1 introduction to bfhi and 10 steps of breastfeeding

Ten steps of successful breast feeding

1. INTRODUCTION TO BFHI AND 10
STEPS OF SUCCESSFUL
BREASTFEEDING
DR VARSHA ATUL SHAH
Lecture 1

2. BABY
FRIENDLY
HOSPITAL
INITIATIVE
(BFHI)

3. What is BFHI
•Worldwide programme of the World Health
Organization and UNICEF, launched in 1991
following the Innocenti Declaration of 1990
•Global effort for improving the role of maternity
services to enable mothers to breastfeed babies for
the best start in life

4. Goals of
the Baby-friendly Hospital Initiative
•To transform maternity facilities through
implementation of the “Ten steps”
•To end the practice of distribution of free and low
cost supplies of breast-milk substitutes to
maternity wards and hospitals

5. BFHI
•Global program
•Sponsors World Health Organization (WHO) and the United Nations
Children’s Fund (UNICEF)
•HPB/MOH
•To encourage, recognize maternity hospitals that offer an optimal
level of care for infant feeding
•Assists hospitals in giving mothers the information, confidence, and
skills needed to successfully initiate and continue breastfeeding
their babies
•Gives special recognition/accreditation to hospitals that have done
so

8. PROTECT
PROMOTE
SUPPORT
BREASTFEEDING

9. WHO/AAP
RECOMMENDATION
•Exclusive breastfeeding for the 1st 6
months
•Continue BF after 6 months together with
complementary food for up to 2 years or
beyond
•Begin skin to skin within 5 minutes of birth
and BF within an hour of birth
•“On demand", day and night
•Avoid bottles or pacifiers

10. 10 Steps
to
Successful
Breastfeeding

11. STEP 1
•Have a written policy that is routinely
communicated to ALL health care staff

12. STEP 1:Why Breastfeeding Policy
•Requires a course of action and provides
guidance
•Helps establish consistent care for
mothers and babies
•Provides a standard that can be evaluate

13. How Should It Be Presented?
It should be:
•Written in 4 languages
(English, Chinese, Malay & Indian)
•Posted or displayed where mothers and
babies are cared for
•Available to all staff caring for mothers
and babies

14. STEP 2
•Train ALL health care staff in
skills necessary to implement
this policy

15. STEP 2:Who are Involved?
•Nurse (20 hours)
•Doctor (8 hours)
•Allied health staff
•Support staff - Clerk ,HCA, Cleaner (15-20
min)
•ANYONE in contact with mothers IN
ANYWAY OR OTHER
STEP 2

16. STEP 2
Areas of knowledge
•Advantages of
breastfeeding
•Risks of artificial
feeding
•Mechanisms of
lactation and suckling
•How to help mothers
initiate and sustain
breastfeeding
•Assess a breastfeed
•Managing
breastfeeding
difficulties
•Hospital breastfeeding
policies and practices

17. STEP 3•Inform all pregnant women about the
benefits and management of
breastfeeding

18. Anternatal Breastfeeding Education
•Antenatal Class
•Brochure / BF booklet/SSC
•Screening of BF Video
•To Document in patient’s notes once
education have been given
STEP 3

19. Content for Antenatal Education
•Benefits of breastfeeding
•Early initiation
•Importance of rooming-in
•Importance of feeding on demand
•Importance of exclusive breastfeeding
•Monitoring if baby is getting enough
•Risks of artificial feeding, use of bottles &
pacifiers (soothers, teats, nipples, etc.)
STEP 3

20. STEP 4•Help mother initiate skin to skin contact
for 1 hr within 5 min after delivery.

21. Dept Involved
•Delivery Suite
–All vaginal delivery
–well baby & mother
•Operating Theatre
–EL LSCS
•Special Care Nursery/NICU
–When mother is well & baby is stable
Posters and brochures will be displayed in
these areas
STEP 4

22. Why Skin to Skin & Early
Initiation?
•Increases duration of breastfeeding
•Allows skin-to-skin contact for warmth and colonization of
baby with maternal organisms
•Provides colostrum as the baby’s 1st immunization
•Takes advantage of the 1st hour of alertness
•Babies learn to suckle more effectively
•Improved developmental outcomes
STEP 4

23. Skin to Skin & Early initiation
at Delivery- How ?
•Keep mother and baby together after delivery
•Place baby on mother’s chest at least an hour
•Initiate breastfeeding when baby shows readiness to
suckle
•Delay non-urgent medical routines for at least one hour
STEP 4

24. STEP 5
•Show mothers how to breastfeed, and
how to maintain lactation even if they
should be separated from their infants
Nurses
Lactation Consultant

25. Basic Information &Technique
•Breast care & massage
•Latching technique
–Modified cradle hold position
–Football hold position
–Lying position
•Monitoring baby’s output
•EBM techniques
–Hand /pump
STEP 5

26. Start expressing if unable to latch
EBM techniques
–Hand /pump
Feed EBM with cup or spoon

27. STEP 6
•Give newborn infants NO food or drink other than
breastmilk ,unless medically indicated

28. THE PERFECT MATCH
Adapted from: Pipes PL. Nutrition in Infancy and Childhood, Fourth Edition. St. Louis,
Times Mirror/Mosby College Publishing, 1989.
STEP 6
Quantity of colostrum per feed & the newborn
stomach capacity

29. Colostrum is enough
•Newborn and infant stomach capacities
are perfectly matched to the amount of
colostrum (about 200 ml/24 hours at day
two) and mature milk (about 800-900
ml/24 hours at 1 year)

30. Why No Routine Supplement?
Why No Bottle/teats? (avoid nipple
confusion)
Hungry
crying baby
Anxious
mother
Easy flow
from bottle
Less
Breastmilk
produced
&
Improper suckling pattern at breast
Baby full –
lazy about sucking

31. Why avoid supplementation?
•Decreases eagerness to breastfeed, leading to reduced
milk supply
•Reduced mother’s confidence in breastfeeding leading
to allergic sensitization of the baby
•Increase chance of infection
•If baby fed by bottle it can result in improper sucking
pattern when breastfeeding
•Involves unnecessary expense

32. RISK OF ARTIFICIAL FEEDING
Baby
•More likely to fall sick.
•Increase risk of obesity
•More diarrhoea and respiratory
infections
•More allergy and milk
intolerance
•Increased risk of chronic
diseases
•Decrease baby desire to
breastfeed
•Risk of necrotizing
enterocolistis (NEC) in preterm
Mother
•Pregnant sooner
•Increased risk of ovarian
and breast cancer
•Interferes with bonding
•Decrease milk production

33. Acceptable Medical Reasons for use
of Breast milk substitutes
STEP 6

34. Medically Indicated for
Supplementation-
Infant Condition
Infant who should not
received breast milk or
other milk except
specialized formula :
•Galactosemia
•Maple syrup urine disease
•Phenylketonuria (PKU)
Infant for who, breast
milk remains the best
option but may need
other food in addition to
breast milk for limited
period :
•Very preterm infants
(<32 weeks gestational age)
•Very low birth weight infants (< 1500g)
•Newborn infants at risk of
hypoglycaemia

35. Medically Indicated for
Supplementation
MATERNAL CONDITION
•Acceptable Feasible Affordable
Sustainable and Safe
Mother who
may need to
avoid
breastfeeding
permanently
•HIV infection – if replacement feeding is AFASS
AFASS=Acceptable feasible affordable,
sustainable , safe
Mother who
may need to
avoid
breastfeeding
temporarily
•Severe illness
- that prevents mother from caring for her
infants
•Herpes simplex virus Type 1
- if lesions on breasts
•Maternal medication
- Sedating psychotherapeutic drug
- Radioactive iodine-131
-Cytotoxic chemotherapy
•Substance abuse

37. Mother Who can Continue
Breastfeeding
•Breast Abscess
•Hepatitis B- infants should get vaccine
•Hepatitis C
•Mastitis ( breast infection )
•TB-if treated and result –ve(FIND OUT )

38. STEP 7
1.Practise Rooming–In
- allow mother & infants to remain
together 24 hours a day.

39. Rooming-in
Why?
•Helps establish and maintain breastfeeding
•Facilitates the bonding process
•Enable demand feeding
•Mother learns feeding cues
•Mother learns to handle and comfort baby
•Baby learns to recognize mother
•Baby sleeps better
•Baby exposed to less infections
STEP 7

41. STEP 8
•Encourage breastfeeding on demand.
Frequently day and night, no restrictions on the
length or frequency of feeds

42. Why demand feeding
•Ensure a good milk supply
•Results in less engorgment
•Reduced crying and temptation to
supplement
•Ensure a contented baby

43. On demand, unrestricted breastfeeding
Why?
•Earlier passage of meconium
•Lower maximal weight loss
•Breast-milk flow established sooner
•Larger volume of milk intake on day 3
•Less incidence of jaundice
From: Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24
hours after birth in full-term neonates. Pediatrics, 1990, 86(2):171-175.
STEP 8

44. STEP 9
•Give NO artificial teats or pacifiers (also
called dummies or soothers) to
breastfeeding infants.

46. Alternatives to Artificial Teats
•Cup
•Spoon
•Finger feeding
•Tube feeding at breast
STEP 9

47. STEP 10
•Foster the establishment of
Breastfeeding Support Groups and
refer mothers to them on discharge
from the hospital or clinic.

48. Support Can Includes:
•Early postnatal or clinic check up
•Home visits
•Telephone calls
•Community services
•Outpatient breastfeeding clinics
•Peer counseling programmes
•Mother support groups
•Family support system

49. Support :
KKH
•KK Ask-a-Nurse Service
8am to 12midnight daily
1900 556 8773
•Lactation clinic 6225
5554
•Postnatal Home Care
•Mother to mother sharing
session
EXTERNAL
BreastFeeding Mothers’ Support Group
6339 3558
Joyful Parenting and Breast-Feeding
6488 0286
Association for Breastfeeding
Advocacy (ABAS) www.abas.org.sg

50. Best Videos
•http://vimeo.com/28619032
•http://www.youtube.com/watch?
v=Cuu8UEXzVQ0&feature=em-
share_video_user

51. The International Code of Marketing
of Breast milk Substitutes

52. •Protection, promote and support of breastfeeding
•Ensure the proper use of breast-milk substitutes,
when necessary,
•Provide adequate information about infant feeding
•Prohibit the advertising or any other form of
promotion of breastmilk substitutes.
AIM

53. Why No Free Milk Samples from Formula
Companies
•Prohibited by the code
•Discourage exclusive breastfeeding
•Encourages mother to supplement baby
•It makes the mother think that the facility approves
giving formula and certain brand
•Some mothers may not be able to afford formula
after samples are used up

54. Regulating Breastmilk Substitutes
•No Advertising of breast milk
substitutes or other products to the
public

55. Regulating Breastmilk Substitutes
•No company personnel to contact /advise mothers
•No free samples to mother

56. Regulating Breastmilk Substitutes
•No promotion in heath services
•No donation of free or subsidized supplies of
breast milk substitutes or other products in any
part of the heath care system.
•Since Jan 2012 ,all
ready to feed formula
have to be purchased
all Singapore Hospital

57. Regulating Breastmilk Substitutes
•No gifts of personal samples to heath
workers
•No picture of infants or other pictures or
text idealizing artificial feeding on labels of
products

58. Regulating Breastmilk Substitutes
•Information to health workers should be scientific
and factual
•Information in artificial feeding should explain
benefits of breastfeeding and costs/dangers
associated with artificial breastfeeding
Important notice:
Breastmilk is the
Best for babies………….

59. Regulating Breastmilk Substitutes
•No sponsorship of space , equipment or
education materials produced by
companies when teaching mothers about
infant feeding.
•Unsuitable products such as sweeten
condensed milk, should not be promoted
for babies .

60. What you can do
•Remove poster that advertise formula, tea juice or
baby cereal, bottles and teats ,any new poster.
•Refused to accept free gifts from companies with
breast milk substitutes or related supplies
•Refused to allow free samples, gift, or leaflets to be
given to mothers
•Ensure breast milk substitutes in hospital out of sight
of pregnant women and mothers.

61. What you can do
•No group teaching of artificial formula preparation to
pregnant women.
•Provide individual private teaching of formula use
postnatally when a baby has a need for it
•Report breaches of the code to appropriate
authorities (SIFECS code)
•Accept only product information from companies
that is scientific and factual, not marketing material.

62. Communication scenario-Total
15 minutes
•2 minutes to read the question and
organise thought
•9 minutes for communicating with patient
•1
st
alarm at 7 minutes when 2 minutes are
left
•4 minutes for the feedback

63. BF and Formula

64. Communication Scenario-1
•You are MO on call.
•You are talking to G4P3, 30 years old single parent Lisa, who had divorced 7
months ago, who has 2 previous well baby girls age 4 and 2 years old. She
had mixed fed both babies only for 4 weeks and full formula feeding since 2
months of age.
Mother delivered at 40 weeks, baby boy by NVD yesterday. Lactation C, OG and
NN doctor have both talked with her about exclusively breastfeeding her baby
boy.
•Although she knows it’s probably best for the baby, she is not sure if she
wants to give full breastfeeding since she will be going to work after the baby
is born. Being single mother, and it will be pretty tough to make ends meet
with a new baby unless she works.
•A friend told her, it was possible to pump her milk but that sounds like it could
be pretty hard and would take too much time.
•As such she does not feel formula feeds are harmful, since she was not also
breastfed as baby, was told by her mum and as such she is doing fine.

65. Your role is to:
1.Ask open-ended questions to find out
her thoughts and feelings about
breastfeeding.
2.Use probes to better understand what
she means.
3.Affirm her feelings.
4.Your role is to communicate benefits of
breastfeeding and harmful effects of
formula feeding.

66. Multiple Choice Question?

67. Question 1
What are the practices or routines done in delivery
suite or postnatal ward that can help mothers to breast
feed successfully ?
All the answers are correct EXCEPT .
1.Start skin contact within 5 minutes after delivery and
early initiation of breastfeeding
2.24 hours rooming in day and night
3.Helping mothers to position and attach babies
4.Use bottles teats to supplement baby when baby is
hungry

68. Question 2
Why is it important to avoid giving supplement or formula to a
breastfed baby unless medically indicated?
All the answers are correct EXCEPT
1. Mother will not empty the breast, leading to reduced
milk supply and engorgement
2. Reduced mother’s confidence in breastfeeding, leading
to formula feeding baby
3. If baby fed by bottle it can result in improper sucking
pattern and latching when breastfeeding
4. Decreased risk of diarrheal and respiratory infection

69. Question 3
These policies or practices are being done in the hospital that can help mother
to have a better chance to breastfeed baby successfully, all are true except:
1.Early skin to skin contact True/False
2.Early start to breastfeeding True/False
3.Providing mother with assistance in breastfeeding True/False
4.Leave baby in nursery at night, to provide rest True/ False
5.Feed baby on demand -day and night True/ False
6.Use cup feeding as alternative True/ False
7.Exclusive breastfeeding ( no BMS) True/False
8.Referring mother to support networks True/False

70. Question 4
Why is demand feeding important for successful
breastfeeding all are true except..
1.Mother will be able to supplement baby with
breastfeeding
2.Mother will have good milk supply and result in less
engorgement
3.Increase weight loss in baby
4.Help ensure a contented baby
5.Reduces crying and temptation to supplement

71. Question 5
Why do we encourage mother to room in
with baby?
1. Mother can bond easily; can recognize hunger cues and can
do demand feeing and baby is exposed to fewer infections.
2. Mother will be able to bottle feed baby easily
3. Confinement nanny/maid will be able to feed baby day and
night such that mum can rest
4. Relatives can see the baby whenever they visit.
5. Parents do not have to walk to nursery to see the baby
6. Siblings can bond with baby

72. Question 6
If a colleague ask you why it is important not
to give mother free formula samples from
the infant formula companies, what reasons
could you give?
1.It encourage mixed feeding, makes breastfeeding more difficult and makes
the mother think that the facility approve giving formula and certain brand .
2.Mother will be able to choose which brand of formula to buy.
3.Mother will have less engorgement if baby is fed on formula.
4.Mother will have an increase in milk supply .

73. Question 7
Where can you get help if you have questions about
feeding baby after you return home. All the
following correct except
1.Get help from the hospital lactation consultant
2.Get help from a health professional
3.Call a helpline
4.Get help from a mother support group or a peer/lay
counselor.
5.Get help from mother who is feeding fromula

74. Question 8
Step 4 of BFHI-Help mother initiate skin
to skin contact for 1 hr within 5 min after
delivery. Which dept is not involved in
step 4 .
1.Del suite ,
2.operating theatre
3.Special case nursery
4.Catering dept

75. Question 9
Step 5:Show mothers how to breastfeed, and how to maintain
lactation even if they should be separated from their infants .What
are the basic information & technique to teach mother all are true
except ..
1.Breast care & massage
2.Latching technique
3.Monitoring baby’s output
4.EBM techniques
5.Show her how to prepare formula sterile way

76. Question 10
Which is not an alternative to feed baby
1.Cup
2.Spoon
3.Teat feeding
4. Tube feeding at breast

77. Answers
•1-4
•2-3
•3-4
•4-3
•5-1
•6-1
•7-5
•8-4
•9-5
•10-3

78. References:
•Evidence for the ten steps to successful breastfeeding. Geneva, World Health
Organization,1998.http://www.who.int/nutrition/publications/infantfeeding/evidence_
ten_step_eng.pdf http://whqlibdoc.who.int/publications/2004/9241591544_eng.pdf.
•Pipes PL. Nutrition in Infancy and Childhood. Boston, Massachusetts, Times
Mirror/Mosby, 1989.
•Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after
birth in full-term neonates. Pediatrics, 1990, 86 (2):171-175.
•World Health Organization.The optimal duration of exclusive breastfeeding :report
of an expert consultation .Geneva:WHO; 2001.
http://www.who.int/nutrition/publications/optimal_duration_of_exc_bfeeding_report_
eng.pdf
•World health Organization. Evidence for 10 steps to successful breastfeeding
.Geneva: WHO;1998.
•Asole, S., Spinelli, A. , Antinucci L.E., and Lallo., D.D.

79. •Albernaz E, Giugliani ERJ, Victora CG. Supporting breastfeeding: a successful experience. J Hum Lact, 1998,
14(4):283-285.
•Breastfeeding and the use of water and teas. Division of Child Health and Development, Update, No.9. Geneva,
World Health Organization, reissued November 1997.
•Cattaneo A, Buzzetti R. Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative. BMJ,
2001, 323:1358-1362.
•Coutsoudis A, Kubendran P, Kuhn L, Spooner, E, Tsai W, Coovadia, HM. South African Vitamin A Study Group.
Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort
study from Durban, South Africa. AIDS, 2001 Feb 16: 15(3):379-387.
•Christensson K, Siles C, Moreno L, et al. Temperature, metabolic adaptation and crying in healthyfull-term
newborns cared for skin-to-skin or in a cot. Acta Paediatr, 1992, 81:481-493.
•DeCarvalho M, Klaus MH, Merkatz RB. Frequency of breast-feeding and serum bilirubin concentration. Am J Dis
Child, 1982, 136:737-738.
•DeCock KM, Fowler MG, Mercier E et al. Prevention of mother-to-child HIV transmission in resource poor
countries. JAMA, 2000, 238 (9):175-82.DeChateau P, Wiberg B. Long term effect on mother-infant behavior of
extra contact during the first hour postpartum. Acta Paediatr, 1977, 66:145-151.
•Guidelines concerning the main health and socioeconomic circumstances in which infants have to befed on
breast-milk substitutes. In: Thirty-Ninth World Health Assembly [A39/8 Add.1-10 April 1986],pp. 122-135, Geneva,
World Health Organization, 1992.
•Guise, J-M, Palda V, Westhoff C, Chan BKS, Helfand M, Lieu T. The effectiveness of primary carebased
interventions to promote breastfeeding: Systematic evidence review and meta-analysis for the US preventive
services task force. Annals of Family Medicine, 2003, 1(2):70-78.
•Haider R et al. Breast-feeding counselling in a diarrhoeal disease hospital. Bulletin of the World Health
Organization, 1996, 74(2):173-179.
•Haider R, Kabir I, Huttly S and Ashworth A. A training peer counselors to promote and support exclusive
breastfeeding in Bangladesh. J Hum Lact, 2002, 18:7-12.

80. References:
•Righard L, Alade MO. Effect of delivery room
routines on success of first breast-feed. Lancet,
1990,336: 1105-1107.
•Righard L, Alade MO. Sucking technique and its
effect on success of breastfeeding. Birth,
1992,19(4):185-189.
•Saadeh RJ, Akré J. Ten steps to successful breast-
feeding: a summary of the rationale and scientific
evidence. Birth, 1996, 23(3):154-160.

81. Reference : international code
•Global Strategy for Infant and Young Child Feeding. Geneva, World Health Organization, 2003.
(http://www.who.int/nutrition/publications/infantfeeding/en/index.html;http://www.who.int/childadolescent-
health/NUTRITION/global_strategy.htm).
•Global strategy for infant and young child feeding: The optimal duration of exclusive breastfeeding.Fifty-fourth
World Health Assembly, Provisional agenda item 13.1, A54/INF.DOC./4. Geneva, World Health Organization,
1 May2001.(http://www.who.int/gb/EB_WHA/PDF/WHA54/ea54id4.pdf).
•Horton S, Sanghvi T, Phillips M, Fiedler J, Perez-Escamilla. Breastfeeding promotion and priority setting in
health. Health Policy and Planning, 1996, 11(2):156-168.
•International Baby Food Action Network. Protecting infant health: A health workers’ guide to the international
code of marketing of breast-milk substitutes. 7th ed. Penang, Malaysia, IBFAN, 1993.
•International code of marketing of breast-milk substitutes. Geneva, World Health Organization, 1981.
•Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding A systematic review.Geneva, World
Health Organization, 2002 (WHO/NHD/01.08;WHO/FCH/CAH/01.23).
•New data on the prevention of mother-to-child transmission of HIV and their policy implications.Conclusions
and recommendations. WHO technical consultation on behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-
Agency Task Team on Mother-to-Child Transmission of HIV.Geneva, 11-13 October 2000. Geneva, World
Health Organization, 2001 (WHO/RHR/01.28).

82. Reference : international code
•Protecting, promoting and supporting breastfeeding: The special role of maternity services. A joint WHO/UNICEF statement.
Geneva, World Health Organization, 1989.
•Report of the expert consultation on the optimal duration of exclusive breastfeeding, Geneva,Switzerland, 28-30 March 2001.
Geneva, World Health Organization, 2001(WHO/NHD/01.09;WHO/FCH/CAH/01.24).
•Resolution WHA 39.28: Infant and Young Child Feeding. Geneva, World Health Organization, 1992.
•Resolution WHA 47.5: Infant and Young Child Nutrition. Geneva, World Health Organization, 1994
• Saadeh R et al., eds. Breastfeeding: the technical basis and recommendations for action. Geneva,World Health Organization, 1993
(WHO/NUT/MCH/93.1).
• The Baby-friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, Section 1:Background and Implementation;
Section 2: Strengthening and sustaining BFHI: A course for decision-makers; Section 3:Breastfeeding Promotion and Support in a Baby-
friendly Hospital; a 20-hour course; Section 4:Hospital Self-Appraisal and Monitoring; Section 5: External Assessment and Reassessment,
New York, New York, UNICEF, and Geneva, WHO, 2008. (http://www.unicef.org/nutrition/index_24850.html?q=printme).
• The International Code of Marketing of Breast-milk Substitutes: Frequently Asked Questions, Geneva, World Health Organization, 2006.
(http://www.who.int/child-adolescenthealth/publications/NUTRTION/ISBN_92_4_159429_2.htm).

84. Thank You!