Breast feeding

Why it is important ?

• Babies who are breastfed are generally healthier and achieve optimal growth and development compared to those who are fed formula milk.
• If the vast majority of babies were exclusively fed breastmilk in their first six months of life – meaning only breastmilk and no other liquids or solids, not even water – it is estimated that the lives of at least 1.2 million children would be saved every year. If children continue to be breastfed up to two years and beyond, the health and development of millions of children would be greatly improved.
• Infants who are not breastfed are at an increased risk of illness that can compromise their growth and raise the risk of death or disability. Breastfed babies receive protection from illnesses through the mother's milk.
• Breastfeeding is the natural and recommended way of feeding all infants, even when artificial feeding is affordable, clean water is available, and good hygienic conditions for preparing and feeding infant formula exist.
• If a mother is HIV-positive, there is a risk that she can transmit HIV to her baby through breastfeeding. Counselling can help her carefully weigh the risks and make an informed decision on which feeding option is best for her baby and most manageable for her.
• Almost every mother can breastfeed successfully. All mothers, particularly those who might lack the confidence to breastfeed, need the encouragement and practical support of the baby's father and their families, friends and relatives. Health workers, community workers, women's organizations and employers can also provide support.
• Everyone has the right to information about the benefits of breastfeeding and the risks of artificial feeding. Governments have a responsibility to provide this information. Communities as well as media and other channels of communication can play a key role in promoting breastfeeding.

What every family and community has a right to know?

1. Breast milk alone is the best food and drink for an infant for the first six months of life. No other food or drink, not even water, is usually needed during this period.
2. Newborn babies should be given to the mother to hold immediately after delivery. They should have skin-to-skin contact with the mother and begin breastfeeding within one hour of birth.
3. Almost every mother can breastfeed successfully. Breastfeeding the baby frequently causes production of more milk. The baby should breastfeed at least eight times daily, day and night, and on demand.
4. Breastfeeding helps protect babies and young children against dangerous illnesses. It also creates a special bond between mother and child.
5. Bottle feeding and giving a baby breastmilk substitutes such as infant formula or animal milk can threaten the baby's health and survival. If a woman cannot breastfeed her infant, the baby can be fed expressed breastmilk or, if necessary, a quality breastmilk substitute from an ordinary clean cup.
6. If a woman is infected with HIV, there is a risk that she can pass the infection to her infant through breastfeeding. In the first six months, this risk is much greater if the infant is fed both breastmilk and other liquids and foods than if fed breastmilk alone. Therefore, it is recommended that the baby receives breastmilk alone for the first six months, unless it is acceptable, feasible, affordable, sustainable and safe to give breastmilk substitutes (infant formula) exclusively.
7. A woman employed away from her home can continue to breastfeed her child. She should breastfeed as often as possible when she is with the infant and express her breastmilk when they are apart so that another caregiver can feed it to the baby in a clean and safe way.
8. After 6 months of age, when babies begin to eat foods, breastfeeding should continue for up to two years and beyond because it is an important source of nutrition, energy and protection from illness.

Supporting Information

Key Messages - Breastmilk alone is the best food and drink for an infant for the first six months of life. No other food or drink, not even water, is usually needed during this period.

Breast milk is the best food a young child can have. It promotes optimal growth and development and protects against illness. Breast milk contains the perfect balance of nutrients for a baby, unlike infant formula, powdered milk or animal milk.

The baby does not need water or other drinks or foods (such as tea, juice, sugar water, gripe water, rice water, other milks, formula or porridge) during the first six months. Even in hot, dry climates, breast milk fully meets a baby's need for fluids.

Breast milk is easy for the baby to digest. A baby has difficulty digesting animal milks, and formula is digested much more slowly than breast milk. Compared to other options, breast milk nourishes the baby more efficiently.

Breast milk protects against illness because it contains antibodies that transfer the mother's immunity or resistance to disease to the child. No other milks contain these antibodies.

Giving a baby under 6 months of age any liquids or foods other than breast milk increases the risk of diarrhoea and other illnesses. Water and other liquids or foods may be contaminated, which can cause diarrhoea.

A baby who takes water or other liquids or foods in the first six months suckles less on the breast. This slows down breast milk production.

If regular weighing shows that a breastfed baby under 6 months of age is not growing well:

• The mother may need help to improve the way the baby takes the breast into the mouth to ensure good attachment so the baby can suckle effectively.
• The baby may need more opportunities to breastfeed. The baby should breastfeed on demand, day and night, at least eight times during a 24-hour period. The baby should be allowed to breastfeed until she or he releases the breast and looks satisfied and sleepy. This shows that the baby has had all she or he wants from that breast. The baby should then be offered the other breast and may or may not want it. The baby should be kept on the breast until she or he has finished suckling.
• A low-birth weight baby may need frequent pauses during breastfeeding.
• The baby may be ill and should be checked by a trained health worker.
• The baby may be getting water or other fluids, which can reduce the intake of breast milk. The mother may need guidance on how to reduce and eliminate other fluids and to increase and give only breast milk.

Feeding a baby only with breast milk and on demand during the first six months can help to delay the return of the mother's menstruation. This may help to delay the next pregnancy. However, there is some possibility – less than 2 per cent – that a mother can become pregnant before her periods return. This becomes increasingly likely after six months.

Key Messages - Newborn babies should be given to the mother to hold immediately after delivery. They should have skin-to-skin contact with the mother and begin breastfeeding within one hour of birth.

• Skin-to-skin contact and breastfeeding soon after birth stimulate production of the mother's breast milk. Breastfeeding also helps the mother's womb contract, which reduces the risk of heavy bleeding or infection and helps to expel the placenta (afterbirth).
• Colostrum, the thick yellowish milk the mother produces in the first few days after giving birth, is the perfect food for newborn babies. It is very nutritious and full of antibodies that help protect the baby against infections. Sometimes mothers are advised not to feed colostrum to their babies. This advice is incorrect. Newborns benefit from colostrum.
• The newborn needs no other food or drink while the mother's milk supply is coming in and breastfeeding is being fully established. Giving any other food or drink may slow the production of milk. It can also increase the chance of diarrhoea and other infections. The milk produced by the mother is nutritious and the right amount for the newborn. The baby should breastfeed as often as she or he wants.
• A baby who has problems suckling in the first few days should be kept close to the mother, offered the breast frequently, helped to take the breast and given breast milk expressed directly into the mouth or fed expressed breast milk from a clean cup (not from a bottle). The mother should receive help to improve the baby's attachment and suckling, and should also be shown how to express breast milk, if necessary.
• A mother's own milk is best for low-birth weight babies. However, not all of these infants are able to feed from the breast in the first days of life. For them, other options are available. In order of preference, they are: expressed breast milk (from the mother); donor breast milk (only if the donor is HIV-tested and the milk is correctly heat-treated); and infant formula. All of these should be given by cup, spoon or paladai (a cup feeding device), or medical tubes used by a trained health worker in a health facility.
• Heat-treated breast milk involves heating expressed breast milk (enough for one or two feeds) in a small pan or in a metal container standing in a pan of water until it comes to a boil. The milk is then left to cool in a clean, covered container before it is fed to the baby by cup. A trained health worker can provide further guidance on expressing and heat-treating breast milk.
• It is best for the mother and her baby to stay together in the same room immediately after birth. If a mother gives birth in a hospital or clinic, she is entitled to have her baby near her, 24 hours a day. She should insist that no formula or water be given to her baby if she is breastfeeding.

Key Messages - Almost every mother can breastfeed successfully. Breastfeeding the baby frequently causes production of more milk. The baby should breastfeed at least eight times daily, day and night, and on demand.

A mother's breasts make as much milk as the baby wants. If the baby suckles more, more milk is produced. Almost every mother can successfully breastfeed and produce enough milk when:

• She breastfeeds exclusively
• The baby is in a good position and is well attached to the breast, with the breast well in the baby's mouth
• The baby feeds as often and for as long as she or he wants, including during the night, and is kept on the breast until she or he has finished suckling. The baby should finish feeding from one breast before being fed from the other breast.

Holding the baby in a good position makes it easier for the baby to take the breast well into the mouth and suckle.

Signs that the baby is in a good position for breastfeeding are:

• The baby's head and body are in line
• The baby is close to the mother's body
• The baby's whole body is turned towards the mother
• The baby is relaxed, happy and suckling.

Holding the baby in a poor position can cause difficulties such as:

• Sore and cracked nipples
• The baby does not receive enough milk
• The baby refuses to feed.

Signs that the baby is well attached:

• More of the dark skin around the mother's nipple (areola) can be seen above the baby's mouth than below it
• The baby's mouth is wide open
• The baby's lower lip is turned outward
• The baby's chin is touching the mother's breast.

Signs that the baby is suckling well:

• The baby takes long, deep sucks
• The cheeks are round when suckling
• The baby releases the breast when finished.

Generally, the mother does not feel any pain in her breast when breastfeeding.

From birth, the baby should breastfeed whenever she or he wants. A baby should be fed on demand at least eight times in a 24-hour period, during both the day and the night. If a newborn sleeps more than three hours after breastfeeding, she or he may be gently awakened and offered the breast.

Crying is not a sign that the baby needs other foods or drinks. It normally means the baby wants to be held and cuddled more the baby's diaper or nappy needs changing, or the baby is too hot or cold. Some babies need to suckle the breast for comfort. More suckling produces more breast milk, which helps satisfy the baby's feeding needs. If the baby cries a lot and does not settle after feeding and being cuddled, the mother may need additional breastfeeding support or the baby might not be well. A trained health worker should be consulted.

Using pacifiers, dummies or bottles can interfere with establishing breastfeeding in the baby's first months of life, as the sucking action for these is different from suckling at the breast. The baby may become used to the bottle teat or pacifier and refuse the breast. This may cause less suckling time at the breast, which reduces milk production. Pacifiers and bottle teats may become contaminated, increasing a baby's risk of illness.

Mothers who fear they do not have enough breast milk often give their babies other food or drink in the first few months of life. This causes the baby to suckle less often, so less breast milk is produced. The mother will produce more milk if she does not give the child other food or liquids and if she breastfeeds often.

Mothers need to be reassured that they can feed their babies under 6 months of age properly with breast milk alone, and they need to be shown how to do it. All mothers, especially those lacking the confidence to breastfeed, need encouragement and support from the child's father and their families, neighbours, friends, health workers, employers and women's organizations. A mother who has undergone a Caesarean birth may require extra help to begin breastfeeding her baby.

Skilled birth attendants can raise awareness and understanding about the benefits of breastfeeding. They should support mothers to initiate and continue breastfeeding and help fathers and other family members accept breastfeeding as a natural and nutritious practice that protects the life of the baby.

Key Messages - Breastfeeding helps protect babies and young children against dangerous illnesses. It also creates a special bond between mother and child.

• Breast milk is a baby's 'first immunization'. It helps to protect against diarrhoea, ear and chest infections, and other health problems. The protection is greatest when breast milk alone is given for the first six months and when breastfeeding continues along with other foods well into the second year and beyond. No other milks, foods or supplements can provide the protection of breast milk.
• Breastfeeding helps a mother and baby form a close, loving relationship – a process called bonding. The close contact and attention help infants feel secure and loved, which is important for their growth and development.
• The father and other family members can help by encouraging the mother to rest quietly while she breastfeeds the baby. They can also make sure the mother has enough nutritious food and help with household tasks and caring for older children.

Key Messages - Bottle feeding and giving a baby breastmilk substitutes such as infant formula or animal milk can threaten the baby's health and survival.

• Babies who do not receive breast milk do not receive protection from illnesses provided by the mother's antibodies and other components that come in her milk. These babies are more likely to get diarrhoea and respiratory and ear infections. Diarrhoea and respiratory infections, such as pneumonia, can be deadly in babies and young children.
• Feeding the baby breast milk substitutes can cause poor growth or illness if (1) too much or too little water is added, (2) the water is not from a safe source and/or (3) the bottles and teats are not cleaned properly. Powdered breast milk substitutes may contain harmful bacteria that can cause illness. Studies suggest that children fed breast milk substitutes, as compared to breastfed children, are at greater risk of childhood obesity and some chronic illnesses, such as heart disease, later in life.
• Feeding the baby breast milk substitutes can be expensive and particularly risky if parents cannot afford to buy enough of a quality breast milk substitute. For example, to feed one baby for the first six months requires 20 kilograms (about 40 tins) of infant formula. Trained health workers should inform all parents considering the use of breast milk substitutes about the costs.
• If it is necessary to feed the baby with formula, it is important to boil clean drinking water first and then add the hot water to the powdered formula. The water should not be added after it has cooled down. The directions for mixing should be carefully followed. This ensures that the right amounts of formula and safe water are mixed and that the process is hygienic. Before giving the formula to the baby, the mother, father or other caregiver must make sure it is not too hot.
• Animal milk and infant formula go bad if left at room temperature (around 20–25 degrees Celsius) for more than two hours. Breast milk can be stored for up to eight hours at room temperature without going bad. Of course, it is better to safely store all types of milk in a clean, covered container, preferably in a refrigerator.
• Cup feeding is safer than bottle feeding because the cup can be easily cleaned with soap and water. Cup feeding also provides some of the contact and stimulation the baby needs, since the person has to hold the baby. Feeding with a cup does not cause problems with suckling at the breast.
• The best food for a baby who cannot be breastfed directly is milk expressed from the mother's breast, given from a clean, open cup. Even newborn babies can be fed with an open cup. If it is necessary to feed a baby with a nutritionally adequate breast milk substitute, it should be fed to the baby by cup.

Key Messages - If a woman is infected with HIV, there is a risk that she can pass the infection to her infant through breastfeeding

HIV testing, treatment and counselling

Pregnant women and new mothers who think they may be infected with HIV should consult a trained health worker for HIV testing and counselling. Women who are HIV-positive should be counselled on how to reduce the risk of passing HIV to their children during pregnancy, childbirth or breastfeeding. They should also be counselled and supported on how to get treatment and care for themselves.

A trained health worker can provide women who are HIV-positive with information on antiretroviral therapy (ART), a group of medicines for people with HIV infection. ART can help reduce the risk of mother-to-child transmission of HIV and contribute to keeping the mother healthy.

All health workers should know if HIV testing and ART are available at their local clinic. They should provide information on these and other related services to pregnant women and new mothers.

Assess the risks and determine what is manageable

The HIV-positive mother should be counselled and provided with information to help her decide which feeding option is best for her baby and most manageable for her. The HIV-positive mother should know that:

• If she breastfeeds exclusively during the first six months she reduces the baby's risk of illness, malnutrition and death
• If she uses breast milk substitutes such as infant formula exclusively she avoids the risk of HIV infection through breast milk
• Shortening the duration of breastfeeding can reduce the risk of transmitting the infection to the infant.

The most appropriate infant feeding option for the child of an HIV-infected mother ultimately depends on individual circumstances. The mother needs to assess the risks through discussion with a trained health worker. The mother infected with HIV has the right to: 1) the information she needs to make an informed decision and 2) all the services and support necessary to help her implement that decision.

Infant Feeding Options

The first six months:

• Feeding the baby with infant formula (breast milk substitutes) should be considered only if it is acceptable, affordable, feasible, sustainable and safe for the mother and child. If all these conditions can be met, the baby can be fed a quality breast milk substitute alone for the first six months, with no breast milk or other foods. This eliminates the risk of passing HIV to the baby through breastfeeding.
• If the HIV-positive mother decides to breastfeed, she should feed her baby breast milk exclusively, giving no other liquids, milks or foods, for the first six months. Feeding breast milk alone in the first six months can reduce a baby's risk of HIV infection compared to giving both breast milk and other foods and liquids ('mixed feeding').
• Mixed feeding not only greatly increases the risk of transmitting HIV to the baby in the first six months but also causes more illness, such as diarrhoea and pneumonia, and malnutrition, and increases the risk of death.

After six months:

• All infants should be started on other foods to meet their growing nutritional needs.
• Women who have breastfed their infants during the first six months should continue to give their babies breast milk along with other foods unless they meet the conditions to give safe replacement foods, including infant formula and other milks and foods. Once a nutritionally adequate and safe diet can be provided, all breastfeeding should stop.

Other Important Information

During counselling, a pregnant woman or new mother with HIV can be helped to determine whether she can provide her baby with a nutritionally adequate and safe diet without breast milk. This assessment should be undertaken not only once, such as before the child is born, but also throughout the period of breastfeeding, with the support of the trained health worker.

If the mother is confident that she can provide sufficient amounts of a quality breast milk substitute, properly and hygienically prepared with clean water, then she can opt to stop all breastfeeding and begin using the breast milk substitute. A trained health worker should provide the mother and father with guidance on safe and clean practices to prepare the breast milk substitute.

A new mother who does not know her HIV status should exclusively breastfeed her child for the first six months and continue breastfeeding for up to two years and beyond in addition to feeding the child other nutritious foods and drinks.

Infants confirmed as HIV-positive should be breastfed so they can receive the benefits of breast milk.

Key Messages - A woman employed away from her home can continue to breastfeed her child. She should breastfeed as often as possible when she is with the infant and express her breastmilk when they are apart so that another caregiver can feed it to the baby in a clean and safe way.

• If a mother cannot be with her baby during working hours, she should breastfeed often when they are together. With frequent breastfeeding, she will continue to produce breastmilk.
• If a woman cannot breastfeed at her workplace, she can express her milk two or three times during the workday and refrigerate it or store it at room temperature for up to eight hours in a clean, covered container. The expressed milk can be given to the child by another caregiver from a clean cup.
• Families and communities can encourage employers to provide paid maternity leave, crèches, and the time and a suitable place for women to breastfeed or express and store their milk. The place should be clean, safe and private. It should have clean water available for washing hands and utensils.

Key Messages - After 6 months of age, when babies begin to eat foods, breastfeeding should continue for up to two years and beyond because it is an important source of nutrition, energy and protection from illness.

• Breast milk remains an important source of energy, protein and other nutrients such as vitamin A and iron, even when babies begin to consume additional foods after 6 months of age. Breast milk helps protect a child against disease for as long as the child breastfeeds.
• It is recommended that a mother continue to breastfeed her child up to two years and beyond – as long as she and the child wish to continue. Breastfeeding can comfort a child who is upset and is an important source of nourishment during a child's illness.

Source: UNICEF