, she should be taught a more effective technique and be encouraged to experiment with different techniques.

To establish and maintain lactation

The information given to a mother if she needs to establish and maintain lactation by milk expression (e.g. for a sick or very preterm newborn baby) is the same for all the methods.

She should start to express milk on the first day, as soon after delivery as she feels able to. At this stage only a few drops of colostrum may be produced but early expression helps breastmilk production to begin, in the same way that a baby suckling stimulates production. At this time the breasts are still soft, making the initial expressions, particularly by hand, easier than when the breasts are full or tender which occurs at approximately 48 to 72 hours after delivery.

She should express as much colostrum or milk as she can, as often as her baby would breastfeed. This should be at least every three 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.

More prolactin is produced at night. (Prolactin is the hormone which makes the milk secreting cells produce milk. This milk is then available for the next expression.) If breastmilk is not removed regularly from the breast, the inhibitor reduces the milk production.

Milk can only be continually expressed from one breast for 3 or 4 minutes before the supply slows down or appears to stop. Milk should then be expressed from the other breast. The mother should then go back to the first breast and start again. This procedure of changing from one breast to the other should be continued until the milk ceases or drips very slowly from the nipple. (A baby suckling has frequent pauses during feeding. This allows the lactiferous sinuses to refill with milk.)

The length of time of expression varies greatly between mothers, therefore it is not a good idea to suggest a time limit.

Special situations requiring expression

A mother who has returned to work and is breastfeeding needs to express as much milk as possible to leave for her baby. It is also very important to express while at work to help to maintain her supply. The use of hand expression or hand pumps are the most convenient methods in this situation.

C A low milk supply

A mother who needs to express her milk for a long period may find it begins to decrease after a while. If this happens she will need to express more frequently (every 1 to 2 hours and at least every 3 hours during the night). It is important to ask this mother about her diet and her rest. If the decrease occurs at approximately six weeks after delivery, ask if she has begun to take an oral contraceptive (the progesterone-only pill is recommended for mothers who are breastfeeding because of the effect of oestrogen on inhibiting milk production).

The health worker should ask the mother about her technique of expression and suggest alternative methods or improvements on her present method, if she thinks these would help.

Hand expression

Hand expression is the most useful way to express milk. It needs no appliance, so a woman can do it anywhere, at any time. It is a particularly effective method of expression for use in clinical situations where waiting to obtain a pump may increase the chances of a more serious pathological condition developing.

How to express breastmilk by hand

Show a mother how to do this for herself. If she needs any help, the helper should guide the mother’s hand with her own.

The mother should:

1 Wash her hands thoroughly.

2 Make herself comfortable.

3 Hold the container near her breast.

4 Put her thumb on her breast above the areola, and her first finger on the breast below the areola, opposite the thumb. She should support her breast with her other fingers.

5 Compress the breast tissue between her finger and thumb. She must press on the lactiferous sinuses. She may be able to feel them, particularly in the first few days after birth. They vary in texture and shape, and may feel like pods or peas!

6 Press and release, press and release. This should not hurt — if it does, slightly reposition the thumb and forefinger. At first no milk may come, but after pressing a few times milk starts to drip out and then to spurt. It may flow in streams if the oxytocin reflex is active.

7 Press the areola in the same way all around the sides of the breast to make sure that milk is expressed from all the lobes of the breast.

8 Avoid rubbing or sliding her fingers along the skin as this may result in friction damage to the skin. The movement of the fingers should be more of a rolling action.

9 Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the milk. It is the same as the baby ‘nipple sucking’.

1 0 Express one breast for at least 3-5 minutes, until the flow slows; then express the other breast. Repeat expressing milk from both breasts in this way until the milk flow ceases. The mother can use either hand for either breast, and change when they tire.

Mothers need to allow 20 to 30 minutes to express milk adequately, especially in the first few days when only colostrum or a little milk may be produced. It is important not to express in a shorter time because the milk may not be removed from the breast sufficiently well enough to promote further milk production.

The above instructions are the basic principles of hand expression. There are a number of additional techniques which may help an individual mother’s milk to flow more easily. These include:

1 Gently shaking the breast and then pressing and releasing as already described.

2 The mother pressing her thumb and first finger inwards towards the chest wall, at the same time as compressing and releasing the breast tissue between the thumb and first finger.

3 Sometimes gently massaging (with a clenched fist, or the flat of the hand transferring pressure) or very gently stroking the breast towards the nipple may also aid the milk flow. Some mothers will find this is sufficient to result in the expression of a small amount of milk but for any substantial quantity of milk it is : usually necessary to follow the steps given above. Mothers often develop their own style of hand expression once they have learnt the basic principles.

A mother can express milk from both breasts at the same time. She will find it helpful to lean forward during expression with a container between her knees for the milk. She needs to pause every few minutes to let the lactiferous sinuses refill with milk.

It is difficult to teach a mother the ‘rhythm’ to use for compression and release of the breast tissue, each mother will develop her own rhythm and she should be encouraged to experiment, for example in the bath.

Hand pumps

If breasts are engorged and painful, it is sometimes difficult to express milk by hand. It can then be helpful to express with a hand pump. These are easier to use when the breasts are full but are not so easy to use when the breasts are soft. There are a number of different designs, all of which work in slightly different ways, some are operated by battery and some by hand. All of them share the funnel attachment which fits over the nipple and areola.

How to use a syringe type hand pump

These pumps are simple to use and easy to clean a sterilise.

1 Put the funnel over the nipple and areola. Ensure there is all round skin contact.

2 Pull the outer cylinder part-way down so that the nipple is drawn into the funnel.

3 Release the outer cylinder and then pull down again. After a minute or two the milk begins to flow, and collects in the outer cylinder.

4 When the milk stops flowing, break the seal, pour out the milk, and then repeat the procedure.

5 Expression should continue until the milk flow ceases or the milk only drips slowly from the nipple.

Where possible, because hand pumps can be expensive, the mother should be able to try out different models before buying one. Some hand pumps are more successful for some mothers than others.

Electric pumps

Electric pumps can be used in hospital. However, they are sometimes not practical for long-term routine use, particularly for mothers who may need to be away from home or the hospital when expression is necessary. To use the pump, the mother has to have access to an electricity supply. Because of the weight of the pumps, they are not portable enough to carry around easily.

Electric pumps also have a funnel attachment which fits over the nipple and areola. Their principle advantages are that they are less tiring for a mother to use and that they help most mothers to produce a greater quantity of milk than the other methods described.

Each mother should have her own sterilising unit for the parts of the pump which need to be cleaned after each expression. It is advisable to change the funnel attachment and the tubing every 24 hours.

Double pumping is a way of expressing from both breasts at the same time. It is quicker than other methods and some studies indicate that it produces high levels of prolactin.


These are soft silicone inserts which fit into the ‘funnel’ attachment of the electric or hand pump. Their purpose is to ‘massage’ the breast tissue and to make the funnel attachment more comfortable for the mother.

Storage of expressed breast milk

Freshly expressed breast milk can be stored for 24 hours in a domestic refrigerator. If it is not going to be used within this period of time it should be stored at -20 degrees centigrade in a freezer, where it can be kept for approximately 3 months. Research indicates that breast milk can be kept at room temperature for at least 8 hours

Breast milk which has been frozen should be defrosted slowly in a refrigerator, or at room temperature. It should not be defrosted in a microwave because this may cause the milk to be an uneven temperature when it is fed to the baby, and may burn the baby’s mouth

Pasteurisation of breast milk is not necessary if it is given to the mother’s own baby. Equipment should be sterilised in individual containers for each mother.


1 Minami J. Helping mothers with letdown. Oregon Areas Leaders’ Letter of La Leche League, 1985.

2 Marmet C. Manual Expression of Breast Milk — Marmet Technique. LLL International reprint No 27. Franklin Park IL, LLLI, 1985.

3 Hamosh M. Breast Milk Storage. Review of literature and recommendations for research needs 1994. Prepared for Wellstart International/WHO/USAID.

4 Sigman M, Burke Ki, Swarner OW et al. Effects of micro waving human milk. ml Am Diet Ass 1989. 89;5:690-692

Expressing and storing breast milk

(insert or circle correct answers)

1 Give 3 reasons why a mother might express her breast milk

a) _________________________________________

b) _____________________________________

c) ____________________________________________

2 3 ways of expressing breast milk are

a) _________________________________________

b) ___________________________________

c) ____________________________________________

3 The best time to teach a mother to hand express is

a) Antenatally

b) First day post partum

c) 2 weeks post partum

4 Expressing breast milk is easier if the______________________________

5 After hand expressing for 3 to 4 minutes the milk flow is likely to

a) increase

b) decrease

6 To establish a milk supply by expression it is helpful to express

a) infrequently b) frequently

7 Breast milk can be stored at room temperature for up ________ to hours.

8 Breast milk can be stored in a refridgerator for up to ________ hours.

9 Breast milk can be stored in a deep freezer for ________ to ________ months.

10 Frozen breast milk should be defrosted

a) slowly

b) quickly

Module 3

Helping a mother overcome breastfeeding difficulties:

Breast conditions


At the end of the session, you should be able to:

Examine a woman’s breasts correctly.

Diagnose and manage the following conditions:

Flat, inverted, and long nipples; . Sore nipples and nipple fissure; Full and engorged breasts;

Blocked duct/lobe and mastitis; Abscess.

Materials required

Information Sheets 8 — 9


There are several common conditions which sometimes

cause difficulties with breastfeeding.

Flat or inverted nipples, and long or big nipples;

Sore nipples and fissured nipples;

Full and engorged breasts;

Blocked duct and mastitis; Abscess.

The diagnosis and management of these breast

conditions are important both to the mothers comfort and to enable breastfeeding to continue.

It is not necessary physically to examine a mother’s breasts as part of routine care because many of the above conditions can be seen easily. However, there may be situations where observation alone does not give sufficient information, or where the mother is concerned about something which cannot easily be seen, and then an examination may be necessary.

Therefore, before considering the various breast conditions which may occur, it is useful to know how to examine the breast effectively.

How to examine the breast

A postnatal breast examination can be carried out before, during or after a feed, depending upon the nature of the problem. The procedure is similar to any breast examination carried out antenatally, though there are some differences.

It is necessary to

First make a visual inspection.

Look at breast size and shape, nipple size and shape and symmetry of the breasts.

Look for any unusual signs such as redness, scars, swellings, rashes, dry skin.

Second palpate the breast.

Procedure for breast palpation:

Ask what symptoms the mother has had, for example, any pain or tenderness.

ii Ask the mother’s permission before the palpation.

iii Be very gentle

iv Use the flat of your hand (fingers together and straight).

V Gently palpate all parts of both breasts feeling the nature of the underlying breast tissue.

Nipple size and shape

Sometimes the size and shape of the nipple makes it difficult for a baby to attach to the breast, though poor attachment can occur whatever the breast or nipple shape.

The two conditions which are most commonly met are flat and inverted nipples, though big and long nipples can also sometimes cause difficulties.

Mothers can breastfeed if they have flat or inverted nipples. They may however, require a lot of help and support, particularly in the initial period after birth.

A baby does not suckle from the nipple. He forms a ‘long teat’ from the nipple and areola, with the nipple.

forming only about one-third of this teat’ in his mouth. The protractility of the breast tissue is more important than the nipple shape.

Protractility improves during pregnancy, and in the first week or so after a baby is born. Therefore, even if a woman’s nipples look flat in early pregnancy, her baby may be able to suckle from the breast without difficulty. In the antenatal period very little prediction can be made based on nipple shape of how successful a mother will be in breastfeeding. Nipple shape may, however, indicate that the mother is likely to require extra help with attachment.

A mother can test for protractability by placing her . fingers and thumb on the areola, either side of the nipple, and gently trying to stretch the nipple out. If the nipple goes in when the areola is squeezed, then it is inverted.

Problems can arise from nipple inversion if the baby is not well attached to the breast. When milk is not effectively removed from the breast, engorgement, mastitis or an abscess can occur.

Fortunately, inverted nipples are rare.

Management of flat and inverted nipples

1 Antenatal treatment is probably not helpful. There is no evidence to show that breast shells (including Woolwich shells) or Hoffman’s exercises (stretching the nipples and areolas) are of any benefit, and therefore these treatments should not be recommended to women in the antenatal period Indeed, ‘nipple shells’ may cause pain, discomfort, skin problems and oedema.

For mothers with flat or inverted nipples, practical help (with positioning and attachment) and support are very important as soon as possible after delivery, when the baby starts breastfeeding:

2 After delivery, help the mother become confident about her ability to breastfeed her baby.

Be realistic and positive. Explain what the initial difficulties may be, but emphasise that patience and perseverence will result in successful breastfeeding. The mother’s breasts will improve and become softer in the week or two after delivery.

Explain to the mother that a baby suckles from the breast — not from the nipple. As the baby breastfeeds, he will stretch the mothers areola and nipple out to form a ‘long teat’.

Practical ways to help a mother There are a number of practical measures which can be used to help mothers:

Encourage skin-to-skin contact.

Allow the baby to explore the mothers breast and attach in his own time. Some babies learn best by themselves. One way of doing this is to lay the baby on the mother’s abdomen with his head midway between her breasts and let him find the nipple and areola himself.

Help the mother to position her most appropriate way.

The mother may need help to decide which position is the most appropriate for her and her baby. The underarm position may give a mother more control of the baby’s head. Leaning over the baby so that the breast is allowed to drop into the babys mouth may help the baby to take more breast tissue into his mouth.

Help the mother with the attachment of her baby.

Aim the baby’s bottom lip at the underside of the areola, and the top lip at the same level as the nipple. This should ideally be taught at the time of the first breastfeed, or as soon as possible on the first day before the milk comes into the breasts and makes the skin tight and attachment more difficult.

Help the mother to make her nipple stand out more before a feed.

Attachment may be simpler if the to stand out as far as possible before the baby is attached to the breast. This may be achieved by using:

i Gentle manual stimulation of the nipple area until the tissue is erect;

ii The syringe method

iii A hand breast pump or breast reliever.

Information Sheet 8 describes and illustrates the syringe method for treating inverted nipples.

Shaping the breast sometimes makes it easier for a baby to attach.

To do this, the mother supports her breast 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. (She should use the same hand position as for hand expression.)

If it is acceptable to both partners, the mother’s partner can suck on her breasts a few times to pull the nipples out.

If the baby cannot suckle effectively in the first one or two weeks after birth, the mother may find the following alternatives useful:

She can express her milk and feed it to her baby with a cup. Expression will help keep the mother’s breasts soft, thus making attachment for the baby easier; it also ensures adequate stimulation for milk production. A bottle should not be used.

If the baby will not take a cup, she can use a syringe to drip breast milk over the nipple and into the baby’s mouth.

The mother can use a breastfeeding supplementer.

She can express a little milk directly into her baby’s mouth. This ensures the baby gets some milk straight away, so he will be less frustrated and he may be more willing to try to suckle.

Give her baby frequent skin-to-skin contact. She could spend a 24 hour period in bed with her baby so that whenever he is hungry he has ready access to the breast.

b The long nipple

Long nipples may be considered to be an advantage for mothers who breastfeed because they are easy for a baby to suckle from. But they can cause difficulties.

A baby is likely to suck only from the nipple, therefore he may not take sufficient breast tissue containing the lactiferous sinuses into his mouth.

It is important to be ready to help this mother with her breastfeeding technique. Help her to get her baby to take some of her breast tissue into his mouth — and not just her nipple. This condition usually resolves as the baby gets bigger.

Sore and fissured nipples

Breastfeeding should be comfortable and pain free. Some mothers may experience a degree of discomfort, and even pain in the first few days of breastfeeding. Usually this only occurs at the beginning of the feed and is temporary.

The commonest cause of sore nipples is poor attachment of the baby to the breast. Poor attachment by itself may cause pain during a feed, even though the nipples appear normal. If poor attachment continues the nipple skin is likely to be damaged causing fissures (often called ‘cracks’). Sometimes the baby looks as if he is sucking only form the nipple.

Other causes are:

Mechanical/hand pumps used for milk expression and which may cause excess stretching of the breast at the junction of the nipple and areola.

The baby being ‘pulled’ off the breast when attached, without the mother first of all breaking the seal between the baby’s mouth and the breast

There is no evidence to suggest that fair skinned mothers are more likely to suffer sore/fissured nipples than any other mothers.

commercial devices which use a similar principle to the syringe are available in some shops and chemists. According to some of the manufacturers’ literature they should NOT be used by lactating mothers or in the last two months of pregnancy. Their primary use is for cosmetic purposes. These devices have occasionally been used by lactating mothers, prior to feeding, to draw an inverted nipple out to aid attachment. When used for very short time periods they do not appear to damage the breast tissue and may be helpful. It is advisable for a mother to be supervised in their use. A hand pump has a larger opening for the breast tissue and is less likely to cause damage to the nipple area.

Undiagnosable pain of the nipples or breasts

There are a small number of mothers who suffer continuing pain with breastfeeding - and for which no cause can be found. It is necessary to make sure that this mother is given as much help and support as possible to minimise her discomfort.

Engorgement and fissured nipples

It is important to breastfeed from soon after delivery. This helps to prevent pressure from the milk building up in the breasts, so reducing the chances of engorgement developing. It is easier for a baby to attach well when the breasts are still soft and there is less chance of nipple damage.

Candida infection

A Candida infection of thrush can make the skin sore and itchy. It often follows the use of antibiotics to treat mastitis or other infections. Some mothers describe burning or stinging which continues after a feed. Sometimes the pain shoots deep into the breast. A mother may say that it feels as though ‘needles are being driven into her breast’.

The skin of the nipple and areola may look red, shiny and flaky and may lose some of their pigmentation. Sometimes the nipple looks quite normal.

Candida may be suspected if the sore nipples persist, even then the baby’s attachment is good. Check the baby for thrush. He may have white patches inside his cheeks or on his tongue, or he may have a rash on his bottom.

Treat both mother and baby with nystatin, or daktarin gel.

Advise the mother to stop using dummies; help her to stop using teats and nipple shields. If these are used, they should be boiled for 20 minutes daily and replaced weekly.

Management of sore nipples

Sore nipples may simply be reddened, or they may have a crack or fissure present. The treatment will be very similar.

First look for a cause:

Observe the baby breastfeeding, and check for sign poor attachment, and notice how the mother finishes a feed.

Examine the breasts.

Look for signs of infection e.g. Candida; engorgement; and/or fissures or any nipple damage.

Look in the baby’s mouth for tongue tie; or signs of Candida infection and also check the baby’s bottom for Candida rash.

If using a breast pump check for inappropriate positioning of the funnel attachment.

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 a change in the baby’s position and attachment is all that is necessary. She can continue breastfeeding, and need not rest her breast.

Begin the feed on the least sore side first: once milk begins to flow, attach the baby on to the damaged breast.

Feed from the least sore side first

Help her to reduce engorgement if necessary She should breastfeed frequently, or express her breast milk

Consider medical treatment for Candida if the skin of the nipple and areola is persistently red, shiny, or flaky, or if there is itchiness, or deep pain, or if the soreness persists. Medical treatment should be to both the mother and baby. -

Then advise the mother:

Not to wash her breasts more than once a day, 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 on the nipple and areola, because these can irritate the skin and there is no evidence that they are helpful.

Suggest that after breastfeeding, or after a shower or bath, that she smooths a little expressed breastmilk over the nipple and areola with her finger. This promotes healing.

Advise the mother not to take the baby off the breast herself but allow him to come off the breast by himself. If it is necessary for the mother to take the baby off the breast before a feed has finished she should insert a finger into the side of the babyIs mouth to break the seal.


In warm weather, a cotton brassiere may be preferable to one made of synthetic material. If necessary, suggest that she leaves her brassiere off for a day or two.

Full and engorged breasts

Full breasts

These occur a few days after delivery, when the mother’s milk ‘comes in’ . Her breasts may feel hot, heavy and hard. However, her milk will flow well. The milk can often be seen dripping from her breasts. This is normal fullness. Sometimes, full breasts may also feel quite lumpy. The only treatment this mother needs is for her baby to breastfeed frequently, to remove the milk. The heaviness, hardness, or lumpiness decreases after a feed, and the breasts feel softer and more comfortable. In a few days, her breasts will adjust to the baby’s needs, and will feel less full (she should not think that her milk has dried up though).

Engorged breasts

Engorgement means that the breasts are overfull, partly with milk, and partly with increased tissue fluid and blood, which interferes with the flow of milk. The breasts may look shiny, because of oedema. The mother’s breasts often feel painful, and her milk does not flow well. This is caused by the pressure of fluid in the breast, and partly because the oxytocin reflex appears not to work well.

When a nipple is stretched tight and flat because of engorgement, it is difficult for a baby to attach to it, and to remove the milk.

Sometimes when breasts are engorged, the skin looks red and the mother has a fever. Mastitis may be suspected. However, the fever usually settles in 24 hours.

It is important to be clear about the difference between full and engorged breasts because engorgement is not so easy to treat.

The causes of breast engorgement are:

Plenty of milk;

Delay in starting to breastfeed;

Poor attachment, so the breastmilk is not removed effectively;

Infrequent removal of the milk; Restricting the length of the breastfeeds.

The three most important ways to prevent engorgement are:

To let the baby start breastfeeding soon after delivery;

To make sure that the baby is well attached to the breast;

To encourage unrestricted breastfeeding.

It can be seen that prevention is closely related to the causes of engorgement. A baby should suckle effectively from soon after delivery, without restrictions on the length or frequency of feeds. Then the milk pressure does not build up in the breasts and engorgement is less likely to occur.

To treat engorgement it is essential to:

Remove the breastmilk.

If milk is not removed:

Mastitis may develop, An abscess may form, and Breastmilk production decreases.

So do not advise a mother to " rest" her breast.

If the baby is able to suckle, he should feed as frequently as he is willing.

This is the best way to remove milk. Check and if necessary correct the babys attachment. Then he removes the milk more effectively. The mother may need to support her breasts if they are large.

If the 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. 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 a number of things which can be done to help her, or that she can do for herself:

A warm compress can be put on her breasts, or

she can take a warm shower;

Her neck and back can be massaged;

Her breast can be lightly massaged

Her breast and nipple skin can be stimulated;

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.

Mastitis is sometimes confused with engorgement. However engorgement affects the whole breast, and often both breasts. Mastitis affects part of the breast, and usually only one breast. However, if engorgement is not relieved, it may lead to mastitis.

The symptoms of mastitis

Mastitis may develop in an engorged breast, or it may follow a blocked duct. A blocked duct occurs when the milk is not removed from part of a breast, usually one of the breast lobes. Sometimes this is because the duct to that part of the breast is blocked by thickened milk

The symptoms are:

A lump which is tender and which follows the outline of breast lobe

There may be 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.

The cause of non-infective mastitis is probably milk under pressure leaking back into the surrounding tissues. The tissues treat the milk as a "foreign" substance. Also, milk contains substances which can cause inflammation.

The result is:

Pain and Swelling

Fever, even when there is no bacterial infection.

Trauma which damages breast tissue can also cause mastitis. This may also be because milk leaks back into the damaged tissues.

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 removal of milk from 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 drain only part of the breast.

Pressure from tight clothes, usually a brassiere, 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 example, 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 a poor suckling position can lead to mastitis.

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 brassiere, 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 grip the areola, and possibly block the milk flow?

Notice if she has large, pendulous breasts, and if the blocked duct is in the lower part of her breast. Suggest that she lifts the breast more while she

feeds the baby, to help the lower part of the breast to drain more efficiently.

Whether or not a cause is found, 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 blockage from the duct. She may notice that a plug of thick material 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.

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 these situations, it is necessary to express the milk. If the milk stays in the breast, an abscess is more likely.

Usually, blocked duct or mastitis improves within a day when drainage to that part of the breast improves. If the mastitis is bilateral, it is important to swab the baby’s nose to see if the infection has been passed by this route. Any infection in the baby should then be treated.

However, a mother needs additional treatment if there are any of the following:

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:


Give either flucloxacillin or erythromycin. Other commonly used antibiotics, such as ampicillin, are not usually effective.

Explain that it is very important that she completes 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 milk removal.


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.

Breast abscess

An abscess is when a collection of pus forms in part of the breast. The breast develops a painful swelling, which feels full of fluid. An abscess needs surgical aspiration by syringe and drainage. If possible, let the baby continue to feed from the breast. There is no danger to the baby. However, if it is too painful, or if the mother is unwilling, show her how to express her milk, and let her baby start to feed from it again as soon as the pain is reduced — usually in 2—3 days. Meanwhile, continue to feed from the other breast.

Good management of mastitis should prevent the formation of an abscess.


1 Alexander JM, Grant AM, Campbell Mi. Randomised controlled trial of breast shells and Hoffman’s exercises inverted and non-protractile nipples. Br Med JNL 1992. 304:1030-1032.

2 The MAIN Trial Collaborative Group. Preparing for breastfeeding: treatment of inverted and non-protractil nipples in pregnancy. Midwifery 1994. 10:200-21 1.

3 Widstrom A-M, Ransjo-Arvidson A.B, Christensson K,Matthiesen A-S, Winberg J, Uvnas-Moberg K. Gastric suction in healthy newborn infants. Acta Paedia Scand 1987. 76:566-572

4 McGeorge DD ‘The Niplette’ : An instrument for the no surgical correction of inverted nipples. Br ml Plast Surg 1994. 47;1:46-49

5 Kesaree N, Banapurnath CR, Banapurnath S, Shamanu Treatment of inverted nipples using a disposable syringe jnl Hem Lact 1993. 9:27-29

6 Hammonds M.The mysterious white spot. Parents Centre 1992. 24-25

7 Thomsen AC, Esperen 1, Maigaard S. Course and treatment of milk stasis, non-infectious inflammation of the breast and infectious mastitis in nursing women. Jnl Obstet Gynecol 1984. 149:492-495.

Breast shell

This is a glass or plastic hemisphere, with a hole in the base, to put over the nipple and surrounding areola. The nipple is pressed through the hole which makes it stand out more. It can be worn under clothing.

If a mother is worried about inverted nipples, and has heard of nipple shells and wants to try to use them, advise her to use them only during feed times. If they are worn between feeds they may cause the problems previously described, and in addition may cause continued pressure on the lactiferous sinuses, thereby, preventing the milk draining efficiently. They are sometimes used when a baby is feeding on one breast to collect the milk draining from the other breast.

Hoffman’s exercises.

Some women may have heard of exercises to stretch nipples. These exercises have not been shown to help. They are unlikely to make any difference to severely inverted nipples. Nipple exercises can sometimes traumatise the breast, and should not be recommended. However, if a woman has heard about exercises and wishes to do them, let her continue but advise her to be very gentle.

Nipple Sheilds

Nipple shields are shaped like nipples or teats and made of rubber or soft silicone. They are worn over the mothers nipple and areola for a baby to suck through. Mothers sometimes use them if they have conditions such as inverted nipples, or sore nipples, or if a baby seems to ‘refuse’ to suckle from her breasts directly, if a baby has difficulty learning to attach because he is small, preterm or weak.

Nipple shields should be used with extreme caution, they are no longer recommended for use without very good reason. They should definitely not be used when a baby is just beginning to learn to breastfeed because it may be very difficult to get a baby to continue to breastfeed without them. Nipple shields can create problems and do not remove the cause of the initial condition, which was responsible for their use in the first place. They can

Reduce the flow of milk;

Cause breast infections, including Candida;

Add to the difficulties some babies may experience with learning more than one suckling technique.

Some mothers find it difficult to stop using nipple shields, and need to be ‘weaned’ off them. But this may take a lot of skill and patience. If a mother wishes to use one, first of all:

Assess the problem

Look for a solution, which avoids the use of a shield

To avoid their use:

Make sure the baby is well attached, using an appropriate position.

If the mother has flat or inverted nipples follow the ‘management’ suggested under the ‘flat and inverted nipples’ section of this session.

If the baby ‘refuses’ or ‘fights’ at the breast, feed him by cup until he settles down, or use the breastfeeding supplementer.

Start the milk flow prior to attaching the baby to the breast, if the baby is preterm , weak or has difficulty learning to suckle.

If a mother still wishes to use a nipple shield make sure she is aware of the drawbacks of their use - and that they are (usually) only a temporary measure. If the mother is discharged using nipple shields her baby should be carefully followed up to ensure he is getting sufficient breast milk for his needs, for example, make sure he is weighed regularly.

When are nipple shields appropriate?

Nipple shields may be useful in a small number of cases. However, they should be used for a short time only ani with very careful supervision. They may be appropriate when:

A mother has a non-protractile and inverted nipple, and nothing else appears to help her attach her baby to the breast.

A mother with a non-protractile nipple whose baby has a cleft lip and/or palate. However, this should not be use until other ways of attaching the baby have been tried, because there is a danger that her breast will not be sufficiently stimulated.

A mother with an over abundant milk supply which causes the baby to refuse the breast.

A mother who is so distressed that she is about to stop breastfeeding altogether because her baby will not or is unable to attach to her breast. A single use of the nipple shield in this situation may help.

Nipple shields are available in two sizes, if they are used, the mother should use the most appropriate size.

Breast shells and nipple shields are available in some shops, and a mother may bring them with her into hospital. Therefore, information about their use should ideally be given in the antenatal period.

Syringe method for treatment of inverted nipples

This method is for treating inverted nipples postnatally, and to help a baby to attach to the breast. It is not certain whether it is helpful antenatally.

A 10 ml syringe is required:

Cutapproximately 3 cm off the adaptor end of the barrel.

Put the plunger into the cut end of the barrel (that is, the reverse of its usual position).

Explain that the mother must use the syringe herself.

She should:

Put the smooth end of the syringe over her nipple, as demonstrated.

Gently pull the plunger to maintain steady but gentle pressure.

Do this for 30 seconds to 1 minute, several times a day.

Push the plunger back to decrease the suction, if she feels pain. (This prevents damaging the skin of the nipple and areola.)

Push the plunger back, to reduce suction, when she removes the syringe from her breast.

Use the syringe to make her nipple stand out just before she puts her baby to the breast.

Module 3

Insufficient milk production.


At the end of this session, you should be able to:

Decide if a baby is getting enough breast milk or not.

Help mothers whose babies are not getting enough milk.

Help mothers who think that they do not have enough breast milk.

Help a mother to increase her breast milk.

Materials required.

Information Sheets 10 and 11


One of the commonest reasons that mothers give for starting bottle feeds, or for stopping breastfeeding, is that they think that they "do not have enough milk". Only very few mothers appear to have a genuinely pathological milk production. In one project designed to investigate the physiological basis of breast milk insufficiency only 2% of women referred for investigation were found to have a genuinely low milk production with pathological origins

Almost all mothers can produce enough milk for one or more babies, indeed the majority of mothers produce more milk than is required. A mother may think she does not have enough breast milk, when her baby may in fact be getting all that he needs.

It is important, therefore, to think not about how much milk a mother can produce, but about how much milk her baby is getting.

When a baby does not get enough breast milk it is usually because he is not suckling often enough, or not suckling effectively. Only rarely is it because his mother is unable to produce sufficient for his needs.

How to decide if a baby is getting enough breast milk or not

Only two signs are really RELIABLE indicators that a baby is NOT getting enough breast milk. These are:

Poor weight gain.

Passing small amounts of concentrated urine.

These signs are POSSIBLE indicators:

They may also mean that a baby is not getting enough milk, but they are not reliable.

A baby not satisfied after his breastfeeds

A baby who cries often

A baby requiring very frequent breastfeeds

A baby requiring very long breastfeeds

A baby refusing to breastfeed

A baby who has hard, dry, or green stools

A baby who has infrequent small stools

No milk comes out when mother expresses

The mother’s breasts did not enlarge and no changes were noticed during pregnancy

The mother’s milk did not ‘come in’ after delivery

Stool frequency

How often a breastfed baby passes a stool is very variable. He may not pass a stool for several days, which is quite normal. When he does pass a stool, it is usually large and semi-liquid. However, he may have eight or more semi-liquid stools in a day. Small dry or green stools may be a sign that a baby is not getting enough breast milk.

Disposable nappies

Disposable nappies absorb urine and make it more difficult to decide if a baby has passed urine. If a mother is worried about her milk supply she can weigh her baby’s nappies. This will help her check the frequency and amount of urine her baby is passing.

Any nappy weighed, whether disposable of made of cloth should be weighed before it is put on the baby and again when it is changed.

ALL the following signs are unreliable.

Even though a mother may think these signs indicate she has insufficient milk, they are all unreliable indicators:

A baby sucks his fingers

A baby sleeps longer after having a bottle feed

A baby’s abdomen is not rounded after feeds

The mother’s breasts are not full immediately after delivery

The mother’s breasts are softer than before

The breastmilk is not dripping out

The mother does not ‘feel’ her oxytocin reflex

Family members ask if she has enough milk

A health worker said she did not have enough milk The mother was told she was too young or too old to breastfeed

The mother was told her baby was too small or too big

The mother had a previous poor experience of breastfeeding

The mother thinks her breast milk looks thin

A mother may worry for any of these reasons but none of them mean that her baby is getting insufficient milk.

To find out if a baby is getting enough breast milk or not:

Check the baby’s weight gain. This is the most reliable sign.

A breastfed baby may lose some weight in the first few days after birth but by day 10 post delivery he should have regained his birthweight. A number of studies have shown that the growth patterns of breast and formula fed babies are different.In the first two or three months after birth, breastfed babies put on weight more rapidly than formula fed babies, but from the third or fourth month they tend to grow more slowly. This is normal. In the first six months of life, a baby should gain at least 500g in weight each month, or 125g each week.

If there is any concern over the baby’s weight gain, look at his growth chart if available, or at any other record of previous weights. Arrange to weigh the baby at regular intervals but avoid test-weighing, because this is a very unreliable measurement.

The scales may not be accurate.

The baby will almost certainly take different amounts at different feeds.

If test weighing is considered necessary, it should be carried out over a 24 hour period.

If the baby is gaining enough weight, he is getting enough milk. If a baby demand feeds from birth, his weight gain may be better than a baby who is initially delayed in beginning to breastfeed. This is because early feeds help stimulate the mother’s milk supply to become established more quickly. A baby who weighs less than his birth weight at 2 weeks of age is not gaining enough weight.

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 breast milk 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. This can tell you quickly if an exclusively breastfed baby is getting enough milk. However, if he is having any other drinks it may not be a reliable sign.

The causes of insufficient milk production

Breastfeeding factors

Delayed start:

If a baby does not start to breastfeed in the first day, his mother’s breast milk may take longer to come in, and he may take longer to start gaining weight.

Infrequent feeds:

Breastfeeding less than 8 times a day in the first 4 weeks, or less than 5-6 times a day at an older age, is a common reason why a baby does not get enough milk. Sometimes a mother does not respond to her baby when he cries, or she may miss feeds, because she is too busy or at work. Some babies are content and do not show that they are hungry often enough. In this case, a mother should not wait for her baby to ‘demand’, but should wake him to breastfeed every 3-4 hours. However, she may not know until she has left hospital if this is the way her baby will behave. If a baby is suckling infrequently the mother’s milk supply may decrease. However, this is not to do with the mother’s capacity to produce milk, but is the ‘supply and demand’ principle at work.Therefore, the mother’s milk supply can be increased with appropriate management.

Scheduled feeds:

Scheduled feeds stop a baby feeding when he is ready so that he may suckle less efficiently and less often. This may result in a decrease in the mother’s milk supply.

No night feeds:

If a mother stops breastfeeding her baby at night before her baby is ready, her milk supply may decrease.

Short feeds:

Breastfeeds may be too short or hurried, so that the baby does not get enough fat-rich hind milk. Sometimes a mother takes her baby off her breast after only a minute or two. This may be because the baby pauses, and his mother decides that he has finished. Or she may be in a hurry, or she may believe that her baby should stop in order to suckle from the other breast. Sometimes a baby stops suckling too quickly, for example if he is too hot, because he is wrapped in too many clothes.

Poor attachment:

If a baby suckles ineffectively, he may not get enough milk.

Bottles and dummies:

A baby who feeds from a bottle or who sucks on a dummy may suckle less at the breast, so his mother’s breast milk supply decreases.

Supplementary feeds:

A baby who has supplementary feeds or other foods and drinks such as, artificial milks, solids, or drinks including plain water, before 4-6 months suckles less at the breast, so the breast milk supply decreases.

Psychological factors (the mother)

Lack of confidence:

Mothers who are very young, or who lack support from family and friends, often lack confidence. Mothers may lose confidence because their baby’s behaviour worries them. Lack of confidence may lead a mother to give unnecessary supplements.

Worry, stress:

In an acute situation if a mother is worried or stressed or in pain, her oxytocin reflex may temporarily not work well, and it may seem as if her milk has ‘dried up’ . There is little evidence to suggest chronic stress permanently affects a mother’s milk supply.

Dislike of breastfeeding, rejection of the baby, and tiredness:

In these situations, a mother may have difficulty in responding to her baby. She may not hold him close enough to attach well; she may breastfeed infrequently, or for a short time. She may give her baby a dummy when he cries instead of breastfeeding him.

Physical condition (the mother)

Contraceptive pill:

Contraceptive pills which contain oestrogens may reduce the secretion of breast milk. Progesterone-only pills and depo-provera are preferred because they do not reduce the breast milk supply.


May reduce the breast milk supply


If a mother becomes pregnant again, she may notice a decrease in her breast milk supply.

Severe malnutrition:

Severely malnourished women may produce less milk. However, a woman who is mildly or moderately undernourished continues to produce milk at the expense of her own body stores, provided her baby suckles often enough

Alcohol and smoking:

Alcohol and cigarettes can reduce the amount of breast milk that a baby takes.

Retained piece of placenta:

This is RARE. A small piece of placenta remains in the uterus, and makes hormones which prevent milk production. The woman may as a result bleed more than usual after delivery, her uterus does not decrease in size, and her milk does not ‘come in’.

Poor breast development:

This is VERY RARE. Occasionally a woman’s breasts do not develop and increase in size during pregnancy, and she does not produce much milk. If the mother noticed an increase in the size of her breasts during pregnancy, then poor breast development is not her problem.

It is not necessary to ask about this routinely. Ask only if there is a problem.

The baby’s condition


A baby who is ill and unable to suckle strongly does not get enough breastmilk. If this continues, his mother’s milk supply will decrease.


A baby who has a congenital problem, such as a heart abnormality, may fail to gain weight. This is partly because he takes less breastmilk, and partly because of other effects of the condition.

Babies with a deformity such as a cleft palate, or with a neurological problem, or mental disability, often have difficulty in suckling effectively, especially in the first few weeks.

How to help a mother whose baby is NOT getting enough breastmilk

If a baby is not getting enough milk, you need to find out WHY.

To find the cause:

Listen and learn (to learn about psychological factors, and how the mother feels)

Take a history (to learn about breastfeeding factors, and any medication the mother is taking)

Assess a breastfeed (to learn about the baby’s attachment and ability to suckle, and to see the relationship the mother has with the baby)

Examine the baby (for signs of illness or abnormality, and to assess his growth)

xamine the mother and her breasts (to learn about her health, her nutrition, and any breast condition)

Once there is some indication of why the baby is not getting sufficient milk it is possible to help the mother, to build her confidence and give her the support to succeed. The mother needs to have the situation explained to her. She can then be helped in the following ways:

By accepting what she thinks and feels, By praising the things she and her baby are doing correctly,

By giving her practical help and suggested ways of approaching the problem which has been identified

Giving her relevant information in language which is appropriate to her needs.

Occasionally it is not possible to find a cause of an apparent poor milk supply or the milk supply does not improve (the baby does not gain weight) even though everything has been done to help the mother. In this case the less common causes should be considered.

Occasionally a mother may need to find a suitable formula milk for her baby. In this case encourage her to:

Continue breastfeeding as much as possible; Give only the amount of formula milk that her baby needs for adequate growth;

Give the formula milk by cup;

Give the formula milk only once or twice a day, so that her baby suckles as often as possible at the breast at other times.

Remember that the need for supplementary feeds before 4-6 months of age should be RARE, and for medical reasons only.

How to help a mother who thinks that she does not have enough breast milk.

Many mothers worry about their breast milk supply, but their babies are getting all the milk that they need.

These mothers lack confidence in their breast milk and in their ability to breastfeed. It is very important to help them, otherwise they may decide to start artificial feeds.

To understand the situation:

Listen and learn (to understand why she lacks confidence. Empathize with how she feels.)

Take a history (to learn about the pressures that she is under from other people to give a formula milk).

Assess a breastfeed (to see if poor attachment could be the problem. If a baby is suckling very often, or for a long time, it may be because he is poorly attached and getting the breast milk inefficiently. He may be getting enough breastmilk.)

Examine the mother and her breasts (to see the shape of her breasts, nipples, and areola. She may lack confidence if they are small or flat, or very large or an unusual shape.)

Build the mother’s confidence and give her support by using your communication skills. especially those in the ‘Building a mother’s confidence’ worksheet.

How to help a mother to increase her milk supply

If a mother has a truly insufficient milk supply the most important thing she can do is to let her baby suckle often to stimulate her breast, provided attachment is good. It is important for her to feed her baby on demand rather than according to any schedule.

In the past, people often advised mothers to ‘rest more, eat more, drink more’ . These are not effective by themselves. 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 want does not increase their breast milk supply. Drinking too much may sometimes reduce the milk supply.

In many communities, special foods, drinks or herbs are recommended, which people believe increase the breast milk supply. They do not work like drugs, but may help a woman to feel confident and relaxed. It may be worth finding out if there are any such recommended foods or drinks in the mother’s community.

Drugs are sometimes prescribed (chlorpromazine, or metoclopramide) to increase breast milk. These drugs may help in difficult situations, but they should not be used routinely. Even if they are used, it is still necessary for the baby to suckle frequently to establish a good supply of breast milk.

The length of time that it takes for a woman’s breast milk supply to increase varies. lt helps if the mother is strongly motivated, and if her baby is willing to suckle frequently. The mother should be prepared that it may take some time for the increase to occur.

If a baby is still breastfeeding sometimes, the breast milk supply increases in a few days. lf a baby has stopped breastfeeding, it may take 1 -2 weeks or more before much breast milk comes.

How to use a breastfeeding supplementer to help increase the milk supply

When a breastfeeding supplementer is useful:

A breastfeedng supplementer is a device for giving a baby a supplement while he is also suckling at a breast which is not producing sufficient milk.

A hungry baby may suckle at an ‘empty’ breast a few times, but he may become frustrated and refuse to suckle any more — especially if he has become used to sucking from a bottle.

To stimulate a breast to produce milk, it is necessary for a baby to suckle. A breastfeeding supplementer helps to encourage him to continue suckling.

Method of use

1 The mother should hold one end of the tube along her breast, securing it with a lightweight adhesive tape above the areola so that the tube goes into the baby’s mouth with her nipple and areola.

2 Put the free end of the tube into the milk in the cup. Find a convenient place for the cup. It may be possible to put it on a table nearby, or it may be easier for the mother to hold it.

3 The tube works like a drinking straw. As the baby suckles on the breast, he gets milk from the cup through the tube.

If the baby gets milk, he continues to suckle and stimulates the breast. This starts the production of breastmilk. As breastmilk is produced, the amount of milk taken from the cup decreases, and eventually the supplementer is no longer needed.

4 It is important that the baby gets the milk fast enough to reward him for stimulating the breast; but not too fast, or he will not stimulate the breast for long enough.

5 If the cup is raised, this makes the milk flows more quickly so it is easier for the baby to get. If you lower the cup, the milk flows more slowly.

6 Tie a knot in the tubing. If the tube is not fine enough, the milk flows too fast. Tying a knot in the tube is a way to slow the flow. (Other possibilities include pinching the tube, or putting a paper-clip on it.)

Other methods of giving supplements

There are a number of other ways to give a baby a supplement while he is suckling at the breast. These methods are useful if a baby does not suckle strongly at the breast, or if a mother finds a supplementer difficult.

A syringe

1 Use a 5-mI or 10-mI syringe.

2 Fix a length of fine gastric tubing to the adaptor, about 5 cm in length.

3 Measure the milk for a feed into a small cup.

4 Fill the syringe with milk from the cup.

5 Put the end of the tube into the corner of the baby’s mouth, and press out the milk slowly as he suckles.

6 Refill the syringe and continue until the baby has had a complete feed.

A dropper

1 Measure the milk for a feed into a cup.

2 Drop the milk into the 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 syringe, dropper or small cup.

1 Position the baby at the breast so that he licks the milk from the breast.

2 Slowly put the nipple and areola into his mouth, and help him to attach to the breast.

3 Continue for 3-4 days until he can suckle strongly.


1 Woolridge MW. Breastfeeding: physiology into practice.

Ch 2, ppl3-30 from: Part 1: Nutrition in the Normal

Infant. In: Nutrition in Child Health. (Ed) Davies DP 1995.

Royal College of Physicians of London.

2 Hitchcock NE, Coy iF. The growth of healthy Australian infants in relation to infant feeding and social group. Med Jnl Aust 1989, 150:306-11.

3 Whitehead RG, Paul AA, Cole Ti. Diet and growth of healthy infants. I Hum Nutr Diet 1989, 2:73-84.

4 Butte NF, et al. Human milk intake and growth in exclusively breast-fed. infants. I Paediatrics 1984, 104: 1 87-95.

5 Heinig Mi, Nommsen LA, Peerson JM et al. Energy and protein intakes of breast-fed and formula-fed infants during the first year of life and their asociation with growth velocity: the DARLING Study. Am jnl C/in Nutr 1993. 58:152-161.

6 Dewey KG, Heinig Mi, Nommsen LA et al. Breast-fed infants are leaner than formula-fed infants at 1 year of age: the DARLING Study. Am jnl C/in Nutr 1993. 57:140-145.

How to help a mother use a breastfeeding supplementer

Show the mother how to:

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

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.

Module 3



At the end of this session, you will be able to:

Help a mother to start breastfeeding g again if she has stopped (relactation).

Help a mother who needs to induce lactation, because she has never breastfed previously.


If a mother has stopped breastfeeding, she may want to start again. This is called re!actation. It is possible even when a mother has not breastfed for many weeks, months or even years. It is also possible to induce lactation in women who have never been pregnant. However, both relactation and induced lactation require a commitment from the mother and a great deal of support from her carers.

When is relactation useful?

The situations when relaction may be useful include:

A baby who has been sick and has not suckled for a prolonged period of time.

A baby who has been artificially fed, but his mother wishes to try breastfeeding.

A baby who becomes ill or fails to thrive on artificial feeds.

A baby in a neonatal unit who has not yet begun to breastfeed and is only able to do so after several weeks.

The mother has been sick and stopped feeding her baby.

A woman who adopts a baby (but who has been pregnant previously).

When induced lactation may be useful

Even a woman who has never breastfed, or who has never even been pregnant, can produce breast milk if she suckles an adopted child This is called induced lactation. The amount of breast milk that such a mother can produce varies, and she may not be able to breastfeed the baby fully.

There are several studies showing that induced lactation is possible

A group of women for whom induced lactation may become increasingly important are in cases of surrogacy.

How to relactate or induce lactation

The same principles and method apply for increasing a reduced milk supply, and for relactation. Therefore, the part of session 3C which discusses increasing the milk supply should be read in conjunction with this section.


To produce breast milk, two kinds of stimulation are required:


The use of a breast pump, hand expression and a baby suckling at the breast. Mechanical stimulation of the breasts may result in increased levels of prolactin and oxytocin.

Drug treatment

A woman who has never been pregnant and who is adopting a baby is likely to benefit from drugs which stimulate breast milk production (see drug therapy).

Most mothers who have been pregnant in the recent past do not need drugs, though for some women they may be helpful.

A mother who wishes to relactate or induce lactation will need to:

Let her baby suckle at the breast every 2 hours, during the night and day.

I Let her baby suck as long as possible. The baby’s intake should be checked by daily weighing. His nappies should also be weighed. If they are very absorbent they will need to be weighed before and after changing to check that the baby is passing urine frequently. If nappies are to be weighed the same scales should be used on each occasion.

Give her baby any formula milk by cup, spoon, syringe or the breastfeeding supplementer while her milk supply is increasing.

Rigidly follow this regime until milk can be expressed, and her baby grows adequately without supplementation.

Some mothers may also find additional breast stimulation from an electric pump is helpful.

The expression of milk may begin between 5 — 10 days after the stimulation and/or drug treatment begins. An adequate milk supply, however, may take up to 6 weeks to achieve.

Other useful information

It is easier to relactate if the baby is very young (less than 2 months) and can be trained to suckle. If the baby has become accustomed to feeding from a bottle it may be more difficult if he is older (e.g. more than 6 months) to persuade him to breastfeed. However, it is possible at any age.

It is also easier to relactate 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.

Drug therapy

Mothers may need to take metoclopramide 10 mg, 3 times a day, for at least 7 days.

A woman who has never been pregnant produced milk will need to:

Follow ALL the advice given previously

Take Metoclopramide 1 0 mgs, three time together with frequent stimulation from (1 0 —1 2 times a day) may be necessary

Most mothers can produce sufficient Volume partially to satisfy their baby’s needs within 6 weeks of commencing treatment and pump stimulation.


1 Hormann E. Breastfeeding the adopted baby. 1977. 4:165.

2 Philips V. Establishment of lactation for the b of an adopted baby. Res Bull Nurs Mothers I 1971. No4.

3 Avery JL. Relactation and induced lactation. Practical guide to breastfeeding, by Riordan & Bartlett Boston 1991 2nd edition. Chapter 13,275 - 290

4 Auerbach KG, Avery JL. Induced lactation: a adoptive nursing by 240 women. Am jnl Dis 135: 340.

5 Lewis Pi et al. Controlled trial of metoclopramide in the initiation of breastfeeding. Brit jnl Clin Phar 9:217.

Refusal to breastfeed and the crying baby


At the end of this session, you should be able to:

Diagnose why a baby is refusing to breastfeed.

Help a mother and baby to breastfeed again.

List different reasons why babies may cry.

Help families of babies who cry a lot to continue with exclusive breastfeeding.

Materials required

Information Sheet 12


This session is concerned with two main problems:

The baby who refuses to breastfeed, or is unwilling to suckle.

The baby who cries a lot.

A mother who experiences these problems with her baby may be very distressed. If the baby refuses to breastfeed, she may feel rejected and frustrated. If her baby cries a lot, she may feel that it is her fault he is so unhappy or that her milk is no good for him.

Breast refusal

There are different kinds of breast refusal.

A baby may attach to the breast, but then will not suckle or swallow, or he suckles very weakly.

A baby may cry and ‘fight’ at the breast when his mother tries to breastfeed him.

A baby may suckle for a minute and then come off the breast choking or crying. He may do this several times during a single feed.

A baby may take one breast, but refuse the other.

It is necessary to decide why a baby is refusing to breastfeed, and how to help the mother and baby to enjoy breastfeeding again.

Causes of refusal to breastfeed

Possible causes include:

The baby is ill, in pain or sedated

Difficulty with breastfeeding technique

Change which upsets baby

Apparent, not real, refusal

Most causes of breast refusal fall into one or other of these groups.

Is the baby ill, in pain or sedated?


The baby may attach to the breast, but suckles less than before.


Pressure on a bruise from forceps or vacuum extraction.

The baby cries and ‘fights’ at the breast as his mother tries to breastfeed him.

Sore mouth (Candida infection (thrush), an older baby teething).

The baby suckles a few times, and then stops and cries.


A baby may be sleepy because of:

Drugs that his mother was given during labour;

Drugs that she is taking for psychiatric treatment.

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 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.

The pressure makes him want to push away from the breast.

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 may be due to one of the above factors or because:

The milk flow is not as good in one breast as in the other;

The baby is not held as securely to feed from the side he refuses.

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 quite simply refuse to suckle.

This is more common when a baby is older, between 3-12 months of age.

Possible causes:

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.

His mother becoming pregnant again.

Apparent but not real breast refusal

Sometimes a baby behaves in a way which makes I mother think that he is refusing to breastfeed. This occur when:

A newborn baby ‘roots’ for the breast. He move 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.

Management of refusal to breastfeed

If a baby is refusing to breastfeed:

a Treat or remove the cause if possible.

b Help the mother and baby to enjoy breastfeeding again.

Treat or remove the cause if possible


Treat infections with appropriate antimicrobials and other therapy.

Refer the baby if necessary to the paediatrician.

If a baby is unable to suckle, he may need to be on the neonatal unit.

Help his mother to express her breastmilk to feed him by cup or by tube, until he is able to breast feed again.


For a bruise: help the mother to find a way to h her baby without pressing on a painful place.

For a candida infection: treat with nystatin or daktarin.

For a blocked nose: explain how she can clear it Suggest short feeds, more often than usual for few days.


If the mother is on regular medication, try to find a alternative which is compatible with breastfeeding.

Breastfeeding technique:

Discuss the reason for the difficulty with the mother

When her baby is willing to breastfeed again, help her with her technique, particularly ensuring that she has him positioned appropriately for his size and gestation, and that she understands how to attach her baby.


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 at the breast.

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 (this may slow the milk flow).

Slow the flow by applying gentle pressure with her thumb and forefinger just behind the lactiferous sinuses during the initial part of the feed. However, care should be taken to ensure the pressure does not cause blocked ducts.

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 the baby is rooting:

Explain that this is normal. The mother can hold her baby at her breast to explore her nipple. Help her to hold him closer, so that it is easier for him to attach.

If it is distraction.

Suggest that she try to feed him somewhere more quiet for a while. The problem usually passes.

Help the mother and baby to enjoy breastfeeding again

Keep her baby close to her all the time.

The mother 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.

The mother should hold her baby often, and give plenty of skin-to-skin contact at times other than feeding times. She should let her baby sleep with her.

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.

The mother should not hurry to breastfeed again, but offer the breast when 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 hold her baby in a different position and then offer him the breast.

If the mother feels her ejection reflex working, she can offer her breast then.

Help the mother to breastfeed her baby in these ways:

She can 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 breast milk and feed it to her baby from a cup (or cup and spoon). If necessary, use formula milk, and feed it by cup.

She should avoid using bottles, teats, nipple shields and dummies.

The crying baby Refusal to breastfeed and the crying baby

A family’s response to a crying baby is different in different societies. So also is the way in which parents handle their children. For example, in societies where babies are carried around more, they cry less. This has been shown to be the case where increased skin-to- skin contact was encouraged soon after birth in a european hospital. If babies sleep with their mothers they are less likely to cry at night. Because babies vary a lot in how much they cry it is impossible to say that some patterns are ‘normal’, and some are not.

However, a baby who is perceived to be ‘crying too much’ may really be crying more than other babies, or his family may be less tolerant of the crying, or less skilled at comforting the baby.

The result of this may be:

A mother believing that her baby is crying because she does not have enough breastmilk.

She may give her baby unnecessary supplementary feeds to settle him. Though supplementary feeds may not make a baby cry less, and may make him more unsettled.

An upset in the relationship between the baby and his mother, such as, a crying baby, may cause tension among other members of the family as well.

The reasons why babies cry

A baby may cry for a variety of reasons, including:



Illness or pain


Mother’s food

Drugs the mother is taking Oversupply of breastmilk


Babies with special needs

The following causes of crying may not be immediately obvious:

Hunger due to a growth spurt:

A baby may seem very hungry over a period of several days, possibly because he is growing faster than before. He may at this time demand to be fed

very often. This is commonest at the ages of about 2 weeks, 6 weeks and 3 months but can also occur at other times as well. If he suckles often for a few days, the breastmilk supply will increase, and gradually he will breastfeed 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: for example,

Cow’s milk, soy, egg, peanuts.

Babies may become allergic to cow’s milk protein after only one or two prelacteal feeds of formula.

Drugs and breastfeeding:

The caffeine in coffee, tea, and cola drinks, can pass into the mother’s breast milk and upset her baby. If a mother smokes cigarettes, or takes other drugs, her baby is likely to become upset and cry. If someone else in the family smokes, that also can affect the baby.


An over-abundant milk supply can occur for a number of reasons. A baby 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 hind milk. 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 the mother has plenty of milk, she may think that she does not have enough for her baby.


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 always clear. This is called ‘colic’. Colicky babies usually grow well, and the crying gradually becomes less after the baby is 3 months old.

Babies with increased needs:

Some babies cry more than others, and need to be held and carried more. In communities where mothers carry their babies with them, crying is less common than in communities where babies are put into a pram or cot during the day for the mother to leave them, or where they are put to sleep in separate cots.

How to help a family with a baby who cries a lot

Look for a cause

Help the mother to talk about how she feels.

Empathise with her feelings.

She may feel she is a poor mother.

She may feel angry with her baby.

She may feel guilty.

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 supplementary feeds or dummies.

Take a history

Ask about the baby’s feeding and behaviour.

Ask about the mother’s diet (particularly if she drinks a lot of coffee, smokes, or takes any kind of medication, including homeopathic remedies).

Ask about any pressures that she is experiencing from her 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.

If the baby is ill or in pain, treat or refer as appropriate.

Build the mother’s confidence and give her support

Accept what the mother thinks and feels

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 correctly

Praise the mother if her baby is growing well, and is not sick

Her breast milk 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

The baby has a real need for comfort. He is not sick, 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.

Supplementary feeds are not necessary, and often do not help. Artificially fed babies also have colic and may develop cow’s milk intolerance or allergy and become worse.

Suckling at the breast for comfort is normal, but giving the baby a dummy may interfere with his ability to suckle.

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 the mother some ways to hold and carry her baby.

Sometimes it is easier for someone other than the mother to carry the baby, so that he cannot smell the breast milk.

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.)

Make one or two suggestions

What you suggest to the mother depends on what you have learnt about the cause of the crying. Causes may vary in different cultures.

Use simple and non-technical language.

Suggestions which may help a mother

If she has an over-abundance of breast milk:

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 hind milk.

It might help if she takes less coffee and tea, and other drinks which contain caffine such as cola. 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 week. 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 eating these foods completely if her diet is considered poor. Offer to discuss the situation with her family, to talk about the baby’s needs and about her need for support.

It is really very important to try to help to reduce any family tension, so that the mother does not feel pressurised to give any unnecessary supplementary feeds.


1 Christensson K, Cabrera T, Christensson E, et al. Separation distress in the human neonate in the absence of maternal body contact. Acta Paed 1995. 84:486-473.

2 Countryman BA. ‘Self-care’, Ch 4, pp 67 In ‘Breastfeeding and Human Lactaction’, Riordan J, Auerbach KG (Eds). Publ. Jones & Bartlett, London. 1993.

How to hold and carry a colicky baby

Babies are most often comforted with closeness, gentle movement, and gentle pressure on the abdomen There are several ways to provide this.

Hold the baby along your forearm, pressing on its back with your other hand. Move gently backwards and forwards.

Sit down and hold the baby lying face down across your lap. Gently rub the baby’s back.

Sit down and hold the baby sitting on your lap, with its back to your chest. Hold it round the abdomen, gently pressing on the abdomen

Hold the baby upright against your chest, with the his head against your throat. You should hum gently, so that a baby can hear you. This is often very successful if a man is holding the baby, a man’s voice is deeper and the baby is often soothed by this!

Module 4.

Helping a mother overcome breastfeeding difficulties: The baby with special needs


At the end of this you will be able to describe:

Why breast milk is the best food for preterm and low-birth-weight babies.

Why it is important to continue breastfeeding or giving breast milk when an infant is sick or jaundiced.

Participants will also be able to:

Help a mother of a preterm or sick baby to give her baby breast milk.

Help a mother to feed her baby by alternative feeding methods, such as: the cup, breastfeeding supplementer.

Materials required

Worksheet 9


The aim of the Ten Steps is to ensure that all mothers establish breastfeeding successfully. Some mothers and some babies, in particular circumstances, will need extra special help. Part 2 of this session examines situations in which the baby’s condition may interfere with effective breastfeeding and how any difficulties arising may be overcome.

Part 1 examines the natural maturation process of the foetus and preterm baby with regards to feeding. It also looks at the different feeding methods which can be used if breastfeeding cannot take place for any reason immediately after birth.


The natural maturation process

All babies go through a maturation process, whether it is during foetal development in utero or, in the case of preterm babies, after their birth. A baby born at term who has completed the process in utero will have developed reflexes which enables breastfeeding to begin soon after delivery.

The sequence of events which contributes to the baby’s maturation and readiness to breastfeed at birth are as follows:

Oesophageal peristalsis and swallowing, which have been observed in the foetus from as early as 11 weeks in utero.

Sucking, which has been described in various

studies to begin between 18 — 24 weeks though in

a prematurely delivered baby it is not considered to be effective for nutritive purposes before 32 — 35 weeks.

Other reflexes important to a baby’s feeding ability such as the ‘gag’ reflex are evident as early as 26 — 27 weeks in prematurely delivered babies.

‘Rooting’ is seen at 32 weeks gestation.

The gastro-intestinal system also matures. For example, the lingual lipases, which are important for the breakdown of dietary fats, are detectable in the foetus from approximately 26 weeks. This is important because production of he pancreatic lipases does not reach adult levels until late infancy.

Natural sequences of feeding and the preterm baby

A preterm or a sick baby may not be able to take any oral feeds initially. He may need to be fed intravenously. Oral feeds should begin as soon as the baby tolerates them. Human milk is the ideal choice to stimulate gut development and encourage the production of gut enzymes and flora. Enteral feeding can be commenced as soon as the gut begins to secrete the necessary enzymes to digest and absorb the nutrients present in the milk. This may occur in babies as early as 25 weeks gestation (though the process may be delayed or prolonged by a baby’s clinical condition).

Development of coordinated suckling

It is evident that babies can already swallow and suck long before 32 weeks, though these reflexes will not be mature, efficient or well co-ordinated in very preterm babies.

From about 32 weeks, many babies can suckle from the breast, and some can breastfeed fully from this age, but they may still have difficulty in coordinating

suckling, swallowing and breathing. They can suckle effectively for a short time, but they often cannot suckle long enough to take all the breast milk that they need.

By about 36 weeks, most babies can coordinate suckling and breathing, and can take all the milk they need by breastfeeding. A term healthy baby is capable of finding and attaching himself to the breast, if placed on his mother’s chest at birth.

The following table provides a guide to the approximate length of time it takes a baby at birth to develop a mature sucking pattern.

The approximate length of time from birth to a mature pattern of sucking

Gestation Number of days

Term 1 — 2 days (max 5 days)

36 — 39 weeks 5 days

34 — 36 weeks 1 — 2 weeks

33 — 35 weeks 2 — 4 weeks

32 — 34 weeks 6 — 8 weeks

This table is adapted from a similar table developed by midwife Penelope Samuel of The Royal Bournemouth Hospital. The original material is from the work of Marjorie Meyer Palmer. (See also Meyer Palmer M, Crawley K, Blanco IA. Neonatal oral-motor assessment scale: A reliability study. Jnl of Perinatol 1993. 8:1;30-35.

The normal nutritive sucking pattern of a healthy baby born at term is a continuo period of between 1 0 — 30 sucks with brief pauses for rest between each period of sucking activity. A preterm baby is characterised by periods of only 3 — 5 sucks with long periods of rest between each period of sucking activity.

The very fast sucking activity which may characterise the beginning of a ‘feed’ is non-nutritive sucking.

Methods of feeding babies according to their maturity

For the first few days, a baby who is very preterm or sick at birth may not be able to take any oral feeds. He may need to be fed intravenously. Oral feeds, however, should begin as soon as they can be tolerated by the baby.

A baby less than about 30-32 weeks gestational age usually needs to be fed by nasogastric tube. Expressed breast milk may be given by this method. The mother can let her baby suck on her finger while he is having tube feeds (though this may encourage an inappropriate sucking technique for breastfeeding), or preferably milk can be expressed onto her nipple which may encourage the baby to lick the milk. This possibly stimulates his digestive tract, and may help promote weight gain. Whenever possible the mother should hold her baby and give him skin-to-skin contact. This can be commenced even when the baby is ventilated. Skin-to- skin contact helps bonding, and helps a mother to produce breast milk because she is likely to be relaxed.

A baby between about 30-32 weeks gestational age

Can begin to take feeds from a small cup, or from a spoon. Cup feeds can be given once or twice a day while a baby is still having most of his feeds by tube. If he takes cup feeds well, the number of tube feeds can be gradually reduced. Another way to feed a baby is by expressing milk from the breast directly into his mouth. At this stage the mother may find the underarm position the most practical way to support her baby.

Helping a mother overcome breastfeeding difficulties

A baby of about 32 weeks gestational age is able to begin suckling at the breast. However, at this stage many babies may only root for the nipple and lick it. They may even attach onto the breast but without suckling, or may take 4 or 5 sucks and then pause for up to 2 or 4 minutes before continuing. It is important not to take a baby off the breast during these long pauses. Leave him on the breast so that he can suckle again when he is ready. He can continue for up to an hour in this way if necessary. Continue giving expressed breast milk by cup or gastric tube, to make sure the baby gets all that he needs until he is able to suckle effectively. Make sure that he suckles in a good posit Good attachment vvi he him to breast feed successfully.

The best positions for a mother to hold her preterm or small baby at her breast are: Across her body, holding him with the arm on the opposite side to the breast he is feeding from.

The underarm position. A baby from about 34-36 weeks gestational age or more (sometimes earlier) can often take all that he needs directly from the breast. However, supplements from a cup may continue to be occasionally required.

For example, a baby may feed well sometimes, but tire and feed poorly at other times. If a baby suckles poorly, offer a cup feed after the breastfeed. If he is hungry, he will take milk from the cup. If he has enough, he will not take milk from the cup.

Time of the first oral feed

If oral feeding is possible as soon as a preterm, low birth-weight or sick baby is born, the first feed should be given within the first 2 hours, and every 2-3 hours thereafter, to prevent hypoglycaemia (low blood sugar).

Until the mother has produced colostrum, feeds of banked donor breast milk are an ideal alternative. If breast milk is not available, glucose water or formula may need to be used instead. Glucose water is not necessary for well, term babies who are not at risk of becoming hypoglycaemic.

Weight as a guide to feeding method

Gestational age is a better guide to a baby’s feeding ability than weight. However, it is not always possible to know gestational age. Many babies start to take milk from the breast when they weigh about 1300-1600 grams. Many can breastfeed fully when they weigh about 1600-1800 grams or less

Alternative methods of feeding

For babies who require admission to a Special Care Baby Unit or to a Neonatal Unit, it may not be possible for the mother to breastfeed in the initial period after birth. Alternative methods of feeding may then be necessary. These include:

Intravenous feeding

Trans-pyloric tubes

Gastric tubes

A cup

Breastfeeding supplementer

A syringe

A spoon and cup

A bottle and specialised teats

These methods can be used in a variety of situations.

Intravenous feeding

This method of feeding is necessary for very sick babies, and for the majority of preterm babies born at less than 32 weeks gestation. Some babies who are hypoglycaemic may also need dextrose saline given intravenously.

If the medical condition of the baby is stable and he is mature enough, he can still breastfeed while also receiving intravenous fluids. Often, s the number of breastfeeds increase, the intravenous fluids are gradually reduced. Even if the baby is too young to breastfeed efficiently he can be held skin-to-skin and near his mother’s breast. He may be able to lick the milk from her breast if she hand expresses a little onto her nipple.

A baby can receive his mother’s expressed breast milk while being fed intravenously if he has a gastric tube, or is able to take milk from a cup.

Trans-pyloric feeding

A trans-pyloric tube is usually used when a baby is ventilated, because it is considered to reduce the risk of aspiration. The tube passes through the stomach into the jejenum and sometimes beyond. This method of feeding has a number of drawbacks. Because it delivers fluid directly into the gut, it by-passes the baby’s mouth and stomach, thus missing out important phases of digestion. Depending upon where in the baby’s gut the tube is placed, the absorption of nutrients may be reduced, leading to an unsatisfactory weight gain. Feeds administered by this route are given continuously.

Expressed breastmilk is the preferred milk type for trans-pyloric tube feeding because it is less irritating to the gut and therefore less likely to cause ecrotising enterocolitis.

Gastric tube feeds

Gastric tube feeds may be necessary in the first few days after birth if the baby is preterm or if he is sick. Milk feeds can either be given continuously into the gastric tube with the aid of a mechanical syringe pump or as bolus feeds. If a breastmilk feed is given continuously, the syringe used on a pump should be positioned so that the nozzle or adaptor of the syringe is placed uppermost (as the creamier part of the milk tends to settle on the top). This ensures delivery of the richer milk first. Only 4 hours worth of milk should be used at any one time in a syringe to avoid the growth of bacteria in the milk. During any attempt at breastfeeding any mechanical pump used to deliver the milk by gastric tube via a syringe should be stopped. When bolus gastric tubes are given breastfeeding should take place before or at the same time as the tube feed.

Gastric tubes may be passed nasally or orally. If an oral tube is left in place for continuous or bolus feeds, care should be taken to ensure the tube is secured at the side of the mouth and cheek so that the tongue is able to move freely. If the tongue is not free to move, breast or cup feeding is very difficult for the baby.

Gastric tube feeds may occasionally be required by a baby who is very sleepy because of maternal medication during labour, or as a result of jaundice.

They may also be used for babies who are hypoglycaemic and who may need one or two feeds to correct the problem.

If a baby is receiving his mother’s breast milk by gastric tube then she should express her milk regularly until he can breastfeed.

A cup

Cup feeds give a baby valuable experience of taking food by mouth, and the pleasure of taste. They stimulate the baby’s digestion. Many babies show signs of wanting to take things into their mouths when they are still preterm, some as young as 30 weeks post conception age, yet they are not able to suckle effectively at the breast.

A cup can be used in a variety of situations where bottles may have previously been the only alternative It can be useful in the following situations:

A preterm baby who is wide awake and restless at feed times.

A baby who shows signs of wanting to suck, e.g., sucking on his fist.

The baby who is not satisfied by tube feeds and is restless after the feed.

The baby who is not yet able to feed directly from the breast, or has only enough energy to satisfy part of his total nutritional needs at the breast.

A term baby whose mother has had a Caesarian section, or is ill after delivery.

A baby with an oral defect, e.g. a cleft lip and/or palate.

A baby who is lacking energy because of a cardiac or respiratory problem.

A baby who cannot take his breast milk directly from the breast in the initial period after birth because he has a neurological problem and cannot yet coordinate his suckling.

Cup feeding is useful because:

A cup is easy to sterilise.

A cup is unlikely 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 securely and look at him, and give him some of the contact that he needs.

A cup does not interfere with suckling at the breast.

A cup enables a baby to control his own intake.

No teat is put into the baby’s mouth.

How to feed a baby with a cup

Follow these steps:

Put some milk into a small cup (a 60 ml medicine measure with a smooth rounded rim can be used).

Hold the baby closely on your lap. Sit him upright or semi-upright (he should not be lying in a breastfeeding position because the milk can then be poured into his mouth and aspiration can occur). Support the back of his head and neck with your hand (See diagram below).

Hold the small cup to the baby’s lips. Tip it so that the milk just reaches his lips. The edges of the cup gently touch the outer edges of the baby’s upper lip, and the cup rests lightly on his lower lip.

At this point, the baby often becomes alert, and opens his mouth and eyes. He makes movements with his mouth and face, and he starts to take the milk into his mouth with his tongue. Babies more than about 36 weeks gestation try to sip the milk.

Some milk may spill from the baby’s mouth. A cloth can be placed on the baby’s front to protect his clothes. Dribbling is more common with babies of more than about 36 weeks gestation, and less common with younger babies.

Milk SHOULD NOT BE POURED into a baby’s mouth — just hold the cup to his lips.

When a 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 he may need feeds more often. Measure his intake over 24 hours, not just at each feed.

General observations

It is normal for the amount of milk that a baby takes at each feed to vary — this is true, whatever the method of feeding, including breastfeeding.

Babies feeding by cup or breastfeeding supplementer may take more or less than the calculated amount. If possible, offer a little extra, but let the baby decide when to stop.

If a baby takes a very small feed, offer extra at the next feed, or give the next feed earlier, 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.

Preterm babies need only very small volumes during the early days. If the mother can express even a small amount of colostrum, it is often all that her baby needs, when given often enough.

The breastfeeding supplementer

The breastfeeding supplementer can be used in the following situations:

Affecting the mother:

A persistent insufficient milk supply.

Breast surgery.

Relactation (or induced lactation).

Affecting the baby:

A weak suck due to prematurity.

A weak suck due to neurological damage.

A baby with a weak suck due to a chromosomal abnormality, e.g. Downs Syndrome.

An unsettled baby who refuses to attach at the breast.

A syringe

Milk trickled onto the breast or areola, so that it trickles onto the nipple area from a syringe may be useful:

For a baby who refuses or is reluctant to attach to the breast;

For preterm babies who do not have the strength to suckle effectively, but are able to lick and swallow the milk trickled onto the breast;

For mothers whose ‘let-down’ reflex is temporarily inhibited for whatever reason.

A spoon and cup

In most of the situations where a cup is useful, a spoon may also be used.

Spoon feeding may take longer than cup feeding.

Three hands are needed to spoon feed! One to hold the baby, one for the cup of milk and one for the spoon. Mothers often find it difficult, especially at night and may not give enough milk to the baby. This is an important reason why the technique is not favoured.

Spoon feeding is safe, if a mother prefers it, and if she is able to give her baby sufficient amounts.

If a baby is very ill, for example with difficult breathing, it is sometimes beneficial to feed him with a spoon for a short time.

A bottle and specialised teats

Babies who may require a special teat connection to a bottle include:

Some babies with a cleft lip and/or palate.

Some babies with chromosomal conditions such as, Pierre Robin Syndrome, who have a very pronounced receding jaw.

In all the above methods (except intravenous feeding) expressed breast milk should be used whenever possible.

Part 2


Babies who may require extra help to breastfeed

effectively include:

The baby who becomes sick at or shortly after birth

The baby with an oral or gut abnormality

The baby with a respiratory or cardiac condition

The baby with a chromosomal abnormality

The preterm baby

The baby who requires or has had surgery

The majority of babies whose needs require specialised help at birth will be admitted to a neonatal unit.

The sick baby

One of the aims of implementing the ‘Ten Steps to Successful Breastfeeding’ is to ensure the well-being of both the mother and the baby. Therefore, in the maternity unit, the initial practical help and support mothers receive may help to reduce the incidence of both jaundice and hypoglycaemia developing in their babies. Both these conditions can cause breastfeeding to fail and the mother to lose confidence in her ability to feed her baby herself.


Early jaundice

Jaundice is a common reason for a baby to be given supplements and to stop breastfeeding. It causes the skin and eyes to become yellow, due to high levels of bilirubin in the blood. The commonest kind of jaundice occurs between the 2nd and 10th days of life.

Jaundice is more common and worse among babies who do not get enough breast milk. Extra fluids such as water or glucose water do not help, because they reduce breast milk intake. If there is a delay in starting to breastfeed, or if breastfeeds are infrequent or restricted in any way, jaundice is more likely to occur. Formula milk feeds may interfere with breastfeeding in all the ways discussed in earlier sessions.

Treatment of early jaundice

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 breast milk should have 20% extra EBM.

Early breastfeeds 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 both to prevent and clear jaundice.

Prolonged jaundice

Prolonged jaundice starts after the 7th day of life, and continues for some weeks. Sometimes it is due to a serious illness in the baby. Sometimes it is apparently due to substances in the mother’s milk — then it is called ‘breast milk jaundice’ . Breast milk jaundice is not common. It is mild, and usually harmless. It clears by itself after some weeks.

If a baby has prolonged jaundice, check his weight, look for signs of infection (especially urinary infection) and feel for liver enlargement.

If the baby is well, feeding well, gaining weight, and his liver is not enlarged, he probably has breast milk jaundice. This is harmless, and it is quite safe to continue breastfeeding.

If the baby is ill, with poor weight gain or an enlarged liver, then the jaundice is likely to be due to a more serious illness. Breast milk is not the cause. Refer the baby to hospital, and continue breastfeeding.

A mother may be advised to discontinue breastfeeding for a 1 2-24 hour period, to confirm the diagnosis of breast milk jaundice. In this case, the mother should express her milk and freeze it until she is able to resume normal breastfeeding (she may also be able to use the milk in the future).

Haemolytic jaundice

Jaundice is sometimes due to haemolysis of the baby’s blood, for example if there is an ABO incompatibility. This more serious kind of jaundice may appear on the first day of life, and the bilirubin may be very high. The baby may need light treatment (phototherapy). Breastfeeding should continue. It is important to help the mother to breastfeed while her baby is receiving treatment.

Phototherapy may make a baby dehydrated, so he needs extra fluids. The best fluid is breast milk, so help the mother to give the baby extra breast milk by cup or tube. (10 — 30% extra fluids may be recommended) If possible, she should breastfeed more often. Sometimes jaundiced babies are sleepy and suckle less at the breast. If necessary, she can express her milk and give extra milk by cup or gastric tube. Give other fluids only if extra breast milk fails to prevent dehydration.


Hypoglycaemia is the term used to describe a low blood glucose concentration. Hypoglycaemia in a baby is a symptom of an underlying illness or it indicates the baby’s inability to adapt to an intermittent pattern of feeding after the continuous supply of glucose it received via the placenta before birth.

A term healthy newborn baby will not normally become hypoglycaemic if he is fed on demand. He does not need to be screened for hypoglycaemia though special attention must be paid at the first feed to ensure the mother is taught how to attach and position her baby correctly at the breast. There is no need for this baby to be given supplementary foods or fluids. A baby’s risk of developing hypoglycaemia can to some extent be determined at birth. Therefore, initially it is important to assess whether the baby is in a low or high risk category. The following criteria can be used to make this assessment.

Low risk factors

The baby at birth:

Term, more than 37 completed weeks. Some authorities consider babies are only at risk if they are below 36 weeks of gestational age.

Between 2.5 kg — 4.5 kgs and appropriate for gestational age (AGA)

Apgar scores of 5 or more at 1 minute

(The mother is healthy, the labour and delivery were uncomplicated. If she is diabetic, she is well controlled, with stable blood glucose levels

The baby should have a normal temperature, colour, breathing pattern and muscle tone.

High risk factors

The baby:Preterm at birth, less than 36 completed weeks. Less than 2.5 kgs at birth - small for gestational age (SGA)

Cold at or after the birth (The mother had a long and difficult labour. If the mother is diabetic, she is poorly controlled, with unstable blood glucose levels).

Breastfeeding and the low risk baby

To help prevent hypoglycaemia from developing a baby needs to be fed early and on demand from birth. It is also important that immediately after birth the baby is completely dried and skin-to-skin contact with the baby held close to the mother. Is breast is commenced. This encourages the early establishment of breastfeeding. Some newborn babies may sleep for long periods after birth. However as long as they are kept warm and breastfed whenever they show signs of being hungry hypoglycaemia should not be a problem.

Breastfeeding and the high risk baby

If breastfeeding is possible the baby at risk should be encouraged to breastfeed as soon after delivery as possible.

If the baby is unable to breastfeed at this time he should be given any colostrum the mother can express together, with any artificial feeds or banked human milk. This can be given by cup or gastric tube. The high risk baby should initially be given feeds regularly. If the baby develops any of the signs of hypoglycaemia, i.e. becomes jittery, apnoeic, cyanosed or has convulsions paediatric advice must be sought urgently and any prescribed treatment followed.

Problems of breastfeeding the sick baby

A full term baby who is sick at birth or shortly afterwards may regress in his ability to feed, and may appear to behave similarly to a less mature baby. Thus, the approach to feeding depends upon the capabilities of the baby rather than on the baby’s actual gestational age and supposed stage of development.

Some conditions which may appear on a postnatal ward cannot be anticipated in the same way as jaundice and hypoglycaemia can be. These include:

A respiratory infection or sore mouth, for example an infection with Candida (thrush) may make suckling difficult.

An infection which may make a baby lose his appetite and refuse to breastfeed, or suckle less than before.

Advantages of breastfeeding the sick baby

If a baby continues to breastfeed when he is ill:

He gets the best nourishment and extra protection.

He loses less weight.

He recovers more quickly (especially from diarrhoea).

He is comforted by suckling. Breast milk production continues.

The baby is more likely to continue breastfeeding when he is well.

How to help breastfeeding succeed if a baby is sick

If a baby is in a neonatal or paediatric unit:

Admit his mother too so that she can stay with him and continue breastfeeding.

If a baby is sick but 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 baby when he is sick. Sometimes a baby likes to breastfeed more when he is ill than before, and this can increase the supply of breast milk.

If a baby suckles, but less than before at each feed:

Suggest that his mother gives more frequent feeds, even if they are shorter.

If a 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 or gastric tube. Let the baby continue to suckle when he is willing. Even babies on intravenous fluids may be able to suckle, or to have expressed breast milk.

If a baby is unable to take expressed milk from a cup:

It may be necessary to give the EBM through a gastric tube for a few feeds.

If a 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.

As soon as her baby recovers, she can start to breastfeed again. If he refuses at first, help him to start again. Encourage his mother to breastfeed often to build up her breastmilk supply.

Some babies, such as those with chronic respiratory or cardiac problems, have very little energy and may tire quickly, regardless of gestational age. They will require a combination of tube feeding, cup feeding and possibly the breastfeeding supplementer, in addition to breastfeeding . . .

Giving a baby donor breastmilk

If a mother cannot express as much breastmilk as her baby needs, the baby may need supplements. Banked donor breastmilk has many advantages over artificial feeds. If a baby has to have supplements of formula milk, continue to give as much of the mother’s own milk as possible. Even a small amount of fresh breastmilk can give a baby anti-infective factors which give valuable protection.

If HIV infection is a concern, one possibility is to pasteurise the mother’s expressed breastmilk. Heating the milk to 62.5°C for 30 minutes kills the HIV virus and then the mother’s milk can be safely used to feed her baby. However, the advice of the paediatricians on HIV and breastmilk should be sought, because there may be local policies which apply in particular areas to the feeding of babies of HIV positive mothers.

The reasons mothers may stop breastfeeding a sick baby

Sometimes mothers stop breastfeeding because they have been misinformed, for example:

Someone says that breastfeeding caused the illness. However, breastmilk does not make a baby ill (though occasionally substances in the mother’s food cause colicky crying).

A health worker advises a mother to stop breastfeeding. This is especially likely when a baby has diarrhoea.

Special needs babies

The majority of babies with special needs, such as babies with Down’s Syndrome or cleft lip and palate, can breastfeed. There is no doubt that breastfeeding these babies will take extra time and patience, and that their mothers need extra help and support, but it is especially rewarding for both the carers and the family when the mother succeeds.

Some babies need to be stimulated to breastfeed often enough and for long enough at each feed, babies with Down’s Syndrome for example. Some babies gain weight slowly, even if they receive enough breastmilk, for example, babies with chronic lung problems (e.g. broncho-pulmonary dysplasia).

Breastfeeding and bonding may also be even more critical for these special needs babies than for other babies.

The principles of caring for special needs babies are the same as for any baby:

Encourage the mother to begin breastfeeding as soon as possible after birth.

Position and attach the baby well, and help him to take a large mouthful of breast.

If he cannot suckle strongly, show the mother how to express her milk.

Feed him the EBM with a cup or spoon until he is able to suckle well.

It is important to let a baby explore the breast and try to attach in his own way.

Some babies with disabilities manage much better than we expect them to.

The baby with a cleft lip and palate

Breastfeeding presents a challenge to the mother of a baby with a cleft lip and/or palate. However, it is possible for a baby with either a unilateral cleft lip, a cleft palate or both to breastfeed. It will require patience, perseverance and a great deal of commitment.

Cleft lip:

To feed this baby:

The mother can cover the cleft in the baby’s mouth with a finger to maintain a vacuum during breastfeeding.

The mother can support her breast with her hand.

When the baby has taken the nipple and sufficient areola into his mouth, the mother can gently push the breast upwards so that the cleft in the baby’s lip is filled with breast tissue.

Cleft palate:

If the baby’s upper lip is intact but there is a small cleft in the soft palate, breastfeeding presents less of a problem because the baby is able to form a seal around the breast with his lips.

However if the cleft is in the baby’s hard palate, breastfeeding may be more of a challenge. The palate is important in the stimulation of the sucking reflex, particularly the area between the hard and soft palate. This may be diminished in a baby with a defect in this area of the palate. The mother needs to keep her breasts soft and pliable, so that they go easily into the baby’s mouth. It is also an advantage if the mother has an efficient ‘let-down’ reflex. It is important that this mother avoids any engorgement.

The positioning and attachment of the baby is vital to his success in breastfeeding. However, as many breastfeeding positions as possible should be tried until one can be found which is satisfactory, because the baby may prefer a position which is not particularly conventional.

Positions for this baby may include:

The baby in a sitting position, supported across his mother’s lap or with him supported alongside the mother’s side with his legs pointing towards the back of the mother (as in the underarm position).

The baby on his back with the mother leaning over to let her breast fall directly into his mouth. This position is useful for a term baby who has a mature swallow reflex.

Cleft lip and palate:

A baby with a unilateral cleft lip and palate can breastfeed but it will require patience. All feeding positions should be tried, until a satisfactory one is found. The mother may find it helpful to insert her index or little finger just under her breast, so that she pushes the breast tissue up to fill the cleft in the baby’s lip, thus creating a seal.

This mother should express regularly to keep her breasts as soft as possible, and make sure she maintains her milk supply.

It may take a few weeks for the mother and baby to establish an acceptable breastfeeding technique, and even then she will have to supplement her baby with an alternative feeding method until surgical closure of the lip and palate takes place.

It may help a mother to establish breastfeeding if she:

Gently hand expresses a little milk into his mouth.

Lets the baby experiment with suckling at the breast as often as possible (it is not uncommon in these early days for a baby to appear very frustrated at the breast).

Expresses her breasts after feeding to ensure the breasts get adequate stimulation.

Uses a breastfeeding supplementer.

The mother will have to accept that during this time she may have to supplement her baby with an alternative feeding method. If at all possible this needs to be introduced while she is in hospital, partly to make certain it is suitable, and partly to give the parents time to practice. Bottles DO NOT have to be used. A cup cup and spoon or the breastfeeding supplementer may be used instead.

It is important to monitor this baby’s growth carefully in the first few days and weeks after birth.

A baby with a bilateral cleft lip and/or palate may not be able to suckle at the breast, but this baby can still be given his mother’s expressed breast milk by cup or cup and spoon. He can also taste and lick any milk expressed on to the nipple, or take milk directly expressed into his mouth from the breast.

If breastfeeding can not be established then bottle feeding may have to be introduced. This does not mean however, that the mother must stop continuing to persevere with breastfeeding as well. Her expressed breast milk can be given by bottle, using a variety of teats.

A baby with ‘tongue-tie’

A baby who has a short frenulum, or ‘tongue-tie’ can sometimes cause his mother to have sore nipples. Many mothers worry that their babies have tongue-tie. In most cases, the baby’s tongue is normal, but a little short. A preterm baby frequently appears to have a degree of ‘tongue-tie’ but as he gets older his tongue grows and lengthens. Most babies with tongue-tie can breastfeed without any difficulty. Sometimes, however, a baby cannot get his tongue far enough over his lower gum to reach the lactiferous sinuses, so he has difficulty suckling effectively. He may not get enough breastmilk, and he may make the nipples sore.

If a baby has difficulty with breastfeeding, and you or his mother thinks that a short frenulum may be the cause, try to get him to take more of the breast into his mouth. In most cases, that is all that is necessary. However if the tongue-tie is severe, or if the difficulties continue, he may need to be referred to a doctor to have the frenulum cut surgically.

The preterm and small for gestational age baby

The term Iow-birthweight (18W) refers to babies with a birth weight of less than 2,500 grams. This includes many babies who are preterm at birth and also

below this weight, but it also includes babies who are small for their gestational age (SGA) but who may be born at or before term, and below the 10th centile for weight for that gestational age. A preterm baby is one born at less than 37 weeks completed weeks of gestation.

The preterm baby

Preterm and SGA babies are at particular risk of infection, and need breast milk. Yet they are given formula milks and bottle feeds more often than larger babies and their mothers are more likely to fail to establish breastfeeding.

The main problems of the preterm baby, particularly between 32 and 36 weeks gestation, are:

An inability to suckle strongly.

A lack of energy.

They need more of some nutrients than breast milk can provide, because of immature body systems (e.g. the renal system).

It can sometimes be difficult for mothers to express sufficient breast milk.

For these reasons, in many hospitals, preterm babies are fed artificially.

Babies who are born preterm may have difficulty suckling effectively at first. But they can be fed on breast milk by tube or cup, and helped to establish full breastfeeding later. It is not necessary for a baby to ‘learn’ to feed from a bottle before breastfeeding. Research has shown that breastfeeding is less stressful for a preterm baby than sucking from a bottle. Indeed, bottle feeding can make it more difficult for a baby to learn to suckle from the breast because he can easily become ‘confused’ about how he is supposed to open his mouth or use his tongue.

Differences between full-term and preterm breastmilk

Preterm milk compared to term milk contains:

More protein than full-term milk ; Higher sodium and calcium levels 4 Lower levels of lactose

Much of the extra protein in milk produced by mothers of preterm babies consists of anti-infective proteins. To grow well, these babies need more protein in their milk than full-term babies do. They also need extra protection from infection. So preterm milk is specially adapted to the needs of a preterm baby.

The expression of milk for a preterm baby

Mothers of preterm babies, who have to express sometimes for as long as 10 — 12 weeks (if their baby is born at 23 — 24 weeks gestation) may experience difficulty in expressing breast milk for such long periods of time. However, if they have a good technique and enough support, it is usually possible. There is no reliable evidence to suggest that mothers of preterm babies produce less milk than mothers of term babies.

It is important to start expressing:

On the day of birth;

Within six hours of delivery if possible. This helps to start the breast milk to flow, in the same way that suckling soon after delivery helps breast milk to ‘come in’ . If a mother can express just a few millilitres of colostrum it is valuable for her baby (In some neonatal units when a baby is ventilated, breast milk is used for mouth care).

If a mother can only express very small volumes at first: Give whatever she can produce to her baby. Even very small amounts help to prevent infection. Help the

mother to feel that this small amount is valuable. This helps her confidence, and will help her to produce more milk. Supplement if necessary with donated breast milk. If necessary, a baby can receive pasteurised donor human milk until his mother can produce enough of her own milk.

If a mother expresses more milk than her baby requires:

A mother who expresses more milk than her preterm or low-birth-weight baby needs can ensure that the baby gets the fat-rich hind milk, which is energy-rich and helps promote good weight gain in the following way:

She can express into two containers. She should 1% express haftof her milk from each breast into one container and the remainder into a second container. To know how much milk to express into the first container, a record of the previous day’s milk volumes from each session of expression should be kept. This provides a guide to how much she is likely to produce at each expression over a 24 hour period.

Therefore, if her baby requires 300 mls in 24 hours and the mother produced a total of 600 mls in the previous 24 hours, she needs to express approximately half of her milk into the first containers and the remaining milk into the second containers. This means that if she produced 100 mls of milk at the first expression of the previous morning, she should express 50 mls into the first container, i.e. approximately 25 mls from each breast. The remaining milk should be expressed into the second container — and it is this milk which is then fed to her baby. All the milk in the first containers should be frozen for use in the future if required.

The milk in the second container has a greater volume of the fat-rich hind milk which can be given to her baby by gastric tube if necessary. Or the milk can be given by cup either before or after the breastfeed.

The small for gestational age baby

Many SGA babies can breastfeed without difficulty, particularly those who are born at term. They are often

very hungry and need to breastfeed more often than larger babies, so that their growth can catch up. Some of these babies may lose no weight at birth.

If a mother is given enough skilled help and support, she can express her breast milk, and feed it

to her baby by tube or cup, until he can breastfeed. She can breastfeed her preterm and/or SGA baby fully much earlier than used to be thought possible.

Extra nutrients

Babies with very low birth weight (1,000 to 1,500g) or extremely low birth weight (less than 1 ,000g) may need extra nutrients in addition to breast milk for a time. Some need extra calcium and sodium, some may need extra protein or energy. How extra nutrients are given depends upon the paediatrician looking after the baby. However, breast milk with additional nutrients protects against infection better than artificial feeds on their own. Breast milk also contains factors which are not found in artificial formulae, such as growth factors.

Skin-to-skin contact

A baby who is preterm, SGA or sick can greatly benefit from skin-to-skin contact with his mother (or father). It has been found to help both bonding and breastfeeding, probably because it stimulates the secretion of prolactin and oxytocin. If a baby is too sick to move, contact can be between the mother’s hand and the baby’s body. If a baby is well enough, his mother can hold him next to her body. Usually the best place is between her breasts, inside her clothes. This is called kangaroo care. It has the following advantages:

The warmth of the mother’s body keeps her baby warm. He does not get cold, and he does not use up extra energy to keep warm. There is less need for incubators.

The baby’s heart works better, and he breathes more regularly.

The baby cries less and sleeps well.

It is easier to establish breastfeeding.

Positions for breastfeeding babies with specia! needs

Below are some practical suggestions about positioning that may be helpful for babies who have difficulty attaching or suckling. It may be necessary to try different positions with a baby until a satisfactory position is found.

1 The modified underarm position.

This may be helpful with babies who feed more easily in an upright position: for example, babies with a cleft palate, or Pierre Robin Syndrome or other oral defects.

The baby sits upright, facing his mother, with his legs along her side, and his feet at her back. He may sit on the bed, or be supported with a pillow. His mother supports his back with her arm, and his head with her hand.

However, some babies with cleft palate breastfeed satisfactorily in a more lying down position.

2 The straddle position.

This is an alternative way for a baby to sit upright to breastfeed. The baby sits up facing his mother, with his legs on either side of one of her legs or abdomen. His back and head are supported by the mother’s hands.

This position may be useful to help a baby to attach to the breast if he has a disability which causes muscular weakness.

The mother supports her breast with the palm of her hand, and the three outside fingers. Her index finger and thumb are free in front of her nipple to support the baby’s chin and cheeks.


1 Lebenthal E, Heitlinger L, Milla P J. Prenatal and Perinatal Development of the Gastrointestinal Tract, from ‘Harries Paediatric Gastroenterology’, Edited by Milla Pi, Muller DPR, Pubi. Churchill Livingstone; 1988 2nd Ed. Ch.1.

2 McBride MC, Danner SC. Sucking Disorders in Neurologically Impaired Infants: Assessment and Facilitation of Breastfeeding — from: Clinics in Perinatology, March 1987, ‘Breastfeeding’ 14:1;109-130.

3 Widstrom A-M, Thingstrom-Pausson J. The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle. Acta PaediatrScand 1993. 82:281-283.

4 Armstrong HC. Breastfeeding low birthweight babies: advances in Kenya. jnl of Human Lact 1 987 3:34-37.

5 Armstrong H. Are feeding bottles ever needed? Breastfeeding Briefs, the Geneva Infant Feeding Association, September 1986.

6 Lang 5, Lawrence Ci, L’E Orme R. Cup-feeding: An alternative method of feeding. Arch Dis Chi!d 1994. 71:365-69.

7 Hawdon JM, Ward-Platt MP, Aynsley-Green A. Neonatal hypoglycaemia — blood glucose monitoring and baby feeding. Midwifery 1993. 9:3-6.

8 Schanler R, Oh W. Composition of breast milk obtained from mothers of premature infants as compared to breast milk obtained from donors. jnl Paediat 1980. 96: 679.

9 Valentine Ci, Hurst NM, Schanler Ri. Hindmilk improves weight gain in low-birth-weight infants fed human milk. ml Pediatr Gastroenterol Nutr 1994. 18:474-477

Worksheet 9

Helping mothers in special circumstances: Feeding the low birthweight and sick baby

In questions 1, 2, and 3, how would you advise the mother about feeding her baby?

Question 1

Mona has just delivered a baby 6 weeks early. He weighs 1 ,500 grams, and s being observed in the special care baby unit. Mona wants to breastfeed, but she is worried that her baby will not be able to.

What could you say to empathise with Mona?

What could you say to build her confidence?

Question 2

Sam is now 8 weeks old. He was born at 26 weeks gestation and was ventilated for 4 weeks. His mother wants to breastfeed him. She has been expressing her breast milk 6 to 8 times a day since he was born. She has been using an electric pump, and always produced much more milk than Sam needs.

In the past two weeks his mother has begun to try to establish breastfeeding, but Sam seems reluctant to suckle when he is attached to the breast. Sam has been given a dummy whenever he is unsettled. His Mother’s EBM has been given by nasal gastric tube, which remains in place.

What advice can you give to the mother to help her:

a To achieve more effective suckling?

b To overcome the potential problem of an over-abundant milk supply.

c To suggest a feeding plan for Sam, which could be used from his birth to his discharge and which shows the most appropriate feeding methods for his needs.

Question 3

Baby Harriet was born at term, and is now 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 Harriet glucose water between breastfeeds.

What relevant information would you give to Harriet’s mother?

How would you advise her mother to feed baby Harriet now?

Module 5

Commercial promotion of breastmilk substitutes: The International Code


At the end of this session, you should be able to:

describe the dangers of commercial promotion of artificial feeding

list the major provisions of the International Code of Marketing of

Breastrnilk Substitutes

list the legal restrictions on formula promotion under current UK Iaw*

list their own responsibilities for complying with the Code

* This session refers to the law in place in the UK. Reference should be made to other national legislation on the promotion of breastmilk substitutes as appropriate


All manufacturers promote their products to encourage people to buy them. Manufacturers of breast milk substitutes, feeding bottles and teats have been so successful around the world in their marketing campaigns that they have often created the impression among both families and health workers that their products are as good as breast milk.

The effects of such marketing include:

undermining women’s confidence in the superiority of breast milk and their ability to breastfeed.

making health workers reliant on breast milk substitute manufacturers for infant feeding information.

Studies have shown that mothers who receive commercial discharge packs containing promotion for breast milk substitutes are more likely to give up breastfeeding earlier and are less likely to breastfeed exclusively than mothers who are protected from this promotion .

Breastfeeding needs to be protected from the effects of breast milk substitute promotion. This is best achieved if the promotion is disallowed by national legislation. However, individual health facilities and health workers can also resist promotion.

In 1 981 , the World Health Assembly adopted the International Code of Marketing of Breast milk Substitutes, which seeks to regulate the marketing of breast milk substitutes, bottles and teats. The UK has adopted only part of the Code as law. The Baby Friendly Hospital Initiative uses the International Code as its standard.

The International Code of Marketing of Breast milk Substitutes

The International Code of Marketing of Breast milk Substitutes was adopted in 1981 and was recommended as a minimum measure for national legislation. It aims:

To protect and promote breastfeeding

To ensure the proper use of breast milk substitutes when these are necessary on the basis of adequate information and through appropriate marketing and distribution.

It is a Code to regulate marketing - it does not disallow the sale of the products. It preserves the right of every woman to choose how she feeds her child. It does seek to stop the promotion of artificial feeding.

The following summary of the International Code of Marketing of Breast milk Substitutes lists the main points of the International Code.

1 No advertising of breastmilk substitutes, feeding bottfes or teats in the health care system or to the public

2 No free samples to mothers or pregnant women

3 No free or subsidised supplies to hospitals

4 No contact between marketing personnel and mothers

5 Materials for mothers should carry clear and full information and warnings

6 Companies should not give gifts to health workers

7 No free samples to health workers except for evaluation or research at institutional level

8 Materials for health workers should contain only scientific and factual information

9 No pictures of babies or idealising images on infant formula labels

10 Labels ‘of other products must provide information needed for appropriate use

Companies are required to comply with the Code, even if it has not been adopted by law.

The Code applies to infant formula, bottles and teats, bottle-fed complementary foods and any other food or drink which is represented as a replacement for breast milk, even if it is not suitable for that purpose.

The International Code in more detail

1. No advertising of breast milk substitutes in the health care system or to the public

Advertising of any product is designed to convey a message which will persuade a consumer to buy it. It is not an objective way to provide product information - advertisements cannot by nature be truly balanced and normally only convey the messages which the manufacturer wants you to hear.

If breast milk substitutes are advertised in hospitals, this undermines the hospital’s health promotion messages and implies that the health care system endorses the product. Infant formula advertising undermines a mother’s confidence in her own breast milk by suggesting that formula is an acceptable, convenient substitute. Consider the implications if a hospital decided to distribute cigarette advertising.

2. No free samples to mothers or pregnant women

Sampling is recognised as one of the most effective promotional methods. Giving free samples of breast milk substitutes is likely to undermine breastfeeding even more than advertising does.

3. No free or subsidised supplies to hospitals

Most mothers who bottle feed will continue to use the brand of baby milk which is used in hospital. Companies therefore compete to supply their milk to hospitals — in some countries they provide their milk free or at a greatly subsidised price (sometimes paying the hospital for this privilege) and even offer payment to hospitals for each baby fed on their milk.

4. No contact between company personnel and mothers

Company personnel are paid to promote a company’ products. They may offer to provide educational services or advice to mothers but they are not likely to provide unbiased information.

5. Information materials for mothers are subject to restrictions

When manufacturers are allowed to provide information materials to mothers, they should not be permitted to use this opportunity to promote their products.

The benefits and superiority of breastfeeding should be stated, as should the negative effect on breastfeeding of introducing partial bottle feeding and the difficulty of reversing a decision not to breastfeed.

Information on using infant formula should only be included where needed. In such cases, the material should also include information on the total cost using the product* and the potential health hazard of unnecessary or improper use.

*on average, 44 x 500g formula tins are needed to feed a baby for 6 months.

6. Companies should not give gifts to health workers

Gifts are intended to create a spirit of goodwill between health workers and company representatives but they are in fact promotional materials. Some company gifts are items which health workers find useful in their jobs and health workers sometimes become reliant on companies for these items. If mothers see health workers using gifts such as pens and mugs which carry a company logo or formula brand name, the company has successfully used the health worker to promote its products.

7. No free samples to health workers

It is possible that samples will be passed on to mothers. Free samples can only be given to health workers for professional evaluation or research at the institutional level. They should be accompanied by the appropriate paperwork, including a research protocol or report of findings.

8. Materials for health workers should be restricted to scientific and factual information Marketing experts are professionals who ensure that their advertising messages are very sophisticated and effective, including when they are targeted at health professionals. But health workers often have to rely on manufacturers of breastmilk substitutes as their only source of information. If health workers are to give balanced and accurate advice, it is essential that they receive complete information which is reliable and free from promotional messages.

9. No babies on infant formula labels. Pictures of happy, healthy babies on infant formula labels are intended to link the product with babies’ well- being. Mothers are encouraged to believe that their babies will be equally healthy if they use the product. Other label pictures, such as teddy bears and other toys, often in human form, are also used to idealise infant formula feeding. These images should not be used. Infant formula labels must also carry a warning that breastfeeding is best and that the formula should only be used on the advice of a health worker. Clear instructions must be included, with a warning of the dangers of inappropriate preparation.

10. What about the labels of other products?

They should provide the necessary information about using the product properly. They should not discourage breastfeeding. The Code is rather vague on the labelling of products other than infant formula. It does not state what ‘necessary information’ should be included. Bottle and teat labels are possibly the best example of an area in which this provision is being ignored. You could argue, for example, that ‘necessary information about the appropriate use’ of a bottle should include sterilisation instructions and warnings against leaving a baby alone with a bottle. Many labels do not carry this information.

3 The main points of the Infant Formula and follow-on Formula Regulations 1995

In 1981, when the World Health Assembly adopted the International Code, it recommended that national governments should implement the entire Code as law.

The European Union then modified the Code into European ‘directives’ . These directives do not contain the whole Code, but have the advantage that EU member states are compelled to turn directives into national law.

In March 1 995, a law was introduced in the UK, based on these European directives. It covers the marketing, composition and export of infant formula and follow- on milk.

A brief overview of the UK law, in comparison with the International Code:

Scope: The Code covers all breast milk substitutes, bottles and teats, while the UK law covers only infant formula and follow-on milk. Most of the law’s restrictions on marketing apply only to infant formula.

Advertising: Outside the health care system, advertising infant formula is illegal in the UK. However, the UK law does allow infant formula advertisements in publications distributed to mothers through the health care system. These advertisements should only contain scientific and factual information and may not carry pictures of babies. The International Code seeks to stop all advertising, including in hospitals.

Labels: Both the Code and the UK law ban baby pictures and other idealising images on infant formula labels and require warnings and information to be carried.

Free samples and supplies: It is now illegal in the UK to give free samples of infant formula to mothers. Hospitals are not permitted to receive free or reduced-price infant formula.

Gifts to the public: Both the Code and the UK law ban gifts to promote sales, as well as coupons giving money off infant formula and all point-of-sale promotion.

Information for mothers: as with the Code, the UK law requires that materials should carry important information and warnings about formula use. Formula companies may only give such information if it is requested by the recipient and distributed through the health care system — these materials may not be marked with the name of an infant formula brand.

Any infringement of the law should be reported in the UK to a Trading Standards Office or Environmental Health Department (addresses can be found in the telephone directory).

4 How manufacturers promote breast milk substitutes

Manufacturers use many different techniques to promote breast milk substitutes. The following list includes some you may be familiar with.

Giving posters and calendars (with company or brand names) to hospitals.

Gifts of useful items to health workers.

Advertising in health worker publications.

Sponsoring meetings, courses, conferences, workshops, etc.

Free meals and trips.

Providing information for both mothers and health workers.

Advertising to mothers.

Other ways may be less obvious.

Follow-on milk promotion is subject to very little restriction. Some manufacturers have changed the names and labels of their follow-on milks so that they look almost identical to the regular infant formulas. This means that an advertisement for a company’s follow-on milk can automatically promote its regular infant formula.

Companies have made changes to ensure that their logos and company names are identical or very similar to their formula brand names: this is because the law in the UK allows materials to carry company names and logos, but not formula brand names.

5 What can individual health workers do to implement the International Code?

Health workers can influence the successful implementation of the International Code in a number of ways. Some of the following ideas may help:

Discuss with colleagues the ethics of accepting company money and gifts.

Refuse to accept company gifts, meals and samples of formula, bottles, teats and dummies.

Identify alternative sources of materials currently provided by breast milk substitute manufacturers, or collaborate with other health workers to produce your own.

Lobby the publishers of journals and conference organisers to drop advertisements for breast milk substitutes.

Do not speak at or attend conferences sponsored by manufacturers of breast milk substitutes.

Ensure that the hospital policy does not allow promotion of breast milk substitutes, bottles, teats and dummies.

Report breaches of the law to the local Trading Standards Office or Environmental Health Department.

6 No promotion of breast milk substitutes in Baby Friendly hospitals

No promotion of breast milk substitutes is allowed in Baby Friendly hospitals. Achieving Baby Friendly status means that hospitals are fulfilling their obligation to the International Code.

The Baby Friendly Hospital Initiative has produced guidelines to assist hospitals in implementing their policies. However, during an assessment, the assessors will check whether any promotion of breast milk substitutes, bottles, teats or dummies takes place in the hospital. This criterion applies to materials displayed or distributed by health workers and/or the health facility, as well as to the sample packs distributed by external companies.

Baby Friendly Hospitals will not permit the display or distribution of any form of promotional material for:

1 . Infant formula or follow-on formula.

Promotional material for an infant formula does not necessarily carry the brand name of the product, particularly in cases where the manufacturer’s name is closely identifiable with the product. This includes material aimed at pregnant women or new mothers which carries the name and logo of an infant formula manufacturer, even if the material does not specifically mention brand names.

2. Other breast milk substitutes, including baby juices, teas and other baby drinks.

The Committee on the Medical Aspects of Food’s Working Group on the Weaning Diet recommends that ‘the majority of infants should not be given solid foods before the age of four 6 The World Health Organization recommends that babies should be exclusively breastfed for at least 4 and if possible 6 months, and that ‘complementary foods are not marketed in ways that undermine exclusive and sustained breast feeding’ .

3. Feeding bottles, teats or dummies.

7 Conclusion

Companies which manufacture breast milk substitutes will always want to promote their products and to expand their markets. Health workers have a responsibility to protect the mothers and babies in their care from such promotion, thereby protecting a mother’s right to an informed choice as to how she feeds her baby.

If hospitals and health workers distribute or display promotion for breast milk substitutes, this undermines their work to promote breastfeeding.

The best way to restrict the promotion of breast milk substitutes is by law. But hospitals and health workers can play a significant role by resisting promotional activities even though they have not been disallowed.


1 Frank DA, Wirtz Si, Sorenson JR and Heeren 1. Commercial discharge packs and breastfeeding counselling: effects on infant-feeding practices in a randomized trial. Pediatrics 1987; 80: 845-854.

2 Pérez-Escamilla R, Pollitt E, Lönnerdal B and Dewey KG. Infant feeding policies in maternity wards and their effect on breastfeeding success: an analytical overview. Am J PublicHealth 1994; 84: 89-97.

3 The International Code of Marketing of Breast milk Substitutes. WHO, Geneva 1981.

4 World Health Assembly resolution 47.5, 1994.

5 World Health Assembly resolution 49. 1 5, 1996.

6 Committee on the Medical Aspects of Food Policy. Weaning and the Weaning Diet. HMSO,1994.

Other useful reading:

Protecting Infant Health: a health worker’s guide to the

International Code of Marketing of Breastmilk Substitutes.

IBFAN Penang, 1993. Available from IBFAN Penang, P0 Box

19, 10850 Penang, Malaysia. ISBN: 983-9075-01-2

Introduction to The Ten Steps to

Successful Breastfeeding


At the end of the session, you should be able to:

Describe the practices summarised by the ‘Ten Steps to Successful Breastfeeding’.

Materials required

Acceptable Medical Reasons for Supplementation’

The sample hospital policy


The ultimate aim of this course is to help mothers and their babies achieve successful breastfeeding and to begin the process for a hospital to gain the

UNICEF/VVHO ‘Baby Friendly Hospital Initiative’ award. The course therefore also aims to give health professionals, and anyone else involved in the care of mothers and their newborn babies, the skills and knowledge to help them promote successful breastfeeding.

This is achieved by implementing and following the ‘Ten Steps to Successful Breastfeeding’.

To do this, the course has 3 main objectives to fulfil:

To facilitate personal education

— By keeping our theoretical knowledge and practical breastfeeding skills up to date.

— By examining our own attitudes and those of the society in which we live towards breastfeeding

To consider how to pass this information on to our colleagues

To examine how to give women information about breastfeeding antenatally and postnatally

The BFHI cannot become a reality without a certain process of change taking place within our hospitals and community. Therefore, in addition to this course it is important to consider:

The timescale to achieve the BFHI award.

What does the health facility hope to get from the training and implementation process?

Who is to be designated with the task of coordinating the process of change? If no-one is to be given that responsibility, how is the process of change to be implemented?

Which hospital departments will be involved? e.g. the maternity unit, the neonatal unit, the paediatric unit, the community?

How is the process to be audited and by whom?

All of these points need to be considered, though the individual needs of each health facility will differ. Therefore, the solutions which are likely to be the most successful are those which result from discussion rather than from a prescribed format of implementation.

The basis for achieving the BFHI is incorporating the ‘Ten Steps’ into our practice. They are, therefore, now briefly examined.

The Ten Steps to Successful Breastfeeding

Health care practices can have a major effect on the success of 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 period of time.

The ‘Ten Steps to Successful Breastfeeding’ provide a guide to good practice, which can be implemented not only in maternity wards, but in any situation where mothers and their babies initiate, establish and maintain breastfeeding.

The ‘Ten Steps to Successful Breastfeeding’ are:

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

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

3 Inform all pregnant women about the benefits and management of breastfeeding.

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

5 Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants.

6 Give newborn infants no food or drink other than breastmilk, unless medically indicated.

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

8 Encourage breastfeeding on demand.

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

1 0 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Step I and Step 2

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

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

The policy mentioned in Step 1 and the training, in Step 2, refer to the practices described in the other eight steps.

The policy embraces the philosophy of the health facility, and the training ensures that whoever helps a mother has the skills and knowledge to put the policy into practice. Implementing the policy is a mandatory

Introduction to the ‘Ten Steps to Successful’

requirement which carries with it certain managerial responsibilites.

Step 3

Inform all pregnant women about the benefits and management of breastfeeding.

All women need to be told about breastfeeding when they come for antenatal care. It is important for them to know that breastfeeding is supported by the health professionals they come into contact with, and that help will be given if required. This also helps women and their families to make an informed choice about infant feeding. (Though it is recognised that for a truly informed choice to be made, information about infant feeding needs to be discussed before the antenatal period, e.g. in schools.)

Women should be given the following information:

The benefits of breastfeeding, and the dangers of artificial feeding.

Most women decide how they are going to feed their babies a long time before they give birth — often even before they become pregnant. If a woman has — decided to bottle feed, she may not change her I mind. But it is possible to help women who are undecided, and give confidence to those who intend — to breastfeed. A woman may be encouraged to breastfeed exclusively instead of partially.

Simple, relevant information on how to breastfeed.

The information given on how to breastfeed depends to some extent on local breastfeeding practices and

the previous experiences of the woman.

Explain what happens after delivery.

A woman should know what is likely to happen at the first few breastfeeds, and the practices in the hospital where she will give birth. This is especially important if the practices in a hospital have changed recently and she has had previous children in the same hospital.

Discuss the woman’s questions.

Let the women decide what they would like to know more about.

Ask about her previous breastfeeding experience if she has other children.

If she breastfed successfully, she is likely to do so again.

If she had difficulties, or if she bottle fed, explain how she can succeed with breastfeeding this time. Reassure her that she will receive help.

Ask if she has any questions or worries.

Encourage her to express any worries or doubts she has about breastfeeding, and try to answer them.

Examine her breasts only if she is worried about them.

She may be worried about the size of her breasts, or the shape of her nipples.

Build her confidence and explain that you will help her.

It is very unusual for a woman’s breasts not to be suitable for breastfeeding. Therefore, most women can be reassured that they will be able to breastfeed.

Tell a woman that help will be available to her when she is in hospital, and also when she goes home.

Step 4

Help mothers initiate breastfeeding within half an hour of birth.

Early contact

A mother should be able to hold her baby immediately after delivery. It is important to dry the baby well after delivery and cover both him and his mother with the same blanket. She should hold him next to her naked skin so that they have skin-to-skin contact. A mother should hold her baby like this as much as possible in the first two hours after delivery. She should let him suckle when he shows that he is ready.

This early contact helps a mother to bond with her baby — that is, to develop a close, loving relationship. Early contact also makes it more likely that a mother will start to breastfeed, and breastfeed for longer.

Separation of mother and baby

When a mother and baby are separated the mother is unable to respond to her baby and put him to her breast when he roots for it. Separating a mother and her baby and delaying starting to breastfeed should be avoided. These practices interfere with bonding, and make it less likely that breastfeeding will be successful.

Practices which interfere with early contact

Practices such as gastric suction can alter a baby’s behaviour and interfere with breastfeeding, and should be avoided if possible. However, where there is a high prevalence of sexually transmitted diseases, it is necessary to put drops or ointment into a baby’s eyes, to prevent blindness.

Another practice which interferes with the success of breastfeeding is giving a mother analgesics and sedation during labour e.g. pethidine. These drugs can cross the placenta and make the baby unresponsive and unwilling to breastfeed. Their use should be minimised.

The first breastfeed

Babies are normally very alert and responsive in the first

1 -2 hours after delivery. They are ready to suckle, and

easily attach well to the breast.

Most babies want to feed within the first two hours after delivery, but there is no exact fixed time. If the first contact with the mother is delayed more than about an hour, breastfeeding is less likely to be successful.

Sometimes in the past, babies have been forced to breastfeed immediately after delivery, before they or their mothers were ready. This is not necessary or helpful. It is best to keep a baby with his mother and let him breastfeed when he shows that he is ready. Help his mother to recognize rooting, and other signs that he is ready to breastfeed. If necessary, help her to put him to her breast — especially if this is her first baby.

Step 5

Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants.

The need for help

If a health worker is not available to help a mother with the first breastfeed, early problems may occur which can lead to failure.

In many health facilities, mothers are discharged within a few hours of delivery, so there are few opportunities for their babiesto establish breastfeeding.

Many mothers do not need help, or need very little. A mother may not know if she needs help or not. It is useful for a midwife to spend time with each mother during an early breastfeed to make sure that everything is going well, and to give her guidance if she needs it. This should be a routine in maternity wards before a mother is discharged — particularly where early discharge is a common practice.

A mother needs to be aware of the signs which show that her baby is ready for a feed. A baby may be wakeful and restless, or make small noises; he may make hand-to-mouth movements, and sucking movements; he may suck his fingers, and root for the breast.

When mothers and their babies are separated

Sometimes a baby has to be separated from his mother because he is ill, or of low-birth-weight, and needs special care.

While they are separated, a mother needs a lot of help and support. She needs help to express her milk. This is necessary both to establish and maintain lactation, and to provide breastmilk for her baby. She may need to be told that her breastmilk is important, and that giving it will really help her baby. She may need help to get her baby to suckle from her breast as soon as he is able.

A low-birth-weight baby can be fed with his mother’s expressed breastmilk. At first, he may have to be fed by nasogastric tube. After a while his mother may be able to feed him expressed milk from a cup. There is no need to use a bottle for these babies, which is more difficult for them than feeding from the breast. Cups provide a more satisfactory alternative.

After a Caesarean section

It is usually possible for a mother to breastfeed within about 4 hours of a Caesarean section — as soon as she has regained consciousness. Exactly how soon depends partly on how ill the mother is, and partly on the type of anaesthetic used. After epidural anaesthesia, a baby can often breastfeed within 1 hour.

A healthy, term baby usually needs no food or drink before his mother can feed him. He can wait a few hours until she is ready.

A baby can ‘room-in’ with his mother in the ordinary way, and she can feed him whenever he is hungry. Most mothers need help to find a comfortable position for the first few days. Often a mother finds it easiest to breastfeed lying down at first.

She may lie on her back, with her baby on top of her.

She may find it easier to lie on her side, with the baby lying beside her and facing her. This prevents the baby pressing on her wound. She may need help to turn over, and to move her baby from one side to the other.

Later, she may like to sit and hold her baby across her abdomen above the operation wound, or under her arm.

Whatever position a mother uses, make sure that her baby is in a good position, facing her breast, so that he is well attached.

Step 6

Give newborn infants no food or drink other than breastmilk, unless medically indicated.

The WHO/UNICEF ‘Acceptable Medical Reasons for Supplementation’ are given at the end of this session

Step 9

Give no artificial teats or pacifiers (also called dummies or soothers) to breastf feeding infants.

Prelacteal feeds

Any artificial feed given before breastfeeding is established is called a prelacteal feed.

The dangers of prelacteal feeds are these:

They replace colostrum as the baby’s earliest feeds.

The baby is more likely to develop gastro-intestinal infections.

He is more likely to develop intolerance to the proteins in the artificial feed.

He is more likely to develop 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 the artificial feed from a bottle with a teat, he may have more difficulty attaching to the breast (nipple confusion or preference). The baby suckles and stimulates the breast less. Breast milk takes longer to ‘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. Babies who are given dummies to suck are also more likely to stop breastfeeding early.

Step 7

Practise rooming-in - allow mothers and infants to remain together -24 hours a day.

Step 8

Encourage breastfeeding on demand.

When babies are separated from their mothers and put in a nursery, they cry more and are more likely to be given bottle feeds. Separating a mother and her baby can interfere with both bonding and breastfeeding.


Rooming-in means that a baby stays in the same room as his mother, day and night, from immediately after birth.

A baby needs to be in a cot close to his mother so that she can reach him when she is lying down in bed. In some hospitals, cots are put at the foot of the mother’s bed but it is better for the cot to be beside her, so that she is able to touch her baby easily.

In some countries babies are put in bed with their mothers. This is ‘bedding-in’. Bedding-in has extra advantages for breastfeeding, because it is easier for a mother to rest and breastfeed. A baby can breastfeed at night or at other times when the mother is asleep without disturbing her. To prevent a baby falling out of the bed, one side of the bed can be put against a wall, and the baby kept on that side. Another way is to make use of ‘cot-sides’ on the bed.

Demand feeding

Rooming-in enables a mother to feed her baby on demand, that is, feeding a baby as often as he wants, both day and night.

A mother does not have to wait until her baby is upset and crying to offer him her breast. She learns to respond to the signs that her baby gives, for example rooting, which show that he is ready for a feed. Because of this, some people prefer the terms ‘unrestricted feeding’ or ‘baby-led feeding’ to ‘demand feeding’.

A baby should suckle for as long as he wants, provided he is well attached.

There is no need to restrict the length of a breastfeed. If a baby is well attached to the breast, his mother should not get sore nipples. Some babies take all the breast milk they want in a few minutes; other babies take half an hour to get the same amount of milk, especially in the first week or two. They are all behaving normally. If a mother takes her baby off her breast before he has finished, he may not get enough hind milk. Usually when a baby has had all that he wants, he releases the breast himself.

A mother should let her baby finish feeding on the first breast, to get the fat-rich hind milk. Then offer the second breast, which he may or may not want.

It is not necessary to feed from both breasts at each feed. If a baby does not want the second breast, his mother can offer that side first next time, so that both breasts get the same amount of stimulation.

Step 10

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. Many mothers are discharged within a day or two after delivery, before their breast milk 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 plan for what happens to a mother once she goes home, because:

She may have difficulties with breastfeeding;

She has to cope with the demands of the rest of the family;

She may have to listen to a lot of different advice about how to feed the baby; 4 She may be isolated, without help; I She may have to go back to work.

If she is to continue to breastfeed successfully, she will need continuing help and support.

Possible sources of help for breastfeeding mothers include:

Supportive family and friends.

This is often the most important source of support. However, some traditional ideas may be mistaken. Many women may have very little support for breastfeeding or they may have friends or relatives who encourage them to bottle feed.

Community health workers

Mothers may benefit from regular visits by health professionals or lay breastfeeding counsellors in the early days of breastfeeding, after discharge from hospital. It may also help a mother if she has a telephone contact number of a health worker who can give her advice if she requires it; or for a lay breastfeeding support group, or if there is an organised breastfeeding group she can attend if she wishes or needs the support of either other mothers or health care staff. Any time that a health worker is in contact with a mother and child under 2 years of age, she should support breastfeeding.

A routine postnatal check at 6 weeks post delivery.

This check could also include observation of a breastfeed, as well as discussion of family planning. In some countries, for example in the United Kingdom, there is a routine postnatal check at 6 weeks after delivery. This check may take place in hospital, at the GP’s surgery, either with a doctor or with a midwife.

A breastfeeding support group. A breastfeeding support group.

Such as:

La Leche League

Many countries have national organisations which

support breastfeeding mothers. La Leche League is an example of an international support group.

In some communities mothers who are or who have been breastfeeding are given a special training in breastfeeding management to help them to give support to other mothers in their community. This is also known as ‘peer group support’.


The implementation of the ‘Ten Steps to Successful Breastfeeding’ depends upon the commitment, enthusiasm and skills of everyone who takes part in this course. The rewards are to know that we have contributed to the long term health of the nation, and in the short term to help mothers and their babies to breastfeed successfully — for as long as they wish.


1 DeChateau P, Winberg B.Long term effect on mother- infant behaviour of extra contact during the first hour postpartum.Acta Paediatr 1977. 66:145-151

2 Perez-Escamilla R, Pollitt E, Lonnerdal B, Dewey K. Infant feeding policies in maternity wards and their effect on breast-feeding success: an analytical overview. Am ml Public Health 1 994. 84; 1:89-97

3 Nylander G, Lindemann R, Helsing E, Bendvold E. Unsupplemented breastfeeding in the maternity ward. Acta Obstet Gynecol Scand 1991 . 70:205-209

4 Kisten N, Benton D, Roa S, Sullivan M. Breast-feeding rates among black urban low-income woman: Effect of Prenatal Education. Pediatr 1990. 80:741-746

5 Pugin E, Valdes V. Labbock M, Perez, Aravena R. Does Prenatal Breastfeeding Skills Group Education

Increase the Effectiveness of a Comprehensive Breastfeeding Promotion Programme? J Hum Lact 1996, 12:1;15-19

6 Widstrom A-M, Wahlberg V, Matthieson AS, et al. Short term effects of early suckling and touch of the nipple on maternal behaviour. Early Hum Devel 1990. 21:153-163

7 Righard L, Alade MO. Effect of delivery room routines on success of first breast-feed. Lancet 1992. 336:1 105-1 107

8 Sosa R, Kennell JH, Klaus MH, Urrutia ii. The effect of early mother infant contact on breastfeeding, infection and growth. In ‘Breastfeeding and the Mother’ Elsesvier, Amsterdam: CIBA Founfstion Symposium 45 (1978) :179-193

9 Righard L, Alade MO. Sucking technique and its effect on success of breastfeeding. Birth 1992. 19;4:185 189

1 0 Fischer PR. The influence of Perinatal Instruction about Breast-Feeding on Neonatal Weight Loss. Pediatrics 1990. 86:313-315

1 1 Perez-Escamilla R, Segura-Millan 5, Pollitt E, Dewey K. Effect of the maternity ward system on the lactation success of low-income urban mexican women. Early Hum Devel 1992. 31:25-40

12 Cronenwett L, Stukel T, Kearney M et al. Single daily bottle use in the early weeks postpartum and breastfeeding outcomes. Pediatrics 1 992 . 90; 5:760-766

1 3 DeCarvalho M, Hall D, Harvey D. Effects of water supplementation on physiological jaundice in breastfed babies. Am mnl Dis Child 1 981 . 56:568-569.

14 Glover J, Sandilands M. Supplementation of breastfeeding infants and weight loss in hospital. mnl Hum Lact 1990. 6:163-166.

1 5 Blomquist HK, Jonsko F, Serenius F, Persson LA. Supplementary feeding in the maternity ward shortens the duration of breastfeeding. Acta Paediatr 1994.


16 Victora CG, Tomasi E Olinto MT, Barros FC. Use of pacifiers and breastfeeding duration. Lancet 1 993. 341:404-40?

17 Yamauchi Y, Yamanouchi I. The relationship between rooming-in/not rooming-in and breastfeeding variables. Acta Paediatr Scand 1990. 79:1017-1 022.

1 8 Buranasin B The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia-Pacific mnl Pubi Health 1 991 . 5:217-220

19 DeCarvalho M, Robertson 5, Friedman A, Klauss M. Effect of Frequent Breastfeeding on Early Milk Production and Infant Weight Gain. Pediatr 1983. 72;3:307-31 1

20 Yamauchi YY, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1 990. 86;2 : 1 7 1 -175

Acceptable Medical Reasons for Supplementation

A few medical indications in a maternity facility may require that individual infants be given fluids or food in addition to, or in place of, breast milk.

It is assumed that severely ill babies, babies in need of surgery and very low birth weight infants (less than 1000 grammes) will be in a special care unit. Their feeding will be individually decided, given their particular nutritional requirements and functional capabilities, though breast milk is recommended whenever possible. These infants in special care are likely to include:

. infants with very low birth weight or who are born preterm, at less than 1000g or 32 weeks gestational age;

. infants with severe dysmaturity with potentially severe hypoglycaemia, and who do not improve through increased breastfeeding or by being given breast milk.

For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements. In order to assess whether a facility is inappropriately using fluids or breast milk substitutes, any infants receiving additional supplements should have been diagnosed as:

. infants whose mothers have severe maternal illness (e.g. psychosis, eclampsia or shock);

. infants with inborn errors of metabolism (e.g. galactosaemia, phenylketonuria, maple syrup urine disease);

a infants with acute water loss, for example during phototherapy for jaundice, whenever increased breastfeeding cannot provide adequate hydration;

infants whose mothers are taking medication which is contraindicated when breastfeeding (e.g. cytotoxic drugs, radioactive drugs and anti-thyroid drugs other than prophylthiouracil).

When breastfeeding has to be temporarily delayed or interrupted, mothers should be helped to establish or maintain lactation, for example through manual or hand-pump expression of milk, in preparation for the time when breastfeeding may be begun or resumed.

For a full discussion of this and related issues, see: Chapter 3, Health factors which may interfere with breastfeeding, in Infant feeding: the physiological basis. Bulletin of the World Health Organisation 67, supplement (1989).

Sample Hospital Policy on Breastfeeding

(Developed by the UNICEF UK Baby Friendly Initiative)


This Hospital believes that breastfeeding is the healthiest way for a woman to feed her baby and recognises the important health benefits now known to exist for both the mother and her child.

All mothers have the right to make a fully informed choice as to how they feed and care for their babies. The provision of clear and impartial information to all parents at an appropriate time is therefore essential.


This policy aims to ensure that the health benefits of breastfeeding and the potential health risks of formula feeding are discussed with all women, so that they can then make an informed choice about how they will feed their baby.

Staff will not discriminate against any woman in her chosen method of infant feeding and will fully support her when she has made her choice.

This policy aims to create an environment where more women choose to breastfeed their babies, and where more women are given sufficient information and support to enable them to breastfeed exclusively for 4-6 months.

It also aims to enable all health care staff who have contact with breastfeeding women to provide full and competent support through specialised training in all aspects of breastfeeding management.


It is crucial that all staff adhere to this policy to avoid conflicting advice. Any deviation from the policy must be justified and recorded in the mother’s and baby’s notes. This should be done in the context of professional judgement and codes of conduct.

The policy should be implemented in conjunction with both the breastfeeding guidelines (where these exist) and the mothers’ guide to the policy (where this exists).

It is the midwife’s responsibility to liaise with the baby’s medical attendants (paediatrician, general practitioner) should concerns arise about the baby’s health.

No advertising of breast milk substitutes, feeding bottles, teats or dummies is permissible in any part of this hospital. The display of infant formula company logos on such items as calendars and stationery is also prohibited.

No routine group instruction on the preparation of artificial feeds will be given in the antenatal period, as this does not provide the information adequately and has the potential to undermine confidence in breastfeeding.

Compliance with this policy will be audited on an annual basis.


Communicating the breastfeeding policy

1 . 1 This policy is to be communicated to all health care staff who have any contact with pregnant women and mothers. All staff will receive a copy of the policy.

1 .2 All new staff will be orientated to the policy as soon as their employment begins.

1 .3 The policy should be available for inspection in all parts of the maternity unit and the visiting areas. The policy must be accessible to women in other forms, for example, on audio or video tapes and in appropriate languages.

Training health care staff

2.1 Midwives have the primary responsibility for protecting and promoting breastfeeding and for supporting breastfeeding women in overcoming related problems.

2.2 All professional staff who have contact with pregnant women and mothers will receive training in breastfeeding management at a level appropriate to their professional group. New staff will receive training within six months of taking up their posts.

2.3 The responsibility for providing training lies with the hospital which will audit and publish results on an annual basis.

Informing pregnant women of the benefits and management of breastfeeding

3.1 Every effort must be made to ensure that all pregnant women are aware of the benefits of breastfeeding and of the potential health risks of formula feeding.

3.2 All pregnant women should be given an opportunity to discuss infant feeding on a one-to-one basis with a midwife (or health visitor). Such discussion should not solely be attempted during a group parentcraft class.

3.3 The physiological basis of breastfeeding should be clearly and simply explained to all pregnant women and some of the common experiences they may encounter discussed.

Initiation of breastfeeding

4.1 All mothers should be encouraged to hold their babies in skin-to-skin contact as soon as possible after delivery in an unhurried environment, regardless of their intended feeding method.

4.2 AU women should be encouraged to offer the first breastfeed when mother and baby are ready. Help must be available from a midwife if needed.

Showing women how to breastfeed and how to maintain lactation even if mother and baby are separated

5.1 A midwife should be available to assist a mother if necessary at all breastfeeds during her hospital stay.

5.2 Midwives should be able to explain positioning and attachment to the mother, not simply latch the baby on for the mother who must be helped to acquire this skill for herself.

5.3 All breastfeeding mothers should be shown how to hand express their milk. A leaflet outlining the process should be provided for women to use for reference.

5.4 When a mother and baby have to be separated for medical reasons it is the shared responsibility of the neonatal nurse caring for the baby and the mothers midwife to ensure the mother is given help to express her milk and to maintain her lactation.

5.5 Mothers who are separated from their babies should be encouraged to express milk at least six to eight times in a 24 hour period.

6.1 No water or artificial feed should be given to a breastfed baby unless prescribed by a midwife or paediatrician who has been appropriately trained.

6.2 Parents should always be consulted if supplementary feeds are recommended and the reasons discussed with them in full.

6.3 Parents who request supplementation should be made aware of the health implications and of the harmful impact which supplementation may have on breastfeeding in order to allow them to make a fully informed choice. Their request and their permission should be recorded in the baby’s notes.

6.4 Any supplements which are prescribed should be recorded in the babys hospital notes along with the reason for supplementation.

7.2 Separation of mother and baby will normally occur only where the health of either the mother or her infant prevents care being offered in the postnatal areas.

7.4 Babies should not be routinely separated from their mothers at night. This applies to babies who are being bottle fed as well as those being breastfed. Mothers who have delivered by Caesarean section should be given appropriate care, but the policy of keeping mother and baby together should normally apply.

8.1 Demand feeding should be encouraged for all babies unless clinically indicated. Hospital procedures should not interfere with this principle.

Indications for supplementary feeds


7.1 Mothers will normally assume primary responsibility for the care of their babies.

7.3 There is no designated nursery space.

Sample Hospital Policy on Breastfeeding

8.2 Mothers should be informed that it is acceptable to wake their baby for feeding if their breasts become overfull.

Use of Artificial Teats, Dummies and Nipple Shields

9.1 Health care staff should not recommend the use of artificial teats or dummies. Parents wishing to use them should be advised of the possible detrimental affects on breastfeeding to allow them to make a fully informed choice. The nformation given and the parents decision should then be recorded in the notes.

9.2 Any mother considering using a nipple shield must have the disadvantages fully explained to her prior to commencing use. She should be under the care of a skilled practitioner whilst using the shield and should be given every help to discontinue use as soon as possible.

Breastfeeding Support Groups

1 0. 1 This hospital supports co-operation between health care professionals and voluntary support groups, whilst recognising that the hospital has its own responsibility to promote breastfeeding.

10.2 Contact telephone numbers and addresses of the infant feeding advisors (where these exist), community midwives, health visitors, and voluntary breastfeeding counsellors will be issued to all mothers and be routinely displayed in all maternity areas.

10.3 Breastfeeding support groups will be invited to contribute to further development of the breastfeeding policy through involvement in appropriate meetings.

Sample Mothers’ Guide to the Hospital Policy on Breastfeeding


This hospital supports the right of all parents to make informed choices about infant feeding. All staff will support you in your decision. We recognise the important health benefits which breastfeeding provides for both you and your child and we therefore encourage you to consider breastfeeding as the healthiest way to feed your baby.


All the staff have been specially trained to help you to breastfeed your baby.

During your pregnancy, you will be able to discuss breastfeeding individually with a midwife or health visitor who will answer any questions you may have.

You will have the opportunity to hold your new baby against your skin soon after birth. The staff will not interfere or hurry you but will be there to support you and to help you with your first breastfeed.

A midwife will be available to explain how to put your baby to the breast correctly and to help with feeds while you are in hospital.

You will be shown how to express your breast milk and you will be given a written sheet on this which you can refer to once you are home.

Most babies do not need to be given anything other than breast milk for their first 4-6 months. If for some reason your baby needs some other feed, this will be explained to you by the staff before you are asked to give your permission.

Normally, your baby will be with you at all times. If any medical procedures are necessary, you will always be invited to accompany your baby.

You will be encouraged to feed your baby whenever he or she seems to be hungry.

We recommend that you avoid using bottles, dummies and nipple shields while your baby is learning to breastfeed. This is because they can change the way your baby sucks, meaning that it can be more difficult for your baby to breastfeed successfully.

Before you leave hospital, you will be given a list of telephone numbers of people who can provide extra help and support with breastfeeding when you are at home.

Barriers to the initiation of The Ten Steps to Successful Breastfeed i ng

To implement the ‘Ten Steps to Successful Breastfeeding’ it is important to have a positive attitude towards each step. This involves examining barriers which may occur during the implementation programme, so that they are anticipated and therefore more easily overcome.

The following suggestions are by no means an

exhaustive list but provide a basis for discussion.

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

1 Lack of support from the hospital administration, nursing, midwifery and medical staff.

STEP 2: Train all health care staff in skills necessary to implement this policy.

1 Staff attitudes:

a Staff do not believe there is a real difference between breastfeeding and artificial formulae.

b Staff perceive that breastfeeding is very time consuming.

c Staff do not recognise the far reaching impact of inconsistent and inaccurate or insufficient information.

2 Attendance at any training sessions is low. Staff are not given time to attend or are called back to the clinical area during the sessions. Attendance at training sessions has to be in the member of staff’s own time. Insufficient number of up-date sessions.

3 Difficulty in sustaining an interest in breastfeeding among the staff and in the clinical areas.

4 A high staff turnover rate, therefore, difficulty in giving all new staff training.

5 Lack of medical interest, support and participation.

Worksheet 1 1

STEP 3: Inform all pregnant women about the benefits and management of breastfeeding.

1 Information is not always given to women in the antenatal period.

2 Women may attend the antenatal clinic late in their pregnancy.

3 Women may not attend antenatal classes.

4 The medical staff seen by the women are not well informed or supportive of breastfeeding.

STEP 4: Help mothers initiate breastfeeding within a half hour of birth.

1 A lack of time

2 Concern among labour ward staff that the initial assessment procedure will be delayed.

3 Lack of skills to assist the mother among labour ward staff.

4 Labour ward staff may feel breastfeeding within 30 to 60 minutes after delivery is not a priority.

5 The labour and delivery room is required for other women.

Step 5: Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants.

1 Lack of understanding among health care staff of importance and/or frequency of inconsistent, inaccurate or inadequate information.

2 Help is not accepted from the lay breastfeeding counsellors in the maternity unit because they are not health professionals.

3 Frustrated health care staff because of lack of time.

4 Lack of health care staff for the number of mothers who need help.

5 The breastfeeding specialist is absent when the mother needs help.

6 Mechanical pumps are over-used for the expression of milk or for mothers having problems initiating their milk flow.

7 The mother is discharged before her baby.

8 The neonatal nursing staff may be responsible for the advice given on lactation, but they may have had no training in breastfeeding management.

STEP 6: Give newborn infants no food or drink other than breast milk, unless medically indicated.

1 Glucose water prescribed if the baby’s blood glucose level drops.

2 No nationally accepted rules to help health care staff determine when to treat hypoglycaemic babies.

3 Discharge packs which contain bottles, teats, dummies or formula or advertisements for these items.

4 Health care staff do not believe that there is a difference in the technique required for ‘suckling’ at the breast or ‘sucking’ on a bottle teat.

5 Mothers request supplementary feeds.

6 Mothers are given drugs which may be contraindicated in breastfeeding.

7 There is no understanding of the impact of formula marketing on an informed infant feeding decision.

STEP 7: Practise rooming-in — allow mothers and infants to remain together — 24 hours day.

1 The mother requests that her baby is taken to the nursery overnight, so that she can sleep.

2 Health care staff have concerns in the maternity unit about security.

3 The night health care staff may have different routines to the day staff.

4 The baby is admitted to a neonatal unit.

STEP 8: Encourage breastfeeding on demand.

1 The doctors want the babies in the nursery to examine them.

2 A lack of time or commitment among the maternity staff to provide the education and support required.

3 Unrestricted visiting hours which interfere with demand feeding. The mother may be too embarrassed to breastfeed in front of visitors.

4 The health care staff do not percieve dummies as causing problems.

STEP 9: Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

1 The mother wants her baby to have a dummy — she does not believe they can do any harm.

2 The mother brings a dummy into hospital with her.

3 Health care staff reluctance to learn alternative methods of feeding.

STEP 10: Foster the establishment of breast- feeding support groups and refer mothers to them on discharge from the hospital or clinic.

1 The hospital staff are not familiar with lay breastfeeding support groups in their area.

2 The mothers are not given a contact number for a support group when they leave the hospital.

3 There is a lack of time and money to provide follow- up care.


1 World Health Organisation. Protecting, promoting and supporting breastfeeding: the special role of maternity services. A Joint WHO/UNICEF Statement. Geneva 1989

Module 7

Clinical Practice 1

Listening and learning and assessing a breastfeed


You will practise ‘listening and learning’ and ‘assessing a breastfeed’ with mothers and babies in a ward or clinical setting.

Materials required

B-R-E-A-S-T Observation Form x 2

Listening and Learning Skills Form x 2 U The Clinical Practice Completion Form

Preparation for a Group Clinical Practice


(Before the clinical practice)

This session provides an opportunity to observe a complete breastfeeding session and use the listening and learning skills already practised, with a mother and baby, in a clinical setting.

You should have the following forms with you

1 B-R-E-A-S-T-feed Observation Form

2 Listening and Learning Skills Form

How to conduct the clinical session

You should work with two or three other participants. One person from each group introduce you all to the mother and explain that you are interested in infant feeding She/he should d the mother for permission to talk to her and for you all to watch her baby feed. She/he should then sit while the other participants should stand quietly in the background.

If the mother is already breastfeeding when she is approached, once permission to observe her has been received, care should be taken to make sure she is not interrupted unnecessarily.

Before or after the breastfeed, the participant who talks to the mother should ask her some open questions about how she is, how her baby is, and how the feeding is going. Encourage the mother to talk about herself and her baby. Practise as many of the listening and learning skills as possible. At the end of the interview/observation, thank the mother for her help.

You should all have the opportunity during this clinical practice to lead the discussion with different mothers.

If you are observing, you should:

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 participant ask open questions. Does the mother talk freely and seem to enjoy feeding her baby

How to use the B-R-EA-S-T-feed Observation Form

Stay quietly watching the mother and baby as the feed continues.

While you observe, fill in the form.

Write the first name (or a code number) of the mother and baby, put a tick beside each sign that is observed and add the time that the feed takes. Under ‘Notes’ at the bottom of the form, write anything else which seems important.

Mistakes to avoid

The term ‘breastfeeding’ should not be used. The mother’s behaviour may change if she feels at all challenged. She may then not feel free to talk about bottle feeding.

Help or advice should not be given to the mother. ..

If a mother seems to need help, a member of staff from the ward or clinic should be informed.

Be careful that the forms do not become a barrier.

If you are talking to the mother you should not make notes while she is talking. You may need to refer to the forms to remind you what to do, but if you want to write, you should do so afterwards. If you are observing record examples of communication skills at the time they occur or afterwards.

Discussion of the clinical session

(After the clinical practice)

Your group should meet the rest of the class at a pre arranged venue.

One person from each group should report briefly on what you have observed.

The following topics should be covered:

1 General observations about the mother and baby.

Signs from the B-R-E-A-S-T-feed Observation Form.

The listening and learning skills which were demonstrated.

2 Preparation for an individual clinical practice in your own time

During this clinical practice you should observe at least one complete breastfeed

1) You should identify an appropriate clinical area for the practice.

2) You or your tutor should request permission well in advance to observe a complete breastfeed in the clinical area chosen.

3) Follow the same order of the clinical practice described in the session outline.

This clinical practice may be arranged either in your own clinical area or in another clinical area, for example, a neonatal nurse may observe a breastfeed on the maternity unit; a midwife from the maternity unit may observe a breastfeed in the community or in the Neonatal Unit.

Where possible participants from different clinical areas should work in pairs during the clinical practices, for example, a neonatal nurse and a midwife. The advantage of this is that you both can then observe and learn about the breastfeeding practices in different clinical areas. When you work in pairs the participant from the clinical area in which the practice is taking place should observe the communication skills (using the ‘Listening and Learning Skills Form’) of the other participant. The participant talking to the mother should use her

B-R-E-A-S-T-feed Observation Form. The participants should swap roles in the other clinical area.

If you are working on your own you should use your B-R-E-A-S-T-feed Observation Form, and fill in the ‘Listening and Learning Skills Form’ after the practice.

Discussion arising from the clinical practice should take place in the feedback session on the next training day. However, when you work in pairs you are encouraged to discuss your experiences during the practices.

If the course tutor is unable to supervise this practice someone from the clinical area approved by the tutor should sign your Clinical Practice Completion Form.

It is important that during the practice the you are able to observe the breastfeed without being disturbed.

B-R-E-A-S-T.feed Observation Form

This form has been designed to help in the assessment of breastfeeding technique through the observation of a feed and as a learning tool for health professionals and mothers. It is suggested that you familiarise yourself with the form by sharing your observations with one or more mothers who are NOT experiencing difficulties before using it where problems are suspected. A tick should be marked on the line if a sign is observed during a breastfeed.

Signs that breastfeeding is going well:

Body position

— Mother fully relaxed and comfortable

— Close body contact between baby and mother

— Baby’s head and body in line

— (Baby’s whole body supported)

— Baby’s upper lip opposite nipple before attachment

— Baby’s chin touches the breast during the feed


— Baby reaches or roots for the breast

— Baby explores the breast with tongue

— Baby calm and alert at the breast

— Baby stays attached to the breast

— Signs of milk release (e.g. leaking)

Emotional bonding

— Secure, confident hold

— Face-to-face attention from mother

— Baby touched a lot by mother


— Breasts soft and full

— Nipples prominent and protractile

— Skin appears healthy

— Breasts look round during a feed

— If visible, more areola above baby’s top lip


— Baby’s mouth wide open

— Lower lip turned outwards

— Cheeks rounded

— Slow, deep sucking bursts with pauses

— Can see or hear swallowing

— Rhythmic swallowing seen

Termination of feed

— Baby releases the breast spontaneously Time spent feeding ______ minutes


Signs of possible difficulty:

— Mother not relaxed, e.g. shoulders tense

— Baby’s body not held close to the mother

— Baby’s has to twist head and neck to feed

— (Only shoulder or head supported)

— Baby’s lower lip opposite nipple before attachment

— Baby’s chin does not touch the breast

— No response to the breast

— Baby not interested in the breast

— Baby restless or fussy

— Baby slips off the breast

— No sign of milk release

— Nervous, shaking or limp hold

— No mother/baby eye contact

— Little touching of baby by mother

— Breasts hard and full/engorged

Nipples flat or inverted, or very long or very big

— Skin damaged

— Breasts look stretched or pulled

— If visible, more areola below baby’s bottom lip

— Baby’s mouth pursed, lips point forward

— Lower lip turned in

— Cheeks tense or pulled in

— Rapid shallow sucks

— Can hear smacking or clicking sounds

— Occasional swallowing seen throughout feed

— Mother takes baby off the breast

Building confidence and giving support

Positioning the baby at the breast

How to conduct this clinical


You will practise ‘building confidence and giving support’ and ‘positioning a baby at the breast’ with mothers and babies in a clinical area.

You will practise your history taking skills.

You will continue to practise the skills used in Clinical Practice 1

Materials required

B-R-E-A-S-T-feed Observation Form

Confidence and Support Skills Form

The Clinical Practice Completion Form

Preparation for a Group Clinical Practice


(Before the clinical practice)

This session provides an opportunity for you to:

1 Practise building the mother’s confidence and giving support, using the 6 confidence and support skills contained in the ‘Building a Mother’s Confidence’ worksheet. Continue to practice the listening and learning skills from Session 2A.

2 Practise using the history taking skills learned in the ‘Taking a breastfeeding history’ session.

3 Continue to practise ‘assessing a breastfeed’ , using the ‘ B-R-E-A-S-T-feed Observation Form’.

4 If possible help a mother to position her baby at the breast, or to overcome any other difficulty she is having with breastfeeding.


You should work with two or three other participants.

If your group is with a mother who needs help positioning her baby at the breast or who asks for help with any other difficulty, your tutor should be informed so that she can either demonstrate how to help the mother or supervise one of your group helping the mother. You should use your history taking skills to learn as much about the mother’s breastfeeding situation as possible.

During the time spent with the mother you should practise as many of the six confidence and support skills as you are able. If possible you should:

— Praise two things the mother and baby are doing correctly.

— Give the mother two pieces of relevant information which are useful to her at this time.

If you are observing, you should:

Record any examples of the confidence and support skills used on the ‘Confidence and Support Skills Form’ which you observe your colleagues practising.

Discussion of the clinical session

(After the clinical practice)

Your group should meet the rest of the class at the pre arranged venue.

One person from each group should briefly report on what you have learnt about:

The mother and her baby and her breastfeeding history,

Any problem the mother was experiencing with breastfeeding and how it was overcome.

The building confidence and giving support skills used during the discussion with the mother.

The Clinical Practice Completion Form should be signed

and dated by yourself and by your supervisor.

2 Preparation for an individual

clinical practice in your own


During this clinical practice you should

observe at least one complete breastfeed

1) This clinical practice should be arranged in the clinical area you normally work in.

2) Follow the same order of the clinical practice described in the session outline.

You should use the B-R-E-A-S-T-feed Observation Form, and fill in the ‘Confidence and Support Skills Form’ after the practice.

It is important to ensure that the practice is a supervised clinical practice which follows the general outline set out in this session. If possible you should be supervised by your course tutor or someone who is able to provide adequate supervision (for example, a breastfeeding advisor in the hospital).

Discussion arising from the clinical practice should take

place in the feedback session on the next training day.

The Clinical Practice Completion Form should be signed and dated by yourself and by your assessor.

Module 7

Clinical Practice 3 (optional)

Hand expression of breast milk


You will observe and practise helping mothers to learn the principles and techniques of hand expression.

The Clinical Practice Completion Form

Clinical preparation for Part 2 of the clinical practice on hand


The Clinical Practice Completion Form should be

signed and dated by yourself and by your tutor.

This clinical practice is in 2 parts. Part 1 is a

demonstration of hand expression in the

classroom or in a hospital setting. Part 2 should

not be completed until part 1 has been


1 ) Identify a clinical area where hand expression can be

taught This can be in the community, in the

hospital or in a clinic.

2) Prepare staff in the clinical area prior to this clinical


3) Identify a mother in the clinical area who can be

approached and needs to be taught how to hand

express her breast milk. Obtain the mother’s

permission before the clinical practice takes place

and explain that there will be two health workers

present, one of whom will be observing (explain to

the mother that you are being supervised as part of

a course on Breastfeeding). Make sure the mother

understands that she is to be taught how to hand

express her breast milk. You should never touch a

mother’s breasts without her permission.

4) Inform a suitable supervisor (tutor or breastfeeding specialist) when a mother is available, so that she may arrange to accompany you.

5)You should teach the mother hand expression using the same procedure as demonstrated in the classroom. You should answer any questions the

mother has and give any relevant information about

expression which may be necessary. If there is any problems you are unable to deal with during the practice refer to your supervisor. If necessary she can

take over the teaching role.

6) Arrange a suitable place for a discussion after the clinical practice.

Clinical Practice 4

Implementation of the Baby Friendly Hospital Initiative


To create an awareness of the environment in which the Baby Friendly Hospital Initiative is to be implemented.

To be aware of what is required by a health facility for it to implement theBaby Friendly Initiative.

Materials required

The Self Appraisal Tool during the next training day.

Suggested Question Sheets (optional)

The Ten Steps to Successful Breastfeeding

Clinical exercise for the implementation the of the Baby Friendly Hospital Initiative

You should be fill out a Self Appraisal Tool in The Clinical Practice Completion Form should be signed relation to either your hospital or the clinical area and dated by yourself and by your assessor.

1 You may work in groups of 2 - 4. Each group

should take 1 or 2 steps each and look at whether they have been implemented in the health facility used in the clinical practice. Questions can be used . from the ‘optional questions for clinical practice 4’.

If possible at least one of your group should be from the clinical area being observed.

You should:

a Interview mothers and different members of staff

(i.e. midwives, auxilliaries, doctors, receptionists etc).

b Observe in clinical areas.

2 If this exercise is to be carried out in the your own time it can either be completed in your normal place of work or in another clinical area (providing permission has been obtained beforehand). Make observations in the area chosen based on the ‘optional questions for clinical practice 4’

You may work on your own or with another course participant. If possible you should each come from different clinical areas and should carry out this exercise together in each others clinical areas.

Your findings can be discussed in the feedback session during the next training day.

This clinical practice should not be carried out before obtaining permission from the senior member of staff of the clinical area involved. This should be obtained prior to the visit.

The results of the clinical visit together with the Self Appraisal Tool can form the basis of a continuing programme for implementing the BFHI programme.

The Clinical Practice Completion Form should be signed and dated by yourself and by your assessor.

Optional questions for clinical

practice 4:

Is there a breastfeeding policy — where is it kept?

How is the policy communicated to the staff?

Is the policy easy to use now? If not, what are the reasons?

Do guidelines exist to ensure implementation of the policy?

2 Are the staff trained to implement the policy?

Which staff are trained?

How is the training carried out?

If NO policy exists — is there any lactation management course for the staff?

1: Do any audits exist to measure staff effectiveness?

3 Ask mothers what information they were given about FEEDING during the antenatal period.

During the antenatal period or in the antenatal classes what were mothers taught about breastfeeding?

At what point antenatally is the subject of breastfeeding introduced and discussed?

I Ask any community staff and antenatal ward staff available what information they give to mothers about breastfeeding, and when they give it.

Ask mothers what information they were given about bottle feeding.

4 Ask postnatal breastfeeding mothers where and when they were first able to put their baby to the breast after delivery.

Ask labour ward staff when the mothers first have skin-to-skin contact with their babies. How long do mothers initially have with their babies?

5 Ask postnatal breastfeeding mothers what instructions they have been given about breastfeeding since delivery.

Ask antenatal staff what information they give to mothers about breastfeeding and when they give it.

Ask what mothers have been taught about the hand expression of breast milk.

Ask the staff to describe the method of handexpression they teach or recommend to mothers.

If the mothers are not shown how to hand express breast milk on the maternity ward, how is the information given to them?

6 Ask mothers whether their babies have had anything other than breastfeeding. If the answer is ‘yes’, when and why was it given? Enquire about the use of dummies.

Ask postnatal and community staff about their policy and practices of giving supplementary fluids.

7 Ask mothers if the babies are kept beside them during the night and during the day.

Ask staff about the hospital policy on ‘rooming-in’.

8 What information are mothers given about WHEN to feed their babies?

9 Is there evidence of bottles, teats or dummies in the ward areas?

If so, where?

Where is artificial formula kept?

10 Is there evidence of further breastfeeding support for

the mothers on discharge from the maternity unit?

On the notice boards?

By word of mouth from the staff?

4 On information sheets?

General observations:

How is breastfeeding promoted?

Where does promotional literature (i.e. posters) come from?

What is illustrated by the materials used?

Where is breastfeeding visually promoted?

What will mothers learn from the materials used

What other information relating to breastfeeding

is available?

Is there information on the WHO code?

Is there information about different feeding methods?

Is there information about hand expression?

Staff awareness.

Do staff seem well informed about breastfeeding issues?

Are they able to attend regular study days,

workshops and/or conferences on breastfeeding?

Who funds these days?

Are they up-to-date in skills?

Were they asked about their attitude towards

breastfeeding during interviews for the post they


How much training in lactation management did they receive in their initial training?

Have they received training specifically to meet the requirements of the Baby Friendly Hospital Initiative

The end.

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