i) If the mother is a working woman-ie she is going to be seperated for many hours from her baby.

ii)To releive painful breast engorgement .

iii)To help the baby feed even when the baby is not strong enough eg in premature babies or in certain conditions such as cleft lip/palate where expressed breast milk has to be given via a special feeding bottle.

iv) If the mother has sore nipples (Painful or cracked). She has to keep the breast milk flowing while she allows the nipples to take rest. During this period the baby can be fed by expressed breast milk.

Technique of Expressing Breast Milk

This can be learnt easily if the mother can visit a clinic/hospital and watch a midwife, nurse or even a mother expressing breast milk.

Breast pumps are also available for those who can afford them.

If you don’t have access to a midwife or a health clinic the following tips can help you:

a)Wash your hand with clean water and allow it to dry using a drier or a clean towel.

b) gently stroke your nipple (rolling movement). This is important because it stimulates the milk let down reflex (release of the hormone oxytocin from the posterior pituitary gland which in turn acts by contracting the smooth muscle cells that line the ducts of the breast.

c) using rhythmic circular movements massage the breast gently with the three middle fingers.Once this is done the milk flows into the ampulla (a dilated space for each major duct that is draining to the nipple,it acts as a temporary storing space for the breast milk. If the baby is in the same room it may help stimulate the milk let down reflex-visual and sound stimulus.

d) After you have done step “C” above ,gently try to locate your ampullae (Notch like feeling bellow and surrounding the nipple- usually 15 to 20 in number). The trick in the final stage of expressing the milk is to gently squeeze on the ampullae which is located below the nipple using the thumb and index finger while pressing the breast towards the chest wall. If this movements are done rhythmically the milk should flow easily.

Never squeeze the tip of the nipple as this will bead to damaged to the narrowing ducts.

Make sure the milk is collected on a sterile container (usually a sterile container is made by boiling it in water or by pouring the boiling water on a container). Important- Make sure that you allow the sterile container to cool down to normal room temperature, otherwise it will destroy the proteins, vitamins and anti-infection factors in the milk.

One must emphasize that practice is the key .Never give up.

How can I store Expressed Breast Milk?

Expressed breast milk can be stored in the fridge or freezer.

How long can I Store Expressed Breast Milk?

If the milk is kept in the fridge (Not frozen) ,it should be used within 48 hours.

Frozed milk should be used within 3 months.

Reference

i) Review of Medical Physiology- William F Ganong 20th Edition.

ii)Oxford Handbook of Clinical Specialties- 6th Edition.

It might be a wise idea to ask for a history of previous problems during breast feeding (Including the history of breast feeding of previous children).

Proper Positioning of the Baby for Breast feeding- Very Important

The mother should be seated comfortably with proper support in a relaxed position.

The baby should be held in a position so that the head is aligned to the breast and the mouth directly in front of the nipple.

The breast must be held with the mothers free hand and the nipple and areola( The dark area surrounding the nipple) offered to the baby to ensure a proper “Latch on”.

As much as possible both the nipple and areola should be inserted into the baby’s mouth.

After feeding the baby should be removed from the breast by placing a finger into the baby’s mouth between the gums.

If the baby sucks on the nipple only (improper “latch on” ) , it may lead to cracked , bleeding or sore nipples.

I have sore/painful cracked nipples. How is it caused and what should I do?

At the commencement of breast feeding the negative pressure in the ductules causes soreness and pain, this should gradually pass of with the establishment of lactation.The soreness can be exacerbated by improper “latch on” (See above).

Treatment is by rinsing the nipple with clean water and allowing it to air-dry. A small amount of expressed breast milk can be applied and allowed to dry, this can hasten the healing process because of the presence of natural anti-microbial factors in the breast milk.

Topical antibiotics may be applied if infection is suspected. The nipple infection could also be due to candida (fungus) in which case topical antifungal agents will be useful.

Ensure that the topical antibiotics/ antifungal is washed off with clean water before commencing feeds.

How long should my baby suck per feeding?

On average the baby must suck for 10 minutes on the first breast and 20 minutes on the second one. There is no hard and fast rule on how long should a baby suck.

It must be emphasized that both breasts must be suckled during a single breast feeding period. At the next feeding time the baby must be placed at the breast last suckled. This encourages emptying of both breasts.

How many times should I breast feed my baby?

There is no hard and fast rule .

Breast feeding should be on demand.

Most babies will feed about 8 to 12 times within 24 hours.

Timed feeding is very demanding and stresses the mother as well as the baby and should be discouraged.

Frequent sucking promotes milk production.

Should I give Prelacteal /Supplimental feeds to my baby?

Prelacteal feeds should be avoided , especially in the first 4- 6 months of age. Prelacteal/Supplemental feeds include water,infant formulae, glucose water and other fluids.

Some of the disadvantages of supplimental feeds are suppression of breast milk production, nipple confusion by the baby and infection through contamination.

There are rare situations where supplemental feeds may be necessary eg severe illness in the mother, severe maternal exhaustion. If supplimental feeds are begun ,they should be discontinued rapidly once the indication for them is resolved.

What is appetite spurt?

This describes periods of excessive crying and irritability of the baby despite adequate breast feeding.

This usually occurs during the second and fourth week of age and at three months of age.

During this period there is the real danger of resorting to supplimental feeds , which usually does not solve the problem.

Patience and reassurance of the mother is needed in this situation.

I am lactating but my breasts are engorged. What could be the problem?

Breast engorgement during lactogenesis (formation of milk) is due the the increased blood and lymph flow to the breast. This is further compounded by poor or infrequent emptying.

This can be managed by frequently emptying the breasts either manually (Manual expression of milk by hand) or sucking

What are plugged ducts?

This refers to focal areas of breast enlargement caused by stasis of milk. It results from inadequate emptying of the breast .

Treatment is by frequent suckling and massaging affected parts during feeding.

What is breast abscess /Mastitis?

This is due to bacterial infection by staphylococcus aureus or strep pyogenes. The usual presenting symptoms are breast pain, fever, swelling and erythema (Reddish appearance around the affected part).

Treatment of this condition requires oral antibiotics and a pain killer such as paracetamol. Moist heat application may also be useful.

Breast feeding should not be stopped during treatment.

In this situation feeding should be started at the unaffected breast to stimulate the milk let down reflex.

References:

i) Paediatrics and child health in a tropical region edited by J. C. Azubuike and K.E. O Nkanginieme-1999

ii) Park’s Textbook of Preventive and Social Medicine by K .Park 17 th edition -2002.

The promotion of breast feeding is of utmost importance . Every woman should be encouraged and helped to successfully breast feed her baby.

All forms of breast feeding promotion should begin early. Breast feeding discussions with teenagers is thought to have the most impact.Ideas held as adolescents persists into adulthood , therefore young adults must be develop positive attitudes to breast feeding. Breast feeding should be introduced into school curriculums . Breast feeding can be discussed under home economics lectures for teenagers.

Promotion of breast feeding during antenatal care

The antenatal care period is an ideal time to educate a mother about the advantages of breast feeding. Education of the pregnant woman on all aspects of breast feeding( including advantages and misconceptions) must be undertaken.

The importance of exclusively breast eeding an infant for the first four to six months must be emphasized .

Adequate balanced nutrition of the pregnant woman themselves must also be emphasized. A well fed woman will produce nutritious milk of adequate quantity.

Many communities have breast feeding support groups. Where available pregnant women should be encouraged to join such groups.

For doctors and midwives the antenatal period is the best time to examine the breasts to look for any anatomical (Physical) abnormalities (Such as inverted nipples). Inverted nipples can be corrected during the antenatal period

Immediately after deliver the baby must be put to the breast within 30 to 60 minutes. Sick babies with a low apgar score will follow a different protocol , but must also be fed by expressed breast milk unless contraindicated (very rarely).

Baby Friendly Hospital Initiative

The UNICEF and WHO in 1991 launched the baby friendly hospital initiative.

It is considered by many as a global movement for mankind. The Baby Friendly Hospital Initiative (BFHI) is directed principally at the health workers and health facility.

The health workers were targetted in the BFHI because the health workers are central in all efforts towards the promotion, protection and support of breast feeding.

The BFHI is implemented by observing the ten steps to successful breast feeding. The ten steps are listed below. Any hospital that supports the BFHI must provide knowledge, facilities and support to a pregnant woman so that she can make informed decision on breast feeding.

Ten steps to successful breast feeding

1) Have a written breast feeding policy that is routinely communicated to all health-cae 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 breast feeding.

4) Help mothers initiate breast feeding within half an hour of birth.

5) Show mother how to breast feed and how to maintain lactation , even if they should be seperated from their infants.

6) Give newborn infants no food or drink other than breast milk, unless medically indicated.

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

Encourage breast feeding on demand.

9) Give no artificial teats or pacifiers (also called dummies or soothers) to breast feeding infants.

10) Foster the establishment of breast feeding support groups and refer mothers to them on discharge from the hospital or clinic.

References:

i) Paediatrics and child health in a tropical region edited by J. C. Azubuike and K.E. O Nkanginieme-1999

ii) Park’s Textbook of Preventive and Social Medicine by K .Park 17 th edition -2002.

The success of breast feeding is attested for by the survival of the human species.

No other type of food is required until the baby is about 4 to 5 months old.

The unparalled value of breast feeding to the infant is well known. It is a safe, protective and nutricious way to feed an infant.

It is well established that a child who is breast fed has greater chances of survival than a child artificially fed. The infant mortality rates in developing countries are 5-10 times higher than children who have not been breast fed.

Despite the numerous advantages of breast feeding , its popularity has declined in many parts of the world. The changes of breast feeding practices has affected the third world communities even more than the developed world. This is mainly because they do not have access to clean drinking water.

Every mother should be encouraged to breast feed her baby. It is also recommended that mothers should exclusively breast feed their babies for the first six months of life.

The advantages of breast feeding can be summarized as follows:

For the Infant

i) Provides essential and adequate nutrients at the correct temperature. It meets the nutritional requirements of the infant in the first few months of life.

ii)It is safe, clean and hygenic.

iii) Breast milk has antimicrobial factors such as lymphocytes, macrophages, secretory IgA , lysozyme ,lactoferrin and anti-streptococcal factor which provide protection against diarrhoeal diseases, necrotising enterocolitis and respiratory infections including otitis media in the first months of life.

iv)Reduced incidence of allergic disorders.

v) There is generalized reduction in childhood illness and hospital admissions.

vi) Promotion of mother-infant bonding and therefore appropriate psychosocial abilities.

vii) Sucking is good for the baby as it helps in the development of jaws and teeth.

viii) Breast milk protects babies from the tendency to obesity.

ix) It prevents malnutrition.

x) Breast milk provides several biochemical advantages such as prevention of neonatal hypocalcemia and hypomagnesemia.

For the Mother

i) Protection against cancer of the breast.

ii) Personal fulfilment and satisfaction of motherhood.

iii) Protection against early pregnancy post-delivery (a type of natural birth control- Lactational amenorrhoea).

iv)Faster involution of the uterus and therefore reduction in post-partum morbidity.

For the Family and Community

i) Reduced morbidity.

ii) Reduction in the cost of child care (Parents do not have to pay for expensive milk substitutes).

iii) It is environmentally friendly- no litters of cans  etc.

iv) Aids family spacing , increases the period of infertility after delivery (lactational amenorrhoed- though not very reliable it has a very great impact on developing countries compared to other contraceptive use).

Problems with breast feeding

This can be divided into medical and psychological

Medical : This is extremely rare – This may be due to some anatomical or physiological abnormality.

Psychological: Very common cause of lactational failure. This includes inadequate knowledge of breast feeding and infant nutition. Common misconceptions and lack of social support are also responsible for problems with breast feeding.

Some of the common misconceptions are given below:

Some Commonly held Misconceptions regarding Breast milk and Breast feeding

i) Colostrum (the initial milk secreted) is dirty milk and should not be given to the baby.

ii) Breast feeding is no longer fashionable.

iii) Loss of sexual activity during lactation.

iv) Breast milk is not enough for the growing infant.

v) Breast size is small and therefore output may be small.

vi) Breast may sag as a result of breast feeding with subsequent loss of sexual appeal.

vii) Breast milk can be poisonous to the baby.

viii) For working mothers early introduction of supplimental feeds to get baby used tp formula milk.

References:

i) Paediatrics and child health in a tropical region edited by J. C. Azubuike and K.E. O Nkanginieme-1999 

ii) Park’s Textbook of Preventive and Social Medicine by K .Park 17 th edition -2002.