Baby-Friendly Hospital Initiative Training Course PDF
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This manual provides a training course for maternity staff on the Baby-Friendly Hospital Initiative. It covers topics such as breastfeeding basics, counseling skills, and postnatal practices. The content emphasizes the importance of supporting breastfeeding mothers.
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Participant’s Manual BABY-FRIENDLY HOSPITAL INITIATIVE TRAINING COURSE FOR MATERNITY STAFF Baby-friendly Hospital Initiative training course for maternity staff: participant's manual ISBN (WHO) 978-92-4-000895-3 (electronic version) ISBN (WHO) 978-92-4-000896-0 (print version)...
Participant’s Manual BABY-FRIENDLY HOSPITAL INITIATIVE TRAINING COURSE FOR MATERNITY STAFF Baby-friendly Hospital Initiative training course for maternity staff: participant's manual ISBN (WHO) 978-92-4-000895-3 (electronic version) ISBN (WHO) 978-92-4-000896-0 (print version) © World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 This joint report reflects the activities of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC- SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO or UNICEF endorses any specific organization, products or services. 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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO or UNICEF concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO or UNICEF in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO and UNICEF to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO or UNICEF be liable for damages arising from its use. Design by Thahira Shireen Mustafa Photo credits: © WHO/Gato Borrero CONTENTS ACKNOWLEDGEMENTS............................................................................................................................................... v ABBREVIATIONS...................................................................................................................................................... vii GLOSSARY.............................................................................................................................................................. ix 1. INTRODUCTION TO THE COURSE..............................................................................................................................1 1.1 WHY THIS COURSE IS NEEDED....................................................................................................................................................... 1 1.2 COURSE OBJECTIVES................................................................................................................................................................... 3 1.3 COURSE COMPETENCIES.............................................................................................................................................................. 3 1.4 THE COURSE AND THE MANUAL..................................................................................................................................................... 9 MODULE 1. GETTING STARTED.................................................................................................................................. 10 SESSION 1. BFHI: KEY COMPONENT OF QUALITY MATERNAL AND NEWBORN CARE..........................................................................................10 SESSION 2. BENEFITS OF BREASTFEEDING...................................................................................................................................................19 SESSION 3. COUNSELLING SKILLS: LISTENING AND LEARNING.......................................................................................................................29 MODULE 2. BREASTFEEDING BASICS......................................................................................................................... 38 SESSION 4. COUNSELLING SKILLS: BUILDING CONFIDENCE AND GIVING SUPPORT............................................................................................38 SESSION 5. HOW BREASTFEEDING WORKS...................................................................................................................................................50 SESSION 6. IMPACT OF BIRTH PRACTICES....................................................................................................................................................64 SESSION 7. POSTNATAL PRACTICES TO SUPPORT BREASTFEEDING.................................................................................................................76 SESSION 8. CLASSROOM CLINICAL PRACTICE – ASSESSING A BREASTFEED.....................................................................................................85 SESSION 9. CLASSROOM CLINICAL PRACTICE: POSITIONING A BABY AT THE BREAST........................................................................................97 SESSION 10. CLINICAL PRACTICE SESSION 1: LISTENING AND LEARNING AND ASSESSING A BREASTFEED.........................................................104 SESSION 11. BREAST AND NIPPLE CONDITIONS..........................................................................................................................................111 SESSION 12. MILK SUPPLY CHALLENGES..................................................................................................................................................132 SESSION 13. CHALLENGES TO FEEDING AT THE BREAST AND ALTERNATIVE METHODS OF FEEDING...................................................................147 SESSION 14. MEDICAL INDICATIONS FOR SUPPLEMENTARY FEEDING............................................................................................................159 SESSION 15. CLINICAL PRACTICE SESSION 2: BUILDING CONFIDENCE AND GIVING SUPPORT – ASSISTING WITH A BREASTFEED..........................169 MODULE 3. BREASTFEEDING SUPPORT.................................................................................................................... 176 SESSION 16. MATERNAL HEALTH.............................................................................................................................................................176 SESSION 17. ANTENATAL PREPARATION FOR BREASTFEEDING......................................................................................................................180 SESSION 18. CLINICAL PRACTICE SESSION 3: ANTENATAL COUNSELLING.....................................................................................................187 SESSION 19. DISCHARGE........................................................................................................................................................................193 MODULE 4. CRITICAL MANAGEMENT PROCEDURES................................................................................................... 199 SESSION 20. THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES AND SUBSEQUENT RELEVANT WORLD HEALTH ASSEMBLY (WHA) RESOLUTIONS (THE CODE)...........................................................................................................................................................199 SESSION 21. FACILITY PRACTICES: IMPLEMENTING THE TEN STEPS.............................................................................................................204 TRAINING MATERIALS TABLE 1. COURSE COMPETENCIES................................................................................................................................................................ 4 DEMONSTRATION 3.J – SUMMARY OF SIX LISTENING AND LEARNING SKILLS...................................................................................................33 DEMONSTRATION 4.A – ACCEPTING WHAT A MOTHER THINKS.....................................................................................................................39 DEMONSTRATION 4.B – ACCEPTING HOW A MOTHER FEELS........................................................................................................................40 DEMONSTRATION 4.C – USING SIMPLE LANGUAGE AND PROVIDING RELEVANT INFORMATION............................................................................43 DEMONSTRATION 4.D – USING SIMPLE LANGUAGE AND PROVIDING RELEVANT INFORMATION............................................................................44 JOB AID: BREASTFEEDING SESSION OBSERVATION.........................................................................................................................................86 HOW TO HELP A MOTHER POSITION HER BABY..............................................................................................................................................98 SKILLS CHECKLIST: LISTENING AND LEARNING............................................................................................................................................108 COUNSELLING SKILLS..............................................................................................................................................................................109 SYRINGE METHOD FOR INVERTED NIPPLES.................................................................................................................................................114 HOW TO FEED A BABY BY CUP..................................................................................................................................................................154 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual iii JOB AID: BREASTFEEDING SESSION OBSERVATION.......................................................................................................................................174 ANTENATAL PREPARATION FOR BREASTFEEDING.........................................................................................................................................181 SPECIAL COUNSELLING AND SUPPORT.....................................................................................................................................................185 JOB AID: ANTENATAL CHECKLIST – INFANT FEEDING....................................................................................................................................191 SUMMARY: INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES..........................................................................................202 HOSPITAL BREASTFEEDING/INFANT FEEDING POLICY CHECKLIST...................................................................................................................221 iv Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Acknowledgements The development of this training curriculum was coordinated by the World Health Organization (WHO) Department of Nutrition and Food Safety, and the United Nations Children’s Fund (UNICEF) Nutrition Section, Programme Division. Thahira Shireen Mustafa, Laurence Grummer-Strawn, and Maaike Arts oversaw the revision of this training curriculum. This training curriculum is an update of the 2009 Baby-friendly Hospital Initiative (BFHI) training materials. Heather Rusi and Dana Hardy provided support in revising the package of the materials. We also thank the guidance and inputs provided the Advisory Commmittee members for this revision process (in alphabetical order): Decalie Brown, Felicity Savage, Hiroko Hongo, Marina Ferreira Rea, Mona Abdulrahman Alsumaie, Mudiwah Kadeshe. The updated materials were used in a pilot training jointly organized by WHO and UNICEF in collaboration with Ministry of Health and Family Welfare, Government of India. The pilot training was held from 11 – 14 March 2019 at Postgraduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India. We appreciate the extensive support provided by Arti Maria, Angela de Silva, Gayatri Singh, and Rachita Gupta, along with the staff of WHO and UNICEF Country offices in India and Sri Lanka and the staff of Dr. Ram Manohar Lohia Hospital, New Delhi, India in organizing this pilot-training. Acknowledgement is given to all the resource persons who participated as trainers and facilitators during the training (in alphabetical order): Dana Hardy, Dhammica Rowel, Dulanie Gunesekera Siriwardene, Nethmini Thenuwara, Preethi Sainia, Shacchee Baweja, and Sila Deb. Special thanks to the many colleagues who participated in the training and provided extensive and valuable comments and suggestions to improve the training materials (in alphabetical order): Alka Mathur, Amlin Shukla, Anita Gupta, Anita Rajorhia, Bahunshisha Kharkongor, Basant, Bhupinder Kaur, Isha Thapar, Jassal, Krishna Bhattacharya, Kriti Jain, Manathunga, Mutum Shanti, Navita, Nidhi Chopra, Preeti Sainia, Priya Gandhi, Pushpamma Sebastian, Reetu Singh, Rohini Sehgal, Ruchika Chugh Sachdeva, Sanarei Thangal, Sangeeta Rani, Sarita Bhagwat, Sebanti Ghosh, Shweta, Sonu Mishra, Sudha, Susan, Tapas Bandyopadhyay, and Veena Bahri. We also greatly appreciate the technical input received from the members of the Baby-Friendly Hospital Initiative (BFHI) Network, International Baby Food Action Network (IBFAN), International Lactation Consultants Association (ILCA), La Leche League International (LLLI) and World Alliance for Breastfeeding Action (WABA) during the revision process of the training materials. WHO gratefully acknowledges the financial contribution of the Bill & Melinda Gates Foundation, the Ministry of Health and Welfare, Republic of Korea and the United States Agency for International Development towards the preparation of this training curriculum. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual v Abbreviations ART antiretroviral therapy ARV antiretroviral BFHI Baby-friendly Hospital Initiative HIV human immunodeficiency virus IgA immunoglobulin A IgG immunoglobulin G TB tuberculosis UNICEF United Nations Children’s Fund WHA World Health Assembly WHO World Health Organization Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual vii Glossary Afterpains: Contraction of the uterus during breastfeeding in the first few days after childbirth, owing to release of oxytocin. Allergy: Symptoms when fed even a small amount of a particular food (so it is not dose related). Alveoli: Small sacs of milk-secreting cells in the breast. Amenorrhea: Absence of menstruation. Anaemia: Lack of red cells or lack of haemoglobin in the blood. Antenatal preparation: Preparation of a mother for the delivery of her baby. Antibodies: Proteins in the blood and in breast milk that fight infection. Appropriate touch: Touching somebody in a socially acceptable way. Areola: Dark skin surrounding the nipple. Artificial feeding: Feeding an infant on a breast-milk substitute. Artificial feeds: Any kind of milk or other liquid given instead of breastfeeding. Artificial teat: The part of a feeding bottle from which a baby sucks. Artificially fed: Receiving artificial feeds only, and no breast milk. Attachment: The way a baby takes the breast into his/her mouth; a baby may be well attached or poorly attached to the breast. Baby-friendly Hospital Initiative (BFHI): An approach to transforming maternity practices as recommended in the joint World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) statement on Protecting, promoting and supporting breastfeeding: the special role of maternity services (1989).1 Bilirubin: Yellow breakdown products of haemoglobin, which cause jaundice. Blocked duct: A milk duct in the breast becoming blocked with thickened milk, so that the milk in that part of the breast does not flow out. Bonding: Development of a close loving relationship between a mother and her baby. Bottle-feeding: Feeding an infant from a bottle, whatever is in the bottle, including expressed breast milk, water, formula, etc. Breast pump: Device for expressing milk. Breastfeeding history: All the relevant information about what has happened to a mother and baby, and how their present breastfeeding situation developed. Breastfeeding support: A group of mothers who help each other to breastfeed. 1 Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health Organization; 1989 (http://apps.who.int/iris/bitstream/10665/39679/1/9241561300.pdf, accessed 9 April 2020). Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual ix Breast-milk substitute: Any food being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not it is suitable for that purpose. Calories: Calories (or kilocalories) measure the energy available in food. Candida: Yeast that can infect the nipple, and the baby's mouth and bottom. Also known as “thrush”. Casein: Protein in milk, which forms curds. Cleft lip or palate: Abnormal division of the lip or palate. Closed questions: Questions that can be answered with “yes” or “no”. Cold compress: Cloths soaked in cold water to put on the breast. Colostrum: The special breast milk that women produce in the first few days after delivery; it is yellowish or clear in colour. Confidence: Believing in yourself and your ability to do things. Commercial infant formula: A breast-milk substitute formulated industrially, in accordance with applicable Codex Alimentarius standards, to satisfy the nutritional requirements of infants during the first months of life up to the introduction of complementary foods. Complementary feeding: The child receives both breast milk, or a breast-milk substitute, and solid (or semi-solid) food. Complementary food: Any food, whether manufactured or locally prepared, used as a complement to breast milk or to a breast-milk substitute. Counselling: A way of working with people so that you understand their feelings and help them to develop confidence and decide what to do. Cup-feeding: Feeding from an open cup without a lid, whatever is in the cup. Chemotherapy: The use of anti-cancer drugs to destroy cancer cells. Dehydration: Lack of water in the body. Ducts, milk ducts: Small tubes that take milk to the nipple. Dummy: An artificial nipple made of plastic for a baby to suck. Also known as a pacifier/soother. Early contact: A mother holding her baby during the first hour or two after delivery. Effective suckling: Suckling in a way that removes the milk efficiently from the breast. Empathize: Show that you understand how a person feels from her/his point of view. Engorgement: The breast is swollen with breast milk, blood and tissue fluid. Engorged breasts are often painful and oedematous and the milk does not flow well. Exclusive breastfeeding: An infant receives only breast milk and no other liquids or solids, not even water, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines. Expressed breast milk: Milk that has been removed from the breasts manually or by using a pump. x Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Express: To squeeze or press out. Fissure: Break in the skin, sometimes called a “crack”. Flat nipple: A nipple that sticks out less than average. Foremilk: The watery breast milk that is produced early in a feed. Formula: Artificial milks for babies made out of a variety of products, including sugar, animal milks, soybean and vegetable oils. They are usually in powder form, to mix with water. Full breasts: Breasts that are full of milk, and hot, heavy and hard, but from which the milk flows. Gulp: Loud swallowing sounds due to swallowing a lot of fluid. Herpes simplex virus type 1 (HSV-1): A virus causing contagious sores, most often around the mouth or on the genitals. Hindmilk: The fat-rich breast milk that is produced later in a feed. HIV: Human immunodeficiency virus. HIV-negative: Refers to a person who has been tested for HIV with a negative result and who knows their result. HIV-positive: Refers to a person who has been tested for HIV, whose results have been confirmed and who knows, and/or their parents know that they tested positive. HIV testing and counselling: Testing for HIV status, preceded and followed by counselling. Testing should be voluntary and confidential, with fully informed consent. The expression means the same as the terms: “counselling and voluntary testing”, “voluntary counselling and testing”, and “voluntary and confidential counselling and testing”. Counselling is a process, not a one-off event: for the HIV-positive client it should include life planning, and, if the client is pregnant or has recently given birth, it should include infant-feeding considerations. Hormones: Chemical messengers in the body. Immune system: Those parts of the body and blood including lymph glands and white blood cells, that fight infection. Immunity: A defense system that the body has to fight diseases. Ineffective suckling; Suckling in a way that removes milk from the breast inefficiently or not at all. Infective mastitis: Mastitis resulting from bacterial infection. Inhibit: To reduce or stop something. Inverted nipple: A nipple that goes in instead of sticking out, or that goes in when the mother tries to stretch it out. Jaundice: Yellow colour of eyes and skin. Judging words: Words that suggest that something is right or wrong, good or bad. Lactation: The process of producing breast milk. Lactation amenorrhea method: Using the period of amenorrhea after childbirth as a method for family planning. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual xi Lactose: The special sugar present in all milks. Lipase: Enzyme to digest fat. Low-birth-weight infant: A baby weighing less than 2.5 kg at birth. Mastitis: Inflammation of the breast (see also Infective mastitis and non-infective mastitis). Mature milk: The breast milk that is produced a few days after birth. Meconium stools: The initial black and tarry stool of a newborn. Micronutrients: Essential nutrients required by the body in small quantities (like vitamins and some minerals). Micronutrient supplements: Preparations of vitamins and minerals. Milk ejection: Milk flowing from the breast due to the oxytocin reflex, which is stimulated in response to the sight, touch or sound of the baby. Milk stasis: Milk staying in the breast and not flowing out. Milk expression: Removing milk from the breasts manually or by using a pump. Mixed feeding: Feeding both breast milk and other foods or liquids. Montgomery's glands: Small glands in the areola that secrete an oily liquid. “Nipple confusion”: A term sometimes used to describe the way babies who have fed from a bottle may find it difficult to suckle effectively from a breast. Nipple sucking: When a baby takes only the nipple into his/her mouth so that he/she cannot suckle effectively. Non-infective mastitis: Mastitis due to milk leaking out of the alveoli and back into the breast tissues with no bacterial infection. Non-verbal communication: Showing your attitude through your posture and expression. Nutrients: Substances the body needs that come from the diet. These are carbohydrates, proteins, fats, minerals and vitamins. Mother-support group: A community-based group of women providing support for optimal breastfeeding and complementary feeding. Open questions: Questions that can only be answered by giving information and not with just a “yes” or a “no”. Oxytocin: The hormone that makes the milk flow from the breast. Pacifier: Artificial nipple made of plastic for a baby to suck (Also called a dummy). Pneumonia: Infection of the lungs. Poorly protractile: Used to describe a nipple that is difficult to stretch out to form a “teat”. Positioning: How a mother holds her baby at her breast; the term usually refers to the position of the baby's whole body. Postnatal check: Routine visit to a health facility after a baby is born. xii Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Prelacteal feeds: Artificial feeds given before breastfeeding is established. Premature, preterm: Born before 37 weeks’ gestation. Prolactin: The hormone that makes the breasts produce milk. Protein: Nutrient necessary for growth and repair of the body tissues. Protractile: Used to describe a nipple that is easy to stretch out. Psychological: Mental and emotional. Reflect back: Repeat back what a person says to you, in a slightly different way. Reflex: An automatic response through the body's nervous system. Rejection of baby: The mother not wanting to care for her baby. Reluctant to feed at the breast: A baby having difficulty to suckle from his/her mother's breast. Replacement feeding: The process of feeding a child who is not receiving any breast milk with a diet that provides all the nutrients he/she needs until he/she is fully fed on family foods. During the first six months, this should be with a suitable breast-milk substitute. Responsive feeding: Feeding infants directly and assisting older children when they feed themselves, being sensitive to their hunger and satiety cues. Restricted breastfeeds: When the frequency or length of breastfeeds is limited in any way. Retained placenta: A small piece of the placenta remaining in the uterus after delivery. Rooming-in: A baby staying in the same room as their mother. Rooting: A baby searching for the breast with their mouth. Rooting reflex: A baby opening their mouth and turning to find the nipple. Scissor hold: Holding the breast between the index and middle fingers while the baby is feeding. Secrete: Produce a fluid in the body. Sensory impulses: Messages in nerves that are responsible for feeling. Sepsis: The body’s life-threatening response to infection that can lead to tissue damage, organ failure, and death Skin-to-skin contact: A mother holding her naked baby against her own skin. Sore nipples: Pain in the nipple and areola when the baby feeds. Sucking: Using negative pressure to take something into the mouth. Sucking reflex: A reflex that allows a baby to automatically suck something that touches his/her palate. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual xiii Suckling: The action by which a baby removes milk from the breast. Supplements: Drinks or artificial feeds given in addition to breast milk. Support: Help. Sustaining: Continuing to breastfeed up to two years or beyond; helping breastfeeding mothers to continue to breastfeed. Swallowing reflex: A reflex whereby a baby automatically swallows when their mouth fills with fluid. Sympathize: Show that you feel sorry for a person, from your point of view. “Teat”: Stretched out breast tissue from which a baby suckles. Thrush: Infection caused by the yeast Candida. The infection occurs in the baby's mouth and forms white spots. Unrestricted feeding: See Responsive feeding. Warm compress: Cloths soaked in warm water to put on the breast. xiv Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Notes ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………….……… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ………………………………………………………………………………………………………..…………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual xv 1. Introduction to the course 1.1 Why this course is needed The first few hours and days of a newborn baby’s life are a critical window for establishing breastfeeding and for providing mothers with the support they need to breastfeed successfully. Since 1991, the Baby-friendly Hospital Initiative (BFHI) has helped to motivate facilities providing maternity and newborn baby services worldwide to better support breastfeeding. It has been adopted by many countries and organizations. The BFHI aims to provide a health-care environment that supports mothers to acquire the skills necessary to exclusively breastfeed for six months, and to continue breastfeeding for two years or beyond. Breastfeeding and appropriate, safe and timely complementary feeding are fundamental to the health and development of children, and important for the health of their mothers. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have long recognized the need for the promotion of exclusive breastfeeding in the first six months of life and for sustained breastfeeding up to two years of age or beyond. A hospital that is designated as baby-friendly must fully implement the TEN STEPS TO SUCCESSFUL BREASTFEEDING. These are a summary of the recommendations of Protecting, promoting and supporting breastfeeding: the special role of maternity services1. This was a joint WHO/UNICEF statement, published in 1989. The “Ten Steps” became part of the Baby-friendly Hospital Initiative in 1991, and the updated version in 2009. They were then revised in 2018 and continue to be valid throughout the world as the basis of the BFHI. There is substantial evidence to show that the Ten Steps improves breastfeeding rates. This updated course is built upon the revised 2018 Ten Steps to successful breastfeeding, the latest version of the guidance for implementing the BFHI in facilities providing maternity and newborn services, and the World Health Organization (WHO) Implementation guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative (BFHI)2. While the BFHI focuses on breastfeeding support, it also provides for integrated care to support all mothers including those who are not breastfeeding. In addition, the BFHI supports women living with HIV3. Many mothers have difficulty breastfeeding from the beginning, and health-care practices in many facilities hinder the process of establishing breastfeeding. However, even mothers who initiate breastfeeding satisfactorily often start supplements or stop breastfeeding within a few weeks of delivery. This may result in malnutrition, which is an increasing problem in many countries. It has been estimated that improved breastfeeding practices would prevent 823 000 annual deaths in children younger than five years of age4. Information on how to feed infants comes from family beliefs, community practices and information from health workers. Advertising and commercial promotion by food manufacturers is sometimes the source of information for many people, including families and health workers. It has often been difficult for health workers to discuss with families how best to feed their infants, owing to the confusing, and often conflicting information available. All health workers who care for women and children during the postnatal period and beyond have a key role to play in establishing and sustaining breastfeeding. Many health workers cannot fulfil this role effectively because they have not been trained to do so. Little time is assigned to counselling and support skills for breastfeeding and infant feeding, in the pre-service curricula of either doctors, nurses, midwives or other professionals. Hence, there is an urgent need, in all countries, to train all those involved in breastfeeding in the immediate postnatal period 1 Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health Organization; 1989 (http://apps.who.int/iris/bitstream/10665/39679/1/9241561300.pdf, accessed 13 March 2020). 2 Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative. Geneva: World Health Organization; 1989 (https://apps.who.int/iris/bitstream/handle/10665/272943/9789241513807- eng.pdf?sequence=19&isAllowed=y, accessed 13 March 2020). 3 Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. World Health Organization and UNICEF; 2016. (http://apps.who.int/iris/bitstream/handle/10665/246260/9789241549707-eng.pdf?sequence=1, accessed 13 March 2020). 4 Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. doi:10.1016/S0140-6736(15)01044-2 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 1 in the skills needed to support and protect breastfeeding. The materials in this training course are designed to make it possible for trainers, even those with limited experience in teaching the subject, to conduct up-to-date and effective training. The course materials available from WHO/UNICEF include modules related to: counselling skills breastfeeding and infant feeding breastfeeding support critical management procedures. The course materials are intended to be conducted in their entirety. However, the course is organized in such a way that the course trainers can decide which sessions from which modules to cover, depending on the priorities and context of the country and the participants. The material could be thus used, for example, to hold a three-day course on the Ten Steps to successful breastfeeding, or courses on specific subjects, such as breastfeeding basics or breastfeeding support. “Counselling” is an extremely important component of this course material. Counselling is more than just listening. You listen to a new mother, try to understand how she feels, and learn from what she is telling you. You can then help her decide for herself what is best for her, from various options or suggestions. This provides her with support and helps her to have the confidence to carry out their own decisions. This course aims to give health workers basic counselling skills, so that they can help mothers and caregivers more effectively. The course material can be used to complement existing courses or as part of the pre-service education of health workers. This course material does NOT prepare people to take full responsibility for caring for mothers breastfeeding their newborn babies. It does not cover in-depth topics on treatment, care and management of sick or low-birth-weight infants, those living with HIV, or those taking antiretroviral (ARV) drugs or antiretroviral therapy (ART). The material covers only aspects specifically related to the Ten Steps to successful breastfeeding. 2 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 1.2 Course objectives After completing this course, participants will have the knowledge, skills and competence to protect, promote and support breastfeeding in the facilities where they work and understand the importance of the Ten Steps to Successful Breastfeeding and translate them into practice. Each session of the course has a set of learning objectives that participants are expected to fulfil. 1.3 Course competencies This course is based on a set of competencies that every participant is expected to learn during the course and subsequent practice, and to follow-up at their place of work. To become competent at something, you need a certain amount of knowledge and to be proficient in certain skills. The following table lists the competencies (column 1), and the knowledge (column 2) and skills required (column 3) for each competency. The “knowledge” part of the competencies will be taught during this course and is contained in the Participant’s manual for later referral and revision by participants. Most people find that they obtain the “knowledge” part of a competency more quickly than the “skills” part. The “skills” part of the competencies will also be taught during this course. However, there may not be time for each participant to become proficient in every skill. This will depend on their previous experience. During the course, every participant should practise as many of the skills as possible, so that they know what to do when they return to their place of work. The competencies are arranged according to area/session and in a certain order. The competencies at the beginning of table 1 are those that are most commonly used, and on which later competencies depend. For example, the competency USE LISTENING AND LEARNING SKILLS TO COUNSEL A MOTHER OR CAREGIVER is used in many of the other competencies. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 3 TABLE 1. COURSE COMPETENCIES Competency Knowledge Skills Session Counselling C1. Use listening and. List the LISTENING AND LEARNING. Use the LISTENING AND LEARNING. S3 learning skills SKILLS SKILLS when counselling a mother whenever engaging. Give an example of each skill or caregiver on feeding an infant in a conversation with a mother C2. Use skills for. List the SKILLS FOR BUILDING. Use the SKILLS FOR BUILDING. S4 building confidence CONFIDENCE AND GIVING SUPPORT CONFIDENCE AND GIVING SUPPORT and giving support. Give an example of each skill when counselling a mother or whenever engaging caregiver on feeding an infant in a conversation with a mother Breastfeeding BF1. Engage in antenatal. Explain why exclusive. Use counselling skills with a. S17, S18 conversation about breastfeeding is important for pregnant woman to listen to her breastfeeding the first six months questions and concerns about. Explain the importance of breastfeeding, and discuss how skin-to-skin contact you may be able to help her immediately after delivery and. Reinforce her previous knowledge the initiation of breastfeeding and give her additional within one hour information according to her. List the special properties of needs including: colostrum and reasons why it. advantages of exclusive is important breastfeeding. Explain good positioning and. the importance of skin-to-skin attachment contact immediately after. List the risks of not delivery breastfeeding. how to initiate and establish breastfeeding after delivery. the importance of colostrum. the optimal breastfeeding patterns. responsive feeding and feeding cues. rooming-in. health-care practices and the help that she will receive after delivery. Demonstrate good positioning and how to attach baby to the breast and ask her to practice with a doll. Apply competencies C1, C2 and parts of BF4 4 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Competency Knowledge Skills Session BF2. Implement immediate. Explain the importance of. Help a mother to initiate skin-to-. S6 and uninterrupted early contact after delivery and skin contact and breastfeeding skin-to-skin of the baby receiving colostrum. Describe the procedure of putting the baby in skin-to- skin contact immediately after delivery BF3. Facilitate. Describe how a baby moves. Help a mother to initiate skin-to-. S6, S7 breastfeeding within to the breast and attaches by skin contact and breastfeeding the first hour, itself, and how to help the. Apply competencies C1, C2, BF5 according to cues baby if needed. Describe how health-care practices affect initiation of breastfeeding BF4. Discuss with a. Describe the physiology of. Explain to a mother the onset and. S2, S5, S14, S16 mother how breast-milk production and stages of milk production breastfeeding works flow including about colostrum and. Explain the physiology of “coming in” of mature milk lactation hormones. Explain to a mother about the. Describe responsive feeding optimal pattern of breastfeeding and implications for the and responsive feeding, at frequency and duration of different stages breastfeeds. Talk to women individually or in. Describe the importance of groups about optimal infant exclusive breastfeeding for six feeding (includes referring a months and continued mother to community resources) breastfeeding for up to two years and beyond BF5. Assist mother getting. Describe the relevant anatomy. Recognize correct positioning,. S5, S8, S9, S10 her baby to latch and physiology of the breast according to the FOUR KEY POINTS and suckling action of the OF POSITIONING baby. Assess a breastfeed using the JOB. Describe effective and AID: BREASTFEEDING OBSERVATION ineffective suckling. Demonstrate how to assess a. Describe the difference breastfeed between good and poor. Identify a mother who may need attachment of a baby at the help breast. Show a mother how to hold and. Explain the FOUR KEY POINTS OF position her baby, by ATTACHMENT demonstrating with a doll. Explain the FOUR KEY POINTS OF. Help a mother to position her POSITIONING baby using the four key points, in. Explain the main positions for different positions the mother: sitting, lying. Show a mother how to support down, side-lying her breast for feeding. Explain different ways to hold. Help a mother to find a the baby: underarm, across, comfortable position for and others breastfeeding. Describe how a mother. Help a mother to get her baby to should support her breast for attach to the breast once they are feeding well positioned. Help the mother to recognize whether the baby is well attached or not Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 5 Competency Knowledge Skills Session BF6. Help a mother. Explain about a baby’s feeding. Help a mother recognize her. S7, S12, S13, S17, respond to feeding cues baby’s feeding cues S19 cues. Describe how the use of a. Help a mother feed her baby baby feeding bottle, teat or pacifier responding to the feeding cues can prevent the mother from recognizing feeding cues of her baby BF7. Help a mother. Explain why expressing breast. Demonstrate to a mother the steps. S13 manage milk milk is useful for mothers or of expressing breast milk by hand expression babies who have difficulty. Apply competencies C1 and C2, feeding at the breast, or who and teach a mother how to are separated from each other express breast milk by hand. Describe the relevant anatomy of the breast and physiology of lactation. List the steps of expressing breast milk by hand. Explain how to stimulate the oxytocin reflex BF8. Help a mother to. Describe alternative methods. Help a mother or caregiver to cup-. S7, S9, S13 breastfeed a low- of feeding feed the low-birth-weight baby. birth-weight or. Explain how to feed a low-. Apply competencies, especially sick baby birth weight or sick baby by BF7 and BF10, to manage these cup infants appropriately. Explain how to introduce a. Help a mother to introduce her LBW baby gradually to the baby gradually to her breast breast, using the same principles of positioning and attachment BF9. Help a mother when. Explain the possible medical. Explain to mother the risks of not. S13, S14 baby needs fluids indications for breastfeeding exclusively using other than supplementation competencies C1 and C2 breastmilk. Explain how to choose an. Help a mother understand the appropriate supplement importance of avoiding any food. Describe the safe preparation or fluids other than breast milk, of giving additional fluids unless medically indicated other than mother’s own milk. Help support a mother whose. List the risks of using a baby needs fluids other than feeding bottle, teat or pacifier breastmilk BF10. Help a mother who. List the advantages of cup-. Teach a mother how to cup feed. S13, S14, S17, S18 is not feeding her feeding her baby safely baby directly at the. Describe how to cup feed a. Practise with a mother how to cup breast baby feed her baby safely. List the risks of using a feeding bottle, teat or pacifier 6 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Competency Knowledge Skills Session BF11. Help a mother. Explain normal newborn. Decide whether a newborn is. S11, S15, S16, S12, prevent or resolve feeding behaviour and intake. getting enough breast milk or not. S13 difficulties with. List the signs and symptoms. Explain the cause of the difficulty breastfeeding that indicate a newborn may to the mother not be getting enough milk. Help a mother whose baby is not. Explain the common reasons getting enough breast milk. why a newborn may not get enough breast milk. Help a mother who thinks her baby is not getting enough milk.. Explain how to prevent and Help a mother whose aby is reluctant manage milk insufficiency in to feed at the breast newborns Recognize flat and inverted nipples. List different reasons why Demonstrate how to use the syringe babies cry in the immediate method for the treatment of postnatal period inverted nipples. Describe the management of a Recognize engorged breasts crying baby in the immediate Recognize sore and cracked nipples postnatal period Recognize mastitis and refer to the List the causes of why a baby appropriate level of care if may be reluctant to feed at the necessary breast Manage a blocked duct appropriately Explain the difference between flat. Apply competencies C1 and C2 and inverted nipples and and BF4 to BF7, and BF10 to about protractility and how to overcome the difficulty, including manage flat and inverted explaining the cause of the nipples difficulty to the mother Explain the reasons why breasts Apply competencies BF7 and BF10 to may become engorged and maintain breast- milk production how to manage breast and to feed the baby meanwhile engorgement List causes of sore or cracked nipples List the causes of a blocked milk duct Explain how to treat a blocked milk duct List the causes of mastitis Explain how to manage mastitis, including indications for antibiotic treatment and referral Explain what is different when treating mastitis in a mother living with HIV Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 7 Competency Knowledge Skills Session BF12. Ensure seamless. Explain how to prepare a. Provide information to a mother. S16, S19 transition after mother for discharge about how to get continuing discharge. Explain the importance of support and help after discharge follow-up care for a new. Help a mother with support to mother and her baby ensure breastfeeding continues. Describe the available longer after discharge community resources to. Help a mother recognize signs support breastfeeding and symptoms that indicate a newborn may not be getting enough milk and to seek medical help when necessary. mothers are given information about how to get continuing support and help after discharge Policies and programmes related to breastfeeding PP1. Implement the. Describe how commercial. Recognize common violations of. S20, S21 International code promotion of breast-milk the Code of marketing of substitutes undermines good. Indicate appropriate actions to take breast-milk breastfeeding practices when violations are identified in substitutes in a. List the major provisions of the health facility health facility the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions (the Code). Describe health-workers’ responsibilities for complying with the Code PP2. Explain a facility’s. Describe quality improvement. Routinely administer client. S21 infant feeding in a facility, as part of the Ten satisfaction surveys or exit policies and Steps interviews to each mother before monitoring. Explain the importance of being discharged if required as systems infant feeding policies part of health-facility monitoring. Explain the global standards. Record the care of each from each of the TEN STEPS mother/baby pair (e.g. early TO SUCCESSFUL initiation, rooming in), and also BREASTFEEDING analyse the data over a period of. Outline the health-care time if necessary for quality practices summarized by the improvement processes TEN STEPS TO SUCCESSFUL. Collect and record data requested BREASTFEEDING by the facility, to ensure standard of care in line with infant feeding policy, which can be evaluated and monitored 8 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 1.4 The course and the manual The course is divided into various sessions and will take different times, according to the modules and sessions selected. It can be conducted over three working days or can be spread in other ways. The sessions use a variety of teaching methods, including lectures, demonstrations and work in smaller groups, including clinical practice sessions in clinical facilities. Sessions can be arranged in different ways to suit the local situation. Your course director and facilitators will plan the course that is most suitable for your needs and will give you a timetable. This manual, the Participant’s manual, is your main guide to the course, and you should keep it with you at all times, except during clinical practice sessions. You will be provided with the sessions selected for your training. In the material provided, you will find a summary of the main information from each session, including descriptions of how to do each of the skills that you will learn. You do not need to take detailed notes during the sessions, though you may find it helpful to make notes of points of particular interest, for example from discussions. Keep your Participant’s manual after the course and use it as a source of reference as you put what you have learnt into practice. This Participant’s manual also contains: copies of the key slides that you might want to memorize forms, lists and checklists for exercises, and practical and clinical practice sessions written exercises that you will be asked to do individually. You will receive separate copies of the forms, lists and checklists to use for the clinical practice sessions, so that you do not have to carry your manual at these times. You will receive answer sheets for each written exercise after you have done the exercise. These enable you to check your answers later, and to study any questions that you may not have had time to complete. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 9 MODULE 1. GETTING STARTED Session 1. BFHI: Key component of quality maternal and newborn care Objectives After completing this session, participants will be able to: ▪ describe the importance of exclusive and continued breastfeeding; ▪ discuss the WHO/UNICEF Global Strategy for Infant and Young Child Feeding; ▪ outline the Baby-friendly Hospital Initiative; ▪ list the Ten Steps to Successful Breastfeeding; and ▪ understand the outline of this course. Exclusive breastfeeding Infant receives only breast milk for the first six months of life. No other food or water. It has the single largest potential impact on child mortality of any preventive intervention5. 5 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet. 2003;362:65–71. doi.org/10.1016/S0140-6736(03)13811-1 10 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual It is part of optimal breastfeeding practices including initiation within one hour of life and continued breastfeeding for up to two years of age or beyond. Breastfeeding has the single, largest potential impact on child mortality of any preventive intervention5. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that infants should be exclusively breastfed for the first six months of life. Breastfeeding should continue for up to two years of age or beyond. To enable mothers/parents/caregivers to establish and sustain exclusive breastfeeding for six months, WHO and UNICEF recommend: immediate and uninterrupted skin-to-skin contact and initiation of breastfeeding within the first hour of life; exclusive breastfeeding – the infant only receives breast milk; breastfeeding responsively – that is, as often and as long as the baby wants, day and night; counselling mothers on the risks and use of supplementary feeding, bottles, teats or pacifiers. Critical window The first hours and days of a newborn infant’s life are a critical window for providing mothers** with the support they need to establish and sustain breastfeeding. Therefore, policies, programmes and facilities must provide this support. NOTE: **In this course, "mothers" will represent all options of lactation and breastfeeding including parents, partners, families, mothers, women and caregivers. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 11 The Global Strategy for Infant and Young Child Feeding Improved breastfeeding practices would prevent an estimated 823 000 annual deaths in children younger than five years of age6. Many children suffer long-term effects from poor infant feeding practices including impaired development, malnutrition, and increased infectious and chronic illness. Creating an empowering environment through policy and programmes can help to support exclusive and continued breastfeeding. 2002: WHO and UNICEF endorsed the Global Strategy for Infant and Young Child Feeding. 2012: WHO sets six global nutrition targets through a comprehensive implementation plan on maternal, infant and young child nutrition. As part of optimal breastfeeding practices, the plan aims to increase rates of exclusive breastfeeding. This slide outlines the aim of the Global Strategy. The Global Strategy does not replace but rather builds upon existing programmes including the BFHI. The Global Strategy calls for: 1) further implementation of the BFHI 2) breastfeeding and lactation management curriculum in health-worker training 3) accurate and up-to-date data on breastfeeding. The Baby-friendly Hospital Initiative The BFHI started as a WHO and UNICEF initiative in 1991. Since then, it has been adopted by many countries and organizations. By 2007, there were already 20 000 hospitals in 152 countries that had achieved “baby-friendly” status. The BFHI aims to provide health-care environments that help mothers acquire the necessary skills to exclusively 6 Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piowz EG, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. doi:10.1016/S0140-6736(15)01044-2 12 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual breastfeed for six months and continue breastfeeding for two years or beyond. It aims to promote universal implementation of all of the Ten Steps to Successful Breastfeeding, which were first written in 1989. In 2018, they were revised and continue to be crucial throughout the world as the basis of the BFHI. The BFHI supports women living with HIV7 in the following two contexts: 1) where national recommendations include avoidance of all breastfeeding 2) where national recommendations include breastfeeding plus antiretroviral therapy (ART). Baby-friendly maternity facility The facility must fully implement the Ten Steps to Successful Breastfeeding, which became part of the BFHI in 1991, and were updated in 2009. They were revised in 2018 and continue to be valid throughout the world as the basis of the BFHI. The BFHI also provides integrated care to all mothers and families, including those who are not breastfeeding, to care for their babies as well as possible. In addition, the BFHI supports women living with HIV8 in the contexts above. The Ten Steps to Successful Breastfeeding The revised Ten Steps include both critical management procedures and key clinical practices. The following two slides outline both these key procedures and clinical practices. We will learn more about these steps throughout the course. Ten Steps: Clinical management procedures 7 WHO/UNICEF. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization; 2016. (http://apps.who.int/iris/bitstream/handle/10665/246260/9789241549707-eng.pdf?sequence=1, accessed 3 April 2020 ). 8 Ibid. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 13 Ten steps: Key clinical practices Improve capacity building Timely and appropriate care for breastfeeding mothers can be provided by staff who possess the knowledge and skills. Training will enable you to develop competence, give consistent messages and implement standards to protect, promote and support breastfeeding. 14 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Course objectives This course will increase your confidence, knowledge and skills when caring for mothers and infants in everyday practice. It will be held over 2–3 days and provide 22 hours of information. During this course, you will have an opportunity to learn and practice the following skills. Overall skills Implement the Ten Steps to Successful Breastfeeding. Improve communication skills to counsel mothers and caregivers. Refer a mother to the appropriate community resources for ongoing support once she returns home. Abide by the International Code of Marketing of Breast-milk Substitutes and relevant WHA resolutions. Breastfeeding/lactation management skills During this course, participants will grow in skills and knowledge to manage a variety of lactations situations. These include, but are not limited to: 1. using listening and learning skills whenever engaging in a conversation with a mother; 2. using skills for building confidence and giving support whenever engaging in a conversation using listening and learning skills to counsel a mother; 3. engaging in antenatal conversation about breastfeeding; 4. implementing immediate and uninterrupted skin-to-skin; 5. facilitating breastfeeding within the first hour, according to cues; 6. discussing with a mother how breastfeeding works; 7. assisting a mother getting her baby to latch; 8. helping a mother respond to feeding cues; 9. helping a mother manage milk expression; 10. helping a mother to breastfeed a low-birth-weight or sick baby; 11. helping a mother whose baby needs fluids other than breast milk; 12. helping a mother who is not feeding her baby directly at the breast; 13. helping a mother prevent or resolve difficulties with breastfeeding; 14. ensuring seamless transition after discharge; 15. implementing the Code in a health facility; and 16. explaining a facility’s infant feeding policies and monitoring systems. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 15 Let's discuss the local and national context Resources: Global Breastfeeding Scorecard https://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard- 2019/en/ World Breastfeeding Trends Initiative (WBTi) – http://worldbreastfeedingtrends.org/ Discussion questions: What did you learn about your own country’s situation? How does this reflect your local context? What are areas of success? What are areas of improvement? 16 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 17 18 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 17 Notes ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… 18 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Session 2. Benefits of breastfeeding Objectives After completing this session, participants will be able to: ▪ state the benefits of optimal infant feeding (exclusive and continued breastfeeding); ▪ list the importance and special properties of colostrum; ▪ describe the main differences between breast milk and artificial milks; and ▪ list the risks of artificial feeding. Introduction As we discussed in Session 1, WHO and UNICEF recommend exclusive breastfeeding for the first six months of life. This means no other food or drinks, even water. Health workers must understand the benefits of breastfeeding. Whilst working with mothers, health workers can help mothers who have doubts about the value and sufficiency of breast milk. In the first six months of life, exclusive breastfeeding provides all the nutrients and water a baby needs. After six months, all babies need complementary foods, in addition to breast milk. However, breast milk continues to be an important source of energy and high-quality nutrients beyond six months of age. NOTE: This is background for the health worker, not messages to give to mothers/parents/caregivers. This information serves to inform the health worker to better care for mothers/parents/caregivers during the antenatal period. When providing counselling and support to mothers/parents/caregivers, health workers must simplify the language and message to promote understanding. Benefits of breastfeeding Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 19 This slide summarizes some of the benefits of breastfeeding. It is useful to think of the benefits of both breast milk (listed on the left) and the process of breastfeeding (listed on the right). Benefits of a baby having breast milk are: it contains the complete nutrients a baby needs it is easily digested and efficiently used by the baby's body it protects a baby against infection it provides long-term protection against chronic non-communicable diseases (such as obesity, hypertension and diabetes). The other benefits of breastfeeding are: it costs less than artificial feeding it helps a mother and baby to bond (to develop a close, loving relationship) it helps the baby's development it protects the mother's health it helps the uterus to return to its previous size which reduces bleeding and prevents anaemia it reduces the risk of ovarian cancer and breast cancer in the mother it helps delay a new pregnancy. Counselling mothers/parents/caregivers When counselling mothers/parents/caregivers about the benefits of breastfeeding, remember to use the principals we will learn in the counselling sessions: accept what a mother/parent/caregiver thinks and feels recognize practices and praise a mother/parent/caregiver give practical help provide relevant information use simple language offer suggestions, not commands. Composition of breast milk 20 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual By looking at the nutrients in breast milk, we can see how they are complete for babies. NOTE: Formula milks are made from a variety of products, including animal milks, soybean and vegetable oils. The short bar shows that although the amounts been adjusted to be like human milk, they are still incomplete for babies as they lack all the other components shown in the tall breast milk bar. Formula milks lack many of the essential qualities present in breast milk, including special antibodies and other bioactive substances that protect babies from illness. In order to understand the composition of artificial milk, we need to understand the differences between animal and human milk. This chart compares the nutrients in breast milk with the nutrients in fresh cow’s and goat’s milk. All the milks contain: fat: provides energy protein: growth lactose: a milk sugar which also provides energy. Note Animal milk contains more protein than human milk. A baby's immature kidneys are unable to excrete the extra waste from the protein in animal milks. Human milk also contains essential fatty acids and are needed for a baby’s growing brain, eyes, and healthy blood vessels. These fatty acids are not present in animal milks can be added to formula milk. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 21 The above slide shows how proteins in different milks varies in quality as well as quantity. While the quantity of protein in cow’s milk can be modified to make formula, the quality of proteins cannot be changed. The protein in cow's milk is casein. Casein forms thick, indigestible curds in a baby’s stomach. Human milk contains more whey proteins. The whey proteins contain anti-infective proteins, which help to protect a baby against infection. NOTE: Artificially fed babies can develop an intolerance to protein from animal milk. They may develop diarrhoea, abdominal pain, rashes and other symptoms when they have artificial feeds containing the different kinds of protein. 22 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Composition of breast milk The composition of breast milk varies from feed to feed and is based on a baby's age. Colostrum is the first breast milk women begin to produce at the end of pregnancy and in the first few days after delivery. It is thick yellowish or clear in colour. It contains higher protein than breast milk later on. A few days after delivery, colostrum changes into mature milk. There is an increased amount of mature milk. A woman's breasts feel full, hard and heavy. Some people call this the milk “coming in,” but this can be confusing to a new mother. It is better for health-care workers to describe the changes in her milk in the first week. Foremilk is the thinner milk and is produced in greater amounts early in a feed. It provides protein, lactose, water and other nutrients. Babies do not need water before six months old, even in hot climates. Hindmilk is the whiter milk produced later in a feed. It contains more fat than foremilk Fat provides the energy in a breastfeed, so it is important for a baby to get both types of milk. NOTE: A common worry includes a mother's milk being "too thin" or "not enough." This is an opportunity for a health worker to build a mother's confidence and provide relevant information. When a baby has both foremilk and hindmilk, they get a complete “meal” including all the water they need. Colostrum Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 23 These slides show the special properties of colostrum and its importance. Colostrum is the first milk a newborn consumes immediately after birth. The amount of colostrum in the first few feeds is very small, approximately 2–10 mL10. Remember, a baby is learning to suck, swallow and breathe. So, these small amounts prevent them from choking. Colostrum contains immune factors to protect a baby. It has more antibodies and other anti-infective proteins than mature milk. This is part of the reason why colostrum contains more protein than mature milk. Colostrum contains more white blood cells than mature milk. Colostrum helps to prevent dangerous bacterial infections and provides the first immunization against many diseases. Colostrum has a mild laxative effect, which helps to clear the baby’s gut of meconium (the first dark stools). This also clears bilirubin from the gut and helps to keep levels low preventing severe jaundice. Colostrum contains many growth factors to develop a baby’s immature intestine. It also provides a protective lining to the baby’s gut. This helps to prevent the baby from developing future allergies and intolerance to other foods. Colostrum is rich in vitamin A, which helps to reduce the severity of infections. The first feeds help this protection. Colostrum is present in the breasts before a baby is born. Babies should not be given any drinks or food before they start breastfeeding. Artificial feeds given before a baby has colostrum increase the risk of allergies and infection. 10 Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C, Academy of Breastfeeding Medicine. Feeding in the healthy term breastfed neonate, revised 2017. Breastfeeding Med. 2017;12:188–98. doi.org/10.1089/bfm.2017.29038.ajk 24 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Protection against infection Breast milk contains white blood cells and a number of anti-infective factors. Breastfeeding protects babies against: diarrhoeal and respiratory illness ear infections, meningitis and urinary tract infections breast milk also contains antibodies against infections that the mother has had in the past. NOTE: A baby should not be separated from their mother when she has an infection because her breast milk helps to protect both of them against the infection. Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual 25 Discussion questions 1) What do you learn from this slide? 2) What do you observe about the correlation between the risk of diarrhoea and the feeding method? 3) What information could be shared with mothers/parents/caregivers from this slide? Psychological benefits of breastfeeding Breastfeeding has important psychological benefits for both mothers and babies. Close contact immediately after delivery helps the mother and baby bond and helps the mother to feel emotionally satisfied. Babies tend to cry less if they are breastfed. Some studies suggest breastfeeding may help a child to develop intellectually. Low-birth-weight babies fed breast milk in the first weeks of life perform better on intelligence tests in later childhood than children who are artificially fed. If mothers decide not to breastfeed, it is important to help them to bond with their babies in other ways apart from breastfeeding. 26 Baby-friendly Hospital Initiative training course for maternity staff: Participant’s manual Risks of not breastfeeding The slide above summarizes the risks of not breastfeeding. Compared to breastfeeding, artificial feeding may take more effort for the mother to bond with her baby. An artificially fed baby is more likely to become ill with diarrhoea, respiratory and other infections. The diarrhoea may become persistent. Artificially fed babies get diarrhoea more often, partly because artificial feeds lack anti- infective factors Also, artificial feeds are often contaminated with harmful bacteria or prepared from unclean water sources. There are barriers in preparation including receiving too few feeds or too dilute feeds The baby may become malnourished and is more likely to suffer from vitamin A deficiency. The baby is more likely to develop allergic conditions including eczema and asthma. The baby may become intolerant of animal milk, so the milk causes diarrhoea, rashes and other symptoms. There is increased risk of some chronic diseases in the child, s
